Week 2 Study Guide
What are the causes of bleeding during pregnancy?
- 1st Trimester: Spontaneous Abortion, Ectopic Pregnancy
- 2nd Trimester: Gestational Trophoblastic Disease
- 3rd Trimester: Placenta Previa, Abruptio Placentae, Vasa Previa
- Other: Recurrent Premature Dilation of the Cervix, Preterm Labor, Hydatidiform Mole
Abortion Types: Must happen before 20 weeks (otherwise, it’s a stillbirth)
Cramps
Bleeding
Tissue Passed
Cervical Opening
Threatened
Mild
Slight Spotting
None
Closed
Inevitable
Mild to
Moderate
None
Usually dilated
Moderate
Incomplete
Severe
Heavy, profuse
Yes
Dilated with
tissue in cervical
canal or passage
of tissue
Complete
Mild
Minimal
Yes
No (cervix
closed after
tissue passed)
Missed
None
None, spotting
None, Prolonged Closed
retention of
tissue
Septic
Varies
Varies;
Varies
Usually dilated
malodorous
discharge
Recurrent
Varies
Varies
Yes
Usually dilated
What are first-trimester spontaneous abortions most commonly caused by? Fetal genetic
abnormalities.
What are second-trimester spontaneous abortions most commonly caused by? Maternal
conditions.
What are the signs and symptoms of an Ectopic Pregnancy?
- Unilateral stabbing pain and tenderness in the lower abdominal quadrant
- Scant dark red, or brown vaginal spotting (lasting 6-8 weeks after the last normal
menses)
What is the pharmacological treatment/education options to treat an ectopic pregnancy?
- If still early, IM Methotrexate (must avoid folic acid if on methotrexate due to a toxic
response).
What is the hallmark sign of an ectopic pregnancy?
- Abdominal pain with spotting within 6-8 weeks after missed menses.
Week 2 Study Guide
What are the 2 types of GTD (Gestational Trophoblastic Disease)?
- Hydatidiform Mole: Benign abnormal growth of the placenta without a viable fetus.
Looks like a cluster of Grapes
- Choriocarcinoma
What are the s/s of GTD?
- Vaginal bleeding: Brown GRAPE CLUSTERS
- Rapid Uterine Growth (increased fundal height)
- Extreme Nausea (Hyperemesis Gravidarum aka Excessive Vomiting)
- Hyperthyroidism
- Pre-eclampsia prior to 24 weeks
What is cervical insufficiency?
- Premature dilation of the cervix, usually in the 2nd trimester (ultrasound will show a
short cervix of <25mm)
How do we treat Cervical insufficiency?
- Cervical Cerclage (Tie off cervical opening [gets removed at 36 weeks])
- Bedrest (No pressure on the cervix)
- Fluids
- Prophylactic Tocolytics
What are the 3 types of Placenta Previa?
- Complete/Total: Cervical opening is completely covered by the placenta
- Incomplete/Partial: Cervical opening is partially covered by the placenta
- Marginal: Placenta attaches to the lower part of the uterus but does not reach the
cervical opening
What are the S/S of Placenta Previa?
- Vaginal bleeding (Painless, bright red in second or third trimester, spontaneous cessation
then recurrence).
- Increased Fundal height
- Soft, relaxed uterus
- Fetus is in a breech, oblique, or transverse position
- Decreased maternal urine output (indicating blood loss)
How do we manage Placenta Previa?
- Monitor bleeding (pad count)
- Close monitoring of FHR
- NO VAGINAL EXAMS
- Bed rest
- Fetal Movement counts
What is Abruptio Placenta?
- Premature separation of a placenta that is normally implanted usually in the 3rd
trimester which can lead to DIC (Disseminated intravascular coagulation) a large blood
clot behind the placenta which leaves the mother's body lacking in clotting factors which
is the leading cause of maternal death.
Week 2 Study Guide
What are the S/S of Abruptio Placenta?
- Abdominal or lower back pain (KNIFE LIKE aka Sharp and stabbing)
- Dark red vaginal bleeding
- Uterine tenderness
- Hypovolemic shock
- Fetal distress
How do we manage Abruptio Placenta?
