1
Q
Define late term pregnancy
A
41 0/7 to 41 6/7 weeks gestation
2
Q
Define postterm pregnancy
A
42+ weeks gestation
3
Q
Risk factors for late term or post term pregnancy
A
-maternal: age ( > 30 years), obesity, genetic predisposition, , previous postterm pregnancies, nulliparity (woman who has never carried a pregnancy beyond the point of viability ie 20 weeks gestation)
-fetal: male sex, oligohydramnios, anencephaly, steroid sulfatase deficiency
4
Q
When are membrane sweeps performed
A
39 weeks
5
Q
Many supposed cases of postterm pregnancy are likely due to_________________
A
suboptimal dating (using LMP alone to calculate the Expected date of delivery)
6
Q
Define oligohydramnios
A
Amniotic fluid volume is LESS than expected for gestational age
7
Q
Diagnosis of oligohydramnios
A
deepest vertical pocket < 2 cm, fetal anomalies
8
Q
Complications for oligohydramnios
A
-intrauterine growth restriction
-birth complications
-potter sequence
9
Q
What is Potter sequence
A
-pulmonary hypoplasia
-craniofacial abnormalities
-wrinkling of the skin
-limb abnormalities
10
Q
Define polyhydramnios
A
fluid volume is MORE than expected for gestational age
11
Q
Etiology for oligohydramnios (LESS)
A
-Fetal: urethral obstruction, bilateral renal agenesis, autosomal recessive, polycystic kidney disease
-Maternal: placental insufficiency, late or postterm pregnancy
12
Q
Etiology for Polyhydramnios (MORE)
A
-Fetal: GI (esophageal atresia, duodenal atresia, stenosis), CNS (anencephaly, myotonic dystrophy), Pulmonary (cystic lung malformation), twin-to-twin transfusion syndrome, fetal anemia
-Maternal: DM, Rh incompatibility
13
Q
Diagnosis of Polyhydramnios
A
-Amniotic fluid index >24 cm or deepest vertical pocket >8cm, fetal anomalies
14
Q
Complications of polyhydramnios
A
-Fetal malposition
-Umbilical cord prolapse
-Premature birth
15
Q
Define suboptimally dated gestational age
A
-gestational age was NOT confirmed or adjusted using US before 22 0/7 weeks gestation
16
Q
Postterm infant complications
A
-Oligohydramnios
-Increased birth weight and macrosomnia –> birth trauma: neonatal brachial plexus palsy, or birth-related clavicle fracture
-Stillbirth
-Low Apgar scores
-Meconium aspiration syndrome
-Neonatal seizures
-Admission to NICU
-Cerebral palsy
-Postmaturity syndrome: changes in appearance (wt. loss, subcutaneous wasting, dry peeling skin)
17
Q
Maternal complications for late-term or postterm pregnancy
A
-prolonged stages of labor
-obstructed labor
-perineal lacerations
-postpartum hemorrhage
-infections: chorioamnionitis, endometritis
18
Q
Define membrane sweeping
A
a procedure involving manually separating the amniotic membranes from the lower uterus wall during a pelvic exam
19
Q
When can membrane sweeping occur
A
39 0/7 weeks
20
Q
Purpose of membrane sweeping
A
-promote the onset of normal spontaneous labor
-decrease the risk of late-term and postterm pregnancy and need for induction
21
Q
Risks of membrane sweeping
A
vaginal bleeding
pain
irregular contractions
22
Q
Define preterm labor
A
Regular contractions and cervical changes before 37 weeks gestation
23
Q
Define preterm birth
A
live birth between 20 0/7 and 36 6/7 weeks gestation
24
Q
Risk factors for preterm labor
A
-previous preterm labor
-short cervical length during pregnancy
-multiple gestations
25
Define preterm labor
regular uterine contractions with cervical effacement, dilation or both before 37 weeks gestation
26
Nonmodifiable risk factors for preterm birth
-Hx of preterm birth
-Cervical insufficiency
-Short cervical length
-Multiple gestations
-Polyhydramnios
-Preterm premature rupture of membranes (PPROM)
-Antepartum hemorrhage (placenta previa, placental abruption
-Uterine abnormalities
-African americans
-Congenital abnormalities of the fetus
27
Modifiable risk factors for preterm birth
Maternal and fetal conditions
-infections (UTI, STIs, vaginal infections)
-HTN pregnancy disorders (preeclampsia, HELLP syndrome)
-DM, gestational diabetes
Lifestyle and environmental factors
-Smoking
-Substance abuse
-Maternal/fetal stress
-Maternal age <18 or >35)
-Low maternal prepregnancy weight
-Short interval b/w pregnancies (<18 months)
28
Clinical features of preterm labor/birth
-regular uterine contractions and associated symptoms of labor (low back pain)
-loss of mucus plug
-cervical effacement or cervical dilation
-rupture of membranes
29
How to diagnosis preterm labor:
