Obstetrics Marrow Pg 475-484 (Obstetrics Complications)
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Questions and Answers

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.

    False

    What condition does MgSO4 help prevent in a newborn?

    cerebral palsy

    MgSO4 is given in all cases of _________.

    <p>preterm labor</p> Signup and view all the answers

    Match the following actions/conditions with their corresponding details:

    <p>MgSO4 = Prevents cerebral palsy Preterm labor = Condition for MgSO4 administration Neuroprotective = Action of MgSO4 Cerebral palsy = Condition prevented by MgSO4</p> Signup and view all the answers

    What is the definition of PROM?

    <p>Membrane rupture beyond 37 weeks but before the onset of labor</p> Signup and view all the answers

    PPROM refers to the rupture of membranes at or after 37 weeks.

    <p>False</p> Signup and view all the answers

    What does the abbreviation PPROM stand for?

    <p>Preterm Premature Rupture of Membranes</p> Signup and view all the answers

    PROM occurs when the membranes rupture _____ the onset of labor.

    <p>before</p> Signup and view all the answers

    Match the following terms to their definitions:

    <p>PROM = Membrane rupture beyond 37 weeks but before labor PPROM = Membrane rupture before 37 weeks Early PPROM = A type of PPROM that occurs early</p> Signup and view all the answers

    Which of the following tests indicates the presence of amniotic fluid?

    <p>Fern Test</p> Signup and view all the answers

    Vaginal discharge has a pH of 7.2 during pregnancy.

    <p>False</p> Signup and view all the answers

    What is a common characteristic of urine that can help differentiate it from amniotic fluid?

    <p>Ammoniacal smell</p> Signup and view all the answers

    The Nitraxine test indicates that amniotic fluid is __________ in nature.

    <p>alkaline</p> Signup and view all the answers

    Match the following tests with what they differentiate:

    <p>Litmus Paper Test = Amniotic fluid vs Vaginal discharge Ultrasound (USG) = Ruptured membrane Actin Test = Placental protein detection Microscopy = Visual examination of discharge</p> Signup and view all the answers

    What is a key clinical finding for diagnosing chorioamnionitis?

    <p>Fetal tachycardia (FHR ≥160 bpm)</p> Signup and view all the answers

    Elevated maternal white blood cell count (≥15000/mm³) is used as a diagnostic criterion for chorioamnionitis.

    <p>True</p> Signup and view all the answers

    What antibiotic combination is preferred for the management of chorioamnionitis?

    <p>Ampicillin + gentamicin</p> Signup and view all the answers

    Chorioamnionitis is definitively diagnosed through _______ with Gram staining and culture.

    <p>amniocentesis</p> Signup and view all the answers

    Match the management strategies with their descriptions:

    <p>Induction of labor = Preferred method of delivery C-section = Considered only for obstetric reasons Metronidazole = Should be added to the antibiotic regimen Vaginal delivery = Preferred delivery method</p> Signup and view all the answers

    What is the main purpose of using tocolytics?

    <p>To allow corticosteroid action</p> Signup and view all the answers

    Tocolytics should be used in cases where gestation is more than 34 weeks.

    <p>False</p> Signup and view all the answers

    Name one important tocolytic that is commonly used in India.

    <p>Nifedipine</p> Signup and view all the answers

    Indomethacin can lead to ___________ and premature ductus arteriosus closure.

    <p>oligohydramnios</p> Signup and view all the answers

    Match the following tocolytics with their characteristics:

    <p>Nifedipine = Most common tocolytic in India; ACOG usage 32-34 weeks Atosiban = Oxytocin antagonist; choice in cardiac disease Indomethacin = Can lead to oligohydramnios and ductus arteriosus closure</p> Signup and view all the answers

    Which diameter is considered the smallest and most important for vaginal delivery?

    <p>Obstetric conjugate</p> Signup and view all the answers

    The pelvic brim is defined as the space measured between the sacral promontory and the pubic symphysis.

    <p>True</p> Signup and view all the answers

    What is the critical obstetrical conjugate measurement that indicates the minimum diameter below which vaginal delivery is not possible?

