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