Inpatient Obstetrical Certification Flashcards

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Questions and Answers

What is the leading cause of perinatal admissions to the ICU?

Diabetes

Infections

Hemorrhagic disorders (correct)

Hypertension

What percentage of deaths is related to pregnancy-related hemorrhages?

17-25%

Most maternal deaths from obstetric hemorrhage after the first trimester are due to?

Placental abruption

Which race is most likely to die from postpartum hemorrhage?

African Americans Signup and view all the answers

What was the mortality rate (2006) for white women, African American women, and Hispanic women in the US?

White women 13.3/100,000, African American women 32.7/100,000, Hispanic women 10.2 Signup and view all the answers

68% of postpartum hemorrhage deaths occur within ______ hours of delivery.

48 Signup and view all the answers

Obstetric hemorrhage is defined as a TBL or more than _______ cc.

1000 Signup and view all the answers

What is the classic sign of placenta previa?

Painless vaginal bleeding in the second or third trimester of pregnancy Signup and view all the answers

If you see painless vaginal bleeding in the second or third trimester of pregnancy, suspect?

Placenta previa Signup and view all the answers

What are the risk factors for placenta previa?

Previous placenta previa, advanced maternal age greater than 40, previous cesarean, short interval between pregnancies, multiparity, previous abortions with curettage, smoking, race (Asian women at greatest risk), large placenta Signup and view all the answers

In patients with suspected placenta previa, which comes first, a speculum examination or a confirmatory ultrasound?

Do the ultrasound first Signup and view all the answers

Fetal blood volume is?

100 ml/kg Signup and view all the answers

What changes are noted during significant blood loss?

Rising pulse rate, increase in respiratory rate, skin changes to pallor, falling blood pressure (a late finding), decreased urinary output, decreased LOC Signup and view all the answers

Characteristic findings in FHR if the mother has significant blood loss?

Initially, tachycardia then bradycardia, sinusoidal-fetal anemia, hypoxia and acidemia, persistent late decelerations Signup and view all the answers

What is the percentage of accreta among women with previa?

5-10% Signup and view all the answers

If a patient has had 2 or more cesarean sections, the likelihood of an accreta is?

Greater than 50% Signup and view all the answers

What is vasa previa?

Fetal vessels cross the placental membranes in the lower uterine segment and cover the cervical os Signup and view all the answers

Velamentous cord insertion is defined as?

Fetal vessels run across chorion and amnion without protective Wharton's jelly before entering the placental surface Signup and view all the answers

What is a succenturiate placenta?

One or more small accessory lobes of placental vascular tissue in membranes that are attached to main placenta by fetal vessels Signup and view all the answers

What is hemolysis?

Lysis of erythrocytes with the release of hemoglobin Signup and view all the answers

What does HELLP stand for?

Hemolysis, Elevated Liver Enzymes, Low Platelets Signup and view all the answers

According to AWHONN, patients with placenta previa should not be discharged to home until they have gone ______ hours without bleeding.

72 Signup and view all the answers

What is a classic symptom of placental abruption?

Painful vaginal bleeding after 20 weeks gestation Signup and view all the answers

What are the risk factors for placental abruption?

Smoking increases risk 90%, maternal hypertension 500% increased risk, multiparity, abortions, illicit drug use, short umbilical cord, abdominal trauma, rupture of membranes (due to sudden uterine decompression), leiomyoma behind placenta Signup and view all the answers

What is the ACOG standard for fetal monitoring for maternal abdominal trauma?

Minimum of 2-6 hours Signup and view all the answers

What does DIC stand for?

Disseminated intravascular coagulation Signup and view all the answers

DIC is?

A pathologic form of clotting that is diffuse and consumes large amounts of clotting factors, causing widespread external or internal bleeding or both Signup and view all the answers

What is a specific diagnostic test for DIC?

D-dimer is positive in 34% of cases of DIC Signup and view all the answers

What is Gestational Trophoblastic Disease?

A condition in which trophoblastic tissue overtakes the pregnancy and propagates throughout the uterine cavity Signup and view all the answers

What is hydatidiform mole characterized by?

Chronic or acute bleeding and a uterus that is large for gestational age. 1 in 1200 pregnancies. 5% turn into choriocarcinoma Signup and view all the answers

What clinical signs indicate Hydatidiform mole?

Preeclampsia in the first trimester, hCG levels above 100,000 mIU/mL, and an enlarged bleeding uterus Signup and view all the answers

_______ % of women with preeclampsia develop HELLP syndrome.

5 Signup and view all the answers

What are the top drug choices for initiating antihypertensives if BP > 160/110?

Hydralazine, Labetalol, Nifedipine Signup and view all the answers

How long does it take before the lung maturity benefits of betamethasone are seen?

