Complications of the Antepartal Period

Def: sound waves having a frequency >20,000 Hz

2 types: TransVaginal ultrasound & TransAbdominal ultrasound

• Used primarily in 1st trimester
• -Evaluates pelvic anatomy
• -Assess developing embryo/fetus for # and size
• -Locate the placenta
• -Screen for fetal & placental anomalies
• -Establish gestational age

• *Do not need a full bladder
• *Place in lithotomy pos. (stirrups)
• *Latex covering

• Fetal viability
• Number, position, gestational age
• Fetal growth patter
• Anomaly scan
• Amniotic fluid volume
• Placental location and maturity
• Assessment of fetal well-being
• *Gender is not 100%
• *Full bladder can give a better pic

• Definition: Biopsy of fetal portion of placenta for fetal genetic studies
• Indications: Age >35, frequent SAB, chromosomal anomalies/defects
• Advantages: Done at 10-12 weeks, results in 2 weeks

• Vaginal spotting/bleeding
• Spontaneous abortion
• Rupture of membranes
• Infection/chorioamnionitis
• Possible limb anomalies (missing!)

*Pelvic rest afterwards (no SEX)

• Definition: measures MSAFP, HCG, estradiol, diameric Inhibin-A
• Findings:
• -Increased levels of MSAFP: neural tube defects, multiples, dates wrong
• -Decreased levels of MSAFP and Increased HcG: Downs syndrome (Trisomy 21)
• -Decreased MSAFP, estriol, & HcG: Trisomy 18

*Not very accurate/specific, done around weeks 16-18

• Done at 15-20 weeks
• Results in 2 weeks
• Prenatal diagnosis

• Maternal age >35
• Parent or previous child with chromosomal abnormalities
• Family history of NTD's (Neural tube defects)
• Fetal abnormalities per Ultrasound
• Women with Xlinked chromosomal disorder
• Fetal hemolytic disease
• Fetal LUNG maturity
• Evaluate alpha fetoprotein

*Might do before c-section to evaluate lungs of fetus

• OCCURS IN <1%
• Pregnancy loss=0.5%
• Maternal hemorrhage
• Infection
• Preterm labor
• Placental abruption
• Damage to intestine or bladder
• Amniotic fluid leakage or embolism
• Risk to fetus: death, hemorrhage, infection, direct injury

*If RH-, needs Rogam for this procedure

• Lecithin to sphingomyelin (L/S) ratio
• Phosphatidylglycerol (PG) level [Both done for lung maturity]
• Shake test
• Karyotype
• RH isoimmunization status
• Alpha fetoprotein levels
• Creatinine levels

*Position in left lateral tilt to prevent fainting

• Definition: non-invasive dynamic assessment of a fetus that is based on acute and chronic markers of fetal disease.
• Assess:
• Fetal tone, fetal movements, fetal breathing movements, amniotic fluid volume (AFI=amniotic fluid index), Non stress test (NST)-
• Scoring: 8-10-low risk for perinatal asphyxia, 4-6: possibly abnormal-repeat within 24 hrs, <6 & low amniotic fluid=delivery indicated and high risk for perinatal asphyxia.

*Accurate indicator of impending fetal death!!!!!!!

• Advantages: non invasive, relatively inexpensive, no side effects, immediate results, a GOOD indicator of fetal well-being, Can be done regularly
• Disadvantages: High # of false-positive results (fetal sleep, medications, fetal immaturity); NOT a good predictor of poor fetal outcomes
• Indications: PIH (pregnancy induced hypertension), diabetes, placenta previa/abruption, postmaturity, decreased fetal activity.

Reactive NST: 2 or more FHR accelerations of 15bpm lasting at least 15 seconds over a 20 minute period

Non reassuring (non reactive) NST: If these criteria are not met within 40 minutes

• Indications: Fetus at risk-IUGR, postdates, DM, non reactive NST, BPP <6
• Contraindications: 3rd trimester bleeding, risk of PTL(preterm labor), PROM, multiple pregnancy, placenta previa, incompetent cervix
• Test procedure: could induce labor!

Reassuring (NEGATIVE): no late decelerations occur with 3 contractions in 10 minutes

Non reassuring (POSITIVE): late decels with at least 2 of the 3 contractions

Suspicious (EQUIVOCAL): late decels with 1 of 3 contractions OR there are contractions q2 minutes in 10 min.

