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Step 3 > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What should always be suspected in a female patient who has not experienced menopause, presenting with amenorrhea, enlarged uterus, or +urinary BHCG?

A

Pregnancy

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2
Q

What tests are used to confirm pregnancy?

A

Transvaginal Sonogram: See gestational sac (bHCG at least 1500)
Abdominal U/S: Fetal Heart motion at 5-6wks
Doppler: Fetal Heart sound around 8-10 wks
Physical Exam: Fetal movement after 20 wks

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3
Q

What tests must be included in routine prenatal screening in first trimester or at initial visit?

A 
CBC
Type and Screen (Rh Ag)
Direct and Indirect Coomb's
Rubella-Ab
HBsAg
Urinalysis
Urine Culture
Gonorrhea/Chlamydia Nucleic Acid Amplification
VDRL/RPR
HIV (ELISA-only with pt. consent)
Pap Smear
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4
Q

What tests must be included in routine third trimester screening?

A

Oral Glucose Tolerance Test: (Fasting 1hr) (24-28 wks)
GBS: vaginal and rectal (35-37 wks)
CBC (24-28wks)
Indirect Coombs Test (for atypical Ab, anti-D)

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5
Q

When is anemia in pregnancy significant?

A

Hb

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6
Q

What is the most reliable indicator for anemia in pregnancy?

A

Low MCV

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7
Q

What is the most common cause of anemia in pregnancy?

A

Iron deficiency (d/t increased hepcidin, which decreases iron absorption and release. Hepcidin is made/secreted by liver)

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8
Q

When is an elevated serum WBC ct significant in pregnancy?

A

WBC >16000/mm3

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9
Q

What is the next step in management for a pregnant woman found to have low Hb and low MCV on routine screening?

A

Iron Supplementation (PO Fe2SO4)

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10
Q

What is the next step in management if a pregnant woman whose anemia is not reversed with iron supplementation?

A

Test for Thalassemia:

Peripheral Smear and RBC Electrophoresis

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11
Q

What is the next step in management for a pregnant pt who has low Hb, high MCV, and high RDW on routine screening?

A

Folate Supplementation

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12
Q

What is the next step in management for a pregnant pt found to have platelets

A

Work up for ITP or HELLP according to presentation

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13
Q

When should Rh- mother’s receive RhoGAM ?

A 
At 28 wks after routine re-screening and if it is Negative for anti-D Abs
Within 72 hrs After delivery
Following miscarriage/abortion
During CVS or Amniocentesis
With heavy vaginal bleeding in pregnancy
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14
Q

What is the next step in management for a G2P1 pregnant pt who is Rh- who will have her 28 wk routine prenatal visit?

A

Re-screen for anti-D Ab with Indirect Coomb’s test.

Give RhoGAM only if Indirect Coombs is NEGATIVE for Ab.

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15
Q

What is the cut off for using Nitrofurantoin to treat Asymptomatic bacturia in pregnancy?

A

Cannot give if pt is >30wks

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16
Q

What is the next step in management for a pregnant woman with a negative Rubella-Ab titer who has had exposure to someone with Rubella infection?

A

Expectant management and vaccinate Mother AFTER delivery

[There is no post-exposure prophylaxis for Rubella]

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17
Q

What is the next step in management for a pregnant pt with +HBsAg on routine screening?

A

Order HBeAg (if elevated, pt is highly infectious)

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18
Q

What is the next step in management for a pregnant pt with –HBsAg ?

A

HBV vaccination (active immunization) during pregnancy

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19
Q

What is the next step in management for a pregnant pt with –HBsAg and was recently exposed to the blood of a someone with HBV?

A

HBIG (passive imm) + HBV vaccine (active imm)

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20
Q

What is the treatment for an infant born to a mother with HbsAg+, HbeAg+ in the third trimester?

A

HBIG and HBV vaccine within 12-24 hrs after birth

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21
Q

What is the treatment for Chronic HBV infection during pregnancy?

A

Interferon or Lamivudine

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22
Q

What is the next step in management for a pregnant woman with +VDRL or RPR on routine prenatal screen?

A

Confirm with FTA-ABS or MHATP (treponema-specific)

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23
Q

What is the next step in management for a pt with + Darkfield microscopy, +FTA-ABS or +MHATP?

A

IM Benzathine Penicillin (1x)

Penicillin Allergic: Desensitize then give IM Benzathine Penicillin (1x) [have epinephrine handy during desensitization]

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24
Q

What is required to obtain an HIV test from a pregnant patient for routine screening?

A

Consent prior to testing

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25
Q

What is the next step in management for a pregnant patient with a +ELISA test for HIV?

A

Confirm with Western Blot (for HIV core/envelope Ag)

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26
Q

What is the next step in management for a pregnant pt who has a +HIV core Ag test?

A

Start triple therapy antiretrovirals

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27
Q

What medication must be included in the retroviral cocktail for HIV + pregnant women?

A

Zidovudine

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28
Q

T/F: A newborn with a +HIV-Ab test has HIV infection?

A

False: HIV-Ab crosses the placenta, ALL newborns of HIV+ women will have positive screening test initially.

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29
Q

What is the next step in management for a pregnant woman with a +Chlamydia/Gonorrhea test?

A

PO Azithromycin + IM Ceftriaxone (1x) for mother and partner

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30
Q

What is the next step in management for a pregnant woman who presents with sx of foul smelling greenish watery discharge with vaginal discomfort?

A

KOH prep of discharge and microscopy
Clue Cells: Metronidazole (PO or gel) or Clyndamicin (suppository or cream)
Trichomonads: Metronidazole (PO)or

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31
Q

What is a complication of Trichomoniasis in pregnancy?

A

Preterm labor

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32
Q

What additional tests should be done in the first trimester for initial pregnancy screening?

A

PPD (high risk mothers)

Induration (not redness) = POSITIVE

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33
Q

What is the next best step in management for a pregnant woman found to have a +PPD?

A

CXR (to r/o active disesae)

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34
Q

What treatment should a pregnant woman with +PPD receive?

A

+PPD/-CXR: INH and Pyridoxime (B6) for 9 mos

+PPD/+CXR==>Sputum Cx, if +Sputum: Triple antiTb med regimen (No streptomycin–ototoxicity)

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35
Q

When should Trisomy 21 testing be offered to pregnant women?

A

Offer bhcg, PAPP-A, Nuchal translucency to high risk mothers (AMA at delivery, h/o previous trisomy 21 fetus/child)

Can confirm with CVS at 10-12 wks

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36
Q

What second trimester test is optional but should be offered to all women, especially those of AMA?

A

Trisomy Triple Marker/Quad Screen at 15-20 wks

MSAFP, bHCG, Estriol, Inhibin-A

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37
Q

What is the next step in management for a pregnant pt with an abnormal MSAFP?

A

U/S to check/verify dates (if error, repeat MSAFP

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38
Q

What is the next step in management for a pregnant pt with elevated repeat MSAFP following date verification?

A

Amniocentesis (for Amniotic AFP) and Acetylcholinesteras

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39
Q

What does an elevated Acetylcholinesterase indicate in pregnancy?

A

Specific for NEURAL TUBE DEFECTs

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40
Q

What is the next step in management for a pregnant pt with a decreased MSAFP?

