Obstetrics Marrow Pg 385-394 (Medical & Surgical complication of Pregnancy)

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Questions and Answers

Which maneuver is considered the first and most effective in the management of difficult labor?

McRoberts maneuver (correct)

Wood's corkscrew maneuver

Jacquemier maneuver

Zavanelli maneuver

Postpartum hemorrhage is the most common complication for mothers during difficult labor.

True

What is the purpose of the Zavanelli maneuver?

To push the fetal head back into the uterus for a cesarean delivery.

The _____ palsy is the most common fetal complication during difficult labor.

Erb's Signup and view all the answers

Match the following maneuvers with their descriptions:

McRoberts maneuver = Flexion and abduction of the leg against the abdomen Jacquemier maneuver = Removes the posterior arm of the baby Wood's corkscrew maneuver = Manual rotation of both shoulders Gaskin maneuver = Mother rolls on all four limbs Signup and view all the answers

For a patient with well-controlled Gestational Diabetes Mellitus (GDM) Type A2, when is the latest recommended delivery week?

<blockquote> 39 weeks </blockquote> Signup and view all the answers

A Cesarean section is indicated for all GDM patients regardless of the baby's weight.

False Signup and view all the answers

What should be done if blood glucose levels fall below 70 mg/dl during labor?

Start IV 5% dextrose Signup and view all the answers

Intrapartum management for GDM includes IV NS at _____ ml/hr.

100 Signup and view all the answers

Match the following postpartum management strategies to their corresponding GDM type:

Check blood sugar: Day 3 post delivery = GDM Insulin requirement reduces from day 2 = Pre GDM Annual 75g OGTT = GDM Shift back to OHA = Pre GDM Signup and view all the answers

What is the definition of proteinuria in pregnancy induced hypertension?

Excretion of protein in urine ≥ 300mg/24 hours Signup and view all the answers

A urine dipstick reading of ≥ 2+ indicates proteinuria.

True Signup and view all the answers

What is the gold standard diagnostic test for proteinuria in pregnancy induced hypertension?

24-hour urine protein excretion Signup and view all the answers

To prevent superimposed pre-eclampsia, all pregnant chronic hypertensive patients should receive low dose __________ daily from 12 weeks.

Aspirin Signup and view all the answers

Match the following findings with their definitions:

Platelet Count < 1 lakh = Sign of end-organ damage Liver enzymes (SGOT/SGPT) raised ≥ 2 times = Sign of end-organ damage S. Creatinine ≥ 1.1 mg/dL = Sign of end-organ damage Pulmonary edema = Sign of end-organ damage Signup and view all the answers

What is the definition of pregnancy-induced hypertension (PIH)?

Blood pressure ≥ 140/90 mm Hg on at least two occasions 4 hours apart Signup and view all the answers

Chronic hypertension in pregnancy can be observed in women with no past history of high blood pressure.

False Signup and view all the answers

What is the difference in the timing of increased blood pressure between chronic hypertension in pregnancy and pregnancy-induced hypertension?

Chronic hypertension occurs since Day 1 of pregnancy, while pregnancy-induced hypertension occurs after 20 weeks of pregnancy. Signup and view all the answers

In pre-eclampsia, the presence of __________ is a key distinguishing feature compared to gestational hypertension.

proteinuria Signup and view all the answers

Match the following conditions with their characteristics:

Chronic HTN = Hypertensive female has conceived Pregnancy-Induced HTN = Normotensive female has conceived Pre-eclampsia = Positive proteinuria Gestational HTN = No positive proteinuria Signup and view all the answers

What defines mild pre-eclampsia in terms of blood pressure?

≤ 140/90 Signup and view all the answers

Severe pre-eclampsia is defined by blood pressure over 160/100.

True Signup and view all the answers

What are the two main types of pre-eclampsia that differentiate based on blood pressure levels?

Mild and Severe Pre-eclampsia Signup and view all the answers

In mild pre-eclampsia, the blood pressure is _____ 140/90.

less than or equal to Signup and view all the answers

Match the following features with their corresponding type of pre-eclampsia:

Blood pressure ≤ 140/90 = Mild Pre-eclampsia Blood pressure ≥ 160/110 = Severe Pre-eclampsia Increased protein in urine = Severe Pre-eclampsia Slight swelling or edema = Mild Pre-eclampsia Signup and view all the answers

What is the most common type of eclampsia?

