108

USMLE Step 2 (Subject) / Obstetrics (Lesson)

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• Hyperemesis gravidarum Severe, persistent nausea and vomiting associated with a > 5% loss of pre-pregnancy weight and ketonuria with no other identifiable cause.Epidemiology:- Occurs in 0.5-2% of pregnancies- Most common in first pregnancy, multiple gestations, and molar pregnancies Clinical features: nausea, vomiting, physical signs of dehydration, hypersalivation, orthostatic hypotension, malnourishment Diagnosis:- Rule out molar pregnancy: Check β-hCG level and ultrasound- Electrolyte disturbances: hypokalemia and hypochloremic metabolic alkalosis- Signs of dehydration (e.g., ↑ hematocrit)- Ketonuria- Measure liver enzymes, serum bilirubin, and serum amylase/lipase Treatment:- Adapt diet and avoid trigger- Administer ginger and/or pyridoxine (vitamin B6)- Doxylamine, prometazine or dimenhydrinate (antihistamines)- If severe: Metoclopramide, ondansetron, prochlorperazine IM/PO
• Gestational and chronic hypertension Gestational hypertension = pregnancy-induced hypertension with onset after 20 weeks gestation. Defined as a systolic blood pressure ≥ 140 mmHg or diastolic blood pressure ≥ 90 mmHg on 2 separate measurements at least 4 hours apart. Chronic hypertension = hypertension diagnosed < 20 weeks gestation or before pregnancy. Treatment:- Monitor BP closely and treat with antihypertensives (e.g., methyldopa, labetolol, nifedipine). - Do not give ACEIs or diuretics (uterine ischemia).
• Antepartum hemorrhage Antepartum hemorrhage is a serious complication of pregnancy occurring within the third trimester (after 20 weeks). - Complicates 3-5% of pregnancies (prior to 20 weeks, bleeding is referred to as threatened abortion) Causes:- Placental abruption- Placenta previa- Vasa previa- Uterine rupture- Stillbirth- Rupture of the membranes in the velametous cord insertion- Trauma
• Ectopic pregnancy Localization: Fallopian tube (ampulla >> isthmus > fimbriae > interstitial), ovarian, abdominal, or cervical Risk factors:- Anatomic alteration of the fallopian tubes: → History of PID→ Previous ectopic pregnancy→ Past surgeries involving the fallopian tubes→ Endometriosis→ Exposure to DES (diethylstilbestrol) in utero→ Bicornuate uterus: Risk factor for interstitial pregnancy- Intrauterine device (IUD)- History of infertility- Hormone therapy Clinical features:- Abdominal pain and vaginal spotting/bleeding, some asymptomatic- Signs of pregnancy: amenorrhea, nausea, breast tenderness, frequent urination- Cervical motion tenerness, closed cervix- Interstitial pregnancies tend to present late, at 7-12 weeks of gestation, because of myometrial distensibility Tubal rupture- Acute course with sudden and severe lower abdominal pain (acute abdomen)- Signs of hemorrhagic shock: e.g., tachycardia, hypotension, syncope- More common in interstitial pregnancy Diagnosis:1. Pregnancy test and a transvaginal ultrasound → Empty uterine cavity in combination with a thickened endometrial lining→ Tubal ring sign→ Possibly free fluid within the pouch of Douglas2. Confirm with a serial hCG without appropriate hCG doubling Treatment:- Methotrexate is sufficient for small, unruptured tubal pregnancies- Surgical options for salpingectomy or salpingostomy with evacuation- Anti-D immunoglobulin (RhoGAM) Complications: Tubal rupture and hemoperitoneum
• Placental abruption The partial or complete separation of the placenta from the uterus prior to delivery.  Epidemiology:- Incidence: ∼ 0.2-1% of pregnancies- Occurs most often in the third trimester- The recurrence rate in subsequent pregnancies is 3-15% Risk factors: - Hypertension (most common cause)- Preeclampsia/eclampsia- Trauma (up to 10% of cases): car accidents, falls, iatrogenic (e.g., post-amniocentesis)- Previous abruption, chorioamnionitis, prolonged rupture of membranes, short umbilical cord- Sudden decrease in intrauterine pressure- Maternal age: < 20 years and > 35 years- Alcohol and cigarette consumption, cocaine use Clinical features:- Continuous, dark, vaginal bleeding - In ∼ 20% of cases, the hemorrhage is mainly retroplacental (concealed abruptio placentae)- Abdominal pain or back pain, uterine tenderness- Hypertonic contractions (rigid uterus), premature labor- Fetal distress (60% of cases)→ Possible diminished or absent fetal movement→ Decelerations seen on fetal heart monitor- Vaginal exam contraindicated: may worsen bleeding!In cases of retroplacental hemorrhage, patients may present with signs of hypovolemic shock without evident vaginal bleeding! Diagnosis: Clinical- Ultrasound (transabdominal, transvaginal): only 25% sensitivity!→ Presentation of the placental position and a possible retroplacental hematoma- Fetal heart rate monitoring- Laboratory tests: CBC, coagulation factors Management: - Hemodynamic control- RhD prophylaxis in RhD negative mothers- Up to the 34th week: Fetal lung maturity induction with corticosteroids (e.g., betamethasone); Aim for a normal delivery- 34th to 36th week: Active uterine contractions present: vaginal delivery; No contractions + no signs of fetal distress + bleeding has stopped: expectant management and observation- All pregnancies are delivered if acute abruption occurs after 36th weeks Complications: - Intrauterine fetal death (occurs in ∼ 12% of cases) - Maternal DIC and hypovolemic shock- Couvelaire uterus→ Retroplacental hemorrhage may extend through the uterus into the peritoneum.→ The myometrium is weakened, with possible subsequent uterine rupture during contractions.
