OBGYN Step 3

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Post Partum Hemorrhage

4 T’s Tone, Trauma, Tissue, Thrombin 

Tone – Uterine Massage – Oxytocin, Tissue uneven uterine lining, D&C, Trauma – pelvic exam, Suture laceration, Thrombin – tamponade bleeding

Postpartum hemorrhage (PPH): Tone (uterine atony), Trauma (laceration), Tissue (retained placenta) & Thrombotic (inherited thrombophilia)

this is helpful so let's start first we're gonna cover obstetrics so postpartum hemorrhage is to find us over

and the most common cause is due to uterine atony and that's from basically

when you're in labor your uterus is contracting a lot and after delivery of

the baby the uterus is weak and then the spiral arteries because of the decreased

tone of the uterus it can't contract fast enough and the

contraction of the uterus actually clamps the spiral arteries so when you

have basically a flaccid weak uterus those spiral arteries are just open and

dilated and they're basically just hemorrhaging and so the main thing I

want you to look for in a vignette is when they say that the uterus is above

the umbilicus because that basically means that it's foggy and big and when a

uterus contracts it gets smaller and it should be below the level of umbilicus

so then the first step is to diagnose it but then the next is to know what to do and the first-line treatment for that is

uterine massage so you want to massage the uterus and help get it to a smaller

size and then afterwards you can also administer oxytocin if needed there's

another type of common cause of postpartum hemorrhage and that is due to

retained placenta – uneven lining – D&C

retained placenta in a vignette usually you'll notice that they'll talk about

the placenta coming out that it may have looked like an incomplete placenta and

it doesn't you know clean and so they might talk about on ultrasound that you see and

uneven endometrial lining so that unevenness is basically describing that

there's retained placenta in the uterus which is causing that uneven lining and

then what you want to do as a D&C to remove that retained placenta if it's

not uterine atony or retained placenta and another common one is 

Lacerations – Forceps delivery even endometrial lining – Pelvic examination suture laceration

lacerations

and so usually in a laceration vignette there will be it's associated with

forceps delivery so when you put the instrument up the vagina or cervix it's

at risk for laceration of course in that vignette then the uterus will be below

the umbilicus and then ultrasound will show even endometrial lining so that

kind of rules everything out so and if there's forceps involved in its most likely laceration and then to treat that

you would do a pelvic examination and inspects for the laceration and then suture it closed so then what I wanted

Active Labor

Adequate contraction every 2-3 minutes contractions > 200 MVU in 10 minutes 1 MVU, 4 hrs of no contractions 6 hrs inadequate contractions, cervix no longer dilating – C-section

to talk about next is active phase of delivery so you know you have your latent phase which is from 0 to 6, 6 to 10

Arrest of Descent – at 10cm cephalopelvic disproportion. Csection

Uterine rupture – intense pain, baby’s head at 0 station now at -3, uterine rupture, difficult to find where baby is in uterus – hard to find baby’s head, laporatomy

Prolapsed cord, umbilical cord through cervix

 

Labor 0 to 6 (passive phase), 6 to 10 centimeters ( active phase), adequate contractions roughly contractions every two to three minutes or > 200 MVU in 10 minutes 

centimeters cervical dilation and then 6 centimeters on to 10 centimeters that is

called active phase why that's important is because you need to know a term

called arrest of active phase so that's defined as four hours of adequate contractions

or six hours of inadequate contractions so then you need to know what is

adequate contractions so adequate contractions is loosely every two to

three minutes you have contractions or if you want a precise definition it's

greater than 200 Montevideo units in ten minutes so a Montevideo unit is

basically the sum of the uterus pressure changes above baseline with each

contraction in ten minutes so if that adds up to over 200 then you have

adequate contraction the cervix is no longer dilated that's called arrest of active phase and

then you want to do a c-section 

10 centimeters – maximum dilation, arrest of descent, MCC cephalopelvic disproportion – C-section

after ten centimeters when you have maximum

dilatation of the cervix to delivery if that takes longer than three hours

that's called arrest of descent and usually the number one cause of that is

due to cephalo pelvic just proportion which basically means that the baby's

head is too big to fit through mom's pelvis and you want to treat that with a

c-section 

uterine rupture – intense pain zero station now negative, difficult to palpate - laparotomy

Uterus Rupture - uterus rupture the vignette will usually talk about how mom was in

labor all of a sudden she had intense pain and the baby's head was originally

at say zero station and now it's at the minus three station that's basically

pathognomonic for uterine rupture and usually they'll also describe that it's

difficult to palpate to find where the baby is in the uterus because the baby

has most likely um is now slipped out of the uterus and in the peritoneal cavity

so when that happens obviously you want to go into a c-section obviously you

want to do a laparotomy and then take the baby out and then elapsed cord which

is basically the umbilical cord has prolapsed through the cervix and obviously since the umbilical cord is in

the way of the path of descent it's too dangerous to deliver vaginally so you

want to deliver through c-section so when we talk about

fetal tachycardia nml 110 – 160 causes maternal fever, pyelonephritis, chorioamnionitis, endometritis

tachysystole 5+ uterine contractions / 10 minutes can cause fetal bradycardia – tocolytic terbutaline beta 2 agonists SE pulmonary edema

 fetal tachycardia

so basically heart rate that's normal for a fetus is between 110 to 160

so anything faster than that what do you think would be the cause of death so

fetal tachycardia the causes are generally maternal fever so if the

baby's heart rate is over you know 170 you shouldn't suspect an maternal fever

common causes of mature fever would be infectious causes right

so like like pyelonephritis chorioamnionitis or endometritis which

I'll talk about later so taxi systole is defined as 5 plus uterine contractions

every 10 minutes so this is too much contractions and this can cause fetal

bradycardia which isn't good for the baby and so you want to treat this with the toe coletek and the first line

