OBGYN - Key Points - Pre & Postpartum + Labor & Delivery

What is CHADWICK SIGN bluish discoloration of the vagina and cervix that is a SIGN OF EARLY PREGNANCY UPTs measure hCG levels. When are urine pregnancy tests positive? NOT BEFORE IMPLANTATION (+ as early as 7-10 days after conception) Implantation Occurs 8-10 days after ovulation (7-9 days after fertilization) Home pregnancy tests Home tests are good, but have more false negatives, especially if done too early before levels are 250 at time of missed period. When concerned about an abnormal pregnancy, ______________ are checked to look for expected increase in level (double every 2 days) serial hCGs What is a Molar pregnancy? (AKA hydatidiform mole)- a rare complication of pregnancy characterized by the abnormal growth of trophoblasts, the cells that normally develop into the placenta What is Polyhydramnios? excess amniotic fluid in amniotic sac How is pregnancy diagnosed? Don't need u/s to diagnosis pregnancy! hCG testing (blood or urine) is enough. Weeks gestation is based on LMP (so 4 weeks gestation is at time of missed period, fertilization occurs at 2 weeks gestation) How do you calculate Estimated Date of Delivery (EDD)? First day of LMP + 7 days - 3 Months EFW is measured in the 2nd trimester via US. What parameters are used to measure estimated fetal weight? HC BPD AC FL What are the important things to know about hCG in pregnancy? Found in maternal plasma and urine, may contribute to causing nausea and vomiting often associated with pregnancy. What are the Cardiovascular changes of pregnancy? o Cardiac output – ↑ 30-50% - Increased heart rate and stroke volume - Late pregnancy, may ↓ in certain positions (pressure on vena cava) o Circulating blood volume ↑ 45-50% o Peripheral vascular resistance ↓ o Arterial blood pressure - ↓ during 1st 24 weeks, then gradual ↑ to non-pregnant levels by term Resistance decreases due to smooth muscle relaxing effect of progesterone, increased production of vasodilatory substances (prostaglandins), and AV shunting to the placenta/fetus What are the normal Cardiovascular exam findings during pregnancy? Which murmurs are abnormal and need to be worked up? Common/normal findings on cardiac exam during pregnancy: - Increased S2 split with inspiration (not fixed) - Mild distension neck veins (↑ plasma volume in pregnancy) - Low grade systolic ejection murmurs (↑ blood flow/CO in pregnancy) - S3 gallop after mid-pregnancy (blood hitting compliant left ventricle) - Anatomically displaced PMI upward and to the left Diastolic murmurs abnormal and should be worked up What are the hematologic changes of pregnancy? ↑ Plasma vol (Gradual increase beginning at 6 weeks, reaches a maximum at 30-34 weeks; Overall, ↑ by 50% (greater in multiple gestations) ↑ RBC vol (later in preg; “physiologic anemia” due to dilution) ↑ WBC Hypercoagulable state 2/2 ↑ Clotting - ↑ risk of venous thromboembolism (2 to 5.5 x normal) - Because the concentration of numerous clotting factors increase in pregnancy o Serum iron needs ↑ (Adequate iron intake is needed to support this increase in RBC volume) What are the pulmonary changes of pregnancy? o Effect on pulmonary functions ↑ TV ↓ RV ↓ FRC ↓ TLC o Mucosal hyperemia = Nasal congestion, “chronic cold” o Anatomic changes due to enlarged uterus (Subcostal angle, chest circumference/diameter and diaphragmatic excursion ↑) What are the renal changes of pregnancy? o Kidneys enlarge ~ 1 cm due to interstitial volume and distended renal vasculature o Renal pelvis and ureters dilate due to relaxing effect of progesterone o Bladder tone decreases with residual volume nUrinary stasis increases incidence of UTI during pregnancy o Bladder capacity ↓ = urinary frequency and incontinence o Renal plasma flow ↑ early, may ↑ by as much as 75% o Glomerular filtration rate ↑ to 50% o Creatinine clearance ↑ o Serum levels of creatinine, uric acid and BUN ↓ (plasma osmolality ↓ due to ↓ Na+ concentrations) o Increased GFR results in increased glucose excretion o Renin, angiotensinogen, and angiotensin all increase + urine dipstick for trace amounts of _______________ doesn't necessarily mean it is pathologic in pregnancy glucose Have ↑ GFR in pregnancy, so have ↑ glucose excretion What are the GI changes of pregnancy? o Morning sickness - Begins ~ 4-8 weeks gestation, usually ends by 14-16 weeks - hCG and