- Left Lateral Position
- Bed rest
- Continuous fetal monitoring
- O2
- Education regarding possible loss of fetus and reduction of recurrence
Placenta Accreta Spectrum (Only happens with repeated uterine scarring)
What is Hyperemesis Gravidarum and what are the S/S?
- Severe form of nausea and vomiting
- Usually resolves by week 20
- Weight loss >5% of pre-pregnancy body weight
- Dehydration, metabolic acidosis, alkalosis, and hypokalemia
How do we manage Hyperemesis Gravidarum?
- Small frequent meals
- Avoid triggers (of nausea)
- Anti-emetics
- Vit B6
- IV Lactated Ringers
- CBC, Liver enzymes, BUN, Electrolytes, Spec. Gravity, Ultrasound
What is the difference between Pre-eclampsia and Eclampsia?
- Pre-eclampsia does NOT have seizures. (Pre-eclampsia + seizures = Eclampsia)
Week 2 Study Guide
Magnesium Sulfate is the treatment for seizures from Eclampsia. What is the antidote to Mag
Sulfate?
- Calcium Carbonate
What must we monitor when a patient is taking Mag Sulfate?
- Fetal Monitoring
- Contraction Monitoring
- Urine Output (Must maintain 30 mL/Hr)
- Breath Sounds
- Pt must be on fluid restrictions of 100-125 ml/hr (Too much fluid causes pulmonary
edema)
What are the 4 signs of toxicity with Mag Sulfate?
- Decreased DTR (Deep Tendon Reflexes) *MOST IMPORTANT SIGN*
- Respiratory Depression
- Cardiac Dysrhythmias
- Collapse and death
What is HELLP Syndrome? (Pre-eclampsia with Liver involvement)
Basically, small blood vessels are damaged due to HTN causing hemolysis (destruction of red
blood cells), and obstruction of hepatic blood flow causes liver enzymes to build up. The
damaged blood vessels bleed so platelets gather reducing the platelet count in the rest of the
body.
- Hemolysis resulting in anemia and jaundice
- Elevated Liver enzymes (ALT, AST, Epigastric pain, and N/V)
- Low Platelets (<100,000/mm) leading to abnormal bleeding and reduced clotting
When do we give Rho-Gam?
- @28 weeks and then within 72 hours of delivery
What is Polyhydramnios?
- Too much amniotic fluid (more than 2000 mL) usually around 32-36 weeks gestation
What are the S/S of Polyhydramnios?
- Shortness of Breath
- Increased abdominal girth and abdominal discomfort
- Increased fundal height
- Contractions
- Difficulty palpating fetal parts and obtaining FHR (fetal heart rate)
- Lower extremity edema from increased pressure on the vena cava
How do we treat Polyhydramnios?
- Removal of fluid
- Indomethacin (decreases fluid by decreasing fetal urinary output)
Week 2 Study Guide
What is Oligohydramnios?
- Less than 500 mL of amniotic fluid between 32 and 36 weeks
- Higher risk of cord compression leading to hypoxia (Check for variable deceleration of
FHR strip)
- Can also occur after 42 weeks
What are the S/S of Oligohydramnios?
- Trickling of fluid from vagina
- Low fundal height
How do we treat Oligohydramnios?
- Serial ultrasounds, NST, BPP
- Birth and amnioinfusion
- Left lateral position
What is Premature Rupture of Membranes (PROM)?
- Spontaneous rupture of the amniotic membranes 1 hr or more prior to the onset of true
labor
- Preterm premature rupture of membranes (PPROM) is after 20 weeks but before 37
weeks
- Only S/S is a gush or leakage of clear fluid from the vagina
What patient teaching must occur before sending a PROM patient home?
- Bedrest with bathroom privileges
- Monitor for contractions, kick count, foul-smelling discharge
- Temp check q4 while awake
- Reduce infection risk (Prevent CHORIOAMNIONITIS: Infection of the chorion and
amnion membranes)
 Do not insert anything into the vagina (no intercourse)
 No tub baths
 Wipe from front to back
How do we treat PROM?
- Cultures
- VS q2
- Ampicillin (For chorioamnionitis)
- Betamethasone (glucosteroid)
 2 IM injections 24 hours apart to enhance fetal lung maturity and surfactant
production
What are the complications of GDM (Gestational Diabetes Mellitus)?