tocolytics is terbutaline which is the beta-2 agonist don't forget at

tocolytics their number-one adverse effect is almond area edema 

beta thalassemia - 

so beta microcytic anemia Hgb a2

thalassemia what would be a marker that would help you distinguish beta

thalassemia from other microcytic anemias it has elevated hemoglobin a2 so

that's a sign to look out for it so remember that 

Physiologic Changes of pregnancy – elevated GFR, metabolic alkalosis (breathe for two ppl), increased Vt lower PaCO2, lower hgb

there's certain changes

that happen with pregnancy that are normal and so usually mom will have

elevated cardiac output elevated GFR and because of the elevated GFR she'll also

have glucose area which is perfectly normal she'll also have metabolic alkalosis

which is expected to be normal too because she has to breathe for two people she'll have increased tidal volume and this will cause her to expire pco2 more so her pco2 is usually lower

than average if it's above 40 that's usually not a normal sign so if you see

alkalosis and a pregnant woman don't panic it's pretty physiologic also remember that basically when mom is

pregnant she has increased plasma volume 2 and this dilutes the red blood cells

and that's physiologic anemia of pregnancy so it's expected for moms who

have anemia during pregnancy as well 

Shoulder Dystocia – shoulder stuck behind pubic bone, is this arrest?, try McRoberts Maneuver – hyperflexion of the hips (knees to chest), Risk Factors: Prior Shoulder Dystocia, macrosomnia -> gestational diabetes, can deliver vaginally complications Erb’s palsy, clavicular fracture, hypoxia or death

Pregestational diabetes < 20 weeks, after 20 weeks gestational different complications

Pregestational dangerous – congenital malformations and cardiac defects

Gestational more preterm labor, macrosomnia, shoulder dystocia

shoulder dystocia is basically when the

anterior shoulder gets stuck behind Mom's pubic bone and the shoulder kind

of gets locked in place so the first thing you want to do before you concede to the diagnosis of

arrest of descent where it's impossible to get the baby out definitely is you

want to try something called the McRoberts maneuver which is hyper flexion of the hips and this should

hopefully pop the shoulder out and that's the first thing you want to do so remember prenatal risk factors for

shoulder dystocia for a mom as if she's had a prior episode of shoulder dystocia

if the baby's macro Soumik and usually macrosomia is caused by gestational

diabetes and remember just a tional diabetes there's a difference between that and pre gestational diabetes which

is the presence of diabetes before week 20 is called pre gestational diabetes

and after week 20 diagnosis as gestational and they're different because they have different

complications associated with them pre gestational diabetes is much more dangerous it associated with congenital

malformations and cardiac defects whereas gestational diabetes is more

associated with on preterm labor macrosomia shoulder dystocia etc

remember with shoulder dystocia if you are able to deliver vaginally than some

complications you could expect our 

Erb’s palsyC5, C6 Klumpke C8-T1 Erbs palsy a clavicular fracture crepitus reassure the patient’s will heal on its own

sometimes hypoxia or death if the baby comes out and a few days after it's born

and it's presenting with the classic or palsy presentation which has a hyper

which is basically an arm that's internally rotated with the wrist flexed

and elbow extended this is a Erbs palsy the parents will usually ask what to do

about it and the correct answer is usually reassure because it tends to self resolved and the same of the

clavicular fracture there will usually be you know crepitus over the clavicle

and then there too is to reassure because it will heal on its own so an important concept

to know is 

Fetal Bradycardia if mom is hypotensive reflex vasoconstriction of spiral arteries attached to uterus increases total peripheral resistance for mom’s circulatory system to get bp up, vasoconstriction of the fetal circulation increasing fetal total peripheral resistance reflex bradycardia

Vasoconstriction of spiral arteries causes fetal bradycardia, uterine atony, cord compression clamps down umbilical artery increases spiral artery leading to fetal bradycardia

Fetal heart rate accelerations

fetal bradycardia how that arises and there's multiple mechanisms

but one of them is maternal hypotension so hypotension so if mom is hypotensive

then she will have reflux vasoconstriction of her spiral arteries

which are the arteries that are attached to her uterus but this also belongs to

her circulatory system so when you have vasoconstriction of these spiral

arteries that's an attempt to increase total peripheral resistance for moms

circulatory system in order to get her blood pressure up however when this

happens this also causes vasoconstriction of the fetal

circulation and that increases the fetal total peripheral resistance big-time as

well so this results in reflex fetal bradycardia so then applying that concept anything

that causes vasoconstriction of the spiral arteries can cause fetal

bradycardia so uterine atony is one of them why because it causes vasoconstriction of

the spiral arteries another one is cord compression cord compression basically

clamps down the umbilical artery and that increases TPR as well which needs

to reflex bradycardia another important thing to know is fetal heart rate

accelerations this is something that we use in

Nonstress test, fetal heart rate over a 20 minute period, times baby will have accelerations

Rule of rate 15 for 15 seconds one acceleration two in 20 minutes good sign 

15:15 2:20, good oxygenation for the baby

non stress tests which is when

you are measuring the fetal heart rate over a 20-minute period to see how many

times the baby will have accelerations so adequate accelerations is the rule of

rate by 15 for 15 seconds that's one acceleration and if you see

two of those in 20 minutes then that is a good sign so if you see two of those

it means there's good oxygenation for the baby and that's a reassuring non-stress test you do a non-stress test

when mom notices decreased movement in the baby also if the non-stress test is basically

equivocal or non conclusive which means in that twenty minutes you did not see

reassuring fetal heart rate accelerations then you move on to

something called a 

Biophysical Profile – extensive BATMN – breathing amniotic fluid measurements, Tone, movement, nonstress test

