371. Obstetrics In Family Medicine

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371. Obstetrics In Family Medicine

 

 

CATEGORY: Medical & Medicine – 500 Courses

COURSE NUMBER: 371

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Syllabus

Part I Preconception and Prenatal Care
1 Physiology …………………………………………………………………………………… 3
Background ………………………………………………………………………………….. 3
Physiology of Menstruation ……………………………………………………………. 4
Physiology of Fertility …………………………………………………………………… 5
Hypothalamic Function ………………………………………………………………. 5
Pituitary Function………………………………………………………………………. 6
Ovulation ………………………………………………………………………………….. 6
Physiology of Pregnancy ……………………………………………………………….. 7
Cardiovascular Changes ……………………………………………………………… 7
Renal/Urinary Changes ………………………………………………………………. 8
Gastrointestinal Changes ……………………………………………………………. 9
Hematological Changes ……………………………………………………………… 9
2 Preconception Counseling ……………………………………………………………. 11
Background ………………………………………………………………………………….. 11
The Patient ……………………………………………………………………………….. 12
The Environment ……………………………………………………………………….. 13
Getting Started ……………………………………………………………………………… 13
Screening ……………………………………………………………………………………… 14
Education …………………………………………………………………………………….. 14
Intervention ………………………………………………………………………………….. 16
3 Prenatal Care ………………………………………………………………………………. 17
Background ………………………………………………………………………………….. 17
Key Domains of Prenatal Information ……………………………………………… 18
Frequency of Prenatal Visits …………………………………………………………… 19
The First Prenatal Visit (See Table 3.1) ………………………………………… 20
Follow-Up Prenatal Visits …………………………………………………………… 25

4 Medications in Pregnancy ……………………………………………………………. 27
Background ………………………………………………………………………………….. 28
General Principles of Medication Use in Pregnancy ………………………….. 28
Chronic Medical Conditions ……………………………………………………….. 28
Acute Medical Conditions ………………………………………………………….. 29
Acute Obstetrical Conditions ………………………………………………………. 29
Therapeutic Categories and Considerations …………………………………… 30
Proven Human Teratogens ……………………………………………………………… 30
Special Considerations …………………………………………………………………… 32
Tobacco ……………………………………………………………………………………. 32
Alcohol …………………………………………………………………………………….. 32
Illicit Drugs ………………………………………………………………………………. 33
Over-the-Counter Medications ……………………………………………………….. 33
OTC Pain Medications ……………………………………………………………….. 33
OTC Cough/Cold/Allergy Medications ………………………………………… 34
Part II Complications of Pregnancy
5 Dysmorphic Growth and Genetic Abnormalities …………………………… 39
Background ………………………………………………………………………………….. 39
History …………………………………………………………………………………………. 40
Physical Examination …………………………………………………………………….. 41
Diagnosis ……………………………………………………………………………………… 41
Obstetrical Screening Tests …………………………………………………………….. 41
What Is Measured ……………………………………………………………………… 41
What Is Detected ……………………………………………………………………….. 42
Confi rmation/Follow-Up …………………………………………………………….. 42
Amniocentesis …………………………………………………………………………… 42
Chorionic Villus Sampling ………………………………………………………….. 43
6 Intrauterine Growth Restriction ………………………………………………….. 45
Background ………………………………………………………………………………….. 46
Risk Factors …………………………………………………………………………………. 47
Fetal-Genetic Factors …………………………………………………………………. 47
Uterine-Environmental Factors ……………………………………………………. 47
Maternal Factors ……………………………………………………………………….. 47
Toxic Exposures ………………………………………………………………………… 48
Constitutional Factors ………………………………………………………………… 48
Complications of Growth Restriction ………………………………………………. 49
Antenatal Tracking and Diagnosis …………………………………………………… 49
Screening for Risks ……………………………………………………………………….. 49
Diagnosis ……………………………………………………………………………………… 51
Management …………………………………………………………………………………. 52
Risk Reduction ………………………………………………………………………….. 52