• Fetal distress
• INDUCED LABOR
• hyperstimulation of uterus

• Used in all high risk pregnancies >28 weeks. Measured by date, hour of day and # of movements
• <10 movements in 2 hours or any change=emergency...CALL 911

• Turning the baby from a breech position to "head down" position.
• Can cause fetal distress
• Do ultrasound, IV-medications (Trabutaline-relaxes uterus but INCREASES HR-jitttteryyyy)

• Maternal problems: uterine anomalies, PIH or 3rd trimester bleeding
• Pregnancy problems: ROM, oligohydramnios, polyhydramnios or placenta previa
• Previous c-section or other uterine surgery
• Multiples
• Non reassuring FHR
• Fetal abnormalities (IUGR, nuchal cord)

*Can hear the FHR right about the umbilicus when baby is breech

• 1. Age: <16 or >35
• 2. Parity: >8 years since last pregnancy, <3 months since last birth, >5 previous births
• 3. Poor OB history: 2 or more previous preterm infants, 2 or more consecutive miscarriages, 1 or more stillbirths, 1 or more infants with gross anomalies, birth defects, history of dystocia (difficult labor), poor self care practices

• Definition: impaired cardiac function
• Pregnancy outcome: depends on degree of cardiac compromise
• Greatest risk: cardiac output increases 30-50% by midpregnancy 28-32 weeks

• Class I: uncompromised
• Class II: slightly compromised
• Class III: Markedly compromised
• Class IV: inability to perform any physical activity without discomfort
• *Class III and IV=almost complete bed rest!!!

• Congestive Heart Failure: most common complication of HD during pregnancy
• Bacterial Endocarditis-infections!
• Decreased Placental Function: IUGR, fetal distress, preterm delivery

Close medical supervision: rest-avoid exertion, limited sodium intake, prophylactic antibiotics (PCN)-for any invasive procedures including birth!

Medications: Digitalis (Increases contractility of heart, don't give when HR is <60), Heparin (if anticoagulant indicated-doesn't cross placenta), furosemide (lasix)

• Dyspnea on exertion or at rest
• Increasing fatigue
• Tachycardia or irregular pulse
• Diastolic murmur at heart apex
• Moist cough with/without hemoptysis
• Palpitations
• edema(pedal, pitting, generalized, & pulmonary)
• Nail bed and circumoral cyanosis
• rales at lung bases

• Definition: relative or complete lack of insulin secretion AND/OR increased resistance to insulin
• Early pregnancy: anabolic state-glucose use & glycogen storage increase by mother and fetus
• 2nd half of pregnancy: increased insulin resisitance d/t increased human placental lactogen (HPL) which increases circulating glucose for fetal use & increases demand on maternal pancreas to produce more insulin.
• Fetus produces own insulin but obtains glucose from mother across placenta; the amount of glucose in maternal circulation stimulates the fetal pancreas to produce more insulin

• Gestational diabetes
• Preconceptional diabetes:
• *without complications: Type 1: insulin dependent; Type 2: non insulin dependent
• *With complications: advanced retinopathy, nephropathy, autonomic neuropathy, coronary artery disease
• *Significant problems for placenta bloodflow*

• Definition:
• *any degree of glucose intolerance that has its onset or its first diagnosis in pregnancy

1st trimester: Decrease insulin needs, hyperglycemic=teratogenic

2nd/3rd trimesters: Increase insulin needs

After delivery: Decreased insulin needs

• Family history of DM
• HIstory of previous stillbirth or SAB's
• Previous baby with congenital anomalies
• Previous baby >9lbs
• Maternal obesity
• recurrent yeast infections
• recurrent glycosuria
• Multiparity, hydramnios (too much fluid), and HTN

• Fasting blood glucose at 28 weeks gestation
• Results at 1 hour
• -normal=<130 mg/dl
• -If >130, do 3 hr 100g GTT fasting
• Diagnose Gestational DM if 2 or more elevated levels

