Obstetrics

• due to shoulder dystocia.
• Risk factors include infant large for gestational age (birth weight >4 kg), maternal diabetes, and maternal obesity
• Excessive traction of the 8th cervical (C8) and 1st thoracic (T1) nerves during delivery can result in the rare complication of left hand paralysis.
• "Claw hand"
• • Extended wrist
• • Hyperextended metacarpophalangeal joints
• • Flexed interphalangeal joints
• • Absent grasp reflex
• • Horner syndrome (ptosis, miosis)
• • Intact Moro & biceps reflexes
• Sometimes, there is associated damage to the sympathetic fibers that run along C8 and T1 that manifests as ipsilateral miosis and ptosis (Horner syndrome).
• Prognosis depends on whether damage was due to nerve stretching or compression as opposed to avulsion.
• Horner syndrome also portends a suboptimal outcome.
• Treatment is controversial but usually involves gentle massages and physical therapy to prevent contractures.
• In most cases, function returns within a few months. If there is no improvement by age 3-9 months, surgical intervention may be considered.
• The differential diagnosis of abnormal arm movement includes such other potential complications of difficult shoulder delivery as fractures of the clavicle or humerus, Erb-Duchenne palsy, and cerebral injury from perinatal asphyxia.

• It involves the 5th, 6th, and sometimes 7th cervical nerves.
• Weakness of the deltoid and infraspinatus muscles (innervated by C5), biceps (innervated by C6), and wrist/finger extensors (innervated by C7) leads to predominance of the opposing muscles.
• The resulting appearance is the characteristic "waiter's tip" posture in this infant.
• Treatment involves gentle massage and physical therapy to prevent contractures.
• Prognosis depends on whether damage resulted from mild nerve stretching or compression as opposed to severe rupture or avulsion.
• Fortunately, up to 80% of patients have spontaneous recovery within 3 months. Surgical intervention can be considered for infants with no improvement by age 3-6 months but is not necessarily curative.
• Extended elbow
• Pronated forearm
• Flexed wrist & fingers
• Intact grasp reflex
• The affected arm may have decreased or absent Moro reflexes, and biceps reflex but grasp reflex should remain intact.

• results from compromised placental or pulmonary gas exchange.
• Severe hypoxia leads to poor perfusion and acidosis initially in peripheral tissues followed by the brain. This infant has neither systemic symptoms nor encephalopathy, making perinatal asphyxia unlikely.

• can result in abnormal arm movement presenting as hyperreflexia and hypertonia.
• This infant does not have hyperactive reflexes or excessive tone and his symptoms are isolated to the lower brachial plexus, making cerebral infarction unlikely.

• Maternal
• • Advanced age
• • Diabetes
• • Excessive weight gain during pregnancy or pre existing obesity
• • Multiparity
• • African-American or Hispanic ethnicity
• Fetal
• • Male sex
• • Post-term pregnancy

• can occur in any delivery but is more common in the setting of instrumental delivery.
• Subperiosteal blood doesn't cross the suture line.
• It usually resolves spontaneously without any sequelae.

• describes a fetus whose buttocks or feet are the presenting part in the birth canal.
• Risk factors for breech presentation include prematurity, multiparity, multiple gestation, uterine anomalies, fetal anomalies, and abnormal placentation.
• Breech presentation should be suspected if the fetal vertex (head) is palpated at the fundus or a fetal presenting part is not palpable on pelvic examination, and should always be confirmed by transabdominal ultrasound.
• Vaginal delivery of a singleton breech fetus is generally contraindicated due to a higher incidence of birth asphyxia and trauma compared to breech cesarean delivery.
• External cephalic version (ECV) involves manual conversion of the fetus to vertex presentation so that the patient can labor and potentially avoid cesarean delivery.
• A patient with a singleton breech fetus with no contraindications to vaginal delivery (eg, placenta previa, active herpes lesion, prior classical cesarean delivery) or ECV (eg, ruptured membranes, abnormal fetal heart tracing, oligohydramnios) should be offered ECV at <:37 weeks gestation.
• A history of a low transverse cesarean delivery is not a contraindication for ECV and does not decrease the likelihood that ECV will be successful.
• Cesarean delivery is indicated if the patient refuses ECV or if ECV fails. Cesarean delivery for persistent breech presentation is performed at 39 weeks gestation.

