10. Obstetrics Flashcards

Question

Describe investigations : Preterm labour (2)

Answer 1

* Fetal fibronectin * U/S for cervical length.

Answer 2

* consider Celestone (betamethasone) (12mg IM q24 x2) * no exams * bed rest * transfer to NICU place * cerclage. * Tocolytic = Nifedipine (CCB) and Indomethacin (block prostaglandins) have best evidence. * If imminent preterm birth (>/= 4 cm or planned preterm birth) &

Answer 3

turtle sign - head retracting after delivery

Answer 4

ALARMER * Apply suprapubic pressure/Ask for help * Legs in full flexion * Anterior shoulder disimpaction * Release posterior shoulder * Manual corkscrew * Episiotomy * Roll over on hands and knees

Answer 5

* acute onset abdo pain * hyper/hypotonic uterine cox * abnormal FHR * vaginal bleeding

Answer 6

r/o abruption, immediate delivery

Answer 7

**First Stage** * Regular contractions causing cervical dilatation +/- effacement * Dystocia: >4 hrs of <0.5cm / hr dilatation or 0 cm / 2hr * Latent : Complete when nulliparous ≥ 4 cm, parous 4-5cm, cervical length generally <1cm * Active : Starts when nulliparous ≥ 4cm, parous 4-5cm **Second Stage** * Full dilatation to delivery of the baby * Dystocia: > 1hr of active pushing w/out descent of presenting part * Passive : Full dilatation w/out active pushing * Active : Full dilatation w/ active pushing **Third Stage** * Immediately after delivery of the baby to delivery of the placenta **Fourth Stage** * Immediately after delivery of the placenta to 1 hr postpartum

Answer 8

* decelerations or abnormal intermittent auscultation * single umbilical artery * velamentous cord insertion * 3 or more nuchal loops of cord * combined spinal-epidural analgesia * labour dystocia * FHR arrhythmia * pre pregnancy BMI >35

Answer 9

Non-pharmacologic * Benefit from self-hypnosis and acupuncture. * Some evidence for water immersion to decrease need for epidural & duration of 1st stage. * Weak evidence for TENS. * No benefit from acupressure, aromatherapy, audio analgesia, or massage **Systemic ** * Nitrous oxide: deep inhalation w/ contraction, short acting. * Opioids: IM, Subcut, IV, can cause n/v, drowsiness, recommend one w/ short half-life to lower negative effects on newbom. * Do NOT use meperidine (Demerol) due to long-acting active metabolites and negative effects on neonatal behaviours **Regional**: * pudendal nerve block (used for perineum during 2nd stage - 10 mL of 1% lidocaine in 2 locations, just inferior to the sacrospinal ligament, just medial to the ischial spine on each side) - perineal infiltration (repair of laceration or episiotomy) - epidural superior pain relief, 1 assisted delivery, maternal hypotension / fever, 1 length of second stage, 1 c/s for maternal distress. Encourage women to maintain mobility and flexibility

Answer 10

* Intermittent auscultation ≤ q5min * continuous electronic fetal monitoring equal or less q15min if caregiver present at all times

Answer 11

* (administering of all 3 (1) prophylactic uterotonic, (2) early cord clamping & (3) controlled cord traction) is no longer recommended for all women (⬇️ risk of maternal bleed, ⬆️ maternal hypertension, ⬆️ pain, ⬆️ return to hospital for bleed, ⬇️ neonatal blood volume. * NO difference in length of 3rd stage, RPOC

Answer 12

* **oxytocin** * give routinely after delivery of baby to ⬇️ PPH * Term - given with the delivery of the anterior shoulder * **Preterm - given after clamping to ⬇️ bolus of blood**

Answer 13

* Traction (once evidence of separation between placenta and uterus, apply umbilical cord traction and suprapubic counter pressure on uterus * can be routinely offered if birth attendant has the skills

Answer 14

* **for infants that do not require resuscitation, delayed clamping of 60 seconds is recommended** (can keep babe warm with warm towel or on mother's abdomen) * **Preterm** - ideal delayed cord clamping ~60-120sec but at least 30sec

Answer 15

for hyperbilirubinemia

Answer 16

Absolute Contraindications * fetal hydrops * need for immediate resuscitation, * disrupted utero-placental circulation (I.e. bleeding vasa previa) * twin-to-twin transfusion Relative Contraindications * risk of hyperbilirubinemia (e.g., polycythemia, severe IUGR, pregestational DM)