1. Evaluate for clinical features of preterm labor
2. Perform site speculum examination (rupture membranes?? or cervical effacement/cervical dilation??)
3. Cervicovaginal fetal fibronectin (fFN test): looking for elevated levels in cervical secretions
4. Transvaginal Ultrasound: if cervical length is > 3 cm
30
How to approach preterm labor: txt
If 34 0/7 to 26 6/7 weeks gestation:
-proceed with normal labor and delivery
If <34 weeks gestation:
-Consider tocolysis to inhibit contractions in consult with OB
-administer steroids for induction of fetal lung maturity
-administer antibiotic prophylaxis for PPROM
If <32 weeks gestation:
-Consider magnesium sulfate for fetal neuroprotection
31
What is tocolysis
Administration of tocolytics to inhibit uterine contractions with the goal of prolonging pregnancy to allow for induction of fetal lung maturity and/or transfer to another medical center
32
Examples of tocolytics
-Beta-mimetics (terbutaline, ritodrine, isoxsuprine)
-Cyclooxygenase inhibitors (indomethacin, sulindac)
-Magnesium sulfate
-Calcium channel blockers (nifedipine)
-Oxytocin antagonists (atosiban)
-Nitric oxide donors (glyceryl trinitrate)
33
Contraindications for tocolysis
-maternal-specific drug contraindications
-nonreassuring fetal cardiotocography
-intrauterine fetal demise
-chorioamnionitis
-antepartum hemorrhage with hemodynamic instability
-severe preeclampsia or eclampsia
-lethal feal anomaly
34
Adverse effects of Nifedipine (maternal and fetal)
Maternal: Hypotension, dizziness, flushing
Fetal: None
35
Adverse effects of Indomethacin (maternal and fetal)
Maternal: esophageal reflux, gastritis, nausea and vomiting
Fetal: renal dysfunction --> oligohydramnios; premature closure of the ductus arteriosus
36
What is the ductus arteriosus
vessel connecting the aorta and pulmonary artery
37
Adverse effects of magnesium sulfate (both maternal and fetal)
Maternal: Signs of magnesium toxicity (hypocalcemia, respiratory depression, pulmonary edema)
Fetal: possibly skeletal abnormalities with prolonged use
37
Adverse effects of Terbutaline (beta-2 adrenergic agonist) for both maternal and fetal
-Maternal: Severe cardiovascular and metabolic conditions (hypokalemia, hyperglycemia, tachycardia, hypotension, pulmonary edema, myocardial ischemia)
Fetal: tachycardia, hypoglycemia
38
Define induction of fetal lung maturity
administration of antenatal steroids to promote the production of surfactant and thereby improve neonatal survival and fetal lung maturity
39
Indications for induction of fetal lung maturity
24 0/7 to 33 6/7 weeks gestation
40
Medications for induction of fetal lung maturity
-Betamethasone and Dexamethasone
41
Define fetal neuroprotection
administration of antenatal magnesium sulfate to reduce the risk of and severity of neurological disorder (ie cerebral palsy)
42
Indication for fetal neroprotection
Preterm labor at <32 weeks gestation
43
When are antibiotics indicated for preterm labor
-GBS prophylaxis
-PPROM antibiotic prophylaxis
44
Pulmonary and cardiovascular complications of preterm labor
-neonatal respiratory distress syndrome
-patent ductus arteriosus (PDA)
-bronchopulmonary dysplasia (BPD)
45
Important neurological complications of prematurity
-Periventricular leukomalacia (PVL)
-Intraventricular hemorrhage (IVH)
-Cerebral palsy
-Learning disability
-Developmental delays
-ADHD
46
Define periventricular leukomalacia
symmetrical, periventricular injury of cerebral white matter (necrosis and cystic formation) caused by ischemia and/or infection
47
Clinical features of periventricular leukomalacia
-spastic cerebral palsy
-intellectual impairment
-visual disturbances
48
Define intraventricular hemorrhage
Bleeding into the ventricles from the germinal matrix, a highly vascularized region within the subventricular zone of the brain from which cells migrate out during brain development
49
Etiology for intraventricular hemorrhage
-low birth weight (<1500 g) and delivery before 32 weeks gestation due to the fragility of the germinal matrix and/or impaired autoregulation of blood pressure
-maternal chorioamnioitis
-hypoxia during or after birth
50
Clinical features of intraventricular hemorrhage due to prematurity
-when: first few days of life
-mostly asymptomatic, but saltatory
-sxs: lethargy, hypotonia, irregular respirations, seizures, bulging anterior fontanelle
-Cranial nerve abnormalities, changes in eye movements
-Signs of acute blood loss (anemia, tachycardia)
51
5 signs of homeostasis dysfunction due to prematurity
-hypothermia: impaired ability to produce an adequate body temperature due to a high surface area
-Body temp: <97.7 C (36.5 C)
-Lethargy, cyanosis
-Txt: putting baby in warmer
-apnea, bradycardia
-hypoglycemia, hyperglycemia
52
Define anemia of prematurity
-impaired ability to produce adequate erythropoietin (EPO)
53
Clinical features of anemia of prematurity
usually asymptomatic
tachycardia
poor weight gain
increased episodes of apnea
54
pathophys of anemia of prematurity
onset of breathing and closure of ductus arteriosus --> increase in tissue oxygenation --> decrease of erythropoiesis
55
Lab findings for anemia of prematurity
low hemoglobin, hematocrit, and reticulocyte count
56
Treatment for anemia of prematurity
iron supplementation
blood transfusions
57
Prevention of preterm labor
1. Address risk factors
-Screen for HTN pregnancy disorders
-Screen for GDM
-Screen for infections
-Counseling for smoking cessation
LACK OF EFFICACY
-screen and txt asymptomatic bacterial vaginosis
-prophylactic IM progesterone
-Activity restrictions
58
What is the strongest predisposing factor for recurrence of preterm birth
Hx of spontaneous preterm birth
59
Signs of cervical insufficiency
Second-trimester pregnancy loss
-preterm birth following a painless vaginal delivery
manifests during 2nd trimester and leads to inability to maintain pregnancy in the absence of contractions or other underlying cause (ie infection)
SIGN: PAINLESS CERVICAL DILATION
60
Define cephalopelvic disproportion
the size of the fetal head is too large for maternal pelvis
61
Define cervical cerclage
procedure where the cervix is temporarily sutured shut
-used to manage cervical insufficiency associated with pregnancy
62
When is a Cervicovaginal fetal fibronectin detection test done?
when there is evidence of early labor (ie preterm contractions)
63
What test is used to assess the risk for preterm delivery in a patient with many risk factors but not evidence of preterm labor? and when? and how?
Cervical length measurement
Transvaginal ultrasound performed between 16 and 24 weeks
short cervical length: <25mm which indicates a high risk of cervical insufficiency and preterm delivery
64
In women with a short cervix during pregnancy what are meds or procedure that can help prolong the pregnancy?