• Placenta previa Presence of the placenta in lower uterine segment, which might lead to partial or full obstruction of the neck of the uterus with high risk of hemorrhage (rupture of placental vessels) and birth complications. Epidemiology: ∼ 0.3-0.5% of all pregnancies Risk factors- Maternal age > 35 years- Multiparity- Short intervals between pregnancies- Previous curettage or cesarean section- Previous placenta previa, previous/recurrent abortion Clinical features:- Sudden, painless, bright red vaginal bleeding- Usually occurs during the 3rd trimester (before rupture of the membranes), stops spontaneously after 1-2 hours, and recurs during birth- Often causes preterm delivery (∼ 45% of cases)- Soft, nontender uterus- Usually no fetal distress Diagnosis:- Transvaginal ultrasound to assess the position of the placenta- Digital vaginal examinations are contraindicated in cases of hemorrhage of unknown cause! Management: - Gestational age < 37 weeks→ No active bleeding AND no evidence of fetal distress: expectant management→ Active bleeding OR evidence of fetal distress: immediate delivery- Gestational age > 37 weeks: immediate delivery- If gestational age < 34 weeks: fetal lung maturity induction with corticosteroids (e.g., betamethasone)- Route of delivery: Lower segment cesarean section Complications: ↑ risk of placenta accreta, vasa previa, preterm delivery, PROM, IUGR, congenital anomalies. 
• Intrauterine growth restriction (IUGR) Defined as an estimated fetal weight ≤ 10th percentile for gestational age. There are two types of IUGR: asymmetrical and symmetrical. Pathophysiology:- Asymmetrical IUGR: Caused by extrinsic factors, which affect the fetus in the later stages of gestation (i.e., third trimester).- Symmetrical IUGR: Caused by intrinsic factors (e.g., genetic abnormalities, infections), which affect the fetus in the early stages of gestation. Diagnosis:- Serial ultrasonography→ Fetal weight below the 10th percentile of a given gestational age→ Small placenta→ Oligohydramnios→ Further assessment of the placenta (e.g., diagnosis of placenta previa and/or calcifications can be a sign of chronic placental impairment) - Doppler velocimetry of umbilical artery: reduced or reversed diastolic flow; ↑ systolic/diastolic ratio- Nonstress test: late decelerations of the fetal heartbeat, bradycardia- Biophysical profile Treatment:- Explore the underlying etiology and correct if possible- Administer steroids to accelerate fetal lung maturity- Perform fetal monitoring with NST, CST, BPP, and umbilical artery Doppler velocimetry Complications: ↑ perinatal morbidity and mortality
• Fetal macrosomia Birth weight > 90th percentile or > 4000-4500 g.A common sequela of gestational diabetes. Diagnosis: Weigh the newborn at birth (prenatal diagnosis is imprecise) Treatment: Planned cesarean delivery may be considered for an EFW > 5000 g in women without diabetes and for an EFW > 4500 g in women with diabetes Complications: ↑ risk of shoulder dystocia (leading to brachial plexus injury and Erb-Duchenne palsy)
• Polyhydramnios Excessive amniotic fluid volume (> 2000 mL in the third trimester) that results in uterine distention and is associated with an increased risk of fetal complications. Etiology: - Fetal anomalies: Esophageal atresia, duodenal atresia and stenosis, anencephaly, meningomyelocele (due to leaking cerebrospinal fluid)- Chromosomal aberrations- Intrauterine infections (e.g., congenital TORCH infections)- Multiple pregnancy: twin-to-twin transfusion syndrome- Maternal conditions: Diabetes mellitus- Rhesus incompatibility: hemolytic disease of the newborn Diagnosis:- Abdominal girth and uterine size large for gestational age- Ultrasound: AFI ≥ 24 cm- Assess for fetal anomalies Treatment:- Amnioreduction: drainage of excess amniotic fluid- Glycemic control in diabetic mothers- Intrauterine exchange transfusion for newborns with hemolytic disease Complications:- Fetal malposition- Umbilical cord prolapse- Premature rupture of membranes- Premature uterine contractions- Premature birth
• Oligohydramnios Amount of amniotic fluid < 500 mL in the third trimester. Etiology:- Fetal anomalies: Urethral obstruction (e.g., posterior urethral valves), bilateral renal agenesis, ARPKD- Chromosomal aberrations (e.g., trisomy 18)- Intrauterine infections (e.g., congenital TORCH infections)- In multiple pregnancies: twin-to-twin transfusion syndrome- Maternal conditions: Late or post-term pregnancies (> 42 weeks of gestation), placental insufficiency, preeclampsia, premature rupture of membranes Diagnosis:- Abdominal girth and uterine size small for gestational age- Amniotic fluid index (AFI): semiquantitative tool to assess amniotic fluid volume (normal: > 5–24 cm)→ Oligohydramnios: AFI ≤ 5 cm- Assess for fetal anomalies Treatment:- Amnioinfusion: infusion of fluid into the amniotic cavity through amniocentesis- Treat underlying cause - Delivery is advised if the fetus is close to term. Complications: Associated with a 40-fold ↑ in perinatal mortality. Musculoskeletal abnormalities (e.g. clubfoot, facial distortion), pulmonary hypoplasia, umbilical cord compression, and IUGR.
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• Rh isoimmunization Fetal RBCs leak into the maternal circulation and maternal anti-Rh IgG antibodies form that can cross the placenta, leading to hemolysis of fetal Rh RBCs (erythroblastosis fetalis). There is an ↑ risk among Rh (-) women who have had a previous SAB or TAB as well as among those who have undergone a previous delivery with no RhoGAM given Diagnosis: Sensitized Rh (-) mothers with titers >1:16 should be closely monitored with serial ultrasound and amniocentesis for evidence of fetal hemolysis Treatment: In severe cases, initiate preterm delivery when fetal lungs are mature. Prior to delivery, intrauterine blood transfusions may be given to correct a low fetal hematocrit. Prevention:- If the mother is Rh (-) at 28 weeks and the father is Rh (+) or unknown, give RhoGAM (Rh immune globulin)- If the baby is Rh (+), give RhoGAM postpartum- Give RhoGAM to Rh (-) mother who undergo abortion or who have had an ectopic pregnancy, amniocentesis, vaginal bleeding, or placenta previa/placental abruption. Type and screen is critical. Complications: Hydrops fetalis occurs when fetal hemoglobin drops to <7g/dL. Fetal hypoxia and acidosis, kernicterus, prematuriy, death.