Answer 17

* Postpartum Hemorrhage * Retained Placenta * Postpartum Fever * Postpartum Hypothyroidism * Postpartum Depression

Answer 18

* blood loss at time of delivery >500 mL vaginal delivery * >1000mL C/S * >can be early or late (after first 24hrs, up to 6 weeks)

Answer 19

Etiology: 4 Ts * **Tone**: uterine atony = most common cause, occurs w/in first 24 hrs, prevent by giving **oxytocin** w/ delivery of anterior shoulder. Atony due to abnormal labour, infection, uterine distention, placental abruption, grand multip, halothane anesthesia * **Tissue**: retained placenta or clots * **Trauma**: laceration of cervix, vagina, uterus; episiotomy, hematoma, uterine rupture * **Thrombin**: coagulopathy (hopefully identified prior to delivery), DIG, ITP, TP, therapeutic anticoagulation

Answer 20

**Basics**: * ABCs, cross & type 4 units * treat underlying cause * 2 large bore IVs and crystalloids, **Medical**: * oxytocin 20U/L NS IV continuous infusion * ergotamine 0.25mg IM/MM q5min up to 125mg (may exacerbate HTN), * Hemabate-0.25mg IM/MM g15min up to 2mg, (but contraindicated in CV, pulm, renal, hepatic dysfunction) **Local**: * bimanual compression/uterine massage, uterine packing **Surgical**: * D&C * laparotomy with bilateral ligation of uterine arteries, hysterectomy * +/- angio embolization

Answer 21

* **Definition**: undelivered placenta > 30min post-delivery of infant * **Etiology**: separated, but not delivered versus abnormal implantation affecting separation (i.e. accreta, increta, percreta) * **RF** : placenta previa, prior C/S, curettage, prior manual placental removal, uterine infection * **Clinical Features**: placenta not delivering or incomplete placenta on delivery. Risk of PPH and infection.

Answer 22

* Explore uterus, assess degree of blood loss * 2 large bore Vs * type and screen * firm traction on umbilical cord wi/suprapubic pressure -> oxytocin 10 IU in 20mL NS into umbilical vein > manual removal -> D&C

Answer 23

fever >38C on any 2 of the first 10 days postpartum, not including the 1st day

Answer 24

* Wind: atelectasis, pneumonia * Water: UTI * Wound: C/S incision or episiotomy site * Walking: Pelvic Thrombophlebitis, DVT * Womb: endometritis * Breast: mastitis, engorgement

Answer 25

* if suspect endometritis: blood and genital cultures. * Otherwise relevant exam and cultures

Answer 26

Clindamycin + gentamicin

Answer 27

* History of Hypothyroidism: likely need to ⬇️ thyroxine dose * New hypothyroidism: often occurs between 6-12 mon

Answer 28

* extension of normal hormonal changes and adjustment * Incidence: 85% of new mothers * Clinical Features: onset **day 3-10** , self-limited, doesn't last more than 2 weeks, mood lability, depressed affect, tearful, fatique, sensitive to criticism, irritable, poor concentration

Answer 29

Major depression episode criteria occurring within **4 weeks or 6 mo** of delivery

Answer 30

* Screen w/ Edinburg Postnatal Depression Scale 1. CBT. IPT 2. citalopram, escitalopram, sertraline 3. exercise, acupuncture, light therapy, bupropion, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, mirtazapine, TCA, venlafaxine, ECT (for severe, psychotic)

Answer 31

Pelvic floor exercises immediate postpartum period /risk of urinary incontinence

Answer 32

Give RhoGAM **300ug IM with 72 hours** of delivery if infant is **Rh positive**

Answer 33

If Nonimmune, Give MMR (may need to delay if pt has been given received immunoglobulin containing products such as RhoGAM or blood products) or Varicella 0.5mL IM

Answer 34

Moderate exercise during lactation, does NOT affect quantity or composition of breast milk

Answer 35

* **Non-lactating**: Can begin combination CP 3 weeks postpartum * **Lactating** : Micronor 6 weeks postpartum and change to OCP when the patient introduces supplemental feeding OR begin OCP at 3 months if breastfeeding exclusively. * Can give **IUD** 6w postpartum

Answer 36

pregnancy complications (HT, DM, idiopathic preterm birth, IUGR, or placental abruption) can identify women w/ underlying, CVD risk factors if any of the above complications: * **6mo postpartum: BMI, BP, lipid, glucose, urinalysis** * **12mo postpartum: BMI + BP** **If GDM: 75g OGTT 6w-Gmo postpartum & A1C q1-3vr** **If HTN: BP q6-12mo** Counsel LSM: physical activity, heart healthy diet, monitor weight **Future Preg: consider aspirin starting at 12-16w GA & early DM screen**

Answer 37

Advise to wait at least 18 months prior to conception

Answer 38

>18 and <59 months

Answer 39

* Transmission risk to fetus is -2% with antiretroviral therapy. * Efavirenz is contraindicated. * Refer to specialist.

