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Ob
Pregnancy Tests
The Centers for Disease Control recommends that all pregnant women
without contraindications receive the influenza vaccination. The maternal
morbidity and mortality from influenza every year in pregnant women is
prevalent and preventable. The vaccine is recommended during flu
season and can be given in any trimester. Pregnant women often have
concerns about medications and vaccines in pregnancy; however, thousands
of women have been studied and there are no known fetal malformations
associated with this vaccine.
Quad Tests This test is done in the second trimester in order to detect
fetuses at an increased risk of Down syndrome, neural tube defects and
Edwards syndrome.
If dates are normal & still AFP is abnormal, next best step depends upon the
gestation age. Do Chorionnic Villous Sampling is gestational age is 12-14
week. Do Amniocentesis if gestational age is more than 15.
Pregnancy & Graves Disease - In many patients with Graves disease, the
circulating levels of thyroid stimulating immunoglobulin (TSI) remain as
high as 500 times the normal value for several months following
thyroidectomy. These lgG autoantibodies cross the placenta and can cause
thyrotoxicosis in the fetus and the neonate by directly stimulating the
fetal thyroid gland. Neonatal thyrotoxicosis is an uncommon clinical entity
characterized by goiter, tachypnea, tachycardia, cardiomegaly, restlessness,
diarrhea and poor weight gain in the infant typically within 1-2 days
following delivery.
Pregnancy & DVT - Pregnancy is a major risk factor for deep venous vein
thrombosis, especially during the peripartum period. Femoral vein is a
deep vein. All the segments of femoral vein are considered deep veins. Deep
vein thromboses require anticoagulation with heparin.
Pregnancy & Renal Function - Renal plasma flow and glomerular filtration
rate are increased in pregnancy, which causes a decrease in the serum
BUN and creatinine from the patient's pre-pregnancy baseline. This
increase in renal function begins early in the first trimester, progresses
gradually until reaching 40% to 50% above the non-pregnant state by mid-
pregnancy, and remains unchanged until term.
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Pregnancy & HIV - The most important intervention for preventing spread
of HIV from mother to child is administration of zidovudine to the mother
throughout pregnancy and labor, as well as to the neonate for the
first 6 weeks of life. This intervention has been shown to decrease the rate
of transmission by 70%. The mother should also be counseled to not
breastfeed, as this increases the risk of transmission.
Pregnancy & HTN - An increase in blood pressure that appears before 20-
weeks gestation is due to either chronic hypertension or a hydatidiform
mole.
Pregnancy & Low Back Pain - It is a very common problem in the 3rd
trimester that is mechanical in nature. The pain is minimal in the
morning, but increases at the end of the day. The main cause of this
pain is believed to be the increase in lumbar lordosis. In addition,
relaxation of the ligaments supporting the sacroiliac and other joints of the
pelvic girdle due to hormonal factors may contribute to the problem.
When splinting and analgesics fail to relieve CTS symptoms, direct injection
of corticosteroids into the carpal tunnel may help.
If the blood glucose value is > 140 mg/dL, a three hour 100 gram OGTT is
then performed. Gestational diabetes is diagnosed if two or more of the
serum glucose values obtained during the three hour test are elevated above
the values listed below:
Once diagnosed, the patients should be first asked to do a trial of life style
modification with diet & exercise. If this fails to decrease the fasting blood
glucose lever to the ideal range, medical treatment should be started. The
ideal range of maternal fasting glucose is between 75 and 90 mg/dl.
Treatment of gestational diabetes is best accomplished with subcutaneous
insulin, which is classified as a category B agent and does not cross the
placenta.
The maternal prognosis of those with ICP is good, as the condition resolves
shortly after delivery. There are no hepatic sequelae. ICP may recur in
subsequent pregnancies, and affected women are also at increased risk of
developing gallstones.
Vs
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The first step in a threatened abortion is to ascertain that the fetus is present
and alive. Once this is confirmed with ultrasound, management is
essentially reassurance and performance of an ultrasonogram one
week later. Bed rest and abstaining from sexual intercourse are usually
recommended because this will prevent any feelings of guilt on the part of
the parents in the case that pregnancy is actually lost; however, there is no
evidence of the benefit of these interventions on the outcome. Just because
there is bleeding per vagina doesnt mean you hospitalize the patient.
Nothing can be done in case of threatened abortion. So reassure & send
them home!
Oxytocin infusion would stimulate uterine contractions and likely expel the
retained fetus, but this can more readily be accomplished with vaginal
misoprostol without systemic effects and the additional invasiveness of an
intravenous catheter.
Mild increase in ALT, AST, bilirubin, amylase, and lipase are seen in up to
50% of hospitalized patients. Elevated amylase and lipase are from salivary
gland due to vomiting. So ignore these.
