OB 3

50%

Increase in estrogen -> RAAS

40%

Declines, lowest pt. at 24-48 weeks

Increases in Les->edema and varicosities

Decreases in 1st trimester

Systolic ejection – in 90% of pregs. And S1 split

• Markings in lungs due to increase in pulmonary blood volume
• Diaphragm elevated 4 cm

• Tidal vol. increases
• Reserve, and residual vol. decreases
• Tot. lung capacity decreases, and functional capacity decreases. Inspiratory vol. increases

• Elevated gfr due to increase in plasma flow
• Renin activity increases

• Organs displaced
• Hypertrophic gums
• Reflux in 80%, increase in gastrin
• Decreased transit time
• Increase risk of gall stone

Reduced plasma albumin

• Anemia
• Iron deficiency common
• Elevated leucocytes
• Preg. Associated thrombocytopenia in 3rd trimester

• Hyperpigmentation,
• Stretch marks, varicosities

Pica, food intake and appetite increase

• Intrauterine
• Transport
• Adult

• Dependent on placenta
• Umbilical vein-o2 blood to liver- shows maternal and placental problems
• Umbilical artery-from common iliac-shows fetal status

• Ligation of umbilical cord causes rise in arterial pressure
• Rise in plasma CO2 and fall in PO2 cause breathing
• Increase in pressure causes closure of the foramen ovale and ductus arteriosus.

• Completed in 1st mos. Of life
• Ductus and foramen completely close

Systolic crescentoid murmur

25-35 lb in pregnancy

Treat asymptomatic bacteria

• Safe- killed virus, toxoid, or recombinant
• Unsafe- live attenuated vaccines

• Minimize vertical x-mission
• Intrapartum AZT infusion and HAART

• Oral Acyclovir for prophylaxis before delivery
• Mortality and morbidity associated w/ HSV infection

Molar pregnancy or multiple gestation

Req. hospitalization

• Age
• Drugs: smoking, caffeine, NSAIDs
• Asherman’s
• Uterine abnormality
• Multiparity
• DM
• Thyroid
• PCOS

• ABD pain
• Vag bleeding
• Amenorrhea
• Early pregnancy

• Ectopic
• Impending SAB
• Infection
• Cervical polyp
• Physiologic implantation

Look for gestational sac early as 4.5 to 5 wks, or at 800hcg

• Absence of fetal cardiac activity
• Absence of fetal pole
• Abnormal yolk sac, fetal HR <100 or subchorionic hematoma=ominous sign.

Not increasing as expected in normal preg.

• Any Painless bleeding before 20th wk.
• Closed os
• Uterine size= EGA

• ABD or lower back pain
• Cervix dilated or ROM=preg. loss

• All POC passed
• Common prior to 12 wks

• Partial expulsion of gestational tissue
• More likely after 12 wks.
• Cervix open , uterus , EGA
• Can have severe bleeding

• Retention of a failed IUP for an extended time
• DIC can occur in 2nd trimester if AB >6 wks

>2 consecutive or 3 tot SABs

Termination of intact pregnancy

Pelvic rest

• Serial HCG, pelvic rest
• D and E
• Misoprostol to induce labor

• Rhogam if RH neg.
• Doxy with D&C
• Methylergonovine maleate-controls hemorrhage

Ectopic pregnancy

• High: Tubal pathology, Previous ectopic, DES exposure, Tubal surgery
• Med/Low: Recurrent PID, Infertility, Multiple sex partners, Smoking, douching, Age

98% tubal

• ABD pain
• Amenorrhea
• Bleeding
• Spotting

Light headedness, shock

Serum hcg and ultrasound

• Surgical if ruptured
• Methotrexate

• Hydatiform mole
• Invasive mole
• Choriocarcinoma
• Placental-site trophoblastic tumor

HCG

Hydatiform mole

• Grape like vesicles fill/distend uterus
• Hyperemesis gravidarum
• Onset of preeclampsia prior to 24 wks

Hydatiform mole that invades the adjacent structures

Cancer preceded by hydatiform mole

Tumor confined to uterus, preceded by hydatiform mole or normal pregnancy

• HCG
• Ultrasound

Painless changes in 2nd trimester causing recurrent pregnancy loss

• Short cervix
• Uterine abnormalities
• Trauma from LEEP or Biopsy
• Collagen abnormalities
• Elevated serum relaxin

• Vag. Fullness and pressure
• Discharge, spotting or bleeding
• ABD or back discomfort

• Progesterone
• Cerclage “purse string suture”

Identical twins

Fraternal twins

• Preterm labor
• IUGR
• Preeclampsia
• Post partum hemorrhage
• Increased risk of SAB

• >35 y/o
• Abnormal screening results
• Fam. HX
• Multiple pregnancy losses
• Maternal conditions –IDDM, lupus, sz, substance abuse
• Exposure to teratogens
• Consanguinity
• Ethnicity-Ashkenazi Jewish

