Notes

While the role of tocolysis in the setting of preterm rupture of membranes is controversial, it may be appropriate in limited settings. Tocolysis may be administered in an attempt to prolong the interval to delivery to gain time for steroids to obtain maximum benefit for the fetus. The risks of chorioamnionitis with continuing tocolytics beyond 48 hours outweighs the benefit of awaiting lung maturity. This may be reasonable in women without evidence of infection or advanced preterm labor. Admittedly, the likelihood of success in this setting is relatively poor, but the potential benefit to the fetus probably outweighs any maternal complication from tocolysis.
The primary risk factor for preterm rupture of membranes is genital tract infection, especially associated with bacterial vaginosis.
Antibiotic therapy with ampicillin and erythromycin given to patients with preterm premature rupture of the membranes has been found to prolong the latency period by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal sepsis.
In some cases of preterm rupture of the membranes, amniocentesis may be performed to detect intra-amniotic infection. The presence of amniotic leukocytes has the lowest predictive value for the diagnosis of chorioamnionitis. Interleukin-6 would be increased in the setting of chorioamnionitis. A low amniotic fluid glucose is an indication of intra-amniotic infection.
17 alpha-hydroxyprogesterone has been shown to reduce the risk of premature labor. 17 alpha-hydroxyprogesterone is administered weekly (starting between 16-20 weeks) until 36 weeks gestation.
While the patient is contracting every four minutes, it is not clear if her contractions are adequate. An intrauterine pressure catheter (IUPC) will help determine if her contractions are adequate and if oxytocin augmentation is appropriate. Prostaglandins are used for cervical ripening and are contraindicated in patients with history of previous Cesarean section
Late decelerations are associated with uteroplacental insufficiency.
Late decelerations when viewed as repetitive and/or with decreased variability are an ominous sign. The can be associated with uteroplacental insufficiency as a result of decreased uterine perfusion or placental function, thus leading to fetal hypoxia and acidemia. Common causes include chronic hypertension and postdate pregnancies
Initial measures to evaluate and treat fetal hypoperfusion include a change in maternal position to left lateral position which increases perfusion to the uterus, maternal supplemental oxygenation, treatment of maternal hypotension, discontinue oxytocin, consider intrauterine resuscitation with tocolytics and intravenous fluids, fetal acid-base assessment with fetal scalp capillary blood gas or pH measurement. An amnioinfusion may be used to treat patients with variable decelerations.
Factors that lead to an over-distended uterus are risk factors for uterine inversion. Grand multiparity, multiple gestation, polyhydramnios and macrosomia are all risk factors. The most common etiology of uterine inversion, however, is excessive (iatrogenic) traction on the umbilical cord during the third stage of delive
Uterine atony is the most common cause of postpartum hemorrhage
Methergine, prostaglandins, misoprostol, and oxytocin are all uterotonics and used to increase uterine contractions and decrease uterine bleeding. Methylergonovine is an ergot alkaloid, which is a potent smooth muscle constrictor. It is also a vasoconstrictive agent and should be withheld from women with hypertension and/or preeclampsia. Misoprostol, prostaglandin E1, used for cervical ripening and labor induction, is a uterotonic agent frequently used for uterine atony, although not FDA approved for this use.
Prostaglandin F2-alpha (Hemabate) is a potent smooth muscle constrictor, which also has a bronchio-constrictive effect. As such, it should be used with caution in any patient with a reported history of asthma.
The following are associated with retained placenta: prior Cesarean delivery, uterine leiomyomas, prior uterine curettage and succenturiate lobe of placenta.
Risk factors for PostPartumHemorrhage include uterine over distension (polyhydramnios, macrosomia, and multiple gestation), prolonged labor, chorioamnionitis, and grandmultiparity
Endomyometritis is a common complication of prolonged labor, prolonged rupture of membranes and multiple vaginal examinations. The infection is polymicrobial, mostly anaerobic and requires broad-spectrum antibiotics for treatment until the patient is afebrile for 24 hours. By adding Gentamicin to ampicillin, you are covering the spectrum of gram-negative organisms.
Breast engorgement is an exaggerated response to the lymphatic and venous congestion associated with lactation. Milk “let-down” generally occurs on postpartum day two or three. If the baby is not feeding well, the breast can become engorged, which can cause a low-grade fever.
The lungs are the most common source of fever on the first postpartum day, particularly if the patient had general anesthesia. Atelectasis may be associated with a postpartum fever. Aspiration pneumonia should be considered in patients who had general anesthesia
Cat A - good with human trials. Cat B animal but no human trials and fine. cat c - animal studies bad but no human studies. cat d - human trials and known risk to fetus. Category X drugs should not be used in pregnancy, because adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks.
Symptoms of Premenstrual Dysphoric Disorder occur in the luteal phase and are absent in the beginning of the follicular phase.
