Step 2 StepUp Obstetrics

12 and 28

implantation (trophoblasts b-hCG)

maternal fetal circulation

distinguish sex

fetal movements

surfactant production (earliest chance for survival)

full term

~2500 kCal

1200mg/day

1mg/day 4wks before attempted pregnancy

30mg/day

60g/day

BMI <19 28-40lbs, 19-26 BMI 25-35lbs, >26 BMI 15-25 (normal should be 25 unless underweight (less) or over weight (more)

1st TM ~2lbs, 1lbs/week in 2nd and 3rd

CO increases 40%, increased SV 10-30%, HR 12-18 BPM. Decrease in systolic/diastolic BP

Decrease in RV, FRC, ERV. Increased TV 40% and minute ventilation

GFR increases 40%

hPL-glucose intolerance, Increased Triglicerides, Cortisol

RBC production, hematocrit decrease, hypercoaguable

EVERYTHING, CBC, Rh, Pap, Gono/Chlam, Urinanalysis, RPR, Rubella titers, PPD, Hep B, HIV, (Cystic Fibrosis in selected population)

Quadruple screen

US Dating, Abnormalities

1hr glucose challenge for DM

GBStrep screening and N. gono/Chlam selected population

b-hCG of 1500mIU/mL vs 6500mIU/mL

9-12wks early detection

16-18wks a-feto, estradiol, hCG, Inhibin A

Increased a-feto, estradiol. Decreased hCG, Inhibin

all low, except Inhibin A

a-feto high

10-22wks, late detection of genetic disroders or Rh sensativity

>16wks indicated after an abnormal quadruple screen, >35yo, risk of Rh sensativity

1hr 50g glucose tolerance test, >140 do 3hr 100g glucose tolerance test, fasting >105, 1hr-190, 2hr-165, 3hr-145.

after 1st TM most frequent in 3rd, Screen at 24-28wks, abn glucose tolerance or a fasting glucose >105. Tx Diet/Exercise, Glyburide, Insulin. F/u fetal development stress test US

follow hemoglobin A1c, control glucose. 3rd trimester echocardiogram and US to follow fetal abnormalities

HTN, Proteinuria, Edema after 20wks gestation. BP >140/90 or 30mmhg rise in systolic or 15 in diastolic. Proteinuria 2+ or >4g/24 hrs. Tx definitive is delivery. severe or far from delivery: MgSO4 siezure prophylaxis, Hydralizine or Labetalol for HTN. (know history of epililepsy, not cured with delivery)

Hemolysis, Elevated Liver, Low Platelets. Form of preeclampsia with poor fetal prognosis.

SIEZURES, tx MgSO4 or Diazapam for siezures, continue for 24hrs after delivery. 25% of siezures within 24hrs postpartum.

Mild-Inhaled B-agonist, Mod Cromolyn or inhaled steriod, Severe oral corticosteriods.

Phenobarbital, drug of choice in early pregnancy, low teratagenicity. Diazapam to break active siezures.

usually in 1st TM. If severe, hyperemesis gravidum. Tx antacids, H2 antagonist or PPI.

US/Doppler studies. Tx IV heparin to treat active DVT PTT 2xNL. Low molecular wt heparin if significant time of delivery, switch to unfractionated 2wks till delivery. STOP all anticoagulants during labor and 6hrs to delivery. Anticoagulants continued postpartum (warfarin, caution when breast feeding)

Maternal arrythmias, Fetal IUGR, premature, stroke

Fetal alcohol withdrawl symptoms (MR, IUGR, sensory and motor neuropathy, facial abnormalities (filthrum)).

Developmental Delays

Prematurity

Maternal infections (needles). Fetal narcotic withdrawl, prematurity, IUGR,

Maternal malnutrition, arrhythmias. Fetal IUGR

Abrupto placenta, Placenta Previa. Spontaneous abortion, prematurity, IUGR, respiratory neonatal infections.

