Documentos de Académico
Documentos de Profesional
Documentos de Cultura
Maternal-Fetal Physiology
Recommended Weight gain
- BMI < 18.5: 28-40 lbs
- BMI 15.5-24.9: gain 25-35 lbs
- 25-29.9: gain 15-25 lbs
- BMI > 30: gain 11-20 lbs
Cardiovascular
- 36% increase in blood volume during pregnancy - 50% plasma and 20% RBC relative
hemodilution of pregnancy! Slight decrease in platelets, slight increase in WBC.
- CO increases up to 33% due to increased HR and SV. Up to 95% of women will have a systolic
murmur due to increased volume. Diastolic murmurs are always abnormal!
- MAP is unchanged or slightly decreased even with increased CO, because SVR
decreases markedly
- Mitral stenosis often presents during pregnancy with afib and inability to lie flat.
Suspect if possible hx of rheumatic fever.
- Peripartum cardiomyopathy: an idiopathic cardiomyopathy that presents w/ heart failure secondary
to LV systeolic dysfunction near the end of pregnancy or several months after delivery. Fatigue, SOB,
palpitations, edema.
- Thromboembolism is the most common cause of maternal mortality! Hypercoagulable state
lasts for 6 weeks after delivery.
- DVT: Venous stasis due to IVC compression and hypercoagulable state (increased fibrinogen) due to
increased estrogen. Note that platelets are actually lower in pregnancy (120 lower threshold vs 150 in
nonpregnant).
- Symptoms: fever, unilateral leg pain, swelling, redness, calf tenderness
- Treat with anticoagulation as for PE, below, along with bed rest and extremity
elevation. In contrast, can treat superficial clots with pain meds. Note that long-term heparin is
associated with osteoporosis. : (
- If untreated, associated with PE in 40% of cases!
Respiratory
- Inspiratory capacity increases by 15% in the third trimester - increased TV and IRV. Respiratory rate
doesnt change, but TV increases. FRC reduces to 80% by term.
- subjective SOB and physiologic dyspnea of pregnancy: Present in up to
75% of women by the third trimester.
- Compensated respiratory alkalosis is normal! Increased minute ventilation
compensated respiratory alkalosis.
- pH = 7.45, HCO3= 19. Also PO2 is 95-105 in pregnancy vs. 90100 mm Hg normally, and PCO2 is 28 mm Hg vs. 40 mg.
- If O2sat is less than 90%, PO2 is < 60 mm Hg! Give supplemental
O2 and get arterial blood gas to look for hypoxemia, CO2 retention, and acid-base status.
- Pulmonary edema: Decreased plasma osmolality increased susceptibility to pulmonary
edema. Common triggers: tocolytics, cardiac disease, volume overload, preeclampsia.
- Pulmonary embolism: venous stasis due to IVC compression and hypercoagulable state (increased
fibrinogen) due to increased estrogen. Dyspnea is the most common symptom! May have chest pain.
Suspect if CXR is clear and no physical exam findings. Confirm the diagnosis with
spiral CT or MRI. D-dimer is not helpful in pregnancy - its always elevated!
- Treat with IV heparin for 5-7 days, then LMWH for at least 3 months (INR 1.5 to 2.5)
through rest of pregnancy and for 6 weeks post partum.
- Check for other causes of thrombosis: Protein C or S deficiency, ATIII deficiency, FVL
mutation, hyperhomocystinemia, and antiphospholipid syndrome.
Gastrointestinal:
- Delayed stomach emptying, decreased LES tone, decreased gut motility
Renal
- GFR increases by 50%, creatinine decreases
- Glucosuria is normal because of increased GFR delivering more glucose to kidneys!
- Ureters and renal pelvis may dilate a bit, R > L, because uterus and right ovarian vein compresses
the right ureter. Sigmoid colon provides some cushioning on the left.
- Urinary tract infections
- Always treat asymptomatic bacteriuria in pregnancy - will cause acute
pyelonephritis in up to 25%. High risk of asymptomatic bacteruria in women with sickle cell trait.
- Screening urine culture at first visit and urinalysis at every prenatal visit
- If pyelonephritis:
- Most common cause of septic shock in pregnancy! E Coli is most
common bug, same as UTI.
- Treat with IV abx - cephalosporin or ampicillin and gentamicin.
Transition to orals once significantly better. Give prophy for the rest of pregnancy (e.g.,
nitrofurantoin). Otherwise risk of return.
- If no improvement after 48-72 hours, suspect urinary tract
obstruction (e.g., stone) or perinephric abscess. Do ultrasound and/or CT.
- Risk of ARDS! Gram negative endotoxin (LPS) is released
when bugs are killed by abx cause leaky capillaries and organ damage (bump
in LFTs, Cr, uterine contractions). Treat ARDS with oxygen, monitor fluid status, and
supportive measures.
Thyroid
- TBG is increased in pregnancy b/c of increased estrogens increased total T4 and total
T3, while free T4 and free T3 stay normal.
- In a pregnant woman without iodine deficiency, thyroid gland can increase up to 10%
Molar pregnancy
- Vaginal bleeding, elevated HCG, uterus larger (or smaller!) than expected. Complete mole often
presents with preeclampsia and larger uterus, higher risk of GTD, hyperemesis gravidarum, theca lutein
ovarian cysts due to hyperstimulation from beta HCG, hyperthyroidism (HCG stimulates the maternal
thyroid). Partial often dx as missed or incomplete abortions, longer gestations, lower beta HCG
- Risk factors: Asian (1/800), > 2 previous miscarriages, diet low in folic acid or low in beta carotene,
previous molar pregnancy (1-2% after one, 10% after two).