• Sequence of prenatal diagnosis
• Impact of prenatal diagnosis
• Ethical considerations

All women

• Offers early risk assessment,
• Reduce number of invasive procedures
• Cannot detect NTD or ventral wall defects

• @ 15-22 wks.
• Can Id NTD, aneuploidy
• Correctly dates pregnancies
• ID risk for renal agenesis (AFP low) and ventral wall defects (AFP high)
• Cannot r/o all aneuploidies

LOW

High

Id Trisomies 13, 18, 21

• 10-12 wks gestation
• Id aneuploidy and single gene conditions
• 1/100 risk for miscarriage

• 12-14 wks. Early diag. of aneuploidy and ONTD
• Higher risk of miscarriage than normal amniocentesis

• Hydrocephaly
• Hydrops
• Omphalocele
• Cardiac defects
• Kidney and bladder defects
• Meningomyelocele
• Cystic hygroma

• 15 wks to term,
• Detects aneuploidy, ONTD, single gene, Rh and lung maturity

After 16 wks

• Fluorescent in situ hybridization
• Id certain aneuploidy , Id chromosomal deletions

Proteinuria and/or pathologic edema

• <20 >35
• Nulliparity
• Multi-fetal gestation
• Hydrops fetalis
• Hydatidiform mole
• Chromosomal anomalies
• UTI
• Gestational diabetes or DM

• HA
• Hyperreflexia
• Photophobia
• Epigastric pain due to elevated liver enzymes
• Edema of face and hands

Low dose asa

Proteinuria and sz

• Hemolysis
• Elevated Liver enzymes
• Low platelets

• Malaise fatigue (primary)
• N/V
• RUQ pain
• Severe HTN
• HA
• +3 protein in urine

• Antihypertensives
• Corticosteroids-improve liver function and fetal lung development
• Anticonvulsants- mag sulfate
• Bed rest
• Delivery only cure

Weight <10th percentile

• Cardiovascular or renal dz
• Low maternal weight gain
• Vaginal bleeding in pregnancy
• Prior stillbirth
• Smoking, etoh, coke, or harry use

Clinical size less than date (<2cm than expected)

• Genetic-malformations, chromo abnormalities
• Congenital-TORCHES
• Placental-Placenta previa, small placenta
• Multifetal gestation

Ultrasound, antenatal treatment

24-28 wks with one hr. Glucola if >25 yo or fam. Hx of DM or ethnic risk

• > 25 y/o
• Prior GDM or fam. Hx
• Prior macrosomic infant >9lb
• Obesity
• Chronic hypertension
• Glycosuria

• 1 hr. Glucola challenge cutoff at 140 mg/dL.
• 3 hr. test is done if abnormal
• 2 abnormal values diagnose GDM

• Diet
• Tight BS control
• Insulin if inadequate.
• Metformin and glyburide controversial

Insulin

• Pre eclampsia
• Infections
• Macrosomia=c-section
• Polyhydramnios
• Preterm labor

• Macrosomia-birth injury
• Major anomalies-cardiac, NTD
• Predisposition to DM and obesity

System for categorizing DM during pregnancy

Big baby, above 4000grams, or approx 9lbs

• Abnormal OGTT
• Maternal obesity, multiparity, previous LGA infant

• C section
• Prolonged labor
• Birth trauma-shoulder dystocia, clav fx, nerve injury

800-1000

• Too much fluid caused by: DM, Twins, Hydrops,
• Fetal abnormalities, >25 cm AFI

• Too little fluid, <5 cm AFI
• Post date, Fetal growth restrictions, premature ROM, Fetal renal abnormalities

Series of uterine contractions -> cervical effacement and dilation and voluntary bearing down

Settling of fetal head in pelvis 2 wks prior to delivery

Passage of small amount of blood tinged mucus from vagina-sometimes signal onset of labor

Lack of cervical change in response to contractions

Last 4-8 wks, irregular, painless with slowly increasing frequency

• Vertex-normal
• Breech
• shoulder

Position of head in pelvis

• Engagement-head below plane of pelvis
• Flexion-passive flexion of fetal head
• Descent-progression of fetus through pelvis
• Internal rotation-rotation of presenting part
• Extension-head is delivered by extension
• External rotation-after delivery of head

• Onset of labor to full dilation
• Can last 6-8hrs
• Progress monitored by cervical effacement

• Between full dilation and delivery
• Desire to bear down, Descent of fetus

• Delivery until expulsion of fetus
• Cervix and vagina should be examined for bleeding
• Placenta usually separates from 2-10 mins
• Placenta should be examined to detect abnormalities

• Qualitatively- External Toco, observation/palp.
• Quantitativly-measurement of intrauterine pressure (most precise)

Mild-15-20mins apart lasting for 60-90 secs

Cervix 4-8 cm, contractions 3 mins apart lasting for 1 min

Contractions last 1 min and are 2-3 mins apart

Difficult child birth, slow abnormal progression of labor, leading cause of primary c section

• Passage (pelvis)
• Passenger (fetus)
• Powers (expulsive force)

