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Flashcards in Clinical Aspects of Pregnancy Deck (80)
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1
Q

What are the major complications that account for 80% of all maternal death?

A
severe bleeding (usually HTN - eclampsia
Obstructed labor
Unsafe abortion 

remainder are caused by diseases like malaria, anemia and HIV/AIDS

2
Q

How many pregnancies are complicated by gestational diabetes?

A

7% are complicated by DM and 90% of that is classified as gestational DM

3
Q

Why do we care about gestational diabetes

A

after 12 weeks, the maternal glucose can cross the placenta and fetal beta cells can produce insulin in response

if maternal glucose is elevated, fetal insulin production will increase, which triggers growth producing macrosomia

also…hyperglycemia in the first 10 weeks of pregnancy while organogensis is taking place is teratogenic and associated with 2-3x increase in congenital malformations and miscarriage (but this isn’t identified by current screening)

4
Q

What percentage of deliveries of women with GDM are macrosomic?

A

20% - over 8 pounds 13 ounces

5
Q

WHen do we screen for asymptomatic gestational diabetes?

A

24-28 weeks

6
Q

What are the risk factors for GDM?

A
35 yrs and older
BMI over 25
family hx of DM
history of previous GDM
macrosomia in previous pregnancy
high risk ehtnic group: hispanic, asian, native, african, pacific islander)

test using the ADA criteria for nonpregnancy adults

7
Q

How do we treat GDM?

A

diet
glyburide (micronase0
glucophage (metformin)
intensive insulin therapy

Treatment aims to achiee glucose levels of 130 per dL one hour postprandially

8
Q

Does early induction for macrosomia help outcomes?

A

it reduces the risk of macrosomia, but doesn’t reduce rates of brachial injuries, hypoglycemia or clavicle fractures

9
Q

True or false: most women will continue needing insulin after delivery for a few months

A

false - usually can stop right away

10
Q

What percentage of women with GDM will devlop T2DM within 5-10 years?

A

50%

so continue screening with oral glucose tolerance test at three year intervals

11
Q

What is the definition of preterm labor?

A

cervical change associated with uterine contractions prior to 37 weeks

in nulliparous women, this is uterine contractions with 2 cm dilation and 80%+ effacement

12
Q

What is the incidence of preterm labor in the US?

A

11% of pregnancies

13
Q

What are the risk factors for preterm labor?

A
premature rupture of membranes (PROM)
multiple gestation
previous preterm birth
hydramnios
uterine anommaly
hx of cervical cone biopsy
cocain abuse
african american
abdominal trauma
pyelonephritis
abdominal surgery in preg
14
Q

What are some general causes of preterm labor?

A
UTI
cervical infection
bacterial vaginosis
generalized infection
trauma or abruption
hydramnios
multiple gestation
idiopathic
15
Q

What are the important questions to ask in the initial assessment of a patient with premature contractions?

A
  1. what is the gestational age
  2. are the membranes ruptured?
  3. is patient in active labor?
  4. is there an infection>
  5. What is the likelihood that the patient will deliver prematurely?
16
Q

What should you do in the evaluation of premature labor?

A

speculum exam to rule out PROM

culture for GBS, chlamydia and gonorrhdea
check fetal fibronectin
ultrasound for EDD, expected fetal weight, fetal presentation, biophysical profile, cervix length

digital exam to see how far she’s dilated

17
Q

What is fetal fibronectin and what does it tell us?

A

It’s a large glycoprotein thought to act as an adhesive of fetal membranes to the decidua

A high value is better at predicting imminent delivery than cervical dilation or uterine activity

high negative predictive value -
if it’s normal - they’re not going to be preterm

18
Q

What should your orders be based on cervical length seen on US?

A

less than 16 mm -
consider cerclage

16-20 - bed rest and remeasure in one week

21-25 mm, reduce physical activity and remeasure in 2 weeks

19
Q

What can you give antenatal for lung maturation if premature delivery is likely?

A

betamethasone (two 12 mg intramusuclar doses 24 hr apart) or dexamethasone ( mg intramuscularly every 12 hours for 4 doses)

20
Q

You can also give tocolytics to slow down the premature labor. What are some drug options for this?

A

nifedipine
indomethacin
terbutaline

21
Q

What percent of pregnancies will be affected by UTI?