- Etiology:
- Complete: either one sperm (XX) fertilizes an empty egg or two sperm (XY) fertilize
an empty egg.
- Trophoblastic proliferation with hydropic degeneration.
- Partial: Two sperm fertilize an egg (XXX, XXY, XYY).
- Diagnosis: Suspect when HCG is way high, size is larger than dates. Confirm with ultrasound - should
see IUP if HCG is so high. Complete mole - snowstorm on ultrasoun, trophoblastic proliferation with hydropic
degeneration. Partial mole - lower beta HCG, marked villi swelling.
- Management:
- D&C, follow HCG to ensure they drop - if they dont, do chemo (20% risk in
complete mole, 5% in partial). Very treatable with chemo, even if mets to the lungs.
- Wait 6 months after HCG zeros before trying for pregnancy again - that could cloud
the picture of recurrence/progression of the mole.
- Do a chest xray - lungs are the most common site for mets. PET scan isnt indicated.
- Methotrexate for post-molar GTD, but not as a sole mode of treatment
Diabetes in pregnancy
- Type 1
Teratogenic exposure
- All or nothing effect in the first two weeks. Organogenesis between 15 and 60 days.
Folic acid
- In general, 0.4 mg daily if non high risk
- Previous NT defect 4 mg folate daily before conception and through first
trimester. Reduces risk by 85%!
Ectopic pregnancy
Risk factors: Salpingitis - especially chlamydia, progesterone IUD, infertility, tubal anomalies or tubal surgery, ART or
ovulation induction
Symptoms:
Amenorrhea for 4-6 weeks, sharp and tearing abdominal pain, irregular vaginal spotting, maybe
adnexal tenderness, maybe palpable adnexal mass (50%). Uterus can be normal in size or slightly enlarged.
- If ruptured:
- Acute worsening of abdominal pain - can be diffuse not just unilateral, peritoneal
signs, cervical and adnexal tenderness, and signs of hypovolemia - maybe syncope, tachycardia,
hypotension, orthostasis. May or may not have vaginal bleeding.
- Can do culdocentesis (spinal needle in posterior vaginal fornix) to look for
hemoperitoneum
Differential: Acute salpignitis, abortion, ruptured corpus luteum, acute appendicitis, dysfunctional uterine bleeding,
adnexal torsion, degenerating lyomyomata, endometriosis
Diagnosis:
-
Measure HCG:
- Threshold HCG level is 1500 for transvaginal ultrasound (best for looking for IU
pregnancies) and 2000 for abdominal ultrasound
- If > 1500, try to see whether an IUI is present - if so, likelihood of ectopic AND
intrauterine is 1 in 10,000. Follow with laparoscopy.
- If HCG < 1500, and patient does not have severe abdominal pain, hypotension,
or adnexal tenderness/mass, then repeat HCG in 48 hours to distinguish missed abortion, early
IU pregnancy, and ectopic pregnancy. Should double every 48 hours, usually x3.
- If HCG increases by 50%, likely to be a normal pregnancy
- If less than 50% increase in first 8 weeks, pregnancy is abnormal but could be in uterus or in tube! Could also have miscarried.
- Ectopic pregnancy suggested if < 50% increase HCG in 48 hours or
levels that dont fall after D&C
- Missed abortion - should be some tissue or fetal pole in uterus.
Diagnose with ultrasound - wont see fetal heart beat
- Use progesterone to correlate
- If progesterone is greater than 25 ng/mL, pregnancy is likely
normal. If less than 5 ng/mL, likely abnormal
Ultrasound findings
- Fetal pole outside the uterus. Or no intrauterine pregnancy if above the HCG
threshold.
- Large amount of intra-abdominal free fluid = blood suggests ectopic.
- Twin infant death and cerebral palsy rates are 5x higher than
singletons, more congenital anomalies (often discordant), higher rates of IUGR, 58%
premature with average gestation of 35 weeks. 12% very premature. Best is 37-38 weeks,
after that mortality increases.
- Prematurity in 50% of twins, 90% of triplets, almost all
quads. Prematurity increased risk of rDS, intracranial hemorrhage, CP,
blindness, low birth weight
- Risk factors: Advancing maternal age, ART, more previous pregnancies and previous
multiples, dizygous - maternal FH, higher FSH, vary with ethnicity
- Identical twins
- Diamniotic dichorionic: division within 3 days of fertilization
- Diamniotic monochorionic: division 4-8 days after fertilzation
- Monoamniotic, monochorionic: division 8-12 days after fertilzation
- Division after 13 days conjoined
- Fraternal: dividing membrane thickness > 2 mm, twin peak (lambda) sign, two placentas - anterior
and posterior placentas
- Superfecundation: fertilzation of two ova at two separate acts of intercourse in the
same cycle
- Twin-to-twin transfusion syndrome
- Common in monochorionic, diamniotic pregnancy (split 4-8 days after fertilzation).