Endometritis – inflammation of endometrium and myometrium ECG – ascending infection + C sections, Tender uterine fundus, Fever, foul smelling lochia (postpartum discharge of blood, mucous and tissue) endometrictis ECG – enometritisi, clindamycin, Gentamicin

Chorioamnionitis – PROM – prolonged supture of the membranes, 18 hours elapsed since water has broken, if mom is still in labor at risk for infection, Ampicillin and gentamicin

CAG – chorioamnionitis, Ampicillin, gentamicin

biophysical profile and that basically is a more extensive

version of the non-stressed test which includes breathing amniotic fluid

measurements tone movements of the baby and the non-stressed test and it gets a

square out of ten but basically if the score is less than four then you want to

deliver right away so we were talking about causes common causes of maternal

infection one of them is endometritis and this is basically inflammation of

the endometrium we can also call it endo Myo metritis which is inflammation of

the endometrium and myometrium usually this is caused from ascending infection

or it's also commonly associated with c-sections which is suspected due to

contamination and the signs will be tender uterine fundus a fever and

foul-smelling lochia and so lochia is postpartum discharge of the blood mucus

and tissue so when you see endometritis you want to treat that first line with clindamycin

and gentamicin another common maternal infection

something called chorioamnionitis which is caused by ascending infection and

it's commonly associated with prolonged rupture of the membranes prolonged

rupture of the membranes means that that there's been 18 hours that have elapsed

since the water has broken and if mom is still in labor for over 18 hours she's

at risk for an infection how you want to treat that is by ampicillin and

gentamicin so if you see 

Nuchal translucency

AFP: mcc underestimation of age, 

Defects in the wall – omphalocele, gastroschisis abdominal wall defect

nuchal translucency on a chance vaginal ultrasound that's a sign

of Down syndrome or trisomy 18 if you see something that's described as

greater than 2 to 2.5 multiples of the median that's equivalent to saying that

there's a neural tube defect elevated AFP is usually I think about things that

are associated with like an incompetent body wall in the fetus it could be

either gastroschisis omphalocele which is basically abdominal wall defects or

neural tube defects and deep through these defects AFP leaks out another

common one that can cause elevated AFP which is actually the most common cause

is underestimation of age so you'll see an AFP much higher than it should be

that's because the baby is actually older you think the baby might be 10

weeks for example but in reality it's 13 weeks old so it's making more AFP and

Down syndrome – thickened nuchal fold translucency, echogenic bowel: duodenal atresia

Triple screen – wrong dating

you would expect remember as common buzzwords associate of town syndrome would be second nuchal fold nuchal

translucency and remember the echogenic bowel which is caused by duodenal

atresia where you'll see the double bubble sign which is a very common association with Down syndrome so yeah

most common abnormal triple scream is wrong dating so twins have complications

as well and they have a higher rate of term delivery congenital malformations

preeclampsia and postpartum hemorrhage 

Twins – higher rate of congenital malformations, preeclampsia / postpartum hemorrhage

Clomiphene – estrogen receptor antagonist at the level of the hypothalamus blocks negative feedback, brain not enough estrogen, stimulates hypothalamus to release more GnRH, LH, FSH to promote ovulation

KB – kleihauer betke before rhogam

Rho antigen found on fetus in Rho negative mom, 

A- No RH antigens, whatever you are missing you create antibodies to what you don’t have

clomiphene is a drug that's used to

induce ovulation and it promotes maturation of multiple follicles leading

to multiple eggs being released and it's used in PCOS polycystic ovarian syndrome

how coma fein works is adds up estrogen receptor antagonist at the level of the

hypothalamus so what this does it basically blocks the negative feedback

so it tricks the brain into thinking that there's not enough estrogen in the

UM being made by the ovaries so this stimulates the hypothalamus to release

more GnRH LH FSH to make more estrogen and by doing this this promotes

ovulation then there's the kleihauer-betke test remember that this is a test that's used before

administering rhogam rhogam is basically the antibodies that prevent

sensitization versus the ROE antigens found on the fetus in a row negative mom

a mom who has for example blood type a negative that negative denotes that she

has no rh antigens on her blood and as you remember from your step one

knowledge and your basic sciences knowledge that whatever you're missing on your own blood you create antibodies

for what you don't have so if you're a blood type o which means you don't have

a you don't have B and if your minus means you don't have Rh then you'll have antibodies against a B and Rh so if a

mama is Rh - she will have RH antibodies

IgM, IgG if they happen to see antibodies. Maternal fetal hemorrhage, placental abruption, cause fetal circulation to mix with mom circulation. Baby red blood cells have Rh positive, Rh positive father

Mom’s IgM antibodies sees Rho antigen on fetal red blood cell, it will type switch, 2nd pregnancy crosses the placenta and destroys blood cells that have Rho positive antigen. The second the younger brother or sister, polyhydramnios – massive destruction from fetal red blood cell