A

Karyotype Analysis

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41
Q

What is the most likely diagnosis consistent with low MSAFO, Low Estriol, High Bhcg, High Inhibin-A

A

Trisomy 21, Down’S Syndrome

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42
Q

What is the most likely diagnosis consistent with low MSAFP, low Estriol, and low bHCG?

A

Trisomy 18, Edward’s Syndrome

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43
Q

What value is considered abnormal for MSAFP?

A

Value >2.5 MoM (multiples of the median)

[Normal:

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44
Q

What is the next step in management for a pregnant pt with a screening (fasting) OGGT >140mg/dL?

A

Fasting 3 hr OGTT (100g) confirmatory test

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45
Q

What are abnormal values for 3hr OGTT in pregnancy and how is Gestational Diabetes diagnosed?

A

Abnormal values: >180 @1hr, >155@2hrs, >140@3hrs

1 abnormal value= Impaired Glc tolerance
2 abnormal values= Gestational Diabetes

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46
Q

What test should be done prior to 3hr OGTT?

A

Plasma glucose (fasting) should be drawn prior to administering testing solution to r/o underlying Diabetes Mellitus

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47
Q

What are safe antiemetic options during first trimester of pregnancy

A

Doxylamine (H1-antihistamine/anticholinergic)
Metoclopromide(pro-motility, dopamine antagonist)
Ondansetron (antiserotonin, 5HT3 antagonist)
Promethazine (H1 antihistamine/anticholinergic)
Pyridoxine (B6)

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48
Q

What is the first step in management for a pt presenting with vaginal bleeding in third trimester of pregnancy?

A

Get pt History, vitals
Place external fetal monitor
Start fluids

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49
Q

Following initial management in third trimester bleed, what is the next step in workup?

A

Transvaginal sono to assess for previa (before speculum/manual exam)
CBC (pay attention to Hb, Hct, platelets)
PT/PTT
D-dimer
Fribinogen
Type and cross-match (in preparation of transfusion)

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50
Q

What is the most likely dx in a pregnant pt presenting with sudden onset vaginal bleeding and severe, constant pelvic pain with a h/o HTN or abdominal trauma?

A

Abruptio Placenta

[the hemotoma may be concealed, in this case the presentation would be scant vaginal bleeding with severe constant pain]

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51
Q

What is a hematologic complication of Placental Abruption?

A

DIC (d/t exposure of thromboplastin (TF, Factor III)–> Factor VII activation–>Factor X, IX activation)

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52
Q

What is the most likely diagnosis in a pregnant pt. presenting with sudden onset vaginal bleeding with NO pain with/without a h/o intercourse, vaginal exam, or trauma prior to bleeding onset?

A

Placenta Previa (marginal, incomplete, complete)

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53
Q

What is a complication of placental villous invasion of the uterine wall?

A

Hysterectomy (Cesarean) d/t intractable bleeding subsequent to
Placenta Accreta: into Endometrium
Placenta Increta: into Myometrium
Placenta Percreta: into Serosa

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54
Q

What is the most likely diagnosis in a pregnant woman who presents with sudden painless vaginal bleeding with fetal bradycardia/distress following artificial rupture of membranes (amniotomy)?

A

Vasa Previa (Velamentous cord insertion with umbilical vessels coursing throughout fetal membranes and passing over internal os)

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55
Q

What is the next step in management for vasa previa?

A

Immediate C-Section

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56
Q

What is a complication of Vasa Previa?

A

fetal Exsanguination

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57
Q

What is the most likely diagnosis in a pregnant pt with a h/o uterine scar now presenting with sudden onset abdominal pain and vaginal bleeding associated with loss of fetal hrt rate, contractions, recession of fetal presenting part, abnormal abdominal contours?

A

Uterine Rupture

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58
Q

What is the management for a pt dx’d with Uterine Rupture?

A

Immediate deliver and surgery for uterine wall repair

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59
Q

What is a maternal complication of uterine rupture?

A

Hysterectomy

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60
Q

What is the next step in management for a pt dx’d with placenta previa but NOT currently bleeding?

A

Admit pt, observe. Maintain stable maternal/fetal vitals.

Give Betamethasone series if

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61
Q

What is the next step in management if pt dx’d with placenta previa presents with continued bleeding w/w/o maternal/fetal deterioration?

A

Emergency C-section

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62
Q

What is the next step in management for a pregnant pt. presenting in labor at > 35 wks GA who has a h/o infant with GBS sepsis but has a negative GBS screen for this pregnancy?

A

Administer GBS prophylaxis (Intrapartum IV penicillin, cefazolin, clindamycin, eythromycin if allergic)

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63
Q

What are high risk indications for GBS Ab administration intrapartum?

A

Maternal Fever
Ruptured Membranes>18 hrs
Preterm delivery
Previous baby with GBS sepsis/infection

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64
Q

When should a pregnant woman with GBS+ culture NOT receive Ab’s?

A

Planned C-section w/o membrane rupture

GBS cx+ in previous pregnancy (but no neonatal manifestations) and GBS Cx- in current pregnancy

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65
Q

What are the complications of vertical GBS transmission?

A

Neonatal Pneumonia and Sepsis (w/in hrs to days after birth)

[Note: Neonatal GBS Meningitis is d/t hospital acquired GBS, not intrapartum and occurs after first week of life]

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66
Q

What is the most likely diagnosis for a pregnant pt presenting with exposure to cat feces/litter box, raw goat milk, or raw meat with mild mono-like syndrome, chorioretinitis, intracranial calcifications, and hydrocephalus?

A

Toxoplasmosis

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67
Q

What is the management for a pregnant pt in first trimester with dx of primary Toxoplasmosis?

A

Pyrimethamine +sulfadiazine IV for serologically confirmed fetal/neonate infection via amniocentesis

Advise to avoid handling kit litter boxes, ingesting raw/undercooked meat, or raw goat’s milk

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68
Q

When is the risk of vertical transmissionof varicella greatest to fetus?

A

When maternal rash develops between 5 dys antepartum and 2 days postpartum.

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69
Q

What is the most likely dx in a neonate presenting with “zigzag” skin rash, limb hypoplasia, microcephaly, microphthalmia, chorioretinitis, and cataracts?

A

Varicella infection

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70
Q

What is the treatment for uncomplicated maternal Varicella infection?

A

PO acyclovir + VariVZIG to mother and neonate

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71
Q

What is the treatment for congenital varicella infection?

A

VariVZIG + IV acyclovir to neonate

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72
Q

What are the best preventative measures for pregnant women and their fetuses against primary Varicella infection?

A

Vaccination (before pregnancy, CANNOT give accine in pregnancy)

Postexposure Prohylaxis: VariZIG within 10 dys of exposure (attenuate effects but will not prevent infection)

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73
Q

In what nervous system region does Varicella remain dormant post primary infection?

A

Dorsal Root Ganglia

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74
Q

What is the most likely intrauterine exposure in a neonate presenting with congenital DEAFNESS, CATARACTS, heart disease (PDA), mental retardation, HEPATOSPLENOMEGALY, THROMBOCYTOPENIA, and BLUEBERRY MUFFIN rash?

A

Rubella (German Measles)

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75
Q

What is the most sommon sequelae associated with congenital Rubella?

A

Deafness

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76
Q

What is the next step in management for a pregnant woman found to be seronegative on routine Rubella titer screening?