24 hours after administration Signup and view all the answers

Magnesium sulfate toxicity can occur rapidly. Toxicity could result in impaired _______ function.

Renal Signup and view all the answers

______ % of eclampsia and HELLP cases occur after delivery.

30 Signup and view all the answers

What does TORCH stand for?

Toxoplasmosis, Other (hepatitis B), Rubella, CMV, Herpes Signup and view all the answers

What does SGA stand for?

Small gestational age; growth is below the 10th percentile Signup and view all the answers

IUGR from placenta insufficiency usually reduces ____ more than _.

birthweight, length Signup and view all the answers

Which is more ominous, symmetrical or asymmetrical growth restriction?

Neonates with symmetrical growth restriction have the poorest long-term prognosis and commonly have chromosomal abnormalities; postnatal nutrition is unable to correct growth deficits: symmetrically grown SGA babies may never catch up in size when compared to unaffected babies Signup and view all the answers

Growth restriction at less than 28 weeks is generally (symmetrical or asymmetrical) in nature.

Symmetrical Signup and view all the answers

Growth restriction at more than 28 weeks is generally (symmetrical or asymmetrical) in nature.

Asymmetrical Signup and view all the answers

What does LGA stand for?

Large for Gestational Age; having a birth weight greater than the 90th percentile on intrauterine growth charts Signup and view all the answers

What is caput succedaneum?

A localized, easily identifiable, soft area of the scalp, generally resulting from a long and difficult labor or vacuum extraction. Extra fluid should be reabsorbed within 12 hours after birth. Crosses suture lines. Signup and view all the answers

What is cephalohematoma?

A collection of blood between the periosteal membrane and a skull bone. Caused by rupture of capillaries from the pressure of birth. No pressure on brain, takes 3-6 weeks to resolve Signup and view all the answers

What is considered postterm?

Delivery after 42 weeks gestation Signup and view all the answers

What is transition in the context of newborn care?

Transition is a response, in part, to the increased level of oxygen in the circulation once air breathing has begun; if oxygen levels remain low, the fetal pattern of circulation may persist, causing blood flow to bypass the lungs. Signup and view all the answers

Fact: Preterm infants may have impaired regulation of blood pressure in the face of apnea, bradycardia, and mechanical ventilation. What are the potential consequences?

Resulting fluctuations in cerebral blood flow are common. These fluctuations predispose fragile blood vessels in the brain to rupture, causing intracranial hemorrhage. Fluctuations in blood pressure can cause loss of brain blood flow, resulting in ischemia. These fluctuations also predispose the preterm infant to develop retinopathy of immaturity. Signup and view all the answers

Fact: Procedure to follow if meconium is present in the amniotic fluids?

Infants who are depressed at birth or make poor attempts to take the first breath should be intubated in the delivery room and suctioning of the trachea should occur to remove meconium below the vocal cords. Infants who attempt to breathe and clear their own airway should be allowed to do so without intervention. Signup and view all the answers

Kernicterus is caused by severe and inadequately treated hyperbilirubinemia during the neonatal period. Bili levels in excess of ______ mg/dl may develop kernicterus.

20 Signup and view all the answers

Fact: Research has shown that healthy full-term neonates with serum bilirubin levels of approximately 18 mg/dl do not have any detrimental effects with an expectant management approach. Elaborate.

Research indicates that in healthy full-term neonates, bilirubin levels of approximately 18 mg/dl can be managed expectantly without negative outcomes. Signup and view all the answers

What is omphalocele?

Protrusion of the intestine and omentum through a hernia in the abdominal wall near the navel. Omphalocele is covered with a sac consisting of peritoneum and amniotic membrane. About 50% of newborns born with omphalocele have cardiac, gastrointestinal, genitourinary, musculoskeletal, and CNS anomalies. Signup and view all the answers

What is gastroschisis?

Defect in abdominal wall not including the umbilicus, absence of peritoneal sac over the contents. Signup and view all the answers

What is congenital diaphragmatic hernia?

Part of the stomach and intestine herniate through a large posterolateral defect of the diaphragm; always occurs on the left because of the liver on the right. Occurs in 1/2200 newborn infants. One lung (usually left) fails to develop normally because of the abdominal viscera in the thoracic cavity. This causes pulmonary hypoplasia and ~45% mortality among live-born infants. Signup and view all the answers

Why should you avoid bag and mask ventilation with a baby that has congenital diaphragmatic hernia?

Air can be forced into the intestine, which will further compromise lung space in the chest. Signup and view all the answers

How should you position a baby with diaphragmatic hernia?

On the affected side, allowing the unaffected lung to expand. In other words, lie the baby on its left side, allowing the right lung to expand. Signup and view all the answers

What is PDA?

