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Obstetrics & Gynecology USMLEworld Notes

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Obstetrics Fetal assessment

• Biophysical profile :

- It's indicated in :

1. High risk pregnancies.

2. Non-reactive NST.

- It consists of the following 5 parameters assessed by ultrasonography:

1. Nonstress test (reactive)

2. Fetal tone (flexion or extension of an extremity)

3. Fetal movement (at least 2 in 30 minutes)

4. Fetal breathing movements (at least 20 in 30 minuttes)

5. Amniotic fluid volume (single pocket greater than 2cm in vertical axis)

8-10	Considered normal. Should be repeated once or twice weekly until term for high risk pregnancies.
decreased amniotic fluid volume and a score of 8	- Delivery is to be considered as fetal compromise is likely.
6 without oligohydramnios	If the pt is greater than 37 weeks gestation  Delivery. If the pt is less than 37 weeks gestation BPP should be repeated in 24 hours and delivery should be done if not improved.
6 with oligohydramnios	If above 32 weeks gestation  required delivery. If less 32 weeks gestation  daily monitoring
4 or less	- Delivery is indicated if the pt is greater than 26 weeks gestation
2 or less	- Severe fetal asphyxia  the baby should be delivered immediately.

 In the presence of oligohydramnios (AFI < 5) : delivery should be considered since it can result in umbilical cord compression and therefore fetal compromise.

• FHR pattern :

• Intermittent variable deceleration is well-tolerated by the fetus.

• Repetitive (>= 50% in a 20 min. period) variable deceleration  requires prompt intervention.

• The first step in the presence of any non-reassuring heart rate is :

Administer oxygen & changing maternal position

 In presence if decreased fetal movement  suspect fetal compromise Non-stress test : reactive  most appropriate next step is : Repeat Non-stress test weekly.

• NST is usually performed in :

1) High risk pregnancies starting at 32 – 34 weeks. 2) Decrease fetal movement in any pregnancy.

• The most common cause of non-reactive is sleeping baby ( do Vibroacoustic stimulation) NOT a diseased baby - Biophysical profile is done when : non-reactive + no response to vibroacoustic stimulation.

Screening during pregnancy

• Between 15-20 weeks  quadruple test to assess risk of Down's (trisomy21) : B-HCG , Inhibin A , Estriol , MS-AFP .

• Edward (trisomy18): B-HCG , Estriol , MS-AFP . (all decreased)

MS-AFP 	In presence of : 1- Inaccurate Gestation Age (first) 2- Multiple gestation 3- Neural Tube defects 4- Abdominal wall defects (gastroschisis, omphalocele)
Most appropriate next step in abnormal MS-AFP  or  is :		Ultrasound	 to rule out the previous four items.

1- Rh testing pregnancy :

- Current guidelines recommend : Rh-blood typing AND testing for Rh antibodies at :

• First prenatal visit  & repeat at 28 weeks  in unsensitized woman (Rh –ve) with her partner either :

• Rh +ve (so the fetus is Rh +ve) or

• Rh unknown

To check the possible maternal alloimmunization during pregnancy  if negative  give anti-D at 28 weeks & at time of delivery.

‒ ABO antibodies: IgM, don’t cross the placenta ‒ Rh antibodies: Ig G, do cross the placenta.

pp

 ABO Alloimmunization incompatibility : Occur in 1^st pregnancy (Primigravida) in contrast to Rh in 2^nd pregnancy Patient is missing a blood type , have antibodies to the missing antigens.

Blood type	Antibodies against
A	B
B	A
O	A & B
AB	----

Mother with blood group O AND Father with blood group AB  will develop baby with blood group either A or B (both differ from mother group )  so resulting in formation of IgG antibodies in the mother wich cross the placenta resulting in "Hemolytic Disease of the Newborn (HDN)" which is :