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Embryo etc stages
- Embryo - up to 8 weeks
- Fetus - 8 weeks-birth
- 1st trim - up to 12 weeks developmental age (14 weeks gestational age)
- 2nd 12-24
- 3rd 24-deliver
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Nagele rulre
LMP-3 mo + 7 days = EDD
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Signs of pregnancy
- Goodell sign: softening of cervix at 4 weeks
- Ladin sign: softening of midline uterus at 6 weeks
- Chadwick sign: blue vagina and cervix at 6-8 weeks
- Telangiectasias/palmar erythema during 1st trim
- Chloasma: hyperpigmentation of face at 16 weeks
- Linea nigra: hyperpigmentation from xiphoid to pubic during 2nd trim
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bHCG levels
- double every 48 hrs for first 4 weeks.
- Peak at 10 weeks
- Drop during 2nd trim
- inc in 3rd trim
- Gestational sac seen at 1000-1500 (5 weeks)
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Pregnancy renal
- Inc GFR due to inc plasma volume
- Dec in BUN/Cr
- Inc in size of kidney and ureters increases risk of pyelonephritis
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Pregnancy hematology
- Inc plasma volume by 50% - anemia
- Hypercoagulable with normal PT, PTT, and INR but inc in fibrinogen and venous stasis
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First trimester care
- See ever 4-6weeks
- 11-14 weeks check age and nuchal
- Fetal heart sounds at end of 1st trim
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2nd trimester care
- Triple or quad test at 15-20 weeks
- Auscultate fetal heart
- Quickening (feel movements) at 16-20 weeks
- US for malformations at 18-20 weeks
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Triple and quad screens
- AFP - inc in dating error, NT defect, abdominal wall defect
- bHCG
- estriol
- inhibin A
- Rest inc sensitivity
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Third trimester care
- every 2-3 weeks then every week after 36 weeks
- Wk 27: CBC
- Wk 26-28: Glc load (50g glc, 1hr later, should be lower than 140. If not, do tolerance test with 100g and check at 1,2,3 hrs)
- Wk 36: Chlamydia, gonorrhea, GBS
- Cervix exam at 37 weeks
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Chorionic villus sampling
9-12 wks if advanced maternal age or genetic diseases
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Amniocentesis
after 15 weeks if advanced maternal age or genetic diseases
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Fetal blood sampling
Rh isoimmunization or for fetal CBC
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Methotrexate
- Folate R antagonist
- 15% dec in 4-7d. If not, repeat. If still no dec, surgery
- Exclusions: done with kids, immunodeficiency, noncompliant, liver disease, 3.5cm or larger, fetal heart rate
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Types of abortions
- Complete: no products of conception on US
- Incomplete: Some products. D&C
- Inevitable: products, bleeding, dilated cervix. D&C
- Threatened: products, bleeding. Bed rest
- Missed: death with products. D&C
- Septic: infection. D&C, levofloxacin and metronidazole
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Times to allow preterm labor
- Severe maternal HTN
- Maternal cardiac disease
- Cervix >4cm
- Maternal hemorrhage
- Fetal death
- Chorioamnionitis
- GA is 34-37 weeks and >2500g
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Tx for preterm labor
- Betamethasone - mature lungs (works within 24hrs, peaks at 48hrs, lasts 7days)
- Tocolytics - Mg sulfate, CCB
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PROM tx
- if chorioamnionitis - deliver now
- If term, wait 6-12 hours to induce
- If preterm - betamethasone, tocolytics, ampicillin and gentamicin. Erythro if pen allergy
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Placenta previa tx
- If large bleeding or drop in hematocrit, pelvic rest
- Immediate Csection if cervix >4cm, severe hemorrhage, fetal distress
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Placental invasions
- Accreta: superficial uterine wall
- Increta: into myometrium
- Percreta: serosa, bladder wall, or rectum wall
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Placental risks, presentation, abruption complications
- HTN, prior abruption, cocaine, trauma
- 3rd trim bleeding, pain, contractions, fetal distress
- Bleeding, premature delivery, uterine tetany, DIC, hypovolemic shock, Sheehan. External type as less complications since more likely to be partial
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Work up for Rh sensitized mom