- Mortality of 70-100%. One baby big, risk of polycythemia, volume overlaod with
polyhydramnios - can cause cardiomegaly, tricuspid regurgitation, heart failure, and hydrops. Other
baby small - anemic, IUGR, oligohydramnios - can still develop hydrops fetalis because of anemia
and high output heart failure.
- Treatment: Laser ablation at selected centers, serial amniotic fluid reduction.
- Management
- Reducing preterm delivery:
- Early, adequate weight gain in first 20-24 weeks is the best
intervention to reduce preterm delivery! Since the pregnancy is likely to be shorter, early
weight gain might help the placenta to develop and give nutrients to baby.
- Prophy cerclage, home uterine monitoring, and bed rest do not
reduce risk of prematurity
- Delivery: If first twin (Twin A) is breech, do c-section. If Twin B is breech, controversy
about optimal mode of delivery.
STDs
-
Bacterial vaginosis: positive whiff test + clue cells. Treat patient w/ metronidazole as usual.
Condition
PAPP-A
Beta HCG
AFP
estradiol
Inhibin A
HCG
Ultrasound
21
Decreased
Increased
Decreased
Decreased
Increased
Increased
Double
bubble
(duodenal
atresia)
18
Decreased
Decreased
Decreased
Decreased
--
Decreased
13
Decreased
Decreased
--
--
--
--
Examining baby
- Non Stress Test: First line, just watch babys heart rate for 20-40 minutes. Normal is at least 2
accelerations. If abnormal, follow with biophysical profile or contraction stress test - they are equivalent.
- Contraction Stress Test: Induce contractions with nipple stimulation or IV oxytocin. Can be done as
long as there is no contraindication to labor. Abnormal if late decels after > 50% of contractions. If normal,
unlikely to have a problem in the next week. Repeat in one week.
- Biophysical profile: US that looks at fetal movement, tone, breathing, amniotic fluid volume, and
FHR. If normal, unlikely to have a problem in the next week. Repeat in a week.
- Modified biophysical profile: Looks at AFI only - can combine with nonstress test if baby has
decreased movement as reported by mom
- Umbilical artery flow velocimetry (Doppler): Only has a role with IUGR. Look at systolic/diastolic
flow ratio. Concerning if flow has stopped during diastole, really bad if flow has reversed during diastole indicates high vascular resistance.
Anemia: If Hgb < 10.5 in pregnancy. Mild if 8-10, severe if < 7.
- Can do trial of iron and recheck in 3 weeks unless risk factors for thalassemia (E.g, south asian)
- Suspect B thalassemia trait if hemoglobin A2 (alpha2 delta 2) levels are elevated. Deficient beta
chain. Usually safe in pregnancy.
- Refer for genetic testing because baby has chance of beta thalassemia if father
also has it. Will seem healthy at birth, but symptoms as Hemoglobin F falls away (alpha2, gamma2).
Life expectancy in the 20s with transfusions.
- Give folic acid, do not give iron.
- Alpha thalassemia: Elevated hemoglobin F
- Sickle cell: Pregnant with sickle cell means more intense anemia, more frequent bouts of sickle cell
crisis, and more frequent infections and respiratory complications.
- But all cases of fever, pain, and low Hgb should be ruled out before concluding that a
sickle ell crisis is going on!
- HELLP syndrome = hemolysis, elevated liver enzymes, low platelets
- treat with delivery! Can be life threatening
Managing mothers heath conditions
- Mitral valve prolapse: If symptomatic (CP, syncope, anxiety, palpitations), treat with beta blocker to
decrease symptoms and reduce risk of life threatening arrhythmias.
- Pyelonephritis: Give IV hydration and antibiotics. If no improvement by 72 hours, then further
evaluation to look for obstruction or stones. Relieve obstruction with double J ureteral stent unless long term
stenting is needed - then percutaneous nephrostomy
- Lupus: NSAIDs for arthralgia and serositis. Severe disease - steroids. Hydroxychloroquine for skin
manifestations.
- Breast cancer:
- Do chemo, but dont do adjunctive radiation as we would for non-pregnant patients.
- Appendicitis: Pregnancy shifts the appendix up and to the flank. Do graded compression
ultrasound
Thyroid disease
- Normally in pregnancy, estrogen increases thyroid binding globulin --> total thyroxine increases while
free T4 and TSH stay the same.
- Hyperthyroidism:
- Most often Graves disease, however in the postpartum period, more likely to be
lymphocytic thyroiditis (positive for anti-microsomal and antiperoxidase antibodies). High
corticosteroid levels in pregnancy suppress the autoimmune antibodies, and a flare happens
postpartum when the levels drop.
- Can cause fetal hyper or hypothyroidism! If hyper treated with moms
PTU. If hypo inject intra-amniotic thyroxine! Otherwise risk of nonimmune hydrops
fetalis.
- Avoid methimazole - risk of aplasia cutis (skin/scalp defects)
- Thyroid storm: Treat with PTU, corticosteroids, beta blocker (e.g., propranolol). If not pregnant or
pregnant and really sick, can give potassium iodide (NOT radioactive iodine), but this can affect fetal thyroid.
- Thyroid storm can cause CHF due to effects on mycardium! If so, use beta blockers
with caution. Use acetaminophen or cooling blankets for high temps.
Hyperandrogenism in pregnancy
- Pregnancy luteomas and theca luteum cysts are the most common causes!
- Luteomas:
- Yellow or yellow-brown masses, often with areas of hemorrhage. Soild, 50% bilateral.