Progesterone supplementation
Cervical cerclage
65
Define biophysical profile and when it occurs and indication
Indication: high-risk pregnancies to evaluate the risk of antenatal fetal death
When: after 28 weeks gestation
66
Purpose of doppler velocimetry of umbilical artery
Assess for placental insufficiency in cases of fetal intrauterine growth restriction (IUGR)
67
Sxs of cerebral palsy
-Seizures
-Intellectual disability
-Nonprogressive spastic paresis (inability of voluntary movement in combination with increased muscle tone, spasticity, clonus, weakness, and tendon reflex activity)
68
What is amnioinfusion used to treat?
Oligohydramnios
69
What is the triad of Potter sequence?
-craniofacial abnormalities
-clubbed feet
-pulmonary hypoplasia
70
Define hemolytic disease of fetus
blood group incompatibility b/w mother and fetus leading to destruction of fetal erythrocytes by maternal antibodies
71
What are the 3 types of hemolytic disease of fetus that are immune based?
1. ABO incompatibility
2. Rh incompatibility
3. Kell blood group system incompatibility
72
Define Coombs test
an agglutination test:
1. to detect hemolytic antibodies and/or complement proteins that are already bound to erythrocytes (DIRECT)
2. unbound anti-erythrocyte antibodies in serum (INDIRECT)
73
Why is it important to administer RhIG to mothers whom are Rh (-) and desensitized?
To protect the fetuses in the future to stop development of Rh antibodies by mom
74
Define hemolytic disease of the fetus and newborn
characterized by destruction of fetal red blood cells and subsequent anemia
75
Describe pathophys of how a woman becomes sensitized for Rh
exposure to fetal Rh-positive blood --> maternal IgG antibodies form against Rh
76
Clinical features of hemolytic disease of fetus and newborn
-Jaundice
-Hepatomegaly
-intrauterine hydrops fetalis
-pallor
77
Describe ABO incompatibility
maternal antibodies against nonself antigens of the ABO system are present even if sensitization has not occurred
78
Rh incompatibility (maternal and fetus)
Maternal: Rh-negative
Fetus: Rh-positive
79
What occurs during Rh incompatibility
Production of maternal IgM antibodies against the Rh antigen after exposure of fetal blood cells to the maternal circulation (ie fetomaternal hemorrhage)
80
Pathophys fo second pregnancy after Rh sensitizing event
Rh-positive fetus: production of maternal IgG anti-D antibodies to fetal RhD antigens --> Rh-IgG agglutination of fetal RBCs with hemolytic anemia --> risk of HDFN with possible hydrops fetalis
81
What are 4 etiologies for nonimmune hydrops fetalis?
1. Congenital heart defects and arrhythmias
2. Chromosomal aberrations (Turner syndrome, trisomy 18, Down's)
3. Severe fetal anemia (thalassemia, twin-to-twin transfusion syndrome)
4. Congenital TORCH infections (ie parvovirus B19 infection)
82
Pathophys for nonimmune hydrops fetalis
fetal anemia --> hypoxia --> low hepatic and renal blood flow --> activation of RAAS --> increase in central venous pressure and decrease in lymphatic flow --> fetal edema
83
Clinical features of hemolytic disease of fetus and newborn
-anemia
-hepatosplenomegaly
-neonatal jaundice: unconjugated bilirubin levels may be too high causing kernicterus
-hypoxia
-prematurity
-scattered petechiae
84
To make a diagnosis of hemolytic disease of fetus and newborn what do you need
1. evidence of hemolysis
2. fetomaternal blood incompatibility
85
To make a prenatal diagnosis of hemolytic disease of fetus and newborn what imaging do you order
1. Ultrasound
--determine if hydrops fetalis is present
--fetal pleural or pericardial effusions
--fetal ascites
--fetal subcutaneous or nuchal edema
--placental edema
2. Doppler sonography of fetal blood vessels: increased flow rate indicates fetal anemia
86
What are the results of a Coombs test for Rh incompatilbity and ABO incompatibility
Rh incompatibility: positive
ABO incompatibility: weak positive or negative
87
Spherocytosis is present for which: ABO or Rh incompatibility
ABO incompatibility
88
Rh positive moms: txt
None
89
Rh negative moms: txt
1. Screen for anti-D antibodies with indirect Coombs test
Positive: Refer to MFM
Negative: RH prophylaxis at 28 weeks or within 72 hours of a Rh-sensitizing event
90
Define antepartum hemorrhage
>20 weeks
91
Bloody show, placenta previa, and placental abruption are all common causes of ...
antepartum hemorrhage
92
Difference between placenta previa and vasa previa
BOTH have painless vaginal bleeding
Vasa previa bleeding occurs after rupture of membranes and more commonly causes fetal distress
93
Risk factors for placental abruption
Hx of previous one, HTN, trauma, smoking, cocaine use, PPROM
94
When is the onset of placenta previa
Prior to rupture of membranes
PAINLESS
95
Sxs of placenta previa
bright red vaginal bleeding
96
Risk factors for uterine rupture
velamentous cord insertion, placenta previa, IVF, multiple gestation
97
Pain level for uterine rupture
severe abdominal pain
98
Onset for uterine rupture
sudden, during labor
99
Sxs of uterine rupture
sudden pause in contractions, fetal distress, vaginal bleeding
100
Onset for still birth
> 20 weeks gestation
101
Define placenta abruption
the partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels
102
Sxs of placental abruption
-sudden vaginal bleeding
-abdominal pain
-rigid uterus, preterm labor
-fetal distress, decelerations
103
What may be seen on US for placental abruption
retroplacental hematoma
104
Management of placental abruption
< 34 weeks: obs, consider tocolytics
34-36 weeks: vaginal delivery if contractions; obs if none
36+ weeks: deliver
105
Complications of placenta abruption
Intrauterine fetal death
Maternal DIC, hypovolemic shock
Couvelaire uterus: retroplacental hemorrhage may extend through uterus into the peritoneum
106
Define placenta previa
presence of placenta in the lower uterine segment, leading to partial or full obstruction of the internal os; high risk of hemorrhage and birth complications
107
Define low-lying placenta
lower edge of placenta lies less than 2 cm from the internal cervical os
108
Clinical features of placenta previa
Sudden, painless bright red vaginal bleeding
Before rupture of the membranes
Soft, nontender uterus
No fetal distress
109
Management of placental previa if found on routine US
if present at 32 weeks: repeat US at 36 weeks
-schedule C-section delivery b/w 36-37 weeks gestation
-if placenta accreta: schedule b/w 34-35 weeks
110
Define vasa previa
condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk for injury if membranes rupture
111
Risk factors/placental anomalies for vasa previa
-velamentous umbilical cord insertion
-bilobate or succenturiate placenta (one + lobes of placenta is separate from main body)
-placenta previa
-low-lying placenta
-multiparity
-IVF
112
Clinical feature of vasa previa
-Painless vaginal bleeding AFTER rupture of membranes
-fetal distress
-fetal death can occur quickly
113
name layers of the trophoblast
114
Painless bright red vaginal bleeding is a sign of what....