A

Advise to avoid infected people
Post partum rubella vaccination

[Note: no post-exposure prophylaxis for Rubella]

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77
Q

What is the most common congential viral syndrome in US?

A

CMV syndrome

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78
Q

What is the most common cause of sensorineural deafness in children?

A

CMV

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79
Q

What are the intrauterine manifestation of congenital CMV infection?

A 
Periventricular Intracranial Calcifications*
IUGR
Chorioretinitis
Prematurity
Microcephaly
Jaundice
Hepatosplenomegaly
Petechiae
Pneumonitis

[Note: most mothers are asymptomatic or develop mild mono-like symptoms]

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80
Q

What are the diagnostic tests used in working up a pregnant pt suspected of CMV infection?

A

Maternal Serum CMV IgM and IgG

[+IgM w/ -IgG, or +IgG ==> recent infection: treat)
-IgM w/ +IgG==> past exposure/Immunity conferred, no fetal risk]

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81
Q

What is the treament for CMV infection in pregnancy?

A

Ganciclovir (or Foscarnet)
[Note: these meds prevent viral shedding /sensorineural hearing loss but does NOT cure CMV]

CMV hyperimmune globulin may reduce risk of congenital CMV in women with primary infection

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82
Q

What preventative measures should be taken against CMV infection in pregnancy?

A

Universal Precautions with all body fluids

Avoid transfusion with CMV-pos blood

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83
Q

What is the next step in management for a pregnant pt. who presents in late third trimester with pain, pruritis, and found to have a localized painful, ulcerated lesion on vaginal mucosa?

A

Schedule C-section (most common cause of vertical transmission is contact with maternal vaginal secretions during active outbreak)

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84
Q

Transplacental HSV infection is one method of acquiring congenital HSV?

A

True

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85
Q

What viral infection is associated with maternal fever, malaise, and diffuse vesicular genital legions?

A

HSV

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86
Q

What are some neonatal complications associated with Congenital HSV?

A 
Meningoencephalitis
Mental Retardation
Pneumonia
Hepatosplenomegaly
Jaundice
Petechiae
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87
Q

How is HSV diagnosed in pregnancy?

A

Culture (vesicle/ulcer )

HSV PCR

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88
Q

What preventative measures are available for pregnant pts against HSV infection?

A

C-section for pt suspected of active HSV genital lesions
No fetal scalp electrode
Standard Precautions (esp with ppl w/ active oral/genital lesions)

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89
Q

What is the treatment for maternal HSV infection?

A

Acyclovir during pregnancy

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90
Q

What is the most effective recommendation for decreasing risk of vertical transmission of HIV?

A

Triple AntiretroviralTherapy immediately and throughout pregnancy, and after (independent of viral load/CD4 count)

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91
Q

What additional recommendations should be followed to decrease risk of vertical HIV transmission to 1%?

A

Avoid breastfeeding
C-section delivery at 38 wks (if viral load >/= 1000 at time of delivery)

Intrapartum IV-Zidovudine for mothers with high viral load at delivery

Avoid artificial Rupture of membranes/fetal scalp electrode (invasive procedures)

Continue Combination therapy in mother for at least 6 wks post partum

Zidovudine to neonate for 6 wks post pirth prophylaxis

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92
Q

T/F: ALL neonates of HIV + mothers will have HIV Ab screening test?

A

True: Maternal anti-HIV IgG crosses placenta

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93
Q

What stage of Syphilis has the highest risk of vertical transmission?

A

Primary and Secondary Syphilis

Lowest risk is Tertiary or latent Syphilis

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94
Q

What is the most likely dx in a neonate presenting with nonimmune Hydrops Fetalis (swollen), Maculopap/vesicular PERIPHERAL rash, anemia, thrombocytopenia, hepatosplenomegaly, and LARGE EDEMATOUS PLACENTA?

A

Congential Syphilis (first trimester/early acquired)

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95
Q

What is the most likely dx in a child >2yo, presenting with saber shins (anterior bowing of tibia), Hutchinson teeth, mulberry molars, saddle nose, and deafness (CN8 palsy)?

A

Congenital Syphilis (late acquired)

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96
Q

What additional test should be ordered for any pregnant woman who tests positive for any STD?

A

HIV test, but only with her consent

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97
Q

Is C-section delivery a good preventative measure against vertical transmission of Syphilis?

A

NO, syphilis Ag crosses placenta!

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98
Q

What is the next step in management for a pregnant woman presenting with painless ulcerative vaginal legion?

A

Darkfield Microscopy ( VDRL/RPR can be false + in Primary Syphilis)

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99
Q

What treatment should be used for Primary and secondary Syphilis in a pregnant pt with Penicillin allergy?

A

Desensitization (with epinephrine on hand)then

IM Benzathine Penicillin x1

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100
Q

During what stage of pregnancy will HBV transmission occur?

A 
Third trimester (primary infection) or
Delivery (Ingest infected vaginal secretions)
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101
Q

The presence of which HBV marker in addition to HBsAg and IgM anti-HBcAb indicates the highest risk of vertical transmission?

A

+HBeAg

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102
Q

What preventative measures should be taken against HBV vertical transmission?

A

Avoid invasive procedures during pregnancy (Amnio)
Immunizations:
HBV vaccine to non-immune -HBsAg mom during
pregnancy.
HBIG +HBV vaccine to mothers for Post Exposure
Prophylaxis

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103
Q

What treatment is given to neonate of mother with HBV infection?

A

HBIG and HBV vaccine (within 12-24 hrs of life)

Note, breastfeeding is ok once neonate receives HBIG and HBV vaccine

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104
Q

How is chronic HBV treated in pregnancy?

A

Interferon (IFN) or Lamivudine

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105
Q

What are some complications associated with sustained HTN in pregnancy?

A

Pre-eclampsia/Eclampsia
Placental Abruption
IUGR
Hypoxia (Poor placental Oxygen Exchange)

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106
Q

What condition is most likely to be diagnosed in a pregnant pt with a BP >140/90 before 20wks gestation or before pregnancy?

A

Chronic HTN

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107
Q

What condition is most likely to be diagnosed in a pregnant pt with a BP >140/90 after 20wks gestation and returns to normal baseline by 6 wks post partum?

A

Gestational HTN

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108
Q

What condition is most likely to be diagnosed in a pregnant pt with a sustained BP >140/90 and proteinuria of >300mg/24 hr (1-2+ on dipstick) without any other symptoms?

A

Mild Preeclampsia

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109
Q

What condition is most likely to be diagnosed in a pregnant pt with any of the following: sustained BP >160/110, proteinuria of >5g/24 hr (3-4+on dipstick), epigastric/RUQ pain, vision changes, pulmonary edema, oliguria, thrombocytopenia, or elevated liver enzymes?

A

Severe Pre-Eclampsia

Note: Eclampsia is severe Preeclampsia + seizure

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110
Q

Who is at highest risk of developing Pre-eclampsia?

A

Primiparas

(Note: Multiple gestation, Molar pregnancy, DM, Age extremes, Chronic HTN, and Chronic renal disease are all risk factors too!)

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111
Q

What is the next step in management for a pregnant pt who presents at > 20wks to routine exam with trace pedal edema, BP >140/90 initial and repeated at 10 min, and trace pedal edema?

A

Urinalysis (check dipstick protein to r/o preeclampsia)

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112
Q

What is the most likely diagnosis in a pregnant pt with a h/o chronic HTN prior to pregnancy now having increasing BP, proteinuria, or warning signs?

