OBSTETRICS

Maternal-Fetal Physiology

Recommended Weight gain

- BMI < 18.5: 28-40 lbs
- BMI 15.5-24.9: gain 25-35 lbs
- 25-29.9: gain 15-25 lbs
- BMI > 30: gain 11-20 lbs

Cardiovascular
- 36% increase in blood volume during pregnancy - 50% plasma and 20% RBC → relative hemodilution of
pregnancy! Slight decrease in platelets, slight increase in WBC.
- CO increases up to 33% due to increased HR and SV. Up to 95% of women will have a systolic murmur due
to increased volume. Diastolic murmurs are always abnormal!
- MAP is unchanged or slightly decreased even with increased CO, because SVR decreases markedly
- Mitral stenosis often presents during pregnancy with afib and inability to lie flat. Suspect if possible
hx of rheumatic fever.
- Peripartum cardiomyopathy: an idiopathic cardiomyopathy that presents w/ heart failure secondary to LV
systeolic dysfunction near the end of pregnancy or several months after delivery. Fatigue, SOB, palpitations,
edema.
- Thromboembolism is the most common cause of maternal mortality! Hypercoagulable state lasts for 6
weeks after delivery.
- DVT: Venous stasis due to IVC compression and hypercoagulable state (increased fibrinogen) due to
increased estrogen. Note that platelets are actually lower in pregnancy (120 lower threshold vs 150 in
nonpregnant).
- Symptoms: fever, unilateral leg pain, swelling, redness, calf tenderness
- Treat with anticoagulation as for PE, below, along with bed rest and extremity elevation. In
contrast, can treat superficial clots with pain meds. Note that long-term heparin is associated with
osteoporosis. : (
- If untreated, associated with PE in 40% of cases!

Respiratory
- Inspiratory capacity increases by 15% in the third trimester - increased TV and IRV. Respiratory rate doesn’t
change, but TV increases. FRC reduces to 80% by term.
- → subjective SOB and physiologic dyspnea of pregnancy: Present in up to 75% of women by the
third trimester.
- Compensated respiratory alkalosis is normal! Increased minute ventilation → compensated
respiratory alkalosis.
- pH = 7.45, HCO3= 19. Also PO2 is 95-105 in pregnancy vs. 90-100 mm Hg normally, and
PCO2 is 28 mm Hg vs. 40 mg.
- If O2sat is less than 90%, PO2 is < 60 mm Hg! Give supplemental O2 and get arterial blood
gas to look for hypoxemia, CO2 retention, and acid-base status.
- Pulmonary edema: Decreased plasma osmolality → increased susceptibility to pulmonary edema. Common
triggers: tocolytics, cardiac disease, volume overload, preeclampsia.
- Pulmonary embolism: venous stasis due to IVC compression and hypercoagulable state (increased
fibrinogen) due to increased estrogen. Dyspnea is the most common symptom! May have chest pain.
- Suspect if CXR is clear and no physical exam findings. Confirm the diagnosis with spiral CT or MRI.
D-dimer is not helpful in pregnancy - it’s always elevated!
- Treat with IV heparin for 5-7 days, then LMWH for at least 3 months (INR 1.5 to 2.5) through rest of
pregnancy and for 6 weeks post partum.

1
 - Check for other causes of thrombosis: Protein C or S deficiency, ATIII deficiency, FVL mutation,
hyperhomocystinemia, and antiphospholipid syndrome.

Gastrointestinal:
- Delayed stomach emptying, decreased LES tone, decreased gut motility

Renal
- GFR increases by 50%, creatinine decreases
- Glucosuria is normal because of increased GFR delivering more glucose to kidneys!
- Ureters and renal pelvis may dilate a bit, R > L, because uterus and right ovarian vein compresses the right
ureter. Sigmoid colon provides some cushioning on the left.
- Urinary tract infections
- Always treat asymptomatic bacteriuria in pregnancy - will cause acute pyelonephritis in up to
25%. High risk of asymptomatic bacteruria in women with sickle cell trait.
- Screening urine culture at first visit and urinalysis at every prenatal visit
- If pyelonephritis:
- Most common cause of septic shock in pregnancy! E Coli is most common bug, same as
UTI.
- Treat with IV abx - cephalosporin or ampicillin and gentamicin. Transition to orals once
significantly better. Give prophy for the rest of pregnancy (e.g., nitrofurantoin). Otherwise ⅓
risk of return.
- If no improvement after 48-72 hours, suspect urinary tract obstruction (e.g., stone) or
perinephric abscess. Do ultrasound and/or CT.
- Risk of ARDS! Gram negative endotoxin (LPS) is released when bugs are killed by abx →
cause leaky capillaries and organ damage (bump in LFTs, Cr, uterine contractions). Treat
ARDS with oxygen, monitor fluid status, and supportive measures.

Thyroid
- TBG is increased in pregnancy b/c of increased estrogens → increased total T4 and total T3, while free T4
and free T3 stay normal.
- In a pregnant woman without iodine deficiency, thyroid gland can increase up to 10%

Molar pregnancy
- Vaginal bleeding, elevated HCG, uterus larger (or smaller!) than expected. Complete mole often presents with
preeclampsia and larger uterus, higher risk of GTD, hyperemesis gravidarum, theca lutein ovarian cysts
due to hyperstimulation from beta HCG, hyperthyroidism (HCG stimulates the maternal thyroid). Partial
often dx as missed or incomplete abortions, longer gestations, lower beta HCG
- Risk factors: Asian (1/800), > 2 previous miscarriages, diet low in folic acid or low in beta carotene, previous
molar pregnancy (1-2% after one, 10% after two).
- Etiology:
- Complete: either one sperm (XX) fertilizes an empty egg or two sperm (XY) fertilize an empty egg.
- Trophoblastic proliferation with hydropic degeneration.
- Partial: Two sperm fertilize an egg (XXX, XXY, XYY).
- Diagnosis: Suspect when HCG is way high, size is larger than dates. Confirm with ultrasound - should see
IUP if HCG is so high. Complete mole - snowstorm on ultrasoun, trophoblastic proliferation with hydropic
degeneration. Partial mole - lower beta HCG, marked villi swelling.
- Management:
- D&C, follow HCG to ensure they drop - if they don’t, do chemo (20% risk in complete mole, 5% in
partial). Very treatable with chemo, even if mets to the lungs.

2
 - Wait 6 months after HCG zeros before trying for pregnancy again - that could cloud the picture of
recurrence/progression of the mole.
- Do a chest xray - lungs are the most common site for mets. PET scan isn’t indicated.
- Methotrexate for post-molar GTD, but not as a sole mode of treatment
- If suspect choriocarcinoma - do not biopsy! Too vascular. Dx with beta HCG. Suspect in a woman
who has recently been pregnant or had a mole.

Preconception Care

Screening
- Sickle cell trait: Do hemoglobin electrophoresis and CBC. Hgb electrophoresis is better than sickle cell
preparation because can also see other Hgb-opathies like Hgb C trait and thalassemia minor. Peripheral
smear is not helpful in
- Thalassemia: Start with CBC, then do Hgb electrophoresis if there are abnormalities.
- Ashkenazi Jews; Increased risk for Fanconi anemia, tay sachs (1/30 are carriers vs. 1/300 non-AJs), CF,
Neimann-Pick disease, Canavan disease, Bloom syndrome, Gaucher’s disease (1/15 carriers)
- Cystic fibrosis: 1/25 non-hispanic whites are carriers
- Fragile X: Most common form of inherited mental retardation
- GBS: Treat with ampicillin during pregnancy if positive for GBS on urine culture or invasive early-onset GBS
in a prior child. Then IV penicillin during labor if GBS was previously positive (even if treated) or if
status is unknown and < 37 weeks gestation, intrapartum fever, or have rupture of membranes > 18
hours.

Maternal risk factors

- Pulmonary hypertension → 25-50% risk of death - decreased venous return and right ventricular filling.
- Marfan syndrome with aortic involvement - 25-50% risk of death
- Aortic coartation with valve involvement - 25-50% risk of death
- Factor V Leiden mutation: 5% of caucasian women - factor 5 is resistant to inactivation by protein C.
- One mutation → 5-10x increase for clots. Homozygous → 80x increased risk.
- Associated with stillbirth, IUGR, placental abruption, preeclampsia.

Viruses in pregnancy
- Hepatitis B: Check LFTs and serologies to determine chronic carrier vs. active hepatitis. Give baby HBIG and
Hep B vaccine.
- HPV/abnormal PAP
- ASC- US: re-Pap after delivery and no need for HPV testing. LGSIL or HSIL → colposcopy.
- Parvovirus B19 = Erythema Infectiosum = Fifth disease:
- In kids: slapped cheeks, high fever. In adults, myalgias, arthralgias, malaise, lacy reticular rash that
comes and goes. 5% chance of impacting fetus.
- Infects fetal bone marrow → aplastic anemia → Hydrops fetalis = excess fluid in two or more body
cavities
- Signs: polyhydramnios → uterine size > dates and fetal parts difficult to palpate. Do weekly
ultrasounds, and then intrauterine transfusion if needed.
- Diagnosis:
- Mom: Serology. IgG indicates past infection (positive after a few weeks) and immunity if IgM
is negative, IgM indicates new infection but can be a false positive or false negative (in first
20 days) → retest in 1-2 weeks and look for IgG and IgM.
- Fetus: Watch for sinusoidal pattern - associated with severe fetal anemia or asphyxia.
Watch for increased velocity in middle cerebral artery
- Other causes of fetal anemia: Rh- mom sensitived to D antigen, fetal to maternal hemorrhage,
thalassemia.

