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OBGYN: ID of the high risk patient
ID of the high risk patient: OBGYN
85
Anatomy
Graduate
09/10/2011

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Term
Maternal death occurs during pregnancy or within __ days after termination of pregnancy.
Definition
- 42 days (6 weeks)
Term
The Maternal Mortality Ratio is defined as __ __ per ____ ___ __.
Definition
- maternal deaths per 100,000 live births

(582 in 1935, 8.9 in 2002)
Term
The maternal mortality ratio is __ times higher for African Americans than it is for Caucasians.
Definition
4
Term
Factors that increase maternal mortality ratio:
Definition
- African American
- Older than 30 for all races
Term
Major causes of maternal mortality (excluding ectopic) in order of most to least:
Definition
1. Pulmonary Embolus
2. Hypertensive Disorders
3. Hemorrhage and Sepsis
Term
How long does it take for physiology to return to normal after pregnancy?
Definition
6 weeks
Term
Perinatal Mortality is __ __ (after __ weeks or greater than __grams) plus __ __ (up to __ days after delivery)/__ __ __.
Definition
- [fetal deaths (after 20 weeks or greater than 500g)+ neonatal deaths (up to 28 days (4 weeks) after delivery)]/(1000 live births)
Term
perinatal mortality = (fetal deaths + neonatal deaths)/1000 live births
Definition
Decreased from 29 in 1970 to <10 in 2000
AA 2x higher than caucasians
Higher for those without prenatal care
Term
Perinatal death is __ times higher for African Americans than it is for Caucasians.
Definition
2
Term
death of the fetus after 20 weeks or 500 grams is fetal death. Prior to 20 weeks, this is considered miscarriage or abortion.
Definition
Term
When should high risk pregnancies be identified?
Definition
before they get pregnant
Term
First prenatal visit:
Definition
- general history
- obstetrical history
- medical history
- physical exam
- laboratory studies
Term
High risk pregnancy factors from general history:
Definition
- low socioeconomic status increases perinatal morbidity and mortality
- age
- substance abuse
- environmental factor
- domestic violence
Term
Perinatal = __weeks pregant up to __ weeks after delivery.
Definition
20 weeks pregnant up to 4 weeks after delivery
Term
Age younger than __ increases ones risk for:
Definition
- younger than 20
- premature births
- late prenatal care
- low birth weight
- uterine dysfunction
- fetal deaths
- neonatal deaths
Term
Age greater than __ increases your risk for:
Definition
- 35
- first trimester abortion (40 3x higher than 30)
- Genetically abnormal conceptuses (trisomy 21, 18, 13, sex chro)
- Medical complications (HTN, DM, preeclampsia)
- Multiple gestations and its complications (3/1000 at age 20, 14/1000 at age 35)
- Higher rates of C-sections
- fetal morbidity and mortality
Term
When __ and older, there is a greater risk that amniocentesis will damage the fetus.
Definition
35
Term
There is a tobacco __ __ __ between smoking and fetal m&m.
Definition
dose response relationship
Term
Cocaine, heroin, and marijuana are associated with ___.
Definition
LBW
Term
__ and __ cause neonatal withdrawal.
Definition
Cocaine and opiods
Term
__ can lead to premature labor and abruption.
Definition
Cocaine
Term
Alcohol- FAS 0.1% of pregnancies. 2% drink daily. No known safe level. TACE questions
Caffiene- no increase in abnormalities, may be a higher rate of SAB with heavy use
Definition
Term
KNOW THIS.