A

Chronic HTN with Superimposed Preeclampsia

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113
Q

What should be included in the diagnostic workup for a pt thought to hv preeclampsia?

A

CBC
Chem-12 (Liver enz, BUN, Cr)
Coagulation panel (PT,PTT)
Urinlaysis with Urine protein

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114
Q

What will labs for a pt with Preeclampsia show?

A

Hemoconcentration (Elevated Hb, HCT, BUN, Cr, Uric Acid)
Proteinuria
Elevated Liver Enzymes (severe)
+/- DIC (severe)

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115
Q

What is the management for a pt with HTN in pregnancy?

A

Diet/Lifestyle only if BP less than (160/110)

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116
Q

What HTN medications are used in pregnancy for mild preeclampsia?

A

Only give if BP sustained at >160/110
First Line: Methyldopa or Labetalol (alpha and beta blocker- preserves placental flow)

Alternative: Nifedipine (CCB)

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117
Q

What BP meds are used in acute elevation of BP or severe preeclampsia?

A

IV Hydralazine or Labetalol

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118
Q

What is the treatment for Eclampsia?

A

Airway protection
IV Magnesium Sulfate (neural protection) bolus and infusion
IV Hydralazine or Labetalol
Serial BP checks and Urine protein
Aggressive, prompt delivery (of all POC) at any gestational age (w/ intrapartum IV Magsulfate, Hydralazine/Labetalol)

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119
Q

What is the most likely dx in a pt who is 2 days post partum with BP>160/100, labs showing elevated LDH, Total bilirubin, AST, ALT, and Thrombocytopenia?

A

HELLP Syndrome

most commonly presents in third tremester to 2 days post partum

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120
Q

How is HELLP syndrome treated in the pregnant pt?

A

1) Immediate delivery at any gestational age

2) Dexamethasone if Plt

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121
Q

When should steroids be stopped in pt with HELLP syndrome in labor?

A

Discontiune steroids when plt ct>100,000 and liver enzymes normalize

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122
Q

What is the recommendation for labor in a pt with mild preeclampsia?

A

Induction (oxytocin infusion) if >/= 36wks-vaginal delivery if fetus and mother are stable

(Note: consider Betamethasone series if fetus is 24-34 wks)

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123
Q

When is C-section indicated in Preeclampsia/Eclampsia/ HELLPsyndrome

A

When mother and/or fetus are in distress/unstable

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124
Q

What are some complications of HELLP syndrome?

A 
DIC
Ascites
Abruptio Placenta
Fetal Demise
Hepatic Rupture
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125
Q

What is the most common cause of thrombocytopenia in pregnancy?

A

Gestational Thrombocytopenia

Third trimester, no other abnormalities/symptoms, Plt cts not lower than 70,000

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126
Q

Women with which cardiopulmonary conditions should be advised against becoming pregnant due to risk of sudden death?

A

Pulmonary Hypertension
H/o post-partum Cardiomyopathy
Severe Valvulopathy
Eisenmenger Syndrome

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127
Q

At what gestational age do the hemodynamic changes associated with normal pregnancy typically peak?

A

28-34wks gestational age

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128
Q

During what period of time can a pregnant woman develop Peripartum Cardiomyopathy?

A

Last month of pregnancy up to 5 mos post-partum

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129
Q

What are the risk factors associated with Peripartum Cardiomyopathy?

A

AMA
Multiparity
Multiple Gestations
Preeclampsia

130
Q

What is the management for Heart Failure in pregnancy?

A

Loop Diuretics
Nitrates
BBlockers
Digoxin (only improves symptoms, no improved outcome)

131
Q

What is management for arrhythmia in pregnancy?

A

Continue rate control medications (same as non-pregnant)

NO amiodarone or warfarin in pregnancy

132
Q

What is appropriate Endocarditis prophylaxis in pregnancy?

A

Daily prophylaxis to pts with rheumatic heart disease

NO prophylaxis for uncomplicated vaginal/cesarean deliveries in pt with valvular disease/ prosthetic valves

Follow Endocarditis prophylactic guidelines for non-pregnant pt.

133
Q

Which valvular diseases do NOT require therapy in pregnancy?

A

Regurgitant Valve Lesions

134
Q

Which valvular lesions can worsen in pregnancy?

A

Stenotic Valve Lesions (esp Mitral Stenosis –> increased risk of pulmonary edema and A-Fib)

135
Q

How is gestational age determined?

A

Crown-Rump length at 10-13 wks

136
Q

When is high resolution ultrasound indicated for fetal evaluation?

A

FHx of congenital malformation or

Abnormal maternal serum markers

137
Q

During what gestational period can CVS be done?

A

10-12 wks

138
Q

What is an indication for CVS

A

AMA, previous child with chromosomal abnormality

139
Q

During what gestational period can an Amniocentesis be performed?

A

Any time >15 wks (w/U/s guidance)

140
Q

What are some indications/uses for Amniocentesis?

A 
Maternal Screen (when serum levels abnormal)
Karyotype Analysis
141
Q

When can Percutaneous Umbilical Blood sample be collected and what can it be used for?

A

After 20wks gestation
Dx: bld gases, karyotype, IgG, IgM
Tx: Intrauterine transfusion for fetal anemia

142
Q

When can Fetoscopy be performed and what are its indications/uses?

A

After 20 wks gestation with anesthesia
Intrauterine surgery
Fetal scalp bx (icthyosis)

143
Q

What is the diagnosis when a pregnant pt presents with fluid leakage/passage without cervical changes?

A

Premature Rupture of Membranes (PROM)

144
Q

What is the most common risk factor for PROM?

A

Ascending lower genital tract infection

145
Q

What is the next step in management when PROM is suspected in a stable patient?

A

External Fetal Monitoring/ Maternal Vitals
Sterile Speculum exam:
Pooling (posterior fornix, can ask pt to valsalva/cough)
Nitrazine Test of fluid
Microscopy of Smear of vaginal fluid swab
U/S: Oligohydramnios

146
Q

What is a significant/feared complication of PROM?

A

Chorioamnionitis

147
Q

What is the typical presentation associated with Chorioamnionitis?

A

Maternal Fever with Uterine tenderness
Confirmed PROM
Absence of URI/UTI

148
Q

What is the next step in management for a pregnant pt who presents with uterine contractions, PROM, and fever?

A

CULTURES/SMEAR and Antibiotics!!!!!:
Cervical cultures (chlamydia/gonorrhea)
Anovaginal culture ( GBS)
KOH prep for Bacterial Vaginosis, Trichomonas, Yeast
IV Ab x7dys (ampicillin + erythromycin)

149
Q

When should tocolytics be given to a woman with PROM?

A

Only if she is Extremely Premature to allow time for transport to tertiary facility and/or to give steroids for fetal lung maturity. (no more than 48 hrs)

150
Q

What are the contraindications for tocolytic use in PROM?

A 
Chorioamnionitis
Nonreassuring fetal status
Severe preeclampsia/Eclampsia
Fetal Demise
Fetal Maturity
Maternal hemodynamic Instability
151
Q

If a pt with PROM is also having contractions, should tocolytics be administered?

A

No

152
Q

How is PROM managed in a pt that is

A

Bed rest at home

153
Q

How is PROM managed in a pt presenting between 24-33 wks?