3
Diabetes in pregnancy
- Type 1
- Increased risk of intrauterine growth restriction → small babies. Or could have big babies.
- Increased risk of miscarriage and congenital anomalies - biggest risks are cardiovascular
malformations and NT defects. 20-25% if HgA1c > 10! Normal risk below 7. Also omphalocele,
duodenal atresia, polyhydramnios (polyuria), preeclampsia, etc. Folate is extremely important.
- Risks to mom: Acceleration of retinopathy, worsening of moderate to severe preexisting renal
damage (no worsening of mild disease)
- Gestational diabetes
- Not at increased risk for congenital anomalies or miscarriage because usual onset is 2nd or 3rd
trimester. Risk of preeclampsia, polyhydramnios, big babies, etc.
- Pregnancy causes insulin resistance! Increased GH, corticotropin releasing hormone, and human
placental lactogen, and progesterone → insulin resistance.
- Treat with diet, then with insulin (gold standard) or glyburide. Metformin hasn’t been tested.
- Managing prenatal diabetes
- Goals: Fasting < 95, 1 hr < 140 post meal and 2 hr post meal < 120
- If abnormal 1 hr 50 g GTT (> 130-140), follow up with 3 hr 100 g GTT (fasting < 95, 1 hr < 180-190, 2
hr < 155-165, 3 hr 140-145). If 2 abnormal values → begin diabetic diet and blood glucose
monitoring
- Glucosuria is not abnormal in pregnancy! Dx gestational diabetes with GTTs.
- Stop ACE inhibitors - teratogenic!
- DKA
- Biggest risk in 2nd and 3rd trimester. Have increased counter-regulatory hormones (esp human
placental lactogen), decreased bicarb → reduced buffering capacity, and increased tendency for
ketosis with increased lipolysis, FFAs, and ketones.
- Precipitated by vomiting, infection, steroids, med noncompliance
- Can happen with BG as low as 200 mg! Suspect if arterial pH is < 7.35.
- Must have high index of suspicion due to vague complaints that can seem like normal pregnancy.
- Decreased FHR variability and late decels = acidosis. Typically baby pH is 0.1 less than mom. Don’t
deliver unless abnormalities continue after DKA stabilization.
- Glycemic control is critical during labor and delivery: Target 80 to 110.
- Hypoglycemia, polycythemia, hyperBR, hypocalcemia, respiratory distress. Not thrombocytopenia.

Teratogenic exposure
- All or nothing effect in the first two weeks. Organogenesis between 15 and 60 days.

Teratogenic drug classification

- Category A: Good studies sowing no increased risk in pregnancy
- Category B: Animal studies show no harm, but no human studies. Or animal studies show adverse effects,
but good human studies show no risk
- Category C: Animal studies show harm, no good human studies, but potential benefits may outweigh risks
(eg. Zoloft).
- Category D: Human studies show risk
- Category X: Known fetal harm, should not use

Specific teratogens
- SSRIs: Okay to use during pregnancy and breastfeeding, but associated with persistent pulmonary
hypertension
- Paroxetine/Paxil: Cardiac defects

4
 - Valproic acid: NT defects, hydrocephalus, craniofacial malformations, hypospadius, limb defects (especially
radial aplasia)
- Warfarin: if need anticoagulation, do LMWH instead
- ACE inhibitors: oligohydramnios/lung hypoplasia, fetal growth retardation, fetal renal failure, hypotension,
joint contractures, death
- Tetracyclines
- Syphillis: Must use penicillin even if anaphylaxis - do desensitization. Give one dose if disease < 1
year, or 3 doses if > 1 year or unkonwn duration.
- Radiation: Biggest risk is 8-15 weeks. Doses < 50 rad show no affect < 8 weeks or > 25 weeks
- Cigarette smoking: Higher risk of placenta abruption, placenta previa, IUGR, preeclampsia, infection

Drugs that are fine

- Insulin, methyldopa
- Ibuprofen - safe until 32 weeks when risk of premature closure of ductus arteriosus
- Asthma meds - albuterol, corticosteroids, theophylline. Not zafirlukast - hasn’t been studied as much.
- Thyroid - propranolol, PTU
- Mental health
- Depression: SSRIs - except paxil. Wellbutrin
- Migraines:
- TCAs are fine
- Bupropion is fine

Vitamins
- Folic acid
- In general, 0.4 mg daily if non high risk
- Previous NT defect → 4 mg folate daily before conception and through first trimester. Reduces risk by
85%!

Ectopic pregnancy

Risk factors: Salpingitis - especially chlamydia, progesterone IUD, infertility, tubal anomalies or tubal surgery, ART or
ovulation induction

Symptoms:
- Amenorrhea for 4-6 weeks, sharp and tearing abdominal pain, irregular vaginal spotting, maybe adnexal
tenderness, maybe palpable adnexal mass (50%). Uterus can be normal in size or slightly enlarged.
- If ruptured:
- Acute worsening of abdominal pain - can be diffuse not just unilateral, peritoneal signs, cervical and
adnexal tenderness, and signs of hypovolemia - maybe syncope, tachycardia, hypotension,
orthostasis. May or may not have vaginal bleeding.
- Can do culdocentesis (spinal needle in posterior vaginal fornix) to look for hemoperitoneum

Differential: Acute salpignitis, abortion, ruptured corpus luteum, acute appendicitis, dysfunctional uterine bleeding,
adnexal torsion, degenerating lyomyomata, endometriosis

Diagnosis:
- Measure HCG:
- Threshold HCG level is 1500 for transvaginal ultrasound (best for looking for IU pregnancies) and
2000 for abdominal ultrasound
- If > 1500, try to see whether an IUI is present - if so, likelihood of ectopic AND intrauterine is 1 in
10,000. Follow with laparoscopy.
5
 - If HCG < 1500, and patient does not have severe abdominal pain, hypotension, or adnexal
tenderness/mass, then repeat HCG in 48 hours to distinguish missed abortion, early IU pregnancy,
and ectopic pregnancy. Should double every 48 hours, usually x3.
- If HCG increases by 50%, likely to be a normal pregnancy
- If less than 50% increase in first 8 weeks, pregnancy is abnormal - but could be in uterus or
in tube! Could also have miscarried.
- Ectopic pregnancy suggested if < 50% increase HCG in 48 hours or levels that don’t fall after
D&C
- Missed abortion - should be some tissue or fetal pole in uterus. Diagnose with ultrasound -
won’t see fetal heart beat
- Use progesterone to correlate
- If progesterone is greater than 25 ng/mL, pregnancy is likely normal. If less than 5
ng/mL, likely abnormal
- Ultrasound findings
- Fetal pole outside the uterus. Or no intrauterine pregnancy if above the HCG threshold.
- Large amount of intra-abdominal free fluid = blood suggests ectopic.

Treatment of ectopic pregnancy

- Surgery if unstable vitals or an acute abdomen, of if the pregnancy is not in the tube - cervical, ovarian, or
cornual (portion of tube that transverses the uterine muscle)
- Salpingectomy if too big for conservative therapy, rupture, or no desire to have kids
- Salpingostomy if unruptured, desire to preserve fertility. Just slice side of tube and remove
pregnancy. However 15% chance of persistent ectopic, so have to follow with serial HCGs
- Methotrexate - given one time, lose dose IM injection. Sometimes need a second dose if HCG does not fall
1. Mother is hemodynamically stable
2. Normal WBC
3. Ectopic is not ruptured
4. < 3.5 cm
5. HCG < 5000 mIU/mL
6. No fetal HR
7. Normal liver enzymes
8. Patient can follow up if her condition changes.
- With methotrexate, may have abdominal pain 3-7 days later, usually do to tubal abortion and less likely
rupture. But 10% can have signs of tubal rupture → surgery.

Other abnormal pregnancies:

- Progesterone < 25 and/or failure of beta HCG to double in 48 hours suggests abnormal pregnancy
- Yolk sac only, no fetal pole: Treat with D&C, expectant management, misoprostol (prostaglandin E1), or
manual vacuum aspiration.
- Note: mifepristone is a progestin receptor antagonist, can be used as emergency contraception or
combined with misoprostol for termination

Prenatal Care

Dating the pregnancy

- Do LMP, but if LMP and physical exam produce different EDDs (> 10 days), then do ultrasound between 14-
20 weeks. It’s the most accurate way to date - can give conception date +/- 3-5 days.

Multiple gestations
- Multiples generally
- Twins will have double AFP and uterine growth will be more than expected

6
 - Risks
- Twin infant death and cerebral palsy rates are 5x higher than singletons, more congenital
anomalies (often discordant), higher rates of IUGR, 58% premature with average gestation of
35 weeks. 12% very premature. Best is 37-38 weeks, after that mortality increases.
- Prematurity in 50% of twins, 90% of triplets, almost all quads. Prematurity → increased risk of
rDS, intracranial hemorrhage, CP, blindness, low birth weight
- Risk factors: Advancing maternal age, ART, more previous pregnancies and previous multiples,
dizygous - maternal FH, higher FSH, vary with ethnicity
- Identical twins
- Diamniotic dichorionic: division within 3 days of fertilization
- Diamniotic monochorionic: division 4-8 days after fertilzation
- Monoamniotic, monochorionic: division 8-12 days after fertilzation
- Division after 13 days → conjoined
- Fraternal: dividing membrane thickness > 2 mm, twin peak (lambda) sign, two placentas - anterior and
posterior placentas
- Superfecundation: fertilzation of two ova at two separate acts of intercourse in the same cycle
- Twin-to-twin transfusion syndrome
- Common in monochorionic, diamniotic pregnancy (split 4-8 days after fertilzation).
- Mortality of 70-100%. One baby big, risk of polycythemia, volume overlaod with polyhydramnios - can
cause cardiomegaly, tricuspid regurgitation, heart failure, and hydrops. Other baby small - anemic,
IUGR, oligohydramnios - can still develop hydrops fetalis because of anemia and high output heart
failure.
- Treatment: Laser ablation at selected centers, serial amniotic fluid reduction.
- Management
- Reducing preterm delivery:
- Early, adequate weight gain in first 20-24 weeks is the best intervention to reduce preterm
delivery! Since the pregnancy is likely to be shorter, early weight gain might help the placenta
to develop and give nutrients to baby.
- Prophy cerclage, home uterine monitoring, and bed rest do not reduce risk of prematurity
- Delivery: If first twin (Twin A) is breech, do c-section. If Twin B is breech, controversy about optimal
mode of delivery.

