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herkimer 2021 > OB > Flashcards

OB Flashcards

1
Q

placenta abruption symptom triad

A
  • uterine contraction
  • hypertonic uterine
  • painful vaginal bleeding/ constant abdo or back pain
  • (non-reassuring FHR)
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2
Q

DDx of vaginal bleeding in 2nd to 3rd trimester

A

non-painful vaginal bleeding

  • placenta previa (20% of bleeds)
  • vasa previa
  • bloody show (PPROM)

“Painful” vaginal bleeding

  • placenta abruption (40% of bleeds)
  • uterine rupture
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3
Q

placenta previa symptoms

A
  • painless vaginal bleeding

- fetal distress

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4
Q

placenta abruption risk factors

A
  • PPROM
  • Multiparity
  • previous abruption
  • HTN
  • T2DM
  • smoking (not in otool’s book)
  • thrombophilia (Fibrinogen)
  • fibroid
  • drugs
  • age < 20 or > 35 y/o (not in FM note)
  • trauma
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5
Q

placenta previa risk factors

A
  • previous placenta previa
  • previous c/s
  • multiparity
  • multiple gestations
  • smoker
  • fibroid
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6
Q

risk factors of vasa previa

A
  • low lying placenta
  • multi-lobed placenta
  • IVF
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7
Q

< Placenta previa>

definition

A

placenta attached to the lower segment of uterus < 2cm from os

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8
Q

What are the symptoms of early show?

A
  • effacement
  • dilation of cervix
  • mucous plug passes
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9
Q

< placenta abruption>

What are the work-ups of placenta abruption?

A
  • u/s with decreased sensitivity (20% with no vaginal bleeding)
  • Kleihauser-Betke (fetal cells in mat blood)
  • fibrinogen
  • CBC, BUN/CRE, Rh and ABO type and cross
  • PT/aPTT (increased risk of DIC)
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10
Q

Vasa previa work-up investigation

and Management

A
  • Apt test
    (positive= fetal blood in vaginal blood; neg: only maternal blood)
  • Wright test/ stain

Management: urgent c/s

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11
Q

management

A
  • OB emergency
  • ABC, IVF, monitor for DIC
  • Pre-term - admit + monitor
  • term + stable: induced VD
  • unstable: c/s
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12
Q

placenta previa management

A
  • u/s to confirm type: accreta vs. increta vs. percreta
  • c-section (try to wait until 37 wks)
  • bed rest, Celestone (for lung maturation)
  • serial CBC, fetal monitoring
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13
Q

DDx of vaginal bleeding in 1st to 2nd trimester

- Non-obstetrical ddx

A

Non-obstetrical ddx:

  • trauma (post-coital, partner violence, sexual assault)
  • genital lesions (cervical polyps, neoplasm)
  • cervicitis/ vaginitis
  • hemorrhagic cyst
  • perineal lesions
  • vulvar varicosities
  • rectal bleeding (lower GI)
  • UTI/ hematuria
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14
Q

DDx of vaginal bleeding in 1st to 2nd trimester

  • Obstetrical ddx
    • 20% of pregnancies will have bleeding before 20 w GA
A
  • physiological bleeding - spotting, implantation bleed
  • abnormal pregnancy (ectopic, molar)
  • abortion
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15
Q

Investigation of vaginal bleeding in 1st to 2nd trimester

A
  • CBC + blood type
  • beta-hCG
  • pap + swabs
  • transvaginal us
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16
Q

Which types of abortion has cervix still closed?

How are they managed?

A
  • threatened abortion (<5%): mild bleed +/- cramps
    > u/s - viable fetus? FHR? ectopic?
  • missed abortion: fetal pole > 6mm w/ no FHR (fetal demise) - NO blood, no uterine activity
    > D+C +/- Oxytocin 50% resolve in 2 wks
  • sepsis abortion (can be closed or open): spontaneous abortion complicated by uterine infection
    > SIRS (temp<36 or>38, leuk<4 or >12, RR>20, HR>90)
    > IV abx (gentamicin + clindamycin)
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17
Q

Def of recurrent/ habitual abortion

A

> or = 3 consecutive pregnancy losses

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18
Q

Def of spontaneous abortion

A

pregnancy loss < 20w GA

* 10% of known pregnancies will end in spontaneous abortion

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19
Q

Antiphospholipid syndrome (APS) diagnosis criteria

A

Clinical criteria (1) AND (2)
(1 ) vascular thrombosis: one or more clinical episodes of arterial, venous, or small-vessel thrombosis in any tissue or organ confirmed by findings from imaging studies, Doppler studies, or histopathology
(2) pregnancy morbidity
- One or more late-term (>10 weeks’ gestation) spontaneous abortions
- One or more premature births of a morphologically healthy neonate at or before 34 weeks’ gestation because of severe preeclampsia or eclampsia or severe placental insufficiency
- Three or more unexplained, consecutive, spontaneous abortions before 10 weeks’ gestation
—————————————————————————-
Laboratory criteria include any of the following:
- Medium to high levels of immunoglobulin G (IgG) or immunoglobulin M (IgM) anticardiolipin (aCL) Anti–beta-2 glycoprotein I
- Lupus anticoagulant on at least two occasions at least 12 weeks apart