7 Preterm Labor …………………………………………………………………………….. 55
Background ………………………………………………………………………………….. 56
Factors Associated with Preterm Labor ……………………………………………. 56
Preconception Factor …………………………………………………………………. 57
Postconception Factors ………………………………………………………………. 57
Diagnosis ……………………………………………………………………………………… 58
Intake Assessment …………………………………………………………………………. 58
History ……………………………………………………………………………………… 58
Physical Examination …………………………………………………………………. 58
Laboratory Studies …………………………………………………………………….. 59
Management …………………………………………………………………………………. 59
Management Prior to 34 Weeks’ Gestation …………………………………… 60
Management at 34–37 Weeks ……………………………………………………… 62
Assessment of Fetal Lung Maturity …………………………………………………. 62
Lecithin-to-Sphingomyelin Ratio ………………………………………………… 62
Phosphatidylglycerol ………………………………………………………………….. 63
Additional Tests ………………………………………………………………………… 63
8 Premature Rupture of Membranes ………………………………………………. 65
Background ………………………………………………………………………………….. 65
Diagnosis ……………………………………………………………………………………… 66
History ……………………………………………………………………………………… 66
Physical Examination …………………………………………………………………. 67
Laboratory ………………………………………………………………………………… 68
Management …………………………………………………………………………………. 69
Management at Term …………………………………………………………………. 70
Preterm Management …………………………………………………………………. 70
9 Early Pregnancy Bleeding ……………………………………………………………. 71
Background ………………………………………………………………………………….. 72
General Approach to Early Pregnancy Bleeding per Vagina ……………….. 72
History ……………………………………………………………………………………… 74
Physical Examination …………………………………………………………………. 74
Ultrasound ………………………………………………………………………………… 75
Laboratory Studies …………………………………………………………………….. 75
Ectopic Pregnancy …………………………………………………………………………. 75
Background ………………………………………………………………………………. 75
Diagnosis ………………………………………………………………………………….. 76
Management ……………………………………………………………………………… 77
Spontaneous Abortion ……………………………………………………………………. 78
Background ………………………………………………………………………………. 78
Diagnosis ………………………………………………………………………………….. 79
Management ……………………………………………………………………………… 80

10 Late-Pregnancy Bleeding …………………………………………………………….. 81
Background ………………………………………………………………………………….. 82
General Approach to Late-Pregnancy Bleeding Per Vagina ………………… 82
History ……………………………………………………………………………………… 83
Ultrasound ………………………………………………………………………………… 84
Physical Examination …………………………………………………………………. 84
Laboratory Studies …………………………………………………………………….. 85
Placenta Previa ……………………………………………………………………………… 85
Background ………………………………………………………………………………. 85
History ……………………………………………………………………………………… 85
Ultrasound Examination …………………………………………………………….. 86
Physical Examination …………………………………………………………………. 86
Laboratory Studies …………………………………………………………………….. 86
Management ……………………………………………………………………………… 86
Abruptio Placenta ………………………………………………………………………….. 87
Background ………………………………………………………………………………. 87
History ……………………………………………………………………………………… 88
Ultrasound ………………………………………………………………………………… 88
Physical Examination …………………………………………………………………. 88
Laboratory Studies …………………………………………………………………….. 88
Management ……………………………………………………………………………… 88
11 Recurrent Pregnancy Loss …………………………………………………………… 91
Background ………………………………………………………………………………….. 91
Diagnosis ……………………………………………………………………………………… 93
Management …………………………………………………………………………………. 93
History ……………………………………………………………………………………… 93
Physical Examination …………………………………………………………………. 94
Diagnostic Studies …………………………………………………………………….. 94
12 Rh Isoimmunization…………………………………………………………………….. 95
Background ………………………………………………………………………………….. 95
Fetal Consequences of Isoimmunization ………………………………………….. 96
Newborn Consequences of Isoimmunization ……………………………………. 96
Diagnosis ……………………………………………………………………………………… 97
History ……………………………………………………………………………………… 97
Physical Examination …………………………………………………………………. 97
Diagnostic Studies …………………………………………………………………….. 97
Management Prior to Isoimmunization ……………………………………………. 97
Management of Pregnancies with Rh-Sensitized Mothers ………………….. 99
Amniotic Fluid Assessment ………………………………………………………… 99
Ultrasonography ………………………………………………………………………… 100
Percutaneous Umbilical Blood Sampling ……………………………………… 100