STDs
- Bacterial vaginosis: positive whiff test + clue cells. Treat patient w/ metronidazole as usual.

Disease screening tests

- Down syndrome: 1 in 800 births w/out prenatal intervention
- CVS: 10-12 weeks
- Loss of 1-3% (compared with 0.5% for amniocentesis). Assoc’ed with limb deformities if done before
10 weeks. More likely than amnio to require multiple attempts because of inadequate sample.
- Lab tests:
- First trimester combined screen at 10-3 weeks:
- Nuchal translucency, pregnancy associated plasma protein, beta HCG
- 85% detection with 5% false positive
- Abnormal pregnancy: decreased PAPP and decreased beta HCG, increased nuchal
translucency
- Note: HCG has two subunits, alpha and beta. The alpha subunit is shared with TSH, FSH,
and LH. The beta subunit is distinct to HCG.
- Second trimester Triple screen at 15-21 weeks: covers Down syndrome, NT defects, and trisomy
18. 69% detection rate for down
- AFP, beta HCG, estriol

7
 - AFP increased: AFP > 2 - 2.5x normal are suspicious for NT defects. AFP also elevated with
underestimation of dates, multiples, abdominal wall defects or skin defects, cystic hygroma,
decreased maternal weight, oligohydramnios
- AFP decreased: trisomies, moles, fetal death, increased maternal weight, overestimation of
maternal age.
- Second trimester Quad screen at 15-21:
- Triple Screen + Inhibin A - 81% detection of Down. MOST EFFECTIVE METHOD IN
SECOND TRIMESTER!
- cell free fetal DNA: 10-22 weeks
- Combined tests
- Sequential screen: First trimester combined screen + second trimester quad screen = 93% detection
of down’s - MOST ACCURATE METHOD!
- Serum integrated screen: If can’t due NT - just due first trimester PAPP-A and second trimester quad
screen - 85-88% detection rate
- Cases
- If abnormal NT but normal first trimester screen (PAPP, HCG) → do detailed ultrasound and
echocardiogram at 18-20 weeks

Condition PAPP-A Beta HCG AFP estradiol Inhibin A HCG Ultrasound

21 Decreased Increased Decreased Decreased Increased Increased Double
bubble
(duodenal
atresia)
18 Decreased Decreased Decreased Decreased -- Decreased
13 Decreased Decreased -- -- -- --

Examining baby
- Non Stress Test: First line, just watch baby’s heart rate for 20-40 minutes. Normal is at least 2 accelerations.
If abnormal, follow with biophysical profile or contraction stress test - they are equivalent.
- Contraction Stress Test: Induce contractions with nipple stimulation or IV oxytocin. Can be done as long as
there is no contraindication to labor. Abnormal if late decels after > 50% of contractions. If normal, unlikely to
have a problem in the next week. Repeat in one week.
- Biophysical profile: US that looks at fetal movement, tone, breathing, amniotic fluid volume, and FHR. If
normal, unlikely to have a problem in the next week. Repeat in a week.
- Modified biophysical profile: Looks at AFI only - can combine with nonstress test if baby has decreased
movement as reported by mom
- Umbilical artery flow velocimetry (Doppler): Only has a role with IUGR. Look at systolic/diastolic flow ratio.
Concerning if flow has stopped during diastole, really bad if flow has reversed during diastole - indicates high
vascular resistance.

Anemia: If Hgb < 10.5 in pregnancy. Mild if 8-10, severe if < 7.

- Can do trial of iron and recheck in 3 weeks unless risk factors for thalassemia (E.g, south asian)
- Suspect B thalassemia trait if hemoglobin A2 (alpha2 delta 2) levels are elevated. Deficient beta chain.
Usually safe in pregnancy.
- Refer for genetic testing because baby has ¼ chance of beta thalassemia if father also has it. Will
seem healthy at birth, but symptoms as Hemoglobin F falls away (alpha2, gamma2). Life expectancy
in the 20s with transfusions.
- Give folic acid, do not give iron.
- Alpha thalassemia: Elevated hemoglobin F
- Sickle cell: Pregnant with sickle cell means more intense anemia, more frequent bouts of sickle cell crisis, and
more frequent infections and respiratory complications.

8
 - But all cases of fever, pain, and low Hgb should be ruled out before concluding that a sickle ell crisis
is going on!
- HELLP syndrome = hemolysis, elevated liver enzymes, low platelets
- treat with delivery! Can be life threatening

Managing mother’s heath conditions

- Mitral valve prolapse: If symptomatic (CP, syncope, anxiety, palpitations), treat with beta blocker to decrease
symptoms and reduce risk of life threatening arrhythmias.
- Pyelonephritis: Give IV hydration and antibiotics. If no improvement by 72 hours, then further evaluation to
look for obstruction or stones. Relieve obstruction with double J ureteral stent unless long term stenting is
needed - then percutaneous nephrostomy
- Lupus: NSAIDs for arthralgia and serositis. Severe disease - steroids. Hydroxychloroquine for skin
manifestations.
- Breast cancer:
- Do chemo, but don’t do adjunctive radiation as we would for non-pregnant patients.
- Appendicitis: Pregnancy shifts the appendix up and to the flank. Do graded compression ultrasound

Thyroid disease
- Normally in pregnancy, estrogen increases thyroid binding globulin --> total thyroxine increases while free T4
and TSH stay the same.
- Hyperthyroidism:
- Most often Graves disease, however in the postpartum period, more likely to be lymphocytic
thyroiditis (positive for anti-microsomal and antiperoxidase antibodies). High corticosteroid levels in
pregnancy suppress the autoimmune antibodies, and a flare happens postpartum when the levels
drop.
- Can cause fetal hyper or hypothyroidism! If hyper → treated with mom’s PTU. If hypo → inject intra-
amniotic thyroxine! Otherwise risk of nonimmune hydrops fetalis.
- Avoid methimazole - risk of aplasia cutis (skin/scalp defects)
- Thyroid storm: Treat with PTU, corticosteroids, beta blocker (e.g., propranolol). If not pregnant or pregnant
and really sick, can give potassium iodide (NOT radioactive iodine), but this can affect fetal thyroid.
- Thyroid storm can cause CHF due to effects on mycardium! If so, use beta blockers with caution. Use
acetaminophen or cooling blankets for high temps.

Hyperandrogenism in pregnancy
- Pregnancy luteomas and theca luteum cysts are the most common causes!
- Luteomas:
- Yellow or yellow-brown masses, often with areas of hemorrhage. Soild, 50% bilateral. High risk of
virilization of female infants, but no treatment during pregnancy - just monitor for mass effects. They
are benign and regress after delivery. Esp common with African Americans.
- Theca Luteum Cyst
- Bilateral ovarian cysts (not solid), associated with multiple pregnancy and moles because they grown
in response to beta HCG. Low risk of virilization of the female fetus. Regress after delivery
- Krukenberg tumors: Bilateral solid ovarian masses that are mets from primary GI tract cancer. Can cause
androgenism of mom and high risk of virilization of female fetus.

Dehydration:
- Tachycardia and ketonuria

Decreased fetal movements

9
 - Do rective non-stress test and amniotic fluid index (AFI = modified biophysical profile) - if reassuring, can
discharge patient home with labor warnings

Miscarriage
- Terminology
- Threatened abortion: Vaginal bleeding < 20 weeks without passage of products. Could be viable
IUP (50%), nonviable IUP (35%), or ectopic (15%). Do ultrasound one week later.
- Inevitable abortion: less than 20 weeks, cramping, bleeding, cervix is dilated.
- Incomplete:less than 20 weeks, cramping, bleeding, open os, some passed tissue and some
retained. Cervix stays open because of continued uterine contractions - trying to expel the retained
tissue
- Distinguish between incompetent cervix, which will open in 2nd trimester without uterine
contractions → do cerclage to reinforce
- Missed abortion: Fetal demise without cervical dilation, bleeding, cramping or passage of products -
basically asymptomatic.
- Recurrent abortion: Three successive spontaneous abortions
- Completed SAB: Cervix closed, follow hCG to zero
- Psychological response: Denial → anger → bargaining → depression → acceptance
- 1st trimester Causes
- Majority of 1st trimester abortions: caused by chromosomal abnormalities - most often autosomal
trisomy (40-50%), triploidy is the next most common.
- Systemic diseases also associated with miscarriage:
- DM - connected to rate of control,
- Chronic renal disease,
- Lupus - if three miscarriages, test for lupus anticoagulant. Treat with aspirin and heparin
- Smoking, alcohol, radiation
- Infections - listeria, mycoplasma, ureaplasma, toxo, syphilis
- Advancing maternal and paternal age, advancing parity
- 2nd trimester causes
- Usually NOT related to genetic abnormalities. Likely causes include uncontrolled diabetes.
- Maternal hypothyroidism is usually associated with menstrual irregularities and infertility, but
less likely a cause of miscarriage
- Incompetent cervix
- Painless cervical dilation → pelvic pressure, bulging membranes, fetal loss
- Can be caused by cone biopsy
- Treatment
- Place a cervical cerclage at 14 weeks
- Some clinicians use prophy progesterone to prevent recurrent abortion or preterm
labor, but no controlled trials support the use for cervical incompetence
- Diagnosis
- Spalding’s sign: overlapping of fetal skull bones suggesting demise
- Management of missed, incomplete, or inevitable abortion: Depends on hemodynamic stability!
- Check blood type and give rhogam
- If hemodynamically stable and reliable for follow up, can do expectant management or medical
management.
- But if dead fetus is in utero for 3-4 weeks, fibrinogen levels can decrease →
coagulopathy. Can manifest as nosebleeds. Be concerned about fibrinogen and platelets in
the low-normal range because that can indicate developing DIC! Do induction of labor.
- Can delay induction in twin pregnancy to enable the twin to mature, but monitor fibrinogen
weekly or biweekly
- Medical management: Mifepristone and misoprostol