Placenta previa
115
If a pt has painless, bright red bleeding in 3rd trimester, active bleeding and Hypotension/fetal distress...what is the next step?
Perform emergency Cesarean delivery
116
What are signs that fetal blood is coming out vaginally rather than maternal blood?
-absence of maternal tachycardia
-Significant vaginal bleeding with no maternal sxs
-Fetal distress (fetal bradycardia)
117
Signs of ruptured vasa previa
-vaginal bleeding
-ruptured membranes
118
During what week do primordial germ cells migrate to genital ridge (developing gonad region)
During week 8
119
When does spermatogenesis begin
Puberty
120
What occurs during puberty to develop seminiferous tubules
Males are born with sex cords that develop a lumen during puberty. These become the seminiferous tubules
121
How many chromosomes and sister chromatids does each have: spermatogonium, primary spermatocytes, secondary spermatocytes, spermatic
Spermatogonium: 2n 2 c
Primary spermatocytes: 2n 4c (DNA synthesis completed)
Secondary spermatocytes: 1n 2c (meiosis I completed)
Spermatids: 1n 1c
122
Spermatids undergo what process to become spermatozoa
Spermiogenesis
123
What occurs during spermiogenesis
-formation of acrosome
-condensation of nucleus
-formation of neck and tail
-shedding most of cytoplasm
124
What cells are behind the blood testis barrier and separated from tubule by Sertoli cells
Spermatogonium
125
Cells that line the seminiferous tubules
Sertoli cells
126
Sertoli cells are stimulated by which hormone
FSH—pituitary gland regulates the quantity of sperm production
127
Leydig cells secrete what
Testosterone
128
129
Which cells regulate spermatogenesis
Sertoli cells
130
Which cells form the blood testis barrier
Sertoli cells
131
Purpose of blood testis barrier
-isolate sperm to protect from autoimmune attack
-controls environment
132
While in utero what occurs with oolongs
Oogonia divide
Begin meiosis I but arrest in prophrase
Max number of oogonia by 5th month in utero (~7million)
133
Events during puberty during oogenesis
A few primary oocytes complete meiosis I each cycle: some form polar bodies and degenerate, others form secondary oocytes (1n2c)
134
During mensrariin what are the steps in oogenesis
-primary oocytes complete meiosis I each cycle
-Meiosis II begins but arrest in metaphase. No fertilization = degenerates. Fertilization = complete meiosis II
-Forms ovum (1n1c)
135
136
Purpose of placenta
Nutrient and gas exchange between mother and fetus
137
Define decidua
Altered uterine lining during pregnancy
138
After ____________ the endometrium reacts and changes
Implantation
139
Location of decidua basalis
Uterus at the site of implantation. Where the uterus interacts with the trophoblasts
140
Location of decidua capsularis
Surrounds the fetus
141
Location of decidua parietalis
Opposite wall of uterus from implantation
142
Define amnion
Inner membrane that covers the fetus
143
144
Purpose of amnion
Holds amniotic fluid to protect the embryo
145
Define chorion
Membrane that surrounds amnion/embryo
146
Purpose of chorion
Derived from trophoblast, supports fetus and amnion
147
Define basal plate of the placenta
Maternal side of the placenta high which interacts with uterine wall and includes the maternal decidua basalis
148
149
Define the chorionic plate
Fetal side of the placenta which is the chorion at the placenta giving rise to chorionic villi
150
What are the two layers of the trophoblast?
Syncytiotrophoblast and cytotrophoblast
151
Define the syncytiotrophoblast and its purpose
-outer layer
-secretes hCG
-begins progesterone synthesis at 10 weeks
-invades endometrium through finger-like projections or villi
-form lacunae which are spaces for maternal blood
152
Define cytotrophoblasts and purpose
-inner layer
-proliferates where cells migrate into syncytiotrophoblast
-secretes proteolytic enzymes to aid invasion
153
In the placenta what structure has contact with maternal blood for exchange of nutrients
Chorionic villi
154
Where do branches of umbilical artery and vein grow to to connect to umbilical cord
Chorionic villi
155
Name of arteries on maternal side of placenta
Endometrial or spiral arteries
156
Placental circulation from maternal side
Spiral artery —> villous space —> endometrial vein
157
Placental circulation from fetal stand point
Umbilical arteries —> chorionic arteries —> capillaries —> umbilical vein ( with O2)
158
T or F: maternal and fetal blood mix
False
-nutrients diffuse such as oxygen and carbon dioxide. Glucose uses facilitated transport and amino acids use active transport
159
160
Define umbilical cord
Connection between embryo and placenta. Derived from fetus
161
What is contained within the umbilical cord what is around it
1 umbilical vein
2 umbilical arteries
Surrounded by Wharton’s jellyfish
162
What are the 2 layers of the development of the umbilical cord
Yolk sac and Allantosis
163
What becomes the urachus
Fibrous remnant of allantois, collecting bladder to umbilicus
164
Define patent urachus
Urine discharge from umbilicus
165
Define vesicourachal diverticulum
Diverticulum of the bladder
166
During pregnancy fetus contains foreign DNA (dads DNA), what protects it from mom’s immune response
Placenta: placenta secretions block immune response
Trophoblast cells do not express many MHC class I antigens
167
Define dizygotic twins
Two pregnancies at the same time.