13 Infection in Pregnancy …………………………………………………………………. 101
Background ………………………………………………………………………………….. 102
Symptoms of Infection in Pregnancy ……………………………………………….. 102
Maternal Infection …………………………………………………………………………. 104
Fetal Infection ………………………………………………………………………………. 104
Antibiotic Use in Pregnancy …………………………………………………………… 105
Sulfonamides …………………………………………………………………………….. 105
Fluoroquinolones ………………………………………………………………………. 105
Aminoglycosides ……………………………………………………………………….. 106
Vaginitis/Vaginosis ………………………………………………………………………… 106
Background ………………………………………………………………………………. 106
History ……………………………………………………………………………………… 106
Physical Examination …………………………………………………………………. 107
Laboratory Studies …………………………………………………………………….. 107
pH Testing ………………………………………………………………………………… 107
KOH “Whiff” ……………………………………………………………………………. 107
Microscopic Examination …………………………………………………………… 107
Treatment …………………………………………………………………………………. 108
Bacterial Vaginosis …………………………………………………………………….. 108
Trichomoniasis ………………………………………………………………………….. 108
Yeast Vaginitis …………………………………………………………………………… 108
Gonorrhea/Chlamydia ………………………………………………………………… 109
Urinary Tract Infections …………………………………………………………………. 109
Background ………………………………………………………………………………. 109
Diagnosis ………………………………………………………………………………….. 110
History ……………………………………………………………………………………… 110
Physical Examination …………………………………………………………………. 110
Laboratory Examination …………………………………………………………….. 110
Treatment …………………………………………………………………………………. 111
Group B Strep ………………………………………………………………………………. 111
Background ………………………………………………………………………………. 111
Diagnosis ………………………………………………………………………………….. 112
Universal Screening …………………………………………………………………… 112
Treatment …………………………………………………………………………………. 112
14 Hypertension in Pregnancy ………………………………………………………….. 113
Background ………………………………………………………………………………….. 114
Diagnosis ……………………………………………………………………………………… 114
Diagnostic Criteria …………………………………………………………………….. 114
History …………………………………………………………………………………………. 115
Physical Examination …………………………………………………………………….. 116
Laboratory Studies ………………………………………………………………………… 116
Management …………………………………………………………………………………. 116
Chronic Hypertension ………………………………………………………………… 116

Pre-Eclampsia ………………………………………………………………………………. 117
Prevention ………………………………………………………………………………… 117
Management ……………………………………………………………………………… 117
Seizure Prevention …………………………………………………………………….. 119
15 Diabetes in Pregnancy …………………………………………………………………. 121
Background ………………………………………………………………………………….. 121
Diagnosis ……………………………………………………………………………………… 122
Pregestational Diabetes ………………………………………………………………….. 123
Management ……………………………………………………………………………… 123
Gestational Diabetes ……………………………………………………………………… 126
Preconception Management ………………………………………………………… 126
16 Multigestational Pregnancy …………………………………………………………. 127
Background ………………………………………………………………………………….. 127
Diagnosis ……………………………………………………………………………………… 129
History ……………………………………………………………………………………… 129
Physical Examination …………………………………………………………………. 130
Laboratory and Diagnostic Studies ………………………………………………. 130
Management …………………………………………………………………………………. 130
Prenatal Care …………………………………………………………………………….. 130
Labor and Delivery ……………………………………………………………………. 131
17 Postdates Pregnancy ……………………………………………………………………. 133
Background ………………………………………………………………………………….. 133
Diagnosis ……………………………………………………………………………………… 134
History ……………………………………………………………………………………… 134
Physical Examination …………………………………………………………………. 135
Diagnostic Studies …………………………………………………………………….. 135
Management …………………………………………………………………………………. 135
Assessment of Fetal Well-Being ………………………………………………….. 135
Part III Labor and Delivery
18 Normal Labor ……………………………………………………………………………… 141
Background ………………………………………………………………………………….. 141
Prelabor ……………………………………………………………………………………….. 141
Labor …………………………………………………………………………………………… 142
Assessment …………………………………………………………………………………… 143
History ……………………………………………………………………………………… 143
Physical Examination …………………………………………………………………. 143
Laboratory Studies ………………………………………………………………………… 144
Management …………………………………………………………………………………. 145
19 Induction and Augmentation ……………………………………………………….. 147
Background ………………………………………………………………………………….. 147
Preparation …………………………………………………………………………………… 148
Pharmacological Options ……………………………………………………………. 148