• Gestational trophoblastic disease Complete moles: Usually result from sperm fertilization of an empty ovum; 46,XX (paternally derived)Incomplete (partial moles): Occur when a normal ovum is fertilized by two sperm; usually 69,XXY and contain fetal tissue Risk factors:- Prior molar pregnancy- History of miscarriage- Patients ≤ 15 and ≥ 35 years- Diet deficient in folate or beta-carotene Clinical features:- Presents with first-trimester uterine bleeding (most common)- Uterus size greater than normal for gestational age- Preeclampsia (before the 20th week of gestation)- Hyperemesis gravidarum- Ovarian theca lutein cysts: bilateral, large, cystic, adnexal masses that are tender to the touch- Hyperthyroidism- Partial mole: Less severe symptoms due to β-HCG levels that are lower than in complete moles Diagnosis:- Lab show ↑ serum β-hCG (usually >100'000 mIU/mL)- Transvaginal ultrasound→ Theca lutein cysts→ Echogenic mass interspersed with many hypoechogenic cystic spaces that represent hydropic villi (referred to as “swiss cheese,” “bunch of grapes,” or “snowstorm”)→ No amniotic fluid→ Lack of fetal heart tones- Chest x-ray: in case of dyspnea or chest pain- Uterine evacuation (for definite diagnosis and treatment): histopathological examination of evacuated uterine specimen Treatment: - Uterine evacuation by dilation and suction curettage- Monitor β-HCG levels until in reference range (usually 8-12 weeks)- Chemotherapy (usually methotrexate) if unresolved (β-hCG values do not decrease, histological features of malignant GTD are present, metastases are present on chest x-ray) Complications: Molar pregnancy may progress to malignant GTD, including invasive moles (10-15%) and choriocarcinoma (2-5%) with pulmonary or CNS metastases. Trophoblastic pulmonary emboli may also be seen.
• Fetal malpresentation Defined as any presentation other than vertex (i.e. head closest to birth canal, chin to chest, occiput anterior).  Risk factors include prematurity, prior breech delivery, uterine anomalies, poly- or oligohydramnios, multiple gestations, PPROM, hydrocephalus, anencephaly, and placenta previa. History/PE: Breech presentaitons are the most common form (affect 3% of deliveries) and involve presentation of the fetal lower extremities or buttocks into the maternal pelvis. - Frank breech (50-75%): The thighs are flexed and the knees are extended- Footling breech (20%): One or both legs are extended below the buttocks- Complete breech (5-10%): The thighs and knees are flexed Treatment:- Follow: Up to 7% spontaneously change to vertex by week 38- External version. Risks are placental abruption and cord compression.- Trial of breech vaginal delivery: Attempt only if delivery is imminent; otherwise contraindicated. Complications include cord prolapse and/or head entrapment.- Elective C-section: Recommended
• Indications for cesarean section For both elective and indicated cesarean delivery, sodium citrate should be used to ↓ gastric acidity and prevent acid aspiration syndrome. Maternal factors:- Prior classical C-section (midline)- Active genital herpes or HIV infection- Cervical carcinoma- Maternal trauma Fetal:- Fetal malposition (e.g. posterior chin, transverse lie, shoulder presentation)- Fetal distress- Cord compression/prolapse- Erythroblastosis fetalis  Both:- Cephalopelvic disproportion (most common cause of 1° C-section)- Placenta previa/placental abruption- Failed operative vaginal delivery- Post-term pregnancy (relative)
• Uterine atony Failure of the uterus to effectively contract and retract after complete or incomplete delivery of the placenta, which can lead to severe postpartum bleeding from the myometrial vessels. Epidemiology: responsible for ∼ 80% of PPH cases Risk factors: overdistention of the uterus- Multiple pregnancy- Post-term pregnancy- Instrumental delivery- Anatomical abnormalities (i.e., fetal, uterine, abnormal placental implantation)- Large for gestational age newborn (e.g., > 4000 g) Clinical findings:- Abnormal vaginal bleeding- Soft, enlarged (increased fundal height), boggy ascending uterus Treatment:1. General measures: Monitoring, adequate large-bore IV access (≥ 16 gauge), ice pack, fluid therapy, oxygenation2. Bimanual uterine massage3. Tranexamic acid: give ASAP to stop fibrinolysis and to reduce mortality4. Uterotonic agents as needed:→ IV oxytocin (diluted in saline)→ IM carboprost or PGF-2α (contraindicated in patients with asthma)→ IM methylergonovine (if no hypertension or arterial disease is present)→ Rectal misoprostol (useful when injectable uterotonic agents are unavailable or contraindicated)
• First-trimester evaluation Initial examination (~10 weeks' gestation):- Personal and family history, previous pregnancies- Screen for violence at home, barriers to care- Gynecological examination (ultrasound, bimanual exam)- Blood pressure- Weight- Laboratory analysis: → Complete blood count→ Hemoglobin: screening for anemia→ Blood typing (ABO and rhesus) → Rhesus negative mothers: prophylactic anti-D immunoglobulins at 28 weeks to prevent alloimmunization- Urine dipstick protein testing: screen and treat asymptomatic bacteriuria!- Screening for STIs→ HIV testing → Gonorrhea, Chlamydia, and Syphilis screening → Hepatitis B surface antigen testing → Rubella and varicella titers- PAP smear- General advice for pregnant women:→ Vaccination against seasonal influenza recommended to all women→ Nutritional recommendations → Tdap vaccine during the 3rd trimester of every pregnancy to provide fetal immunity to pertussis Frequency of check-ups:- Until the 28th week of pregnancy: monthly- From the 28th week until the 36th week: every two weeks- From the 36th week until birth: every week