• Effects are r/t the degree of control of blood glucose levels b/t 70-120 mg/dl & degree of vascular involvement
• Long term glucose control: glycosylated hemoglobin (HbA1C)-measures % of Hbg with glucose bound to it, levels depend on amount of glucose available during the red blood cell's 120 day lifespan

*In labor, try to keep blood sugar <100

• 1. Maternal hydramnios (Increase in amniotic fluid)
• 2. Pregnancy induced hypertenstion (PIH)
• 3. infection
• 4. Maternal Hypoglycemia
• 5. Spontaneous abortion
• 6. Preterm labor
• 7. Intrauterine growth restriction (IUGR)= decreases blood supply which increases risk for stillbirth
• 8. Worsening retinopathy

*increase in fetal urine output=increase volume of amniotic fluid in mothers!!!! NOT GOOD

• Increase incidence of stillbirth (usually after 36 weeks)
• fetal congenital anomalies (cardiac, CNS)
• Macrosomia (large body)
• hypoglycemia
• hyperbilirubinemia
• Delayed fetal lung maturity=RDS (Respiratory distress syndrome)-bc of increase fetal insulin
• Fetal asphyxia and death

• Understanding of disease process (s/s of hypoglycemia, ketoacidosis)
• Diet/exercise
• Medications-insulin use
• Home monitor glucose levels/urine for ketones
• Clinic appts q1-2 weeks
• Fetal testing

• Maternal serum alpha fetoprotein @ 16-18 weeks
• Ultrasound (anomalies, amniotic fluid volume, size)
• Non stress test-NST-weekly from 28-32 weeks
• Fetal Kick counts
• Biophysical profile (BPP)
• Amniocentesis for lung maturity
• Induction of labor

• risks to self and newborn: Increase c-section, longer hospitalization, NICU for infant, risk of stillbirth
• Postnatal DM: 35-50% of women with gestational DM develop DM within 15 yrs
• Should be tested at 6 weekds pp with GTT

• Autosomal dominant blood disorder: more common in women of European descent
• Causes activated protein C resistance resulting in venous thromboembolic events (VTE)!!
• Pregnancy-associated with 5-6x increased risk of VTE
• Heterozygous (1 copy)=5-10x increased risk for VTE
• Homozygous (have 50-100x risk)
• complications: HTN, placental abruption, SAB, intrauterine fetal demise, IUGR
• Prophylaxis: heparin therapy

• def: premature expulsion of fetus <20 weeks or <500 grams
• Increased risks: >35 years old, systemic diseases, hx of >3 SAB's, tobacco and alcohol use
• CAUSES:
• -Fetal factors: defective embryological development, faulty ovum implantation
• -Placental factors: premature seperation of normally implanted placenta, abnormal implantation, abnormal platelet function
• -Maternal factors: infection, sever malnutrition, reproductive system abnormalities, endocrine problems, trauma, drug ingestion

• Vaginal bleeding/spotting in 1st 20 weeks
• May be lower abdominal cramping/dull backaches
• ROM: tissue or clot-like material from vagina
• May have thinning cervix, Increased cervical dilation
• Fever
• malaise, s/s of infection
• grief reaction

Complete: all of fetus and placental material has been expelled from uterus before 20 weeks gestation

Missed: death of fetus with retained products of conception (POC)

Habitual: >3 or more consecutive pregnancies

Septic: SAB or TAB complicated by a pelvic infection, usually begins as endometritis and may spread, primary cause of maternal mortality in developing countries

Diagnosis: falling HcG levels=death of fetus, by ultrasound

Management: pelvic rest (nothing in VAG), CBCs, monitor VS, assess bleeding/cramping/pain, prepare for surgery prn, medical management: prostaglandins-misoprostel, Rhogam if RH negative

• T-Toxoplasmosis
• O-Other: gonorrhea, syphilis, varicella, hep B, GBS, HIV
• R-rubella
• C-cytomegalovirus (CMV)
• H-herpes

• pregnancy related or physiologic (UTI)
• exposure to teratogenic infections
• STIs
• Children at daycare (cmv)
• cat litter exposure (toxo)

Diagnostic tests: Screen throughout pregnancy-torch titer, IGM-recent infection (igM doesnt cross placenta) so IgM in baby=strongly suggestive of exposure, IgG-past.