- Infant:
 Spontaneous Abortion
 Preterm/stillborn
 Polyhydramnios
 Macrosomia (big bebe)
Week 2 Study Guide
-
Maternal:
 Increased risk for urinary and vaginal infections
 Increased risk of postpartum hemorrhage due to increased uterine stretching
What are the Risk Categories of cardiac issues in pregnancy?
- Class I: Asymptomatic; no limitation of physical activity
- Class II: Symptomatic (dyspnea, chest pain) with increased activity
- Class III: Symptomatic (fatigue, palpitation) with normal activity
- Class IV: Symptomatic at rest or with any physical activity
Lab values showing Iron Deficiency?
- HGB<11
- HCT<33%
What do we give to a patient who can’t tolerate oral iron supplements?
- IM/IV Iron Dextran
What is Thalassemia?
- An inherited blood disorder caused when the body doesn't make enough hemoglobin
- 2 types:
 Alpha (minor): Little effect on pregnancy except for mild, persistent anemia
 Beta (Major): NO PREGNANCY due to lifelong, severe hemolysis, anemia, and
premature death
TORCH:
- Toxoplasmosis: A parasite from cat feces and raw meat. Can be transmitted through the
placenta. Effects on the baby include: Low birth weight, enlarged liver and spleen, and
neurological damage. Treated with meds for the first year of life.
- Cytomegalovirus: Spread by droplets/bodily fluids. Effects on the baby include: Mental
retardation, blind/deaf, purpuric (small purple spots caused by blood leakage) skin
lesions, hepatosplenomegaly, and seizures. Prevented with hand-washing.
- Rubella: Mild viral disease. Effects on the baby include: Microcephaly (small head),
mental retardation, congenital abnormalities, and death.
- Herpes: Avoid letting the baby touch lesions. May need a c-section to prevent uterine
exposure after membrane rupture. Limit any procedures that expose the baby to
bleeding.
 Type 1: Fever blisters or cold sores
 Type 2: Genital Herpes
 Acyclovir given to mother before birth to reduce chance of lesions
Week 2 Study Guide
What is Precipitous Labor? What is mom and baby at higher risk of with Precipitous Labor?
- Labor that lasts 3 hours or less from the onset of contractions to the times of delivery.
- DO NOT LEAVE THE PATIENT UNATTENDED
- Mom is at higher risk for:
 Hemorrhage
 Tissue Trauma
 Uterine Rupture
 Amniotic Fluid Embolism
- Baby is at higher risk for:
 Fetal Hypoxia
 Intracranial Hemorrhage
What is fetal fibronectin?
- A glycoprotein made by the chorion which acts as a glue attaching the fetal sac to the
uterine lining.
- If a swab shows increased levels, labor will start in the next 7-14 days
What are the 3 parameters looked at when measuring the cervix?
- Cervical length and width
- Funnel width and length
- Percentage of funneling
How do we manage preterm labor?
- Tocolytics: May prolong pregnancy for 2-7 days wile steroids are given for fetal lung
maturity
- Antibiotic Prophylaxis: For Group B strep
What is a normal contraction pattern?
- 4 contractions every 20 minutes or 8 contractions per hour
Induction: Stimulating contractions via medical or surgical means
Augmentation: Enhancing ineffective contractions after labor has begun
What bishop score is best for a successful induction?
- 8+. If not there, a cervical dilation method is required.
Uterine Rupture
- Obstetric emergency usually marked by sudden fetal bradycardia. We manage this by
prepping for urgent c-section and continuous monitoring
Week 2 Study Guide
What is post-term labor and what are the maternal and fetal risks?
- Pregnancy continuing past the end of 42 weeks
- Maternal Risks:
 Cesarean birth
 Dystocia (Dysfunctional Labor)
 Postpartum hemorrhage
 Infection
- Fetal Risks:
 Macrosomia
 Shoulder dystocia
 Brachial plexus injuries
 Low APGAR score
 Post-maturity syndrome
 Cephalopelvic disproportion
What is an External Cephalic Version?
- An ultrasound-guided, hands-on procedure to externally manipulate the fetus into a
proper birthing position that is usually performed at 37-38 weeks.
- Contraindications include:
 Uterine anomalies
 Previous C-section
 Cephalopelvic disproportion
 Oligohydramnios
 Third-trimester bleeding
 Uteroplacental insufficiency