10
 - If patient is actively bleeding and anemic → D&C
- Can perforate the uterus - if see fatty tissue, do laparoscopy. If see bowel, do laparotomy
- Management of a complete abortion
- Follow serum HCG to ensure that it returns to zero
- Management of septic abortion: Treat as septic if the patient has a fever!
- Blood and endometrial cultures
- Broad spectrum antibiotics
- Surgical evacuation of uterine contents

Bleeding at any point in pregnancy

- Cervicitis: gonorrhea, chlamydia, trichomonas
- Cervical cancer:

Bleeding in 1st trimester of pregnancy

- First trimester 20-40% pregnancies
- Etiologies
- Ectopic pregnancy - can be life threatening!
- Symptoms: Abdominal pain, amenorrhea 4-6 weeks, irregular vaginal spotting (bleeding can
be heavy or light)
- Risk factors: progesterone IUD, previous ectopic pregnancy, infertility, salpingitis (esp
chlamydia), congenital abnormalities of the tubes, ART and ovulation induction,
- Internal os closed
- Miscarriage - threatened, inevitable, complete, incomplete. Most common cause (15-20% of
pregnancies)
- More likely to have heavy bleeding
- Os can be open or closed
- Pregnancy implantation
- Cervical, vaginal, or uterine pathology - polyps, inflammation/infection, trophoblastic disease
- Diagnosis
- If heavy bleeding - more likely to be ectopic or miscarriage

Third trimester bleeding

- Causes:
- Placental abruption
- Symptoms: crampy midline abdominal pain, bleeding, uterine hypertonicity, maybe fetal
distress, often have hypertension
- Risk factors:
- HTN, preeclampsia,
- Smoking, cocaine (maternal HTN and vasoconstriction),
- Trauma
- Prolonged rupture of membranes, premature rupture of membranes
- Hx of prior abruption
- Uterine fibroids - especially submucosal
- Polyhydramnios
- Short umbilical cord
- Dx:
- Vaginal bleeding, tachysystole on tocometer (intense contractions every 1-2 mins)
and evidence of fetal anemia (tachycardia, sinusoidal HR)
- Ultrasound is not a good way to diagnose - fresh blood behind placenta has the
same echotexture as the placenta itself

11
 - Can have concealed abruption: Bleeding is contained behind the placenta, no
vaginal bleeding!
- Risks: Bleeding out, DIC/coagulopathy (a big risk! happens in ⅓ of cases severe enough to
cause fetal death), fetomaternal hemorrhage (test with Kleihauer Betke) hysterectomy, fetal
neuro injury or death, higher risk of uterine atony and PPH
- Management: Depends on the fetal age, hemodynamic status, and maternal hemodynamics
- Delivery is the usual choice - can do vaginal delivery if patient is stable with no active
bleeding or signs of fetal compromise. If fetus has died and/or there is coagulopathy,
vaginal is safest for mom. But may need emergency c-section sometimes, too.
- Blood products and IV fluids to maintain Hct 25 to 30%
- Will often have HTN or preeclampsia with volume replacement - may need to start
Mg sulfate for preeclampsia prophylaxis
- Kleihauer Betke to assess for fetomaternal hemorrhage (different solubilities of
maternal/fetal Hgb)
- Future pregnancies following abruption w/ loss: Consider induction of labor slightly before the
time of abruption w/ loss to avoid repeat abruption
- Placenta previa -
- Symptoms: Painless bleeding after the mid-second trimester. Often without warning, but may
have history of bleeding, e.g., during intercourse.
- Diagnosis: Do an ultrasound even before any type of vaginal exam, because that can cause
bleeding.
- Management:
- Usually the first episode doesn’t necessitate delivery. But second or third may force
delivery. So do expectant management as long as the bleeding is not excessive.
Then do cesarean at 34 weeks.
- If repeated episodes of bleeding, move towards c-section - catastrophic bleeding can
occur as cervix dilates if vaginal delivery is pursued - don’t induce labor!
- Might actually resolve if diagnosed early! E.g., if diagnosed in second trimester, do
repeat ultrasound in third trimester (32 weeks) to assess whether c-section is
necessary
- Bloody show: cervix is very vascular, with dilation a small amount of bleeding can occur. Can
distinguish from other bleeding because it will be mixed with mucous.
- Dx: Do an ultrasound! Avoid digital cervical exam before checking for abnormal placenta - risk of
hemorrhage.

Rh sensitization
- Mechanism:
- Mom develops anti-D antibodies - can affect subsequent pregnancies.
- If Rh-neg mother delivers a baby without rhogam, risk of isoimmunization is less than 20%! 2% risk
with SAB and 5% with elective termination.
- Rhogam only protects against D-antigen. Can still become sensitized to other RBC antigens
- Rhogam dosing:
- Give at 28 weeks after testing for sensitization with indirect Coombs test and again w/in 72 hours of
delivery. Also w/in 72 hours after amniocentesis, CV sampling, or any bleeding.
- Standard dose of 300 micrograms of drug will neutralize 30 cc of fetal blood (15 cc of fetal RBCs).
- Can also determine precise dose by measuring incidence and size of fetal transplacental hemorrhage
- Kleihauer Betke test stains a sample of maternal blood, the mother’s RBCs go pale while fetal
RBCs stain because of fetal Hgb
- Risks:
- Fetal anemia - test with doppler ultrasound and middle cerebral artery peak systolic velocity. Can
also get this info from invasive testing - amniocentesis or cordocentesis.

12
 - Can also look for bilirubin in amniotic fluid as a way to assess the severity of hemolysis.
Do spectrophotometric measurements of the optical density between 420 and 460 nm -
deviation from 450 due to heme pigment.
- Fetal hydrops: Volume overload from decreased hepatic protein production → collection of fluid in 2
or more body cavities - ascites, pericardial and/or pleural fluid, scalp edema. Also placentomegaly
(edema) and polyhydramnios.
- Treatment:
- Severe disease → fetal blood transfusion! Best to do into the umbilical vein, but can also due
intraperitoneal transfusion when IV transfusion is impossible, but slower correction of anemia.
- Maternal plasmapheresis if blood transfusion not possible

Other isoimmunizations:
- Lewis lives (IgM, does not cross placenta), Kell kills, and Duffy (Rh) dies. In general, no great risk unless titer
is greater than 1:8.

Hyperemesis gravidarum
- Severe, persistent nausea and vomiting with > 5% weight loss of prepregnancy weight.
- Higher risk with anything that increases placental size, because of increased beta HCG - multiples, molar
pregnancy. Do a pelvic ultrasound.
- Management: orthostatic vital signs, serum electrolytes, BUN, creatinine, thyroid function testing, urinalysis
- Treat with ginger, vitamin B6, supportive care.

Preeclampsia
- Patients are usually unaware of HTN and proteinuria. Usually only aware of HA, RUQ or epigastric pain,
vision changes, weight changes = edema
- Etiology:
- Vasospasm and leaky blood vessels → serum leaks out → local hypoxemia → hemolysis, necrosis,
end-organ damage
- Early onset is likely related to placental factors, later onset is related to constitutional factors like
obesity - later onset has a better course.
- Risk factors: previous hx, chronic HTN, multifetal pregnancy, first pregnancy, very young or age > 40
- Complications:
- Placental abruption, eclampsia w/ possible intracerebral hemorrhage, coagulopathies, renal failure,
hepatic subcapsular hematoma, hepatic rupture, uteroplacental insufficiency, microangiopathic
anemia
- Hepatic rupture: Sudden, severe abdominal pain, abdominal distension, syncope, hypotension, and
tachycardia.
- Diagnostic categories of HTN:
- Prehypertension: 120-139/80-89
- Chronic hypertension: BP 140/90 or greater before pregnancy or before 20 weeks gestation
- Gestational Hypertension: BP > 140/90 that develops after 20 weeks
- Preeclampsia: HTN after 20 weeks with proteinuria - PC ratio > 0.3 or > 300 mg/24 hrs. Usually also
have nondependent edema (face, hands), but that’s not a requirement.
- Mild, severe, or super imposed (increased BP or new onset proteinuria with chronic HTN)
- Severe preeclampsia: SBP > 160 OR DBP > 110, OR proteinuria > 5 g OR features of end organ
damage other than just proteinuria. Can estimate proteinuria with a dipstick - 3+ to 4+ is consistent
with severe disease, 1+ to 2+ is consistent with mild disease. Suspect if HA, RUQ or epigastric pain,
vision changes, etc.
- Thrombocytopenia (< 100k)
- Liver enzymes at least twice normal
- New renal insufficiency (creatinine > 1.1 or doubling in the absence of other renal disease)