S/S: asymptomatic or vague, nospecific s/s (fatigue, enlarged lymph nodes, fever, mono-like s/s, genital infection, cervical inflammation, rash)

• Single celled parasite called toxoplasma gondii
• Mostly asymptomatic
• Transmission: Transplacental, ingestion of cat feces (litter box, gardening), eating/contact with contam. raw or partly cooked meat esp pork lamb venison, unpastuerized goat milk, drinking contaminated water, receiving infected organ transplant or blood transfusion (rare)

• S/S: flu-like, swollen lymph nodes, incubation periods is 10 days
• With active maternal infection is 40% risk fetus will get infection
• Treatment: erythromycin, sulfadiazine
• Fetal effects: SAB, fetal hydrocephalus, blindness, deafness, mental retardation

• Can be transmitted to newborn during birth!
• Pregnancy/fetal effects: SAB, preterm delivery, PROM, opthalmia neonatorum (blindness)

• Transmitted to newborn during birth
• Pregnancy/fetal effects: PROM, preterm labor, low fetal birth weight, fetal conjunctivitis, pneumonia, opthalmia neonatorum, chronic otitis media

• Increase risk varicella pneumonia if acquired during pregnancy
• Fetal complications: risk of congenital varicella syndrome (1st trimester)-skin scarring, small head, eye problems, LBW, small limbs, retardation. If contracted within 5 days before and 2 days after delivery: newborn at risk for disseminated varicella infection=newborn mortality

Treatment: antiviral meds: acyclovir and varicella zoster immunoglobulin (VZIG) for both women and newborn

• Treponema pallidum
• Transmitted: either in utero or at delivery
• If mother is treated before 18th week, usually not transmitted to fetus
• Preg/fetal effects: SAB, neonatal infection, fetal death, preterm delivery, neonatal CNS, dental, corneal disorders

• Group B streptococcus (GBS): leading cause of neonatal sepsis. 40-70% pass bacteria to newborns during birth, only 1-2% actually get the infection
• Recommended screening: vaginal swab at 36 weeks; Rx with PCN in labor to decrease rate of transmission
• Preg/fetal effects: PTL, PROM, chorioamnionitis, UTI, PP sepsis in mom, stillbirth
• Neonatal effects: sepsis, pneumonia, RDS, apnea, shock; meningitis

• If acute infection in 1st trimester: 10% transmission, if in 3rd trim: 80-90% transmission!
• If + or unknown maternal hepatitis status: newborn needs hepB vaccine and hepB immunoglobulin (HBIG) within 12 hours of birth
• Preg/newborn effects: PTL, LBW, fetal death

• (Herpes virus family)
• Virus most frequently transmitted during pregnancy and most likely to cause neonatal disease
• Maternal S/S: often asymptomatic, flu-like
• Diagnosis: viral culture-CMV antibodies=recent infection
• Transmission: respiratory droplet (hospitals, daycares)
• No effective prevention or treatment

Preg/fetal effects: fetal/newborn death, retardation, deafness, hydrocephalus, microcephaly, learning disabilities. 90% of infected fetuses are asymptomatic at birth: develop s/s within 1 year!

• Fetal/newborn HIV/AIDS:
• Vertical transmission=infection via placenta (increased risk with inflammation of fetal membranes, maternal drug use, prolonged ROM)
• Also transmitted via contact at birth, breast milk

• 3 part ZDV (zidovudine, AZT, or retrovir)
• starting at 14-34 weekds
• reduces risk of transmission of fetus by 70%
• IV ZDV in labor
• Newborn: ZDV liquid form x6weeks

• Def: german measles/3day measles
• S/S: fever, rash, cold sxs, mild lymphedema
• Transmission: by respiratory droplets: highly infectious
• Risk factors: contact with young children
• No treatment
• No immunization during pregnancy: need to postpartum-avoid pregancy for 3 months!