SMOKING INCREASES RISK FOR __ __.
Definition
PLACENTAL ABRUPTION
Term
Radiation is associated with __ __, __ __, and __ __ (not seen with less than 5 rad).
Definition
- birth defects
- spontaneous abortion
- childhood leukemia
Term
Noxious chemicals may make mom sick, but not known to harm baby
Definition
Term
High risk factors from Obstetric history:
Definition
- Parity
- Ectopic pregnancies
- Preterm deliveries
- Second trimester losses
- Macrosomnia
- History of perinatal death
- Cesarean delivery
- PIH
- chronic HTN
Term
Nulliparous women have increased rates of __ __ __.
Definition
pregnancy induced hypertension (PIH)
Term
Grand Multiparas is defined as __ or more pregnancies resulting in viable fetuses have higher rates of __, __, and __ __.
Definition
- 5
- previa
- hemorrhage
- dizygotic twins
Term
If one has history of ectopic pregnancy, increased likelihood of recurrence.
Definition
Term
If one has a history of preterm delivery, there is a _ to __% recurrence.
Definition
25 to 40% recurrence
Term
PIH: gestational hypertension: high blood pressure 140/90 twice at least 6 hours apart,
Definition
Term
If a patient has HTN prior to 20 weeks of gestation, it is __ __ not __ __ __.
Definition
- chronic hypertension NOT pregnancy induced hypertension
Term
preeclampsia =
Definition
HTN + proteinuria
Term
WHAT ARE THE NUMBER 1 AND NUMBER 2 RISK FACTORS FOR PRETERM DELIVERY:

TEST KNOW THIS
Definition
1. MULTIPLE GESTATIONS
2. HISTORY OF PRETERM DELIVERY
Term
High risk from obstetric history, factors associated with history of second trimester loss:
Definition
- genetic problem with fetus
- problem with mother: incompetent cervix, may need cerclage
Term
Macrosomnia is a risk factor from obsetric history, expand on this:
Definition
macrosomnia (>4000 g)
- previous glucose intolerance
- shoulder dystocia
- Cesarean delivery
- Postpartum neonatal hypoglycemia
Term
After 10 weeks, chances of miscarriage decreases quite a bit.
Definition
Term
Mom’s feels lots of contractions and passes baby at 22 weeks and she HURTS
Definition
Preterm delivery
Term
If PAINLESS DILATION AND GOES INTO SEE DOCTOR
Definition
incompetent cervix- put in cerclage at 14 weeks
Term
In normal babies, the head should be the biggest part. With glucose intolerance/macrosomnia, sometimes the trunk is biggest part, so have to worry about it getting stuck.
Definition
Term
Postparum neonatal hypoglycemia: moms sugar high, baby sugar high, baby has insulin high, even after delivery insulin high> low blood glucose
Definition
Term
History of perinatal death may indicate underlying problems such as:
Definition
Glucose intolerance/ GDM
Collagen vascular dz
Congenital anomalies
Chromosomal abnormalities
Preterm labor
Hemolytic disease
Abnormal labor
Antiphosphilipid syndrome (APS)
Thrombophilia
Term
Cesarean delivery
Usually recommend attempted vaginal delivery unless:
Definition
Classical uterine incision
Active herpes infection
Sub adequate HIV control
Previous myomectomy with penetration into myometrium
Term
previous C section deliveries are high risk deliveries.
Definition
Term
Classical uterine incision is going up and down> cannot deliver vaginally after that b/c high risk of uterine hemorrhage.
Definition
Term
If the viral load is less than ___ with HIV, the baby can still be delivered vaginally.
Definition
1000
Term
Rupture less than 1% with LTCS
transverse incision c section much less likely to rupture than classical incision
Definition
Term
If you have severe pre-eclampsia in pregnancy> the chances of getting it next pregnancy is higher and more likely to get it earlier on in pregnancy.