progesterone causes relaxation of smooth muscle - Not only in the morning - Hyperemesis gravidarum (Weight loss, electrolyte imbalance; Often requires hospitalization with parenteral fluids & electrolyte replacement) o Decreased gastric motility (2/2 Progesterone causes delayed gastric emptying and ↓ esophageal tone with incompetent GE sphincter à GERD/heartburn) o Delayed gallbladder function o Hemorrhoids (2/2 Constipation and ↑ venous pressure) o Dietary cravings (or aversions) - paper, clay, dirt o Ptyalism – excessive saliva production What are the skin changes of pregnancy? o Spider angioma on upper torso, face and arms – due to estrogens o Palmar erythema due to ↑ estrogens o Sweat and sebum production ↑ causing acne o Hair growth maintained during pregnancy nHair loss ~ 2-4 months after pregnancy o Striae gravidarum - Purple or pink stretch marks - Lower abdomen, thighs and breasts - Due to stretching of normal skin - Will eventually turn white or silvery o Hyperpigmentation due to ↑ estrogen and MSH - Skin nevi ↑ in size and color (rapid changes need to be removed to rule out malignancy) - Linea negra - Melasma (AKA chloasma or “mask of pregnancy”) o Melasma (mask of pregnancy) o Linea alba -- linea negra What are the breast changes of pregnancy? o Breasts increase in size 25-50% - Blood flow to breasts increases - Estrogen stimulates ductal growth - Progesterone stimulates alveolar hypertrophy o Breast tenderness and tingling oAreola/nipple hypertrophy and hyperpigmentation o Montgomery follicles (Small elevations (sebaceous glands) around areola enlarge) o Colostrum is formed in preparation for milk production What are the MSK changes of pregnancy? o Lumbar lordosis - shifted center of gravity (Causes low back pain) o Effects of relaxin and progestin - laxity of ligaments (28-30 weeks gestation pubic symphysis separates) What are the Ophthalmic changes of pregnancy? o Blurred vision due to increased thickness of the corneas associated with fluid retention and decreased intraocular pressure - Transient, usually returns to baseline after delivery What are the Reproductive Tract changes of pregnancy? o Vulva ↑ vascular effect (vulvar varicosities) o Vagina ↑ vaginal discharge (leukorrhea) - Due to pregnancy hormones o Uterus - significant ↑ in size - 70 grams -- 1100 grams - 10 mL -- 5 liters 70 grams = a large egg 1000 grams = a bag of sugar That’s the uterus not the baby 10 mL = 2 tsp What are the Endocrine changes of pregnancy? o Diabetogenic affects of pregnancy - Hyperglycemia, hyperinsulinemia, and reduced tissue response to insulin o Thyroid levels - Estrogen induces hepatic production of TBG à increased total T4 and total T3 - Free T4 and free T3 are unchanged, so woman is euthyroid during pregnancy o Adrenal gland hormones - Estrogen causes cortisol-binding globulin à elevated levels of serum cortisol o Ovaries and placenta - All hormones increase during pregnancy except hCG which peaks at 8-10 weeks gestation, then decreases The concentration of free plasma cortisol progressively increases from 1st trimester to term What are the Dental changes of pregnancy? o Incidence of dental caries should not change unless diet lacks calcium o Gingiva become more edematous and soft and bleed easily - Gingival disease ↑ - Dental care during pregnancy (Local anesthetics without epinephring; Sparing use of x-rays with pelvic shielding) What qualifies as Prolonged contractions? 6 contractions in 10 minutes or duration 2 minutes Normals: - Multigravida = Contractions every 5 minutes for 1 hour - Primigravida = Contractions every 3-4 minutes, 45-60 seconds, for 2 hours Define 1st, 2nd, and 3rd Trimesters: 1st: 0 - 12 weeks 2nd: 13 - 27 weeks 3rd: 28 - 40 weeks - Preterm = 20 - 36 6/7 weeks - Term = 37-41 6/7 weeks * early term: 37 0/7 to 38 6/7 * term: 39 0/7 to 40 6/7 * late term: 41 0/7 to 41 6/7 When is induction recommended (which GA?) Post term 42 0/7 weeks and beyond *Consider at late term (41 0/7 to 41 6/7 ) Define gestational age age of fetus/newborn, in weeks, from first day of mother's last normal menstrual period What medications should you ensure pregnant patients are on? PNV and FOLIC ACID What is Leopolds maneuver? Purpose: to determine the presentation and position of the fetus and aid in the location of FHR Method: explain procedure to pt, have woman empty bladder, wash hands, stand