• Diagnosis: screening early, IgG antibodies (titir of 1:10 or >=immune to rubella, titer of 1:8 or <=minimall/no immunity)
• Fetal/neonatal effects of 1st trimester:
• -in 1st 8 weeks, 80% with birth defects
• -SAB, fetal blindness, hearing loss, heart disease, retardation, death
• Fetal/neonatal effects of 2nd trimester:
• -deafness, congenital cataracts, heart disease, liver impairment with jaundice, blood formation disorders (anemia thrombocytopenia)

• Initial outbreak: 2-7 days after exposure
• Antibody test: 3-4 months after initial exposure
• Antivirals used during 3rd trimester to decrease risk of transmission (Valacyclovir or Valtrex)
• C-section recommended if visable lesions
• Fetal effects: SAB, PTL, IUGR, neonatal infections of skin, eyes, nose, liver, CNS, seizure, jaundice

• common "fifth disease": mild rash in children-lasts 7 days and provides lasting immunity "slapped cheek", rash on face trunk and limbs
• Adults with no immunity: may develop rash/joint pain for a week to months
• More common in 1st half of pregnancy, severe fetal anemia, SAB

• Pregnant women 20x more likely to contract than other adults
• Mild flu-like s/s-stiff neck, confusion, loss of balance, convulsions
• DX: blood test
• Rx: antibiotics
• Fetal effects: SAB, death, PTL, infection
• PREVENTION: do not eat hot dogs/meat unless reheated until steaming hot, soft cheeses, refridgerated smoked seafood, do not drink raw unpasteurized milk/cider

• Contractions between 20-37 weeks
• Causes:
• -maternal:CV and renal disease, DM, PIH infections, abdominal surgery, incompetent cervix, PROM.
• -fetal: infection, hydramnios, multiple pregnancy, death

• <18 or >35
• Hx of preterm labor
• Multiple pregnancy
• Hydramnios
• smoking
• poor hygeine/nutrition
• infection
• uterine fybroids
• sexual acitivity
• drug use, dehydration

• Rhythmic uterine contractions
• Cervical dilation and effacement
• Possibly ROM
• Expulsion of musuc plug, bloody show
• backache
• feeling that "something is not right"
• pelvic pressure
• increase in vag discharge, abd cramping
• Fetal fibronectin (fFN) not normally in fetal membranes and decidua: +fFN b/t 18-36 weeks, -fFN: very low risk of birth within 7 days

*If >4 contractions in 1 hr=calll!!!!!!

• Teaching of s/s of PTL & actions to be taken
• Medical: assess s/s labor, cervical dilation and effacement, status of membranes, bloody show, sterile spectrum exam for amniotic fluid
• -vag cultures r/o infection
• -monitor uterine activity and fetal status
• -VS, bedrest, side lying position

• Tocolytic meds:
• -Ritodrine IV or PO
• -Terbutaline sulfate IV, SQ, PO: beta adrenergic agonist, side effects: increase HR, decrease hyperglycemia
• -Magnesium sulfate IV: cns depressent, side effects: warm, affects calcium, decrease respirations
• -Nifedipine PO, SL: calcium channel blocker
• -Indomethacin PO: prostaglandin synthetase inhibitors (stopped using!?)
• Steroid therapY: stimulates lung maturity; 24-34 weeks, 24-48 hrs before delivery (betamethasone)
• Antibiotics

• Def: HTN disorder of pregnancy developing after 20 wks
• -gestational htn; no proteinuria/edema
• -preeclampsia: htn >140/90 or increase >30mm hg systolic or >15mm hg , proteinuria, edema
• -eclampsia: preeclampsia progressed to tonic-clonic seizures

• Family hx of HTN or previous hx of PIH
• poor prenatal care
• weight extremes and age extremes
• primigravida
• multiples
• preexisting DM, HTN or renal disease
• hydatiform mole
• RH incompatibility
• Infection, exposure to toxins

• Unknown cause
• Loss of resistance to angiotensin II-decrease prostacyclin (a vasodilator prostaglandin) which increases effect of thromboboxane (vasoconstricting prostaglandin)
• Loss of normal vasodilation of uterine arterioles +maternal vasospasm +increase peripheral vascular resistance=decrease in placental perfusion
• Decrease in renal perfusion=decrease urine output, increase serum creatine, BUN, uric acid, resulting in sodium retention (edema)

• Sodium retention=increase in extracellular volume, increase sensitivity to angiotensin II, edema
• Stretching of glomerular endothelial walls-escape of protein molecules=decrease serum albumin and proteinuria
• Decrease serum albumin concentration=decrease plasma colloid osmotic pressure=edema
• Decrease intravascular volume=Increase blood viscosity and increase hct