High risk of virilization of female infants, but no treatment during pregnancy - just monitor for mass
effects. They are benign and regress after delivery. Esp common with African Americans.
- Theca Luteum Cyst
- Bilateral ovarian cysts (not solid), associated with multiple pregnancy and moles
because they grown in response to beta HCG. Low risk of virilization of the female fetus. Regress
after delivery
- Krukenberg tumors: Bilateral solid ovarian masses that are mets from primary GI tract cancer. Can
cause androgenism of mom and high risk of virilization of female fetus.
Dehydration:
-
Terminology
- Threatened abortion: Vaginal bleeding < 20 weeks without passage of products.
Could be viable IUP (50%), nonviable IUP (35%), or ectopic (15%). Do ultrasound one week later.
- Inevitable abortion: less than 20 weeks, cramping, bleeding, cervix is dilated.
- Incomplete:less than 20 weeks, cramping, bleeding, open os, some passed tissue
and some retained. Cervix stays open because of continued uterine contractions - trying to expel the
retained tissue
- Distinguish between incompetent cervix, which will open in 2nd
trimester without uterine contractions do cerclage to reinforce
- Missed abortion: Fetal demise without cervical dilation, bleeding, cramping or
passage of products - basically asymptomatic.
- Recurrent abortion: Three successive spontaneous abortions
- Completed SAB: Cervix closed, follow hCG to zero
Psychological response: Denial anger bargaining depression acceptance
1st trimester Causes
- Majority of 1st trimester abortions: caused by chromosomal abnormalities - most
often autosomal trisomy (40-50%), triploidy is the next most common.
- Systemic diseases also associated with miscarriage:
- DM - connected to rate of control,
- Chronic renal disease,
- Lupus - if three miscarriages, test for lupus anticoagulant. Treat with
aspirin and heparin
- Smoking, alcohol, radiation
- Infections - listeria, mycoplasma, ureaplasma, toxo, syphilis
- Advancing maternal and paternal age, advancing parity
2nd trimester causes
- Usually NOT related to genetic abnormalities. Likely causes include uncontrolled
diabetes.
- Maternal hypothyroidism is usually associated with menstrual
irregularities and infertility, but less likely a cause of miscarriage
- Incompetent cervix
- Painless cervical dilation pelvic pressure, bulging
membranes, fetal loss
- Can be caused by cone biopsy
- Treatment
- Place a cervical cerclage at 14 weeks
- Some clinicians use prophy progesterone to prevent
recurrent abortion or preterm labor, but no controlled trials support the use for
cervical incompetence
Diagnosis
- Spaldings sign: overlapping of fetal skull bones suggesting demise
Management of missed, incomplete, or inevitable abortion: Depends on hemodynamic stability!
- Check blood type and give rhogam
- If hemodynamically stable and reliable for follow up, can do expectant management
or medical management.
- But if dead fetus is in utero for 3-4 weeks, fibrinogen levels can
decrease coagulopathy. Can manifest as nosebleeds. Be concerned about
fibrinogen and platelets in the low-normal range because that can indicate developing DIC!
Do induction of labor.
10
Placental abruption
- Symptoms: crampy midline abdominal pain, bleeding, uterine
hypertonicity, maybe fetal distress, often have hypertension
- Risk factors:
- HTN, preeclampsia,
- Smoking, cocaine (maternal HTN and
vasoconstriction),
- Trauma
- Prolonged rupture of membranes, premature rupture
of membranes
- Hx of prior abruption
- Uterine fibroids - especially submucosal
- Polyhydramnios
- Short umbilical cord
- Dx:
11
12
- Standard dose of 300 micrograms of drug will neutralize 30 cc of fetal blood (15 cc
of fetal RBCs).
- Can also determine precise dose by measuring incidence and size of fetal
transplacental hemorrhage - Kleihauer Betke test stains a sample of maternal blood, the mothers
RBCs go pale while fetal RBCs stain because of fetal Hgb
Risks:
- Fetal anemia - test with doppler ultrasound and middle cerebral artery peak
systolic velocity. Can also get this info from invasive testing - amniocentesis or cordocentesis.
- Can also look for bilirubin in amniotic fluid as a way to assess the
severity of hemolysis. Do spectrophotometric measurements of the optical density between
420 and 460 nm - deviation from 450 due to heme pigment.
- Fetal hydrops: Volume overload from decreased hepatic protein production
collection of fluid in 2 or more body cavities - ascites, pericardial and/or pleural fluid,
scalp edema. Also placentomegaly (edema) and polyhydramnios.
Treatment:
- Severe disease fetal blood transfusion! Best to do into the umbilical
vein, but can also due intraperitoneal transfusion when IV transfusion is impossible, but slower
correction of anemia.
- Maternal plasmapheresis if blood transfusion not possible
Other isoimmunizations:
- Lewis lives (IgM, does not cross placenta), Kell kills, and Duffy (Rh) dies. In general, no great risk
unless titer is greater than 1:8.
Hyperemesis gravidarum
- Severe, persistent nausea and vomiting with > 5% weight loss of prepregnancy weight.
- Higher risk with anything that increases placental size, because of increased beta HCG - multiples,
molar pregnancy. Do a pelvic ultrasound.