• Indications for cesarean delivery regardless of fetal lie (eg,failure to progress during labor, non-reassuring fetal status)
• Placental abnormalities (eg, placenta previa or abruption)
• Oligohydramnios
• Ruptured membranes
• Hyperextended fetal head
• Fetal or uterine anomaly
• Multiple gestation

• is used for the breech extraction of a malpresenting second twin.
• Breech delivery of a second twin has a lower risk of asphyxia than cesarean delivery and is not contraindicated.
• Because internal podalic version involves a vaginal breech delivery, it is contraindicated in singleton gestations

• No cervical change for >4 hours with adequate contractions
• No cervical change for >6 hours with inadequate contractions
• With an intrauterine pressure catheter in place, the peak contraction pressure minus the baseline intrauterine pressure (both in mm Hg) determines the number of Montevideo units (MVUs) for the contraction.
• Contractions generating more than or equal to 200 MVUs in a 10-minute interval are considered adequate

can be used to manage a protracted second stage of labor when the cervix is completely (10 cm) dilated.

• also known as intraamniotic infection (IAI).
• This complication is common In patients who have prolonged rupture of the membranes (ROM), which occurs before onset of labor and is defined as prolonged when rupture lasts >18 hours between the time of rupture and birth.
• However, IAI can also occur in patients with intact membranes. Infections are usually polymicrobial (vaginal or enteric flora) and ascend from the vagina, move up the cervical canal into the uterus, and spread through the amniotic fluid, amniotic membranes, placenta, and uterine decidua.
• Diagnosis is based on the presence of maternal fever and ~ 1 of the following: uterine tenderness, maternal or fetal tachycardia, malodorous amniotic fluid, or purulent vaginal discharge.
• Amniotic fluid does not need to be purulent or malodorous to make the IAI diagnosis.

• Chorioamnionitis should be treated with intravenous broad-spectrum antibiotics (eg, ampicillin, gentamicin, clindamycin) and delivery
• These interventions can reduce the risk of life-threatening neonatal infection and other complications.
• Therefore, this patient should receive oxytocin to accelerate labor.
• Cesarean delivery is reserved for standard obstetric indications (eg, fetal distress, breech presentation, multiple prior cesarean deliveries) and not for chorioamnionitis exclusively

• Maternal: Uterine atony, postpartum hemorrhage, endometritis
• Neonatal: Premature birth, infection, encephalopathy, cerebral palsy, death

• Trisomy 18 : MSAFP De beta-hCG De estriol De Inhibin A N
• Trisomy 21 : MSAFP De beta-hCG In estriol De Inhibin A In
• Neural tube or abdominal wall defect : MSAFP In beta-hCG N estriol N Inhibin A N

• is performed in the second trimester (15-20 weeks)
• consists of maternal serum a-fetal protein (MSAFP), beta -hCG, estriol, and inhibin A
• Women age greater than 35 are at increased risk of fetal aneuploidy.
• This patient's profile is most consistent with Down syndrome, which is caused by meiotic nondisjunction (trisomy 21 ) or Robertsonian translocation.
• Down syndrome has a profile of low MSAFP, low estriol, elevated beta -hCG, and increased inhibin A level.
• The quadruple screen detects -80% of fetuses with Down syndrome but has a false-positive rate of -5%.
• Patients with abnormal quadruple screening results can be offered cell-free fetal DNA testing, which measures circulating, free maternal and fetal DNA in maternal plasma and has a sensitivity and specificity of up to 99%.
• An ultrasound should be performed to evaluate for fetal anomalies.