KB test, momcells places a substances, eliminates mom’s blood tells you what percentage of blood sample has fetal red blood cells 50 – 50 give rhogam, 10% fetal red blood cells. Rhogam – antibodies that take out fetal red blood cells. To hide it from mom’s preexisting antibodies

that are IgM they would only switch to IgG if she happens to see antigens that

are found in her circulation so a lot of times in maternal fetal hemorrhage so

like placental abruption anything that can cause the fetal circulation to mix with

mom circulation that means the fetuses red blood cells will enter mom circulation which means that the baby

red blood cells have Rh positive on it for example the baby might have gotten

it from the Rh positive father right if the dad was Rh negative then the there's

no way the baby would have had Rh positive one of the parents has to have it so if the moms IgM antibodies see

that Roe antigen on the fetal red blood so it will type switch to IgG and that

means for the second pregnancy it'll automatically cross the placenta and destroy any red blood cells that may

have roll positive antigen on the fetal red blood cells which means the second

the younger brother or the younger sister will end up with polyhydramnios due to like massive destruction of the

fetal red blood cells so my point is the kleihauer-betke test you take the sample

of mom's blood and you look at under a slide and they put a substance on the

plate which basically tells you what percentage it eliminates mom's blood it

dissolves it but basically it tells you what percentage of that blood sample has

fetal red blood cells if it's like 50/50 then you give a certain dose of rhogam

if it's like only 10% fetal red blood cells then you give a lower dose of bro gamma and row gammas antibodies that

will take out the fetal red blood cells in order to hide it from Mom's

pre-existing antibodies so then she doesn't have sensitization 

Preeclampsia – hypertension with proteinuria P/C > 0.3 greater than 300 mg of proteins per day + hypertension 140 / 80, associated with complications, preterm delivery, placental abruption, fetal hypoxia

Dangerous for mom – complications, urinate out protein, edema from third spacing decreased intravascular decreased oncotic pressure, pulmonary edema

Most feared – preeclampsia severe features – eclampsia, preeclampsia + seizure

Severe features > 160 / 110 or evidence of end organ damage

PULMONARY edema – furosemide

Herpes simplex – acyclovir up to delivery

Delivery vaginally if no lesions

 

so next is preeclampsia preeclampsia is defined as

hypertension with proteinuria so you have to have proteinuria and how

do you define proteinuria that's a protein to at one ratio of greater than 0.3 or

greater than 300 milligrams of protein per day if you have that plus

hypertension which is one over 140 over 90 this is defined as preeclampsia

preeclampsia is dangerous because it is associated with a lot of

complications such as preterm delivery placental abruption fetal hypoxia etc

but it's also dangerous for the mom in that she can have a lot of complications

because she's urinating out so much protein she's prone to getting edema

from third spacing due to decreased intravascular oncotic pressure and she

can get pulmonary edema etc and so also the most feared complication as the

progression of preeclampsia to preeclampsia with severe features to the

most feared one which is a clamp SIA and a clamp SIA is basically just preeclampsia which now has gotten so

severe that it's caused seizures and that's called eclampsia preeclampsia with severe features is defined as

preeclampsia where the blood pressure is over 160 over 110 or with evidence of

end organ damage whether it's a kidney damage like a cute kidney injury or

elevated liver enzymes or encephalopathy so first-line treatment for pulmonary

edema would be furiosa mite which is a loop diuretic another thing is a 

HSV leading to delivery, 

Hemophlus ducreyi – genital ulcers, chancroid, histology school of fish, ragged edges, necrotic base – CTX, Azithromycin

Chancre, smooth hard border – Syphilis, IM PCN, 2nd, condyloma lata, palmar rash, tertiary – neurosyphlis tabes dorsalis, syphlic aortitis, encephalitis, longer IV pcn

mom who

has herpes simplex virus you want to give her a psych levere leading up to

delivery and if she's adherent to the acyclovir then she can deliver vaginally

if there are no new genital lesions however if she's experiencing prodrome

such as like itchiness or pain or new genital lesions or

then she should do a c-section next is chancroid which is caused by

Hema Phyllis Duke reaiiy and remember this is action this is the one of the few genital ulcers that are painful the

other one would be herpes and so shank roid will be described as having ragged

edges on necrotic base and on histology it has the school of fish description

and then you want to treat it with ceftriaxone and as a throw Meissen versus a chancre which is a painless

ulcer which has a smooth hard border and this is caused by syphilis and you want

to treat that with intramuscular penicillin and remember it can advance

to the second stage which has the condyloma Lata with the palmer ash and

it can also advance to the tertiary stage which causes neurosyphilis tabes

dorsalis cephalic a or Titus and Saif Titus etc and those ones you want to

treat that with longer IV penicillin so 

risk factors for placental abruption – trauma, htn, cocaine, polyhydramnios

trauma, htn, cocaine, smoking

amniotic sac so heavy causing detachment, poor blood flow can cause detachment

painful, third trimester, 

decreased arteriolar diameter poor blood flow

are trauma previous abruption hypertension cocaine polyhydramnios

because I just think of it as the the amniotic sac is so heavy that it can

cause detachment and then cigarette use and you know if you think about it like cocaine hypertension cigarette use these

are all associated with decreased arteriolar diameter and that can cause

poor blood flow to the placenta which makes it weaker which can cause it to detach and abruption is one of the types

of third trimester leading remember that it's very painful the mom will have

abdominal pain a lot of uterine contractions and it's an vaginal

bleeding but this is painful compared to placenta previa which is

painless bleeding and that's caused by the abnormal position the placenta covering the cervical Oz

C-section increased risk for placenta previa, scar tissue, bad site for implantation due to uneven surface, increased placenta previa, increta, accrete, percreta

Accrete shallow form, incretainto the myometrium, percreta all the way to the uterus and invade the bladder causing hematuria

AIP, accrete percreta, C-section percreta goes to endometrium won’t detach

when you do a c-section you're now at an increased risk for placenta previa

because of that scar tissue it makes it so that the human body is very smart

it'll notice that that scar tissue is a bad site for plantation due to like the

uneven surface so that causes mom to be increased for having placenta previa

also it increases the risk once you have placenta previa you're also at increased

risk for something called placenta in Crito placenta accreta placenta percreta placenta accreta

is the shallowest form where your placenta basically attaches to the

beginning of the myometrium listen to accreta it goes into the myometrium and

then placenta percreta goes all the way through the uterus and sometimes it

might even start invading the bladder and then this can cause hematuria if mom has any of these cases of

placenta accreta percreta in Krita which basically means that the placenta is

fused to the endometrium then the only option is to do c-section at delivery

because that placenta more detach and it'll cause massive postpartum hemorrhage next is the 

Cutaneous manifestations – intrahepatic cholestasis, itching at night on palms and soles, elevated liver enzymes, increased bile acids and bile salts, itchy, elevated bile salts, LFTs treat with urodial, lowers serum bile acids levels PUP: pruritic urticarial plaques and papules of pregnancy – stretch marks over abdomen, itchy, plaques and papules, eczyma dermatitis striae, itchy, benign steroids, herpes gestationalis: bullous pemphigoid, antibodies IgG attack the desmosomes intermediate filaments, treatment steroids, vesicles on the abdomen

big three

cutaneous manifestations of pregnancy the first is intrahepatic cholestasis of

pregnancy this is characterized by really severe itching at night especially on the palms and soles there

will be elevated liver enzymes due to liver damage but the key here is

elevated systemic bile acid levels these bile acids or bile salts will deposit on

the skin which causes severe pruritus so remember it's very itchy elevated bile

salts elevated lfts and you want to treat this with Urso dial which

basically lowers serum bile acid levels next is pup which is paretic Dudek

aerial acts papules of pregnancy mama when she is pregnant will develop stretch marks over

her abdomen but these stretch marks will actually start to get really itchy

she'll also develop plaques and papules and of like an eczema like dermatitis

type of presentation over these striae and then it's very very itchy but it's

benign and you treat it with steroids next is herpes just de chillon us which is basically like bullous pemphigoid of

pregnancy if you remember you know like pemphigus vulgaris and bullous pemphigoid bullous pemphigoid is when

you have the antibodies the IgG that attacks the Hemi desmosomes which are

intermediate filaments that anchor cells to the basement membrane you get antibodies attacking that and then she

met with this is corticosteroids and its presence with you know vesicles on the abdomen and extremities next is 

Acute fatty liver of pregnancy – deliver right away, N/V, hypoglycemia, elevated LFTs, mitochondrial dysfunction, deliver immediately

Increased DVT compression of IVC, increased systemic estrogen, hypercoagulable state

Symptoms – one leg bigger than the other in lots of pain, do a venous duplex

DVT can lead to pulmonary embolism

Abrupt onset dyspnea, tachycardia, tachypnea with a low PaO2, PE pregnant women CT angio – radiation is toxic to the baby do a V/Q scan

PE heparin / rivaroxaban

acute

fatty liver of pregnancy when you hear this remember this is an emergency the baby is at an immediate high risk of

death and you want to deliver right away so how do you define this main thing is like nausea and vomiting

hypoglycemia elevated liver enzymes this is caused by mitochondrial dysfunction

of breaking down fatty acids and yeah you want to deliver this baby immediately remember that pregnant women

are at increased risk of DVT via compression of the IVC which leads to

stasis and also due to the increased systemic estrogen which puts you in a

hypercoagulable state and then if mom develops symptoms of a DVT which is you

know one leg bigger than the other that is in a lot of pain you wanna do a venous duplex what what's dangerous is

that a DVT can lead to a pulmonary embolism a PE and the main things you

want to look for in a PE is abrupt onset of dyspnea tachycardia and tachypnea

with the low pulse ox or low pao2 if you have that then it's most likely a

PE and remember Ana pregnant you don't want to do a CT angio because

the radiation is toxic to the baby so you want to do a VQ scan also to treat a

PE you start with heparin or you can treat with rivaroxaban 

Amniotic fluid embolism – bloodstream through delivery, presents as PE, confusion and rash on chest, associated with C-section, supportive

Amniotic fluid embolism – DIC disseminated intravascular coagulation, magnesium, deliver right away

Eclampsia with severe features – magnesium and deliver

First sign of magnesium toxicity – hyporeflexia

DIC associated with abruption / preeclampsia and amniotic fluid embolism

amniotic fluid

embolism is another complication of delivery and this is when the amniotic

fluid gets into the maternal bloodstream through delivery and this is basically

presents like a PE - but it causes confusion and then rash on the chest and

its associated with c-section and abruption and then treatment for this is mainly

just supportive and then remember that amniotic fluid embolism can cause di C

anytime someone with preeclampsia has severe features or has progressed to

eclampsia then you want to remember two things you give magnesium and you deliver right

away and why do you give magnesium that's because it prevents seizures and

if they have a clamp SIA they already have seizures so you give magnesium as well but sometimes you have to monitor

because it's easier to have toxic magnesium levels so they tend to ask you

what is the first sign of magnesium toxicity and that's usually hyporeflexia

and that's the first line so yeah di c is associated with abruption

preeclampsia and amniotic fluid embolism 

Term start of week 37, start of 42 post term before 32 give magnesium to help develop nervous system of fetus and decrease cerebral palsy

Magnesium up to 32

Preterm deliveries – tocolytics up to week 34 terbutaline, indomethacin, up to 34 to delay delivery, dexamethasone up to week 37 promote long term maturity

