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Questions and Answers
What is the primary action of MgSO4 in obstetric complications?
What is the primary action of MgSO4 in obstetric complications?
- Enhances fetal growth
- Inhibits uterine contractions
- Reduces maternal blood pressure
- Neuroprotective (correct)
MgSO4 is administered only in cases of post-term labor.
MgSO4 is administered only in cases of post-term labor.
False (B)
What condition does MgSO4 help prevent in a newborn?
What condition does MgSO4 help prevent in a newborn?
cerebral palsy
MgSO4 is given in all cases of _________.
MgSO4 is given in all cases of _________.
Match the following actions/conditions with their corresponding details:
Match the following actions/conditions with their corresponding details:
What is the definition of PROM?
What is the definition of PROM?
PPROM refers to the rupture of membranes at or after 37 weeks.
PPROM refers to the rupture of membranes at or after 37 weeks.
What does the abbreviation PPROM stand for?
What does the abbreviation PPROM stand for?
PROM occurs when the membranes rupture _____ the onset of labor.
PROM occurs when the membranes rupture _____ the onset of labor.
Match the following terms to their definitions:
Match the following terms to their definitions:
Which of the following tests indicates the presence of amniotic fluid?
Which of the following tests indicates the presence of amniotic fluid?
Vaginal discharge has a pH of 7.2 during pregnancy.
Vaginal discharge has a pH of 7.2 during pregnancy.
What is a common characteristic of urine that can help differentiate it from amniotic fluid?
What is a common characteristic of urine that can help differentiate it from amniotic fluid?
The Nitraxine test indicates that amniotic fluid is __________ in nature.
The Nitraxine test indicates that amniotic fluid is __________ in nature.
Match the following tests with what they differentiate:
Match the following tests with what they differentiate:
What is a key clinical finding for diagnosing chorioamnionitis?
What is a key clinical finding for diagnosing chorioamnionitis?
Elevated maternal white blood cell count (≥15000/mm³) is used as a diagnostic criterion for chorioamnionitis.
Elevated maternal white blood cell count (≥15000/mm³) is used as a diagnostic criterion for chorioamnionitis.
What antibiotic combination is preferred for the management of chorioamnionitis?
What antibiotic combination is preferred for the management of chorioamnionitis?
Chorioamnionitis is definitively diagnosed through _______ with Gram staining and culture.
Chorioamnionitis is definitively diagnosed through _______ with Gram staining and culture.
Match the management strategies with their descriptions:
Match the management strategies with their descriptions:
What is the main purpose of using tocolytics?
What is the main purpose of using tocolytics?
Tocolytics should be used in cases where gestation is more than 34 weeks.
Tocolytics should be used in cases where gestation is more than 34 weeks.
Name one important tocolytic that is commonly used in India.
Name one important tocolytic that is commonly used in India.
Indomethacin can lead to ___________ and premature ductus arteriosus closure.
Indomethacin can lead to ___________ and premature ductus arteriosus closure.
Match the following tocolytics with their characteristics:
Match the following tocolytics with their characteristics:
Which diameter is considered the smallest and most important for vaginal delivery?
Which diameter is considered the smallest and most important for vaginal delivery?
The pelvic brim is defined as the space measured between the sacral promontory and the pubic symphysis.
The pelvic brim is defined as the space measured between the sacral promontory and the pubic symphysis.
What is the critical obstetrical conjugate measurement that indicates the minimum diameter below which vaginal delivery is not possible?
What is the critical obstetrical conjugate measurement that indicates the minimum diameter below which vaginal delivery is not possible?
The pelvic inlet lies at the level of the __________.
The pelvic inlet lies at the level of the __________.
Match the following pelvic measurements with their definitions:
Match the following pelvic measurements with their definitions:
What is the primary consequence of post-term pregnancy in relation to fetal weight?
What is the primary consequence of post-term pregnancy in relation to fetal weight?
The color of amniotic fluid in post-term pregnancies is typically a bright blue.
The color of amniotic fluid in post-term pregnancies is typically a bright blue.
What enzyme is essential for synthesizing estrogen from DHEA in the placenta?
What enzyme is essential for synthesizing estrogen from DHEA in the placenta?
In post-term pregnancy, the volume of amniotic fluid decreases by approximately ______ ml.
In post-term pregnancy, the volume of amniotic fluid decreases by approximately ______ ml.
Match the conditions with their corresponding consequences:
Match the conditions with their corresponding consequences:
Which of the following is a risk factor for macrosomia?
Which of the following is a risk factor for macrosomia?
Macrosomia is a relative contraindication for vaginal birth after c-section (VBAC).
Macrosomia is a relative contraindication for vaginal birth after c-section (VBAC).
What is the best method to assess fetal weight?
What is the best method to assess fetal weight?
The best ultrasound parameter for assessing macrosomia is the fetal abdominal circumference of at least ______ cms.
The best ultrasound parameter for assessing macrosomia is the fetal abdominal circumference of at least ______ cms.
Which of the following conditions requires GBS prophylaxis during labor?