Only way to cure preeclamplsia is delivery.
Definition
Term
Chronic HTN predisposes pts to the following when pregnant:
Definition
- Superimposed preeclampsia
- Placental abruption
- Perinatal loss
- Maternal morbidity
- Myocardial infarction
- Uteroplacental insufficiency
- CVA
Term
Cardiac Disease
May worsen in pregnancy because of the hemodynamic changes of pregnancy the following are associated with a high maternal mortality and termination usually recommended:
Eisenmenger syndrome
Primary Pulmonary Hypertension
Marfan with aortic root dilation
Hemodynamically significant mitral or aortic stenosis
Fetus depends on adequate supply of oxygenated blood, if not present, retarded growth may occur, or even death
Infants of parents with cardiac abnormalities have increased chances of cardiac disease
Definition
Term
The following cardiac diseases are associated with high maternal mortality and termination is recommended:
Definition
- Eisenmenger syndrome
- Primary Pulmonary HTN
- Marfan with aortic root dilation
- Hemodynamically significant mitral or aortic stenosis
Term
Pulmonary diseases have unpredicatable responses with pregnancy
Definition
Term
Renal disease with pregnancy usually has good outcomes if the Cr is below __. Up to _ is normal in pregnancy b/c of the ___ GFR.
Definition
- below 1.5
- up to 1
- increased GFR
Term
Diabetes in pregnancy increases risk of:
Definition
- congenital anomalies (2-3x)
- fetal mortality
- neonatal morbidity- RDS, macrosomnia, hypoglycemia, hyperbilirubinemia, hypocalcemia
Term
Caudal regression syndrome and cardiac anomalies tend to occur in babies whose moms were ___.
Definition
diabetic
Term
Thyroid disease in pregnancy if untreated is very bad.
Definition
just don't give radioactive iodine to pregnant woman
Term
SLE in pregnancy increases __ __, ___, and ___.
Definition
- placental abruption
- IUGR
- preeclampsia
Term
PREGNANCY IS A HYPER-COAGULABLE STATE.
OCPS INCREASE RISK OF THROMBOEMBOLIC EVENTS, BUT NOT EVEN CLOSER TO WHAT PREGNANCY DOES.
Definition
Term
Thromboembolic disease- pregnancy alone will predispose women to TE. Usually need anticoagulant prophylaxis if previous history of TE/PE. Warfarin causes birth defects. Heparin does not cross the placenta.
Definition
Term
If pregnant patient has history of PE or TE, probably needs to be on anticoagulant therapy. Put them on __ NOT __.
Definition
heparin NOT warfarin b/c heparin does not cross placenta
Term
Genetic diseases- such as PKU can result in malformation if diet not followed
Consanguinity- increases SAB and recessive diseases
Ethnicity
Tay-Sachs (Ashkenazi Jews and French Canadians)
Canavan disease (Ashkenazi Jews)
Thalassemias (Mediterranean, SE Asian, Indian, African)
Sickle cell (African, Mediterranean, Caribbean, Latin American, Indian)
Cystic Fibrosis (Caucasian)
Definition
Term
Infectious diseases can place mother and fetus at risk if they occur during pregnancy
Definition
Cytomegalovirus-increased congenital anomalies
Herpes simplex virus- neonatal infection, potentially devastating
Toxoplasmosis- another reason to not like cats
Parvovirus- severe anemia, hydrops, fetal death
VZV- limb hypoplasia, neonatal disseminated infection
HBV- Vertical transmission
HIV
Term
Toxoplasmosis: have lady with cat NOT change litter box and have person that changes it do it outside, people from France who eat raw meats are also at risk, also people on farms at risk. So if new onset of seizure not automatically preeclampsia, could be this.
Definition
Term
Parvovirus: pregnant woman who has been exposed to parvo> IgG and IgM to parvo and get an ultrasound to look for hydropic changes: edema that occurs due to severe anemia (antibodies destroying own blood cells> high output cardiac failure> third spacing). Tell them to be washing their hands and that they will probably be fine just do all these tests.
Definition
Term
VZV: limb hypoplasia, those motheres that have chicken pox and just delivered a couple of days ago> those are the babies you really worry about
Definition
Term
Autoimmune disorders may lead to:
Definition
