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Flashcards in 16 OB Deck (83):
1

GBS
-when to give mom ppx (4)
-how to tx baby

Penicillin:
1. any positive screen at weeks 35-38
2. asx bactiuria
3. GBS+ in the past, ever
4. prolonged ROM

newborn sepsis, assume GBS, give ampicillin

2

ROM, spontaneous
-means how long before delivery (normally)
-do what to confirm (3)

signals <1h to delivery, usu
1. confirm with speculum exam looking for fluid pooling
2. confirm with nitrazine test (paper turns blue) or fern sign
3. confirm with U/S to make sure now oligohydramnios

3

Bloody show

bloody show (mucus plug released), happens beginning of labor, before/after contractions start

4

Immigrant pregnant female, going into labor at 35wks
-think what

GBS unknown

Do Penicillin in pROM or ppROM with unknown GBS status

5

When are tocolytics contraindicated?
think 3 categories

1. maternal: Preeclampsia
2. fetal: fetal distress
3. high OB risk: pROM for infxn, abruption

Obviously premature baby must be delivered now, going to NICU

6

Pregnant mom, maternal serum AFP is low.
think what

What if high AFP?

low AFP, think Downs.
high AFP, think neural tube

But, get U/S to make sure dates correct. MCC abnormal AFP is wrong dates.

7

Sxs, congential:

Toxo
CMV

triad:
diffuse calcifications
hydrocephalus
chorioreitinitis

periventricular calcifications
IUGR
microcephaly

8

twin twin transfusion
-what twin types

smaller twin does better (reduced bili load)

mono/di and mono/mono

9

Pt with hypothyroidism on levothyroxine, presents for prenatal visit.
What to do for following thyroid

Increase levothyroxine dose now because need to make more thyroid hormone. Follow TSH but change dose now

10

Prolonged/Arrested active phase
-dx
-do what

Prime: >5h (1.2 cm/h), Multip: >4h (1.5cm/h)
Prolonged: slow change
Arrest: no change

Think causes as 3 P's:
Power--check contractions (3 in 10, 40mm)
Passenger
Pelvis

-If contractions weak, do oxytocin. C/S if no improvement after 2h
-If contractions adequate, consider C/S

11

Hyperthyroid dz diagnosed in pregnancy
-how to tx

Can't do RAIU or anything radioactive
Surgery, wait until 2nd trimester (fetus already developed)

12

episiotomy
medial vs mediolateral

Medial: heals, hurts, possible recto-vag fistula
mediolat: no heal, no hurt

13

Postdates
-what is postdates, what dangers (which most likely)
-how to manage/approach

>42weeks. danger of dystocia, macrosomia.
most likely is oligohydramnios

If dates correct:
If cervix good, induce. If cervix not good, C/S

If dates unsure: wait and C/S when baby ready/distress (follow baby with BPP NST, 2x/week U/S to check for oligohydramnios)

14

How does TSH/T4 change in pregnancy

TBG increases, so:
higher total T4, but normal free T4 and TSH

15

Pregnant mom has Hep B Ag+
-do what for birth

Hep B acquired through birth canal

1. C/S
2. IVIG to baby, day of delivery
3. Hep B vaccine to baby, day of delivery

16

Pregnant mother 32 weeks. Has edema of legs. think preeclampsia.

leg edema can be normal late in pregnancy b/c uterus pressing on IVC

17

Normal labor, describe all stages/phases:

Remember graph

Stage 1, Latent phase--regular contractions causing dilation/effacement. to 4cm cervix
Stage 1, active phase--4cm - full 10cm dilation

Stage 2--full dilation to delivery finishes

Stage 3--end of delivery to delivery of placenta

18

HELLP syndrome
-what is it
-do what

Hemolysis
Elevated LFTs
Low Platelets (petichiae)

Mg, Deliver now!!

Think of HELLP as a 'Curable DIC'

19

fetal monitoring: what are the accel/decel types

VEAL CHOP

variable--cord
early--head
accels--OK
late--placental insuff (BAD)

20

Prolonged latent phase
-dx
-MCC
-do what

cervix <4cm. >20h in prime, >14h in multip
-MCC is analgesics (opioids given too soon, wait it out)

-once dx'd, check if contractions are adequate:
3 in 10min, and >40mm each

You can rest/wait. Or, speed things up with ripening (balloon) or oxytocin for stronger contractions

21

postpartum bleeding
-MCC

-uterine atony

22

gest diabetes
-what meds
-how do you know it is controlled

no oral meds!
-insulin
-very tight control in gest diabetes. <95 fasting glucoses.