Answer 40

* Discuss potential pregnancy outcomes related to seizures and seizure medications. * Moderate risk for folic acid (1mg 3mo prior to conception) * Lowest dose of one medication recommended, when possible. * **Valproic acid, lithium, and topiramate are contraindicated.** * **L****ess risk with Carbamazepine and lamotrigine.**

Answer 41

* Delay conception until good control is achieved. * Discuss natural history of disease during/after pregnancy. * **Cyclophosphamide, Methotrexate, and Leflunomide are contraindicated.** * **Avoid estrogen-containing contraception** options in women with SLE and positive/unknown antiphospholipid antibody. * Discuss use of aspirin and heparin with rheumatologist for women with SLE and antiphospholipid antibody syndrome.

Answer 42

* Counsel re: + risk for VTE during pregnancy and postpartum * Many will require anticoagulation treatment. * Coumadin is contraindicated.

Answer 43

* Achieve euthyroid state prior to conception**(preferably TSH <2.5** Prior to conception (poor evidence). * **Women with hypothyroidism should increase their dose of levothyroxine by 30% as soon as pregnancy occurs.** * Radioactive iodine is contraindicated. * Screen all women for CBC and TSH, prior to conception.

Answer 44

* Varicella (avoid pregnancy for 1 month) * Measles / Mumps / Rubella (avoid pregnancy for 3 months)

Answer 45

* Folic Acid * calcium 1000mg daily through food ‡supplements. * essential fatty acid rich diet, including omega 3 and 6. * vitamin D 600 IU daily through supplementation * vitamin B12 2.6 ug daily through supplement * Caffeine <300mg /day * avoiding raw/undercooked meat and fish and unpasteurized milk and cheese, fish high in mercury (avoid Tuna steak, shark, swordfish, marlin, shellfish) * If at risk, screen for iron deficiency anemia

Answer 46

* **Low risk** 0.4-1.0mg daily * **Mod Risk **(personal Hx of folate sensitive congenital anomaly, FamHx NTD, maternal DM, teratogenic meds anticonvulsant, metformin, methotrexate, Septral], maternal Gl malabsorption [celiac, BD, gastric bypass sx], liver dz, renal dialysis, EtOH over use): 1mg 3 mo prior to conception, if not preg in 6mo, ⬇️ folic acid to 0.4mg x 6mo * **High risk**: (personal NTD history [mom or dad or previous pregnancy w/ NTD): 4mg 3 mo prior to conception, if not preg in 6mo, ⬇️folic acid to 0.4mg x 6mo

Answer 47

* recommend at least 150 minutes of moderate to vigorous aerobic physical activity per week in episodes of 10 minutes or more. * Add muscle and bone strengthening activities at least 2 days per week

Answer 48

* Normal fetal movement = >26w GA > 6 movements / 2 hours * If <6/hrs: Non stress test: if normal = daily movement counting -> if normal & risk IUGR OR nonstress test abnormal = biophysical

Answer 49

screen ALL between 24-28w GA w/ non fasting 50g OGCT * If 50g OGCT < 7.8 mmol / L, no further testing needed * If 50g OGCT 7.8 - 11, order a 2hr 75g OGTT * Diagnose GDM if FBG 25.3, 1hr ≥ 10.6, 2hr 29.0 * If 50g OGCT ≥11.1 mmol / L, GDM diagnosed * Altemative: only 75g OGTT, dx GDM if FBG ≥ 5.1, 1hr ≥ 10, 2hr ≥ 8.5