13
 - Pulmonary edema
- New onset cerebral or visual disturbances - including severe headache
- Preeclampsia labs/studies:
- Measure BP twice, 6 hours apart.
- CBCP (check hemoconcentration and platelets), urinalysis and 24 hour urine protein collection
(proteinuria), LFTs, LDH (hemolysis), uric acid (usually increased with preeclampsia).
- Biophysical profile for baby (uteroplacental insufficiency)
- Prevention: Low dose aspirin may decrease risk of preeclampsia in high risk patients. Won’t help low risk
patients
- Treatment:
- Preterm < 37 weeks: Observation until severe criteria are noted or a term gestation is reached.
- Delivery is not based on the degree of proteinuria - even > 5g in 24 hours can be watched.
Oliguria is the renal threshold for delivery..
- Must deliver if oliguria, other signs of severe preeclampsia (pulmonary edema, platelets
< 100k, LFTs doubled, severe HA or visual disturbances), unable to control BP with 2 max
doses of anti HTN meds.
- Can manage severe BP as noted below.
- Term: Magnesium sulfate and delivery.
- Biggest risk for ecclampsia is just before delivery, during labor, and 24 hours after. Give Mg
sulfate during labor and 24 hour pospartum to lower seizure threshold. Therapeutic range
is 4-7 mEq/L.
- 8 → CNS depression, 10 → lose DTRs, 15 → respiratory depression/paralysis, 17 →
coma, 15+ → cardiac arrest
- If given Mg, risk of respiratory distress to baby
- Renally excreted - monitor urine output. Also watch for respiratory depression,
dyspnea (can cause pulmonary edema). First sign of toxicity is loss of DTRs.
- Blood pressure management: Helpful for severe BP in preeclampsia and for chronic HTN. But it is not
useful for mild HTN in preeclampsia. Magnesium won’t help with HTN - have to treat severe HTN with
antihypertensive meds.
- Hydralazine is often the HTN drug of choice in the acute setting. Can also use labetalol.
- Aim for < 160 systolic and 105 diastolic. Goal is to reduce BP to a safe range (prevent
maternal stroke, abruption) without compromising uterine perfusion.
- Follow up:
- Follow up in 1-2 weeks to check blood pressures and proteinuria.

Eclampsia
- Patient with preeclampsia has convulsions or seizures, but can happen without high BP or proteinuria!
- Biggest risk is just before delivery, during labor, or within 24 hours after.
- Management: Treat with magnesium sulfate. Second line = valium, hydantoin, tiagabine, and barbituates.
Can be added as second agents.

HELLP syndrome:Hemolysis, elevated liver enzymes (up to 1000), platelets < 100k.. Can cause swelling of liver
capsule and liver rupture!
Possible to only have elevated LFTs and low platelets, without hemolysis!

Differential diagnosis of abnormal LFTs in pregnancy

- Acute Fatty Liver of Pregnancy: Nausea, vomiting, jaundice, hypoglycemia (unique to AFLP, can’t break
down glycogen), coagulopathy, acute liver failure, acute renal failure. Less likely to have hypertension than
HELLP/ Maybe due to mito dysfunction in oxidizing FA’s. Treat with delivery!
- Preeclampsia: LFTs 100-300 range, HTN, proteinuria
- HELLP: Elevated liver enzymes up to 1000, platelets < 100k

14
 - Idiopathic cholestasis of pregnancy: Generalized itching, LFTs may be normal to > 1000, elevated bile
acids
- Treat with antihistamines, ursodeoxycholic acid, cholestyramine (binds bile acids)
- Assoc’ed with increased risk of prematurity, fetal distress, and fetal loss, especially when
accompanied by jaundice or markedly elevated bile acids.
- Also increased risk of gallstones

Itching in pregnancy
- Idiopathic cholestasis of pregnancy: see above
- Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP): Erythematous papules and hives
beginning on the abdomen and spreading to buttocks, surrounded by a narrow pale halo. More common in
first pregnancy, third trimester. Etiology is unknown. Have lymphocytic and histiocytic infiltration of epidermis
with edema. No adverse effects on baby (the little puppp is fine!). Treat with topical steroids and
antihistamines.
- Herpes gestationis: erythematous blisters on extremities > abdomen with intense itching. Not HSV - it’s
thought to be autoimmune with IgG to basement membrane. Do immunoflorescent staining of bx. Increased
fetal growth retardation and still birth, baby can get it transiently too. Tx with oral steroids.

Placental abnormalities
- Placental abruption
- Symptoms: crampy midline abdominal pain, bleeding, uterine hypertonicity, maybe fetal distress,
often have hypertension
- Risk factors: HTN, preeclampsia, smoking, cocaine, trauma, prolonged rupture of membranes, hx of
prior abruption, polyhydramnios
- Dx: vaginal bleeding, tachysystole on tocometer (intense contractions every 1-2 mins) and
evidence of fetal anemia (tachycardia, sinusoidal HR)
- Risks: Bleeding out, DIC, hysterectomy, fetal neuro injury or death
- Treatment: Emergency c-section with fluids and blood products
- Placenta previa
- Placenta in an abnormal spot
- Double set up team with c-section team ready to go
- Placenta accreta
- Placenta grows into the myometrium. Risk factors = previous Cesarian deliveries - 50% risk with four
previous C-sections, low anterior placenta.
- Vasa previa:
- Umbilical cord vessels grow into membranes with the vessels overlying the internal cervical os, and
therefore are vulnerable to fetal exsanguination upon rupture of membranes.
- Symptoms: rapid deterioration of the fetus, but maternal vital signs should be okay
- Risk factors: bilobed placenta, low lying placenta, multifetal pregnancy, IVF
- Diagnosis: If women have these risk factors or suggestive US findings, do a color Doppler US → plan
for cesarean between 35 and 36 weeks. Don’t want rupture of membranes!
- Management
- If discovered during pregnancy, do a planned cesarean between 35 and 36 weeks
- If suspected during labor, avoid digital vaginal exam! Do an Apt test to distinguish fetal
blood from maternal blood. If mom is Rh-, also do Kleihauer-Betke test and rosette test to
determine the amount of fetal blood in maternal blood stream.

Maternal sepsis
- Most often caused by acute pyelonephritis

Syncope in Pregnancy

15
Differential:
Syncope, seizure, hypoglycemia, cardiac arythmia, hypovolemic shock, stroke, septic shock, adrenal insufficiency,
intoxication, domestic violence, PE, brain tumor

Preterm Labor

Term staging
- Early term: 37, 38
- Full term: 39, 40
- Late term: 41
- Post term: 42

Preterm complications
- Pulmonary hypoplasia: Risk if delivered < 25 weeks
- Don’t do an elective c-section or elective induction before 39 weeks - higher risk of complications! Only do if
medically indicated

Braxton-Hicks contractions
- Short, less intense than true labor, discomfort is in lower abdomen and groin.
- True labor = strong, regular uterine contractions → progressive cervical dilation and effacement

Preterm labor generally:

- Contractions with cervical change (in a nulliparous patient, at least 2 cm dilated and 80% effaced) between 20
weeks and before 37 completed weeks.
- Preterm contractions (without cervical change)
- 50% resolve spontaneously - can do expectant management. Usually felt in the lower
abdomen, as opposed to true labor which is more in the back and the upper abdomen.
Usually relieved by sedation, unlike true labor. Also interval does not shorten and they do not
increase in intensity.
- If dehydrated - PO fluids or IV hydration
- Most often idiopathic.
- Risk factors = dehydration, uterine distortion (fibroids, structural malformations), cervical incompetence
(usually dx early in the second trimester), hx of cervical cone biopsy, intra-amniotic infection, multiple
gestations, cocaine, African American, Abdominal trauma, pyelonephritis, abdominal surgery during
pregnancy
- 17-alphahydroxyprogesterone reduces risk of preterm labor. Give weekly injections from 16 to 36
weeks. Bedrest is not helpful.
- Preterm labor diagnosis
- Fibronectin at 24-35 weeks: ECM protein that adheres fetal membranes and uterine decidua. It’s
normally present in the first half of pregnancy. But abnormal later! Thought to indicate disrupture of
the mom-baby interface.
- Use to screen for preterm labor 24-35 weeks - if symptomatic, NPV of 99%, 99/100 will not
deliver in next 2 weeks. PPV in sympptomatic is 17%.
- Use for aysmptomatic screening 22-30 weeks. NPV of 97%.
- Transvaginal cervical length ultrasound measurements: Short cervix with lower uterine segment
change is worrisome.
- Work up
- Hx of risk factors, speculum exam for ruptured membranes, serial digital cervical exams, CBC, urine
drug screen (esp cocaine), urinalysis/culture/sensitivities, cervical tests for G&C (gonorrhea is an
16
 especially serious risk factor), GBS culture, ultrasound for fetal weight and presentation, BV (but
treatment doesn’t seem to affect risk)
- Preterm labor management
- Tocolysis - only before 36 weeks! Indomethacin, nifedipine, terbutaline, ritodrine.
- Terbutaline:
- Often the 1st line drug.
- Beta 2 agonist, works by increasing cAMP in cells → decreased free calcium..
- Side effects: tachycardia, hypotension, anxiety, chest tightening/pain
- Avoid with cardiac arrhythmias or diabetes, can’t use for longer than 48 hours
- Rotadrine: Not in diabetes
- Nifedipine: One of the most common ones. CCBs work by preventing calcium entry into
muscle cells. CI in cardiac disease, don’t use with Mg sulfate. Risk of pulmonary edema.
- Indomethacin: Prostaglandin synthetase inhibitor - blocks conversion of arachadonic acid to
PG. Avoid in late pregnancy (> 33 weeks, ductus arteriosus), avoid with liver or renal disease
- Mg sulfate: Works by competing with calcium for entry into cells. Not effective. Avoid in
myasthenia gravis!
- Lungs: Lung development determines whether risks of continuing pregnancy outweigh benefits of
prolonging
- Fetal lungs mature at 34 weeks or if presence of phosphatidylglycerol in vaginal fluid.
- Betamethasone if at risk of delivering preterm - not after 32 weeks!
- Increases lung development, reduces risk of intracerebral hemorrhage and necrotizing
enterocolitis. Does not cause increased growth or increase risk of infection.
- Neuroprotection for baby: Magnesium sulfate
- If intra-amniotic fever (fever, elevated WBCs, tender fundus) → deliver baby! Can induce labor
- Note: no role for progesterone in managing preterm labor - only used 16-36 weeks for prophy with
singleton pregnancy and history of preterm birth or short cervical length on ultrasound < 24 weeks

