Pregnancy

·         In a normal pregnancy, ß-hCG levels approximately double every 48 hours, and serum progesterone is typically greater than 10 ng/mL.

·         Pregnancy is a hypercoagulable state due to increased clotting factors and venous stasis.

·         To decrease group B streptococcal neonatal sepsis, the CDC recommends screening with vaginal and rectal cultures in the late third trimester and prophylaxis in labor for patients who carry the bacteria.

·         In Hyperemesis gravidarum, for women with severe, prolonged vomiting, supplemental thiamine should be given to prevent Wernicke's encephalopathy.

·         RULES OF 15:

15% of the obstetric population have abnormal glucose load test (GLT)

15% of patients with abnormal GLT have abnormal OGTT

15% of patients with abnormal OGTT require insulin

15% of all patients with GDM have infants > 4000 gm

Capillary levels are about 15% higher than plasma levels after meals.

·         Screening for GDM is done with the 1-hour 50 gm glucose tolerance test at ~28 weeks, gestation, and diagnosis is made with the 3-hour 100-gm glucose tolerance test if the 1-hour screen is positive.

If a woman has a history of GDM, her lifetime risk of developing type 2 DM is 36%, which is why a 2-hour 75-gm glucose tolerance test is recommended 6 weeks postpartum.

·         The sulfonylurea glyburide does not cross the placenta in significant quantity.

·         PTU is the first-line treatment for hyperthyroidism because methimazole is associated with a risk of aplasia cutis.

·         "Trimethadione syndrome" consists of developmental delay, low-set ears, palate anomalies, irregular teeth, speech disturbances, and V-shaped eyebrows. Intrauterine growth retardation, short stature, cardiac anomalies, ocular defects, simian creases, hypospadias, and microcephaly are also often present. Up to two-thirds of exposed fetuses will manifest congenital defects. Because trimethadione is associated with a greater risk of anomalies compared with other anticonvulsants, its use should be abandoned.

·         Do not forget subacute bacterial endocarditis prophylaxis at the time of delivery in women with cardiac valvular disease and ventricular septal defects.

·         Peripartum cardiomyopathy:

1.       Heart failure within the last month of pregnancy or 5 months postpartum

2.       Absence of prior heart disease

3.       No determinable cause

4.       Echocardiographic indication of left ventricular dysfunction: ejection fraction < 45%, fractional shortening < 30%, or left ventricular end-diastolic dimension > 2.7cm/m2.

·         Women with myasthenia gravis should not receive magnesium sulfate.

·         The main fetal risk of maternal ITP is that of intracranial hemorrhage (ICH).

·         Conditions Specific to pregnancy presenting as ruq pain:

Severe preeclampsia-nausea, vomiting, and right upper quadrant pain may all be present.

Hepatic capsule rupture-a dramatic complication of severe preeclampsia/HELLP syndrome, marked by sudden onset of upper abdominal pain, nausea, vomiting, and fever. Rupture may be heralded by shock and hypotension; the diagnosis is rarely made prior to emergent laparotomy. Maternal mortality has historically exceeded 60%, but is thought to be decreasing secondary to advances in imaging techniques and heightened awareness.

Acute fatty liver of pregnancy-newly associated with a heterozygous deficiency of long-chain 3-hydroxyacyl-CoA dehydrogenase and the patient carrying an affected (homozygous) fetus. In this rare condition (approximately 1 in 1000 deliveries), the patient presents with acute liver failure, renal failure, hypoglycemia which may lead to coma, bleeding diatheses, and metabolic acidosis. The maternal and fetal mortality is approximately 25%.

·         The most common risk factor for Premature Cervical Dilation (PCD) is a history of previous PCD. Congenital cervical hypoplasia and intrauterine diethylstilbestrol (DES) exposure have been reported as risk factors for PCD. Acquired risk factors include previous trauma to the cervix. Cervical conization, amputation, obstetric laceration, and forceful dilatation are examples of such traumas.

·         Fetal fibronectin assays of cervical samples have a high negative predictive value and therefore are used to rule out preterm labor.

Preterm labor does not occur at an increased frequency in diabetic women.

·         Face presentations can deliver vaginally if mentum anterior, but brow presentations are unstable and convert either to face or vertex presentation.

·         An initial spontaneous abortion, irrespective of the karyotype or sex of the child, does not change the risk of recurrence in a future pregnancy. The rate is commonly quoted as 15% of all known pregnancies.

In spontaneous losses, trisomy 16 is the most common trisomy, with 45,X the most common single  abnormality found. At term, trisomy 16 is never seen and 45,X is seen in approximately 1 in 2000 births. It is estimated that 99% of 45,X and 75% of trisomy 21 conceptuses are lost before term.

·         EXERCISE & PREGNANCY:

Women with uncomplicated pregnancies can continue to exercise during pregnancy if they had previously been accustomed to exercising prior to becoming pregnant. Studies indicate that well-conditioned women who maintain an antepartum exercise program consisting of aerobics or running have improved pregnancy outcomes in terms of shorter active labors, fewer cesarean section deliveries, less meconium-stained amniotic fluid, and less fetal distress in labor. On average, women who run regularly during pregnancy have babies that weigh 310 g less than women who do not exercise during pregnancy. Even though birth weight is reduced in exercising pregnant women, there is not an increased incidence of intrauterine growth retardation. The American College of Obstetricians and Gynecologists recommends that women avoid exercising while in the supine position to avoid a decrease in venous return to the heart, which results in decreased cardiac output. In addition, women should modify their exercise based on symptoms. There is not set pulse above which exercise is to be avoided; rather, women should decrease exercise intensity when experiencing symptoms of fatigue. Non-weight-bearing exercises will minimize the risk of injury. Since the physiologic changes associated with pregnancy will persist from 4 to 6 weeks following delivery, women should not resume the intensity of prepregnancy exercise regimens immediately following delivery.