Recurrent fetal loss
Placental infarction
Preeclampsia in early pregnancy
Thromboembolic phenomena
Autoimmune thrombocytopenia
Term
Being short and underweight increases the risk for:
Definition
- preinatal morbidity and morality
- LBW
- preterm delivery
Term
Obesity increases the chance of:
Definition
- HTN
- DM
- aspiration with anesthesia
- wound complications
- thrombembolism
Term
High risk from physical exam:
Definition
Obstructive lesions of vagina, vulva, cervix
Pelvimetry revealing contracted pelvis
Uterine evaluation
Fibroids associated with higher rates of: SAB, premature labor, dysfunctional labor, pp hemorrhage, obstruction of labor if in lower uterine segment, unstable lie, compound presentation and pain from degeneration
Incompetent cervix
Mullerian anomalies- septae, bicornuate uteri, etc.
Term
Breeches are NOT delivered any more. Singleton breech delivery> poor neonatal outcomes are higher and higher risk of develomental delays
Definition
Term
hydrops is :
Definition
severe anemia
Term
High risk lab studies:
Definition
Blood Type/ Ab screen- Rh isoimmunization =>hydrops => fetal demise
Minor antigens (Kell, Kidd, Duffy) can cause severe hydrops from anemia
Syphilis screen- disease can result in SAB, IUFD, congenital infection
Gonorrhea may cause chorioamnionitis, PPROM, PTD, neonatal eye infection, sepsis, maternal arthritis, rash or peripartum fever
Chlamydia can cause neonatal conjuctivitis, pneumonia, late pp endometritis
Term
every kid gets eryhtromycin in their eyes when delivered
Definition
Term
Rubella infection can cause early abortion or severe congenital anomalies. Can only give vaccine ___ because it is a ___ ___vaccine.
Definition
postpartum
live attenuated
Term
Asymptomatic bacteriuria (3-5% of pregnant women) Treat it. Acute pyelo will develop in 20-40% of untreated women.
Definition
Term
With Trisomy 21 positive screening, there is low __ ___ and __ and high __.
Definition
- low alpha fetoprotein and estriol
- high hCG
Term
What would markers show on a positive trisomy 18 screen?
Definition
- low alpha fetoprotein
- low estriol
- low hCG
Term
High alpha feto protein can be seen with:
Definition
- neural tube defects
- multiple gestations
- fetal demise
- abruption
- ompthalmocele
- gastroschisis
Term
Unexplained MSAFP may be associated with third-trimester complications
Definition
Term
Cannot treat mom with Hep B during pregnancy. So when baby is deliveried give baby Hep B ___ within __ __ of delivery and then start __ __ __after delivery, then at 2 months, and 6 months.
Definition
- immunoglobulins within 1 hour
- vaccine 12 hours after delivery
Term
Assessments of fetal well being:
Definition
Self assessment
Nonstress Test
Ultrasound
Contraction stress test
Term
With a Non-Stress Test, have the mom lay on her __ side. The bottom line is mom's ___ and the top is the __ __ __.
Definition
- left
- contractions
- fetal heart rate

want to see see 2 accelerations at least 15 minutes above baseline lasting for at least 15 seconds
Term
Ultrasound-Biophysical Profile components:
Definition
- NST
- Amniotic fluid > 2 cm
- Tone-flexion or extension of extremity
- Movement
- Fetal breathing-1 or 2 30 seconds

each one counts for 2

8 or 10/10 is reassuring these scores mean less than 1/1000 chance baby has died

if score of 6 at 36-38 week> deliver

if score of 6 at 30 weeks> think it through
Term
The Umbilical Artery Doppler looks at umbilical artery __ __. You want a normal systolic/diastolic ratio. A __ ratio or __ __ __ indicates compromise.
Definition
- vascular resistance
- reduced ratio or reversed diastolic flow

Looking for reverse end diastolic flow.

When go through diastole, should still have forward flow, its just a lot less. But if the bottom peak of triangles is crossing the line> reverse flow, need to be delivered
Term
Contraction Stress Test:
Definition
Rarely used anymore
Similar to NST
Ocytocin (pitocin) use
or manual stimulation
If not sure if they will tolerate labor well> 3 contractions in 10 minutes > probably will tolerate labor?
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