-Two zygotes with two separate ova fertilized by 2 separate sperm
-“fraternal twins”
168
Define monozygotic twins
-one zygote divides into 2
-one ova fertilized by one sperm
-“identical twins”
169
What type of twins share a placenta
Monozygotic twins
170
What are the genera length of pregnancy for single, twins, triplets
Single = 40 weeks
Twins = 37 weeks
Triplets = 33 weeks
171
What is the amnion and chorion for dizygotic twins
Dichorionic diamniotic
2 separate placentas
172
173
What type of twins are common in IVF
Dizygotic twins
174
Define amnion and chorion for monozygotic twins
1-3 days: 2 placentas, dichorionic, diamniotic (divides during morula stage)
4-8 days: mono chorionic diamniotic (blastocyst stage)
9-12 days: monochorionic monoamniotic (implanted blastocyst)
13+ days: monochorionic monoamniotic CONJOINED TWINS
175
Risks for twins (maternal and fetal)
Maternal: gHTN, preeclampsia
Fetal: growth restriction, congenital abnormalities, preterm delivery
176
What are the 2 ways to date a pregnancy?
-Embryonic age: age dated to fertilization (academic practice)
-Gestational age: age dated to last menstrual period (embryonic stage + 2 weeks) (clinical practice)
177
Location of fertilization
Ampulla of fallopian tube
178
When does implantation occur
6 days after ovulation
179
What secretes hCG?
Syncytiotrophoblast
180
Describe the test to detect pregnancy
Tests for beta subunit of the human chorionic gonadotropin hormone
181
Describe the structure of hCG
-2 glycoprotein subunits “heterodimer glycoprotein”
-alpha and beta subunit: alpha subunit is the same as LH, FSH, and TSH
182
What does hCG bind to
LH receptors in corpus luteum causing the corpus luteum to be maintained which continues to release progesterone
183
What is the purpose of the corpus luteum continuing to release progesterone
Prevents menstruation which maintains pregnancy for the first 10 weeks
184
Term for altered uterine lining during pregnancy
Decidua
185
2 types of decidua
1. Decidua basalis: uterus at site of implantation; interacts with trophoblasts
2. Decidua capsularis: surrounds the fetus
3. Decidua parietalis: opposite wall of the uterus
186
Name: inner membrane that covers the fetus
Amnion, holds the amniotic fluid
187
Name: membrane that surrounds amnion/embryo
Chorion; derived from trophoblast, supports fetus and amnion
188
Basal plate of the placental, which side
Maternal side of the placenta; in contact with the uterine wall
189
Chorionic plate of placenta: which side
Fetal side of placenta, give rise to the chorionic villi
190
Define trophoblast
Outer layer of blastocyst --> develops into the placenta
191
What are the two layers of the trophoblast
1. Syncytiotrophoblast: outer layer
2. Cytotrophoblast: inner layer
192
What has contact with maternal blood
Chorionic villi
193
What secretes hCG
syncytiotrophoblast layer of trophoblast
194
Placental circulation on fetal side
umbilical arteries (deO2) --> chorionic arteries --> capillaries --> u. vein
195
Placental circulation on maternal side
endometrial (spiral artery) --> villous space --> endometrial vein
196
T or F: mixing of maternal and fetal blood
False
197
Which type of antibodies can cross the placenta
IgG
198
What are the layers of the umbilical cord
Yolk sac
Allantois: outpouching of hindgut
199
What structure becomes the urachus
Allantois or Allantoic duct (connection between bladder and umbilical cord)
200
If there is urine discharge from the umbilicus what is the anamoly
patient urachus
201
How is the fetus protected from maternal immunity?
trophoblast cells do not express many MHC class 1 antigens in the placenta
202
What does cerebral palsy affect
Muscle tone
Development of movement
Posture
203
Risk factors for cerebral palsy
-prematurity/low birth weight
-TORCH infection
-perinatal complications (chorioamnionitis, asphyxia)
-birth trauma with intracerebral hemorrhage
-periventricular leukomalacia (injury to white matter caused by ischemia)
-structural abnormalities
-neonatal seizures
-kernicterus
-postnatal infections such as meningitis, encephalitis
-thyroid disease in pregnancy
204
Three types of cerebral palsy
Spastic
Ataxic: intention tremor, lack of balance and coordination
Dyskinetic: abnormal involuntary movements (choreoathetoid, dystonic)
205
Features of spastic cerebral palsy
-Spastic paresis of multiple limbs
-Joint contractures
-Scissors gait
-Persistence of primitive reflexes
-Increased muscle tone in limbs
-increase in deep tendon reflexes
-persistence of primitive reflexes
-toe walking/equinus deformity
-muscle weakness/atrophy
-hip dislocation
-scoliosis
-hearing or vision impairment
-intellectual disability
-Seizure disorder
-upper motor neuron signs (hyperreflexia, clonus)
-behavioral difficulities
-ADHD
206
Features of all types of cerebral palsy
intellectual disability
Seizure disorder
207
Birthing parents at risk of premature delivery are given what medication
magnesium sulfate if under 32 weeks
208
Reasons for CP
non-progressive damage to the brain in utero or during infantile development up to age of 3 years
Due to the incomplete myelination, immature glial cells, fragile germinal matrix, oxidative stress in underdeveloped brain
209
What do you order for a diagnosis of CP
-cranial ultrasonography : intracerebral hemorrhage, hypoxi-ischemic injury, structural abnormalities
-MRI: lesions,
-EEG: for suspected seizures
210
Treatments for cerebral palsy
Nonpharm:
--PT, OT, speech therapy, orthotic devices, nutritional support
Pharm:
--antispasmodics (baclofen, dantrolene)
--anticonvulsants
--anticholinergics
Surgery
211
Define amnioinfusion, indication, and complications
Treats:
--oligohydramnios (which can harm normal fetal lung development)
--cord compression and reduce complications if there are signs of distress during labor
