1. gingival disease
2. hemorrhoids

• Progesterone causes increased sensitivity of central chemoreceptors to carbon dioxide. This results in increased ventilation and decreased arterial CO2. 
• ABG will show compensated respiratory alkalosis (compensated for by increased excretion of bicarb).

1. Increased split of 2nd heart sound with inspiration
2. Distended neck veins
3. Low grade systolic ejection murmur (Diastolic murmurs are NOT normal).
4. May have S3 gallop after mid-pregnancy

• Preeclampsia sx: HA, visual disturbance, dyspnea, epigastric pain, face/hand sweeling
• Ask all patients that are greater than 20 weeks gestation.

Sx - painless loss of urine with concurrent with valsalva (cough, sneeze, lifting. No urge to void.

PE - loss of bladder angle, hypermobile urethra, or cystocele

Diagnostic test - cystometric examination to diffrentiate from urge incontinence

Tx - initial tx with timed voiding (behavioral tx) and pelvic musclature strengthening (kegel exercises). Later tx - urethropexy, midurethral sling procedures

Dysuria and/or urger to void. Sometimes coughing or sneezing can provoke a bladder spasm so that a delay of several seconds is notes before urine loss. 

Dx - cystometric examination shows uninhibited contractions.

Tx - Anticholinergic medication (ex. oxybutynin) to relax detrusor muscle (surgery may worsen)

Loss of urine associated with overdistended, hyptotonic bladder.

Sx - loss of urine with valsalva; dribbling.

Dx - Postvoid residual (catheterization) shows large amount of urine.

Tx - intermittent self-catheterization

• Fistula between bladder/ureter and vagina.
• Dx - dye into bladder shower vaginal discoloration
• Tx - surgical repair of fistulous tract

1. Cancer screening (ex. colon cancer screening started at age 50)
2. Age-appropriate immunizations (ex. VZV vaccine for anyone >/= 60 yo, pneumococcal >/= 65 yo).
3. Screening for common diseases (ex. BMD in postmenopausal women).

1. gush of blood
2. lengthening of cord
3. globular-shaped uterus
4. uterus rising to anterior abdominal wall

*even after 1 or 2 signs are present, the operator should be cautious not be put undue tension on cord (may be partially but not completely separated).

1. Weight-bearing exercise
2. Calcium
3. Vitamin D
4. Estrogen replacement therapy (progestin should be added if woman still has uterus, in order to prevent endometrial cancer).

• All postmenopausal women over age 65
• Any postmenopausal women at risk for osteoporosis and presenting with a bone fracture

1. IV fluids (1st PRIORITY = restore bp)
2. source control - remove nidus of infection
3. antibiotic tx
4. monitoring perfusion and organ function

• Sunburn-like rash and/or desquamation is typical
• Initial antibiotic tx is usually IV nafcillin or methicillin, unless MRSA is suspected - in which case, vancomycin is used. 

• 1st stage: onset of labor to complete dilation of cervix
• 2nd stage: complete cervical dilation to delivery of infant
• 3rd stage: delivery of infant to delivery of placenta

Contractions every 2-3 min, firm on palpation, lasting at least 4-60 seconds. (>200 Montevideo units).

• Latent: usually < 4cm, cervix mainly effaces rather than dilates. Lasts up to 14 hrs in multipara, 20 hrs in nullipara.
• Active: usually > 4 cm. Rapid dilation.

• For nullipara: =/> 1.2 cm/hr
• For multipara: =/> 1.5 cm/hr
• If cervical dilation is less than this = protraction of active phase
• If there is no progress in the activee phase for 2 hrs = arrest of active phase (may be indication for c/s if contraction are adequate).

• "Mirror images" of uterine contractions; caused by fetal head compression. Benign. 

• Most common decelerations
• Abrupt decline and abrupt resolution 
• caused by cord compression. 
• If they're intermittent with abrupt return to baseline, they can be observed.

• Subtle/gradual decline that is offset from uterine contraction.
• Can be caused by uteroplacental insufficiency (hypoxia) and may suggest fetal acidemia.

• Nullipara: =/< 2 hrs; 3 hrs if epidural
• Multipara: =/< 1 hrl 2 hrs if epidural

3rd stage: =/< 30 min (nulli or multi)

Anthropoid pelvis has anteroposterior diameter that is greater than the transverse diameter, with prominent ischial spines and a narrow anterior segment.

Anthropoid pelvis predisposes to persistent fetal occiput posterior position.