A 
Hospitalization
Betamethasone series (if
154
Q

What is the management for a pt with PROM presenting at >34 wks?

A

Initiate delivery (in stable mom and baby - vaginal delivery)

155
Q

In what stage of labor is a woman with uterine contractions that have been occurring between 14-20 hrs and cervical dilation to about 4cm at a rate

A

Stage 1-Latent Phase

156
Q

In what stage of labor is a woman with regular uterine contractions and rapid cervical dilation at a rate of appx >1.2(primipara) - >1.5 (mutipara)cm/hr?

A

Stage 1-Active Phase

157
Q

What is the definition of Arrest of labor in stage 1 active phase?

A

When there is no change in cervix in 2+ hours of Active phase Stage 1 labor

158
Q

What are some common causes associated with arrest of labor?

A

Passenger: fetal size/presentation
Passage: Cephalopelvic disproportion
Power: Inadequate/dysfunctional contractions

159
Q

How is arrest of stage 1 labor managed?

A

If inadequate/hypotonic contractions –> IV Oxytocin
If Hypertonic contractions –> Give morphine sedation
If contractions are adequate –> Emergency C-Section

160
Q

What is the definition for prolonged latent phase of stage 1 labor?

A

Cervix dilates>/=3cm and no change in 14-20 hrs

161
Q

What is the most common cause of prolongation of Latent phase of labor?

A

Medications (analgesics)

162
Q

What is the management for prolonged latent phase of labor?

A

Rest and sedation

163
Q

What denotes the end of Stage 1 labor?

A

Complete cervical dilation

164
Q

What stage of labor is a pt in when they are fully dilated/effaced?

A

Stage 2-Descent (ends with fetus delivered)

165
Q

What is considered Stage-2 arrest of labor?

A

Failure to deliver fetus within:
3hrs (primipara w/ Epidural)
2hrs (primipara w/o epidural; Multipara w/Epidural)
1hr (multipara w/o epidural)

166
Q

What are some common causes of Stage 2 arrest of labor?

A

Abnormal passenger, passage, power

167
Q

What is the management for arrest of stage-2 labor?

A

Fetal Head not engaged –> Emergency C-Section

Fetal Head engaged–> Try Forceps or vacuum extraction

168
Q

What occurs during stage 3 of labor?

A

Expulsion of placenta

169
Q

What should be considered in a pt presenting with prolonged Stage 3 of labor?

A

Placenta Accreta, Increta, Percreta (if it takes longer than 30 min)

170
Q

What is the management for Prolonged stage 3 of labor?

A

Uterine Massage
IV oxytocin
If oxytocin fails–> manual removal
Hysterectomy if all else fails

171
Q

What are possible clues to prolapsed cord during labor/delivery?

A

Sudden fetal bradycardia or Severe Variable Decelerations (indications of possible hypoxemia)

172
Q

What is the next step in management for a female in labor who now has a prolapsed cord?

A

Put pt in Knee-to-Chest position
Elevate presenting fetal part
Terbutaline (b2-agonist)decrease force of contractions
Immediate C-Section

NOTE: DO NOT try to replace cord

173
Q

What is the concern regarding umbilical cord prolapse?

A

Decreased fetal oxygenation –> hypoxemia

174
Q

How does Terbutaline aid in the management of umbilical cord prolapse?

A

B2 agonist–>increases Adenylyl Cyclase–>increase cAMP–> inhibits MLCK phosphorylating activity –> decreased contractile force –>Smooth muscle relaxation

This pthwy is mediated by Gs protein

175
Q

What is a possible fetal response to maternal terbutaline administration?

A

Tachycardia

176
Q

A fetal heart tracing showing a baseline hr of 110-160bpm, accelerations, no late or variable decelerations, beat-to-beat variability is considered to be what kind of tracing?

A

Reassuring

177
Q

What components of a fetal heart tracing would indicate a non-reassuring tracing?

A

Baseline tachy/bradycardia
Absent accelerations
Repeated variable and/or late decels
No beat-to-beat variability

178
Q

What is usually the underlying cause for early decelerations on fetal heart tracing?

A

Head Compression (with contractions)

179
Q

What is an underlying cause for variable decelerations on fetal heart tracing?

A

Cord Compression

180
Q

What is an underlying cause of late decelerations on fetal heart tracing?

A

Uteroplacental insufficiency

181
Q

What is the normal fetal heart rate range?

A

110-160 bpm

182
Q

What are some common causes of fetal tachycardia/bradycardia?

A

Medications :
Tachycardia–> B-agonists (terbutaline/ritodrine)
Bradycardia–> B-blockers, local anesthetics

183
Q

What possible condition could the presence of sinusoidal fetal heart tracing pattern indicate?

A

Fetal Acidosis

184
Q

What possible condition could the presence of severe variable fetal heart tracing pattern indicate?

A

Fetal Hypoxia

185
Q

What is the next step in management for a pt at term in active labor who is receiving oxytocin, morphine for pain, whose cervix is not fully dilated but 100% effaced, membranes intact, no vaginal bleeding, and fetal heart tracing showing fetal tachycardia, with minimal variability, and repetitive late decelerations?

A

1)Evaluate Strip for nonreassuring patterns
2)Identify non-hypoxic causes (meds)
3)Start Intrauterine resuscitation:
Discontinue oxytocin (or other inciting meds)
IV Fluids (normal saline)
High Flow Oxygen
Change maternal position (to left lateral)
Vaginal Exam (r/o cord prolapse)
Scalp stimulation (ck strip for accelerations)
4)Prepare for delivery if strip doesn’t improve
5)Fetal scalp pH (nml >7.20) if strip is equivocal and cervix is dilated and membranes ruptured

186
Q

When is Vacuum or Forceps delivery indicated?

A

Prolonged Stage 2(most common)
Nonreassuring tracing without contraindications
To avoid maternal pushing in cases of cardiopulmonary conditions with increased risk of sudden death

187
Q

What are the indications for Cesarean delivery?

A

Cephalopelvic Disproportion (with failure of progression or arrest)
Fetal malpresentation
Nonreassuring Strip
Placenta/Vasa Previa
Infection (Herpes lesions present, HIV)
Uterine Scar (myomectomy, h/o classical uterine incision)

188
Q

When should forceps/vacuum NOT be used in delivery?

A 
When fetal head is not clearly visible/accessible
If membranes Not ruptures
Fetal head not engaged
Head orientation not certain
Small pelvis
Cervix NOT fully dilated
189
Q

What are the contraindications for a VBAC?

A

H/o Classical uterine incision
Infection (Active vaginal herpes)
Uterine scar

190
Q

What is the next step in management for a pregnant pt at routine follow-up visit at 37 weeks with a fetus that is in breech/transverse position?

A

Offer External Cephalic Version and discuss possibility of Cesarean delivery

191
Q

What is the most common cause of excessive post partum bleeding?

A

Uterine Atony

192
Q

When should post- partum hemorrhage be suspected?

A

Rapid/Protracted Labor
Chorioamnionitis
Medications (MgSO4, Halothane)
Overdistended uterus (grand multiples)

193
Q

What is the next step when a woman is having persistent post-partum bleeding following placental delivery?

A

Uterine massage and Uterotonic medications

194
Q

What are some medications that can be used to manage excessive post-partum bleeding?

A

Oxytocin
Methylergonovine
Carboprost

195
Q

What are the main differences between Carboprost and Misoprostol?

