big obstetrics huge big time rush 2.0

Nifedipine (Procardia)

Tocolytic, suppresses preterm uterine contractions

Calcium channel blocker, take PO

Contraindications = hypotension or hemodynamic stability

Monitor maternal blood pressure + pulse, assess contractions and fetal status

Indomethacin (Indocin)

Tocolytic, short-term preterm contractions particularly at earlier gestational ages

NSAID, cox-inhibitor

Given PO or rectal

watch for GI bleeding, significant renal dysfunction or bleeding disorders

Why do you avoid Indomethacin at 32 weeks of gestation or later

it can cause the fetal ductus arteriosus to constrict/close

Progesterone

Prevent preterm birth particularly with short cervix

Not an acute medication, PREVENTITIVE

Vaginal insert

Mag Sulfate

Electrolyte/anticonvulsant

Seizure prophylaxis for preeclampsia with severe features

Decrease CNS excitability

Fetal neuroprotection for preterm birth

IV

Contrainidications for mag sulfate

Myasthenia gravis

mag sulfate warning signs

decreased/absent reflex, respiratory depression, falling urine output

Betamethasone

Glucocorticoid

Given when preterm delivery is likely to promote fetal lung maturation by increasing surfactant production

Give IM

Monitor for glucose in mother

Terbutaline Brethine

Beta-2 adrenergic agonist, tocolytic

Relaxes uterine smooth muscle, reducing contractions

Contraindications = significant cardiac disease

Misoprostol (Cytotec)

Cervical ripening and labor induction

Postpartum hemorrhage

softens and ripens the cervix, stimulates uterine contractions, promotes uterine contraction to help reduce bleeding

Rectal, vaginal, or oral

Why do you not give oxytocin and misoprostol together and why

they both stimulate uterine contractions, which can cause excessive uterine activity

Uterine tachysystole → reduced fetal oxygenation, fetal distress, uterine rupture

what is uterine tachysystole

5 contractions over 10 minutes, averaged over 30 minutes

Dinoprostone (Cervidil, prepidil)

cervical ripening

prastaglandin e2 analog

contraindicated when labor or vaginal birth is contraindicated (prior uterine incisions or major uterine surgery)

Adverse effects = uterine tachysystole

How is cervidil given

Dinoprostone

vaginal insert

How is prepidil given

Dinoprostone

Endocervical gel

how do you give oxy for labor

iv

how do you give oxy for pph

IM/IV

Naplbuphine (Nubain)

Moderate to severe Pain managment

Opioid

Butorphanol (Stadol)

Opioid

Moderate to severe pain management

Morphine

Severe pain management

Opioid

Hydrocodone

Opioid

Moderate to severe pain

Ibuprofen

NSAID analgesic

Mild to moderate pain

watch for GI bleed, renal damage

Fetanyl

opioid

severe acute pain, anesthesia

Ondansetron (Zofran)

For Nausea and Vomiting

Serotonin receptor antagonist

Promethazine (Phenergan)

First-gen antihistamine

for Nausea/Vomiting

Metoclopramide (Reglan)

for nausea/vomiting

Dopamine receptor antagonist

Methylergonivine (Methergine)

Prevention or treatment of uterine atony and postpartum hemorrhage

Produce sustained smooth muscle contraction and vasoconstriction, reducing bleeding from the placental site

what is major contraindication for methylergonivine (methergine)

hypertension, preeclampsia

it constricts the blood vessels

you should question this if the pt has htn or pre e

carboprost tromethamine (hemabate)

strongly stimulates uterine smooth muscle to contract

what is a major contraindication to hemabate (carboprost tromethamine)

asthma

hemabate/carboprost can cause bronchospasm

you should questionn carboprost of the patient has asthma

Tranexamic Acid (TXA)

Antifibrinolytic

Slows donwn breakdown of fibrin blood clots and helps stabilize blood clots

Adjunct treatment for postpartum hemorrhage

Contraindications = active intravascular clotting, consider thromboembolic history

Lasinoh (Lanolin nipple cream)

topical skin protectant

helps protect dry or irritated nipples during breastfeeding

Docusate (Colace)

Stool softener

Tucks Pads

witch hazel pads

for temporary relief of perineal or hemorrhoidal discomfort after birth

Epifoam

topical corticosteroid and local anesthetic for relief of itching, inflammation, discomfort in area specified

Rhogam

give at 28 weeks

give again within 72 hours after delivery if infant is rh positive

mmr and varicella

can be given after delivery

avoid pregnancy 28 days after vaccination

you can still breastfeed

tdap

you can get during pregnancy

inactive flu vaccine can be given during pregnancy

yes

vit k

help with blood clotting factors

erythomycin opthalmic ointment

prevent ophthalmia neonatorum caused by neisseria gonorrhoeae

routine eye prophylaxis

do you use naloxone for neonatal opioid withdrawal

no

labetalol

severe hypertension

lowers vascular resistance

patients can be fall risk

nifedipine

ca2+ channel blocker

maintenance treatment of hypertension in pregnancy

also used as a tocolytic

medroxypreogesterone acetate (depo-provera)

progestin contraceptive, injectable

150mg IM every 13 weeks

suppresses ovulation, thickens cervical mucus, alters endometrium

medoxyprogesterone acetate (depo-provera) adverse effects

irregular bleeding, amenorrhea, weight changes, headache

normal baseline fhr

110-160

absent variability

no detectable fluctuations

concerning

minimal variability

5 bpm or less

reflects sleep, prematurity

moderate variability

6-25

reassuring, intact nervous system

marked variability

greater than 25 bpm

accelarations definition after 32 weeks

increase of 15 bpm lasting at least 15 seconds

accelerations definition before 32 weeks

increase of 10 bpm lasting for 10 seconds

Early decels

head compressions

mirrors the contraction

its okay, continue monitoring

variable decels

umbilical cord compression

abrupt decrease (V, U, or W)

reposition, assess for cord compression/prolapse

consider amnioinfusion

late decel

uteroplacental insufficiency

onset occurs after the beginning of the contraction

nadir (lowest point) occurs at the peak of the contraction

reposition laterally, asses bp and uterine activity, stop oxy if infusing, correct hypotension, o2

epdural analgesia

given in epidural space

monitor for hypotension

maintain iv access, administer fluids as indicated, fall prevention, monitor bladder function, reposition laterally if needed

4 Ts for the causes of PPH

• tone (uterine atony)

• trauma (lacerations, uterine rupture)

• tissue (retained placenta)

• thrombin (coag abnormalities)

what is the first line med for uterine atony

oxytocin

chronic hypertension

present before pregnancy or diagnosed before 20 weeks

gestational hypertension

new bp >140/>90 either/or AFTER 20 weeks

no diagnostic features of preeclampsia (no proteinuria, no signs of organ dysfunction)

preeclamspia

new onset hypertension after 20 weeks with proteinuria and/or qualifying organ dysfunction

eclampsia

new onset seizure with preeclampsia

HELLP syndrome

hemolysis, elevate liver enzymes, low platelets

severe range bp

>160/>110

what is the pathophysiology of preeclampsia

abnormal placental development and maternal vascular dysfunction leading to widespread endothelial injury, vasoconstriction, and impaired organ perfusion

• can affect the brain, kidneys, liver, lungs, placenta

what are the risk factors for pre e

• previous preeclampsia

• first pregnancy

• multiple gestation

• chronic htn

• diabetes or kidney disease

• certain autoimmune disorders

• family history of preeclampsia

red flags for preeclampsia with severe features

• persistent severe headache

• visual disturbances

• RUQ or epigastric pain

• severe-range blood pressure

• SOB

• thrombocytopenia

• worsening renal or liver function

• new confusion or neurologic changes (cerebral edema)

Expected diagnostic tests for pre e

CBC with platelets

creatinine and renal function

AST/ALT and other liver studies

Urine protein assessment

fetal surveillance (NST, ultrasound, BPP)

maternal complications of pre e

• Eclampsia and stroke

• HELLP syndrome

• Acute kidney or liver injury

• Pulmonary edema

• Disseminated Intravascular Coagulation (DIC)

fetal complications of pre e

• Fetal growth restriction

• Placental insufficiency

• Preterm birth

• Placental abruption

• Fetal compromise or stillbirth in severe cases

How to manage pre e

• assess BP frequently

• assess headache, vision, epigastric pain, respiratory status, reflexes, and mental status