Which of the following conditions requires GBS prophylaxis during labor?
Corticosteroids are recommended for both early and late PROM management.
Corticosteroids are recommended for both early and late PROM management.
Match the formulas to their respective conditions they assess:
Match the formulas to their respective conditions they assess:
At what gestational age is GBS screening recommended for all pregnant women?
At what gestational age is GBS screening recommended for all pregnant women?
GBS prophylaxis is administered ______ during labor.
GBS prophylaxis is administered ______ during labor.
Match the indications for GBS prophylaxis with their descriptions:
Match the indications for GBS prophylaxis with their descriptions:
What is the obstetric conjugate if the diagonal conjugate is measured at 14 cm?
What is the obstetric conjugate if the diagonal conjugate is measured at 14 cm?
The contracted pelvis is defined by an obstetric conjugate measuring less than 10 cm.
The contracted pelvis is defined by an obstetric conjugate measuring less than 10 cm.
What shape describes the cavity of the pelvis?
What shape describes the cavity of the pelvis?
The plane of least pelvic dimensions has an anteroposterior diameter of __________.
The plane of least pelvic dimensions has an anteroposterior diameter of __________.
Match the following pelvic measurements with their descriptions:
Match the following pelvic measurements with their descriptions:
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Study Notes
Magnesium Sulfate
- Neuroprotective agent
- Prevents cerebral palsy
- Given in all cases of preterm labor and premature rupture of membranes
Premature Rupture of Membranes (PROM)
- Membrane rupture after 37 weeks but before the onset of labor
- Preterm Premature Rupture of Membranes (PPROM) occurs before 37 weeks
Differentiating between Amniotic Fluid and Urine
- Urine has an ammoniacal smell
- Leak of urine when coughing indicates urine
Differentiating between Amniotic Fluid and Vaginal Discharge
- Amniotic fluid is alkaline (pH 7.2)
- Vaginal discharge is acidic (pH 3.5 during pregnancy)
- Nitraxine test:
- Turns blue (Alkaline) - Amniotic fluid
- Remains yellow (Acidic) - Vaginal discharge
- Possible false positive due to blood, semen, and bacterial vaginosis
- Litmus paper test
- Turns blue (Alkaline) - Amniotic fluid
- Remains yellow (Acidic) - Vaginal discharge
- Fern Test
- Fern-like pattern - amniotic fluid
- Absence of pattern - vaginal discharge
- Microscopic examination of vaginal discharge can help differentiate between amniotic fluid and vaginal discharge
- Other tests:
- Ultrasound
- Kit Test
- Actin Test
- Amnisure Test
Chorioamnionitis
- Can be diagnosed if a patient with ruptured membranes has a temperature of 39°C
- Clinical findings:
- Fetal Tachycardia (FHR ≥ 160 bpm)
- Elevated maternal WBC count (≥15,000/mm³)
- Purulent discharge from the internal os
- Maternal tachycardia and uterine tenderness are not diagnostic criteria for chorioamnionitis
- Definitive Diagnosis:
- Amniocentesis with Gram staining and culture
- Histopathological examination (HPE) of the fetal membranes
- Management:
- Antibiotics: Ampicillin + gentamicin
- Preferred delivery - Induction of labor, vaginal delivery
- C-section not preferred, only if there is an obstetric reason
- Add Metronidazole to treatment
- Continue antibiotics until a patient is afebrile for 24 hours
Tocolytics
- Used to allow corticosteroid action
- Maximum use up to 48 hours
- Tocolytics recommended for preterm labor (< 34 weeks)
- No role for tocolytics in term labor (> 34 weeks)
- Important tocolytics:
- Nifedipine (CCB) - most common in India
- Atosiban (Oxytocin antagonist) - Tocolytic of choice in cardiac disease
- Indomethacin - can lead to oligohydramnios and premature closure of the ductus arteriosus
Pelvic Brim
- Boundaries:
- Promontory
- Sacro-iliac joint
- Iliopectineal line
- Upper border of ascending rami of pubic bone
- Pubic crest
- Pubic symphysis
Pelvic Inlet
- At the level of pelvic brim
- True conjugate: Distance from sacral promontory to upper border of pubic symphysis (11 cm)
- Obstetric conjugate: Distance from sacral promontory to middle border of pubic symphysis (10.5 cm - smallest and most important)
- Diagonal conjugate: Distance from sacral promontory to lower border of pubic symphysis (12 cm)
- Critical obstetrical conjugate: Minimum diameter below which vaginal delivery is not possible (13 cm)
- Oblique diameters: Distance between sacro-iliac joint on one side to ileo-pectineal eminence on other side (12 cm)
Pelvic Cavity
- Lies at the level of ischial spines between pelvic inlet & anatomical outlet
- Shape: Truncated cylinder
- Anterior wall: Shallow, formed by pubic bone
- Posterior wall: Deep and concave, formed by sacrum
Plane of Greatest Pelvic Dimensions & Plane of Least Pelvic Dimensions
- **Plane of greatest pelvic dimensions**
- Anterior boundary: Lower border of pubic symphysis
- Posterior boundary: Junction of S2-S3 vertebrae
- Lateral extent: Obturator foramen
- AP diameter: 12 cm
- Transverse diameter: 12 cm
- **Plane of least pelvic dimensions**
- Anterior boundary: Lower border of pubic symphysis
- Posterior boundary: Junction of S4-S5 vertebra
- Lateral extent: Ischial spines
- AP diameter: 10 cm
- Transverse diameter: Bispinous diameter (smallest diameter) - 11.5 to 12 cm
- Significance:
- Plane of greatest pelvic dimensions has no obstetric significance
- Plane of least pelvic dimensions is the smallest pelvic diameter and is most important obstetrically
Post-Term Pregnancy and Macrosomia
- Total duration of pregnancy: 9 months + 7 days/40 weeks/280 days
- Post-term pregnancy: ≥ 42 weeks (≥ 294 days)
- First step if history of post-term pregnancy: Review menstrual history
- Color of amniotic fluid: Saffron/Yellowish green
- Amniotic fluid volume (AFV) ↓ (~200 ml) after 42 weeks
Pathophysiology of Post-Term Pregnancy
- Placenta cannot synthesize estrogen independently.