A

Carboprost: PGF2-alpha analog, CANNOT be used in pt w/ HTN

Misoprostol: PGE1 agonist, can use in pt with HTN

196
Q

Which uterotonic medications can be used in pts with HTN?

A

Misoprostol

197
Q

What is the most likely diagnosis in a woman who just delivered and has completed stage 3 of labor but upon examination of the pacenta, some of the cotyledons are missing?

A

Retained placenta

198
Q

What is the management for retained placenta?

A

Manual removal or U/s guided curettage

Hysterectomy if accreta/increta/percreta present and/or cannot control bleeding

199
Q

When should DIC be suspected in a post-partum pt?

A

Oozing-type bleeding from IV sites/lacerations with a contracted uterus

200
Q

What hematologic condition are Abruptio Placenta, Severe Preeclampsia, Amniotic Fluid Emboli, or Prolonged retained Fetus associated with?

A

Disseminated Intravascular Coagulation (DIC)

201
Q

What is the next step in management for a woman who just delivered her placenta and upon examination, the uterus cannot be palpated and a beefy-appearing, bleeding mass is visible within the vagina?

A

Uterine Inversion

202
Q

What are the next steps in management for a post partum woman who presents with Urinary Retention with a residual volume of >250ml?

A

Give Bethanechol, if this fails–> Catheter (2-3 dys max)

203
Q

What are absolute contraindications to breastfeeding?

A

HIV
HTLV-1
HSV lesions on breast
Active Tb
Drug/Medication use/abuse (not alcohol or cigarettes)
Cytotoxic medications (MTX, cyclosporine)
Galactosemia

204
Q

When can an IUD/Diaphragm be placed for contraception following delivery?

A

Not before 6 wks post partum

205
Q

Which contraceptive option(s) can be used while breastfeeding?

A

Progestin-only methods

206
Q

When can combined E-P contraceptive methods be used relative to delivery?

A

Not before 3wks post partum if not breast feeding

207
Q

What is the mechanism by which Progestin-only contraceptives prevent pregnancy?

A

Ingibit GnRH (mid cylce)–> Decreased FSH/LH –> Anovulation

208
Q

What is the next step in management for a pt who delivered about 6 hours ago by Cesarean Section with general anesthesia now complaining of incisional pain, and on exam has mild fever, few scattered rales bilaterally, and cannot take deep breath due to pain?

A

Incentive Spirometry and Ambulation

209
Q

What are 2 risk factors associated with post partum atelectasis?

A

General anesthesia use and inadequately controlled incisional pain

Cigarette Smoking

210
Q

What is the next step in management for a woman on post-partum day 1 with high fever, CVA tenderness who has had multiple vaginal exams and urethral catheterizations.

A 
Urinalysis/Urine Cx
IV antibiotics (Single Agent, nitrofurantoin or ciprofloxacin)
211
Q

What is the most likely dx in a woman on post partum day 2-3 who had a c-section following hospitalization for PROM and now has fever, uterine tenderness, but no peritoneal signs?

A

Endometritis

212
Q

What is the next step in management for a post partum pt with endometritis?

A

IV antibiotics (multi-agent, Gentamicin + Chlindamycin)

213
Q

What is the most likely diagnosis in a pt who keeps spiking fevers despite antibiotics and on exam has erythema, fluctuance, or drainage associated with her c-section incision on postpartum day 4-5?

A

Wound infection

214
Q

What is the management for wound infection in post partum pt?

A

IV Antibiotics
Wet-to-Dry dressing
Closure by secondary intention (ex packing, wound vac)

215
Q

What are the history and clinical findings associated with septic thrombophlebitis?

A

Prolonged labor

Persistent wide range fevers (on broad spectrum antibiotics) on postpartum day 5-6

216
Q

What is the management for post partum septic thrombophlebitis?

A

IV heparin 7-10 days

217
Q

What is the most likely diagnosis in a woman who is breast feeding and presents 1-3 weeks post partum with unilateral erythematous, swollen, tender breast with cracked nipple?

A

Mastitis

218
Q

What is the most likely organism associated with mastitis?

A

S.aureus

219
Q

What is the treatment for mastitis?

A

Nafcillin (PO)

Continue bilateral breast feeding

220
Q

What antihypertensive medications should never be given/started during pregnancy?

A

ACEi/ARBs
Renin Inhibitors
Thiazide Diuretics

221
Q

What is the leading cause of MATERNAL death in the US?

A

Pulmonary Embolism

222
Q

When should Anticoagulation be given?

A

DVT or PE in pregnancy
Afib with underlying heart disease
Antiphospholipid Ab Syndrome
Severe Heart Disease (EF

223
Q

What is the anticoagulant of choice in pregnancy and why?

A

Low Molecular Weight Heparin

It does NOT cross placenta

224
Q

Which anticoagulant should not be given during pregnancy?

A

Warfarin (crosses placenta)

225
Q

Which anticoagnulant is associated with orthopenia?

A

Unfractionated Heparin

226
Q

How are pt with a h/o DVT/PE in prior pregnancy or h/o underlying thrombophilia managed during pregnancy?

A

LMW Heparin prophylactically throughout pregnancy
Unfractionated Heparin during Labor/delivery
Warfarin for 6 wks Post-partum

227
Q

What are the most common underlying thrombophilias?

A 
Factor V Leiden (resistant to Protein C)
Prothrombin gene mutation
Antiphospholipid Antibody Syndrome
Hyperhomocysteinemia (MTHFR)
Antithrombin III Deficiency
228
Q

What are 2 fetal complications associated with HYPERthyroidism in pregnancy

A

Growth Restriction

Stillbirth

229
Q

What are 2 complications associated with HYPOthyroidism in pregnancy?

A

Intellectual deficits

Miscarriage

230
Q

What are effects of pregnancy on Thyroid hormones?

A

Increased Total T3 and T4 d/t estrogen effects on liver–>
Increased TBG release

231
Q

What adjustment should be done to pt on Thyroid replacement medication during pregnancy?

A

Increase dose of Levothyroxine by 25-30%

232
Q

What is the only Thyroid replacement drug of choice in pregnancy?

A

Levothyroxine

233
Q

What is the drug of choice for symptomatic HYPERthyroidism in pregnancy?

A

B-Blockers (Propranolol)

234
Q

What is the drug of choice for treating HYPERthryoidism during pregnancy?

A

Propylthyouracil (PTU) for First Trimester

Methimazole for Second and Third Trimesters

235
Q

What are the fetal side effects of PTU use?

A

It crosses placenta and can cause:

Goiter and Hypothyroidism

236
Q

When does Congenital Grave’s disease typically become apparent in neonate?

A

7-10 days after delivery (when medications effect subside)

237
Q

What Thyroid-related Ab’s cross the placenta?

A

Thyroid-Stimulating Immunglobulins
and
Thyroid-Blocking Immunglobulins

238
Q

What are some clinical findings in fetus associated with exposure to Thyroid Immunglobulins in utero? (3)

A

Goiter
Fetal Tachycardia
Growth Restriction

239
Q

What are the target values for blood sugar in a pregnant pt?

A

> 90 and

240
Q

What is the initial management for a pregnant woman dx with Gestational Diabetes (GDM)?

A

Diet and Light Exercise

241
Q

What is the treatment of choice in pregnancy of diet and exercise fail to meet target values?