Steroids help to lessen respiratory distress syndrome

 

so there's three drugs you can give

leading up to term and remember term as described as a start of week 37 the

start of week 42 is considered a term it fits before week 32 you want to give

magnesium because this helps development of the nervous system of the fetus and

it helps prevent cerebral palsy you give magnesium all the way up to week 32

after that you don't need to give magnesium anymore the next thing you want to think about giving for preterm

deliveries is tocolytics so tocolytics can be used up to week 34 common

tocolytics would be like butylene indomethacin and you want to

give this up to week 34 to help delay delivery so the baby can mature more and

then the last one is betamethasone which is a steroid and you can give this up to

week 37 and the reason why you want to give steroids up to week 37 is to help

promote lung maturity yeah so steroids have been proven to minimize the chance

of respiratory distress syndrome 

so if it's week 32 you want to give magnesium

tocolytics and steroids at week 34 tocolytics and steroids up to week 37

you give just steroids after that you don't need to supplement so neonatal infections remember the big three

neonatal infections less than 3 months old – GBS + listeria

group B strep agalactiae, listeria BELL: B strep e. coli Listeria

BEL

bacteria that are associated with infections in babies less than three

months old and that's Group B Strep eagle-eye and Listeria so that spells up

l ee l and those are the three kind of neonatal infections which are so she'd

of like meningitis 

PPROM – rupture of amniotic fluid – oligohydramnios, baby no longer floating in low gravity environment and can compress the umbilical cord

VEAL CHOP MINE

Variable deceleration, Cord Compression, Maternal Repositioning

Early deceleration, Head compression, Identify labor progress

Acceleration Okay No interventions

Late deceleration Placental Insufficiency Execute interventions

Oligohydramnios

another mechanism I want to talk about is preterm premature

rupture of the membranes so with preterm premature rupture of the membranes

you'll have leakage of amniotic fluid which leads to a logo hi jam nose when

you have a Lego hi jam nose this basically means that the baby is no longer floating in like a low gravity

environment and its weight can compress the umbilical cord when this compresses

it can cause recurrent variable decelerations which is what you'll see on the fetal

heart rate tracing where the heart rate of the baby dips down really quick and

then comes back up really quickly because the normal deceleration is usually the head compression one is when

 

 

you have the uterus contracting and then the heart rate will come down and up

gradually as a mirror image hypoxia is the second one where it will go down

gradually and come back up but it's late it's always late after the uterine

contraction and then the last one is recurrent variable decelerations which is random dips and

heart rate that come back up very quickly it's not gradual it's very sudden and this is a sign of cord

 

compression so if you see the recurrent variable decelerations you should think that there's a cord

hypoxia – is late

recurrent variable sudden – cord compression

recurrent variable – cord compression reposition the mom so baby isn’t squishing the umbilical cord or give amnio infusion

compression and what you want to do is reposition the mom so that she doesn't

so that the baby isn't squishing the umbilical cord or you want to give amnio

infusion 

Parvovirus – subtly in pregnant women – arthralgias, myalgias – rheumatoid arthritis MCP, metacarpal phalangeal joint not feeling well

RA = months to years

Parvo – days to weeks

Parvo – destroys fetal erythrocytes – aplastic anemia, destruction of all three cells lines

Red blood cells, white blood cells, platelets

Aplastic crisis just decreased RBCs, baby’s heart rate will speed up to optimize perfusion make up for decreased RBCs leading to heart failure leading to pulmonary edema and third spacing

Hydrops fetalis

RBCs, destroyed liver will make up by making RBCs, compromise and liver makes less albumin, less intravascular oncotic pressure, third spacing

another mechanism i want to talk about is parvo virus so parvo virus

can present very subtly and the pregnant mother which presents with arthralgias

malaise and myalgias I kind of think of it as very similar sounding to

rheumatoid arthritis she'll have like metacarpal phalangeal joint pain not feeling well but it's more transient

compared to rheumatoid arthritis which is more like over the course of months but adult parvo virus is more like acute

onset last the last few days and so when the mom is affected with parvo virus

this actually attacks on the fetal

erythrocytes the reticulocyte and when it destroys all the funeral

reticulocytes this causes something called aplastic anemia which shouldn't be confused with

aplastic crisis aplastic anemia is when you have destruction of all three cell

lines which destroys you know platelets white blood cells and red blood cells aplastic crisis is when you have just

decreased red blood cells when you have decreased red blood cells then the

baby's heart rate will speed up tachycardia to try and optimize perfusion to make up for the decreased

amount of red blood cells but what will happen is this will lead to heart failure and then when it leads to heart

failure that will lead to pulmonary edema and third spacing and this leads to high drops

Vitalis but remember that also when the red blood cells are

being destroyed so much delivery we'll try to make up for it by trying to make more red blood cells but by doing that

it has to compromise it makes less albumin and when you have less elbe you mean that has less intravascular oncotic

pressure and that exacerbates even more third spacing and that's kind of like the mechanism for hydrops fetalis

Hydrops fetalis – decreased RBCs, Increased Cardiac output, pulmonary edema, third spacing, liver more RBCs, liver less albumin more third spacing

 sign

what would be a fetal heart rate tracing sign of anemia that's sinusoidal heart rate pattern

which you see the sign waves that would be something you would see in a parvovirus infection of the fetus what

 

Sinusoidal waves, parvovirus

Lupus – complete heart block, CMV, CMV 

MR DICS – microcephaly, retardation, deafness, intraventricular calcicications,  Seizures

 

 

would you see in a mother who has lupus a mother who has lupus is associated in

the fetus with a complete heart block next is CMV and CMV is characterized by

having mnemonic for cytomegalovirus so C stands for Koryo retinitis M stands for

microcephaly and V stands for ventricular calcification and you prevent this by hand washing and not

sharing utensils with kids and that's one of the common perinatal infections

CMV – handwashing not sharing utensils

Toxoplasma: Cranial calcifications, undercooked meats, chorioretinitis, hydrocephalus

Pyramethamine sulfadiazine treat Bactrim

rubella Cataracts, patent ductus arteriosus, deafness

another one has Toxoplasma which is caused by eating undercooked meats or

cysts from cat feces and this has a triad of cranial calcifications Koryo

retinitis and hydrocephalus and you treat the mom with Spira my son and the

fetus with Pyrrha F amine or sulfadiazine there's also rubella and rubella triad is cataracts deafness and

cardiac anomalies do you remember what the cardiac anomaly is it's patent

ductus arteriosus or pulmonic stenosis 

amniotic fluid volume 5 to 25 centimeters

oligohydramnios, polyhydramnios

oligohydramnios 3 cm oligohydramnios 30 polyhydramnios

sinusoidal, polyhydramnios, middle cerebral artery doppler increased flow anemia

normal amniotic fluid volume is usually

from 5 to 25 centimeters it's important to know this because sometimes they'll

indirectly tell you oh look oh hi dream yes or polyhydramnios so if it's 3

centimeters and that's Allegro Hydra meiosis if it's 30 that's polyhydramnios so what's another way to diagnose anemia

in the fetus other than the fetal heart rate which would be sinusoidal another way is you can do the middle cerebral artery, below 10th percentile be reverse flow fetal hypoxia

cerebral artery Doppler studies if you see increased flow this is anemia this

is a way that also detect it in babies who have sickle cell another way to

diagnose intrauterine growth restriction which is defined as size of the fetus

below the 10th percentile is to measure the umbilical artery Doppler and then

reverse flow in the umbilical artery as a bad sign that's basically saying if

there's fetal hypoxia and you want to deliver right away in the baby who was just born air horn – getting

 

Chlamydia + gonorrhea

Gonorrhea days 3-5

Chlamydia days 7+

Erythromycin

CTX, azithromycin

Gonorrhea – erythromycin

Chlamydia – not effective with topical eye drops, oral systemic

conjunctival

conjunctival infections and you want to cover for chlamydia and gonorrhoea

so gonorrhea happens in day 3 to 5 and chlamydia tends to happen on day 7 for

come on a caucus that's where you give the erythromycin topical eye drops that

prevents a monocle conjunctivitis but for chlamydia it's not effective

with topical eyedrops you want to give oral systemic and that's if you have

conjunctivitis on day 7 

VL < 1000 HIV vaginally over C-section

Hepatitis B: antibodies: vaccinations

so an HIV mom can only deliver vaginally if her viral

load is less than a thousand copies of RNA per mil if it's greater than that

then she has to do a c-section if a mom has hepatitis B then you should give

hepatitis B antibodies and vaccinations at birth so there's also something

called 

TPO, Microsomal

Inflammation leading to destruction of gland releasing preformed thyroid hormone

Hyperthyroidism, iodine uptake test how to conclude things based on iodine studies

Radioactive iodine uptake lots of uptake thyroid actively making new thyroid

Thyroid gland is not actively making new thyroid

Postpartum thyroiditis, hyperthyroid decreased uptake, hyperthyroidism caused by active thyroid gland 

Iodine uptake test low, lots of uptake new gland

postpartum thyroiditis which is found in patients who have the same

antibodies as Hashimoto's thyroiditis which is anti-thyroid peroxidase and

anti microsomia antibodies but basically what happens after birth is you get

inflammation of the thyroid which leads to destruction of the gland and then

this basically releases all the preformed thyroid hormone which causes

transient hyperthyroidism at this point if you do an iodine uptake it'll be low

and iodine uptake they like to test you on this because they want you to know how to conclude

certain things based on the iodine studies and radioactive iodine uptake if there's a

lot of uptake that's a sign that the thyroid is actively making new thyroid

and if it's not taking anything up then that means that the thyroid gland isn't

making any more new thyroid so in postpartum thyroiditis you will be hyper

thyroid but there will be decreased uptake because this hyperthyroidism is

caused by an inactive thyroid gland that is leaking out all the preformed thyroid

after that happens it becomes hypothyroid and then recovers back to you thyroidism so for example someone

Graves TSH receptor antibodies lots of thyroid hormone, radioactive iodine, diffuse uptake

with like Graves disease you know the TSH receptor antibodies are causing you to make so much thyroid

hormone all the time so if you were to give someone with Graves disease a

radioactive iodine uptake then you'll see diffuse uptake because that iodine is getting sucked up into the thyroid

gland and it's the thyroid making factory and they're hyper thyroid because they're actively making thyroid

hyperthyroid actively making thyroid

postpartum inflammation and leakage

but in postpartum thyroiditis this is due to inflammation and leakage and not

due to active formation and then you should know about 

symmetric – head and body equal size, chromosomal, torch, toxoplasma, syphilis, rubella, herpes

asymmetric – head big, body not, hypoxia, placental insufficiency, htn, poor nutrition

baby during development to shunt blood supply to head and favor development of ehad over body