A

5%

22
Q

Bacterial vaginosis increases the risk for what?

A

prematur fupture of membranes, preterm delivery and peurperal infections

23
Q

How do we treat bacterial vaginosis in pregnancy?

A

vaginal metronidazole to decrease nausea

24
Q

What is chorioamnionitis?

A

infection of the placenta - presents with maternal fevers, elevated maternal white blood count and uterine tenderness
fetal tachycardia

25
Q

What are the typical infections that can affect the fetus?

A
TORCH
Toxoplasmosis
Other: Parvovirus, HIV, Niesserie gonorrhea, chlamydia, hepatitis B, syphilis
Rubella
CMV
HSV
26
Q

What is the risk with parvovivrus?

A

fetal hemolytic anemia (fetal hydrops)

27
Q

What is associated with congenital rubella syndrome?

A

deafness
cardiac abnormalities
cataracts
mental retardation

28
Q

True or false: a woman with HIV should decrease her anti-HIV drugs to avoid teratogenic effects.

A

false - she should stay on regular triple therapy

29
Q

What issues can be associcated with toxoplasmosis?

A

severe if transmitted to the fetus during the first trimester - seizures, hydro/microcephaly, hepatosplenomegaly, jaundice, chorioretinitis

30
Q

If someone comes in with vaginal bleeding during pregnancy, what should you do in workup?

A

abdominal ultrasound FIRST!
gentle speculum exam
no binary exam

31
Q

What are the two main concerns with antepartum bleeding?

A

placenta previa

placenta abruption

32
Q

What would be the issue with painless bleeding?

A

previa

33
Q

What would be the issue with bleeding associated painful contractions?

A

placenta abruption

34
Q

What is complete placenta previa?

A

whne the placenta completely covers the internal cervical os

35
Q

WHat is partial placenta previa?

A

when the placenta partially coveres the internal cervical os

36
Q

What is a low lying placent?

A

when the edge of the placenta is within 2-3 cm of the internal cervical os

37
Q

What is placental abruption?

A

premature separation of a normally implanted placenta

38
Q

What is vasa previa?

A

when the umbilical cord vessels insert into the membranes with the vessels overlying the interal cervical os

raises concern for fetal exsanguination upon rupture of the membranes

39
Q

A history of post coital spotting earlier during pregnancy suggests what?

A

placenta previa

40
Q

What are the risk factors for placetna previa?

A
grand multiparity
prior C-section
prior uterine curettage
previous palcenta previa
multiple gestation
41
Q

What is the management for placental previa?

A

delivery by C-section

42
Q

WHat is placenta accreta?

A

invasion of the placenta into the uterus - which is more common with placenta previa

43
Q

What are the predisposing/precipitating factors for placental abruption?

A
hypertension
advanced maternal age
multiparity
multiple pregnancy
diabetes mellitus
trauma
external/internal version
delivery of first twin
rupture of membranes with polyhydramnios
44
Q

What percentage of pregnancies are affected by abruption? what’s the mortality rate?

A

ocurs in 1-5% of pregnancys ( is the cause of 30% of third trimester bleeding)

15% mortality rate

45
Q

What is the treatment for abruption?

A

stabilize the patient
prepare for the possibility of future hemorrhage
prepare for preterm delivery
deliver if bleeding is life threatening or fetal testing is non-reassuring

46
Q

What are the variations of the breech presentation?

A

complete breech
incomplete breech
frank breech

47
Q

After a breech extraction and delivery, what do you need to check for in the baby?

A

hip dysplasia

48
Q

What do we attempt if someone is breech? Does it work?

A

external podalic version

usually most successful if you do it and then induce right after because baby will just flip back around because there’s usually a reason fro the breech presentation!!

49
Q

What is the biggest concern with all the abnormal presentations?

A

prolapsed umbilical cord

50
Q

What are the 5 general itiologies for hypertension in pregnancy?

A
chronic hypertension (just continuing on)
pregnancy-induced HTN
pre-eclampsia
Eclampsia
HELLP syndrome
51
Q

WHen do we call it chronic hypertension?

A

BP 140/90 before pregnancy or at less than 20 weeks gestation

52
Q

Treatment of chornic hypertension in pregnancy is controbersion, but what are some options?