Complications: Potter sequence, developmental dysplasia of the hip
Define: transabdominal or transcervical infusion of fluid into the amniotic cavity to restore normal amniotic fluid volume
212
If a pregnant person has phenylketonuria what is the treatment to prevent it from damaging the baby
Strict phenylalanine restriction
213
Signs of PKU or phenylketonuria in an fetus
Intrauterine growth restriction
Neurological sxs: intellectual disablity, spasticity, seizures, microcephaly, congenital heart disease
214
What structure passes posterior to the infundibulopelvic ligament at the level of the pelvic brim
Urter
215
What is a Graafian follicle
Final follicular stage of folliculogenesis
216
Location of the uterus
-posterior to the bladder and anterior to the rectum
-most of the posterior supravaginal cervix and uterine body are covered by peritoneum
217
Course and function of the ovarian arteries
Course: a branch off the abdominal aorta
Function; Supplies the proximal portion of the uterine body
218
Fill in the blank
219
Course & function of the uterine artery
Course: branch off the internal iliac artery; crosses the ureter anteriorly in the broad ligament
Function: supplies the distal portion of the uterus and the cervix
220
Course and function of the uterine vein
Course: venous plexus in the uterine wall --> uterine veins --> internal iliac veins; uterine veins cross the ureter in the broad ligament
Function: Drains the uterus
221
Ligation of the uterine arteries in a hysterectomy carries a risk of injury to _____
ureter
222
Uterus innervation: sympathetic course and function
Course: T10-L2 --> superior hypogastric plexus --> inferior hypogastric plexus --> uterovaginal plexus
Function: vasoconstriction, uterine contraction
223
uterus innervation: parasympathetic course and function
Course: S2-S4 --> pelvic splanchnic nerves --> inferior hypogastric plexus --> uterovaginal plexus
Function: vasodilation
224
Uterine innervation: Viscerosensory course and function
Course
-Uterus: afferent fibers follow sympathetic efferent fibers to T10-L2
-Cervix: some afferent fibers follow parasympathetic efferent fibers to S2-S4
Function: visceral pain: includes referred pain
225
3 layers of the uterus
endometrium, myometrium, perimetrium
226
Define endometrium and its two layers
Define: mucosal layer consisting of 2 layers
1. Simple columnar epithelium
2. Connective tissue/stroma
227
The simple columnar epithelium of the uterus also has _____ glands. Describe their length with each part of the cycle
Tubular glands
Long during the proliferative phase and coiled during the secretory phase
228
What does the myometrium contain
blood vessels, nerves, lymphatics
229
During the secretory phase the functional layer to the endometrium divides into what two layers
Stratum compactum and stratum spongiosum
230
The cervix is composed of mostly ______
fibroelastic connective tissue
231
What are the 3 layers of the cervix and types of cells there
1. Endocervix: composed of simple columnar epithelium
2. Cervical transformation zone: site of squamocolumnar junction: border between metaplastic squamous epithelium and simple columnar epithelium
3. Ectocervix: stratified squamous epithelium (nonkeratinized)
232
In which layer of the cervix is the squamocolumanar junction located
Cervical transformation zone
233
Embryology: the uterus, cervix, fallopian tubes and proximal part of the vagina are derived from which embryologic structure:
Paramesonephric duct
234
When does the fusion of the two paramesonephric ducts occur during pregnancy?
7-8th week of gestation and complete by 12th week
235
What are 3 paramesonephric duct anomalies
1. Septate uterus
2. Bicornuate uterus
3. Didelphic uterus
236
Name this type of paramesonephric duct anomaly
Septate uterus
237
Label
238
Most common site of fertilizaton by sperm
the ampulla of the fallopian tube
239
4 functions of fallopian tubes
1. during ovulation, an oocyte from the ovary enters the distal segment of a fallopian tube
2. Most common site for fertilization: the ampulla
3. movement of cilia and contraction of the muscular layer facilitate the transport of the ovum to the uterus for implantation
4. secretion of nutrients for gametes
240
Fill in the blanks
241
What cells are these?
What is the diagnosis?
Clue Cells; bacterial vaginosis
242
What organism is this? What is the diagnosis?
Trichomonads
Trichomonas Vaginalis
243
What are these and what is the diagnosis?
Pseudo hyphae
Vulvovaginal Candidiasis or yeast infection
244
What is this? Diagnosis? Treatment?
1. Candida glabrata
Txt: intravaginal boric acid
245
Define latent phase of labor
<6cm of cervical thining
246
Define active phase of labor
6-10cm of cervical dilation
247
Define arrest of active phase
no progress of active labor phase (> 6cm) with ruptured membranes
-4 hours with adequate contractions
-6 hours with inadequate contractions
248
Stages of labor
1st: onset of labor to complete dilation of cervix
2nd: complete cervical dilation to delivery of infant
3rd: delivery of infant to delivery of placenta
249
Normal fetal heart tones
110-160 bpm
250
3 types of decelerations
1. Early (mirror image of uterine contractions)
2. Variable (abrupt jagged dips below the baseline)
3. Late (offset following the uterine contraction)
251
Define accelerations
episodes of fetal heart rate that increases above the baseline for at least 15 bpm and last for at least 15 seconds
252
How long should latent labor last for nullipara and multipara?
Nullipara: <18-20 hours
Multipara: <14
253
How long should the second stage of labor last for nullipara and multipara?
Nullipara: <3 or <4 if epidural
Multipara: <2 or <3 if epidural
254
How long should the 3rd stage of labor last?