Some patients may also have ketones in the urine. This may be due to either
starvation (you dont eat a lot when you are vomiting a lot) or Diabetic
ketoacidosis. DKA presents with an anion gap metabolic acidosis with
LOW bicarbonates while Hyperemesis Gravidum presents with
Hypochloremic metabolic alkylosis with HIGH bicarbonates. Elevated
bicarbonate levels suggest alkalosis from vomiting.
Inducing labor and opting for vaginal delivery may be used in cases
where labor is in an advanced stage.
Cesarean section is used in the management of placental abruption when
there are obstetrical indications, or when there is a rapid deterioration of
the state of either the mother (hypotension) or the fetus (variable
decelerations) and labor is in an early stage such that vaginal delivery is not
emergently possible.
VS
Vasa previa is a rare condition in which the fetal blood vessels traverse the
fetal membranes across the lower segment of the uterus between the baby
and the internal cervical os (velamentous cord insertion). These vessels are
vulnerable to tearing during natural or artificial rupture of the membranes.
The condition carries a high fetal mortality rate (75%) due to fetal
exsanguinations, when this condition is diagnosed, the treatment is an
immediate caesarian section delivery ("crash C-section").
Preeclampsia
Mild Preeclampsia - Mild preeclampsia is defined clinically by hypertension
greater than 140/90 mmHg and proteinuria greater than 0.3g/24h
(300mg/24h) after the 20th week of gestation.
Preeclampsia Management
If the pregnancy is not at term and/or the fetal lungs are not yet mature,
then the patient is managed with bed rest and close observation.
Hypertension usually responds to these measures, but methyldopa can be
used to treat sustained blood pressures in excess of 160/110.
Dexamethasone administration between the 24th and 34th weeks of
gestation to accelerate lung maturity should be considered. Once the fetal
lungs are deemed mature, delivery should be carried out
The most effective agent used for the treatment and prevention of seizures
in eclampsia is magnesium sulfate. Lorazepam and phenytoin are more
useful in status epilepticus. Bottom line, management of eclampsia is
Mag Sulfate. Dont bother about anti epileptics.
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HELLP Management -
A mother with blood group O and a father with blood group AB will have a
child with either blood group A or blood group B (both differ from the
mother's blood group). Hemolytic disease of the newborn (HDN) is mainly
seen in a group O mother who has a group A or B baby. The A and B antigens
are antigenic and cause the mother to form lgG antibodies to A or B that can
cross the placenta (can also form some lgM antibodies to the A antigen and
other minor antigens). Only the lgG antibodies can cross the placenta, but
varying titer levels result in HDN, which is mild in most patients, with
neonatal jaundice successfully treated with phototherapy. However, the titers
can be higher in certain populations (e.g .. Africans and African Americans)
and lead to more severe HDN.
ABO incompatibility reactions can occur in the first pregnancy because both
A and B antigens are found in food and bacteria in the environment. These
antigens can induce various degrees of antibody production in group O
individuals. In contrast, Rh(D) alloimmunization reactions typically occur in
the second pregnancy onwards, with greater severity. Also, Rh(D) antibodies
are typically all lgG at higher titers that cross the placenta and cause more
significant disease.
Exposure during the first pregnancy is usually required before causing
disease in the second pregnancy. This patient has low risk of
alloimmunization because both she and her husband are Rh(D)+.
False Labor - False labor usually occurs in the last 4- 8 weeks of pregnancy.
It is important to differentiate false labor from true labor. In false labor,
contractions are felt in the lower abdomen, are irregular, occur at an
interval that does not shorten and do not increase in intensity. In the last
month of pregnancy, patients may experience contractions that become
rhythmic, occurring every 10 to 20 minutes, and contractions of greater
intensity, mimicking more closely the contractions of actual labor. In all cases
of false labor, however, contractions are NOT accompanied by progressive
cervical changes and are usually relieved by sedation. All such patients
need reassurance.
FGR is suspected when fundal height is at least three cms less than
the actual gestational age in weeks, and confirmation of FGR is
subsequently obtained by ultrasonography. Abdominal circumference is
the most reliable index for estimation of fetal size because it is affected in
both symmetric and asymmetric fetal growth restriction.
These tests are done to confirm the fetal well being. Decreased fetal
movements is the most common indication.
Non Stress Test - Whenever the fetal body moves, there is an increase in
the heart rate called Accelerations. A Reactive NST is presence of 2
accelerations in 20 mins with the following criteria
This is reassuring of fetal well being. If NST is reactive, next best step is to
Repeat weekly NSTs.
A Non Reactive NST means the above criteria are not met. This might
mean the baby is asleep or in trouble. To rule out sleeping, Vibroacustic
Stimulation Test. If the baby was asleep, this test will wake up the baby. A
positive test indicates fetal well being & a negative test calls to do a BPP.
If the pregnancy is not yet term and the mother is stable, expectant
management with close monitoring of the mother and fetus is the treatment
of choice. At 36 weeks gestation, amniocentesis should be done in order to
assess lung maturity. If the fetal lungs are mature, elective cesarean section
can be performed.
PPROM Rupture of the fetal membranes at any time before the onset of
labor is referred to as premature rupture of membranes (PROM). When
rupture occurs before term, it is known as preterm PROM (PPROM). The
diagnosis of ROM is mainly clinical. The patient usually complains of either a
gush or continual leakage of clear fluid from the vagina. On examination,
amniotic fluid may be noted in the vagina or leaking from the cervix when
the Valsalva maneuver or slight fundal pressure is applied. When PPROM is
diagnosed, amniotic fluid sampling to measure fetal lung indices is
mandatory. Ultrasound examination should also be performed to detect
fetal anomalies, determine gestational age and measure amniotic volume. If
the pregnancy is less than 34 weeks gestational age, and the US ratio is less
than 2.0, then prematurity is a major concern. Steroid treatment is
effective at this stage of pregnancy (between 24 and 34 weeks) in
accelerating lung maturity and should be used.
PROM - Rupture of the fetal membranes at any time before the onset of
labor is referred to as premature rupture of membranes (PROM).
Caesarean hysterectomy is used as the last resort but can be effective and
lifesaving in the treatment of postpartum hemorrhage.
Infertility
According to the recent studies, male factor accounts for 20-30% of the
infertility causes. Semen analysis should be performed early in the
evaluation of the infertile couple, usually as the initial screening test. It
evaluates sperm concentration, motility, and morphology and allows
identifying azoospermia and severe oligospermia as obvious causes of
infertility. Although cutoff values for semen analysis exist, there is a broad
overlap in the values of the semen measurements in fertile and infertile
samples; therefore. borderline results should be interpreted with caution.
Anovulation as a potential cause of infertility can be evaluated using basal
body temperature (BBT) measurement, serum progesterone measurement,
and endometrial sampling.
The most common cause for decreased fertility in women in their fourth
decade who are still experiencing menstrual cycles is age-related
decreased ovarian reserve. One in 5 women age 35-39 is no longer
fertile. Infertility due to aging can be assessed using an early follicular phase
FSH level, a clomiphene challenge test or an inhibin-B level.
The causes of protraction and arrest disorders can generally be broken into
disorders of the 3 P's: powers (i.e ..contractions). passenger (i.e .. baby).
or passage (i.e .. pelvis). The differential diagnosis would, therefore, include
hypotonic contractions, epidural anesthesia, cephalopelvic disproportion,
malpresentation, etc. If the uterine contractions appear adequate as per the
external tocometer & the infant is of normal size and appropriately presented
in the LOA position, then the most likely diagnosis in this case is an
abnormality in the passage of the fetus leading to cephalopelvic
disproportion, likely the result of prominent ischial spines felt on physical
examination. Increased molding of the fetal skull is also suggestive of
cephalopelvic disproportion. Given that there is an underlying anatomic
abnormality that is unlikely to resolve and that the arrest of dilatation and
descent has already been prolonged, operative management with
cesarean section is the best choice at this time.
Lochia Rubra It is the first discharge, red in color because of the large
amount of blood it contains. It typically lasts no longer than 3 to 5 days after
birth. It is characteristic of the first few days following delivery. No treatment
is necessary. Management is reassurance.
Lochia Serosa - After 3 to 4 days, the color becomes pale and the
discharge is then called lochia serosa. It subsequently turns white or yellow
and is then termed lochia alba. If a foul smelling lochia is noted,
endometritis should be suspected.
Combined contraceptive pills may decrease milk production and pass into
the milk. The effects of combination oral contraceptive use on the
breastfeeding infant have yet to be determined.
Postpartum Lactation Supression - At delivery, milk production is
activated by two major mechanisms: the sudden decrease in estrogen and
progesterone that, prior to delivery, interfere with the action of prolactin on
lactation and the release of prolactin and oxytocin through the stimulatory
effect of suckling. Prolactin is responsible for milk synthesis whereas oxytocin
mediates contraction of the lactiferous glands and ducts resulting in the
excretion of milk. Lactation suppression is indicated for patients such as in
this case or those who do not desire to breastfeed. Lactation suppression is
accomplished by use of a tight-fitting bra, avoidance of nipple
stimulation or manipulation, application of ice packs to the breasts and
analgesics to manage the pain. There is no role for medications in the
suppression of breast milk production.
Bromocriptine was commonly used but is no longer FDA approved for this
purpose because of the side effects. It is a dopamine agonist that acts by
inhibiting prolactin secretion by the anterior pituitary thus suppressing
lactation.
Breast abscesses are rare and present similarly to mastitis but with a
palpable, fluctuant mass.
They are treated with antibiotics and drainage.