• Genetic screening First-trimester screening:- Timing: 11-13 weeks gestation→ Sonographic nuchal translucency (NT)→ β-HCG (human chorionic gonadotropin) in maternal serum→ PAPP-A (pregnancy-associatedprotein A) in maternal serum- Risk of aneuploidy is evaluated based on maternal age, lab results, and ultrasound.Trisomy 21: ↑ HCG, ↓ PAPP-A, thickened NT (> 95th percentile)Trisomy 18: ↓ HCG, ↓↓ PAPP-A, ↑ NTTrisomy 13: ↓↓ PAPP-A, ↑ NTNeural tube defects: ↑ HCG Second trimester screening: Quad screen test- Timing: 15-20 weeks gestation→ In maternal serum: HCG, Alpha-fetoprotein (AFP), Estriol, Inhibin A- Risk is evaluated based on maternal age, lab results, and ultrasound.Trisomy 21: ↑ β-HCG, ↓ AFP, and ↓ free estriol, ↑ inhibin ATrisomy 18: ↓↓ β-HCG, ↓ AFP, and ↓↓ free estriol, ↔ inhibin ANeural tube defects: ↑ AFPAbdominal wall defects: ↑ AFP Cell-free fetal DNA testing (cffDNA):- Timing: From 10 weeks gestation onwards- Fetal DNA is isolated from a maternal blood specimen for genetic testing- Identifies chromosomal aberrations (high specificity and sensitivity for trisomy 21 > trisomy 18 > trisomy 13)- Determine the gender of the fetus Chorionic villus sampling (CVS):- Timing: 10-13 weeks- Transcervical or transabdominal removal of chorionic tissue under sonographic guidance- Analysis of DNA for genetic diagnosis in early pregnancy- Complications: Miscarriage (approximate risk: 2-3%) Amniocentesis:- Timing: From the 15th week of pregnancy onwards- AF is extracted under sonographic guidance via transabdominal puncture for diagnostic purposes- Complications: Miscarriage (approximate risk: 0.5-1%); Premature rupture of the membranes
• Gestational diabetes Impaired glucose tolerance diagnosed during pregnancy; associated with an increased risk of maternal and fetal morbidity. Epidemiology:- Occurs in 5-7% of all pregnancies- Usually in the second and third trimesters Risk factors:- Major risk factors for type 2 diabetes- Gestational diabetes in prior pregnancy- Recurrent pregnancy loss- At least one birth of a child diagnosed with fetal macrosomia Screening and diagnostics:- First and second trimester (the first 24 weeks of pregnancy): the diagnosis of diabetes mellitus and gestational diabetes is confirmed with two independent measurements ≥ 126 mg/dL and 92-125 mg/dL respectively- Third trimester (at 24-28 weeks): Recommended in all pregnancies!→ Initial screening: 50-g, one-hour oral glucose challenge test: positive if > 140 mg/dl→ Confirmation test: 100-g, three-hour oral glucose tolerance test (oGTT): positive if  > 140 mg/dl (fasting > 95; 1 hour > 180; 2 hour > 155) Treatment:- Dietary modifications and regular exercise (walking)- Strict blood glucose monitoring (4x daily)- Insulin therapy if glycemic control is insufficient with dietary modifications- Metformin and glyburide in patients who refuse insulin therapy- Regular ultrasound to evaluate fetal development- Consider inducing delivery at week 39-40 if glycemic control is poor or if complications occur Complications:- Gestational hypertension- Preeclampsia, eclampsia, and HELLP syndrome- Urinary tract infection- Diabetic fetopathy
• Stages of labor First stage = Period from the onset of labor until complete dilation of the cervix has occurred- Latent phase→ Occurs during onset of labor (regular contraction) → ends at 6 cm of cervical dilation→ Characterized by mild, infrequent, irregular contractions with gradual change in cervical dilation (< 1 cm per hour).→ Duration: Primipara: < 20 hours; Multipara: < 14 hours- Active Phase→ Occurs after the latent phase at ≥ 6 cm of cervical dilation → ends with complete (∼ 10 cm) cervical dilation→ Characterized by an increase in the rate of cervical dilation (1-4 cm per hour)- Spontaneous rupture of membranes usually occurs during the onset of labor. Second stage = Period that begins once the cervix is completely dilated and ends with the birth of the infant- Duration: Primipara: < 3 hours; Multipara: < 2 hours- Regular uterine contractions increasing in frequency and intensity- Crowning: the appearance of the fetus's head at the vaginal opening as contractions progress- Delay cord clamping for ∼ 1 minute; alternatively milk the cord (to enhance blood transfusion to the newborn) Third stage = Period that begins with the birth of the infant and lasts until the complete expulsion of the placenta- Duration: 30 minutes- Uterine contractions (in order to expel the placenta)- Fundal massage: massaging of the uterine fundus to induce its contraction and stop bleeding- Oxytocin, administered after cutting the umbilical cord (reduces blood loss by inducing stronger uterine contractions)- Controlled traction while allowing the placenta to separate spontaneously (Brandt-Andrews maneuver)- Examine the placenta to confirm completeness, which should also consist of the umbilical cord, complete amniotic membranes, and 3 blood vessels (one vein, two arteries). Fourth stage = 2-hour postpartum period- Requires monitoring to rule out hemorrhage or preeclampsia
• Obstructed labor Arrest of vaginal delivery because of a mechanical obstruction. Etiology:- Fetal: malpresentations, malpositions, congenital anomalies, macrosomia- Maternal: bony or soft tissue masses in maternal pelvis Clinical features:- High presenting part; not engaged; ruptured membranes- Moulding: extent of overlap of the fetal skull bones; excessive during obstructed labor- Caput succedaneum (= A scalp swelling that is formed in the neonate by the stagnation of fluid within the layers of the scalp)- Frequent uterine contractions- Edematous vulva Management:- Cesarean section for any maternal etiologies or congenital anomalies- Compound presentation→ If the head is engaged → forceps delivery with/without repositioning of the arm→ If head is not engaged → cesarean section- Transverse lie: Cesarean delivery is recommended- Persistent occiput posterior position: Lateral positioning of the mother to achieve a 90° rotation of the fetal head, stimulate uterine contractions- Breech presentation→ No intervention necessary before 37 weeks' gestation, as most fetuses spontaneously convert to cephalic presentation as they get closer to term→ External cephalic version: Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery, unless there are contraindications.→ Cesarean section: if external cephalic version is unsuccessful or contraindicated (e.g., in active labor, fetal distress)