• Increase intracellular sodium and decrease intracellular potassium levels=hyperreflexia
• Cerebral vasospasm=headaches
• Cerebral edema & vasoconstriction=seizures

• BP 140/90 or increase systolic BP of 30mm hg/15 mm diastolic twice, 6 hrs apart.
• Proteinuria-trace to 1+,2+
• Mild-mod pretibial edema with weight gain of 5 lb/week

• BP> 160/110
• Proteinuria 3+, 4+ or >4-5 grams in 24 hrs
• Sudden large weight gain, facial edema, pitting pretibial edema
• CNS irritability (headache, hyperreflexia, retinal edema, dyspnea, epigastric pain, N+V)
• Labs: Increase hct, liver enzymes (ALT, AST), BUN, creatinine, uric acid

• BP >160/110
• Grand mal seizures, coma, stroke, fetal and maternal death
• -cerebral hemorrhage, pulm edema, CHF

• Side lying bedrest
• quiet, calm environment
• high protein diet, no salt restriction
• Monitor VS, edema, lung sounds, DTR (deep tendon reflexes), renal function (I&O), fetal status
• emergency meds/equip at bedside

• Magnesium Sulfate:
• Therapeutic blood levels: 5-8mg/dl
• Assess urine output
• Assess for TOXICITY!!! (depressed DTRs, R<12-14/min, flaccid muscles, over-sedation, confusion
• Extreme thirst
• Hypotension, circulatory collapse
• ANTIDOTE TO magnesium sulfate: calcium gluconate!

*Risk for postpartum hemorrhage...boggy uterus*

• Def: immune reaction by mother's blood against the blood group factor on fetus' red blood cells
• ABO: mother O Fetus A,B
• -20% of pregnancies
• RH

**NOT normal for those (+'s) to get into mother's circulation

After delivery, more is leaked into mother

Antibodies starting to form after pregnancy=NOT GOOD

Antibodies are trying to attack new fetus=not good! TREAT WITH RHOGAM/prevent. works up to 72 hours

• Hemolysis of fetal rbc-immature rbc production (erthryoblastosis fetalis)
• Jaundice, marked fetal edema, CHF
• Kernicterus, permanent neuro damage

• Blood group testing
• Antibody screening (indirect Coombs test)
• Direct coombs test on infant after birth

Unsensitized mother: Rhogam at 28 weeks and within 72 hrs of birth. Rhogam is an anti RH gamma globulin that prevents production of maternal antibodies to fetal cells.

Sensitized mother (isoimmunization): close fetal monitoring, including amniocentesis, percutaneous umbilical cord blood sampling, indirect coombs test

• Def: persistant servere vomiting beyond 1st trimester, resulting in electrolyte, metabolic & nutritional imbalances.
• Causes: ?Increase in HcG, ?Helobacter pylori. Increase incidence with primigravidass, multifetals, & women with psych disorders

• S/S: electrolyte imbalance/acidosis (ketosis, confusion, drowsiness, muscle weakness)
• Management: Hospitalization, IV, TPN prn, medications (zofran)
• Complications: dehydration, electrolyte imbalance, severe weight loss, metabolic alkalosis [LAB finding: hypokalemia!]

• Def: developmental placenta anomaly that converts chorionic villi into a mass of clear vesicles.
• Causes: Unknown patho, neoplastic process, more common in Asians!
• S/S: Increase uterine size, excess N+V, intermittent bright red/brownish vag bleeding by 12 weeks, very high hCG
• Diagnosis: ultrasound, s/s of hyperthyroidism (weight loss, bulge eyes, hair falling out)
• Management: D&E/hysterectomy, pelvic exam and HCG monitoring for 1 year bc malignant disease can develop, avoid pregnancy for 1 year!, chemo..