An anatomic and functionally open shunt exists between the pulmonary artery and the aorta. In babies between 500-1500 grams, PDA occurs in 37%. In full-term infants, the PDA becomes functionally closed by 12 hours of age. Signup and view all the answers

What is coarctation of the aorta?

A narrowing of the upper thoracic aorta that produces an obstruction to blood flow through the aorta. Signup and view all the answers

What are four examples of acyanotic defects?

Patent ductus arteriosus, atrial septal defects, ventricular septal defect, coarctation of the aorta Signup and view all the answers

What are three examples of cyanotic defects?

Tetralogy of Fallot, transposition of the great arteries, hypoplastic left heart syndrome or single ventricle Signup and view all the answers

What are the two goals of antepartum testing?

To identify fetuses that are at risk for permanent injury or death due to disrupted oxygenation; to identify fetuses that are healthy, thus preventing the use of unnecessary intervention Signup and view all the answers

Crown rump length is the most accurate measurement for EGA when in the ______________ trimester.

First Signup and view all the answers

Biparietal diameter is among the most accurate measurements for EGA in the ______________ trimester.

Second Signup and view all the answers

Although infants born at weeks gestation have been known to survive, most authorities believe that _ weeks is the time of earliest survival.

22, 23 Signup and view all the answers

Surfactant is made up of phospholipids. What are the two most common phospholipids in surfactant?

Lecithin and phosphatidylglycerol (PG) Signup and view all the answers

What is the role of surfactant?

Prevents the collapse of the alveoli Signup and view all the answers

What is alpha-fetoprotein?

A blood test that measures the level of alpha-fetoprotein in the mother's blood during pregnancy as an indicator of possible neural tube defects Signup and view all the answers

What is quad screening?

Blood test done at 16-18 weeks to measure AFP, HCG, Estriol, and Inhibin A Signup and view all the answers

Doppler measurement of the peak velocity of systolic blood flow in the ___________ can safely replace invasive testing in the management of Rh-alloimmunized pregnancies.

Middle cerebral artery Signup and view all the answers

AFI of less than 5 cm is considered diagnostic for oligohydramnios. 5cm equals __________ of fluid.

500 ml Signup and view all the answers

Polyhydramnios is an AFI of greater than _______ cm of amniotic fluid.

25 Signup and view all the answers

What is the normal AFI at term?

10-24 cm of fluid Signup and view all the answers

What is the low normal AFI at term?

5-9.9 cm of fluid Signup and view all the answers

___________ % of newborns have a major anomaly.

1-2 Signup and view all the answers

Fetal lung maturity is determined by an amniocentesis. What is the lab test called?

L/S ratio. The lecithin/sphingomyelin ratio. Signup and view all the answers

L/S ratio is not a valid indicator of lung maturity if the mother is diabetic. In diabetic mothers, the presence of _______ is highly predictive of fetal lung maturity.

PG (phosphatidylglycerol) Signup and view all the answers

What does definitive fetal lung maturity testing require?

L/S ratio greater than 2:1 AND the presence of PG Signup and view all the answers

What is reactive NST for the term fetus?

2 or more accelerations ≥15 bpm, lasting at least 15 seconds within 20 minutes. Maximum testing period 40 minutes. Signup and view all the answers

What is reactive NST for the preterm fetus?

2 or more accelerations of at least 10 bpm, lasting at least 10 seconds within a 20 minute period. Maximum testing period 90 minutes. Signup and view all the answers

For fetuses >30 weeks gestation, a FHR greater than ______ bpm is considered tachycardia.

160 Signup and view all the answers

What is a nonreactive NST at term defined as?

No accelerations or no accelerations that meet the 15x15 criteria within a 40 minute period. Even one acceleration is considered inadequate. Signup and view all the answers

What is a nonreactive NST in the preterm fetus defined as?

An NST with no accelerations or no accelerations that meet the 10x10 criteria within the maximum testing time of 90 minutes. Signup and view all the answers

What should be done if variable decelerations are present during an NST?

An assessment of amniotic fluid is indicated. Signup and view all the answers

If variable decelerations are seen during the NST and they are nonrepetitive and less than 30 seconds in duration, what does this imply?

Then the fetus is considered to not be compromised and there is little, if no, need for intervention. Signup and view all the answers

The proper placement for the fetal acoustic stimulator is?

Near the fetal head Signup and view all the answers

What is the appropriate use of the fetal acoustic stimulator?

1-2 seconds for the first application. If there is no fetal response, the stimulus may be repeated every 1 minute up to three times to achieve longer durations of time, not to exceed 3 seconds for each stimulus. The maximum time of application is 9 seconds (three applications that equal a total of 9 seconds). Once a fetal response (i.e. accelerations) is achieved, additional stimuli are not required. Signup and view all the answers

When should the fetal acoustic stimulation not be used?