- If <1:16, no tx
- >1:16 amniocentesis at 16-20 weeks
- If fetal cells Rh+, evaluate fetal bili
- If low - repeat in 2-3 weeks. Medium 1-2 weeks
- If high - percutaneous umbilical blood sample for fetal hematocrit
- If low hematocrit - intrauterine transfusion
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Tx of hypertension in pregnancy
methyldopa, labetalol, or nifedipine
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Mild vs severe preeclampsia
- Mild: >140/90, 1-2+ proteinuria or 24hr >300mg, edema in hands, feet and face
- Severe: >160/110, 3+ or >5g, generalized edema, mental status change, vision change, impaired liver fxn
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Tx of preeclampsia
- If term - deliver
- Preterm mild - betamethasone, Mgsulfate for sz ppx
- svere - mg sulfate, hydralazine, deliver or betamethasone
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HELLP
- HTN
- Elevated Liver enzymes
- Low Platelets
- tx as eclampsia
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Risks of pregestational DM
- preeclampsia
- abortion
- infection
- postpartum hemorrhage
- congenital anomalies, macrosomia
- preterm labor
- Neonatal hypoglycemia
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Extra tests for DM pregnancy
- EKG
- 24 hr urine for cr an protein
- HbA1C
- Ophtho exam
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Tx of DM pregnancy
- Diet and exercise but no weight loss
- NPH night and aspart premeal
- No sulfonylureas
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IUGR: types, causes, complications
- symmetric <20wks, asymmetric >20wks
- chrom, NT defects, infection, twins, HTN or renal disease in mom, smoking
- Premature, stillbirth, hypoxia, low IQ, sz, retardation
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Macrosomia
- >4500g
- Fundal height >3cm more than GA
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Nonstress test
- 2 fetal movements, HR accelerations within 20 min
- If nonreassuring, wake baby up with vibroacoustic stimulation
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Biophysical profile
- Nonstress test
- 1+ chest expansions in 30 min
- 3+ movements in 30 min
- Fetus flexes
- Amniotic fluic index
- Each is 2 pts. normal is 8-10pts, <4 is abnormal
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Normal fetal heart rate
- 110-160
- With accelerations of 15+ above baseline for 15-20 seconds twice within 20 min
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Decelerations
- Early: dec in HR with contractions due to head compression
- Variable: dec in HR and return to baseline due to umbilical cord compression
- Late: After contraction started, no return to baseline until contraction ends due to fetal hypoxia
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Lightening
fetal descent to pelvic brim
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Stages of labor
- 1: onset-full dilation. 6-18hrs in primipara, 2-10 in multipara
- Latent: onset-4 cm. 7hrs, 5hrs
- Active: 4cm-full. 1cm/hr min, 1.2cm/hr min
- 2: full dilation-delivery. 30min-3hrs, 5-30min
- 3: deliver-delivery of placenta. 30 min
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Steps of stage 2 labor
- Engagement - enters pelvis
- descent
- flexion
- internal rotation - at ischial spines, moves sagittal sutures into forward position
- extension
- external rotation- ant shoulder first
- delivery of ant shoulder
- derlivery of post shoulder
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Induction of labor
- Prostaglandin E2 for cervical ripening. Contraindicated in asthmatics
- Oxytocin for contractions
- Amniotomy
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Arrest disorders
- Cervical - no dilation for 2hrs
- Fetal - no descent for 1 hr
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Types of breech and tx
- Frank - hips flexed, extended knees
- Complete - flexed hips and knees
- Footling - one or 2 legs first
- External rotation after 36 weeks
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Shoulder dystocia steps
- McRoberts: flex moms knees
- Rubin: push post shoulder twd head to rotate baby
- Woods: rotate shoulders by pussing post shoulder to back
- Deliver post arm
- Fracture fetal clavicle
- Zavanelli: push back and Csection
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Postpartum hemorrhage, types, tx
- Bleeding >500ml
- Early is within 24 hours
- Late is 1d-6 weeks
- Exam, compression and masage, oxytocin
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