- Management: orthostatic vital signs, serum electrolytes, BUN, creatinine, thyroid function testing,
urinalysis
- Treat with ginger, vitamin B6, supportive care.
Preeclampsia
- Patients are usually unaware of HTN and proteinuria. Usually only aware of HA, RUQ or epigastric
pain, vision changes, weight changes = edema
- Etiology:
- Vasospasm and leaky blood vessels serum leaks out local hypoxemia
hemolysis, necrosis, end-organ damage
- Early onset is likely related to placental factors, later onset is related to constitutional
factors like obesity - later onset has a better course.
- Risk factors: previous hx, chronic HTN, multifetal pregnancy, first pregnancy, very young or age > 40
- Complications:
- Placental abruption, eclampsia w/ possible intracerebral hemorrhage,
coagulopathies, renal failure, hepatic subcapsular hematoma, hepatic rupture, uteroplacental
insufficiency, microangiopathic anemia
- Hepatic rupture: Sudden, severe abdominal pain, abdominal distension, syncope,
hypotension, and tachycardia.
- Diagnostic categories of HTN:
- Prehypertension: 120-139/80-89
- Chronic hypertension: BP 140/90 or greater before pregnancy or before 20 weeks
gestation
- Gestational Hypertension: BP > 140/90 that develops after 20 weeks
- Preeclampsia: HTN after 20 weeks with proteinuria - PC ratio > 0.3 or > 300 mg/24
hrs. Usually also have nondependent edema (face, hands), but thats not a requirement.
13
14
- Management: Treat with magnesium sulfate. Second line = valium, hydantoin, tiagabine, and
barbituates. Can be added as second agents.
HELLP syndrome:Hemolysis, elevated liver enzymes (up to 1000), platelets < 100k.. Can cause swelling of liver
capsule and liver rupture!
Possible to only have elevated LFTs and low platelets, without hemolysis!
Differential diagnosis of abnormal LFTs in pregnancy
- Acute Fatty Liver of Pregnancy: Nausea, vomiting, jaundice, hypoglycemia (unique to AFLP, cant
break down glycogen), coagulopathy, acute liver failure, acute renal failure. Less likely to have hypertension
than HELLP/ Maybe due to mito dysfunction in oxidizing FAs. Treat with delivery!
- Preeclampsia: LFTs 100-300 range, HTN, proteinuria
- HELLP: Elevated liver enzymes up to 1000, platelets < 100k
- Idiopathic cholestasis of pregnancy: Generalized itching, LFTs may be normal to > 1000, elevated
bile acids
- Treat with antihistamines, ursodeoxycholic acid, cholestyramine (binds bile acids)
- Assoced with increased risk of prematurity, fetal distress, and fetal loss, especially
when accompanied by jaundice or markedly elevated bile acids.
- Also increased risk of gallstones
Itching in pregnancy
- Idiopathic cholestasis of pregnancy: see above
- Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP): Erythematous papules and hives
beginning on the abdomen and spreading to buttocks, surrounded by a narrow pale halo. More common in
first pregnancy, third trimester. Etiology is unknown. Have lymphocytic and histiocytic infiltration of epidermis
with edema. No adverse effects on baby (the little puppp is fine!). Treat with topical steroids and
antihistamines.
- Herpes gestationis: erythematous blisters on extremities > abdomen with intense itching. Not HSV its thought to be autoimmune with IgG to basement membrane. Do immunoflorescent staining of bx.
Increased fetal growth retardation and still birth, baby can get it transiently too. Tx with oral steroids.
Placental abnormalities
- Placental abruption
- Symptoms: crampy midline abdominal pain, bleeding, uterine hypertonicity, maybe
fetal distress, often have hypertension
- Risk factors: HTN, preeclampsia, smoking, cocaine, trauma, prolonged rupture of
membranes, hx of prior abruption, polyhydramnios
- Dx: vaginal bleeding, tachysystole on tocometer (intense contractions every 1-2
mins) and evidence of fetal anemia (tachycardia, sinusoidal HR)
- Risks: Bleeding out, DIC, hysterectomy, fetal neuro injury or death
- Treatment: Emergency c-section with fluids and blood products
- Placenta previa
- Placenta in an abnormal spot
- Double set up team with c-section team ready to go
- Placenta accreta
- Placenta grows into the myometrium. Risk factors = previous Cesarian deliveries 50% risk with four previous C-sections, low anterior placenta.
- Vasa previa:
- Umbilical cord vessels grow into membranes with the vessels overlying the internal
cervical os, and therefore are vulnerable to fetal exsanguination upon rupture of membranes.
- Symptoms: rapid deterioration of the fetus, but maternal vital signs should be okay
- Risk factors: bilobed placenta, low lying placenta, multifetal pregnancy, IVF
15
Preterm Labor
Term staging
-
Preterm complications
- Pulmonary hypoplasia: Risk if delivered < 25 weeks
- Dont do an elective c-section or elective induction before 39 weeks - higher risk of complications!
Only do if medically indicated
Braxton-Hicks contractions
- Short, less intense than true labor, discomfort is in lower abdomen and groin.
- True labor = strong, regular uterine contractions progressive cervical dilation and
effacement
Preterm labor generally:
- Contractions with cervical change (in a nulliparous patient, at least 2 cm dilated and 80% effaced)
between 20 weeks and before 37 completed weeks.
- Preterm contractions (without cervical change)
- 50% resolve spontaneously - can do expectant management.