    <p>13 cm</p> Signup and view all the answers

    The pelvic inlet lies at the level of the __________.

    <p>pelvic brim</p> Signup and view all the answers

    Match the following pelvic measurements with their definitions:

    <p>True conjugate = Line drawn from sacral promontory to upper border of pubic symphysis Obstetric conjugate = Line drawn from sacral promontory to middle border of pubic symphysis Diagonal conjugate = Line drawn from sacral promontory to lower border of pubic symphysis Critical obstetrical conjugate = Minimum diameter for vaginal delivery</p> Signup and view all the answers

    What is the primary consequence of post-term pregnancy in relation to fetal weight?

    <p>Macrosomia</p> Signup and view all the answers

    The color of amniotic fluid in post-term pregnancies is typically a bright blue.

    <p>False</p> Signup and view all the answers

    What enzyme is essential for synthesizing estrogen from DHEA in the placenta?

    <p>Aromatase</p> Signup and view all the answers

    In post-term pregnancy, the volume of amniotic fluid decreases by approximately ______ ml.

    <p>200</p> Signup and view all the answers

    Match the conditions with their corresponding consequences:

    <p>Anencephaly = Hypoplastic fetal adrenals Fetal demise = Decreased fetal movement Down's Syndrome = Decreased production of C19 steroids Oligohydramnios = Cord compression</p> Signup and view all the answers

    Which of the following is a risk factor for macrosomia?

    <p>Post-term pregnancy</p> Signup and view all the answers

    Macrosomia is a relative contraindication for vaginal birth after c-section (VBAC).

    <p>True</p> Signup and view all the answers

    What is the best method to assess fetal weight?

    <p>Ultrasound with specific formulae.</p> Signup and view all the answers

    The best ultrasound parameter for assessing macrosomia is the fetal abdominal circumference of at least ______ cms.

    <p>35</p> Signup and view all the answers

    Which of the following conditions requires GBS prophylaxis during labor?

    <p>Previous history of a baby with neonatal sepsis</p> Signup and view all the answers

    Corticosteroids are recommended for both early and late PROM management.

    <p>False</p> Signup and view all the answers

    Match the formulas to their respective conditions they assess:

    <p>Johnson's formula = Estimate fetal weight based on fundal height Hardlock formula = Ultrasound fetal weight assessment Shepherd formula = Another method for ultrasound fetal weight estimation N formula = Adjusts fundal height measurement for fetal position</p> Signup and view all the answers

    At what gestational age is GBS screening recommended for all pregnant women?

    <p>35-37 weeks</p> Signup and view all the answers

    GBS prophylaxis is administered ______ during labor.

    <p>intrapartum</p> Signup and view all the answers

    Match the indications for GBS prophylaxis with their descriptions:

    <p>Previous history of neonatal sepsis = Required for prophylaxis Positive GBS screening result = Required for prophylaxis GBS bacteriuria during pregnancy = Required for prophylaxis No complications or history = Not required for prophylaxis</p> Signup and view all the answers

    What is the obstetric conjugate if the diagonal conjugate is measured at 14 cm?

    <p>13 cm</p> Signup and view all the answers

    The contracted pelvis is defined by an obstetric conjugate measuring less than 10 cm.

    <p>False</p> Signup and view all the answers

    What shape describes the cavity of the pelvis?

    <p>Truncated cylinder</p> Signup and view all the answers

    The plane of least pelvic dimensions has an anteroposterior diameter of __________.

    <p>10 cm</p> Signup and view all the answers

    Match the following pelvic measurements with their descriptions:

    <p>Diagonal Conjugate = Measured from the sacral promontory to the lower border of the pubic symphysis Obstetric Conjugate = Always less than diagonal conjugate due to anatomical considerations Transverse Diameter = Measured across the widest part of the pelvic inlet Interischial Diameter = Smallest diameter during the pelvic measurement</p> Signup and view all the answers

    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

    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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    Explore essential concepts of Magnesium Sulfate as a neuroprotective agent in preterm labor and the differentiation between amniotic fluid, urine, and vaginal discharge. This quiz covers key tests and signs related to premature rupture of membranes and maternal care during pregnancy.

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