Answer 50

* Target A1C<6%, FBG 3.8-5.3, 1hr postprandial <7.8, 2hr <6.7 * Monitor Fasting + postprandial 4/d on insulin, 4/d every 2d not on insulin * Nutritional counseling, if not in target in 1-2w, then start insulin * Starting at 24w GA, Monitor fetal growth 03-4w & ⬆️ control if concern for macrosomia, ⬇️ control if concern for SGA (order Dopplers) * at 36w GA order weekly test, NST or NST + AFI or biophysical (more frequent if obese, poor glycemic control, LGA, PIH, SGA) * Offer induction 38-40w GA * Postpartum- monitor newborn for hypoglycemia (breastfeed to ⬇️ risk) * Repeat 75g OGGT between 6w + 6mo postpartum (15-50% risk of DM) normal FBG<6.1, 2hr 7.8, A1C <6%. dx DM FBG ≥ 7, A1C ≥ 6.5%

Answer 51

* Encourage dietary / lifestyle changes, eat anything appealing (II-C) * If NO iron deficiency, stop prenatal vitamin w/ iron. Take folic acid in T1 * ** Pyridoxine Vit Bc) 10mg°D or Diclectin 10mg 0D (max 8 tabs / d) * ADD Gravo/ 50mg g4-6hr (max 200 mg/d)*** Altemative: * acupressure (3 finger breadths above wrist between 2 tendons * ginger 250mgQD (NNT =3 after 6d), not to be used close to labour, hx vaginal bleed or miscarriage or clotting disorder (risk of hemorrhage) * mindfulness-based cognitive therapy as adjunct to pyridoxine adjuncts: treat GERD (antacid / H2blocker / PPI), mood disorder, H Pylori

Answer 52

* Targets: Trimester 1 TSH 0.2-2.5, after 20w GA 0.2-3.5 * Known Hx: TSH <2.5 Prior to conception (poor evidence). TSH when pregnancy confirmed (1dose 30-40% by 4-6w/ GA) Hypothyroidism dx in pregnancy: Stabilize TSH ASAP * Monitor TSH q2-3 w vs. 4-6 w (controversial) until 20w GA * Likely need to ⬇️dose / pre pregnancy dose postpartum

Answer 53

**Definition** : small for gestational age > fetus < or = 10% on u/s (Il) * IUGR -> fetus < or = 10:% on u/s b/c pathologic process (IlI) * **Diagnosis**: based on u/s (Do NOT rely on SFH) **Types**: "symmetrical vs. "asymmetrical" less important than evaluating fetal anatomy, uterine and umbilical artery * Asymmetry: brain is spared, * Symmetry: TORCH, genetics **Etiology**: cigarettes, drugs, TORCH, genetic anomalies **Screening**: Trisomy 21, if + > uterine dopplers@19-23w GA * SF is less than GA by >3 -> biophysical +/- umbilical doppler

Answer 54

* lx: amniocentesis if ⬆️ risk aneuploidy, Consider TORCH screen * Maternal: ongoing monitoring for preeclampsia + no smoking. Consider adding low dose asa Fetal: * If previable (<500g +/- <24w GA) > monitor * If viable (>500g + >24w GA) -> EFW, AFV, umbilical Doppler, in 3%9 trimester - weekly biophysical profile * If growth continues along the curve -> weekly biophysical + umbilical artery Doppler. * Consider delivery 38-40w GA If growth plateaus <34w GA -> corticosteroids, ⬆️surveillance 2- 3/w, consider hospitalization / consulting MFM + peds * If >34w GA + normal studies -> continue weekly surveillance + consider delivery after 37 weeks * If >34W GA + abnormal (AFV<5cm or DVP<2cm): BPP+ Doppler study, consider delivery

Answer 55

* big for dates, u/s, consider amnio, refer * Maternal: GDM, Fetal: fetal hydrops, genetics, Gl problem

Answer 56

* small for dates, u/s, IVF, vesico amnionic shunt * Renal problem, placenta hypoxia, PROM

Answer 57

* In opioid use disorder, use opioid agonist (i.e. methadone /buprenorphine). * Detox reserved for select patients. Counsel about neonatal withdrawal + monitoring. * **Can still breastfeed on opioid agonist**

Answer 58

* Hx uterine rupture, uterine reconstruction * classic /inverted T uterine scar * placenta previa * malpresentation

Answer 59

* **rupture rate<1%** * **Success 75%** * **Allowed but ⬆️ risk** : ≥ 2 c/s, <18mo of c/s, induction of labour * **Not contraindicated** : multiple gestation, GDM, postdates * Needs continuous fetal monitoring, avoid PGE, use foley for induction

Answer 60

* ↑ age * ↑BMI * GA>40w * BW>4000g * hx dystocia Can use a VBAC calculator tool to calculate odds of success

