ONLINE MED ED NOTES- OB

Physiology of Pregnancy

Cardiovascular Pulmonary Clotting Cascade

 MAP= CO x SVR  Mom increases  1’ hemostasis: PLTs
 CO= HR x SV minute - adhesion
 Mom vasodilates which ventilation to - activation
causes a decrease in help expel CO2 - aggregation
BP decrease in SVR for her and fetus  In pregnancy VWF increases
 CO compensates by  Gravid uterus increases adhesion
increasing HR when enlarged  2’ hemostasis clotting
 INCREASE in preload can also impede cascade
 Decrease in Hgb due to ability to take - fibrinogen activated to fibrin
dilution anemia / deep breaths due - pregnancy causes increase in
increased RBC volume to pressure on clotting factors
 Increase in uterine size diaphragm - decrease in C, S (anti-clotting
can cause IVC factors)
compression - increased risk of DVT and PE

Kidneys Weight GI
 Increase in GFR due to  Weight gain is  GERD due to relaxation of
increased blood flow dependent on the LES
 Decrease in creatinine weight before  Nausea due to increased
 As gravid uterus grows pregnancy levels of B-hcG in first
can get a obstructive  “Quarter System” trimester
uropathy most  <18.5 BMI 1/wk  Constipation due to
commonly at the pelvic  18.5-25 0.75.wk progesterone relaxing
brim  25-30 0.5/wk effects on smooth muscle
 >30 0.25 lb/wk due motility agents and
stool softners
 Gallbladder disease
 Iron deficiency

First Trimester Evaluation

 First trimester evaluation should happen around week 10

Pre-Conception
 Focus on pts SAFETY
- Genetics, Age pregnancy
- DV, Abuse, social support
 Prenatal Vitamins folic acid prevent NT defects
  Vaccines pt should be up to date with influenza, hep B, MMRV
 Lifestyle smoking illicit drugs and alcohol cessation
 Optimization of disease DM, HTN, Hypothyroidism/ achieving adequate
control

Personal
 Ask pt if the pregnancy is desired or not?
 Offer options such as termination, family planning and adoption
 Assess any barriers to care ensure access to health care
 Tracking vital signs and weight gain

Pregnancy
 Gravida  # of times a pregnancy has occurred
 Para  # of births
-T, P, A, L
 Get information regarding SH, PMH, Surg Hx, FH, and medications

Dx and Screening
 First test is usually a urine pregnancy test
 Best test is an US confirms if there is a intrauterine pregnancy , determines
gestational age and assesses for multiple gestations
 Can also use a serum B-hcG

Labs
 Blood test for ABO, Rh-Ag status, baseline Hgb/Hct, HIV, Hep B Ag status,
RPR, Titers for Varicella and Rubella
 Urine screening U/A and culture, baseline proteinuria, screen for G/C
 CytologyPap smear
 Genetic screens CF for Caucasians, Sickle Cell trait in African americans

Follow up
 q 4 weeks for first two trimesters/ week 28
 q 2 weeks till 36 weeks
 q 1 week till birth

Genetic Screening

Aneuploidy screen for the following

 Down Syndrome  Trisomy 21
 Edwards Trisomy 18
 Patau’s Trisomy 13
 Risk increases with increased maternal age  asymptomatic screening
Screening
 If test is negative low risk
 If test is positive high risk
- invasive testing for confirmatory results

First Trimester Screening

 US for NT  <3mm
 PAPP-A
 B-hcG levels

Second Trimester Screening

 Triple Screen
- hcG, AFP, estriol
 Quad Screen
- hcG, AFP, Estriol, Inhibin A
 Combined screening
- test during first and second trimester
- increases sensitivity
 Sequential Screen
- first trimester screen if negative follow up with second trimester
- if positive invasive procedures
- intervene earlier
 Cell free DNA
- obtain fetal DNA from maternal blood; non-invasive

Third Trimester Screening

End of Second Trimester Week 20-28 screening consists of;

GDM Allo-immunization Maternal Anemia
 Blood sugar  Mom Rh status  Mom Hgb
 Diabetes that appears >20 weeks  Rh Ag “-“; had  Normal drop in
 Uncontrolled DM in the first 8 baby in past that Hgb/Hct ~ 10
weeks of development can cause was Rh Ag “+”  /30 @ 28 weeks
cardiac abnormalities in fetus lead mom to be  Most often is
 GDM can lead to macrosomia and RhAntibody “+” due to iron
shoulder dystocia  Dx Rh-Ab “-“: deficiency
 Increased risk pts include: BMI and baby is  Dx with CBC and
>30, previous GDM, Pre-diabetic possibly Rh + then Iron studies
screen earlier administer  Tx. With oral
 Dx 1 hour glucose tolerance test Rhogam/RhDIg Iron and Folate
with 50g glucose; + if >140 @28 weeks and
 Next 3 hour glucose tolerance 72hrs within
test delivery
- measure fasting > 90
 - 1hr >180
- 2hr > 155
- 3hr >140
 **Need any 2 to be positive
 Tx: POST PRANDIAL insulin