asx bacteriuria high risk for pyelonephritis ucx, asymptomatic, ppx antibiotics

nonpregnant, nitrofurantioin, TMP, SMX, fluoroquinolones

pregnant can’t give TMP SMX neural tube defects inhibit folate 

no fluoroquinolones hurt bones and tendinopathy

pregnant amoxicillin, nitrofurantoin, cephalopsporins

symmetric growth and

asymmetric growth in babies who have intrauterine growth restriction they can

have symmetric growth which means the head and body or equal size versus asymmetric growth which is where the

head is really big and that and then the body is a lot smaller in comparison and the symmetric ones are caused by

chromosomal or like the torch congenital infections like Toxoplasma syphilis

rubella CMV herpes but asymmetric growth is caused by hypoxia like placental

insufficiency so like hypertension smoking poor nutrition this causes the

baby during its development to shot all the blood supply to the head and favor

development of head over the body as a sacrifice so remember asymptomatic bacteriuria and

pregnancy is high risk for pyelonephritis so that's why you do the

urine culture in the first trimester and if it's asymptomatic you still give

prophylactic antibiotics so the first line UTI is in pregnancy are like

amoxicillin cephalosporin and nitro for aunt Owen but in non pregnant UTI is the

first lines first line is like TPMS MX nitro fianto in or fluoroquinolones well

in pregnant people you can't give TPMS MX because it can cause neural tube defects because it inhibits folate and

you can't give fluoroquinolones because fluoroquinolones hurt the bones and it causes tendinopathy

yes so basically remember the the first-line drugs for pregnant UTI or amoxicillin cephalosporins or nitro for

GBS prior to delivery 4 hours ampicillin

4 cases

1) Prior child w/ GBS infection

2) GBS on urine culture

3) ASX or SX UTI

4) GBS screening 35 – 37 weeks

an twin also you want to know when to give ampicillin prophylaxis for mom in

terms of Group B Strep prior to delivery and usually you give it four hours before delivery the

scenarios where you give a prophylactic ampicillin or penicillin is if the mom

has had a prior pregnancy where a kid has had infection by Group B Strep or

during this pregnancy she was found to have Group B in her urine culture or if

during this pregnancy she's had a UTI whether it's symptomatic or asymptomatic

then you're gonna give prophylaxis for a group B strep no matter what word by

default - during weeks 35 to 37 you usually give you do a genital culture

anyways an anal culture to check for Group B Strep if that's positive then you're gonna

give ampicillin penicillin prophylaxis four hours to delivery as well if the

mom you don't know her Group B Strep status because she wasn't following up

to her clinic visit they you give Group B Strep under three

conditions 

1) Maternal infection

2) Prolonged rupture of membranes 18 hours

3) Preterm delivery – give ampicillin or penicillin prophylaxis

one is maternal fever two is prolonged rupture of the membranes which

has created than 18 hours of rupture of the membranes which I talked about

earlier and the third is if you don't know her status and she's preterm then

you're gonna give ampicillin or penicillin prophylaxis 

ECG – endometritis clinda and genta

remember the most common cause of post c-section fever is

endo Myo metritis and you treat that with gentamicin and clindamycin then

there are 

fluctuant – fluid underneath the skin dicloxacillin and I and D

breast abscesses the main cause is staph aureus and this is a red

block Xuan is the key word fluctuate means that it feels like there's fluid underneath the skin and you want to

treat that with dicloxacillin and incision and drainage and if it's hard

to tell the difference between that and cellulitis then you want to use the ultrasound

Vitamin D + K in breast milk 

remember breastfeeding has all the vitamins except which to vitamin D and

vitamin case you want to supplement that you should also know the differences between breast milk and formula milk

breast whey and casein, formula has more casein, casein is harder to digest, prefer breast milk exclusively for the first 6 months

breast milk has two proteins way and calcium and formula milk also has them

but it has a way higher ratio of calcium than breast milk and Cassie has a lot

more harder to digest which is why we prefer breast milk exclusively for the

first six months before giving any food or eating anything else the baby should be purely dependent on breast milk for

the first six months because it has a lot of antibodies and lysozymes and

protective factors in it and it's been studies have shown that babies who are

breastfed have lower rates of allergies and infections and also it helps up mom

breast feeds lower chance of gestational diabetes

because when mom breast feeds she has lower chances of getting breast cancer remember that gestational diabetes so

Visit 1: CBC, UA, STDs, HIV, Rubella, Blood smear, Pap smear

Week 28 visit diabetes, rhogam, CBC anemia

Week 35 to 37

this is another thing to the prenatal visit the week 28 visit and then the

week 35 to 37 are very important the first visit you

wanna do all everything your standard like CBC UA um s check for all the STDs

HIV you want to check for rubella um check for blood typing do pap smear but

then in week 28 that's when you check for three things diabetes you want to do

a follow-up CBC to see how anemic she is if she's like still within range and

then give rhogam shot if she is uh ro- but this is where you will check for

diabetes and how you do that as you first do the 

50 gram if greater than 140 might have diabetes

Gtt – glucose tolerance 100 grams hours 1, 2, 3, 180, 160, 140

If 2/3 too high gestational diabetes

50 gram glucose load after

one hour if it's greater than 140 then that means she might have diabetes so we

advance to the second stage which is the glucose tolerance test you give her a hundred grams of glucose this time and

you measure her glucose at hours one two and three if it's greater than 180 161

and you diagnosed her with gestational diabetes and then with gestational

diabetes the first-line treatment is going to be diet but then if she doesn't

improve her glucose levels with diet then the second line you want to start

is insulin if you do a

fundal height test – incongruent with baby’s age, do ultrasound

 fundal height test and you notice that it's

incongruent with the baby's age then the next step you want to do is an

ultrasound to see what's happening that is it probes tetrax and then the next part we're going to talk about fine