Premature rupture of membranes: Rupture of membranes before labor. Preterm premature rupture of membranes is
rupture < 37 weeks before onset of labor. Latency period is the time between rupture of membranes to onset of labor.
- At 28-34 weeks, 50% will go into labor within 24 hours and 80% within 2 days. At term, 90% go into labor
within 1 day of rupture of membranes.
- Risk factors:
- Genital tract infection, especially bacterial vaginosis, are the biggest risk factor.
- Also smoking, shortened cervical length
- Risk of recurrence is 32%
- Bed rest and tocolytics do not reduce risk of PROM, use cerclage only if incompetent cervix. 17-
alphahydroxyprogesterone DOES reduce risk of preterm labor.
- Dx: Examine vaginal fluid (NOT cervical mucous) for ferning, nitrazine test, ROM plus. Maternal urine is
also nitrazine positive. Avoid digital examination of cervix.
- Treatment
- Antibiotics! (maybe ampicllin and gentamycin) They are the best med to delay labor - can prolong
latency by 5-7 days and reduce maternal amnionitis and neonatal sepsis. Tocolytics and
betamethasone can also prolong pregnancy, but not for 7 days.
- Tocolysis to prolong interval for delivery and enable steroids to work. Don’t continue tocolytics
beyond 48 hours - risk of chorioamnionitis. Avoid if signs of infection or advanced preterm labor.
- Steroids (betamethasone) to minimize pulmonary hypoplasia.
- Give < 32 weeks with ruptured membranes - but avoid if chorioamnionitis (earliest sign is fetal
tachycardia).
- Give up to 34 weeks if membranes are not ruptured!
- Delivery if > 34-35 weeks or when there is evidence of fetal lung maturity (phosphatidyl glycerol
in the vaginal pool of amniotic fluid, lecithin/sphingomyelin ratio > 2)

17
Intraamniotic infection
- Suspect if fetal tachycardia. Most accurate method to confirm is with amniocentesis and gram stain
- Listeria can cause intraamniotic infection without rupture of membranes via transplacental spread! Suspect if
hx of unpasteurized milk products.

Fetal growth restriction

IUGR is growth < 10%. (macrosomia is > 90%). If < 3 or 5%, likely to be a true problem. Otherwise might just be a
constitutionally small baby. Diagnose based on ultrasound, not based on fundal height which can be unreliable.
1. Assymetric: Head and length are normal, abdomen is small. Usually uteroplacental insufficiency (hypoxia,
insufficient nutrition).
2. Symmetric: Intrinsic growth failure or an early event secondary to organ problems, fetal aneuploidy, or
severe or early intrauterine infection (rubella, CMV, syphylis, varicella, toxo). No bacteria cause IUGR!

Risks:
- Early: meconium aspiration, necrotizing enterocolitis, hypoglycemia, respiratory distress, hypothermia, and
thrombocytopenia
- Late: CV disease, COPD, diabetes, HTN - basically divert energy to the brain at the expense of these organs.

Management: Twice weekly AFI and NSTs, weekly systolic/diastolic ratios

- Assess AFI: Likely to have oligohydramnios due to reduced fetal blood volume, renal blood flow, and urinary
output - chronic hypoxia → diversion of blood from kidneys to other organs.
- 90% of oligohydramnios pregnancies = growth restricted
- 8-18 AFI is normal. 5-6 is oligohydramnios, > 20 is polyhydramnios.
- Systolic/diastolic ratio of the umbilical artery: Increase reflects increasing vascular resistance, common
with IUGR. Severe resistance → reverses end diastolic flow! Bad news. But normal flow is very reassuring.
- Non stress test, contraction stress test, biophysical profile.

Delivery
- > 37 weeks: just deliver
- 32-36 weeks: deliver if no growth over 2-4 weeks, non-reassuring fetal testing, absent or reversed end-
diastolic flow.
- < 32 weeks: Reverse end diastolic flow (absent is okay!), persistent non-reassuring fetal testing
- Give steroids < 34 weeks!
- Examples:
- If decreased fetal movement with size less than dates (20%) but no IUGR and normal NST, then just
continue with weekly NSTs
- Deliver IUGR babies at term if NSTs and AFI are reassuring. Induce babies with IUGR at 36 weeks
with oligohydramnios and abnormal umbilical artery studies.

Post Term Pregnancies

41 weeks is late term, 42 weeks is post term.

- Risk factors: placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, inaccurate/unknown
dates, and extrauterine pregnancy
- Risks: Macrosomnia, oligohydramnios, meconium aspiration, uteroplacental insufficiency and dysmaturity.
- Dysmaturity = withered, meconium stained, long nails, fragile, and small placenta. Great risk for still
birth
- Management

18
 - Controversy! Inducing labor reduces risk of fetal death, but increases risk of c-section if cervix is not
favorable.
- At 41 weeks: If cervix is not favorable, can follow with regular NSTs and AFIs. Risk of fetal death is 1-
2/1000. If cervix IS favorable, then induce with prostaglandin E1 (misoprostol)
- At 42 weeks: Induce.

Intrapartum Care

Labor warnings
- Contractions every 5 mins for 1 hr, rupture of membrane, fetal movement less than 10 in 2 hrs, vaginal
bleeding

What to do when a woman presents in labor:

- Review records, focusing on any complications and dating criteria
- Targeted physical exam: material vital signs, fetal HR, abdominal, pelvic. Does not routinely include prenatal
ultrasound
- If patient thinks she has ruptured membranes or is uncertain → speculum exam with nitrazine

Normal labor has 4 Stages

- Stage 1: Onset of labor to full cervical dilation
- Latent phase: Cervix < 4 cm-6cm
- 18-20 hours if nulliparous, 14 hours if multiparous
- If longer → prolonged latent phase. Can observe or do oxytocin if indicated
- Active phase: period of rapid cervical dilation, 1-2 cm per hour, generally reached when the cervix >
4-6 cm
- Cervix should dilate > 1.2 cm/hr for nulliparous, 1.5 cm/hr for multiparous
- If slow → protracted active phase. Assess 3Ps, observe vs. oxytocin. Only do c-section if
cephalopelvic disproportion
- If no change for 2 hours with adequate contractions → arrest of active phase. Assess
3Ps. If adequate contractions → c-section. Otherwise oxytocin and reassess.
- Adequate contractions: Every 2-3 mins, for 40-60 seconds. Or can add up the mm Hg
above baseline (Montevideo unit) for each contraction for 10 minutes. Want to see at
least 200 Montevideo units in 10 minutes.
- Stage 2: Full dilation to delivery of baby
- Stage 3: Delivery of baby to delivery of placenta
- Stage 4: Delivery of placenta to two hours later

Phases of labor
- Latent phase: Cervix < 4 cm..
- Arrest of labor:
- Prolonged latent phase: Prolonged if > 20 hours for first baby, > 14 hours for multipara.
- Treat with rest or augmenting labor. Do not rupture membranes
- Secondary arrest of labor: Active phase of labor, but no cervical change for > 4hours.
- Treat with amniotomy, if no change, then give oxytocin
- No indication for forceps if fetal stage is +1

Induction of labor
- Closed cervix:
- Give cytotec = misoprostol = prostaglandin E1 prior to pitcocin. Risk of uterine hyperstimulation
with prostaglandin cervical ripening agents (esp misoprostol) → fetal bradycardia.
- Foley bulb is preferred over prostaglandins when previous c-section due to risk of cervical rupture.
19
 - Can’t do foley or rupture of membranes

Augmentation of labor
- Give to a woman in labor if her contractions start to become further apart after rupture of membranes.

Fetal heart rate monitoring - interpretation

● Baseline: Normal is 110-160.
○ Fetal tachycardia is > 160 - can be sign of distress or infection - often with maternal fever or
chorioamnionitis.
○ Bradycardia: Prolonged bradycardia may be from uterine hyperstimulation
● Variability: Fluctuations in the baseline that are irregular in aplitude and frequency. Measure from peak to
trough. Maternal drugs can cause loss of variability.
○ 0-5 above baseline: minimal
○ 6-25 above baseline: moderate
○ > 25 is marked
● Acceleration: abrupt increase in FHR above baseline - at least 15 bpm for at least 15 seconds
○ Normal reactivity is at least 2 15 x15 accels within 20 mins > 32 weeks, or 10 x 10 <.32 weeks
● Deceleration
○ Early - Symmetric SLOW fall and rise in HR, decrease starts with onset of the contraction. Caused by
head compression, not ominous.
○ Late decel: Begin after the peak of the contraction, returns to baseline only after the contraction has
resolved. Uterine placental insufficiency - often chronic HTN or postdate pregnancies. Can be
worrisome - move towards c-section if t hey don’t resolve
■ Management:
● Change mom’s position to left lateral to increase perfusion to the uterus, give mom
oxygen and treat hypotension, discontinue oxytocin, consider tocolytics and
intraveous fluids, access fetal acid-base status with scalp capillary bloodgas.
● Improve uteroplacental perfusion before c-section!
○ Variable decels: Can be whenever. Usually abrupt fall and rapid stop. Will give the baby fluid or
reposition baby - typically caused by cord compression. Increased risk w/ oligohydramnios.
■ Management: Amnioinfusion!
○ VEAL CHOP: variable compression, early head, a nothing, late placenta
● Sinusoidal: Regular, smooth, undulating form with 2-5 cycles/min, 120-160 bpm, no baseline variability
● Fetal heart tones are described in three categories:
○ category 1 is not worried: HR 110-160, moderate variability, maybe accels, maybe early decels, no
late or variable decels
○ 2 is a little worried:
○ 3 is worrisome: Sinusoidal

