vasa previa

Rupture of membrane --> painless bleeding --> fetal brady

Immediate C section!!!

placenta previa

painless late trimester bleeding with ultrasound dx.
risk factors: multiparity, advanced maternal age
risk of placenta accreta --> C section hysterectomy, Sheehan's, ATN.

management: emerge C section - if mom or fetus in jeopardy, scheduled C section - 36 wks when lung maturity confirmed by amnio, vaginal delivery - if placental edge is > 2cm from os, conservative watch - bed rest if remote from term, replace blood loss if needed.

abruptio placenta

normally implanted placenta separates from uterus, most manifest as overt external bleeding, painful, late-trimester.
risk of DIC

management: emergency C section - if mom or fetus in jeopardy, induce vaginal delivery- if pregnancy > 36 wks or if fetus is dead, conservative observation.

pregnancy landmarks

FHT first heard by doppler at 10 wks, movement first felt between 16-20 weeks.

first trimester (to 13 wks):
- n/v, fatigure, breast tenderness, increased urination, spotting, gain 5-8lbs.

initial prenatal tests: cbc - mcv (folate def?), platelets (HELLP); Rubella IgG, HepB (antigen E:v infectious, surface ag:prev or current, surface ab:nl); blood type and abs; STD screen; TB screen; UA; HIV.

midtrimester: AFP, quad screen (15-20 wks).

second trimester (to 26 wks):
- round ligament pain, braxton-hicks contractions, quickening, gain 1lb each wk after 20 wks

third trimester (to 40 wks):
- low libido, lower back pain, leg pain, increased urination, braxton-hicks contractions
- lightening: fetus head into pelvis and easier to breathe for mom
- bloody show: cervical dilation before labor
- continue to gain 1lb/ wk

labs: gestational DM screen, atypical ab screen (before giving rhogam at 28wks

antenatal fetal testing:
NST - nonreactive can mean fetal sleeping, drugs, prematur, CNS anomalies - do vibroacoustic stim and if still nonreactive to BPP
BPP - 8-10 nl/ 4-6 deliver if fetus >=36 wks, repeat in 12-24hrs or do CST if < 36 wks/ 0-2 deliver regadless of age!
CST - neg is good - repeat in a week/ positive is bad, but 50% false positives, deliver if >= 36 wks/ contraindicated if previous classical c section, myomectomy, placenta previa, incompetent cervix, preterm ROM, preterm labor.

hCG

From syncytiotrophoblast - first detectable at 10 days, peaks at 10 wks, plateaus at 20.

alpha subunit like: LSH, FSH, TSH
beta subunit: unique

high levels: twins, hytadifiform mole, choriocarcinoma, embyronal carcinoma
low levels: ectopic preg, abortion

hcg < 5,000 don't expect to see sac on transabd ultrasound - do transvaginal