Usually felt in the lower abdomen, as opposed to true labor which is more in the back and the
upper abdomen. Usually relieved by sedation, unlike true labor. Also interval does not shorten
and they do not increase in intensity.
- If dehydrated - PO fluids or IV hydration
- Most often idiopathic.
- Risk factors = dehydration, uterine distortion (fibroids, structural malformations), cervical
incompetence (usually dx early in the second trimester), hx of cervical cone biopsy, intra-amniotic infection,
multiple gestations, cocaine, African American, Abdominal trauma, pyelonephritis, abdominal surgery during
pregnancy
16
Premature rupture of membranes: Rupture of membranes before labor. Preterm premature rupture of membranes is
rupture < 37 weeks before onset of labor. Latency period is the time between rupture of membranes to onset of labor.
- At 28-34 weeks, 50% will go into labor within 24 hours and 80% within 2 days. At term, 90% go into
labor within 1 day of rupture of membranes.
- Risk factors:
17
- Genital tract infection, especially bacterial vaginosis, are the biggest risk factor.
- Also smoking, shortened cervical length
- Risk of recurrence is 32%
- Bed rest and tocolytics do not reduce risk of PROM, use cerclage only if incompetent
cervix. 17-alphahydroxyprogesterone DOES reduce risk of preterm labor.
- Dx: Examine vaginal fluid (NOT cervical mucous) for ferning, nitrazine test, ROM plus. Maternal
urine is also nitrazine positive. Avoid digital examination of cervix.
- Treatment
- Antibiotics! (maybe ampicllin and gentamycin) They are the best med to delay labor
- can prolong latency by 5-7 days and reduce maternal amnionitis and neonatal sepsis. Tocolytics and
betamethasone can also prolong pregnancy, but not for 7 days.
- Tocolysis to prolong interval for delivery and enable steroids to work. Dont continue
tocolytics beyond 48 hours - risk of chorioamnionitis. Avoid if signs of infection or advanced preterm
labor.
- Steroids (betamethasone) to minimize pulmonary hypoplasia.
- Give < 32 weeks with ruptured membranes - but avoid if
chorioamnionitis (earliest sign is fetal tachycardia).
- Give up to 34 weeks if membranes are not ruptured!
- Delivery if > 34-35 weeks or when there is evidence of fetal lung maturity
(phosphatidyl glycerol in the vaginal pool of amniotic fluid, lecithin/sphingomyelin ratio > 2)
Intraamniotic infection
- Suspect if fetal tachycardia. Most accurate method to confirm is with amniocentesis and gram stain
- Listeria can cause intraamniotic infection without rupture of membranes via transplacental spread!
Suspect if hx of unpasteurized milk products.
Fetal growth restriction
IUGR is growth < 10%. (macrosomia is > 90%). If < 3 or 5%, likely to be a true problem. Otherwise might just be a
constitutionally small baby. Diagnose based on ultrasound, not based on fundal height which can be unreliable.
1. Assymetric: Head and length are normal, abdomen is small. Usually uteroplacental insufficiency
(hypoxia, insufficient nutrition).
2. Symmetric: Intrinsic growth failure or an early event secondary to organ problems, fetal aneuploidy,
or severe or early intrauterine infection (rubella, CMV, syphylis, varicella, toxo). No bacteria cause IUGR!
Risks:
- Early: meconium aspiration, necrotizing enterocolitis, hypoglycemia, respiratory distress,
hypothermia, and thrombocytopenia
- Late: CV disease, COPD, diabetes, HTN - basically divert energy to the brain at the expense of these
organs.
Management: Twice weekly AFI and NSTs, weekly systolic/diastolic ratios
- Assess AFI: Likely to have oligohydramnios due to reduced fetal blood volume, renal
blood flow, and urinary output - chronic hypoxia diversion of blood from kidneys to other
organs.
- 90% of oligohydramnios pregnancies = growth restricted
- 8-18 AFI is normal. 5-6 is oligohydramnios, > 20 is polyhydramnios.
- Systolic/diastolic ratio of the umbilical artery: Increase reflects increasing vascular
resistance, common with IUGR. Severe resistance reverses end diastolic flow! Bad news. But
normal flow is very reassuring.
- Non stress test, contraction stress test, biophysical profile.
Delivery
18
19
Phases of labor
- Latent phase: Cervix < 4 cm..
- Arrest of labor:
- Prolonged latent phase: Prolonged if > 20 hours for first baby, > 14 hours for
multipara.
- Treat with rest or augmenting labor. Do not rupture membranes
- Secondary arrest of labor: Active phase of labor, but no cervical change for >
4hours.
- Treat with amniotomy, if no change, then give oxytocin
- No indication for forceps if fetal stage is +1
Induction of labor
- Closed cervix:
- Give cytotec = misoprostol = prostaglandin E1 prior to pitcocin. Risk of
uterine hyperstimulation with prostaglandin cervical ripening agents (esp misoprostol)
fetal bradycardia.
- Foley bulb is preferred over prostaglandins when previous c-section due to risk of
cervical rupture.
- Cant do foley or rupture of membranes
Augmentation of labor
- Give to a woman in labor if her contractions start to become further apart after rupture of membranes.
Fetal heart rate monitoring - interpretation
Baseline: Normal is 110-160.