• Placenta accreta is when there is abnormal adherence of the placenta to the uterus (villi are attached to myometrium). 
• The major risk is hemorrhage. infection is a 2nd risk.
• The management is usually a hysterectomy.

• Placenta increta: abnormally implanted placenta penetrates into the myometrium
• Placenta percreta: abnormally implanted placenta penetrates entirely through the myometrium to the serosa. Invasion of the bladder is often noted.

1. Placenta previa*
2. Low lying placenta*
3. Prior cesarean scar or other uterine scar (risk increases with # of prior c/s) that affects the endometrium
4. Uterine curretage
5. Fetal Down Syndrome 

*Low lying placenta or placenta previa diagnosed in 2nd trimester may resolve in 3rd trimester b/c lower uterine segment grows more rapidly. 

• IM ceftriaxone for gonorrhea AND
• oral azithromycin or doxycycline for chlamydia which is often also present

• Yellow exudative vaginal discharge
• Postcoital spotting - occurs because endocervix becomes erythematous and friable. 

• Salpingitis
• Infectious arthritis - usually migratory, large joints
• Systemic - eruptions of painful pustules
• Gonococcal pharyngitis
• Conjunctivitis and blindness in newborn (can be either gonorrhea or chlamydia).

• Assume chlamydia - treat with doxycycline or azithromycin. (Do not need to also treat gonorrhea).

• Vaginal discharge with "fishy" odor
• Vaginal pruritis
• Note: neither chlaymdia nor gonorrhea typically cause vaginitis.

• Biggest risk factor is fetal macrosomia, particularly in a woman who has GDM. 
• Other risk factors: multiparity, maternal obesity, prolonged 2nd stage of labor

• First actions are McRobert's maneuver or suprapubic pressure.
• If these do not work, clinician may try Wood's corkscrew manuever, delivery of the posterior arm, or Zavanelli maneuver (cephalic replacement and c/s).
• Fundal pressure should NOT be used once shoulder dystocia is encountered.

•  Biggest risk factor is taking unopposed estrogen, others include:
• early menarche/late menopause
• obesity
• chronic anovulation
• ER-secreting ovarian tumors
• HTN
• DM
• Personal or FHx of breast or ovarian cancer
• Nulliparity

• Atrophic endometrium - low estrogen level causes endometrial and vagina tissue to become friable.
• Other common causes (in descending order): HRT, endometrial CA, endometrial polyps, endometrial hyperplasia

Endometrial cancer is staged surgically (and sub-classified by histologic grade, G1-G3).

• 0 - CIS
• I - confined to uterus
• II - Cervix and uterus
• III - local and/or regional spread (vagina, adnexa)
• IV - bladder or bowel mucosa or distant mets/LNs

Complete surgical staging includes:

• TAH with bilateral salpingoopherectomy
• Pelvic and paraaortic lymphadenctomy
• pelvic washings
• omentectomy

• colposcopic examination of the cervix
• curettage of the endocervix
• endometrial sampling

• VB caused by placenta previa is painless.
• Bleeding in placental abruption is painful d/t uterine contractions and/or excess uterine tone. 

1. grand muliparity
2. prior cesarean delivery
3. prior uterine curretage
4. previous placenta previa
5. multiple gestation (d/t increased SA of placenta).

• HTN
• Trauma 
• Cocaine
• Short umbilical cord
• Uteroplacental insufficiency
• Submucous leiomyomata
• Sudden uterine decompression (polyhydramnios)
• Cigarette smoking
• PPROM

• Concealed abruption: when bleeding occurs completely behind the placenta and no external bleeding is noted.
• Couvelaire uterus: bleeding into the myometrium causing a reddish discoloration. 

• The entire clinical picture must be taken as a whole.
• Sx: painful vaginal bleeding (not present in concealed abruption)
• Consider risk factors
• US is NOT helpful.
• Serial Hgb levels, following fundal height and FHR can be helpful, as well as testing for fetal RBCs from maternal blood (Kleihauer-Betke test).

• Ovarian torsion is the twisting of the ovarian vessels and can lead to ischemia. It's the most frequent and serious complication of a benign ovarian cyst.
• It usually presents either at 14 weeks (when the uterus rises above the pelvic brim) or very soon after delivery when the uterus rapidly involutes.
• Sx: acute onset of colicky pain, nausea, vomitting 
• Tx:surgeon can untwist pedicle and observe the ovary for viability (reperfusion). If possible, conserve ovary and just do cystectomy. Oophorectomy is indicated if perfusion cannot be restored. 

• Cholecystitis
• Appendicitis
• Ovarian torsion
• Ectopic pregnancy
• Placenta abruption

1. amenorrhea
2. vaginal spotting/bleeding
3. abdominal pain

1. iron deficiency (MC cause of anemia during pregnancy, overall).
2. Thalassemias

• Elevated HbA2 suggests a beta thalassemia disorder.
• Elevated HbF suggests an alpha thalassemia disorder.

• African American, Southeast Asian, or Mediterranean descent

• Give iron supplementation and reassess Hb level in 3-4 weeks. 
• If anemia persists - evaluate iron stores.

• sulfonamides
• nitrofurantoin (commonly used to treat UTIs during pregnancy)
• antimalarial drugs
• Sx can include jaundice, fatigue d/t anemia, and dark colored urine d/t bilrubinemia.

• In a multipara: must see cervical change associated with ctx before 37 weeks and after 20 weeks
• In a nullipara: uterine ctx + a signle cervical exam revealing 2 cm dilation and 80% effacement is sufficient to diagnose preterm labor.

• ffn = basement membrane protein that helps bind placental membranes to decidua of uterus
• vaginal swab is used to detect
• negative result is associated with 99% chance of NOT delivering w/in 1 week. 
• Transvaginal cervical lengt measurements on US can also help determine risk of preterm delivery. [shortened cervix (< 25 mm) with lower uterine segment changes are + findings].

• Identify cause
• Give steroids is < 34 weeks
• Tocolysis is considered if < 34-35 weeks.

• Mechanism: competitive inhibition of Ca+
• SE: pulmonary edema, maternal and neonatal respiratory depression, osteoporosis when used long term
• CI: mydocardial damage, heart block, diabetic coma, do not use with CCBs

• mech.: beta-2 agonists - smooth muscle relaxation
• SE: pulmonary edema, increased pulse pressure, HYPERglycemia, HYPOkalemia, tachycardia
• CI: arrhythmia, HTN, seizure d/o

• Mechanism: calcium channel blocker (blocks SM ctx)
• SE: CHF, MI, pulmonary edema, respiratory depression, severe hypotension, neonatal depression, osteoporosis with long term use
• CI: hypotension. Do not give with magnesium.

• mechanism: NSAID - decreased PG synthesis
• SE: closure of fetal ductus arteriosus which can lead to neonata pulmonary HTN, oligohydramnios
• CI: should not be given in 3rd trimester b/c of effects on fetus

• mechanism: synthetic progesterone - inhibits pituitary gonadotropin release, maintains pregnancy. Weekly injections can be given from 20-36 weeks to prevent preterm labor in women @ high risk.
• SE: breast tenderness, dizziness, abdominal pain, intermittent bleeding
• CI: undiagnosed vagina bleeding

How is UTI dx confirmed?

What is the empiric tx when pregnancy pt has sx of a UTI (4)? What organism does this tx target? What other organisms can cause UTIs (4)?

•  UTI dx is confirmed by UA and/or culture & sensitivity
• Tx: sulfa agents, cephalosporins, quinolones, nitrofurantoin (no TMP in pregnancy)
• Targets E. Coli = MC etiologic agent (80% of cases)
• Other causal organisms: enterobacter, klebsiella, pseudomonas, proteus

• Sx are likely caused by urethritis. Often does not respond to abx used for cystitis.
• Common causal organism = chlamydia trachomatis. Others: gonorrhea, trichomonas
• Confirm with urethral swab for chlamydia.

1. incomplete emptying of bladder
2. ureteral obstruction
3. immune suppression

In pregnant women, asymptomatic bacteriuria is ALWAYS treated, because up to 25% of untreated cases lead to acute infxn. Women with Sickle Cell trait have increased incidence of asymptomatic bacteriuria.

• Nonpregnant pt may be treated with oral TMP/SMX or a fluoroquinolone for 10-14 days. These pts should be re-examined within 48 hrs.

• During pregnancy, tx is inpatient with IV abx
• Often use ampicillin & gentamicin or a cephalosporin
• Following resoluiton of sx, pregnant women often are treated with suppressive antimicrobials (ex. nitrofurantoin) for the remainder of the pregnancy.

• They both have alkaline pH and + Whiff test (fishy odor). Both can be treated with metronidazole.
• BV: excessive anerobic bacteria (not a "true infxn"), clue cells, white homogenous discharge, vagina is not inflammed
• Trichomoniasis: trichomonads, green/yellow frothy discharge, intense inflammation, punctate lesions of cervix. "Hardy" - may be isolated from wet surface up to 6 hrs after inoculation.

1. genital tract infxn (endometritis)
2. PID
3. Pregnancy complications - preterm delivery, PPROM

1. pregnant
2. taking broad-spectrum abx
3. diabetic
4. immunocompromised

• Congenital adrenal hyperplasia , usually due to deficiency of 21-hydroxylase.
• It's also the MC endocrine cause of neonatal death. 

• PCOS usually has gradual onset of hirsutism and irregular menses since menarche.
• Sertoli-Leydig cell tumor had rapid onset hirsutism or virilization, i.e. deepening of voice, male pattern balding, clitoromegaly, etc. (+/- adnexal mass). 

• Cushing's dz
• Adrenal tumor
• Congenital adrenal hyperplasia
• PCOS 
• Sertoli-Ledig cell tumor

• MC cause of abnormal triple screen is incorrect dates. Another common cause = multiple gestation.
• Next step = ultrasound to determine correct GA, identify possible multiple gestation, and exclude fetal demise.

• Thickened nucal fold
• Shortened femur length
• Echogenic bowel
• Double bubble sign may also be present is there's duodenal atresia

• stillbirth
• growth restriction
• pre-eclampsia
• placental abruption
• Some practitioners will perform serial ultrasounds and antenatal testing to monitor for these complications.

decreased urine output (d/t decreased RBF)

By the time hypotension occurs in a young, healthy pt, 30-40% of blood volume has been lost.

• Mullerian agenesis
• Androgen insensitivity 
• Dx with karyotype or testosterone level
• Mullerian agenesis - XX, normal testosterone level, pubic hair present. 1/3 have renal anomalies.
• Androgen insensitivty - XY, male level of testosterone, scant pubic hair.
• Both have absent uterus, blind vagina

• Make dx with hysterosalpingogram - radiopaque dye shows obliteration of the endometrial cavity
• Confirm by hysteroscopy
• Best tx is hysteroscopic resection

• pregnancy test
• prolactin level
• TSH level
• gonadotropin levels

• Most are strands of avascular, fibrous tissue; may also have some inactive endometrium or myometrium
• Myometrial adhesions - usually dense and vascular - poor px
• Atrophic and sclerotic endometrium without adhesions carry worst prognosis. Usually found after radiation or tuberculous endometritis. Not amenable to any tx. 

1. small cluster of calcifications
2. masses with irregular borders
3. architectural distortion
4. asymmetrically increased tissue density when compared with prior studies a corresponding area in opposite breast
5. Non-mammogram finding - skin thickening

1. needle localization (mammographic guidance)
2. stereotactic core biospy

• produces similar findings on mammogram as breast cancer
• should be excised to confirm the dx

How is primary amenorrhea defined?

What does primary amenorrhea with abscence of breast development suggest?

• primary amenorrhea = no menarche by 16 yo
• hypoestrogenic state, MC cause: gonadal dysgenesis (most commonly Turner's).

• hypogonadotropic hypogonadism
• delayed puberty (ex. breasts @ Tanner stage 1).
• difficulty or inability to smell

• Retained POC can lead to persistent bleeding and also serve as a nidus for infxn. 
• Infxn is usually polymicrobial, ascending infxn.
• Tx = broad spectrum abx with anerobic coverage (ex. combo of gentamicin and clindamycin) & uterine curettage, usually done ~4 hrs after starting abx
• Hemorrhage often complicates the curettage. 
• Potential complication = septic shock. Monitor pt's bp, oxygen, urine output closely.

• magnesium sulfate
• oxytocin during labor
• rapid labor and/or delivery
• overdistension of the uterus (macrosomia, multifetal gestation, polyhydramnios)
• intra-amniotic infxn
• prolonged labor
• high parity

• First: uterine massage and concurrent IV oxytocin
• If these are ineffective, may give IM methergine, IM PGF2-alpha, or rectal misoprostol.

• Stabilize patient - ensure large bore IV & IV infusion of isotonic fluid, blood product available, monitor mental status, bp. HR, urine output, etc. Get anesthesia on board.
• Surgical tx may include laparotomy with uterine a. or internal iliac (hypogastric) a. ligation and hysterectomy.
• Artery ligation decreases pulse pressure to uterus. 

1. Methergine is contraindicated in women with HTN (risk of stroke).
2. PGF2-alpha is contraindicated in women with asthma d/t potential for bronchoconstriction.

• Definition: hemorrhage occuring after first 24 hrs
• MC cause: subinvolution of the placental site = eschar over placental bed falls off and lack of myometrial ctx @ the site leads to bleeding
• Usually occurs 10-14 d postpartum.
• Tx: oral ergot alkyloid (methergine) and careful f/u.  Alternatively may use IV oxytocin or IM PGF2-alpha.

• Retain POC
• Often presents with uterine cramping and bleeding, +/- fever, foul smelling lochia.
• US helps confirm dx
• Tx: uterine curettage and broad spectrum abx

1. breast budding (thelarche, mean age = 10.8)
2. pubic and axillary hair (pubarche/adrenarche, mean age = 11)
3. growth spurt (1 year after thelarche)
4. Menarche (~2.3 years after thelarche, mean age =12.9).

Normal puberty occurs between 8-14 yo, average duration of 4.5 years. 

• low FSH, low estrogen (central defect)
• poor nutrition/eating d/o, extreme exercise, chronic illness, stress, primary hypothyroidism, Cushing's, pituitary adenomas, craniopharyngiomas.

• Tx goals: initiate and sustain sexual maturation, prevent osteoporosis from hypoestrogenemia, and promote full height potential
• Hormonal therapy: combined OCPs and human growth hormone.

• oral antistaphylococcal abx, ex. dicloxacillin (staph aureus = MC etiology in postpartum mastitis; comes from infant's nose & throat)
• continued breastfeeding or pumping

Air drying and avoid using harsh soap.

(Also, poor positioning of infant can lead to improper latching which can cause cracked/bleeding nipples.)

• usually noted during 1st week postpartum
• Due to vascular congestion and milk accumulation
• Pt complains of breast pain and induration, may have low-grade fever (< 24 hrs)
• Infant feedings around-the-clock help alleviate
• Tx: breast binder, ice packs, analgesics

• presence of fluctuance or a fluctuant mass in the breast
• persistent fever after 48 hrs of abx
• US helps confirm dx - see fluid collection
• Tx - surgically drain purulent collection (or drain by US-guided aspiration). Also give anti-staph abx

• Noninfected collection of milk d/t blocked mammary duct
• Leads to nonerythematous fluctant mass with sx of breast pressure/pain
• Usually resolves spontaneously; may need aspiration

• Generally speaking (and during pregnancy): Graves disease
• Postpartum, women are more likely to have destructive lymphocytic thyroiditis.

• Sx of thyroid storm: CNS dysfunction (coma, delirium) and autonomic instability (hyperthermia, HTN, hypotension), diarrhea.
• A potential complication of thyroid storm is CHF due to effects of thyroxine on myocardium. 
• Tx during pregnancy: PTU, steroids (prevent T4 to T3 conversion), beta blockers. Pts should be monitored in ICU. 

• Untreated maternal hypothyroidism can lead to neonatal and childhood neurodevelopmental delays

• PTU inhibits peripheral conversion of T4 to T3. 
• PTU can induce a bone marrow aplasia, leading to leukopenia and sepsis. 
• PTU is the most commonly used medication for hyperthyroidism in pregnancy, because methimazole has been possibly associated with aplasia cutis congenital (skin & scalp defects).

• often occurs 1-4 mo postpartum
• As corticosteroid levels from pregnancy fall, auto-Abs are no longer suppressed.
• antimicrosomal and antiperoxidase Abs often present
• can cause hyperthyroidism and later hypothyroidism

• Maternal hyperthyroidism can lead to fetal hypo or hyper-thyroidism. 
• Untreated fetal thyrotoxicosis can result in nonimmune hydrops and fetal demise.
• Best screening test for hyperthyroidism is TSH level. 

1. azithromycin
2. erythroymcin
3. amoxicillin

• Antibiotic eyedrops prevent gonococcal conjunctivitis, but they do NOT prevent chlamydial conjunctivitis. 
• Neonatal chlamydial conjunctivitis is treated with oral erythromycin for  14 d. 

• chlaymdial cervicitis does NOT cause adverse problems with pregnancy, such as preterm labor or PPROM (unlike GC).
• It has been implicated in neonatal conjunctivitis and neonatal pneumonia through inoculation during the birth proces. Therefore, important to screen close to time of delivery. 
• For mom, chlamydial infxn can result in cervicitis, urethritis, and late postpartum endometritis (2-3 wks post delivery).