Renal

CN 8, skeletal abnormalities

Facial Abn, IUGR, MR, Cario, NTD

Fetal demise

Cleft Palate

Clear cells cancer of vagina

cartilage

prematurity, fetal demise. safer than warfarin

Goiter, hypothyroid, MR

fetal demise, abnormal genitalia

neonatal withdrawl

facial abnormalities, IUGR, MR, Cardio

CNS abnormalities, Cardiovascular abnormalites, facial and spontaneious abortion

Kernicterus

skeletal, limb and teeth discoloration

limb abnormalities

NTD, facial, cariovasacular, skeletal

Spontanoues abortion, IUGR, CNS, facial and MR

outside of uterus at ampula of fallopian tube, abdominal pain. b-hCG low for gestational age. Tx <6wks methotrexate, anything else IV hidration surgical excision.

<20wks gestation, 25% all pregnancies. B-hCG assess fetal age, US to asses fetal viability.

cervical os closed, no expelled uterine contents, US detects viable fetus Tx: bed rest, limited activity

cervical os opened, no expelled uterine contents, US may detect fetusTx: D&C

cervical os opened, some expelled uterine contents, Tx: D&C

cervical os closed, All expelled uterine contents, Tx: None

cervical os closed, no expelled uterine contents, US detects unviable fetus Tx: None

>20 weeks of gestation. Tx Dilation and Evacution if <24wks, induced labor if >28wks

initial finding abd circumfrence <10th percentile

(baby issues or drugs) congenital infection, chromosomal abnormalities or maternal drug use Length:abdominal ratio normal

(maternal or multiple) multiple gestations, poor maternal health, placental insufficiency. Length:abdominal ratio increased

L:S >2 or phosphatidylglycerol in amniotic fluid.

MgSO4, terbutaline, ritodrine, indomethacin, nifedipine

manual exam not performed due to increased infection risk, ferning, nitrazine paper blue. US confirm oligohydramnios and asses residual volume. Tx >34wks delivery. Chorioamnionitis delay deliver until anbiotics started.

before 38 wks, labor (>8uterine contractions/hr, cervical dilation and effacement).

Implantation near cervical OS, painless vaginal bleeding in 3rd trimester. US to determine location. Tx Tocolysis and Cesarean.

premature separation, painful vaginal bleeding, US inconsistently shows separation. Tx mild-bedrest, delivery or cesarean for hymodynamically unstable.

Tx starting at 20wks weekly follow-up, 36wks activity restriction and frequetn nonstress tests. Vertex-vertex vaginal delivery, all other require caesarean.

Effects of fetal movement on heart rate. Normal reactive if 2 or more 15bpm accelerations fo fetal heart rate lasting 15 seconds each within 20 min

Nonstress test, Bishop Score: amiotic fluid index, fetal breathing rate, fetal movement, fetal tone 8-10 is good, anything else fetal distress

5-23 cm

>1 episode or rhythmic breathin lasting 20 sec in 30 min period

>2 episodes discrete fetal movement withing 30 min period

1> spine and limb extension with return to flexion

beat to beat variability ~5 bpm, long-term heart rate variability, heart rate accelerations (2 accelerations of 15 bpm lasting at least 15 seconds within 20 minute period)

head compression

uteroplacental insufficiency, fetal hypoxia, prompt delivery

umbilical cord compression, change mother position

start of uterine contractions till 4cm dilated. Time for 1' stage Nullparous 6-18 hrs Multiparious <10hrs

4cm -10 cm

10cm-Delivery, Null <3hrs Multi<30min

<30min

hemodynamic stabilization of mother for 1hr

fetal head down, chin tucked, occiput directed towards birth canal.

protiens, fat, minerals, IgA

protiens, fat, water, lactose

0-none 1-<100 2->100bpm

0-none 1-poor weak cry 2- good strong cry

0-poor 1-some movement 2- active movement

0-none 1- grimace 2-strong cry

0-blue pale 1- pink torso 3-pink

complete xx-father, incomplete fetal parts xxy, grape like vesicles US snowstorm appearance,

malignant trophoblastic neoplasm, CT metastasis