<30 minutes
255
if there is cephalopelvic disproportion
C-section
256
what procedure may safely reduce the rate of C-section when repetitive variable decelerations are seen
Amnioinfusion
256
Define cephalopelvic disproportion
abnormal pelvis or excessively large baby
256
Define adequate uterine contractions
contractions every 2-3 minutes, firm on palpatation, lasting for 40-60 seconds
-over 200 Montevideo units
256
Define categories of NST
1: normal baseline and variability with accelerations, no decels
2: all other
3: absent baseline variability with recurrent late or variable decelerations , bradycardia or sinusoidal heart rate pattern
256
normal heart rate assessment of fetus
110-160 bpm
accelerations, and variability
256
Category 3 tracings are associate with which complications and require what interventions
Complications: low pH, hypoxia, encephalopathy, cerebral palsy
INterventions: intrauterine resuscitative maneuvers --> C section
257
What procedure can assess fetal acid-base status when abnormal NST is present
scalp stimulation can induce an acceleration which indicates a normal umbilical cord pH
258
For women at 36 weeks with malpresentation what can be done
External cephalic version
259
To avoid shoulder dystocia/birth trauma and C-section should be performed for babies weighing...
>5000 g in nondiabetic
>4500 g in diabetic
260
Intervention for tachysystole
Tachysystole: uterine contractions >5/10 minutes averaged over 30 minutes
Intervention: decrease/stop ocytocin or give beta-mimetic agent
261
Intervention for hypotension due to epidural
IV fluid bolus, if not working then administer vasopressor agent such as ephedrine
262
Intervention for rapid cervical dilation
positional changes, obs
263
Intervention for umbilical cord prolapse
-Cord through the cervix
-Intervention: elevate presenting part and emergency C-section
264
Intervention for placental abruption
Support BP, stabilize pt, consider C-section if progressive
265
Intervention for uterine rupture
Emergency C-section
266
Hemoglobin level dur pregnancy
more than 10.5, less than this indicates anemia
267
Define Thalassemia
decrease in production of one or more the peptide chains (most common are alpha and beta chains) that make up the globin molecule.
Results: ineffective erythropoiesis, hemolysis, anemia
268
If a pregnant women presents with mild anemia and no risk factors for hemoglobinopathies (ie AA or mediterranean descent) then what happens...
txt with supplemental iron and reassess hemoglobin level sin 3-4 weeks
if anemia persists then ---> eval for iron stores such as ferritin level and hemoglobin electrohoresis
269
what test can distinguish between iron deficiency anemia and thalassemia
hemoglobin electrophoresis
270
classifications of thalassemias:
beta-minor (usually asymptomatic in people)
--usually safe during pregnancy. mom takes folic acid
beta-major: childhood problems. at birth seem fine but then as hemoglobin F levels fall no beta chains can replace it), severe anemia and failure to thrive; life expectancy is 30s
271
Concern for prengnacy in patient with sickle cell trait or sickle cell disease
Trait: None,
infants with sickle cell disease have no symptoms until about 4 months when hemoglobin F down trends
Disease: more prone to sickle cell crisis, more frequent infections, and pulmo complications
High incidence of fetal growth retardation and perinatal mortality
272
#1 reason for macrocytic anemia during pregnancy
Decrease levels of folic deficiency
273
Pregnant woman takes nitrofurantoin for UTI. what can occur and why?
She has G6PD deficiency and may develop hemolytic anemia triggered by the medication (sulfonamides, nitrofurantoin, antimalarial agents)
Sxs: dark colored urine due to bilirubinuria, jaundice and fatigue due to hemolytic anemia. Common in African American population
274
Define pancytopenia
reduction of RBCs, WBCs, and platelets
275
What test level would clinch a diagnosis of HELLP syndrome?
elevated serum LDH or fragmented erythrocytes
276
most common cause of anemia in pregnancy
iron deficiency
277
what tests are elevated suggesting beta-thalassemia and alpha=thalassemia
beta-thalassemia: elevated A2 hemoglobin
alpha-thalassemia: elevated hemoglobin F level
278
who develops a vaso-occlusive crisis (ie acute chest syndrome) and what is the txt
Who: patient with sickle cell anemia
Acute chest syndrome: affects the lungs and is dx by new pulmonary infiltrate, dyspnea, hypoxia after r/o PE or pneumonia
279
4 signs of placental separation
1. gush of blood
2. lengthening of the cord
3. globular and firm shape of the uterus
4. the uterus rises up to the anterior abdominal wall (contracting up to ab wall)
280
what occurred?
"shaggy, reddish bulging mass noted adjacent to the placenta" comes out while delivering the placenta. Slight lengthening of the cord
Uterine inversion, placenta did not fully detach and uterus inverted and came out of the vagina
281
Define abnormally retained placenta
third stage of labor that has exceeded 30 minutes
282
Define uterine inversion
"turning inside out" of the uterus, fundus of the uterus moves through the cervix into the vagina
283
how to avoid averting a uterus during 3rd stage of labor
wait spontaneous separation of the placenta from uterus before putting traction on the cord
284
Txt for uterine inversion
-uterine relaxation anesthetic agent given (ie halothane, terbutaline and magnesium sulfate) then uterotonic agents are given such as oxytocin to prevent re-inversion
-emergency surgery
285
What happens after 30 minutes and the placenta is still not delivered?