Mechanical Options …………………………………………………………………… 148
Induction ……………………………………………………………………………………… 149
20 Pain Management in Labor …………………………………………………………. 151
Background ………………………………………………………………………………….. 151
Nonpharmacological Management ………………………………………………….. 152
Pharmacological Management ………………………………………………………… 152
Narcotic Analgesia …………………………………………………………………….. 152
Local Anesthesia ……………………………………………………………………….. 153
Epidural–Spinal Anesthesia ………………………………………………………… 153
21 Operative Delivery ………………………………………………………………………. 155
Background ………………………………………………………………………………….. 155
Forceps Delivery …………………………………………………………………………… 156
Use of Forceps ………………………………………………………………………….. 157
Vacuum-Assist Delivery ………………………………………………………………… 157
Cesarean Section …………………………………………………………………………… 158
Part IV Complications of Labor and Delivery
22 Prolonged Labor …………………………………………………………………………. 161
Background ………………………………………………………………………………….. 161
Complications of Labor …………………………………………………………………. 162
Prolonged Latent-Phase Labor …………………………………………………….. 162
Failure to Dilate/Efface ………………………………………………………………. 163
Failure to Descend …………………………………………………………………….. 165
23 Shoulder Dystocia ……………………………………………………………………….. 167
Background ………………………………………………………………………………….. 167
Diagnosis ……………………………………………………………………………………… 168
Management …………………………………………………………………………………. 169
24 Malpresentation ………………………………………………………………………….. 171
Background ………………………………………………………………………………….. 171
Occiput Positions ………………………………………………………………………….. 172
Diagnosis ………………………………………………………………………………….. 172
Management ……………………………………………………………………………… 172
Nonoccipital Presentations ……………………………………………………………… 172
Breech Presentation ………………………………………………………………………. 173
Compound Presentation …………………………………………………………………. 174
25 Fetal Heart Rate Monitoring ……………………………………………………….. 175
Background ………………………………………………………………………………….. 175
Normal Fetal Heart Tracings …………………………………………………………… 176
Evaluation of Fetal Heart Rate Baseline …………………………………………… 176
Tachycardia ………………………………………………………………………………. 177
Bradycardia ………………………………………………………………………………. 177

Evaluation of Fetal Heart Rate Variability ………………………………………… 177
Acceleration ……………………………………………………………………………… 177
Early Deceleration …………………………………………………………………….. 178
Variable Deceleration …………………………………………………………………. 178
Late Decelerations …………………………………………………………………….. 178
26 Maternal Fever in Labor ……………………………………………………………… 179
Background ………………………………………………………………………………….. 179
Diagnosis ……………………………………………………………………………………… 180
History ……………………………………………………………………………………… 180
Physical Examination …………………………………………………………………. 180
Diagnostic Studies …………………………………………………………………….. 180
Management …………………………………………………………………………………. 181
27 Postpartum Hemorrhage ……………………………………………………………… 183
Background ………………………………………………………………………………….. 184
Complications Causing Hemorrhage ……………………………………………….. 184
Uterine Atony ……………………………………………………………………………. 184
Lacerations ……………………………………………………………………………….. 184
Retained Placenta ………………………………………………………………………. 185
Coagulopathy ……………………………………………………………………………. 185
Uterine Inversion ……………………………………………………………………….. 185
Diagnosis ……………………………………………………………………………………… 185
Management …………………………………………………………………………………. 185
Laceration ………………………………………………………………………………… 186
Persistent Bleeding …………………………………………………………………….. 186
28 Perineal Laceration and Episiotomy …………………………………………….. 189
Episiotomy …………………………………………………………………………………… 189
Background ………………………………………………………………………………. 189
Perineal Laceration ……………………………………………………………………….. 190
Background ………………………………………………………………………………. 190
Part V Postpartum Management
29 Newborn Evaluation ……………………………………………………………………. 195
Background ………………………………………………………………………………….. 195
The Examination …………………………………………………………………………… 196
History ……………………………………………………………………………………… 196
Physical Examination …………………………………………………………………. 196
Laboratory and Diagnostic Studies ………………………………………………. 198
Vaccination ……………………………………………………………………………….. 198
30 Routine Hospital Postpartum Management ………………………………….. 199
Background ………………………………………………………………………………….. 199
Postpartum Day 1 ………………………………………………………………………….. 200
History ……………………………………………………………………………………… 200
Physical Examination …………………………………………………………………. 200

Laboratory Studies …………………………………………………………………….. 201
Management ……………………………………………………………………………… 201
Postpartum Day 2 ………………………………………………………………………….. 202
History ……………………………………………………………………………………… 202
Physical Examination …………………………………………………………………. 202
Laboratory Studies …………………………………………………………………….. 203
Management ……………………………………………………………………………… 203
31 Complications of the Hospital Postpartum Period ………………………… 205
Background ………………………………………………………………………………….. 205
Fever ……………………………………………………………………………………………. 206
Infection ………………………………………………………………………………………. 206
Endometritis ……………………………………………………………………………… 206
Urinary Tract Infections ……………………………………………………………… 207
Index ………………………………………………………………………………………………….. 209

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