A

Insulin

242
Q

How is insulin managed during pregnancy?

A

Must increase dose as pregnancy progresses (increased hPL production)

Must stop insulin infusion after delivery (bc requirement falls drastically following delivery of placenta)

243
Q

What type of hypoglycemic medication should be avoided while breastfeeding and why?

A

Oral Hypoglycemics

-they can transfer to breastmilk and cause hypoglycemia

244
Q

What is done for routine monitoring of diabetic pt in pregnancy?

A

HBA1c each trimester
Triple Marker Screen (16-18 wks)-ck NTD
Monthly Sono-Ck for IUGR/macrosomia
Monthly BBP
Weekly NST and AFI at 32wks (if on insulin, macrosomia, h/o stillbirth,or HTN)
Start NST and AFI at 26 wks (if pt has small vessel disease or poor glycemic control)

245
Q

What should be done for the management of pt with Gestational Diabetes Mellitus (GDM)?

A

2-hr 75g OGTT @ 6-12 wks Post-partum (to ck for resolution of DM)

246
Q

What is a rare but significant anatomic abnormality that can be associated with overt DM?

A

Caudal Regression Syndrome

247
Q

What tends to be associated with a HBA1c >8.5 in a pregnant pt with preexisting DM?

A

Congenital Malformations (esp NTD)

248
Q

Are congenital malformations associated with Gestational Diabetes or underlying Diabetes Mellitus?

A

Underlying DM

GDM does not become problematic until second trimester and congenital malformations occur mainly in first trimester

249
Q

How is labor managed in a pt with DM?

A

1)Delivery target: 40 wks GA
2)Induction: 39-40wks GA or earlier if 2.5; phosphatidyl glycerol presence =lung maturity)
3)Schedule C-section if >4500 g (risk of shoulder
dystocia)
4)D5W and Insulin Drip to (maintain maternal blood
glucose b/w 80 and 100 mg/dL)
5) Stop insulin drip immediately after placental delivery
6) Maintain glucose with Sliding Scale

250
Q

What is the most likely diagnosis in a pregnant pt at 20 wks with dizygotic twins who is of Swedish descent with intense itching, especially at night, involving her palms and soles. There is a positive FHx and no rash on physical exam but c/o dark colored urine.

A

Intrahepatic Cholestasis of Pregnancy

251
Q

What are some risk factors associated with intrahepatic cholestasis of pregnancy?

A

European heritage

Multiple Pregnancies

252
Q

What tests should be done to dx Intrahepatic Cholestasis of Pregnancy?

A

Serum Bile Acids (10-100 fold increase)

253
Q

What is the treatment for Intrahepatic Cholestasis of Pregnancy?

A 
Ursodeoxycholic Acid (decreases cholesterol absorption, dissolves gallstones- only while taking the medication)
(Antihistamines and cholestyramine may help symptoms)
254
Q

What is the treatment for asymptomatic Bacteruria in pregnancy?

A

Outpt: Nitrofurantoin; Alt- Cephalexin or Amoxicillin

255
Q

What is the most likely dx in a pregnant woman presenting with urgency, frequency, or burning and found to have a positive Urine Culture?

A

Acute Cystitis

256
Q

What is the treatment for Acute Acystitis?

A

Outpt: Nitrofurantoin; Alt- Cephalexin or Amoxicillin

257
Q

What is a complication of untreated asymptomatic bacteruria or acute systitis?

A

Pyelonephritis

258
Q

What is the most likely dx in a pregnant woman who presents with urgency, frequency, or burning, fever and CVA tenderness and found to have a positive Urine Culture?

A

Pyelonephritis

259
Q

What is the treatment for Pyelonephritis?

A

1) Admit to Hospital
2) IV Hydration and Ab (IV Cephalosporin or Gentamicin)
3) IV Tocolysis

260
Q

What are some complication of Pyelonephritis?(4)

A 
Preterm Labor/Delivery
Severe cases:
 -Sepsis
 -Anemia
 -Pulmonary Dysfunction
261
Q

What are the options for first trimester elective Abortion?

A

Dilation & Curettage (D&C)-before 13wks, most common
Medical Abortion: w/in 63 days (~9wks) of amenorrhea
-Mifepristone-(Progesterone antagonist) and
-Misoprostol-(PGE1 agonist)

262
Q

What medications need to be given when a pt is having D&C for abortion?(3)

A

Prophylactic Abs
Conscious Sedation
Paravertebral Block (local)

263
Q

What are some rare complications of D&C abortion and how are they managed?

A

Endometritis (PO Ab’s)

Retained Products of conception (repeat curettage)

264
Q

What are two rare complications of medical abortion and how are they managed?

A 
Retained POC (D&C)
Sepsis (Clostridium sordellii-IV antibiotics)
265
Q

What is the definition of Spontaneous Abortion?

A

Expulsion of embryo/fetus

266
Q

What is the most common initial presentation of Spontaneous Abortion?

A

Uterine Pain/Cramping

Vaginal Bleeding

267
Q

What is the definition for Fetal Demise?

A

In utero death of fetus >20wks GA

268
Q

What is the most common symptom pts will report associated with fetal demise?

A

Loss of fetal movement

269
Q

What is the most likely dx for a pt who presents with a h/o recent vaginal bleeding and passage of clots but on exam her cervix is closed and u/s shows no product of conception?

A

Complete Spontaneous Abortion

270
Q

What is the management for a Complete SAB?

A

Follow-up BhCG

271
Q

What is the most likely dx for a pt who presents with a recent h/o vaginal bleeding and passage of clots, on exam her cervix is closed and u/s shows some products of conception?

A

Incomplete SAB

272
Q

What is the management for an Incomplete SAB?

A

D&C

273
Q

What is the most likely dx for a pt who presents with vaginal bleeding, passage of clots and on exam her cervix is dilated and u/s shows products of conception present?

A

Inevitable SAB

274
Q

What is the management for Inevitable SAB?

A

Medical Induction or D&C

275
Q

What is the most likely dx for a pt who presents with vaginal bleeding but on exam her cervix is closed and u/s shows products of conception present and fetal heart motion/beat identified?

A

Threatened Abortion

276
Q

What is the management for a pt with Threatened Abortion?

A

Bed Rest

277
Q

What is the most likely dx for a pt whose u/s shows a dead fetus and products of conception?

A

Missed Abortion

278
Q

What is the most likely dx for a pt who presents with a h/o recent vaginal bleeding and passage of clots no fetal heartbeat detected and pt has fever, positive cx?

A

Septic Abortion

279
Q

What is the management for Missed Abortion?

A

Medical Induction or D&C

280
Q

What is the management for a pt with a Septic Abortion?

A

D&C

IV Levofloxacin + Metronidazole

281
Q

What is the most common cause of Spontaneous Abortion?

A

Chromosomal Abnormalities

282
Q

What are risk factors associated with SAB?

A

AMA
H/o previous SAB
Maternal SMoking

283
Q

What is the most common cause of Fetal Demise?

A

Unknown–> Idiopathic

284
Q

What risk factors are associated with Fetal Demise?(5)

A 
Antiphospholipid Ab Syndrome
Overt MAternal DM
Maternal Trauma
Severe Maternal Isoimmunization
Fetal Infection
285
Q

What are the steps to working up a SAB in the first trimester ?

