complicated preg

• SHOULDER DYSTONIA=fetal fx of arm that can result in brain hypoxia and death. This results from impaction of shoulder against pubic symphysis; inc morbidity/mortality

  • tx= perform mcroberts maneuver, suprapubic pressure, rubin maneuver

  BREECH PRESENTATION= occurs when fetal pelvis/LE engage in pelvic inlet, confirmed via US. baby moves into this position at 28wks so baby is small enough to rotate

  • types= frank breech, complete breech, footling breech
  • dx= leopald’s maneuver, XR, US
  • Cesarean delivery thru abd/uterine incision
• Incompetent cervix

  Leading cause of 2nd trimester pregnancy loss
• Risk factors for incompetent cervix

  • Cervical trauma
  • Congenital cervical abnormality
  • History of short cervical length
• Incompetent cervix

  • Recurrent painless cervical dilation leading to 2nd trimester pregnancy loss
  • Can be diagnosed once it occurs in consecutive pregnancies
• Signs and symptoms of incompetent cervix

  • Pelvic pressure
  • Braxton-Hicks like contractions
  • Cramping/backache
  • Discharge changes
• Physical exam findings in incompetent cervix

  • Normal early on
  • Later the cervix appears open, more frequent contractions, hourglass membranes
• Treatment for incompetent cervix

  1. Cerclage

  2. Supplemental progesterone starting at 6 weeks
• Premature preterm rupture of membranes (PPROM)

  Membrane rupture before onset of contractions before 37 weeks
• Risk factors for PPROM

  • STIs
  • Group B Streptococcus
• Treatment for PPROM

  1. Prophylactic antibiotic therapy (azithromycin+ampicillin)

  2. Magnesium sulfate for neuroprotection (at 24-32 weeks)
• Indications to start delivery with PPROM

  1. Intrauterine infection

  2. Placental abruption

  3. Non-reassuring fetal testing

  4. High risk cord prolapse
• Premature rupture of membranes (PROM)

  Membrane rupture at term without spontaneous uterine contractions
• Risk factors for PROM

  • Infection
  • Smoking
  • Amniotic stretch
  • Low BMI
  • Multiple gestation
  • Bleeding
  • History of preterm birth
• Chorioamnionitis


  Intra-amniotic infection where normal genital tract flora can colonize and infect membranes, uterine cord then the fetus
• Risk factors for chorioamnionitis

  • Ureaplasma and mycoplasma species
  • Group B Streptococcus
  • Associated with PROM
• Clinical features of chorioamnionitis

  • Fever
  • Maternal leukocytosis
  • Maternal/fetal tachycardia
  • Uterine tenderness
  • Bacteremia
  • Purulent/malodorous amniotic fluid
• Maternal sequelae of chorioamnionitis

  • Dysfunctional labor
  • Localized infection
  • Sepsis
• Diagnostic tests for chorioamnionitis

  • Positive gram stain
  • Glucose <14
  • WBC >30
  • Positive leukocyte esterase
• Treatment for chorioamnionitis

  Broad spectrum antibiotics

  Intrapartum: ampicillin+gentamicin or ampicillin-sulbactam or cefoxitin

  Cesarean: ampicillin+gentamicin; azithromycin+metronidazole or clindamycin
• Anti-D alloimmunization

  Mom's immune system has been exposed to RhD-positive red blood cells
• Causes of anti-D alloimmunization

  • Transplacental hemorrhage
  • Injection with needles contaminated with Rh+ blood
  • Inadvertent transfusion of Rh-positive blood
• Effects of anti-D alloimmunization

  • Hemolytic disease of fetus/newborn
  • Fetal anemia
  • Hydrops fetalis
• Treatment for anti-D alloimmunization

  1. Test fetal DNA in amniocytes

  2. Monitor fetal anemia and treat it

  3. Give patient Rho Gam shots at 28 weeks and as needed to prevent
• Umbilical cord prolapse

  Umbilical cord descends into lower uterine segment, below presenting part
• Types of umbilical cord prolapse

  • Funic presentation (cord palpable through membranes)
  • Overt (cord displaced into vagina)
• Management of umbilical cord prolapse

  1. section before membrane rupture for funic presentation
  2. section for overt prolapse

  Monitor fetal heart tones, Trendelenburg position to relieve pressure, +/- c-section for occult prolapse
• Fetal distress

  Requires fetal surveillance of heart rate, amniotic fluid volume, fetal response to stimulation during labor
• Causes of fetal distress

  • Uteroplacental insufficiency (placenta compromised, cannot efficiently provide oxygen/nutrients, remove waste)

  Manifests as fetal hypoxia, shunting of blood to vital organs, transient, repetitive late decelerations on fetal heart tracing
• Postpartum pituitary disorders

  Sheehan's syndrome: postpartum pituitary gland necrosis, lactotroph cell destruction of anterior pituitary (in postpartum hemorrhage)
• Acute symptoms of Sheehan's syndrome

  • Low blood pressure

  High heart rate

  Hypoglycemia

  Hypovolemia

  Agalactorrhea

  Amenorrhea
• Chronic symptoms of Sheehan's syndrome

  • Fatigue

  Weakness

  Hair loss

  Constipation

  Weight gain

  Difficulty concentrating

  Cold intolerance

  Low blood pressure

  Low heart rate