Antepartum eclampsia Signup and view all the answers

Atypical eclampsia can occur less than 20 weeks into pregnancy.

True Signup and view all the answers

What imaging technique is used as the investigation of choice (IOC) for eclampsia?

MRI Signup and view all the answers

In cases of gestational hypertension, if the blood pressure is greater than or equal to ______ mmHg, it should be managed like severe pre-eclampsia.

160/110 Signup and view all the answers

Match the following types of eclampsia with their occurrence:

Antepartum = Occurs before delivery Intrapartum = Occurs during labor Postpartum = Occurs after delivery within 48 hours Atypical = Occurs with atypical signs Signup and view all the answers

What is a potential maternal complication of hyperglycemia during pregnancy?

Candidiasis Signup and view all the answers

Oligohydramnios is associated with diabetic vasculopathy and increases the risk of placenta previa.

True Signup and view all the answers

What is considered hypoglycemia in terms of blood sugar level during pregnancy?

Blood sugar less than 70 mg/dL Signup and view all the answers

Symptoms of hypoglycemia may include ______, sweating, and palpitations.

tremors Signup and view all the answers

Match the following symptoms of hypoglycemia with their descriptions:

Tremors = Shaking or trembling of the body Sweating = Excess perspiration Palpitations = Rapid or irregular heartbeat Extreme fatigue = Severe tiredness and lack of energy Signup and view all the answers

What is the role of extravillous trophoblast during normal pregnancy?

It remodels high resistance vessels into low resistance vessels. Signup and view all the answers

Phase 1 of trophoblastic remodeling occurs at approximately 12 weeks of pregnancy.

True Signup and view all the answers

What happens if trophoblastic invasion is incomplete during pregnancy?

High resistance in the intervillous space, decreased blood volume in the intervillous space, and placental ischemia occur. Signup and view all the answers

Maternal Natural Killer (NK) cells play a role in the __________ of spiral arteries.

remodeling Signup and view all the answers

Match the following phases of trophoblastic remodeling with their corresponding descriptions:

Phase 1 = Replacement of the decidual segment's lining at 12 weeks Phase 2 = Replacement of the myometrial segment's lining at 16-20 weeks Signup and view all the answers

What is the mature Lecithin/Sphingomyelin ratio indicating lung maturity?

2:1 Signup and view all the answers

The lamellar body count is used to assess lung maturity.

True Signup and view all the answers

What is indicated by the presence of >50% orange cells in the Nile blue sulphate test?

Lungs mature Signup and view all the answers

The most common late complication in children born to mothers with gestational issues is __________.

T2DM Signup and view all the answers

Match the following tests with their purpose regarding lung maturity:

Lecithin/Sphingomyelin ratio = Maturity test for surfactant presence Phosphatidyl glycerol = Best test for lung maturity Lamellar body count = Assessment of surfactant production Nile blue sulphate test = Microscopic examination of fetal skin cells Signup and view all the answers

What is a potential consequence of maternal hyperglycemia during pregnancy?

Increased risk of cesarean section Signup and view all the answers

Pederson's Hypothesis states that fetal hyperglycemia leads to decreased fetal growth.

False Signup and view all the answers

What is IUGR an abbreviation for?

Intrauterine Growth Restriction Signup and view all the answers

Maternal hyperglycemia can lead to increased risk of __________, which can result in fetal death.

stillbirth Signup and view all the answers

Match the following complications with their descriptions:

Macrosomia = Large fetal size due to excess fetal insulin Hypoglycemia = Low blood sugar levels in the newborn after birth RDS = Respiratory issues due to insufficient surfactant Congenital Malformations = Defects present at birth linked to pre-gestational diabetes Signup and view all the answers

Which of the following is associated with maternal diabetes during pregnancy?

Higher risk of necrotising enterocolitis in newborns Signup and view all the answers

Hyperglycemia in mothers can lead to oxidative stress and edema in the fetus.

True Signup and view all the answers

What electrolyte imbalances may occur in newborns due to maternal diabetes?