Advanced Prenatal Testing

Procedure When Risk Extra

1st : IUP, GA, Multi-fetal - 1st GA +/- 1 week
gestation
Fetal US 2nd: Oligo/Poly 2nd GA +/- 2 weeks
3rd : Fetal well being,
confirm lie/orientation 3rd GA +/- 3 wks

> 20 weeks in the setting of - Highly sensitive

Fetal Anemia/ DOES NOT provide Dx
Trans-cranial
alloimmunization or access; used to
Doppler
- Used to measure blood screen OUT anemia
flow
> 16 weeks to test for Risk of fetal loss Only reliable for >16
Genetic Disorders such as 1/300 wks ethical issue
Amniocentesis Down’s Syndrome once get results is
much later in
pregnancy
>10 weeks; used for Genetic Risk of fetal loss Early detection allows
CVS
Testing 1/500 for early termination
Percutaneous Can be used between 20-34 Used in the setting of Can transfuse with as
Umbilical weeks gestation Fetal anemia to it allows for access
Blood confirm the dx and
Sampling/ help tx
PUBS

Medical Disease
UTI
 Screen for asymptomatic bacteriuria via URINALYSIS
 Assess for urgency, frequency, dysuria cystitis
- + fever, chills, n/v, CVA tenderness pyelonephritis
 DO NOT treat asymptomatic bacteriuria
- symptomatic is tx with AMOXICILLIN or nitrofurantoin
- can NOT use bactrim or cipro because they are TERATOGENIC
 Treat pyelonephritis with admittance and CEFTRIAXONE
- if does NOT improve; consider an ABSCESS  use US and tx for 14 days
 After tx repeat UA
Thyroid
 Hyperthyroidism Fetal demise
 Hypothyroidism Cretinism
 Dx with TSH levels
- LOW TSH Hyper
- HIGH TSH Hypo
 Tx PTU used in first trimester, Methimazole in rest for HYPER
- HYPO Levothyroxine  ensure to adjust dosage
 Increase in TBG increase in Levo

Seizures
 All anti-epileptic drugs are TERATOGENS
 Differentiate between dx of epilepsy and pre-eclampsia seizures
 L drugs are SAFE Leviteracetam and Lamotragine
 Valproic acid, Phenytoin and Carbamazepine NO NO
 Assess the balance between risks of drugs and seizure meds
- baby are more susceptible to drugs early on in pregnancy
- if seizures are controlled then may consider halting drugs
 Should be on Folic acid to prevent NT defects

HTN
 BP goal should be < 140/80
 SAFE medications alpha-methyl dopa, Labetolol, Hydralzine
 DO NOT USE ACE inhibitors, ARBs, CCBs, Diuretics
 Requires TIGHTER screening for Pre-eclampsia
 Test UA every time

DM
 Before Pregnancy
- A1c<7%/90 day avg. with diet and exercise
- change orals to insulin
 During Pregnancy
- increased insulin requirement
- due to hormone increasing insulin demand
- BASAL BOLUS strategy long acting at night, short acting at meals
- Target POST prandial sugar
 AFTER delivery
- decrease/tone down insulin
 Uncontrolled sugar BEFORE development can cause cardiac malformations
 Uncontrolled sugar DURING pregnancy macrosomia and shoulder dystocia,
need for C/S
Normal Labour
 Point at which ACTIVE labor begins6 cm dilated

Stage 1 Stage 2 Stage 3

LATENT  10cm DELIVERY of  Delivery of fetus
- 0cm6cm fetus delivery of
- normal: 20 hours for  3 hours NULLI PLACENTA
NULLIPARA, 14 hrs  2 hours MULTI  Should take NO
for MULTI longer than 30
minutes
ACTIVE
- 6cm10cm
- 1.2 cm/hr NULLI
- 1.5cm/hr MULTI

Cervical Change
 Breakage of DISULPHIDE bonds allows the cervix to go from stiff to loose;
allowing baby to pass through and for progression of labor to occur
 Allows for Softening, Effacement, Dilation, Position  Fetal head engagement
 Can stimulate this process with balloon, prostaglandins, and OXYTOCIN

Fetal Station
 Ischial spine= position 0
 Anything BELOW POSITIVE/”+”
 Anything ABOVE negative/”-“