• are associated with open neural tube defects and abdominal wall defects.
• Maternal folic acid deficiency is a risk factor for failure of primary neurulation, which can result in myelomeningocele.
• Gastroschisis is a paraumbilical bowel evisceration with no covering membrane
• omphalocele is a peritoneum-covered sac at the umbilicus.

• This patient's presentation of vaginal bleeding/spotting, lower abdominal pain, and adnexal tenderness is suspicious for an unruptured ectopic pregnancy.
• The majority of ectopic pregnancies occur in the fallopian tube.
• Most ectopic pregnancies are related to prior infection with chlamydia and/or gonorrhea causing tubal damage, and these infections are often asymptomatic (subclinical pelvic inflammatory disease).
• Other risk factors include prior tubal surgery, prior ectopic pregnancy, and in vitro fertilization.
• The diagnosis of ectopic pregnancy is made by a pregnancy test combined with transvaginal ultrasound (TVUS).
• Ectopic pregnancy is virtually ruled out if TVUS shows an intrauterine gestational sac in the setting of a positive p-hCG test.
• Conversely, ectopic pregnancy is confirmed if the gestational sac is seen at an ectopic site.
• TVUS is also useful in evaluating for rupture of the tube or other structures, which presents as free fluid (blood) in the pelvic cul-de-sac and/or abdomen.
• Transabdominal ultrasound cannot reliably visualize a gestational sac in early pregnancy.

Endocervical nucleic acid amplification tests are indicated in cases of suspected genital tract infection (eg, cervicitis, pelvic inflammatory disease).

• A gestational sac normally implants in the upper fundal region; implantation in the outer quadrants (cornual areas) is abnormal.
• specific risks for a cornual ectopic pregnancy include uterine anomalies (eg, bicornuate "heart-shaped" uterus) and in vitro fertilization.
• Due to the abundant blood supply in the cornual region from both uterine and ovarian vessels, rupture in this area may result in life threatening hemorrhage.
• lntraabdominal bleeding causes peritoneal inflammation and findings of diffuse abdominal pain.

• endometrial glands and stroma outside the uterus.
• Patients with endometriosis can have chronic pelvic pain and/or infertility, or be completely asymptomatic and diagnosed during an unrelated surgical procedure.
• The amount of endometrial implants does not correlate with symptom intensity.
• Intraoperative findings can include adhesions (eg, scar tissue). powder-burn lesions, flesh-colored or dark nodules, and collections of "chocolate" fluid (endometrioma).
• Biopsy confirms the diagnosis.
• When endometriosis is incidentally found in an asymptomatic patient, treatment is not indicated.
• It is appropriate to observe for the development of future symptoms and initiate treatment as needed.
• Conservative treatment of symptomatic endometriosis includes nonsteroidal anti-inflammatory drugs, oral contraceptives, or a progesterone intrauterine device (IUD).
• Copper IUD has no effect on endometriosis. Leuprolide, a gonadotropin-releasing hormone agonist, treats symptomatic endometriosis by suppressing estrogen stimulation of the ectopic endometrial glands. This medication is poorly tolerated due to menopausal symptoms.
• Definitive treatment consists of surgical resection and hysterectomy with oophorectomy

• Chronic hypertension AND 1 of the following:
• • New-onset proteinuria or worsening of existing proteinuria at ≥20 weeks gestation
• superimposed
• • Sudden worsening of hypertension
• • Signs of end-organ damage

• is defined as a systolic blood pressure ~140 mm Hg and/or a diastolic blood pressure ~90 mm Hg.
• Chronic hypertension predates pregnancy but can be diagnosed any time before 20 weeks gestation.
• To make a diagnosis of chronic hypertension during pregnancy, blood pressure should be elevated at 2 measurements taken ~4 hours apart.