• Direct fluorescent antibody tests
• PCR

• abortion
• preterm labor
• preterm premature ROM
• chorioamnionitis
• neonatal sepsis
• disseminated dz is more common in pregnant women, esp during 2nd or 3rd trimester

• all women should be screened as early as possible in pregnancy and again at the time of L&D.
• Assess stage of HIV infxn 
• Initiate HAART - decreases risk of perinatal transmission to <2%.
• Offer schedule c/s - must be prior to labor or ROM to be efffective
• If delivering vaginally, pt should receive IV ZDV during labor and neonate receives oral ZDV syrup.
• Discourage breastfeeding. 

• Can cause fetal anemia leading to hydrops fetalis (<20 weeks are at increased risk).
• Anemia occurs because the virus destroy erythroid precursors in bone marrow (aplastic anemia).
• May also cause abortion or stillbirth. 

• Children: high fever and "slapped cheeks" (5th Dz)
• Adults: myalgias, malaise, lacy/reticular rash that comes and goes. 20% of adults have no sx.
• Pregnant pts with acute infxn should have weekly ultrasounds for 10 weeks to assess for fetal hydrops.
• If fetal hydrops is found, then refer for possible intrauterine transfuison 

• gestational diabetes
• isoimmunization
• syphilis
• fetal cardiac arrhythmias 
• fetal intestinal atresias/ GI malformations
• fetal CNS anomalies
• fetal chromosomal abnormalities
• fetal nonimmune hydrops (may be assoc with fetal supraventricular tachycardia)
• multiple gestation 

• Incubation period is 20 days
• This is important because if pt has negative IgM and IgG, but it's < 20 days since exposure, pt could still have early infxn. Must repeat IgG and IgM test in 1-2 weeks. 

• fetal HR pattern that resembles sinus wave with cycles of 3-5/min 
• indicative of severe fetal anemia or asphyxia

• Endomyometritis.  
• The mechanism is ascending infection of polymicrobial vaginal organisms.
• The main responsible organisms are anerobic bacteria, especially bacteroides. 

• endomyometritis
• mastitis
• wound infxn
• pyelonephritis

• Broad spectrum antimicrobrial tx with anerobic coverage, ex. IV gentamicin and clindamycin
• Usually improves after 48 hrs of tx
• If not improved after 48 hrs, there may be an enterococcal infxn - add ampicillin.
• If fever persists despite triple antibiotic tx for 48-72 hrs, then reevaluate pt (esp check for wound infxn) do CT of abdomen/pelvis (possbile abscess or infected hematoma, SPT)

• Surgically opened and drained. Then give abx.
• [Pt doesn't respond to initial tx with only antibiotics]

• Bacterial infxn of pelvic venous thrombi, usually involving ovarian vv
• due to spread of bacterial infxn from placental implantation site
• may have fever but look well; +/- palpable pelvic mass
• Dx confirmed by CT or MRI
• Tx: antimicrobial tx and heparin

• Syphilis < 1 yr duration: single IM penicillin
• Syphilis > 1 yr: 3 courses of penicillin at 1 week intervals
• Can use erythromycin or doxycycline for nonpregnant women that are allergic to penicillin. 
• After tx, nontreponemal test is followed quantitatively ever 3 mo for at least 1 year. (Should be negative by 1 year, if not, check for neurosyphilis). 

• Nontreponemal tests (RPR and VDRL): titers fall with tx.
• Specific serologic tests are Ab tests directed against the treponemal organism (MHA-TP, FTA-ABS) and remain positive for life.

• IV broad spectrum abx (ex. ampicillin and gentamicin) and
• delivery (IOL , regardless of gestational age. Vaginal delivery ok) 

• low SES
• STIs
• cigarette smoking
• cervical conization
• emergency cerclage
• multiple gestations
• hydramnios
• placental abruption

• onset of labor (most common)
• preterm delivery and its complications (ex. RDS)
• chorioamnionitis
• placental abruption
• necrotizing enterocolitis

• After 34-35 weeks: IOL
• Before 32 weeks: usually managed expectantly - give antenatal steroids if no overt infxn (not given after 32 weeks with PPROM); also give broad antibiotic tx to delay delivery and decrease risk of chorioamnionitis.
• If fetus demonstrates lung maturity (phosphatidyl glycerol in amniotic fluid), then deliver (despite GA).