manual extraction is generally attempted
-no oxytocin until the delivery of the placenta (allows uterus to contract to stop bleeding after placental removal)
286
How long to wait until clamping the cord of the infant? and what is the benefit
30-60 seconds
Benefit: increasing total iron stores and hemoglobin levels, decreasing risk of intraventricular hemorrhage in infants
287
Common complication of uterine inversion
hemorrhage
288
Risk factors for shoulder dystocia
1. Macrosomnia
2. Maternal diabetes
3. Obesity
4. Induction of labor
5. Previous shoulder dystocia
289
Txt for a shoulder dystocia
1. McRobert's maneuver: material thighs are flexed against the maternal abdomen to straighten the sacrum relative to the lumbar spine and rotate the symphysis pubis anteriorly toward the maternal head
2. Suprapubic pressure: push fetal shoulder into an oblique plain
IF not working
-Wood's corkscrew manuever (progressivly rotating the posterior shoulder in 180 degree fashion)
-delivery of posterior arm
-Zavanelli maneuver (cephalic replacement with immediate C-section)
290
Signs of shoulder dystocia during delivery
-fetal head retracted back toward the maternal introitus "turtle sign"
-shoulder is usually behind the maternal symphysis pubis
291
Consequence of shoulder dystocia for baby
-Erb's palsy: brachial plexus injury involving C5-C6 nerve roots
-clavicle fractures
-hypoxic-ischemic encephalopathy
292
Sxs of fetal cord prolapse
-fetus head is unengaged in labor (ie cervix is dilated but fetal head still remains at negative station indicating it is not filling the maternal pelvis)
-rupture of membrances causes fetal bradycardia
-transverse fetal lie or footling breech presentation are also causes of cord prolapse
293
Txt of fetal cord prolapse
1. digital examination of the vagina to assess for the umbilical cord, which would be coming out through the cervical os
2. If prolapse confirmed--> elevated presenting part digitally --> emergency C-section
294
Define engagement during labor
largest transverse diameter of the fetal head had negotiated the bony pelvic inlet
295
Define fetal bradycardia
<110 bpm for > 10 minutes
296
Steps to diagnosis fetal bradycardia
confirm by internal fetal scalp electrode or ultrasound to distinguish between fetal and maternal pulse
vaginal exam to assess for cord prolapse
Positional changes to left side
oxygen
IV fluids
no oxytocin
***IV terbutaline may be given to help relax the uterine musculature in efforts to increase blood flow and O2 to fetus
**NO ATROPINE
297
Steps after coming fetal bradycardia
1. placement of the mom on her side to move uterus from the great vessels (improving blood return to the heart)
2. IV fluid bolus if the mom is volume depleted
3. give 100% O2 be face mask
4. stop oxytocin
298
Most common finding in a uterine rupture
fetal heart rate abnormality such as bradycardia, deep variable decelerations or late decels
299
Prolonged fetal decels or fetal bradycardia assoicated with misoprostol cervical ripening is due to what?
uterine hyperstimulation: greater than 5 uterine contractions within 10 minutes
300
Purpose of hysterosalpingography and define it
Purpose: eval of infertility to evaluate the patency of the f. tubes, detect developmental abnormalities (ie unicornuate or septate uterus), presence of polyps, submucosal myomas, or adhesions
Define: inject dye and then look with X-rays
301
What is this
Candida albicans---yeast infection; vulvovaginitis
302
define cystocele
prolapse of the urinary bladder of the anterior wall of the vainga
303
Uterovaginal prolapse define
prolapse of the uterus and vagina through the vaginal opening
304
define rectocele
Rectum prolapsing into the posterior wall of the vagina
305
txt steps for uterine atony leading to postpartum hemorrhage
1. IV oxytocin, uterine massage, and compression
2. If that doesn't work, IM prostaglandin F2-alpha (Hemabate) or rectal misoprostol
306
Define uterine atony
myometrium has not contracted to cut off the uterine spinal arteries that supply the placental bed
307
Txt for postpartum hemorrhage
1. bladder emptying, uterine massage, dilute oxytocin
2. prostaglandin F2-alpha or rectal misoprostol
3. IV, foley catheter, monitor vitals, move to OR
4. Compression stiches if wants more children, ligation of blood supply, uterine arteries, hysterectomy
---suture ligation of the ascending branch of the uterine artery or the utero-ovarian ligament or internal iliac (hypogastric) artery
---stitches: B-lynch stitch
308
Contraindication for Methergine/methylergonovine and what is it
HTN
an ergot alkaloid agent that induces myometrial contraction as a txt for uterine atony
309
Most common cause of postpartum hemorrhagee
uterine atony
310
Name two uterotonic agents for postpartum hemorrhage and their contraindications
Methylergonovine/Methergine: HTN, risk of stroke
IM prostaglandin F2-alpha: asthma, risk of bronchoconstriction
311
RF for uterine atony: (7)
Magnesium sulfate
Oxytocin during labor
Rapid delivery or labor
Overdistenstion of the uterus (macrosomnia, hydraminos)
Intraamniotic infection (chorioamnionitis)
Prolonged labor
high parity
312
What is msAFP serum testing and what do the results mean
MSAFP (Maternal Serum Alpha-Fetoprotein) is a blood test during pregnancy (weeks 15-20) that screens for risks of neural tube defects (like spina bifida) and chromosomal abnormalities (like Down syndrome) by measuring fetal protein levels in the mother's blood, with high levels potentially indicating defects and low levels suggesting Down syndrome
313
When is serum testing appropriate during pregnancy
15-20 weeks
314
At what age is the fundus usually between the umbilicus and the pubic bone
16 weeks
315
Next step if elevated msAFP at later gestational age
genetic counseling and referral for amniocentesis
316
Define neural tube defect
failure of closure of the embryonic neural folds leading to an absent cranium and cerebral hemisphere (ancephaly) or nonclosure of the vertebral arches (spina bifida)
317
What is the triple or trisomy screen
used to identify pregnancies complicated by neural tube defeccts, Down Syndrome, or trisomy 18
-analyzes 3 chemicals to determine risks: alpha-fetoprotein, hCG, unconjugated estriol
318
Pathophys of alpha-fetoprotein and its interprettation
it is glycoprotein synthesized by fetal yolk sac and then later by fetal gastrointestinal tract and liver. when there is an opening in the fetus not covered by skin, levels of AFP increase in amniotic fluid and maternal serum.
Maternal serum AFP = MOM
Levels >2.0 to 2.5 MOM are suspicious for neural tube defects and warrant further evaluation
Levels <2.0 possible Down syndrome; hcg elevated in these babies
Trisomy 18: all markers are low
319
First trimester screening for Down syndrome and trisomy 18
pregnancy-associated plasma protein (PAPP-A) and free B-hcG with sonographic measurement of nuchal translucency;
-decreased PAPP-A and free B-hCG (except for trisomy 21 it is increased), nuchal translucency thickened
-Inhibin A increased in trisomy 21
320
After abnormal PAPP-A and trisomy triple labs returned what are the next steps?
-basic US to confirm gestational age
-multiple gestations?
-fetal demise?
Then amniocentesis or targeted US (preferred)
-Fetal karotype through amniocentesis
321
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