• Def: embryo implants anywhere except uterine endometrium
• Causes: conditions that alter ovum passage through tubes (Decrease incidence with combined ocps, increased in last 30 years bc of IUD's, STIs and surgery's)

**It can implant anywhere: tube, in the muscle, cervix, ovary, ABDOMEN!!

• Risk factors: Scarring, adhesions (use of IUD, tubal surgery), previous ectopic pregnancy, tubal ligation
• S/S: Last menstraul period consistant with possible pregnancy, may be asymptomatic or dizziness, sharp abd pain(often unilateral), referred shoulder pain, vag bleeding, adnexal mass tenderness (pain from "tube"), s/s of shock

• Diagnosis: Beta HcG confirms pregnancy; vaginal u/s after 4-5 wks confirms extrauterine pregnancy, pelvic exam.
• Management: Monitor VS, bleeding, pain; prepare for surgery-lapratomy with ruptured tube, laparoscopy without.
• Medical management: methotrexate (only if caught early enough) 4-5wks, Watch for Cullen's sign: blood in perineum (blueness around umbilicus)

• 
• Def: painless effacement and dilation of cervix usually in 2nd trimester, often diagnosed by repetitive 2nd trimester losses or by transvag ultrasound
• Causes: many factors; abnormal cervix, biochemical alterations, uterine malformations (bicornuate uterus, pic above).
• Management: elective cerclage at 14-16 wks, suture and tie uterus. Education r/t s/s of preterm labor, bedrest/trendelenberg position (puts pressure off cervix), hospitlization, remove suture with s/s of labor

• Def: Hgb<10 g/dL ; Hct<35% during 2/3 trimester, common
• Causes: nutritional deficiences, acute and chronic blood loss
• Risk factors: previous preprego anemia, poor nutrition, multiples, smoking, alcohol

• S/S: excess fatigue, HA, tachy, brittle fingernails, smooth red shiny tongue
• Management: instruct about sources of iron and supplementation. iron best absorbed on empty stomach, high fluids/fiber to avoid constipation, vit C increases absorption, expect black stools, milk inhibits absorption
• Complications: PTL or birth, poor wound healing, infection, cardiac failure in labor, Increase risk for postpartum hemorrhage

• Def: autosomal recessive disorder-adult Hb A is abnormally formed hemoglobin S. Hgb S causes rbcs to be crescent shaped which clogs capillaries in spleen, bone marrow and placenta
• risk factors: Africans, central america, caribbean...
• S/S: Hx of frequent illness, acute reoccuring episodes of tissue, abd, and joint pain, appears unnourished, long thin extremities. *Antibiotics to prevent infections**
• Maternal risk: vaso-occlusive crisis-infection. Fetal risk: IUGR, prematurity, death.
• Manangement: Increase hydration, avoid infections, seek immediate treatment

• Placenta previa:
• -low lying: placenta is close to opening of uterus..watch for bleeding!
• -Partial: placenta is partially covering opening
• -Complete: entire placenta is blocking baby=c-section!

• Multiparity
• Increase maternal age
• Previous c-section or uterine incisions
• Prior placenta previa
• closely spaced pregnancies
• uterine tumors
• previous induced abortions

• Bright red, PAINLESS BLEEDING, after 20th week of pregnany
• Abd soft, non tender; uterus relaxes b/t contractions
• FHR stable, fetal presenting part unengaged
• Diagnose: ultrasound

• NO CERVICAL EXAM with any prego woman with vaginal bleeding!!-you can stick fingers thru placenta..hemorrhage!
• Monitor VS/bleeding; observe for shock
• Monitor FHR
• Blood work, IV, strict bed rest
• If preterm..giver betamethasone so lungs develop
• Complications: hemorrhage, fetal distress, IUGR, C/S, preterm birth, PROM

• Placenta accreta: placenta attaches too deep in uterine wall but does not penetrate the uterine muscles.
• Increta: placenta implants into uterine muscle.
• Percreta: placenta penetrates thru entire uterine wall and attaches to another organ, such as bladder!!

• Premature seperation of a normally implanted placenta during the 2nd half of pregnancy
• Medical emergency=risk of maternal hemorrhage and fetal death, 10-30% develop clotting defects (DIC)

• Maternal HYPERTENSION (44%)
• Cocaine abuse
• Abdominal trauma

• Concealed or external dark red bleeding
• Uterus firm-board-like, uterine outline possibly enlarging or changing shape
• SEVERE CONTINUOUS PAIN
• FHR present or fetal distress
• Couvelaire uterus (blood gets pushed back into uterus...pp hemorrhage!)