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20
Q

absolute contraindication of medical abortion

A
  • ectopic
  • chronic adrenal failure
  • inherited porphyria
  • uncontrolled asthma
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21
Q

relative contraindication of medical abortion

A
  • unconfirmed GA
  • IUD
  • concurrent systemic corticosteroid
  • hemorrhagic disorder or concurrent anti-coagulation
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22
Q

Risks of medical/induced abortion

A
  • bleeding
  • cramping/pelvic pain
  • GI symptoms (N/V/diarrhea)
  • headache
  • fever or chills
  • pelvic/ lower genital infection
  • mortality (0.3 per 100,000, most from infection or undiagnosed ectopic)
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23
Q

Efficacy of medical/induced abortion

A

Before 49d after LMP ( 7w GA): as effective as surgical abortion
up to 70d after LMP (10w GA): highly effective

24
Q

Regimen of medical/ induced abortion

A

mifepristone 200mg oral AND
misoprostol 800 mcg
** Rh immunoglobulin (RhoGAM) given 24 hr prior to medical abortion

25
Q

common s/e of medical/ induced abortion

A
  • cramping
  • bleeding
  • n/v/d
  • dizziness
  • fever
  • headache
26
Q

complications of medical/ induced abortion

A
  • retained products (may need 2nd dose of misoprostol)
  • ongoing pregnancy
  • post-abortion infection
  • toxic shock syndrome
27
Q

What is the cause of toxic shock syndrome

A
  • toxin-mediated acute life-threatening illness

- precipitated by infection with either Staphylococcus aureus or group A Streptococcus (GAS) =Streptococcus pyogenes

28
Q

What are the typical symptoms of toxic shock syndrome?

A
  • high fever, rash, hypotension, multiorgan failure (involving at least 3 or more organ systems)
  • desquamation, typically of the palms and soles, 1-2 weeks after the onset of acute illness
  • can also include severe myalgia, vomiting, diarrhea, headache, and non-focal neurologic abnormalities
29
Q

medical conditions likely cause toxic shock syndrome

A

Menstrual (tampon-used) toxic shock syndrome (50%) - most are staphylococcus infection

Non-menstrual Staph toxic shock syndrome:  
Surgical wound infections
Postpartum infections
Focal cutaneous and subcutaneous lesions
Deep abscesses
Empyema
Peritonsillar abscess
Sinusitis
Osteomyelitis

Soft tissue infections from group A Streptococcus (GAS):
necrotizing fasciitis, myositis, or cellulitis

30
Q

Oral contraceptive pill (combo hormonal) benefits

A 
Cycle regulation
decrease flow
anemia
increase BMD
decrease dysmenorrhea/ pelvic pain
decrease perimenopausal syndrome (PMS), acne, hirsutism, endometrial/ovarian/ colorectal ca
decrease risk of fibroid
decrease ovarian cyst, benign breast disease, salpingitis
31
Q

Contraindication of oral contraceptive pill (combo hormonal)

A
  • < 4wk postpartum (breastfeeding) or < 21d postpartum (no breastfeeding)
  • Smoker (>=15 cigarette/d) > 35 y/o
  • Vascular disease
  • HTN (BP>=160/100)
  • Active VTE
  • Hx of VTE not on anticoagulants + high risk
  • Major surgery with prolonged immobilization
  • Thrombophilia
  • CAD
  • CVA
  • Complicated valvular disease
  • SLE w/ + /unknown APA
  • Migraine w/ aura
  • Peripartum cardiomyopathy
  • Current breast CA
  • Severe cirrhosis
  • Hepatocellular adenoma
  • Malignant hepatoma
32
Q

Treatment target of pregnancy induced hypertension (PIH)

A

DBP < 85 mmHg

33
Q

pharmacotherapy of PIH

A

Non severe: 140-160/90-110

  • Labetalol (beta-blocker)
  • methyldopa (central-acting alpha2 agonist)
  • long acting nifedipine (CCB)

NOT ACEI or ARB
NOT atenolol or prazosin prior to delivery

Severe: BP > 160/110 “considered ob emergency”
tx in hospital + continuous FHR monitor
- nifedipine, parenteral labetalol/ hydralazine

34
Q

recommendation for women at high risk of pre-eclampsia

A

The U.S. Preventive Services Task Force:

1) pregnant women at high risk of preeclampsia take low-dose aspirin (81 mg per day) after 12 weeks’ gestation
2) Delivery is generally indicated at 37 weeks’ gestation for women who have gestational hypertension or preeclampsia without severe features.