Postterm pregnancies should be followed with antepartum fetal surveillance because perinatal morbidity and mortality increases beginning at 41 weeks of gestation. Many practitioners use twice-weekly testing with some evaluation of amniotic fluid volume beginning at 41 weeks of gestation. A non-stress test and amniotic fluid volume assessment (a modified BPP) should be adequate. The non-stress test is an assessment of fetal well-being that measures the fetal heart rate response to fetal movement. The normal or reactive non-stress test occurs when there are two fetal heart rate accelerations of 15 beats/minute for 15 seconds within 20 minutes
Postterm pregnancies are associated with placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, inaccurate or unknown dates and extrauterine pregnancy.
Postterm pregnancies are associated with macrosomia, oligohydramnios, meconium aspiration, uteroplacental insufficiency and dysmaturity.
repetitive ariable decelerations - amnioinfusion
The incidence of infants with dysmaturity approaches 10% when the gestational age exceeds 43 weeks. Infants are described as withered, meconium stained, long-nailed, fragile and have an associated small placenta
When a pregnancy is complicated by fetal growth restriction, various fetal physiologic parameters require assessment. In growth-restricted pregnancies, oligohydramnios is frequently found. This finding is presumably due to reduced fetal blood volume, renal blood flow and urinary output. Chronic hypoxia is responsible for diverting blood flow from the kidney to organs that are more critical during fetal life. The significance of the amniotic fluid volume with respect to fetal outcome has been well documented. Ninety percent of patients with oligohydramnios delivered growth restricted infants. These infants experienced a high rate of fetal compromise. The systolic/diastolic (S/D) ratio of the umbilical artery is determined by Doppler ultrasound. An increase in the S/D ratio reflects increased vascular resistance. It is a common finding in IUGR fetuses. A normal S/D ratio indicates fetal well-being. As vascular resistance increases, the S/D ratio increases. With severe resistance, there is absence and ultimately reversal of end-diastolic flow. These findings are associated with an increased rate of perinatal morbidity and mortality, and a higher likelihood of a long-term poor neurologic outcome. Options for antenatal testing include the non-stress test, contraction stress test, and the biophysical profile. Any of these may be used in a growth-restricted fetus as a means of detecting possible or probable fetal asphyxia.
Uteroplacental insufficiency can lead to asymmetric growth restriction. Asymmetric growth restricted infants typically have a normal length, but their weight is below normal. On ultrasound, there is a head-sparing effect, meaning that the head/brain is spared of the reduced blood flow that is a result of uteroplacental insufficiency. Thus, the fetal abdomen measures below normal and the head remains very close to normal. There is an asymmetrical growth pattern that is usually detected during the third trimester and reflects uteroplacental insufficiency.
Typically, polyhydramnios is not associated with asymmetric growth restriction (the most common form of IUGR), since an asymmetric growth pattern reflects poor uterine blood flow and limited substrate availability. In fact, oligohydramnios is frequently identified in pregnancies complicated by fetal growth restriction.
Epidemiologic studies indicate that fetal growth restriction is a significant risk factor for the subsequent development of cardiovascular disease, chronic hypertension, chronic obstructive lung disease and diabetes - no increased risk of osteoporosis
Delivery is indicated in a fetus with IUGR at 36 weeks gestation with oligohydramnios and abnormal umbilical artery Doppler studies. Although there is an increased incidence of fetal intolerance of labor, induction of labor is generally preferred over elective Cesarean delivery.
While poorly controlled pre-existing diabetes is associated with an increased risk of congenital anomalies, gestational diabetes is not associated with increased risk of congenital anomalies.
ultrasound measurement of crown-rump length is considered the most reliable (+/- 4 to 5 days) in the first trimester.
A fetal head with measurements greater than 12 cm could benefit from delivery by Cesarean section.
This patient meets all the requirements for an operative vaginal delivery. Forceps application requires complete cervical dilation, head engagement, vertex presentation, clinical assessment of fetal size and maternal pelvis, known position of the fetal head, adequate maternal pain control and rupture of membranes. Strict adherence to the guidelines suggested by the American College of Obstetricians and Gynecologists (ACOG) for low forceps delivery does not increase the fetal or maternal risks when performed by an experienced operator.
Amniotic fluid index: An AFI between 8-18 is considered normal. <6, oligohydraminios
Chorionic villus sampling (CVS) is a prenatal test that can detect genetic and chromosomal abnormalities of a fetus. The loss rate with amniocentesis is quoted as 0.5% vs. ~1 to 3% for chorionic villus sampling. CVS is performed between 10 and 12 weeks gestation, while amniocentesis is performed after 15 weeks. Early CVS (<10 weeks gestation) is associated with an increase in rare limb abnormalities. It is more likely that a CVS will involve multiple attempts – a failure to obtain an adequate sample of cells and the woman requiring a repeat test later on – when compared with amniocentesis.