Professional Documents
Culture Documents
First Trimester
Tips
Schedule visit to the gynecologist, start prenatal vitamins, folic acids Avoid alcohol and smoking; environmental hazards Get genetic counseling ( optional)
Initial Tests
First visit to doctor: Blood tests- hormones, blood type, Rh (rhesus) factor, hemoglobin, rubella (German measles), hepatitis B, syphilis, and HIV, Tay-Sachs, cystic fibrosis, sickle cell anemia, Urine Tests- Hcg, UTI, kidney infection, blood tests, albumin
Risks or complications
Miscarriages can occur due to low levels of progesterone; chromosomal abnormaties (robertsonian translocation) Bleeding, severe abdominal pain, cramps due to ectopic pregnancy- mimics appendicitis ( causes of ectopic pregnancy- PID, ruptured appendix, past tubal surgery) Placenta previa- painless bleeding in any trimester placenta attached to lower uterine segment; causes- surgeries, C sections, multiple births Severe nausea and fatigue- dehydration, anemia malnourishment increase in birth defects in baby and can induce premature labor Mood swings- depression, anxiety stress- weakened immune system- increase in flu constipation frequent urination, food cravings and aversion weight gain
Snowstorm Pattern
Molar pregnancy
Ectopic Pregnancy
Unruptured Signs: missed periods, bleeding and unilateral pain, Prescribe methotrexate or perform salpingostomy. Give methothrexate1. beta HCG <6000 mIU, 2. no fetal activity Follow up with serial beta HCG to ensure pregnancy resolution . If Salpingotomy is performedfollow up with serial beta HCG to ensure pregnancy resolution Ruptured Signs- increase HR, decrease in BP, guarding, rigidityTests- do laparotomy: salpingectomy (not salpingostomy)
Missed Abortion If ultrasound revealed non viable pregnancy No vaginal Bleeding but cramping, cervical dilation Perform: D & C; misoprostal or wait for spontaneous abortion
Incomplete Abortion if ultrasound shows cervix is open perform D & C or emergency suction as it is inevitable abortion
Second Trimester
Tests
Week 15-20 - quadruple marker screening test: measures: 1. alpha-fetoprotein (AFP), 2. human chorionic gonadotropin (hCG), 3 . Inhibin A, 4. Estrogen produced by the placenta. Predicts:- Down syndrome more accurately Triple screen testAFP, hCG and unconjugated estriol Mother 35 year and older with suspicious AFP or Quad screen- Amniocentesis Amniocentesis ( 15- 18 weeks) low AFP= Down syndrome High AFP-wrong gestational age, twins, omphalocele, neural tube defect, death of baby
Tests
Glucose sceening test ( 24- 28 weeks) to detect gestational diabetes CBC RPR ( rapid plasma reagin) for syphillis Urine culture
Gestational diabetes
Subtypes: Type A1 abnormal oral glucose tolerance test (OGTT), but normal blood glucose levels during fasting and two hours after meals Treatment: diet modification Type A2: abnormal OGTT plus abnormal glucose levels during fasting and after meals; Treatment- diet modification and medication is required Causes: Previous history, family history, maternal age, ethnicity ( African Americans), obesity, PCOS etc. Symptoms: no visible symptoms or increase in thirst, frequent urination, nausea, vomiting, yeast infections, blurry vision
Non-challenge blood glucose tests If plasma glucose level > 126 mg/dl (7.0 mmol/l) after fasting or >200 mg/dl (11.1 mmol/l) on any random occasion This confirms gestational diabetes ( no further testing is required)
Screening glucose challenge test Performed between 24 28 weeks; simplified version of the oral glucose tolerance test (OGTT) Patient drinks a solution containing 50 grams of glucose, and then blood glucose levels are measured after an hour. Levels > 140 mg/dl (7.8 mmol/l) confirms GD
Oral glucose tolerance test ( OGTT) Performed morning after the all night fast of about 8 -14 hours Patient is asked to drink normally 100 g of glucose solution, blood glucose levels are measured at several times after GD is confirmed if: After Fasting > 95 mg/dl After 1 hour > 180 mg/dl After 2 hour > 155 mg/dl After 3 hour > 140 mg/dl (5.33 mmol/L) (10 mmol/L) (8.6 mmol/L) (7.8 mmol/L)
Management fast-acting insulin before the meal, oral hypoglycemics- glyburide, Metformin Complications Macrosomia in fetus- difficult delivery, hypoglycemia in neonatals, respiratory distress syndrome ( impaired surfactant secretion), pre-eclampsia, congential deformities
Third Trimester
Placenta abruptio