Hypocalcemia, Hypokalemia, Hypomagnesemia Signup and view all the answers

Study Notes

Management of Difficult Labor

HELPERR mnemonic for managing difficult labor
Call for help: Includes liberal episiotomy
Legs maneuver (McRobert's maneuver): Flexes and abducts legs against abdomen, straightening the sacrum, increasing available space
Suprapubic pressure + McRobert's maneuver: Sustained in thrusts
Enter maneuver: Manual rotation of shoulders (Wood's corkscrew or Rubin's)
Remove (Deliver) posterior arm of baby: Jacquemier maneuver
Roll on all four limbs: 4-limb (Gaskin) maneuver
Zavanelli maneuver: Last resort, pushes fetal head back into uterus, leading to cesarean
Complications: Fractured clavicle (cleidotomy), obsolete: symphysiotomy, other measures: fundal pressure (contraindicated)

Complications

Fetal: Erb's palsy is most common, injury to C5, C6, arm internally rotated, adducted, and pronated
Maternal: Postpartum hemorrhage (PPH) is most common, nerve injury (most common) during McRobert's maneuver, lateral cutaneous nerve of the thigh

Termination of Pregnancy

Type A1 GDM (well-controlled on diet): ≥ 39 weeks
Type A2 GDM (well-controlled on drugs): ≥ 39 weeks
Type A2 GDM (not well-controlled on drugs): ≥ 37 weeks
Vaginal delivery is preferred, Cesarean section indicated for babies ≥ 4.5 kg

Intrapartum Management

Mild GDM, on medical management: skip morning dose
Hourly blood sugar monitoring with glucometer during labor
NPO (nothing by mouth)
IV NS @ 100ml/hr
Insulin added to IV NS depending on blood sugar levels

Blood Sugar Levels and Insulin Dosage

90-120 mg/dl: No insulin added
120-140 mg/dl: 4U insulin added to 500ml NS
140-180 mg/dl: 6U insulin added to 500ml NS
≥ 180 mg/dl: 8U insulin added to 500ml NS
If blood glucose < 70mg/dl (Hypoglycemia): Start IV 5% dextrose

Postpartum Management

GDM: Check blood sugar on day 3 post delivery, discharge at 6 weeks, follow up with 75g 1hr OGTT
Pre GDM: Insulin requirement decreases, shift back to OHA from day 2 of delivery, refer to endocrinologist if needed

Pregnancy Induced Hypertension: Part 1

Proteinuria: ≥ 300mg/24 hours, Protein/Creatinine ≥ 0.3, urine dipstick ≥ 2+
Signs & end organ damage: Platelet count < 100,000, liver enzymes raised, S.Creatinine ≥ 1.1 mg/dL, pulmonary edema, visual symptoms/cerebral edema
ALP (Alkaline Phosphatase): Produced by placenta, heat stable

Antenatal visit and PIH

Measure blood pressure (BP) at every visit
Repeat BP after 4 hours if ≥ 140/90 mm Hg
Screening Test: Urine dipstick for proteinuria (≥ +1)
Diagnostic Test: 24-hour urine protein excretion (Gold standard)

Chronic HTN with superimposed pre-eclampsia:

Hypertensive female conceives + develops uncontrollable BP, new onset proteinuria, or new onset signs of end-organ damage after 20 weeks
Bad prognosis
Prevention: Low dose Aspirin started daily from 12 weeks

PREGNANCY INDUCED HYPERTENSION : PART 1

Definition: BP ≥ 140/90 mm Hg on two occasions 4 hours apart
Exception: If BP is ≥ 160/110 mmHg, repeat in 15 minutes, start anti-hypertensive medication if still high

Chronic HTN in Pregnancy vs Pregnancy induced HTN (PIH)

Chronic HTN in Pregnancy: Hypertensive female has conceived with past history of high blood pressure
PIH: Normotensive female has conceived with no prior history of high blood pressure
Chronically elevated BP: Since day 1 of pregnancy vs after 20 weeks of pregnancy
BP Normalization: Occurs after delivery vs within 14 weeks of delivery

Pre-eclampsia vs Gestational HTN

Pre-eclampsia: ↑ BP with proteinuria and signs of end-organ damage
Gestational HTN: ↑ BP after 20 weeks of pregnancy without proteinuria or signs of end organ damage