• Superimposed preeclampsia
• Maternal
• • Postpartum hemorrhage
• • Gestational diabetes
• • Abruptio placentae
• • Cesarean delivery
• Fetal
• Fetal growth restriction
• • Perinatal mortality
• • Preterm delivery
• • Oligohydramnios

• occurs when a provider refuses to provide care due to moral conflict.
• Providers who cannot, in good conscience, provide treatment that a patient requests, are obligated to refer the patient in a timely fashion to another provider who can.
• Provider conscience does not take precedence over other ethical principles (eg, autonomy, justice, beneficence, nonmaleficence).

• • Amniotic fluid leak
• • Cervical incompetence
• • Multiple gestation
• • Placenta abruption or previa
• • Premature labor
• • Preeclampsia/gestational hypertension
• • Severe heart or lung disease

• • Contact sports (eg, basketball, ice hockey, soccer)
• • High fall risk (eg, downhill skiing, gymnastics, horseback riding)
• • Scuba diving
• • Hot yoga
• 20-30 minutes of moderate-intensity exercise on most or all days of the week is recommended. Patients who are exercising at moderate intensity should be able to engage in normal conversation during the activity.

avoidance of dehydration, which can cause contractions, and avoidance of prolonged periods of lying supine, which are associated with decreased venous return and placental perfusion.

• Fetal growth restriction (FGR) is an ultrasound estimated fetal weight <10th percentile for gestational age.
• F.GR can be symmetric or asymmetric.
• Symmetric FGR is a global, proportionate growth lag that affects fetal organs uniformly and begins during the first trimester.
• Causes of symmetric FGR include fetal chromosomal anomalies and first trimester/congenital infection (eg, toxoplasmosis, cytomegalovirus).
• In asymmetric FGR, abdominal growth restriction is more pronounced than growth restriction of the head as a result of fetal adaptation to chronic placental insufficiency.
• Maternal vasculopathy (eg, hypertension, pregestational diabetes) can cause inadequate utero-placental perfusion and chronic fetal hypoxia. In response, fetal redistribution of blood flow to vital organs (eg, brain, heart, placenta) occurs at the expense of less vital organs (eg, abdominal viscera), resulting in "head-sparing" FGR

• In normal fetal development, the fetal abdomen grows exponentially during the second and third trimester
• Insults (eg, hypoxemia) at this stage of pregnancy cause fetal blood flow to be redistributed to the vital organs (eg, brain) and away from the abdomen, resulting in an asymmetric, or " head-sparing," growth pattern

First trimester congenital infection (eg, malaria, toxoplasmosis, syphilis, cytomegalovirus, rubella, varicella) results in symmetric FGR.

• depend on prepregnancy BMI.
• Inadequate or excessive weight gain is associated with an increased risk for fetal and maternal complications. Underweight (BMI <18.5 kg/m2) patients are advised to gain 12.7-18. 1 kg (28-40 lb) during pregnancy.
• Pregnant patients who are underweight or do not gain an appropriate amount of weight during pregnancy are at increased risk for fetal growth restriction and preterm delivery.

• evaluates for fetal hypoxia.
• It is performed in pregnancies with a high risk of fetal demise due to maternal (eg, hypertension, diabetes mellitus) or fetal (eg, post-term pregnancy, growth restriction) conditions.
• The most common surveillance modality is the biophysical profile (BPP), which includes a nonstress test (NST) and an ultrasound evaluation of amniotic fluid, fetal tone, movement, and breathing movement.
• Each parameter is assigned a score of 0 or 2 and summed for a total of 0-10.

should demonstrate ~2 heart rate accelerations that are <:15 beats/min above baseline and 2:15 seconds long within a 20-minute period; however, the test can last up to 40 minutes to account for a 20-minute fetal sleep cycle. A BPP of 0-4/10 indicates fetal hypoxia and necessitate.s urgent delivery. A BPP of 6/10 is equivocal and should be repeated in 24 hours (Choice F). A normal BPP score is 8- 10/10 and rules out fetal hypoxia.