• Diagnosis: U/S, CBC, coagulation profile
• Complications: severe hemorrhage, shock, renal failure, DIC, maternal and fetal death
• Management: monitor VS, bleeding, FHR activity, degree of abd rigidity, signs of shock, NO VAG EXAM or anything that would stimulate uterine activity, abd girth

• H-hemolysis
• E-elevated
• L-liver enzymes
• L-low
• P-platelets

S/S: epigastric or RUQ pain, N+V, flu-like s/s, history of malaise for past few days, sig weight gain with edema, HTN, increase D Dimer test (used to r/o throbotic disease)

• causes/risk factors: HTN/preeclampsia, thrombocytopenia, obesity, multiparity, hx of high risk pregnancies
• Management: bedrest, monitor kidney/liver function, platelets (most reliable indicator of syndrome), evaluation of uteroplacental insufficiency: kick counts, NST, BPP, mag sulf infusion, prompt delivery of infant >32 wks
• complications: IUGR, RDS, perinatal mortality worse than maternal, Increase risk acute renal failure, pulm edema,hepatic rupture, increase risk placenta abruption and DIC

• Def: inflammation of upper urinary tract + urine culture
• causes: #1 risk factor-hx of lower UTI; also kidney stones
• s/s: severe colicky pain, N+V, dehydration, dysuria, freq/urgency, suprapubic discomfort, flank pain, fever, chills
• Management: Hydration, in pregnancy-IV antibiotics followed by orals, bedrest, teaching of s/s of UTI
• Complications: IUGR, preterm L&D

• Def: >2000cc of amniotic fluid, chronic or acute. exact cuase unknown
• Associated factors: DM, congenital anomalies, RH isoimmunization, multiples
• S/S: abd discomfort, dyspnea, orthopnea, edema of legs &abd, uterine size>expected, fetal outline diff. to palpate and hearing FHR

• Management: High protein, low salt diet, mild sedation, amniocentesis to remove excess fluid, induction of labor if fetus is mature.
• Complications: umbilical cord prolapse +/or placenta abruption with ROM; Increase incidence malpresentations, increase perinatal mortality from fetal malformations, preterm births, uterine dysfunction in labor, Increase pp hemorrhage

• Def: severely reduced amniotic fluid; occurs with PROM; rare. Fetus easily palpable and outlined, ballotable
• Associated factors: postmature infants, IUGR, renal anomalies, dysfunctional slow labor,diagnosed by u/s.

• Management: US, NST, BPP, kick counts, hydration, side lying bedrest, good nutrition, amnioinfusion (for variable decels...makes cord float)
• Complications: prolonged dysfunctional labor, renal anomalies, wrinkled leathery skin, increase skeletal deformities, fetal distress in labor d/t cord compression

• Def: premature rupture of membranes prior to labor
• -there is also PPROM (preterm premature rupture of membranes) prior to 37wks
• -also prolonged rupture of membranes, >12hrs before birth.

• Unknown, but associated with:
• -previous hx of PROM
• -multiple pregnancy
• -malpresentation
• -hydramnios
• UTI, infections

• S/S: watery, clear, or meconium stained amniotic fluid leaking. Foul-smelling vag discharge assoc with uterine tenderness (infection!!)
• Diagnosis: Sterile spectrum exam-+ferning+nitrazine paper+amnisure.
• Complications: risk of RDS, fetal sepsis malpresentation, umbilical cord prolapse, increase risk for placenta abruption

• Assess for amniotic fluid
• Assess FHR
• Temp q2 hours
• avoid cervical exams
• monitor uterine activity
• Assess s/s of infection!! =fetal tachycardia
• Bedrest, antibiotics, betamethasone for fetal lung maturity if <37wks

• -Ages 21-24 most common-
• Effects: IUGR, prematurity, death, seizures, SAB, abruption, fetal alcohol syndrome
• Signs of maternal addiction: constricted pupils, dental acries, mood swings, rhinitis, anorexia, no prenatal care, fast hr, stds

Listlessness, poor muscle reflexes, poor feeding, uncoordinated suck-swallow, HIGH pitched cry, jitterness, inability to be consoled when crying.

• *Trauma is the most common cause of non-obstetric death amoung prego women in the U.S.**
• Causes: MVAs, domestic violence, falls