Fetal tachycardia is > 160 - can be sign of distress or infection - often with maternal
fever or chorioamnionitis.
Bradycardia: Prolonged bradycardia may be from uterine hyperstimulation
Variability: Fluctuations in the baseline that are irregular in aplitude and frequency. Measure from
peak to trough. Maternal drugs can cause loss of variability.
0-5 above baseline: minimal
6-25 above baseline: moderate
> 25 is marked
Acceleration: abrupt increase in FHR above baseline - at least 15 bpm for at least 15 seconds
Normal reactivity is at least 2 15 x15 accels within 20 mins > 32 weeks, or 10 x 10
<.32 weeks
Deceleration
Early - Symmetric SLOW fall and rise in HR, decrease starts with onset of the
contraction. Caused by head compression, not ominous.
Late decel: Begin after the peak of the contraction, returns to baseline only after the
contraction has resolved. Uterine placental insufficiency - often chronic HTN or postdate
pregnancies. Can be worrisome - move towards c-section if t hey dont resolve
Management:
20
21
Engagement
Descent
Flexion
Internal Rotation
External Rotation
??
??
Breech
-
22
Vaginal tears
Vaccum
-
The rate of c-sections is increasing mainly due to fewer women having VBAC (because of increased complications,
especially uterine rupture). Other causes - many obs dont do instrumental vaginal deliveries, fewer do vaginal breech
deliveries.
Indications
-
Consider if fetal head > 12 cm, placenta previa (complete or partial), breech
23
If mom gets meperidine during delivery baby can end up with narcosis = deep stupor or unconsciousness.
Give naloxone for meperidine, not for general anesthesia (not opiates)
If history of substance abuse during pregnancy, do not give naloxone! Can
send baby into life-threatening withdrawal! Give positive pressure ventilation and prepare to intubate
if necessary.
In response to positive pressure ventilation, will have good HR but poor respiratory effort.
Other cases:
1. Baby born limp, apneic, bradycardic, + covered in meconium Intubate with an endotrach tube and
suction meconium out
2. Diaphragmatic hernia: Baby born w/ cyanosis, respiratory distress, scaphoid abdomen, heart
sounds on right side & decreased on left side. Herniated bowel into chest pulmonary hypoplasia. Do
endotrach intubation! Bag mask will increase bowel gas and make it worse!
3. Baby born lethargic with HR of 40: If HR < 60 despite PPV with 100% oxygen, then do
chest compressions for 30 seconds. If HR still < 60 epinephrine
4. Choanal atresia! Crying baby appears normal, but respiratory distress when she stops crying.
When crying, can breathe through mouth. But otherwise obligate nose breather until 4 months.
a. May be part of CHARGE syndrome: Colomboa, Heart defects, Atresia of the
choanae, Renal anomalies, Growth impairment, and Ear abnormalities/dearfness
Other issues in Immediate Care of the Newborn
Chorioamnionitis
- Mother has fever, baby has tachycardia. Expect baby to be born septic - lethargic, pale, fever
- Diagnosis: Amniocentesis - glucose < 20, elevated interleukin 6. Presence of WBCs has low
predictive value.
HIV treatment
- Give zidovudine during pregnancy, IV in labor, and give it to baby immediately after birth
reduce risk of transmission from 25% to 2%. Test for HIV at 24 hours.
- Breastfeeding is not encouraged.
Postpartum Care
Postpartum Hemorrhage
- Definition: > 500 mL after vaginal delivery, > 1 L after Cesarian delivery
- Remember ABCs first!
- Reduce risk with oxytocin after delivery, early cord clamping, gentle cord traction with uterine counter
traction with a well contracted uterus
- Early Causes of PPH: Uterine atony, genital tract lacterations, placenta accreta, retained placenta,
uterine inversion. One early question is whether the bleeding is supracervical or cervical or lower in the
genital tract.
- Uterine atony is most common cause of early PPH
- Risk factors for atony:
- Magnesium, oxytocin
- Prolonged labor
- Anything that really stretches or tires out the uterus
(big babies, long labor, multiples, hydramnios, oxytocin, general anesthesia
- Intraamniotic infectino
- High parity
- Management
24
25
removal.
Blood products
- FFP: Fibrinogen, Factors V and 8. Give if DIC and hemorrhage are evident or if the coagulation
profile is very abnormal.
- Cryoprecipitate: Fibrinogen, Factor 8, Von Willebrand Factor
Sheehan Syndrome
- Significant blood loss anterior pituitary necrosis. Loss gonadotropin, TSH, ACTH. Often
goes unnoticed for many years!
- Treatment: estrogen, progesterone, TSH, adrenal hormones
Postpartum fever
- Most often endometritis. Breast engorgement can also cause a mild fever after milk let down on day
2-3
- Differential: UTI, lower genital tract infection, wound infection, pulmonary infection, thrombophlebitis,
mastitis
- Wound infection (e.g, from c-section)
- Open the wound up, drain purulent material, give abx
- Septic thrombophlebitis
- Fevers, but eating and walking normally, no other sign of infection or problem
- Thrombosis of the venous system of the pelvis. Sometimes see on CT scan. Treat
with short term. anticoagulation and antibiotics
Puerperal Infection/Endometritis
- Fever, diffuse abdominal tenderness, marked cervical motion tenderness.