• Sedation
• Anesthesia before active phase
• Uterine dysfunction
• Fetopelvic disproportion

Slow cervical dilation in active phase and slow descent

• Fetopelvic disproportion
• Malpositions of fetus
• Aesthesia
• Sedations and tumor

• Arrest of dilatation
• Or arrest of descent

• Age
• DM, HTN, Obesity
• Macrosomia
• Short maternal stature
• High station at dilation
• Pelvic abnormalities

Uterine rupture, postpartum hemorrhage, decreased uteroplacental perfusion

Dorsiflexion of hips against abdomen – widens pelvis

No evidence to support routine use

• Ischemia of uterus during contractions
• Dilation of cervix
• Distention of vagina

• Narcotics used in 1st stage
• Regional anesthesia
• General anesthesia used when regional anesthesia cannot be give for c section

Beyond 42 wks

• Meconium aspiration
• Uterine infection
• Labor dystocia,
• Macrosomia and c sectio

• If favorable cervix failure is low
• Fetal compromise-non reassuring NST
• Gestational HTN or PIH, preeclampsia/eclampsia
• Postterm
• PROM
• Hx of rapid labor, distance from hospital

• Prior classical c section
• Genital herpes
• Placenta previa
• Umbilical cord prolapse
• Transverse lie

Predicts likelihood of successful labor induction, scores >6 are favorable

• Cervical ripening agents
• Membrane stripping
• Oxytocin
• Mechanical dilation
• Amniotomy

• Prolonged labor, premature separation of placenta
• Placenta rupture and lac of cervix
• Infection
• Hemorrhage,
• Cord prolapse
• Poor apgar

• Frank
• Complete
• Footling
• Compound presentation
• Fetal extremity presents along with presenting part, hand presenting with head most common

Occiput posterior or transverse

Pressure on mothers abd to turn fetus after 36 wks

• Operative Vaginal
• Cesarean section

• Immediate or potential fetal compromise
• Prolonged second stage

• Trauma –MVA, domestic
• Ectopic
• Placenta previa
• Placenta abruptio

• Uterine rupture
• Uterine inversion
• Birth trauma
• Retained placenta
• Uterine atony
• Obstetric lacerations
• DISC
• Von Willebrand’s

fundus through cervix-shock out of proportion to blood loss

Uterine atony- uterus fails to contract

Adheres to myometrium

Placenta invades myometrium-retained placental parts

Placenta invades through myometrium-hysterectomy

Painless vaginal bleeding, dx by ultrasound-c section

• Painful vaginal bleeding and fetal distress
• Premature separation of placenta

• Hypertension
• Trauma
• Smoking, cocaine
• Preterm rom
• Thrombophilia
• Chorioamnionitis
• Rapid decompression of uterus

• DIC
• Renal cortical tubular necrosis
• Uterine atony

• Oxytocics
• Bimanual message and compression
• Surgical

• Rupture of membranes before onset of labor
• If before 37 wks. -> PPROM

• Intraamniotic infection
• Prior hx
• Lower SEC
• Uterine overdistention
• Cervical cerclage

Sudden gush of fluid or continued leakage, reduced size of uterus

Pooling, ferning, Nitrazine positive

• GBS prophylaxis
• Steroids less than 32 weeks

Actively delivered regardless of gestational age

Manage like preterm labor

Prolong latent period and decrease infection rates

• Prior to 32 wks with no infection
• Lung development, decrease in necrotizing enterocolitis and intraventricular hemorrhage

Limit to 48 hrs to permit administration of corticosteroids

Delivery before 37 wks.

• Smoking
• Maternal age
• Social factors-stress
• Prior preterm delivery (strong risk factor)

• Cervical length-reliable
• Fetal Fibronectin testing- negative predictor

Progesterone

• Minimal success and no improvement of outcomes
• Allows adm. of steroids and transport to hosp. with NICU

PTL and PPROM

Should be universally practiced

10-30%, bacteruria indicates heavy colonization

• Early- first 6 days of life
• Late- after first 6 days- nosocomial or community acquired

35 to 37 wks.

• If positive PCN
• PCN allergy cefazolin or clindamycin

Doubles risk of asymptomatic bacteriuria

Gm neg- e coli, proteus, klebsiella

• Higher risk of preterm delivery
• Rx for symptoms, treatment does not show improved outcomes

• No rx 30%
• AZT alone 6%
• AZT + VL undetectable

Acute Vs chronic via LFT and Core antibodies

Give Recombivax and HBIg do neonate after delivery

Yes

Yes after infant is vaccinated

All OB pts. With VDRL, RPR

Treat with acyclovir (preg. Cat C)

Most common heart, eye, ears

Post partum

• Higher fatality rate
• Pneumonia
• Encephalitis
• If contracted before 20 weeks-microcephaly, limb

Varicella immune globulin may interrupt transmission.

• TOxoplasmosis
• Rubella
• Cytomegalovirus
• Herpes Simples