• Abnormal labor Etiology: the 3 P's - Pelvis: size and shape of the maternal pelvis (e.g., small bony pelvis)- Passenger: size and position of the infant (e.g., fetal macrosomia or abnormal orientation)- Power: strength and frequency of contractions (e.g., dysfunctional contractions) Prolonged first stage:- Prolonged latent phase: > 20 h in a primipara; > 14 h in a multipara→ Management: Rest, hydration, analgesia; oxytocin may be considered- Prolonged active phase: < 1.2 cm/h in primipara; < 1.5 cm in a multipara→ Management: Augmentation with oxytocin for hypotonic contractions + analgesia - Arrested active phase: ≥ 6 cm cervical dilation with ruptured membranes and no cervical change for ≥ 4 hours→ Management: Cesarean section Prolonged second stage: Failed delivery of the baby after 3 h in a primipara and after 2 h in a multipara- Management:→ Augmentation with oxytocin if uterine contractions are inadequate and progress is > 1 cm after 60-90 minutes of pushing→ Trial of forceps or vacuum delivery if the fetal head is engaged AND maternal contractions are adequate→ Cesarean section if the fetal head is not engaged Prolonged third stage of labor: Failed delivery of the placenta after 30 minutes- Managment→ Manual removal of the placenta→ Hysterectomy if the above approach fails
• Premature rupture of membranes (PROM) Rupture of membranes occurring before onset of labor at term. Epidemiology: ∼ 15% of pregnancies Risk factors:- Ascending infection (common)- Cigarette smoking- Multiple pregnancy- Previous PPROM Clinical features: Sudden “gush” of pale yellow or clear fluid from the vagina  Diagnosis:- Sterile speculum examination→ Litmus test or nitrazine test: test strips turn blue→ Positive fern test: fern pattern on glass slide→ Positive IGF1: IGF1, normally present in amniotic fluid, appears in the cervix if membranes rupture. Complications:- Umbilical cord prolapse- Placental abruption- Chorioamnionitis
• Preterm premature rupture of membranes (PPROM) Rupture of membranes before onset of uterine contractions AND before 37 weeks' gestation. Epidemiology: occurs in 2-5 % pregnancies Risk factors: - Previous PPROM- Genitourinary infection (e.g., asymptomatic bacteriuria, bacterial vaginosis)- Antepartum bleeding Diagnostics:- Vaginal pooling or fluid from cervix- Nitrazine-positive (blue) fluid- Ferning on microscopy Management:- < 32 weeks: Antenatal corticosteroids, tocolytics, magnesium sulfate, penicillin if GBS positive or unknown, and planned delivery ≥ 34 weeks- 32-33 6/7 weeks: Antenatal corticosteroids, penicillin if GBS positive or unknown- ≥ 34 weeks: Delivery of the fetus is usually recommended- Unstable patients: require prompt delivery of the fetus Complications:- Preterm delivery- Pulmonary hypoplasia- Intraamniotic infection- Placental abruption- Umbilical cord prolapse
• Chorioamnionitis Etiology:- Infection of the amniotic fluid, fetal membranes, and placenta- Most commonly due to Ureaplasma urealyticum (up to 50% of cases), Mycoplasma hominis (up to 30% of cases), Gardnerella vaginalis, bacteroides, group B Streptococcus, E. coli Risk factors:- Prolonged labor or premature rupture of membranes (PROM)- Pathological bacterial colonization of vaginal tract (e.g., STDs, frequent UTIs)- Iatrogenic: multiple digital vaginal exams, invasive procedures (e.g., amniocentesis) Clinical features:- Fever (> 38 °C or > 100°F)- Tachycardia > 120/min- Uterine tenderness, pelvic pain- Malodorous and purulent amniotic fluid, vaginal discharge- Premature contractions, PROM- Fetal tachycardia > 160/min in cardiotocography Diagnostics: Chorioamnionitis is a clinical diagnosis (fever plus ≥ 1 additional symptom). - Leukocytosis > 15'000 cells/μL (∼ 70-90% of cases)- ↑ CRP- Bacterial cultures- Group B Streptococcus screening: cervicovaginal and rectal swabs Management:- Vaginal birth: IV ampicillin + gentamicin (broad coverage)- Cesarean birth: IV ampicillin + gentamicin + clindamycin (anaerobe coverage to minimize post-cesarean complications, e.g., endometritis)- Swift delivery is generally indicated to minimize both maternal and fetal complications.- Cesarean section is not generally indicated, but is often necessary because of obstetrical complications (e.g., insufficient contractions).
• Preterm labor Regular uterine contractions with cervical effacement, dilation, or both between 20-37 weeks gestation. Epidemiology: - Preterm birth rate in the US: approx. 12% of all live births- Leading cause of neonatal morbidity and mortality Risk factors:- History of preterm birth- Cervical insufficiency- Multiple gestation- Infections- Polyhydramnios- Hypertensive pregnancy disorders- Diabetes mellitus, gestational diabetes- Uterine anomalies (e.g., anomalies of Mullerian duct fusion, uterine fibroids)- Placenta previa- Placental abruption- Smoking/Substance use (e.g., alcohol or drugs)- Maternal age (< 18 years, > 40 years) Clinical features: - Regular uterine contractions and associated symptoms of labor- Cervical dilation ≥ 3 cm, effacement, or both- Premature rupture of membranes Treatment:- Single course of antenatal steroids (IM betamethasone or IM dexamethasone)→  Indication: 24-34 weeks gestation with a risk of delivery within the next 7 days- Tocolysis: administration of tocolytics (beta-agonists, NSAIDs) to inhibit uterine contractions and prolong pregnancy→ Recommended for up to 48 hours to enable administration of antenatal corticosteroids in preterm labor→ First-line: beta-adrenergic agonists, NSAIDs, or calcium-channel blockers (nifedipine)→ Second-line: Magnesium sulfate- Antibiotics for group B streptococcus (GBS) prophylaxis
• Eclampsia Severe form of preeclampsia with convulsive seizures and/or coma. Epidemiology: < 0.1% of all deliveries Clinical features:- Onset: the majority of cases occur in the intrapartum and postpartum period- Most often associated with severe preeclampsia (but can be associated with mild preeclampsia)- Warning signs: headaches, RUQ pain, hyperreflexia, and visual changes- Eclamptic seizures: generalized tonic-clonic seizures (usually self-limited) Management:- Stabilization: Airway management, supplemental oxygenation- Magnesium sulfate IV (first-line). Antidote: calcium gluconate IV if early signs of magnesium toxicity (decreased deep tendon reflexes, respiratory depression)→ Alternative or supportive: lorazepam or diazepam IV if unresponsive to magnesium sulfate- Position patient on left lateral decubitus position → prevent placental hypoperfusion through compression of the inferior vena cava and reduce the risk of aspiration in the mother - Delivery: once the mother is stable and seizures have stopped.
• HELLP syndrome A life-threatening form of preeclampsia HELLP is an acronym: H = hemolysis; EL = elevated liver enzymes; LP = low platelets Epidemiology: ∼ 0.5% of all pregnancies Clinical features:- Onset: most commonly > 27 weeks gestation (30% occur postpartum)- Preeclampsia usually present (∼ 85%) - Nonspecific symptoms: nausea, vomiting, diarrhea- RUQ pain (liver capsule pain; liver hematoma)- Rapid clinical deterioration (DIC, pulmonary edema, acute renal failure, stroke, abruptio placentae) Management:- IV fluids- Blood transfusions- Antihypertensive agents (labetalol, hydralazine)- Magnesium sulfate for seizure prophylaxis- Delivery if ≥ 34 weeks gestation or at any gestational age with deteriorating maternal or fetal status (If the fetus is viable, delay labor until 24-48 h after corticosteroid administration)
• Multiple pregnancy Predisposing factors:- Advanced maternal age (> 35 years)- Previous multiple pregnancy- Use of fertility enhancing treatments- Maternal family history of dizygotic twins Dizygotic twins:- ⅔ of all twin pregnancies- Fertilization of two oocytes with two spermatozoa- Dichorionic-diamniotic Monozygotic twins:- Dichorionic-diamniotic (∼ 20-30%; separate day 0-3): Each twin has an individual amniotic sac and placenta.- Monochorionic-diamniotic (∼ 70%; separate day 4-8): The twins share a placenta and have individual amniotic sacs.→ Complications: Twin-twin transfusion- Monochorionic-monoamniotic (∼ 1-5%; separate day 9-12): The twins share both the placenta and amniotic sac.→ Complications: Cord entanglement, conjoined twins Diagnostics:- Fundal height and abdominal girth are unusually large for the gestational age.- Two or more fetal heart rates can be heard on auscultation.- Ultrasound→ Dichorionic twins: lambda sign→ Monochorionic twins: T-sign Prenatal care:- Frequent early evaluations for monochorionic twins to assess for twin-twin transfusion syndrome- From the 32nd week of pregnancy: weekly prenatal care visits, including ultrasound, to monitor fetal growth
• Postpartum hemorrhage Definitions:- Blood loss > 500 mL after vaginal birth - Blood loss > 1000 mL for cesarean section - Primary PPH (most common): blood loss within 24 hours- Secondary PPH: blood loss from 24 hours to 12 weeks postpartum Risk factors:- Prolonged or induced labor- Chorioamionitis- Multiple gestation- Polyhydramnios- Grand multiparity- Operative delivery Etiology:- Uterine atony (most common)- Retained placnta- Genital tract laceration- Uterine rupture- Bleeding diathesis Complications:- Thromboembolism- Sheehan syndrome- Abdominal compartment syndrome Treatment:1. General measures: oxygenation, IV fluids2. Bimanual uterine massage3. Tranexamic acid: give ASAP to stop fibrinolysis and to reduce mortality4. Uterotonics: IV oxytocin, methylergonovine, carboprost (if no asthma), misoprostol5. Intrauterine balloon tamponade6. Uterine artery embolization7. Last resort: Hysterectomy
• Abnormal placenta separation Abnormal placental attachment = Defective decidual layer of the placenta leading to abnormal attachment and separation during postpartum period Epidemiology: 0.2-1% of all pregnancies Risk factors: prior damage to the endometrium- History of uterine surgery (e.g., endometrial ablation, hysteroscopic removal of intrauterine adhesions, dilatation, and curettage)- Prior births by cesarean section- Placenta previa Types: - Placenta accreta (80% of cases): chorionic villi attach to the myometrium (but do not invade or penetrate the myometrium) rather than decidua basalis. - Placenta increta (15% of cases): chorionic villi invade or penetrate into the myometrium.- Placenta percreta (5% of cases): chorionic villi penetrate the through the myometrium, penetrate the serosa, and in some cases, adjacent organs (e.g., rectum or bladder) Clinical features:- Retained products of conception (RPOC): any placental fragments or membranes that remain within the uterus due to abnormal placental separation in the postpartum period, suggested by:- Abnormal uterine bleeding or postpartum hemorrhage at the time of attempted manual separation of the placenta- Fever- Pelvic or uterine tenderness Treatment: If the placenta does not separate within 30 minutes after birth or there is evidence of postpartum hemorrhage, the following measures are to be taken:1. General measures: Monitoring, adequate large-bore IV access (≥ 16 gauge), ice pack, IV fluids, oxygenation2. Brandt-Andrews maneuver: One hand is placed on the abdomen, securing the uterine fundus and preventing uterine inversion. The other hand applies steady downward traction on the umbilical cord.3. Uterotonic agents- Oxytocin- Carboprost (Prostaglandin F2-alpha)4. If only partial removal of placenta is suspected: postpartum inspection of the placenta and fetal membranes → sonography to locate the succenturiate placenta5. Manual palpation, followed by dilation and curettage (D&C) or vacuum removal of RPOC under anesthesia/regional anesthesia and high-dose IV administration of uterotonic agents 6. Last resort: hysterectomy Follow up: serial β-hCG with oral contraception
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• Uterine inversion Obstetric emergency in which the uterine fundus collapses into the endometrial cavity, turning the uterus partially or completely inside out following vaginal birth. Risk factors:- Nulliparity- Cord traction (Brandt-Andrews maneuver) and excessive fundal pressure (Crede's maneuver) during the third stage of labor- Difficult removal of the placenta- Use of uterine muscle relaxants (e.g., magnesium sulfate)- Fetal macrosomia- Uterine anomalies (e.g., relaxed lower uterine segment and cervix) or tumors- Placenta accreta- Previous uterine inversion Clinical findings:- Brisk postpartum hemorrhage- Round mass (inverted uterus) protruding from the cervix or vagina- Absent fundus (top of the uterus) at the periumbilical position during transabdominal palpation Diagnosis: based on clinical findings; ultrasound (hyperechoic mass in the vagina with central hypoechoic cavity) confirms diagnosis in uncertain cases Treatment:- Discontinue oxytocin- Administer crystalloids and blood products as needed- Reposition uterus manually, if impossible → administer uterine relaxant (e.g., nitroglycerine, terbutaline, or magnesium sulfate), if ineffective → surgical repair- Following successful uterine repositioning: oxytocin to induce placental extraction and prevent reinversion
• Antepartum fetal surveillance Nonstress test (NST) = a noninvasive test (CTG) that measures FHR reactivity to fetal movements- Indications: maternal medical conditions (e.g., gestational diabetes, preeclampsia) or fetal conditions (e.g., fetal heart defects, fetal growth restriction)- Usually performed in the third trimester (after the 32nd gestational week)- A normal NST would show ≥ 2 FHR accelerations.- Reactive nonstress test: if the nonstress test is normal→ High-risk conditions: weekly nonstress tests→ Uncomplicated pregnancy: reassurance and discharge- Non-reactive nonstress test: if the NST is nonreactive (< 2 FHR accelerations)1. Perform vibroacoustic stimulation and record the NST for another 20 minutes2. If the NST is still non-reactive: check the biophysical profile (BPP) or perform contraction stress test Contraction stress test (CST): measures FHR reactivity in response to uterine contractions. Such contractions are stimulated with oxytocin administration. Biophysical profile (BPP): a noninvasive test that evaluates the risk of antenatal fetal death, usually performed after the 28th gestational week→ Ultrasound exam: Fetal movement, fetal tone, fetal breathing, amniotic fluid volume→ NST (optional, not always performed)- Interpretation→ Total score ≥ 8 points: no signs of fetal compromise at the time of testing → reassurance→ Total score ≤ 4 points: potential fetal compromise → delivery is indicated (if pregnancy duration is < 32 0/7 weeks, administer steroids and continue close monitoring)
• Vasa previa Condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture. Epidemiology: 1/2500 births Risk factors:- Placental anomalies (e.g., bilobate or succenturiate placenta, velamentous umbilical cord insertion)- Placenta previa- Multiparity- In-vitro fertilization Clinical features:- Painless vaginal bleeding (fetal blood) that occurs suddenly after rupture of membranes- Fetal distress (e.g., fetal bradycardia; decelerations or sinusoidal pattern on fetal heart tracings) Diagnostics:- Transabdominal or transvaginal ultrasound with color Doppler shows fetal vessels overlying the internal os and decreased blood flow within fetal vessels Treatment: Emergency cesarean if there are signs of fetal distress
• Cervical insufficiency Painless cervical dilation, in the absence of uterine contractions and/or labor, in the second trimester of pregnancy. Risk factors:- Previous midtrimester pregnancy loss and/or preterm birth- Previous obstetric or gynecological trauma (e.g., termination of pregnancy, rapid delivery, multiple gestations, or cervical conization)- Cervical connective tissue weakness (e.g., Ehlers-Danlos syndrome) Clinical features:- Painless cervical dilation with or without prolapsed membranes- Pelvic cramps or back ache (contractions are usually minimal or absent!)- ↑ Volume, changed color (yellow or blood-stained), and/or thinner consistency of vaginal discharge Diagnosis:- Clinical diagnosis typically before 24 weeks' (may be up to 28 weeks') gestation; or- History of ≥ 2 previous midtrimester pregnancy losses or ≥ 3 preterm births not explained by any other cause, and a transvaginal ultrasound cervical length < 25 mm before 24 weeks' gestation Treatment:- Serial cervical ultrasound monitoring should be commenced in high-risk women (i.e., previous preterm birth) between 16-24 weeks' gestation.- Cervical cerclage- Vaginal progesterone supplementation- Strict bed rest is not recommended
• Forceps delivery A forcep is a metal device that enables gentle rotation and/or traction of the fetal head during vaginal delivery. Indications:- Prolonged second stage of labor- Breech presentation- Nonreassuring fetal heart rate- To avoid/assist maternal pushing efforts Prerequisites:- Skilled clinician- Full cervical dilation- Engagement of the fetal head- Knowledge of exact position and attitude of the fetal head- Emptied maternal bladder Advantages (compared to vacuum delivery):- Scalp injuries are less common- Cannot undergo decompression and “pop off” Complications:- Maternal: obstetric lacerations (cervix, vagina, uterus)- Fetal: head or soft-tissue trauma (e.g., scalp lacerations, injured ears), facial nerve palsy
• Vacuum delivery A vacuum extractor is a metal or plastic cup, attached to the fetal head with a suction device, that enables traction of the fetal head during vaginal delivery. Indications:- Prolonged second stage of labor- Nonreassuring fetal heart rate- To avoid/assist maternal pushing efforts Prerequisites:- Skilled clinician- Gestation ≥ 34 weeks- Engagement of the fetal head- Full cervical dilation- Emptied maternal bladder Advantages (compared to forceps delivery):- Requires minimum space- ↓ incidence of third- and fourth-degree perineal tears- Less knowledge about exact position and attitude of the fetal head is acceptable Complications:- Maternal: suction of maternal soft tissue → hematomas or lacerations- Fetal: cephalohematoma, scalp lacerations, life-threatening head injury (e.g., intracranial hemorrhage or subgaleal hematoma)
• Cesarean section The delivery of a newborn through a vertical or horizontal incision in the lower abdominal and uterine wall. Indications:Primary cesarean section:- Placenta praevia totalis- Refractory HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), severe preeclampsia- Severe uterine abnormalities (e.g., myoma) of the mother- Maternal skeletal deformities- Fetal growth retardation with circulatory depression- Premature birth, if further risk factors are present, e.g., infection- Fetal malformations that hinder a natural birth (e.g., severe hydrocephalus) Secondary cesarean section (after PROM and/or onset of phase 1):- Prolonged labor in: → Premature birth→ Intra-amniotic infection→ Abnormal fetal position (e.g., breech presentation, longitudinal position)→ Maternal exhaustion; ineffective contractions Emergent cesarean section:- Severe vaginal bleeding of unknown etiology (suspected placental separation!)- Suspected uterine rupture- Pathological CTG (particularly persistent, severe fetal bradycardia)- Fetal acidosis- Immediate threat to life of mother or fetus
• Absolute contraindications to the use of OCPs 1. Undiagnosed vaginal bleeding2. Pregnancy3. Thromboembolic disorders4. History of CVA/Stroke5. CAD6. Breast cancer7. Any estrogen-dependent cancer8. Any tumor of the liver9. Tobacco use in a woman over the age of 35 years
• Shoulder dystocia Obstetric emergency in which the anterior shoulder of the fetus becomes impacted behind the maternal pubic symphysis during vaginal delivery Epidemiology: ∼ 0.2-3% of births Risk factors:- History of shoulder dystocia- Fetal macrosomia- Prolonged second stage of labor- Maternal diabetes mellitus- Maternal obesity- Post-term pregnancy Clinical features:- Features of arrested active phase of labor- Turtle sign: the fetal head is partially delivered but retracts against the perineum- Failed restitution of the head Treatment:1. The patient should stop bearing down and lie supine with the buttocks on the edge of the bed.2. Perform shoulder dystocia maneuvers:- First-line: McRobert's maneuver = Abduct, externally rotate, and hyperflex the maternal hips (with the maternal legs pulled towards the head).- Rubin's maneuver: Suprapubic pressure (proximal to the symphysis pubis) is applied to the posterior part of the impacted anterior shoulder.- Wood's maneuver: Manually rotate the fetal shoulder girdle by applying pressure to the anterior part of the posterior shoulder.- Delivery of posterior arm
• Postpartum endometritis Etiology: Mostly polymicrobial (2-3 ascending organisms, e.g., Gardnerella vaginalis, Staphylococcus epidermidis, group B Streptococcus and/or Ureaplasma urealyticum) that are usually found in the normal vaginal flora Risk factors:- Cesarean section (C-section)- Prolonged labor- Multiple cervical examinations- Retained products of conception after delivery or abortion- Meconium in amniotic fluid- Low socioeconomic status Clinical findings:- Fever, chills, malaise- Lower abdominal pain, uterine tenderness- Foul-smelling lochia Diagnostics: Primarily a clinical diagnosis- Blood and urine cultures Treatment:- IV clindamycin and gentamicin- Ampicillin-sulbactam is a reasonable alternative if resistance to clindamycin is a concern.- If there are any retained products of conception: curettage to remove retained products- Hysterectomy in case of life-threatening complications, no response to conservative therapeutic measures
• Amniotic fluid index A semi-quantitative estimate of amniotic fluid volume measured antenatally via ultrasonography of a pregnant uterus. It is part of the biophysical profile. 8-18 = normalAFI ≤ 5 cm = oligohydramniosAFI ≥ 24 cm = polyhydramnios Deepest vertical pocket method:< 2 cm = oligohydramnios2-8 cm = normal> 8 cm = polyhydramnios
• Down syndrome comorbidities Neurology:- Intellectual disability- Early-onset Alzheimer disease Cardiology:- Complete atrioventricular septal defect- Ventricular septal defect- Atrial septal defect Gastroenterology:- Duodenal atresia- Hirschsprung disease Endocrinology:- Hypothyroidism- Type 1 diabetes mellitus- Obesity Hematology:- Acute leukemia Rheumatology:- Atlantoaxial instability
• Birth-related clavicle fracture Most common fracture during birth (∼ 2% of deliveries) Clinical features:- Usually asymptomatic- Possible pseudoparalysis- Bone irregularities, crepitus, and tenderness over the clavicle possible on palpation- Possible brachial plexus palsy Diagnostics: clinical diagnosis; X-ray only indicated in cases of gross bone deformation Treatment:- Reassurance and promote gentle handling of the arm (e.g., while dressing)- To avoid discomfort, pin shirt sleeve to the front of the shirt with the arm flexed at 90 degrees- Consider analgesics- Follow-up 2 weeks later to confirm proper healing: via clinical findings of a callus formation, and possibly an x-ray- Usually self-resolves within 2-3 weeks without surgical intervention or long-term complications
• Routine prenatal laboratory tests Initial prenatal visit:- Rh(D) type, antibody screen- Hemoglobin/hematocrit, MCV- HIV, VDRL/RPR, HBsAg- Rubella & varicella immunity- Pap test (if screening indicated)- Chlamydia PCR- Urine culture- Dipstick for urine protein 24-28 weeks: - Hemoglobin/hematocrit- Antibody screen if Rh(D) negative- 50-g 1-hour GCT 35-37 weeks: - Group B Streptococcus culture
• Intrauterine fetal demise Definition: Fetal death at ≥ 20 weeks Risk factors:- Nulliparity- Obesity- Hypertension- Diabetes mellitus Clinical features:- Decreased or absent fetal movement Diagnostics: Ultrasound Management:- 20-23 weeks: Dilation & evacuation OR vaginal delivery- ≥ 24 weeks: Vaginal delivery Evaluation:- Fetal: Autopsy; examination of placenta, membranes & cord; Karyotype/genetic studies- Maternal: Kleihauer-Betke test for fetomaternal hemorrhage; Antiphospholipid antibodies; Coagulation studies
• Breastfeeding benefits & contraindications Benefits:- More rapid uterine involution & decreased postpartum bleeding- Faster return to prepartum weight- Improved child spacing- Improved maternal-infant bonding- Reduced risk of breast & ovarian cancer- Improved immunity- Improved GI function- Prevention of infectious diseases: Otitis media, gastroenteritis, respiratory illnesses, UTIs- Decreased risk of childhood cancer, type 1 diabetes mellitus, necrotizing enterocolitis Contraindications:- Active untreated tuberculosis (mothers may breastfeed after 2 weeks of anti-tuberculin therapy)- Maternal HIV infection (in developed countries where formula is readily available)- Herpetic breast lesions- Varicella infection < 5 days prior or within 2 days of delivery- Specific maternal medications- Chemotherapy or ongoing radiation therapy- Active abuse of street drugs or alcohol- Fetal galactosemia
• Breech presentation No intervention necessary before 37 weeks' gestation, as most fetuses spontaneously convert to cephalic presentationas they get closer to term External cephalic version:- Should be offered in all cases ≥ 37 weeks who would like to attempt a vaginal delivery, unless there are contraindications. - Involves manual adjustment of fetal position by applying pressure on the mother's abdomen - Cesarean section: if external cephalic version is unsuccessful or contraindicated (e.g., in active labor, fetal distress) - Assisted vaginal delivery: → In emergent cases where cesarean delivery was not possible→ For a low-risk pregnancy, if the patient wishes to avoid surgery Complications:- Abruptio placentae- Intrauterine fetal demise
• Montevideo units A measurement of uterine contraction during labor. Measurements are made by placing a pressure catheter within the uterus and adding the pressure of individual contractions over the course of 10 minutes. 200-250 MVUs is considered adequate uterine contractions during the active phase of labor.
• Second stage of labor Definition: stage of labor that begins once the cervix is completely dilated and ends with the birth of the infant Insufficient fetal descent after pushing for - ≥ 3 hours if nulliparous- ≥ 2 hours if multiparous Risk factors:- Maternal obesity- Excessive pregnancy weight gain- Diabetes mellitus Etiology:- Cephalopelvic disproportion- Malposition- Inadequate contractions- Maternal exhaustion Management:- Operative vaginal delivery- Cesarean delivery
• Fetal heart rate tracing patterns Category I: Requires all the following criteria:- Baseline 110-160/min- Moderate variability (6-25/min)- No late/variable decelerations- ± Early decelerations- ± Accelerations Category II: Not category I or III (indeterminate pattern) Category III: ≥1 of the following characteristics:- Absent variability + recurrent late decelerations- Absent variability + recurrent variable decelerations- Absent variability + bradycardia- Sinusoidal pattern

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