• monitor urine output, labs, fetal status

• seizure precautions

• prescribed antihypertensives

• administer mag sulfate when indicated

• prepare for delivery

what is the definitive treatment for pre e

delivery

when eclampsia happen

anytime: before, during, or after birth

what is the priority for a eclamptic patient

protect, support oxygenation and the airway, emergency assistance

what makes HELLP different from pre e

the patient can have significant epigastric or RUQ pain, nausea, abnormal labs when

• hypertension or

• proteinuria

are not present

Complications of HELLP

• liver hematoma or rupture

• hemorrhage

• DIC

• renal injury

• placental abruption

mag sulfate toxicity

• respiratory depression

• diminished or absent deep tendon reflexes

• poor urine output

• lethargic mental status

• could cause cardiac arrest

you should also monitor fhr

what to do if mag toxic

• stop the infusion

• notify provider

• support airway and breathing

• prepare to administer calcium gluconate

• obtain labs, monitor vitals

what hydralazine do

lower bp is severe situations, given IV

what nifedipine do

lower bp during pre e and can also be a tocolytic

ccb

what hormone contributes to insulin resistance in pregnancy

human placental lactogen

particularly in the second and third trimesters

why does pregnancy cause insulin resistance

to help ensure extra glucose is in the bloodstream so that it is available to the fetus

how is gestational diabetes screened and diagnosed

1. one-hour glucose challenge test

2. three-hour glucose tolerance test

what is the one hour glucose challenge

drink 50g of glucose, test sugar after 1 hr

• under 130 to 140 → standard, no need for further testing

• 140-189 → elevated, need 3 hour

• 190 or higher → usually high enough, no need for 3 hour

what is the three hour glucose tolerance test

fast for 8-12 hours before hand, can drink water

• draw blood for fasting blood sugar

• drink a more highly concentrated sweet liquid

• draw blood at 1 hour, 2 hours, and 3 hours

if two or more readings from fasting, 1 hour, 2 hour, or 3 hours are higher than normal, then you are diagnosed with gestational diabetes

how to manage gestational diabetes

• 3 meals ad 2-3 snacks per day to prevent massive post-meal blood sugar spikes and overnight hypoglycemia

• 40-45% complex, high-fiber carbs

• 20-30 minutes of moderate exercise

• inusin

• oral diabetics

in first trimester, insulin needs typical decrease and second and third trimester, insulin needs will increase

true

maternal complications of gestational diabetes

• risk for pre e

• higher chance of c section

• increased future type 2 diabetes risk

• polyhydramnios may occur because the fetus is peeing more

• delivery complications

fetal complications of gestational diabetes

• LGA → shoulder dystocia and birth trauma

• neonatal hypoglycemia

• respiratory complciations

• hyperbilirubinemia and polycythemia

why newborn develops hypoglycemia with the mom has diabetes

increase glucose crossing the placenta so that baby produces more insulin

• after birth, glucose supply drops but insulin remains high → hypoglycemia

how often do you glucose screen for LGA/ baby of diabetic mother

1. feed within first hour

2. check glucose 30 minutes after

3. repeat every 2-3 hours

what do you do for postpartum diabetes testing

75 g oral glucose test at 4-12 weeks

what is preterm labor

regular uterine contractions with cervical change before 37 weeks

contractions alone do not establish labor/preterm labor

what does it mean when the patient says they need to poop during labor

the baby is pushing down on the rectum and is movingn down through the birth canal

• do not encourage pushing until fully dilated

• you can tell them to pant/blow/quick shallow breaths, breathe through the urge to push

risk factors for preterm labor

• previous preterm birth

• multiple gestation

• uterine or cervical abnormalities

• genitourinary infection

• smoking or substance exposure

• short cervical length

• some maternal medical conditions

what is bloody show

passage of mucus and small amounts of blood from the vagina as the cervix

• a mucus plug seals the cervix to prevent the uterus from infection

• as the cervix dilates, small blood vessels can break

does a short cervix increase the risk for preterm birth

yes

what is fetal fibronectin

• protein that acts like glue to attach the fetal membranes and placenta to the lining of the uterus

If membranes and uterine lining begin separating, fetal fibronectin can appear in vaginal secretions

what does a negatve fetal fibronectin mean

• suggest the patient is unlikely to deliver in the next 7-14 days