<ol> <li>During a vaginal examination 2. During contractions 3. In the presence of decelerations</li> </ol> Signup and view all the answers

What should be done if, in response to acoustic stimulation, the fetus elicits a prolonged acceleration of tachycardia?

There is no need to elicit any additional accelerations. However, the FHR should return to the previously established FHR baseline before discharging the patient to home. Signup and view all the answers

Study Notes

Perinatal Admissions and Hemorrhage

Leading cause of ICU admissions in perinatal cases: Hemorrhagic disorders.
Pregnancy-related hemorrhages account for 17-25% of maternal deaths.
Maternal deaths from obstetric hemorrhage post-first trimester primarily due to placental abruption.
Higher risk of postpartum hemorrhage deaths in African American women.

Maternal Mortality Rates

Mortality rates per 100,000 live births (2006):
- White women: 13.3
- African American women: 32.7
- Hispanic women: 10.2

Postpartum Hemorrhage (PPH)

68% of deaths from PPH occur within 48 hours of delivery.
Obstetric hemorrhage defined as blood loss over 1000cc.
Painless vaginal bleeding in the second or third trimester indicates placenta previa.

Placenta Previa

Risk factors include previous placenta previa, advanced maternal age (>40), prior cesareans, multiparity, and smoking.
Confirmatory ultrasound should precede a speculum examination in cases of suspected placenta previa.

Fetal and Maternal Blood Loss Effects

Fetal blood volume: 100 ml/kg.
Significant maternal blood loss leads to tachycardia, respiratory increase, pallor, hypotension, decreased urinary output, and altered LOC.
Initial FHR response to maternal blood loss: tachycardia followed by bradycardia and persistent late decelerations.

5-10% incidence of accreta in women with previa.
Over 50% chance of accreta in women with ≥2 cesarean sections.
Vasa previa signifies fetal vessels covering the cervical os, posing risks.

Complications Such as HELLP and DIC

HELLP syndrome stands for Hemolysis, Elevated Liver Enzymes, Low Platelets.
DIC: a pathologic coagulation condition leading to diffuse clotting and bleeding; D-dimer test positive in 34% of cases.

Gestational Trophoblastic Disease

Characterized by abnormal trophoblastic tissue proliferation, potentially leading to hydatidiform moles (1 in 1200 pregnancies) which can convert to choriocarcinoma.

Hypertensive Disorders in Pregnancy

Five main categories: gestational hypertension, preeclampsia, eclampsia, chronic hypertension, and preeclampsia superimposed on chronic hypertension.
5% of preeclampsia cases progress to HELLP syndrome.
Initiate antihypertensives if BP exceeds 160/110; preferred drugs: Hydralazine, Labetalol, Nifedipine.

Newborn Conditions and Monitoring

Kernicterus related to untreated hyperbilirubinemia (bili levels >20 mg/dl).
Positive fetal outcomes in high bilirubin levels with appropriate monitoring.
Omphalocele involves intestinal protrusion through abdominal wall defects, often accompanied by multi-system anomalies.

Congenital Conditions and Management

Gastroschisis: abdominal wall defect without a sac over contents.
Congenital diaphragmatic hernia affects lung development and poses high mortality (approx. 45%).
Non-invasive testing methods, like Doppler measurements, can replace invasive tests in managing Rh-alloimmunized pregnancies.

Assessment and Testing Procedures

Amniotic fluid index (AFI) interpretations: oligohydramnios (AFI <5 cm), polyhydramnios (AFI >25 cm).
Cord insertion abnormalities include velamentous insertion and succenturiate placenta.

NST and Fetal Monitoring

Reactive NST for term fetuses: ≥2 accelerations of 15 bpm lasting 15 seconds within 20 minutes.
Nonreactive NST indicates inadequate accelerations in the required timeframe; presence of variable decelerations during NST necessitates amniotic fluid assessment.

Bio-Physical Profile Evaluation

Intrauterine Apgar or bio-physical profile assesses CNS reflex activities including NST, fetal breathing, body movements, tone, and qualitative amniotic fluid volume.
Fetal tone disappears when fetal pH drops, indicating distress.

Growth Restrictions and Their Implications

SGA: growth below the 10th percentile; IUGR affects birth weight more than length.
Symmetrical growth restriction relates to poorer long-term outcomes compared to asymmetrical.

Summary of Fetal Well-being Indicators

Surfactant predominantly consists of lecithin and phosphatidylglycerol, critical for lung maturity by 37 weeks.
The serum L/S ratio aids in predicting fetal lung maturity, especially important in diabetic mothers.

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Description

This set of flashcards covers key concepts related to inpatient obstetrical certification. Topics include causes of perinatal ICU admissions, maternal mortality, and factors affecting obstetric hemorrhage. Ideal for healthcare professionals preparing for certification exams.