A

Pelvic/Speculum Exam (ck for bleeding and dilation)

Ultrasound (ck fetal cardiac activity +/-, POC)

286
Q

What is the most feared complication when a pregnant woman presents with fetal demise >2wks?

A

DIC (d/t Tissue Thromboplastin elevation from dying fetal organs)

287
Q

WHat should be ordered on CCS for a pt in whom coagulopathy is suspected?

A

CBC-platelet Count
PTT/PT
D-dimer
Fibrinogen

288
Q

What is the next step in management for a pt presenting with fetal demise and DIC is confirmed

A

Immediate delivery of fetus

289
Q

What is the most likely dx in a 24 yo pt who comes to clinic w/ left side abdominal and flank pain, LMP 7 wks ago, and denies n/v or fever with an IUD and pelvic exam showing slightly enlarged uterus, closed cervix, tenderness on bimanual exam but no palpable adnexal mass and serum bhCG is 2650mIU?

A

Ectopic Pregnancy (Amenorrhea, Vaginal Bleeding, Unilateral Abdominal Pain)

290
Q

What is the most likely dx in a 24 yo pt who comes to clinic w/ left side abdominal and flank pain w/ rebound and guarding and rigidity, hypotension, tachycardia LMP 7 wks ago, and denies n/v or fever with an IUD and pelvic exam showing slightly enlarged uterus, closed cervix, tenderness on bimanual exam but no palpable adnexal mass and serum bhCG is 2650mIU

A

Ruptured Ectopic Pregnancy

  • Hemodynamic Instability
  • Peritoneal Signs present on Exam
291
Q

What is the treatment for a Ruptured Ectopic Pregnancy?

A

1) Immediate Laparotomy/slpingectomy
2) RhoGAM is RH- mother
3) Follow-up with bhCG to ensure complete removal

292
Q

What is the workup for an ectopic pregnancy?

A

1) bhCG >1500mIU
2) U/s- not intrauterine pregnancy seen

Note: absence of adnexal mass on exam does NOT r/o ectopic pregnancy

293
Q

What are some common risk factors for ectopic pregnancy and which is most common?

A

1) H/o previous ectopic pregnancy
2) Any other cause of tubal scarring/adhesions:
- Infection: PID (most common) and IUD
- Surgical Hx:Tubal ligation/ surgery
3) Congenital: DES exposure in utero

294
Q

What bhCG value corresponds to visible intrauterine pregnancy on vaginal U/s?

A

bhCG >1500 mIU (5wks)

295
Q

What bhCG value corresponds to visible intrauterine pregnancy on abdominal U/s?

A

bhCG >6500 mIU (6wks)

296
Q

What is the next step in management for a pt who presents with amenorrhea for several weeks and endorses sexual activity but her serum bhCG is

A

Repeat BhCG followed by repeat Sono when quantified BhCG is >1500mIU.

297
Q

What is the treatment for an ectoic pregnancy that has not ruptured?

A

1) Methotrexate or Laparascopy w/ Salpingostomy
2) RhoGAM to RH- moms
3) F/u bhCG

298
Q

What are the indications for Methotrexate use to manage abortion or ectopic pregnancy? (4)

A

Pregnancy mass

299
Q

What is the next step in management for a pregnant woman presenting at 19 wks in the ED with lower pelvic pressure, no contractions, fetal membranes bulging from vagina cervix cannot be palpated?

A

R/o Chorioamnionitis

300
Q

What is the most likely dx in a pregnant woman presenting at 19 wks in the ED with lower pelvic pressure, no contractions, fetal membranes bulging from vagina cervix cannot be palpated?

A

Cervical Insufficiency

301
Q

What are risk factors for cervical insufficiency?

A

Second trimester Abortion
Cervical Laceration During Delivery
Deep Cervical Conization
DES exposure

302
Q

When should elective Cerclage be performed in a pt with cervical insufficiency?

A

13-16 wks GA with >/= 3 unexplained midtrimester pregnancy losses

303
Q

What must be done prior to urgent Cerclage being placed in a pt with cervical insufficiency?

A

R/o labor and r/o chorioamnionitis

304
Q

When should cerclage be removed?

A

36-37 wks (after fetal lung maturity)

305
Q

What is the next step in management for a woman who has no symptoms and no prior h/o preterm labor but has short cervix on routine transvaginal sono b/f 16-20 wks?

A

Transvaginal Cervical Surveillence –> repeat after 20 wks if short cervix persists

(Note: only perform cerclage if evidence of cervical dilation and chorioamnionitis and labor are r/o)

306
Q

What is the definition of IUGR?

A

EFW

307
Q

What is required prior to dx’ing a fetus with IUGR?

A

Must have accurate dates.

308
Q

What is the next step in management for a pregnancy for which accurate GA/EDC is unknown?

A

Early Sonogram (16-20wks)

[Note: NEVER use late sonogram to adjust dates in pregnancy]

309
Q

What are the conditions associated with Symmetric IUGR?

A

Fetal Causes (Intrinsic Causes-genetic/fetal infection):

  • Aneuploidy
  • Infection (eg TORCH)
  • Structural Anomalies (CHD, NTD, Ventral Wall Defect)
310
Q

What are the U/S findings for Symmetric IUGR?

A

All fetal measurements are small

311
Q

What is the next step in management for a pregnancy that has a report of symmetric IUGR?

A

Detailed Sonogram
Karyotype
Fetal Infections Screening

312
Q

What are the conditions associated with Asymmetric IUGR for Maternal Causes?

A

Extrinsic Factors ( Low Oxygen and nutrient transfer from placenta–> fetal hypoxia—-> hypoglycemia and Polycythemia (decreased glycogen/fat stores and increased Erythropoietin)

  • Hypertension
  • Small Vessel Disease (ex SLE)
  • Malnutrition
  • Tobacco, Alcohol, Drugs
313
Q

What are the conditions associated with Asymmetric IUGR for Placental Causes?

A

Infarction
Abruption
Twin-twin transfusion
Velamentous Cord Insertion

314
Q

What might the U/s show for a pt with Asymmetric IUGR?

A

Decreased Abdomen Measurements

Normal Head Measurements

315
Q

What is the next step in management for a pt dx’d with Asymmetric IUGR?

A

1)Serial Sonograms: to monitor
2)Nonstress Test
3)Amniotic Fluid Index (decreased, esp w/ severe
uteroplacental insufficiency
4)BBP
5)Umbilical Artery Doppler

316
Q

Waht is the definition of fetal Macrosomia?

A

EFW >90-95% for GA or birth wt of 4000-4500b

317
Q

What are the risk factors associated with Fetal Macrosomia?(7)

A 
GDM
Overt DM
Prolonged Gestation
Obesity
Excessive Wt Gain in pregnancy
Multiparity
Male Fetus
318
Q

What are some maternal complications of fetal Macrosomia?

A

Injury during delivery
Post-partum Hemorrhage
Emergency C-Section

319
Q

What are some fetal complications of Macrosomia?(3)

A

Shoulder Dystocia
Injury during birth
Asphyxia

320
Q

What are some neonatal complications of fetal Macrosomia?

A

Hypoglycemia

Erb Palsy

321
Q

What is the management for fetal Macrosomia?

A

Elective C-section if:
-EFW >4500g in diabetic mother
OR
-EFW >5000g in non-diabetic mother

Step 3 (12 decks)

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