Answer 61

* Previa = covering os * lowing lying = ≤ 20mm from os

Answer 62

* note placenta position during anatomy scan >18-20w * If ≤ 20mm = u/s ≥ 32w GA. If still ≤ 20mm @ 32w GA = u/s 36w GA * no vaginal / anal sex, insertion of foreign body into vagina/rectum * If 11-20mm @ 36w GA (or ≤ 10mm & no risk factors)- trial spontaneous vaginal delivery. * Otherwise C/S (POCUS prior to sx) 36-38w (previa), 37-39w (low)

Answer 63

Give RhoGAM to Rh neg women at * <12wGA, abortion/threatened/ectopic/ molar /CVS ->120mcg IM * >12wGA, abortion/threatened/ectopic/molar /CVS -> 300mcg IM * Amniocentesis > 300 mcg IM * 28w GA w/ fetal Rh unknown or positive > 300 mcg IM (alternative is 120 mcg IM @28 + 34 w GA) * 72hrs after delivery of Rh-positive baby (if NOT given, give as soon as recognized up to 28d) -> 300 mcg IM

Answer 64

* BMI 240-delivery at 39-40wGA * elective c/s if projected BW 25000g (0 DM) ≥ 4500g (DM)

Answer 65

↑ frequency T2 + T3 b/c ↑risk preterm labour

Answer 66

* **HTN** : office/hospital BP ≥140/90mmHg, confirm w/ home BP 2135/85 * **Transient HTN** : BP ≥ 140/90 that is NOT confirmed on retest * **Masked HTN** : BP <140/90 in office and ambulatory ≥135/85 * **Resistant HTN** : 3 antihypertensives for BP control at 220 weeks GA * **Non severe HTN**: 140/90 to 160/110 mmHg, consider confirming persistent HTN w/ home or ambulalory BP * **Severe HTN** : ≥160/110mmHg **repeat in 15 min, **OB emergency** * **Chronic HTN / Pre-existing HTN**: <20 weeks GA (no ACEi / ARB). Dx pre-eclampsia if resistant HTN or worsening proteinuria or >1 adverse condition (see signs + symptoms + complications) * **Gestational hypertension** : new dx >20 weeks GA * **Eclampsia** : new seizure activity in preg/postpartum w/out olher cause * **HELP** : preeclampsia w/ hemolysis, ↑ LFTs, ↓ platelets

Answer 67

Matemal: * Convulsion / retinal detachment, stroke, TIA * Thrombocytopenia / DIC / HELLP (hemolysis, elevated liver enzymes, low platelets) * Pulmonary edema / oliguria / AKI Fetal: * Placental abruption * IUGR, Oligohydramnios * Fetal hydrops * Absent / reversed umbilical artery

Answer 68

* Calcium supplement (>500g/d) If low (<200mg/d) dietary calcium * No EIOH (II-2), smoking cessation to prevent low weight (-E) * + exercise (I-A), + folic acid to prevent neural tube defect (1-A),

Answer 69

* High risk = hx pre-eclampsia, BMI> 30, chronic HTN, DM, CKD, SLE, assisted reproduclive therapy, antiphospholipid antibody syndrome * Mod risk = prior abruption / still birth, age >40, nulliparity, multifetal preg, hx SGA * **IF 1 high risk or 22 mod risk factors: ASA 81mg -162 mg QHS starting after 12w GA (per USPSTF), before 16w (per SOGC) and dc at 36w** * Calcium supplement (>500g/d) if low calcium intake (<900mg/d) * NO high dose folic acid beyond first trimester * + exercise (I-A), and if overweight provide dietary counseling * NOT recommended: vit C+E

Answer 70

discuss at 34-35+6w GA, consider at 36-36+6w

Answer 71

w/out preeclampsia: delivery 38 and 39+ 6 w GA. If new HTN ≥37 GA, discuss initiating delivery

Answer 72

delivery between 38 and 39+6 w GA

Answer 73

Non severe = BP 140-159 / 90-109 mmHg, 1. **Labetalol** 100-400mg 80-TID, **methyldopa** 250-500mg BID-®0, **long acting (XL) oral nifedipine** 20-60mg OD, other **beta-blocker** (acebutolol, metoprolol, pindolol, propranolol). Do not use labetalol in asthma, caution in DM. no nifedipine in aortic stenosis, methyldopa may cause depression 2. Clonidine, Hydralazine, Thiazide diuretics NOT ACE or ARB, NOT Atenolol or prazosin prior to delivery