A

beta blockers
calcium channel blockers
methyldopa
diuretics

53
Q

What hypertension drug do you NOT give in pregnancy

A

ACE inhibitors - associated with neonatal renal failure

54
Q

When do we call it pregnancy-induced hypertension?

A

hypertension without proteinuria at greater than 20 weeks gestation

usually mild to moderate. maternal risks are small

55
Q

When do we call it pre-eclampsia?

A

over 140/90 after 20 weeks of gestation in a woman whos BOP was previously normal WITH proteinuria

non-dependent edema is usually present, but not a criterion

56
Q

What percentage of pregnancies are effected by pre-eclampsia?

A

5-8%

57
Q

What do we think pre-eclapsia is caused by?

A

probably some sort of placental vasospasm

58
Q

True or false: pre-eclampsia is more common in a woman’s first pregnancy.

A

true - but this may be because women who have pre-eclampsia are more likely to chose not to get pregnant a second time.

59
Q

What are the risk factors for pre-eclapsia?

A

previous pre-eclampsia in other pregnancies

chronic hypertension

low dietary calcium

60
Q

How can you reduce the risk for pre-eclampsia?

A

calcium supplementation

low dose aspirin if they have a history of Pre-ec, chronic hypertension, diabetes, autoimmune disease, renal disease or gestational hypertension

61
Q

What are the complications of pre-eclampsia?

A
eclampsia (seizures)
placenta abruption
coagulopathies
renal failure
hepatic subcapsular hematoma
hepatic rupture
uteroplacental insufficiency
62
Q

At what BP do we consider the pre-ec severe?

A

160/110

63
Q

At what level of proteinuria do we consider it severe?

A

over 5 g in 24 hours

64
Q

What are some other signs of severe pre-eclampsia?

A
oliguria
pulmonary edema or cyanosis
impariment of liver funtion
visual or cerebral disturbnances
pain in epigastric or RUQ
decreased platelets
intrauterine growth restriction
65
Q

What is the treatment for pre-ec?

A

delivery!

control BP wth hydralazine or labetolol

Magnesium sulfate to prevent seizures

66
Q

What is hELLP syndome?

A

Hemolysis (DIC)
Elevated Liver enzymes
Low Platelet counc

67
Q

What fetal monitoring would you do in pre-ec or other hypertension?

A

you try to buy time before having to deliver…

  1. obtain nonstress test twice weekly
  2. biophysical profile weekly
  3. ultrasonogrphay every 3-4 weeks
68
Q

True or false: If you are concerned, yo can tell the woman to count fetal movements

A

false - doesn’t improve outcomes and increases anxiety leading ot more triage evaluations

69
Q

How do we do non-stree testint?

A

patient is connected to the montiro to measure baby’s heart rate, which hsould go up when baby moves

70
Q

When do you do an oxytocin stress test?

A

WHen the non-stress test was concerning

71
Q

How do you do a oxytocin stress test?

A

give IV oxytocin to induce contractions

the FHT should show VARIABILITY without decelerations with the contractions

72
Q

What is assessed in the biophysical profile/

A

five categories with 0-2 score

amniotic fluid volume
fetal tone
fetal activity
fetal breathing movements
fetal heart rate reactivity (nonstress0
73
Q

What is considered a normal biophysical profile score?

A

8-10

74
Q

BIshop’s score for induction is used for what?

A

guides us about whether we can successfully attempt induction

75
Q

What are the 5 things that go into a bishops score?

A
position of the cervix
consistency of the cervix
effacement
dilation
fetal station

each one goes from 0-3

76
Q

A score of ___ would suggest favorable induction?

A

10

77
Q

What are the methods to ripen the cervix?

A

mechanical with balloon catheter
oxytocin
prostaglandins (Dinoprostone - Cervidil or Misoprosol - Cytotec)

78
Q

What drugs can you use during pregnancy to treat depression?

A

you can use TCAs, but prefer SSRIs

Save buproprion for smoking cessation typically, but can use if nothing else worked

79
Q

Can you use these during breast feeding as well?

A

yes

there will be byproducts in the milk, but this doesn’t seem to affect the infant

80
Q

What are the three screening tools for postpartum depression?

A

Edinburgh Postnatal Depression Scale
PHQ-9
Beck Depression Inventory