Fetal Position
 OPTIMAL position longitudinal CEPHALIC
- baby axis is aligned with mom, presents at VERTEX
 Longitudinal BREECH birth baby comes out feet first
- most common reason for C/S
- can try external version
 Transverse baby lies horizontal
 Best way to assess is LEOPOLD position
Abnormal Labor
If Labor is taking too long to progress; options include:
 Balloon
 amniotomy rupture of membranes to allow the fetal head to push on
cervix by removing the cushion
 Misoprostol
 Oxytocin increase frequency and strength of contractions
- treats arrest or prolonged ACTIVE phase; if FAILS c/s
 If stage 2 is PROLONGED
- baby position; NEGATIVE c/s
- baby position; POSITIVE Forceps, vacuum
 If stage 3 is PROLONGED
- baby has been delivered placenta is waiting to come out
- start with UTERINE MASSAGE to help contract down
- administer OXYTOCIN
- manual extraction*** last resort

3 P’s
 Passenger size of the fetus
- if too big resort to c/s
 Pelvis size of the outlet
- if too small c/s
 Power strength of the contraction
- can be modified with use of OXYTOCIN
- use MONTEVIDEO units 200 mvu in 10 mins with use of IUPC

L and D Pathology
 < 24 weeks gestation Abortion
 24-37 weeks Pre term birth
 37-42 Term birth
 42 + Post term
 ROM is only normal when the fetus is at TERM and is associated with
contractions
 PrematureROM at TERM but NO contractions
 PretermPrematureROM at PRETERM
 Duration of Labor SHOULD NOT >18 hrs
- if >, is called prolonged rupture of membranes

Rupture of Membranes/ ROM

 Spontaneously
 Artificially
 Pathologic
- infection such as GBS, vaginal flora or STI
  Membrane is present to help cushion baby and protect baby from any
ascending infection
 Breaking of membranes rush of fluid/breaking water
 Can be clear, bloody, stained with meconium
 Dx. With speculum exam
- will see pooling
- do a nitrazine test and look for FERNING
- US may show oligohydramnios
 Tx: to deliver if at TERM or < less 24 weeks
- if in between need to weight benefits and risks in terms of lung maturity
and possibility of infection

PROM
 Premature rupture of membranes
 Usually occur at TERM, but is associated with NO contractions
 Most often cause of INFECTION; GBS
 Dx: clinical, assess GBS status
 Tx: Deliver
- if GBS + or unknown administer AMPICILLIN
- if GBS - ; wait

pPROM
 Preterm Premature Rupture of Membranes
 Most commonly due to infection
 Dx: clinical presentation
 Tx: >34 weeks Delivery
- <24 abortion
- 24-37 give steroids for fetal LUNG MATURATION and Tocolytics to help
relax uterine contractions if present if >34 weeks

Prolonged ROM
 Worried about infection ENTERING
 Labor >18 hours
 Tx: Deliver based on severity and GBS status
 Should be concerned about endometritis or chorioamnionitis
- sx of fever
- tx: AMPICILLIN, GENTAMYCIN AND CLINDAMYCIN

Risk of Preterm Baby

 Idiopathic
 Smoking
 Decreases maternal age
 Multiple gestation
 PPROM
  Anatomical defects of the uterus
 Labour CONTRACTIONS + cervical CHANGE

Post Term Baby

 Baby can end up macrosomic shoulder dystocia
 Fetal Dysmaturity
 Pt is >40 weeks by contraception
 Pt is > 42 weeks by dates
 Tx: is based on how sure you are of dates
- sure, cervix is favorable Induction
- sure, cervix is unfavorable c/s
 Can also complete a non stress test and perform a biophysical profile

Eclampsia
 All about vasoconstriction increased SVR increase in BP
Dx BP Timing U/A Sx Tx F/u
Transient >140/>80 Non-sustained - - - Keep a log to
HTN BP monitor BP

Chronic HTN >140/>80 Sustained BP - - -Alpha- Keep track with

<20 weeks methyldopa more frequent
gestation -Labetalol U/A and US
-Hydralazine

Gestational >140/>80 Sustained BP - - -Alpha- Keep track with

HTN >20 weeks methyldopa more frequent
gestation -Labetalol U/A and US
-Hydralazine - Monitor for
possible
progression into
Pre-eclampsia
Mild preE/PEC >140/>80 Sustained Protein - >37 weeks More
without severe elevation of BP >300ng/dL Deliver frequent/weekly
features after 20 weeks <37 wait follow ups
gestation
Severe PreE/ >160/>110 Sustained Protein + Mag sulfate +
PEC with elevation of BP >5g/dL Delivery
severe features after 20 weeks usually by
gestation Induction
Eclampsia n/a n/a n/a SEIZURES Mag sulfate+
Delivery C
SECTION
HELLP Syndrome
 Hemolysis
 Elevated Liver Enzymes (ALT/AST)
 LOW PLTs
 Treated the same as ECLAMPSIA
 Severe features include:
- RUQ abdominal pain stretch of Gleesons capusule
- Increased LFTs
- Low PLTs
- Increase CREATININE
- Pulmonary Edema
- Headaches, Vision changes
- BP >160/110