Answer 74

Severe: BP >160/110 * tx in hospital + continuous FHR monitor 1. nifedipine capsule, parenteral labetalol, parenteral hydralazine 2. nitro infusion, methyldopa po, labetalol po, clonidine po 3. refractory: sodium nitroprusside NOT MgSO, as monotherapy but add it to prevent eclampsia in severe HTN or adverse / end-organ damage

Answer 75

* Administered for pre-eclampsia + ≤ 34+6 weeks GA * Consider if gestational HTN ≤ 34+6 w/ GA if planned delivery in 7d * Consider if delivered by elective c/s ≤ 38+6 w GA

Answer 76

**MgSO; 4g IV over 20min then 1g/hr** MgSO, for prophylaxis in severe pre-eclampsia, and consider in non- severe pre-eclampsia

Answer 77

* Platelets ≥50 w/ hemolysis + ↑ LFTs: blood products prior to delivery IF ↑bleeding, platelet dysfunction, rapidly ↓platelets * Platelets 20 - 50 w/ hemolysis + ↑ LFTs: platelet transfusion prior C-section and consider prior transfusion prior to vaginal delivery IF excessive bleeding, platelet dysfunction, rapidly ↓ platelets * Platelets ≤ 20 w/ hemolysis + ↑ LFTs: transfusion prior to delivery

Answer 78

* Measure BP daily on day 3 to 7 postpartum * Target <140/90 * Nifedipine XL, labetalol, methyldopa, captopnil, enalapril * Consider thrombo prophylaxis if pre-eclampsia * Confirm resolution of end-organ damage * Avoid NSAIDs (especially if oliguria, ↑Cr, platelets <50) >>6 weeks postpartum (expect to normalize in 6-12mo) * Screen pts with pre-existing HTN or persistent postpartum HTN -> urinalysis, Cr, lytes, FBG, cholesterol, ECG * Healthy diet + exercise

Answer 79

w/ / live or live-attenuated

Answer 80

* Symptoms: fever, fatigue, sore throat, hepatitis * Complications: 15% newborns w/ CMV have permanent neuro issues * Prevention: hand washing, toy washing, no sharing drinks / kissing kids

Answer 81

CMV IgG + IgM, amniocentesis for CMV. newborn test for CMV

Answer 82

Tx: inconsistent evidence for antivirals

Answer 83

* if colony 2100,000CFU/mL - treat * if <100,000 CFU/mL - not treat * Regardless of colony size, use prophylactic abx at delivery * If +bacteruria, regardless colony size, do NOT retest w/ GBS swab

Answer 84

* Document hx of genital herpes early in preg * If no personal Hx of HSV but partner has HSV - do type specific serology early in preg & again at 32-34w GA. Can offer antiviral suppression to partner in conjunction w/ condoms * Can tx severe maternal symptoms throughout peg w/ acyclovir * If 1° HSV in 3rd trimester ( greatest risk transmission 30-50%), offer C-section + do neonatal cultures after delivery * If recurrent HSV (low risk transmission 2-5% if lesion) : acyclovir 400mgTID or valacyclovir 500mgBID @ 36w GA * If pt has prodrome or lesions at delivery - offer C-section * Congenital / neonatal infection -> IV antiviral therapy (acyclovir)

Answer 85

* antiviral ≥ 3mo (prefer ≥ 6mo) & 2 undetected viral load 1/mo * PrEP if serodiscordant & can't confirm adherence / viral suppression * If trial condomless sex, ensure no genital infections (ex. BV, ulcers) + do regular HIV testing for seroconversion. Refer if not preg in 6-12mo. ♀♂ Serodiscordant w/ virologic suppression - condomless sex or referral * **♀+HIV** and ♂-HIV > can try 6 mo home insemination * ♀-HIV and **♂+HIV **> consider sperm washing w/ IUI * **♀+HIV** single /same sex partner > IUI preferred (increase success) * **♂+HIV** single / same sex partner > refer to fertility clinic * **♀♂+HIV** w/ virologic suppression > 6mo timed condomless sex (risk HIV super-infection + drug resistant strains) or sperm wash lUl

Answer 86

* antiretroviral regardless of CD4 (do NOT delay start) * Immunize: Hep B, Pneumococcal, Flu * Monitor plasma viral load q 4-8 w + drug toxicities * If viral load <1000c/ml. = SVD, if ↑ viral load = c/s * Newborn: 6w antiretroviral therapy, HIV test at 1, 3, 18 mo * no breastfeeding