23

ppROM
-what is it
-do what

preterm, premature ROM: "Both Baby and Mom not ready"

24-36 weeks. If <24, nonviable
Dilemna of delivering now (lower infxn risk) vs keeping inside (develop lungs)

Get L/S ratio. If >2, lungs OK, deliver.
If <2, steroids, Amp-Gent. NO TOCOLYTICS b/c already ROM

24

Twin types:
-what each is at risk for?

Risks are added from one above:

Di/Di, dizygotic--breech, preterm, placenta previa
Di/Di, monozygotic
Mono/Di--twin-twin transfusion
Mono/mono--conjoined twins, cord entanglement

25

3rd trimester labs
-what main things (3)

1. gest diabetes
2. anemia
3. Rh

26

Non stress test
-what is it, looking for what
-how often get it

Fetal heart rate monitoring
first test to assess fetus and r/o fetal demise

Looking for 15,15,2 in 20
15 sec of 15bpm increase, 2x in 20 min

high risk OB pts get NST q1week until delivery (from the time of low fetal mvmnt)

27

Prolonged 3rd stage
-definition
-do what

Should be 30min for placenta to come out. Dx is always power issue (uterus too tired to push)

1. uterine massage, then
2. oxytocin, then
3. manual manipulation if all else fails

28

Prolonged 2nd stage
-definition
-do what things

No epidural 2h, epidural 3h
Still assess Power (3 in 10, 40mm), Passenger, Pelvis. Increase power (oxytocin) if not strong enough.

If station 0 to -2, do C/S
If station 1,2: do Vacuum or Forceps

29

Postpartum bleeding, algorithm
-ddx (5), their sxs/tx

>500ml vaginal, >1000ml C/S
Uterine palpation:

Boggy--uterine atony. massage, oxytocin
Absence--uterine inversion. speculum exam, push back in or surgery to tack
Firm--retained placenta. D+C/Surgery (accreta, increta, percreta)
Normal--vag lac
Normal--DIC

30

3rd trimester bleeding
-how to separate life threatening causes
-do what for each

Painless:
placenta previa--U/S (transverse lie), NST, then C/S
vasa previa--NST, then C/S

Painful:
uterine rupture--Crash C/S!
placental abruption--you have time for U/S and NST, then C/S

31

Quad screen: what levels:

Down's
Trisomy 18
Neural tube defects

maternal serum:
AFP
Estriol (E3)
B-HCG
Inhibin A

Down's: low AFP, low E3,high HCG
T-18: low,low,low
Neural: high AFP

Inhibin A: high in Downs, low in T18

32

biophysical profile
-what looking for

BPP: Do U/S

-breathing
-muscle tone
-movement
-AFI (amniotic fluid index)--looking at all 4 quadrants deepest fluid measurement
-NST

All max score 2. 8+ is reassuring. <8 do CST

33

Normal labor max times:

Latent phase, prime
Latent, multip
Active phase, prime
Active, multip

Latent phase, prime--20h
Latent, multip--14h

Active:
Prime: >5h (1.2 cm/h)
Multip: >4h (1.5cm/h)

34

Pregnant mother delivers, then goes into DIC
-think what

placental embolism

also, amniotic embolism can cause PE and then DIC

35

Pregnant mother in 3rd trimester is concerned about decreased fetal movement.
-What tests, what order?

1. NST (fetal HR monitor) looking for 15,15,2 in 20. vibrate if not reactive
If not reactive:
2. BPP (U/S criteria)
If 0-2: deliver now, C/S. baby dying.
8-10: leave in, reassuring.
If 2-8 and <36wks:
3. CST--this is rarely done anymore as next step.

36

All twins:
increased risk of what? (3)

breech birth, malpresentation
preterm delivery (-4 weeks each)
placenta previa

37

Preeclamptic pregnant mother, gets sz
-do what

Eclampsia.
Give Mg, deliver now, no waiting. C/S if necessary

38

placental abruption
-risk factors (3)

painful 3rd trimester bleeding

HTN
trauma
cocaine

39

Pregnant mother 32 weeks. Has BP 160/110, HA and vision change.

think what, do what things?
-labs
-give what meds
-what else

severe preeclampsia. Mg+urgent delivery

Get: CBC, DIC panel, LFTs
Give: Mg to ppx sz, labetalol/hydralazine to lower BP
Goal: stabilize and deliver, induce if necessary

40

Pregnant female with non-gestational diabetes
-how to manage

no orals, do insulin
-goal <150 fasting. Compared to gestational <95

41

Postpartum hemorrhage, unexplained. Do what in what order

Arterial ligation:

uterine a,
hypogastric a,
hysterectomy

42

U/S degree of error in dx fetal age

trimester 1: +/- 1 week
so on.

43

Sxs, congenital:

Syphilis
Rubella

saddle nose, saber shins, rhinitis

deafness, cataracts, heart dz

44

uterine rupture
-story to know

Mom in labor, gets epidural. Suddenly, contractions stop. Uterus is boggy, FHR goes down, fetal distress. No pain, no vaginal bleeding. Crash C/S now!

No pain with epidural
Bleeding not always occur

45

emergency contraception
-what is it
-use within how many days

levonorgestrel is Plan B. High dose hormones, prevent implantation

Use within 5 days of sex

can also use high dose OCPs

46

Preeclampsia pt, now breathing shallow and hyporeflexia
-think what, do what

Mg toxicity
Give Ca carbonate, stop Mg

47

3rd trimester bleeding:
what ddx

4 deadly:
placenta previa
vasa previa
uterine rupture
abruption

2 MCC
polps
cervical lesions

48

Alarm sxs for severe eclampsia? (3)

HA
vision change
epigastric pain

49

Amniocentesis vs CVS
-what are each, what weeks
-when to do each

CVS: 6-12 weeks, higher risk loss
Amnio: 16 wks+ (2nd trimester). Too late to do easy abortion (now needs suction curettage if unwanted fetus)

Consider CVS in high risk (moms 35+, hx of trisomies)

50

Female just delivered baby 8h ago. Has 38 fever, continued bloody discharge, and firm nontender uterus

Think what?

Lochia rubra. (sounds like endometritis though)

Normal red vaginal d/c after delivery. Nontender uterus Low grade fever without overt signs of toxicity is normal.

Endometritis: think toxic pt, foul smelling d/c, leukocytosis, tender uterus

51

Mg toxcity
-sxs
-antidote

Think of Mg like Ca.

HyperMg:
-hyporeflexia
-resp depression
-death

Give Ca carbonate

52

Anemia screening in pregnant mom
-why and when to act

Anemia is normal. Nadir 28-30wks, can be 10

If Hgb<10 or Hct<30, check MCV and ferritin to see if Fe def. If not, then might have to do bone marrow bx to diff ACD from Fe def.

53

Pregnant female, 32 weeks. You measure BP 145/92.
Now think what, do what

preeclampsia?
Look at edema of hands--earliest sign of PreE getting bad. Ask abd pain
Get:
CBC, looking for hemoconcentration (2/2 3rd spacing)
UA: protein

54

postpartum hemorrhage from Uterine atony
-treatment escalation ladder (5)

massage
oxytocin
packing
arterial embolization
hysterectomy

55

prolonged ROM, mom has fever, septic
-think what, do what

This is chorioamnionitis (endometritis if 8h after delivery)

Broad spectrum: Amp+Gent+MTZ, or Zosyn
Deliver if haven't!

56

Down's prenatal quad screen:

AFP low
E3 low
B HCG high
Inhibian A high

57

Preeclampsia
mild, severe, eclampsia
-criteria

Mild preeclampsia:
BP>140/90
urine>300mg/24h

Severe:
>160/110 (same as fetal HR), protein >5g/24h
OR alarm sx

Eclampsia:
-with seizures

58

female with chronic HTN gets pregnant
-how to know if preeclampsia
-what meds to use

can't use BP
get UA for protein, U/S for IUGR

HTN in pregnancy: H,M,L,N

59

Station

how far physically baby is
-2
-1
0--entering vagina (?)
1
2--vaginal entrance now, about to crown

60

Fetal anemia
-how to screen, confirm, when, and tx
-who at risk

screen: transcranial doppler after 20 weeks. At risk includes isoimmunization risk

confirm dx and tx requires PUBS (percutaneous umbilical blood sampling)--putting IV in fetus to transfuse blood. Do >20wks

61

Varicella in pregnancy
-what to know, careful for what
-What if mom gets chickenpox during pregnancy

Secondary reactivation (shingles): give acyclovir to mom

Primary viremia is most dangerous!! If mom never had chickenpox or vaccine, then get vaccine before pregnancy. But NO VACCINE during pregnancy, causes viremia. ISOLATE mom from any kids that might have chickenpox.