Sudden onset of dark red painful bleeding in 3rd trimester (around 30 weeks) associated with uterine contractions; severe constant pain normally occur during hypertension, trauma, or due to cocaine, smoking etc. Placenta gets detached from the implantation site premature; can lead to DIC Treatment: insert bore IV and foley cathether initial step in all cases If patient is stable- tocolysis with magnesium sulfate If patients is at 36 weeks or after with controlled bleeding- vaginal delivery If patient is unstable- emergency C- section
Uterine Rupture
Sudden onset of abdominal pain and vaginal bleeding; loss of fetal heart rate; uterine contractions; recession of fetal head History of uterine scar/incisions or aggressive oxytocin supplementation; preivous myometromy
Treatment If patient is stable- uterine repair surgery If patient is unstable hysterectomy (also if patient desires no more pregnancy in future)
Pre-Eclampsia
Mostly occur at 32 weeks but can develop at 20 weeks as well Triad: proteinuria, hypertension and edema headaches, blurry vision, pain, intense edema of face and legs, hemolysis, increase liver function tests, low platelets Death can occur due to acute respiratory distress syndrome or cerebral hemorrhage Causes: ongoing conditions like hypertension, diabetes, renal diseases, autoimmune disorders; Placenta ischemia Treatment: Delivery of fetus, bed rest, treat hypertension, diet modification
Eclampsia
Pre-eclampsia + seizures Treatment- IV magnesium sulfate and diazepam
Tests
GBS screening Group B Streptococcus is a part of normal flora of genital tract in 20 40% women but can results in neonatal infection and death Vaginal and rectal cultures are obtained in 35- 36 weeks In GBS positive women- treatment with antibiotics If there is a premature labor- treatment with IV penicillin or ampicillin is required regardless of the cultures or prior lab tests Other tests taken during 35- 36 weeks Chlamydia, Gonorrhea, HIV etc. NST non stress test- monitor uterine contractions; fetal heart rate
Baby s gluteus is facing the direction of birth canal; Flexion of hips, extension of knees, Increase chances of looping umbilical cord
Frank breech
Complete Breech
Ideal for labor; baby s head is positioned downward it faces the back of the mother
Baby is positioned crosswise; shoulder will enter the pelvis Requires cesarean section
Transverse lie
Baby s booth feet are leading to the birth canal, umbilical cord cab wrap around the womb, cutting the blood supply
Footling breech
Complications
Placenta accreta- heavy bleeding after the delivery malformed decidual layer of the uterus causes the placenta to attach to the myometrium Causes- placenta previa, C section etc Retained placental tissue leads to postpartum hemorrhage C section Infections, blood loss, injury to fetus, anesthesia complications, nausea, constipation, maternal death, immature fetal lungs, incision scars, placenta previa, placenta accreta
Fetal abnomalities
Esophageal Atresia chocking spells at birth in order to diagnose it, the NG tube is inserted in the mouth, if it is coiled up in the upper chest and this will confirm the diagnosis Imperforate Anus absence of normal anal opening, absence of flatulence or stool at birth Congenital Diaphragmatic Hernia Dyspnea at birth; X-ray will reveal- loops of bowel in left chest Omphalocelle the sac which is formed from an outpouching of the peritoneum, protrudes in the midline through the umbilicus Gastroschisisthe intestines protrude outside the fetal abdomen with no protective membrane Exstrophy of Urinary Bladder Failure of the abdominal wall to close during the fetal development and results in the protrusion of the posterior bladder wall through the lower abdominal wall.
Still in a sac
Gastroschisis
Thank You!
References
Wikipedia (2012) Gestational Diabetes; Retrieved from: http://en.wikipedia.org/wiki/Gestational_diabetes Wikipedia (2012) Group B Streptococcus; Retrieved from: http://en.wikipedia.org/wiki/Group_B_streptococcal_infection American Pregnancy Association (2012) Premature Birth Complications; Retrieved from: http://www.americanpregnancy.org/labornbirth/complicationspremature.htm Webmd (2010) Cesarean section Risks and Complications; Retrieved from: http://www.webmd.com/baby/tc/cesarean-section-risks-and-complications josephmedman (2011)USMLE Alogarithms; Retrieved from: http://www.youtube.com/user/josephmedman/featured
Hoffman M (2008) Health and Pregnancy, retrieved from: http://www.webmd.com/baby/healthtool-fetal-positions-slideshow Nihira M (2009) Health and Pregnancy; Retrieved from: http://www.webmd.com/baby/1to3-months Le T, Bhushan V, Vasan N (2010) First aid for the USMLE step 1; 20th Edition; Mc Graw Hill productions