Answer 87

if high risk + unknown status = tx w/ prophylaxis during delivery & to infant postpartum & defer breastfeeding until testing done

Answer 88

* Asymptomatic 25-50% * fever * conjunctivitis, * sore throat, coryza * H/A * malaise * lymphadenopathy * polyarthritis * Rash: face, spread to trunk + extremities, resolves in 3d

Answer 89

* newborn deafness * pulmonary stenosis / PDA / VSD * retinopathy * cataracts * mental retardation * microcephaly * thrombocytopenia * DM * thyroiditis * behavioural problems

Answer 90

* IgM-, IgG- = susceptible: repeat 4w after contact or 7d symptom * IgM-, IgG+ = immune: repeat 4w after contact or 7d symptoms * IgM+, IgG+ = reinfection if repeat 2-3w ↑ IgG(×4) - consider fetal testing or u/s surveillance * IgM+, IgG- = infection: repeat, if IgG- immunize after delivery, if IgG+ (seroconversion) then rubella infection in pregnancy

Answer 91

* Do NOT immunize during pregnancy (Il-B) * If exposure or suspected infection (confirm DA) - matemal serology * 1-12wGA: infection/congenital defect 80%, consider termination * 13-16wGA: infection54%, defect 35%, fetal testing + termination * 17-22wGA: infection36%, min defect, u/s surveillance * 23-40wGA: infection progressing 30-100%: u/s surveillance

Answer 92

* **Clinical**: asymptomatic, fever / rash (slapped cheeks) / arthralgia * **Transmission**: respiratory secretions, usually in spring, viremia 4-14d after exposure, 50-70% of reproductive ♀ have immunity * **At Risk Population**: day care / elementary school teachers * **Screening**: NOT recommended in low-risk pregnancy * **Complications**: fetal transmission, fetal loss (risk 13% if <20w GA, 0.5% if >20w GA), hydrops (3%),

Answer 93

* exposure to Parvovirus or symptoms * if fetal hydrops or intrauterine fetal death * **Immune**: parvovirus Pos |gG, neg IgM, repeat in 2-4w * **Susceptible**: neg parvovirus IgG and IgM

Answer 94

* **Clinical**: 90% asymptomatic, flu-like symptoms. Incubation 5-18d * **Transmission**: ingestions raw / undercooked meat (contaminated H2O, oocyst-infected cat feces (gardening w/out gloves), vertical transmission * **Prevention**: avoid preg x6mo if infected. Ø raw meat / egg, wear gloves w/ soil / cat litter, disinfect litter box, keep cat inside, Ø raw cat food * **Screen**: Screen only if at risk (immunocompromised, HIV positive)

Answer 95

+|gG & IgM, repeat in2-4w if: TORCH u/s (severe IUGR intracranial calcification, micro/hydrocephaly, ascites, ↑ liver / spleen

Answer 96

* **Epi**: >90% antennal population is +VZV IgG antibody (immune), incubation 10-21d, infectious 48hrs prior to rash until vesicles crust * **Symptoms**: Fever, malaise, pruritic maculopapular rash becomes vesicular & crusts * **Transmission**; droplet, effects ~0.2-0.3% pregnancies **Complications**: * pneumonitis (5-10% of infected pregnancy 9), intubation (~50% of pts w/ pneumonitis), death * Newborn: congenital varicella, congenital malformation (chorioretinitis, cerebral cortical atrophy, hydronephrosis, and cutaneous and bony leg defects)

Answer 97

* Preconception counselling re: immunization -> immunize non-immune women Pre pregnancy (II-3B) or if unable to, then postpartum * Do NOT immunize during pregnancy (I-3D) * Document hx of previous infection, vaccination hx, or varicella IgG * If exposure or suspected infection: Do maternal serology. * If serology not available for 96 hrs, or patient Nonimmune -> administer varicella zoster **immunoglobulin** If **infected**: * Discuss risks / complications. * Detailed u/s to assess for fetal consequences (Ill-B) * If serious infection (ex. Pneumonitis) > treat w/ antiviral (**acyclovir** 800mg 5/d)

Answer 98

* q4 weeks to 28 weeks * then q2w until 36w GA * then q1w until delivery

10. Obstetrics Flashcards

(127 cards)