If mom gets chickenpox, then give IVIG

62

Baby in breech position
-do what

at 37 weeks, do Leopold maneuvers
-if fail, plan C/S

63

Hyperemesis gravidarum
-what is it
-dx, check for what
-tx

think 'Severe morning sickness' that goes into 2nd trimester (morning sickness should not)

-N/V with volume depletion, so bad there is weight loss and starvation ketosis
-do B-HCG to make sure not molar
Tx: IVF, antiemetics

64

Post partum hemorrhage: how much blood loss is too much

vaginal
C/S

vaginal: 500ml
C/S: 1000ml

65

irregular contractions before labor

Braxton Hicks. not regular contractions. not labor

66

When to suspect twin pregnancy

-uterus is large for dates
-AFP high on quad screen

Do U/S

67

Effacement

cervical ripening. stim by:
-fetal head engagement/balloon
-PGE2 (so indomethacin is tocolytic)

68

Pregnant mom has HIV
-do what for birth
-what if mom not on HAART
-how to screen baby

HIV does not cross placenta; it is transmitted by blood-blood contact. So,

-C/S (reduce blood mingling)
-keep mom on HAART. If not, then give AZT at delivery

HIV Ab cross placenta, so baby will have HIV Ab+. Wait 6 months for Ab to go away, then can screen.

69

Placenta accreta
-what are the different types

shallow-deep:

accreta--endometrium only
increta--to myometrium
percreta--to serosa

70

Preterm labor
-how to buy more time (4)
-what else to give

You can only buy hours-days with tocolytics:
1. Mag (best)
2. B agonist (terbutaline)
3. CCB (nifedipine)
4. prostaglandins (indomethacin)

Give steroids for lung maturation, follow L/S ratio (>2, deliver)

71

prolonged ROM
-what is it
-do what

ROM >18h before delivery

Risk of GBS goes way up. Give amoxicillin, watch closely for chorio and endometritis

72

Pregnant mom, worried about her child with Downs or other abnormality. What to ask before doing CVS/amnio?

Does she intend to abort if positive result?? Otherwise, unnecessary risk

73

chorioamnionitis
-do what

Abx and deliver!
Abx--Zosyn or amp-gent-MTZ

Deliver: induce if contractions started, otherwise C/S

74

gestational diabetes
-when to screen, what week
-how to screen

3rd trimester (screen must be after week 20)
-1h GTT. If >140, then:
-fasting glu. if >125, dx made. If <125, do:
-3h-GTT. 2 criteria needs to be met (next several hrs)

75

cervical insufficiency
-what is this, do what

hx of cone bx or frequent GYN infections. Cervix not tight enough, placenta will fall out.

Do circlage at weeks 12-14
REMOVE before ripening.

76

Give Rhogam within __hours of blood mixing

72h, for mother whose criteria fulfilled

also give at 28 weeks for those pts

77

Herpes in pregnancy
-do what
-can herpes cross placenta?

Herpes spread by baby contact with ulcer. So do C/S, give mom acyclovir

Herpes secondary reactivation (ulcers) is not viremia, so no placental crossing. However, primary herpes viremia will cross placenta. (Varicella same way)

78

Contraction stress test
-what is adequate test?
-when must deliver immediately?

IUPC
3 contractions in 10 min
look for accels/decels

-late decels
-fetal brady (<100)

79

Pregnant mom:
how to screen Rh, when to give Rhogam

Screen:
1. Rh of mom
2. anti-Rh Ab if mom is Rh-

Give Rhogam at 28wks and delivery if:
1. Dad is Rh+ or unknown,
2. Mom is Rh- and anti-Rh negative

If mom already has anti-Rh, too late. Get trans-cranial doppler to see if baby is risk for fetal anemia

80

pROM
-what is it
-do what

premature ROM: "Baby's ready, mom's not." >36wks
Rupture, but absence of uterine contractions!
Caused by ascending infxn (usu E Coli)

Confirm ROM (3 steps),
Empiric coverage: Amp+Gent,
then induce.

81

vasa previa
-story

triad of: ROM, followed by painless bleeding, then fetal brady

Do NST, then U/S

82

Postpartum hemorrhage from retained placenta after delivery
-explain mech
-who at risk
-do what after dx and tx?

Placenta tears b/c
1. Burrows deeply (accreta)
2. expands wide (accessory lobe). (blood vessels to placenta edge)

Moms with multiple pregnancies higher risk

Think oil drilling analogy

Afterwards, beware retained piece and CC! Follow B-HCG, give OCPS x1y

83

variable decels
-think what, careful for what

cord compression. No big deal b/c baby can compensate. Can try to reposition mom and give O2 but usu not necessary

Do NOT induce ROM, loss of fluid will increase cord compression.