Fetal HR monitoring - procedure

- Types of tests
- Nonstress test: Looks at FHR in response to fetal movement - normal reactiveness is at least 2
15x15 accels in 20 minutes (two in twenty)
- Vibroacoustic stimulation: If non-stress test is non-reactive
- Contraction stress test: assesses uteroplacental insufficiency and looks for persistent late
decelerations after contractions (3/10 minutes)
- If FHR can’t be monitored externally (e.g., mom can’t lie still) → place fetal scalp electrode
- Must confirm FHR before epidural placement!
- Decreased variability - sedating meds, fetal acidosis
- Variable decelerations - cord compression, cord prolapse, uterine rupture (also can see late decels or deep
variable decels)

20
 - Fetal bradycardia - cord prolapse, uterine rupture, uterine hyperstimulation = greater than five contractions in
10 mins (prostaglandin cervical ripening agents, especially misoprostol)

Management of fetal bradycardia

- Differentiate maternal HR from fetal HR! Can do with ultrasound or scalp electrode
- Assess for cord compression with vaginal exam!
- Place patient on left side to improve venous return
- IV fluid bolus if she may be depleted - if that is not successful, give ephedrine a pressor agent
- 100% oxygen via face mask
- Stop oxytocin if that is being given
- If cord compression → immediate c-section
- If fetal HR drops when baby is about to be delivered (+2 fetal station), give the mom one or two pushes to
deliver, and then do emergency forceps or vaccuum assisted delivery (“assisted operative delivery”)

Contraction monitoring
- Can use intrauterine pressure catheter - strength & frequency of contractions.
- Cases
- If catheter is placed and a lot of bleeding is noted, possibility of placental separation or uterine
perforation! Withdraw catheter, monitor fetus - if baby is okay, replace catheter.

Cardinal Movements
ED FIRE REX
Engagement
Descent
Flexion
Internal Rotation
External Rotation
??
??

Breech
- 3-4% of women, especially in preterm.
- Frank breech with buttocks presenting is most common Both legs up by head in V
- Incomplete breech: One foot up to head, the other tucked down
- Complete breech: two feet crossed and tucked
- Risk factors: prematurity, multiples, problems with the baby - genetic disorders/anencephaly/hydrocephaly,
placenta previa, uterine anomalies, uterine fibroids
- Management: Give it until 37 weeks to correct, then attempt external cephalic version if there are no placental
abnormalities, fetopelvic disproportion, or hyperextended fetal head. If it doesn’t work, then do c-section.
- Give rhogham with the external cephalic version!

Shoulder dystocia
- Risk factors: Multiparous, macrosomia - obese mom, gestational diabetes (increased fetal shoulder and
abdomen weight)
- Danger of brachial plexus injury - especially Erb’s palsy (C5, C6 - useful hand on useless arm)
- Management
- McRoberts maneuver: Mom flexes thighs to abdomen to straighten the sacrum relative to the
lumbar spine and move the pubic symphysis anteriorly toward the maternal head.
- Suprapubic pressure to push fetal shoulders into an oblique plane
- Others: corkscrew maneuver, delivery of posterior arm (risk of humerus fracture)
- Zavenelli maneuver - cephalic replacement and cesarean
21
 - Avoid fundal pressure because increased risk of neonatal injury!

Cord prolapse
- Sustained fetal bradycardia or variable decelerations.
- Risk when membranes are ruptured and baby is not yet engaged, or is transverse or footling presentation.
Lower risk with frank breech and vertex presentations.
- Do a c-section, even if FHR is stable! Elevate the fetal head with a vaginal hand and go to the OR

Uterine rupture
- Signs/symptoms:
- Baby: Fetal bradycardia, deep variable decels, or late decels.
- Mom: Sudden or worsening abdominal pain (can be masked by pain meds), uterine contraction
abnormalities, intraabdominal bleeding +/- vaginal bleeding
- Diagnosis: Clinical or radiologic - see disruption of all layers
- Risk factors: previous c-sections (0.78% - higher risk with vertical incision, lower risk with previously
successful VBACs)
- Intrauterine pressure catheters are not helpful and can actually confuse the picture!
- Do immediate c-section! Uterine repair vs. hysterectomy. VBAC calculator - young, successful VBAC, c-
section

Meconium
- Amnioinfusion to dilute meconium does NOT decrease risk of meconium aspiration syndrome or impact
neonatal outcomes. (only do amnioinfusion for repetitive variable decels to alleviate cord compression)

Vaginal tears
● 1st degree - through the vaginal epithelium
● 2nd degree - vaginal fascia and perineum.
● 3rd degree - rectal sphincter partial or complete - can be internal, external, or both
● 4th degree - through the rectal mucosa

Assisted vaginal delivery (forceps)

- Forceps
- Completely dilated, head is engaged and vertex, no pelvic/head size discrepancy, adequate maternal
pain control, rupture of membranes.
- No increased risk to baby or mom when guidelines are followed and provider has experience.

- Vaccum
- More comfortable for mom than forceps, lower rate of lacerations
- Risks to baby - lacerations, cephalohematoma, jaundice

Cesarean Sections

The rate of c-sections is increasing mainly due to fewer women having VBAC (because of increased complications,
especially uterine rupture). Other causes - many ob’s don’t do instrumental vaginal deliveries, fewer do vaginal breech
deliveries.

Indications
- Consider if fetal head > 12 cm, placenta previa (complete or partial), breech

Risks in future pregnancies

22
 - Higher risk of placenta accreta, where placenta grows into the myometrium

VBAC
- Likelihood of successful VBAC decreases with number of previous c-sections - 70-80% after one c-section,
and 70% after two. Better chances if done for non-recurring conditions (breech, placenta previa) rather than
baby being too big for pelvis.
- Risk of rupture after one previous low transverse c-section is approximately 1%. No data on whether more c-
sections increase risk.

Newborn Resuscitation

APGAR Scores: Do at 1 minute to evaluate well being just before delivery. If 1 minute score < 3 → resuscitate
immediately! But in practice, HR, color, and RR are used to determine need for resuscitation. 5 minute score is a
measure of how successful resuscitation was.
1. Appearance/Color: 0 if blue and pale, 1 if body is pink but extremities are blue (acrocyanosis), 2 if
completely pink
2. Pulse/HR: 0 if absent, 1 if < 100 bpm, 2 if > 100 bpm
3. Grimace/Reflex: (response to catheter in nose): 0 if no response, 1 if grimace, 2 if cough or sneeze
4. Activity/Tone: 0 if limp, 1 if some flexion of extremities, 2 if flexion and active motion
5. Respiration: 0 = no effort, 1 = slow or irregular, 2 = good effort and crying

Baby born blue and floppy → evaluate HR and respiration

● If irregular respiration or HR < 100 bpm → PPV by bag mask. Recommended flow 10L/min.. Give naloxone
if narcosis (e.g., meperidine during delivery)
● If HR < 60, give chest compressions

If mom gets meperidine during delivery → baby can end up with narcosis = deep stupor or unconsciousness.
● Give naloxone for meperidine, not for general anesthesia (not opiates)
○ If history of substance abuse during pregnancy, do not give naloxone! Can send baby into life-
threatening withdrawal! Give positive pressure ventilation and prepare to intubate if necessary.
● In response to positive pressure ventilation, will have good HR but poor respiratory effort.

Other cases:
1. Baby born limp, apneic, bradycardic, + covered in meconium Intubate with an endotrach tube and suction
meconium out
2. Diaphragmatic hernia: Baby born w/ cyanosis, respiratory distress, scaphoid abdomen, heart sounds on
right side & decreased on left side. Herniated bowel into chest → pulmonary hypoplasia. Do endotrach
intubation! Bag mask will increase bowel gas and make it worse!
3. Baby born lethargic with HR of 40: If HR < 60 despite PPV with 100% oxygen, then do chest compressions
for 30 seconds. If HR still < 60 → epinephrine
4. Choanal atresia! Crying baby appears normal, but respiratory distress when she stops crying. When crying,
can breathe through mouth. But otherwise obligate nose breather until 4 months.
a. May be part of CHARGE syndrome: Colomboa, Heart defects, Atresia of the choanae, Renal
anomalies, Growth impairment, and Ear abnormalities/dearfness

Other issues in Immediate Care of the Newborn

Chorioamnionitis
- Mother has fever, baby has tachycardia. Expect baby to be born septic - lethargic, pale, fever
- Diagnosis: Amniocentesis - glucose < 20, elevated interleukin 6. Presence of WBCs has low predictive
value.
23
HIV treatment
- Give zidovudine during pregnancy, IV in labor, and give it to baby immediately after birth → reduce risk of
transmission from 25% to 2%. Test for HIV at 24 hours.
- Breastfeeding is not encouraged.