·         This significant arterial hypotension resulting from inferior vena cava compression is known as supine hypotensive syndrome or inferior vena cava syndrome. Therefore, it is not recommended that women remain in the supine position for any prolonged period of time in the latter part of pregnancy. When patients describe symptoms of the supine hypotensive syndrome, there is no need to proceed with additional cardiac or pulmonary workup.

·         ROUND LIGAMENT PAIN: Each round ligament extends from the lateral portion of the uterus below the oviduct and travels in a fold of peritoneum downward to the inguinal canal and inserts in the upper portion of the labium majus. During pregnancy, these ligaments stretch as the gravid uterus grows further out of the pelvis and can thereby cause sharp pains, particularly with sudden movements. Round ligament pain is usually more frequently experienced on the right side due to the dextrorotation of the uterus that commonly occurs in pregnancy. Usually this pain is greatly improved by avoiding sudden movements and by rising and sitting down gradually. Local heat and analgesics may also help with pain control.

·         ECV has an average success rate of about 60%; it is most successful in parous women with an unengaged breech and a normal amount of amniotic fluid (all conditions that exist in the patient described).

·         A biophysical profile (BPP) is another type of antepartum surveillance test and involves using a real-time ultrasound device and Doppler ultrasound to record fetal heart rate. The BPP looks at the following variables: fetal heart rate accelerations (NST), fetal breathing, fetal movements, fetal tone, and amniotic fluid volume. To achieve a perfect score, the fetus must have a reactive NST, at least one episode of breathing lasting longer than 30 s within 30 min, at least three discrete body movements within 30 min, at least one extension-flexion movement of a limb within 30 min, and a single vertical pocket of amniotic fluid measuring 2 cm. A modified BPP entails performing an NST and assessing the amniotic fluid index; a reactive NST and an AFI greater than 5 is a normal or negative test. The false-negative rate for BPP and modified BPP is 0.8 in 1000.

·         The therapeutic range of serum magnesium to prevent seizures is 4 to 7 mg/dL. At levels between 8 and 12 mg/dL, patellar reflexes are lost. At 10 to 12 mg/dL, somnolence and slurred speech commonly occur. Muscle paralysis and respiratory difficulty occur at 15 to 17 mg/dL, and cardiac arrest occurs at levels greater than 30 mg/dL.

·         Spectinomycin is the treatment of choice for pregnant women who have asymptomatic N. gonorrhoeae infections and who are allergic to penicillin. Erythromycin is another drug that is effective in treating asymptomatic gonorrhea.

·         Pruritic urticarial papules and plaques of pregnancy (PUPPP) is the most common dermatologic condition of pregnancy. It is more common in nulliparous women and occurs most often in the second and third trimesters of pregnancy. PUPPP is characterized by erythematous papules and plaques that are intensely pruritic and appear first on the abdomen. The lesions then commonly spread to the buttocks, thighs, and extremities with sparing of the face. The first-line treatment for PUPPP is oral antihistamines and topical corticosteroids. If these treatments do not give relief, oral steroids should be administered. The rash will resolve quickly following delivery, but delivery would not be the first-line treatment.

Herpes gestationis is a blistering skin eruption that occurs more commonly in multiparous patients in the second or third trimester of pregnancy. The presence of vesicles and bullae help differentiate this skin condition from PUPPP.

Prurigo gestationis is a very rare dermatosis of pregnancy that is characterized by small, pruritic excoriated lesions that occur between 25 and 30 weeks. The lesions first appear on the trunk and forearms and can spread throughout the body as well.

In cases of intrahepatic cholestasis of pregnancy, bile acids are cleared incompletely and accumulate in the dermis, which causes intense itching. These patients develop pruritus in late pregnancy; there are no characteristic skin changes or rashes except in women who develop excoriations from scratching.

Impetigo herpetiformis is a rare pustular eruption that forms along the margins of erythematous patches. This skin condition usually occurs in late pregnancy. The skin lesions usually begin at points of flexure and extend peripherally; mucous membranes are commonly involved. Patients with impetigo herpetiformis usually do not have intense pruritus, but more commonly have systemic symptoms of nausea, vomiting, diarrhea, chills, and fever.

·         Three techniques for cervical cerclage are used today.

1. Shirodkar technique. In the more complicated of the two procedures using a vaginal approach, the suture is almost completely buried beneath the vaginal mucosa at the level of the internal os. It can be left in place for subsequent pregnancies if a cesarean section is performed. This procedure requires dissection of the bladder and is associated with an increased blood loss.
2. McDonald technique. This procedure is a simple purse-string suture of the cervix and is simpler, incurring less trauma to the cervix and less blood loss than the Shirodkar procedure (Fig. 12-4).
3. Abdominal placement. This uncommon, permanent procedure is used in women with a short or amputated cervix or in those in whom a vaginal procedure has failed. Cesarean birth is necessary for delivery.

·         When tocolysis requires multiple agents, chorioamnionitis must be considered.

·         Current IUD use, not past IUD use, places the patient at risk for ectopic pregnancy. Chronic endometritis is not associated with ectopic pregnancy because this inflammation does not involve the fallopian tubes. Age is not a risk factor for ectopic pregnancy