35
Q

diagnosis of preeclampsia

A

New-onset hypertension after 20 weeks’ gestation (a systolic BP of at least 140 mm Hg or a diastolic BP of at least 90 mm H g on at least two occasions, taken at least four hours apart, plus new-onset proteinuria or a severe feature) PLUS 1 of the following:

proteinuria
thrombocytopenia
renal insufficiency
impaired liver function
pulmonary edema
cerebral or visual symptoms
36
Q

management of eclampsia

A

MgSO4

37
Q

risk factors of PIH

A 
HTN in previous pregnancy 
CKD 
autoimmune 
DM 
HTN 
1st pregnancy > 40 y/o 
BMI > 35
family history of pre-eclampsia 
multiple pregnancy 
interval > 10 yr
38
Q

Definition of IUGR

A

small for gestational age SGA: fetus < 10th % on u/s

IUGR: fetus < 10th percentile on u/s b/c pathologic process

39
Q

etiology of IUGR

A

Asymmetry: brain is spared
Symmetry: TORCH, genetics

Etiology: cigarette, drugs, TORCH, genetic anomalies

40
Q

contraindication of VBAC (vaginal birth after C-section)

A
  • Hx of uterine rupture
  • uterine reconstruction
  • classic/inverted T uterine scar
  • placenta previa/ malpresentation
41
Q

Risk factors of GDM

A
  • previous GDM
  • family hx
  • hx of macrosomnia
  • > 25 y/o
  • obese
  • PCOS
  • steroid
  • aboriginal/ hispanic/ asian/ african
42
Q

Test for GDM

A

24-28w GA with non-fasting 50g OGCT
`1) Normal: < 7.8
2) Needs 2hr 75g OGCT: 7.8-11
3) GDM confirmed: = or > 11.1 mmol/L

For 2hr 75g OGCC: 
Diagnose GDM if 
FBG =/> 5.3,  
1hr =/>  10.6, 
2hr=/>  9.0
43
Q

treatment target of GDM

A

1) A1C < 6%
2) FBG 3.8-5.3
3) 1 hr postprandial < 7.8
4) 2 hr postprandial < 6.7

44
Q

Management of GDM

A

offer induction 38-40 wk GA

repeat 75 OGTT between 6w to 6 mo postpartum

45
Q

management of hyperemesis gravida

A

pyridoxine (Vit B6) or Diclectin 10mg (max 8 tabs/d)
can add gravol
monitor if dehydration
dietary/lifestyle changes, eat anything appealing
treat GERD (antacid/H2 blocker/ PPI), mood disorder, H. Pylori

46
Q

management of placenta previous

A

C/S at 36-38 GA

47
Q

timing of Tdap in pregnancy

A

offer 21-32w GA for every pregnancy regardless of hx

48
Q

Complications of Varicella infection in pregnancy

A 
Maternal: 
- pneumonitis (5-10% among pregnancy varicella)
  --- treated with antiviral (acyclovir) 
- intubation, death 
Newborn: 
- congenital varicella 
- congenital malformation: 
   > chorioretinitis 
   > cerebral cortical atrophy 
   > hydronephrosis 
   > cutaneous and bone leg defects
49
Q

Management of pregnancy Varicella infection

A
  • DO NOT immunize during pregnancy
  • if exposed to suspected infection:
    do maternal serology
    • if no available in 96 hr, or non-immune
      ==> give varicella zoster immunoglobulin
50
Q

Conceiving with HIV + counseling

A
  • antiviral > 3mo & 2 undetected viral load 1/mo

- PrEP if serodiscordant & can’t confirm adherence/ viral suppression

51
Q

Mgt of preg/postpartum with HIV+ women

A
  • antiretroviral regardless of CD4
  • monitor plasma viral load q4-8w + drug toxicity
  • if viral load < 1000c/ml: SVD; if increased: C/S
  • newborn:
    &raquo_space;> 6w antiretroviral therapy
    &raquo_space;> HIV test @ 1, 3, 18 mo
  • NO breastfeeding
52
Q

Counseling for postpartum contraception

A
  • Non-lactating:
    &raquo_space;> can begin combination OCP 3 weeks postpartum
  • Lactating:
    1) Micronor 6 weeks postpartum and change to OCP when introducing supplemental feeding2) can begin OCP at 3 months if breastfeeding exclusively
    3) can give IUD 6 weeks postpartum
53
Q

Etiology of postpartum fever (> 38 degree on any 2 of the first 10 days postpartum, not including the 1st day)

A 
Wind: atelectasis, pneumonia 
Water: UTI 
Wound: C/S incision or episiotomy site 
Walking: pelvic thrombophlebitis, DVT 
Womb: endometritis 
breast: mastitis, engorgement

Ix: blood and genital culture
Mgt: clindamycin + gentamicin = empiric treatment for wound infection

54
Q

risk factors of uterine atony

A
  • abnormal labour
  • infection
  • uterine distension
  • placental abruption
  • grand multip
  • halothane anesthesia
55
Q

Etiology of post-partum hemorrhage

A

At the time of delivery, > 500ml vaginal delivery OR > 1000ml C/S, can be late (after first 24 hrs, up to 6 weeks)

4T -
» Tone: uterine atony (most common) occurs within 24 hr
» Tissue: retained placeta or clots
» Trauma: laceration of cervix, vagina, uterus, episiotomy, hematoma, uterine rupture
» Thrombin: coagulopathy, DIC, ITP, TTP, on anticoagulation

herkimer 2021 (21 decks)

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