Snapshot A 35-year-old woman at 42 weeks of gestation presents for an induction of labor due to postterm pregnancy. She reports positive fetal movement, and denies vaginal bleeding. After amniotomy is performed, a change in fetal heart monitor is noted. Maternal repositioning is performed. (Variable decelerations) Biophysical Profile (BPP) Five measurements of fetal well being, each rated on scale of 0 or 2 measure fetal breathing gross body movements fetal tone extremity extension and flexion amniotic fluid volume nonstress test (NST) Scoring 8-10 is reassuring 6 is equivocal delivery if > 36 weeks repeat BPP in 24 hours if < 36 weeks ≤ 4 is abnormal requires immediate intervention Fetal Heart Rate (FHR) Normal FHR 120-160/min Tachycardia is FHR > 160/min causes include maternal fever fetal hypoxia prematurity anemia (maternal or fetal) chorioamnionitis hyperthyroidism Bradycardia is FHR < 110/min for > 10 minutes causes include congenital heart block maternal β-blockers FHR variability reliable indicator of fetal well being causes of decreased variability include fetal hypoxia congenital heart anomalies Electronic Fetal Heart Rate Monitoring (EFM) Tracing Interpretation Accelerations ↑ FHR at least 15/min above baseline for ≥ 15 seconds and < 2 minutes in a 20 minute period when gestational age is > 32 weeks or 10/min for ≥ 10 seconds when gestational age is < 32 weeks considered a reactive NST (needs the presence of at least 2 accelerations) suggests fetal well being if this was a NST during pregnancy (not intrapartum), management would be routine-follow-up Early decelerations ↓ FHR (not below 100/min) that coincide with uterine contraction nadir of the deceleration meets the apex of the uterine contraction results from pressure on fetal head (fetal head compression) resulting in vagus nerve stimulation and reflex bradycardia physiologic and not harmful to fetus Variable decelerations may not coincide with uterine contractions rapid ↓ in FHR (often < 100/min) with variable recovery reflex mechanism due to umbilical cord compression rupture of membrane can lead to umbilical artery compression correct by shifting maternal position or amnioinfusion if membranes ruptured considered first-line if maternal repositioning does not improve FHR tracing, amnioinfusion can be considered Late decelerations begins after uterine contraction has started associated with uteroplacental insufficiency and viewed as potentially dangerous causes include placental abruption maternal diabetes maternal anemia maternal sepsis postterm pregnancy hyperstimulated uterus repetitive late develerations require intervention Sinusoidal tracing sine-wave like pattern associated with increased morbidity and mortality indicative of severe fetal anemia e.g., severe hypoxia and Rh disease
QUESTIONS 1 of 6 1 2 3 4 5 6 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.OB.4867) A 28-year-old G1P0 woman at 42 weeks gestation is admitted to the maternity ward for induction of labor. She states that her prenatal care has been notable for gestational hypertension. She has been taking her multivitamin daily. She feels fetal movement and denies any vaginal bleeding. Her temperature is 98.6°F (37°C), blood pressure is 107/54 mmHg, pulse is 72/min, and respirations are 20/min. Her cervix is 0 cm dilated, and the fetus is in cephalic position. The fetal heart monitor shows a heart rate of 130/min. She agrees to have an epidural catheter placed for analgesia. Shortly thereafter, amniotomy is performed. No vaginal bleeding is observed. While attending to documentation of the procedure, the nurse calls your attention to a change in the fetal heart monitor, shown in Figure A. What is the most likely cause for this finding? Review Topic QID: 109557 FIGURES: A 1 Epidural analgesia 15% (6/41) 2 Cord compression 39% (16/41) 3 Vasa previa 2% (1/41) 4 Fetal head compression 10% (4/41) 5 Uteroplacental insufficiency 34% (14/41) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.OB.4867) A 28-year-old G1P0 woman who is 30 weeks pregnant presents to the women's health center for a prenatal checkup. She is concerned that her baby is not moving as much as usual over the past five days. She thinks she only felt the baby move eight times over an hour long period. Her prenatal history was notable for morning sickness requiring pyridoxine. Her second trimester ultrasound revealed no abnormal placental attachment. She takes a multivitamin daily. Her temperature is 98.6°F (37°C), blood pressure is 120/70 mmHg, pulse is 80/min, and respirations are 16/min. The patient's physical exam is unremarkable. Her fundal height is 28 cm, compared to 26 cm two weeks ago. The fetal pulse is 140/min. The patient undergoes external fetal monitoring. With vibroacoustic stimulation, the patient feels eight movements over two hours. What is the best next step in management? Review Topic QID: 109560 1 Reassurance 0% (0/0) 2 Induction of labor 0% (0/0) 3 Oxytocin challenge 0% (0/0) 4 Biophysical profile 0% (0/0) 5 Inpatient monitoring 0% (0/0) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 4 (M2.OB.95) You are the intern on the labor and delivery floor. Your resident asks you to check on the patient in Bed 1. She is a 27-year-old prima gravida with no significant past medical history. She has had an uncomplicated pregnancy and has received regular prenatal care. You go to her bedside and glance at the fetal heart rate tracing (Image A). What is the most likely cause of this finding? Review Topic QID: 105265 FIGURES: A 1 Fetal head compression 78% (18/23) 2 Utero-placental insufficiency 0% (0/23) 3 Cord compression 13% (3/23) 4 Fetal distress 4% (1/23) 5 Congenital heart block 0% (0/23) M2 Select Answer to see Preferred Response PREFERRED RESPONSE 1 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK