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The most common adnexal mass in early pregnancy is the corpus luteum, which may become cystic and enlarge to 6 cm in diameter Any persistent mass over 6 cm should be evaluated by ultrasound examination; unilocular cysts are likely to be corpus luteum cysts, whereas septated or semisolid tumors are likely to be neoplasms The incidence of malignancy in ovarian masses over 6 cm in diameter is 25% Ovarian tumors may undergo torsion and cause abdominal pain and nausea and vomiting and must be differentiated from appendicitis, other bowel disease, and ectopic pregnancy Patients with suspected ovarian cancer should be referred to a tertiary perinatal center to determine whether the pregnancy can progress to fetal viability or whether treatment should be instituted without delay
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Giuntoli RL et al Evaluation and management of adnexal masses during pregnancy Clin Obstet Gynecol 2006 Sep;49 (3):492 505 [PMID: 16885656]
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PREVENTION OF PRETERM (PREMATURE) LABOR
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Preterm (premature) labor is labor that begins before the 37th week of pregnancy; it is responsible for 85% of neonatal illnesses and deaths The onset of labor is a result of a complex sequence of biologic events involving regulatory factors that are still poorly understood Significant risk factors for the onset of preterm labor are a past history of preterm delivery, premature rupture of the membranes, urinary tract infection, exposure to DES, multiple gestation, and abdominal or cervical surgery In high-risk women (prior preterm birth), ultrasound measurement of cervical length (< 25 mm) in the second trimester may also identify a significant risk Low rates of preterm delivery are associated with success in educating patients to identify regular, frequent uterine contractions and in alerting medical and nursing staff to evaluate these patients early and initiate treatment if cervical changes can be identified Distinguishing true from false labor in patients with a history of previous preterm births can be facilitated by the use of fetal fibronectin measurement in cervicovaginal specimens This ubiquitous protein can be released by several different stimuli Its absence (< 50 ng/mL) in the face of uterine contractions in a patient with a previous preterm birth has a negative predictive value of 93 97% for delivery within 7 14 days Despite initial promising findings, several prospective randomized controlled trials have failed to demonstrate a benefit of home uterine activity monitoring in preventing preterm birth On the other hand, a recent study has suggested that weekly injections of 17 -hydroxyprogesterone caproate from 16 to 36 weeks of gestation in
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PREVENTION OF HEMOLYTIC DISEASE OF THE NEWBORN (ERYTHROBLASTOSIS FETALIS)
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The antibody anti-Rho(D) is responsible for most severe instances of hemolytic disease of the newborn (erythroblastosis fetalis) About 15% of whites and much lower proportions of blacks and Asians are Rho(D)-negative If an Rho(D)-negative woman carries an Rho(D)-positive fetus, she may develop antibodies against Rho(D) when fetal red cells enter her circulation during small fetomaternal bleeding episodes in the early third trimester or during delivery, abortion, ectopic pregnancy, abruptio placentae, or other antepartum bleeding problems This antibody, once produced, remains in the woman s circulation and poses the threat of hemolytic disease for subsequent Rhpositive fetuses
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Obstetrics & Obstetric Disorders
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women with a history of preterm delivery can substantially reduce the rate of recurrent preterm birth In more acute situations, intravenous magnesium sulfate is effective, as are intravenous -adrenergic drugs Magnesium sulfate is given as a 4- or 6-g bolus followed by a continuous infusion of 2 3 g/h The rate may be increased by 1 g/h every 30 minutes to 2 hours until contractions cease or a blood magnesium concentration of 6 8 mg/dL is reached Magnesium levels are determined every 4 6 hours to monitor the therapeutic blood level After contractions have ceased for 12 24 hours, magnesium can be stopped and the situation reassessed Uterine smooth muscle is largely under sympathetic nervous system control, and stimulation of 2-adrenergic receptors relaxes the myometrium Consequently, inhibition of uterine contractility often can be accomplished by the administration of -adrenergic drugs such as terbutaline Alternatively, use of an oxytocin receptor antagonist might also be expected to inhibit uterine contractility However, trials of one such antagonist, atosiban, have shown only minimal efficacy Terbutaline can be given as an intravenous infusion starting at 25 mcg/min and increased by 25 mcg/min every 20 minutes until contractions cease or to a maximum dose of 20 mcg/min Terbutaline can also be administered as subcutaneous injections of 250 mcg every 3 hours Oral terbutaline therapy following parenteral treatment is often elected and consists of giving 25 5 mg every 4 6 hours With terbutaline, a dose-related elevation of heart rate of 20 40 beats/min may occur An increase of systolic blood pressure up to 10 mm Hg is likely, and the diastolic pressure may fall 10 15 mm Hg during the infusion Nifedipine has also been used in doses of 10 20 mg orally every 4 6 hours Blood pressure may fall with nifedipine, but cardiac output increases considerably Transient elevation of blood glucose, insulin, and fatty acids together with slight reduction of serum potassium have been reported with -adrenergic drugs Fetal tachycardia may be slight or absent No drugrelated perinatal deaths have been reported with -agonists Maternal side effects requiring dose limitation are tachycardia ( 120 beats/min), palpitations, and nervousness Fluids should be limited to 2500 mL/24 h Serious side effects (pulmonary edema, chest pain with or without electrocardiographic changes) are often idiosyncratic, not doserelated, and warrant termination of therapy One must identify cases in which untimely delivery is the sole threat to the life or health of the infant An effort should be made to eliminate: (1) maternal conditions that compromise the intrauterine environment and make premature birth the lesser risk, eg, preeclampsia-eclampsia; (2) fetal conditions that either are helped by early delivery or render attempts to stop premature labor meaningless, eg, severe erythroblastosis fetalis; and (3) clinical situations in which it is likely that an attempt to stop labor will be futile, eg, ruptured membranes with chorioamnionitis, cervix fully effaced and dilated more than 3 cm, or strong labor in progress In pregnancies of less than 34 weeks duration, betamethasone, 12 mg intramuscularly, or dexamethasone, 16 mg intramuscularly, repeated in 12 24 hours, is administered to hasten fetal lung maturation and permit delivery
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