beside, faciterm-36ng woman's head 4 maneuvers True labor is defined as regular painful contractions that result in cervical change (dilation and effacement). Define each - Cervical Dilation: measured in centimeters, closed-10cm - Effacement: thinning of the cx, measured in %, from 0-100% - Station: refers to the presenting part in relation to the ischial spines What is effacement? shortening and thinning of the cervix during the first stage of labor False labor is defined as Braxton-Hicks Contractions. How does it differ from true labor? - Irregular, generally painless uterine contractions - May occur every 10-20 minutes - Increase in intensity during the last weeks of pregnancy - As they increase in frequency and intensity they are distinguished from true labor by lack of cervical change. What is bloody show? It is a small amount of blood at the vagina that appears at the beginning of labor and may include a plug of pink-tinged mucus that is discharged when the cervix begins to dilate. What is dropping or lightening? Last month of pregnancy, head of fetus settles in mother's pelvis How do you tell Vaginal fluid vs amniotic fluid when concerned for premature rupture of membranes in pregnancy (rupture of amnion/chorion prior to labor) Amniotic will have a + Nitrazine pH paper test What is the LONGEST stage of labor? first stage Define the 3 stages of labor. -Stage 1: Beginning of regular contractions to full cervical dilation (10 cm) - Latent and Active stages -Stage 2: Full cervical dilation to delivery of the fetus -Stage 3: After infant is born until Delivery of the placenta Stage 1 of labor: Latent vs Active LATENT: - Onset of labor to initiation of active labor - Painful contractions that lead to slow cervical change ACTIVE: - Period of more rapid cervical change - Starts at 6cm dilation - Rate of cervical change: ** 0.5 – 0.7 cm per hour for nulliparous women ** 0.5 – 1.3 cm per hour for multiparous women SMFM and ACOG consensus Safe Prevention of the Primary Cesarean Section proposes the “active phase arrest should be reserved for women who are 6cm with ROM who fail to progress despite at least 4 hrs of adequate contractions or at least 6 hours of oxytocin Labor isn't a passive process. Uterine contractions alone do not push the fetus through the pelvis and vagina alone. There are different mechanics that labor that consistent of 3 variables. Name them Power, Passenger and Passage Lie: Longitudinal axis of the fetus relative to the longitudinal axis of the pelvis. Transverse, longitudinal, oblique Presentation: The presenting fetal part that overlays the pelvic inlet. Cephalic, Breech or Shoulder Position: Refers to whether the fetus is facing down when mom is on her back (ie: OA, ROA or LOA) or facing up (OP) aka: sunny side up Station:Refers to where the presenting part of the fetus is in regard to the maternal ischial spines in centimeters.-3 is 3 cm above the IS, -2 is 2cm, 0 station is @ the IS and + 1 is 1 cm below the IS and so on. Spontaneous labor Arrest of labor is defined as the lack of spontaneous labor. Spontaneous labor = More than or equal to 6 cm dilatation (active phase) with membrane rupture and one of the following: 1) 4 hours or more of adequate contractions (e.g., more than 200 Montevideo units), examine cervix about every 2 hours. or 2) 6 hours or more of inadequate contractions (with oxytocin) and no cervical change What are the 3 types of declerations? Early → Decelerations that occur with a contraction (Generally, not ominous) Late → A smooth decrease in FHR after the start of contraction (Generally, associated with fetal hypoxemia) Variable → Most common decel seen that Represents umbilical cord compression (Most ominous when repetitive and severe @ 60 bpm) What is a major sign of fetal distress? ***Late Decelerations and Variable Decelerations are FHR patterns that can indicate fetal distress - Decrease in Fetal Movement - Meconium-stained amniotic fluid Late decelerations are a/w... Generally, associated with fetal hypoxemia. §Maternal hypotension §Excessive uterine activity §Placental dysfunction §Potential of perinatal morbidity and mortality Maternal hypotension secondary to epidural Oxytocin augmentation can cause excessive uterine activity or hyperstim of the uterus Chronic dz like maternal HTN, DM and collagen vascular disorders can cause placental dysfunction