- < 3% of vaginal deliveries, 5-10x more common with Cesarean deliveries. Usually caused by a mix of
aerobes and anaerobes, most causitive bugs are staph aureus and streptococcus. Can also happen after
termination!
- Symptoms: Most common cause of postpartum fever! Often have uterine fundal tenderness,
maybe foul smelling lochia
- Risk factors in vaginal birth: prolonged labor or prolonged rupture of membranes, multiple vaginal
examinations, internal fetal monitoring, removal of placenta manually, low socioeconomic status.
- Management: IV antibiotics!
- Use gentamicin and clindamycin (for anaerobes) after c-section, or gentamycin
and ampicillin after vaginal (dont need as much anaerobic coverage). Add ampicillin if no
improvement after 48 hours (enterococcus).
26
D&C.
- If no improvement after 48-72 hours with triple abx, do a CT of abdomen and pelvis
to look for an abscess, infected hematoma, or pelvic thrombophlebitis.
Follow with ultrasound. E.g., after abortion may see products of conception. Would then require
Postpartum blues
- Signs of depression that last < 2 weeks. Happens in 40-85% of women after delivery
Postpartum depression
- 10-15% of women. Biggest risk factor is a prior history of depression.
- Begins 2 weeks-6 months after delivery. Lasts > 2 weeks.
- Ambivalence to the newborn is a red flag for depression rather than postpartum blues.
Breastfeeding
Breastfeeding is recommended as exclusive source of nutrition for 6 months. More likely to initiate it if physicians or
nurses encourage it.
Benefits of breastfeeding
- Increased uterine contraction from oxytocin release
- Reduced risk of ovarian cancer, may also have reduced risk of breast cancer
- Reduces fetal infections because of secretory IgA, lactoferrin (inhibits certain iron-dependent bugs in
the GI tract), and lysozyme (enzyme that protects against E coli and other bugs)
- Must supplement with Vit K at birth and Vit D at 2 months.
Contraindications: HIV, active tuberculosis, the rest are obvious
Suppression of lactation
- Breast binding, ice packs, analgesics. Avoid breast stimulation or milk expression. Hormones
predispose to clots, bromocriptine is associated with HTN. strokes, seizure.
Physiology of breastfeeding
- Progesterone, estrogen, placental lactogen, prolactin, cortisol, and insulin stimulate growth and
development of milk secreting apparatus of the mammary gland
- Prolactin is responsible for synthesis of milk. Present in pregnancy, but action is inhibited by
estrogen and progesterone. After delivery, estrogen and progesterone inhibition is lifted
prolactin can stimulate milk synthesis.
- Oxytocinstimulates the ejection of milk - stimulated by suckling better than breast pump does
How to breastfeed
- Mother and baby must be belly-to-belly in order for baby to take a large portion of the areola into its
mouth - otherwise increased risk of bleeding and cracked nipples
- Hospital policies: Getting baby to breast within 30 mins, give mom unlimited access to baby
- Signs that baby is getting enough: 3-4 stools in 24 hours, 6 wet diapers in 24 hours, weight gain,
sound of swallowing
- Engorgement: Treat with frequent nursing, warm showers/compresses, massage, hand expressing
milk to soften, good support bra, pain meds 20 mins before breastfeeding
Mastitis
- Usually 2-4th week postpartum (vs 1st 24 hours = breast engorgement). Red, tender, swollen breast
and fever, chills, malaise, tachycardia. Should not have fluctuance! Suggests abscess.
- Most often staph aureus from the babys throat.
27
- Risk factors: past hx of mastitis, engorgement and inadequate milk drainage (sudden increase in
sleep duration, replacement with formula or pumped milk, weaning, pressure on the duct from tight clothes or
sleeping on stomach, cracked or clogged nipple, poor latch)
- Treat with dicloxacillin or cephalexin, culture breast milk before starting abx. Continue to breast
feed or pump.
- If at risk for MRSA (HIV, recent abx, health care exposure) then treat with
clindamycin, bactrim, or vancomycin
- If fluctuance or no improvement after 48 hrs of abx suspect breast abscess! Get an ultrasound.
Treat with surgical drainage or ultrasound guided aspiration and with abx.
- If persistence of symptoms despite abx, worry about inflammatory breast cancer get a biopsy,
dont do imaging because you wont see anything.
Galactocele
- Noninfected collection of milk due to blocked mammary duct palpable mass, breast
pressure, pain. No erythema, no fever.
- Should go away on its own, if not aspiration to prevent abscess formation.
Candida
- Sensitive, sore nipples, burning pain in the breasts worse with feeding. Nipples pink and shiny with
peeling at periphery.
- Inspect babys mouth, too!
Post partum complications
Pelvic Congestion Syndrome
- Chronic pain due to pelvic varicosities. Get vasodilated when exposed to high concentrations of
estrogen, worse premenstrually and during pregnancy, aggravated by standing, fatigue, and sex
- Described as pelvic fullness or heaviness, can extend to vulva and legs
- Associated with vaginal discharge, backache, urinary frequency. Can have menstrual cycle defects
and dysmenorrhea
Nerve entrapment syndrome
- Low transverse incision neuropathy of the iliohypogastric or ilioinguinal nerve. Pain is
worse with adduction of the thigh.
- Iliohypogastrci - cutaneous sensation of the groin and skin of the pubis
- Ilioinguinal - sensation of the groin, symphysis, labia, upper inner thigh
28