Magnesium Checks
 Look for DECREASED Deep Tendon Reflexes/DTR
 If this is the case can cut off the respiratory drive of the diaphragm and can
lead to death
 Tx CALCIUM

Multiple Gestations/ Types of Twinning

 Egg + Sperm Fertilization  1 Reproductive unit/zygote
 Zygote is surrounded by amnion SAC
 Amnion is surrounded by CHORION forms the PLACENTA

Steps:
1. Analyze Gender
- Different genders Di zygotic, Di Chorionic, Diamniotic
– Same gender potential for Monozygotic with dichoronic, diamniotic (Split
between day 0-3)
- If there is only ONE placenta with septal sac Monochorionic, diamniotic
(split between day 4-8) RISK OF TWIN TWIN TRANSFUSION
- If there is only ONE placenta, ONE amnion Mono mono (split day 9-12)
2. DI DI
- risk of preterm labor for every 1 extra gestation you are likely to deliver 4
weeks EARLY
- risks of mal-presentation due to limited space
- increased risk of C/S
- increased risk for PPH
3. MONO MONO
- Increased risk of conjoined twins  split occurred >12 days gestation
- Increased risk of cord entanglement
- better to deliver via C -SECTION
Post Partum Hemorrhage/ PPH
 Can be defined as a loss of blood >500cc vaginal delivery
 >1000cc blood loss in C/S
 Can be defined based on the status of the UTERUS
 If bleeding is unexplained or unable to follow a cause tx the same as a large
GI bleed to help keep patient hemo stable
- insertion of 2 LARGE BORE IV (16 or 18 gauge) bolus IV fluids
- intervene surgically with either
 Uterine artery LIGATION via OB: most commonly done when pt is already
in a C/S
Uterine artery EMBOLIZATION via Interventional Radiologist
 TOTAL abdominal hysterectomy via OB

Uterus Status
 ABSENT
- uterine INVERSION
- tx: manually, may need tocolytics to help relax muscle at first followed by
uterine tonics to help hold in place
 BOGGY
- Uterine ATONY
- tx with fundal massage and use medications ex. Oxytocin to help contract
down
 FIRM
- RETAINED placenta
- tx: with D&C, possible hysterectomy
 NORMAL
- can be result of a vaginal LACERATION
- rare causes: DIC, bleeding disorder

Uterine Atony
 Usually a result of prolonged labor, cessation of oxytocin, use of tocolytics
 Leads to PPH and Boggy uterus
 Tx: first intercention is UTERINE MASSAGE
 Can then use Oxytocin, Methergine, Hemabate
 If meds fail surgery

Uterine Inversion
 Uterus contracts so hard it falls through
 May occur during delivery with Oxytocin or due to placental cord traction
 Dx is based on a clinical presentation; w or wo speculum
 Tx: MANUAL placement
- may need tocoyltics to calm uterine muscle tp put into place followed by
oxytocin to keep in place
Vaginal Lacerations
 Laceration most often in cervix and vagina macrosomic babies or
precipitous labor
 PPH with NORMAL uterus
 Tx: first hold tight and admin PRESSURE
- if does not work admin anesthetics and then use sutures

Retained Placenta
 Placenta is buried a little deeper into the ENDOMETRIUM ACCRETA
 Placenta has extended into MYOMETRUM INCRETA
 Placenta has extended through uterus and possible to other organs
PERCRETA
 If part of the placenta tears away blood vessels still attached to uterine
lining will continue to bleed and result in PPH
- Tx: with D&C if does not improve hysterectomy
- Want to keep track of B-HcG levels after this occurrence possibility of
leading to CHORIOCARCINOMA

DIC
 Due to production of Fibrin clots
 Platelets get CONSUMED DECREASED levels of PLTs
 RBC are sheered as they circulate through clots DECREASE Hgb and
Schistocytes
 Fibrinogen is being consumed DECREASED Fibrinogen
 Factors are being consumed DECREASED INR
 Tx PLATELETS, PRBCs, CRYOPREC., FFP**

Antenatal Testing