Eclampsia

Definition: Severe pre-eclampsia with generalized tonic clonic seizures
Types: Antepartum (most common, worst prognosis), Intrapartum, and Postpartum
Atypical Eclampsia: Onset of seizure > 48 hours after delivery or < 20 weeks of pregnancy, prolonged loss of consciousness, localized edema in posterior cerebral hemisphere (MRI)

Gestational Hypertension

50% cases progress to pre-eclampsia
BP ≥ 160/110 mmHg → manage like severe Pre-eclampsia
If no proteinuria/signs of end organ damage: Provisional diagnosis of Gestational Hypertension
Recheck BP 12 weeks after delivery: Normalizes → Gestational HTN/Transient HTN in pregnancy, if still raised → revised diagnosis to Chronic HTN

Mild vs Severe Pre-eclampsia

Mild Pre-eclampsia: BP ≤ 140/90 and proteinuria ≤ 300mg/24 hours
Severe Pre-eclampsia: BP ≥ 160/110 mmHg or proteinuria ≥ 5g / 24 hours
Complications: Severe pre-eclampsia can lead to eclampsia, maternal and fetal complications

DIABETES IN PREGNANCY: PART 3

Maternal Complications

Hyperglycemia: Asymptomatic bacteruria, candidiasis, puerperal sepsis
Infections: Increased risk
Polyhydramnios: Increased risk of PTL, PROM, cord prolapse, PPH, subinvolution
Oligohydramnios: If diabetic vasculopathy/PIH+, increased risk of PIH, placenta previa
Increased risk of: T2DM in the future, Cesarean section, ketoacidosis

Hypoglycemia

Blood sugar < 70 mg/dL
Symptoms: Tremors, sweating, palpitations, extreme fatigue, tingling sensation
Management: 3 teaspoons glucose in 100 mL water, or 6 teaspoons sugar in 100 mL water

Fetal Complications in Diabetes During Pregnancy

Pederson's Hypothesis: Maternal hyperglycemia leads to fetal hyperglycemia and increased insulin production
Consequences: Macrosomia, prolonged labor, increased chances of Cesarean section, IUGR, increased risk of abortion, increased risk of stillbirth, oxidative stress and edema, hypoxia, shoulder dystocia
Neonatal Complications: Neonatal hypoglycemia, hypocalcemia, hypokalemia, hypomagnesemia, RDS, NEC, hypoxia, congenital malformations (only in pre-gestational diabetes)

Note

Hormones for fetal growth: Insulin and Insulin-like growth factors (IGFs) are needed
Anemia: Not usually a major issue in cases of maternal diabetes during pregnancy

PREGNANCY INDUCED HYPERTENSION PART 2

Events in Normal Pregnancy

Extravillous trophoblast (Endovascular part): Replaces the lining of spiral arteries, converting high resistance vessels into low resistance vessels, occurs in two phases: Phase 1 (12 weeks) and Phase 2 (16-20 weeks)

Pathophysiology

Incomplete trophoblastic invasion: Leads to high resistance in intervillous space, decreased blood volume, and placental ischemia

Medical and Surgical Complications in Pregnancy

Late complications in child: T2DM (1-3%), obesity, metabolic X syndrome

Lung Maturity Tests

Lecithin/Sphingomyelin ratio: mature ≥ 2:1, immature < 2:1
Phosphatidyl glycerol: Best test (Done ≥ 35 weeks), present = mature, absent = immature
Lamellar body count: 50,000/mL: 100% lungs mature, 30,000 - 40,000/mL AF: positive test
Bedside test/Shake test/Bubble test: Obsolete
Nile blue sulphate test: Obsolete

Shoulder Dystocia

Obstetric emergency: Inability to deliver fetal shoulder within 1 min of head delivery
Turtle sign +ve: Receding of fetal head into perineum

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Description

This quiz covers key techniques and maneuvers for managing difficult labor, focusing on the HELPERR mnemonic. It explores various methods such as the McRobert's maneuver and Zavanelli maneuver, along with potential complications for both fetal and maternal health. Test your understanding of these critical practices in obstetrics.