OBSTETRICS /GYNECOLOGY
10. PLACENTAL ABRUPTION
(occurs in up to 40% of major blunt trauma)
shearing and decel. forces, often little outward evidence of trauma...
can cause fetal distress
Kleihauer-Betke test: SAB, trauma (placental abruption>> US won’t see,
place on CEFM r/o
fetal distress): used to determine FMH, VB with Rh negative
moms (Rhogam or not). FFN test: r/o PTL. 63% of placental
abruption won’t show VB,
most sensitive is fetal distress. need cardiotocographic
monitoring/best way to assess for abruption ---
women with placental abruption 54x
more likely to have DIC (placental release of thromboplastin into maternal
circulation)
234. HEELP SYNDROME: usually seen with pre-eclampsia, third trimester or 30% post-partum
- hemolysis, elevated LFT's, low platelets <100,000
(3rd trimester, schistocytes on smear, inc. bilirubin LDH/AST/ALT, RUQ pain)
↑ LDH, if untreated can lead to hepatic failure or rupture/ capsular hematoma, ARF, hyponatremia, cortical blindness, seizures, CHF , DIC
TREATMENT: Magnesium, steroids, delivery
- platelet transfusion may be indicated when counts are less than 20K or if evidence of bleeding
- steroids have NOT been shown to be effective
- abdominal distention ----> may be indicative of ruptured hepatic hematoma (if stable, percutaneous embolization of hepatic artery may be done)
TTP (less 24 wks, mental status changes, fever, renal failure, hemolytic anemia, thrombocytopenia s/sx (FATRN)
tx: plasmophoresis, steroids
(NO PLATLETS FOR TTP, may lead to rapid deterioration)
53. Eclampsia -- [Hypertensive Emergency of Pregnancy ] headache, visual disturbances , hyper-reflexia, agitaiton, seizures, AMS, elev. uric acid in 80%
most commonly occurring AFTER 20 WEEKS, or post partum (30%)
in post-partum ---> HA is MC presenting symptom, however classic features such as HTN, proteinuria, edema often absent
- one goal of therapy in patient with post-partum eclampsia is to prevent progression to eclampsia
- magnesium sulfate has been shown to be effective
- brain damage due to intracranial hemorrhage or ischemia can lead to permanent neurologic damage and is the most common cause of death in women with eclampsia
(Seizure + HTN pregnant pt): tx with IV Magnesium (6 g over 15 min then
2g/hr). Mg levels 4-7mg/dl. Watch for signs of Magnesium toxicity : decreased respirations, pulm edema, bradycardia, loss of DTR's
Tx with calcium gluconate 1 g slow IVP.
Mg won’t affect fetal-maternal blood flow
unlike lorazapam, phenytoin and phenobarbital.
Ultimate treatment = delivery of fetus
Posterior reversible encephalopathy syndrome -- HA, confusion, visual changes, seizures, with white matter changes on MRI -- rare but potentially
lethal complication of eclampsia
PPCM (peripartum cardiomyopathy)
- fatigue, cough, orthopnea, dyspnea on exertion, PND, pedal edema...signs usually progressive
- elev BP, tachycardia, rales, S3 gallop, jvd, peripheral edema
- criteria
- development of HF in last month of pregnancy or within 5 months of delivery
- absence of identifiable cause for the heart failure
- absence of recognizable heart disease prior to last month of pregnancy
- LV dysfunction
Treatment -- similar to CHF
- oxygen, diuretics, vasodilators, and arrhythmia management
49. Eight cardinal movements in labor : 1unengaged fetal vertex in low OA, 2descent fetal
vertex with flexion of head, 3 internal rotation from vertex to OA, 4 further internal
rotationto OA and descent to vertex, 5fetal head extension under pubic syphilis, 6external
rotation (pause to remove nuchal cord if present 25% cases), 7delivery anterior shoulder then 8upward traction to deliver
posterior shoulder.
...APGAR (0-2) for each of HR, resp effort, muscle tone, crying/reflex irritibility, color
30. Puerperal mastitis: staph aureus. Tx: ceph, continue breast feeding or pumping. If
abscess present surgery.