- Placenta depends on fetal adrenal glands for the synthesis of estrogen (E1, E2, E3)
- Decreased levels of estrogen (↓ myometrial contractility) can make initiating labor difficult
Causes of Post-Term Pregnancy
- Maternal diabetes
- Anencephaly
- Fetal demise
- Down's Syndrome
- Deficiency of sulphatase and aromatase
Consequences of Post-Term Pregnancy
- Macrosomia: Fetal weight ≥ 4.0 kg
- Oligohydramnios
- Cord compression → Variable decelerations
- Fetal distress
- Meconium aspiration syndrome
- Placental Ageing → Utero-placental insufficiency → Late decelerations → Fetal distress
- Oligohydramnios
Management of Premature Rupture of Membranes (PROM)
- Early PROM: Induction of labor
- Late PROM: Induction of labor not recommended
- Chorioamnionitis: Not recommended for early PROM, but may be present in late PROM
- Corticosteroids: Not recommended
- Tocolytics: Not recommended
- Magnesium Sulfate (MgSO4): Not recommended
- Group B Streptococcal (GBS) Prophylaxis: Recommended if POG < 32 weeks and membrane ruptured for ≥ 18 hours, or fever ≥ 100.4°F for 4 hours
GBS Prophylaxis
- Screening: ACOG recommends screening all pregnant women at 35-37 weeks using a rectovaginal swab
- Prophylaxis: To prevent early neonatal sepsis - Indications: - Previous history of a baby with neonatal sepsis - GBS bacteriuria anytime during pregnancy - Positive screening result - Preterm labor - PROM - Rupture of membranes for ≥ 18 hours - Fever ≥ 100.4°F for 4 hours during labor
- No need for screening if none of the above indications apply
- Time of administration: Intrapartum (during labor)
- Preferred drug: Benzyl peroxide
- Alternatives: Ampicillin/cefazolin; if allergic to penicillin: vancomycin/clindamycin
Macrosomia
- Risk Factors:
- Post-term pregnancy
- Maternal diabetes
- Maternal obesity
- Male fetus
- Complications:
- Increased chance of C-section
- Instrumental delivery
- Organ least affected by macrosomia: Brain
- Management:
- Best mode of delivery: Vaginal delivery
- Indication of C-section:
- Baby weight ≥ 4.5 kg in diabetic patients
- Baby weight ≥ 5.0 kg in non-diabetic patients
- Macrosomia is a relative contraindication for VBAC (Vaginal Birth After C-section)
Assessment of Fetal Weight
- Best method (Ultrasound): Formulae (Hardlock; Shepherd)
- Best Ultrasound parameter: Abdominal circumference of fetus (≥ 35 cm)
- Clinical estimation of fetal weight: Johnson's formula (Fetal weight (in grams) = (Fundal height (in cm) - n) x 155)
- n= 12 (If head is above ischial spines)
- n = 11 (If head is below ischial spines)
Abdominal Circumference (AC) Measurement: Ultrasound
- Structures visible:
- Umbilical vein
- Portal vein
- Fetal stomach
- Hockey-stick sign
- Structures that should not be visible:
- Kidney
- Cord insertion
Clinical Pelvimetry
- Diagonal conjugate: Only perform if the sacral promontory is not palpable and diagonal conjugate > 12cm.
- Obstetric conjugate = Diagonal conjugate (1.5 cm to 2 cm)
- Contracted pelvis:
- OC < 10 cm
- DC < 11.5 cm
- Female pelvis: Gynecoid/Transverse oval (TD > AP diameter)
Labor and Puerperium
- Cavity:
- Lies at the level of ischial spines between pelvic inlet & anatomical outlet.
- Shape: Truncated cylinder
- Anterior wall: Shallow, formed by pubic bone.
- Posterior wall: Deep and concave, formed by sacrum.
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