Postpartum Care

Postpartum Hemorrhage
- Definition: > 500 mL after vaginal delivery, > 1 L after Cesarian delivery
- Remember ABCs first!
- Reduce risk with oxytocin after delivery, early cord clamping, gentle cord traction with uterine counter traction
with a well contracted uterus
- Early Causes of PPH: Uterine atony, genital tract lacterations, placenta accreta, retained placenta, uterine
inversion. One early question is whether the bleeding is supracervical or cervical or lower in the genital tract.
- Uterine atony is most common cause of early PPH
- Risk factors for atony:
- Magnesium, oxytocin
- Prolonged labor
- Anything that really stretches or tires out the uterus (big babies, long labor, multiples,
hydramnios, oxytocin, general anesthesia
- Intraamniotic infectino
- High parity
- Management
- Uterine massage and IV dilute oxytocin
- Increase uterine contractions:
- Methergine = methylergonovine: Ergot alkaloid, potent smooth muscle
constrictor. Also a vasoconstrictor, avoid if HTN and/or preeclampsia
- Prostaglandin F2-alpha = hemabate: Potent smooth muscle constrictor,
also has a bronchoconstrictive effect - avoid in poorly controlled or severe
asthma! Avoid giving IV because of bronchoconstriction! Must do IM.
- If continues to bleed, place 2 large bore IVs, Foley catheter, call for blood, monitor
vitals, move to the OR
- If continue to bleed and somewhat stable, consider IU balloon or embolization
- If continues to bleed → laparatomy
- B lynch suture: Uterine compression suture - good approach if uterine atony
is the cause
- Ligation of pelvic arteries - ascending branch of the uterine arteries
(ligation of the full uterine artery would mean a hysterectomy is necessary) or
hypogastric artery
- Hysterectomy as a last resort
- Genital tract lacerations is another early cause - suspect if uterus is firm!
- Inspect vaginal side walls and cervix
- Placenta accreta:
- Causes retained placenta and severe post partum hemorrhage.
- Risk Factors: previous c-sections w/ low lying anterior placenta. Higher risk with more c-
sections. Placenta previa (especially with prior c-sections), implantation in lower uterine
segment, uterine curettage, Down syndrome of fetus, mom > 35 yrs
- Diagnosis: Difficult to see with ultrasound or MRI. Usually at delivery. If seen in second
trimester, might resolve in third trimester because the lower uterine segment grows more
rapidly (transmigration of the placenta)

24
 - Management
- End up with retained placenta. When manual extraction is attempted, can’t find a
cleavage plane.
- Hysterectomy is safest! Leave the placenta in place, remove it along with the
uterus. But in a younger patient who really wants more children, consider removing
as much placenta as possible and packing the uterus. Risk of excess mortality.
- Retained placenta
- Risk Factors: Prior c-sections, uterine leiomyomas, prior uterine curettage, succenturiate lobe
of placenta
- Management: Attempt manual extraction by looking for a cleavage plane between placenta
and uterus. Do not pull on the placenta → risk of uterine inversion.
- Coagulopathy
- Suggested if bleeding from multiple venipuncture sites together with abruption
- No local treatment will help
- DIC - simultaneous bleeding and clotting
- Uterine inversion:
- Biggest risk factor is excessive traction on umbilical cord during placenta delivery - must wait
for placenta to separate!
- 4 signs that it’s ready: gush of blood, cord should lengthen, uterus becomes globular,
uterus moves to anterior abdominal wall.
- If not ready within 30 minutes, try for mechanical removal.
- Risk increases with factors that cause an over-distended uterus or with placenta at top of
fundus
- Causes hemorrhage because uterus can’t contract.
- Treatment:
- Place 2 large bore IVs - this person will almost definitely hemorrhage. Blood products
to maintain Hct between 25 and 30%.
- Give meds to relax uterus and allow for reversion - basically tocolytics (terbutaline,
Mg) and halothane anesthetic if really difficult to get back in due ot closed cervix.
Once in place, give oxytocin to contract uterus.
- May need emergency surgery
- Late causes of PPH (> 24 hours after delivery)
- Subinvolution of the placental site - usually 10-14 days later.
- Eschar over the plcental bed falls off - lack of myometrial contraction at the site → bleeding.
- Usually not seriously anemic
- Give methergine, misoprostol, or prostagland F2 alpha

Blood products
- FFP: Fibrinogen, Factors V and 8. Give if DIC and hemorrhage are evident or if the coagulation profile is very
abnormal.
- Cryoprecipitate: Fibrinogen, Factor 8, Von Willebrand Factor

Sheehan Syndrome
- Significant blood loss → anterior pituitary necrosis. Loss gonadotropin, TSH, ACTH. Often goes unnoticed for
many years!
- Treatment: estrogen, progesterone, TSH, adrenal hormones

Postpartum fever
- Most often endometritis. Breast engorgement can also cause a mild fever after milk let down on day 2-3
- Differential: UTI, lower genital tract infection, wound infection, pulmonary infection, thrombophlebitis, mastitis
- Wound infection (e.g, from c-section)

25
 - Open the wound up, drain purulent material, give abx
- Septic thrombophlebitis
- Fevers, but eating and walking normally, no other sign of infection or problem
- Thrombosis of the venous system of the pelvis. Sometimes see on CT scan. Treat with short term.
anticoagulation and antibiotics

Puerperal Infection/Endometritis
- Fever, diffuse abdominal tenderness, marked cervical motion tenderness.
- < 3% of vaginal deliveries, 5-10x more common with Cesarean deliveries. Usually caused by a mix of
aerobes and anaerobes, most causitive bugs are staph aureus and streptococcus. Can also happen after
termination!
- Symptoms: Most common cause of postpartum fever! Often have uterine fundal tenderness, maybe foul
smelling lochia
- Risk factors in vaginal birth: prolonged labor or prolonged rupture of membranes, multiple vaginal
examinations, internal fetal monitoring, removal of placenta manually, low socioeconomic status.
- Management: IV antibiotics!
- Use gentamicin and clindamycin (for anaerobes) after c-section, or gentamycin and ampicillin after
vaginal (don’t need as much anaerobic coverage). Add ampicillin if no improvement after 48 hours
(enterococcus).
- If no improvement after 48-72 hours with triple abx, do a CT of abdomen and pelvis to look for an
abscess, infected hematoma, or pelvic thrombophlebitis.
- Follow with ultrasound. E.g., after abortion may see products of conception. Would then require D&C.

Postpartum blues
- Signs of depression that last < 2 weeks. Happens in 40-85% of women after delivery

Postpartum depression
- 10-15% of women. Biggest risk factor is a prior history of depression.
- Begins 2 weeks-6 months after delivery. Lasts > 2 weeks.
- Ambivalence to the newborn is a red flag for depression rather than postpartum blues.

Breastfeeding

Breastfeeding is recommended as exclusive source of nutrition for 6 months. More likely to initiate it if physicians or
nurses encourage it.

Benefits of breastfeeding
- Increased uterine contraction from oxytocin release
- Reduced risk of ovarian cancer, may also have reduced risk of breast cancer
- Reduces fetal infections because of secretory IgA, lactoferrin (inhibits certain iron-dependent bugs in the GI
tract), and lysozyme (enzyme that protects against E coli and other bugs)
- Must supplement with Vit K at birth and Vit D at 2 months.

Contraindications: HIV, active tuberculosis, the rest are obvious

Suppression of lactation
- Breast binding, ice packs, analgesics. Avoid breast stimulation or milk expression. Hormones predispose to
clots, bromocriptine is associated with HTN. strokes, seizure.

Physiology of breastfeeding

26
 - Progesterone, estrogen, placental lactogen, prolactin, cortisol, and insulin stimulate growth and development
of milk secreting apparatus of the mammary gland
- Prolactin is responsible for synthesis of milk. Present in pregnancy, but action is inhibited by estrogen and
progesterone. After delivery, estrogen and progesterone inhibition is lifted → prolactin can stimulate milk
synthesis.
- Oxytocinstimulates the ejection of milk - stimulated by suckling better than breast pump does

How to breastfeed
- Mother and baby must be belly-to-belly in order for baby to take a large portion of the areola into its mouth -
otherwise increased risk of bleeding and cracked nipples
- Hospital policies: Getting baby to breast within 30 mins, give mom unlimited access to baby
- Signs that baby is getting enough: 3-4 stools in 24 hours, 6 wet diapers in 24 hours, weight gain, sound of
swallowing
- Engorgement: Treat with frequent nursing, warm showers/compresses, massage, hand expressing milk to
soften, good support bra, pain meds 20 mins before breastfeeding

Mastitis
- Usually 2-4th week postpartum (vs 1st 24 hours = breast engorgement). Red, tender, swollen breast and
fever, chills, malaise, tachycardia. Should not have fluctuance! Suggests abscess.
- Most often staph aureus from the baby’s throat.
- Risk factors: past hx of mastitis, engorgement and inadequate milk drainage (sudden increase in sleep
duration, replacement with formula or pumped milk, weaning, pressure on the duct from tight clothes or
sleeping on stomach, cracked or clogged nipple, poor latch)
- Treat with dicloxacillin or cephalexin, culture breast milk before starting abx. Continue to breast feed or
pump.
- If at risk for MRSA (HIV, recent abx, health care exposure) then treat with clindamycin, bactrim, or
vancomycin
- If fluctuance or no improvement after 48 hrs of abx → suspect breast abscess! Get an ultrasound. Treat with
surgical drainage or ultrasound guided aspiration and with abx.
- If persistence of symptoms despite abx, worry about inflammatory breast cancer → get a biopsy, don’t do
imaging because you won’t see anything.

Galactocele
- Noninfected collection of milk due to blocked mammary duct → palpable mass, breast pressure, pain. No
erythema, no fever.
- Should go away on its own, if not → aspiration to prevent abscess formation.

Candida
- Sensitive, sore nipples, burning pain in the breasts worse with feeding. Nipples pink and shiny with peeling at
periphery.
- Inspect baby’s mouth, too!

Post partum complications

Pelvic Congestion Syndrome

- Chronic pain due to pelvic varicosities. Get vasodilated when exposed to high concentrations of estrogen,
worse premenstrually and during pregnancy, aggravated by standing, fatigue, and sex
- Described as pelvic fullness or heaviness, can extend to vulva and legs
- Associated with vaginal discharge, backache, urinary frequency. Can have menstrual cycle defects and
dysmenorrhea

27
Nerve entrapment syndrome
- Low transverse incision → neuropathy of the iliohypogastric or ilioinguinal nerve. Pain is worse with adduction
of the thigh.
- Iliohypogastrci - cutaneous sensation of the groin and skin of the pubis
- Ilioinguinal - sensation of the groin, symphysis, labia, upper inner thigh

28