General OB Flashcards
(192 cards)
1
Q
Incidence of macrosomia?
A
1.5%
2
Q
Risk of shoulder dystocia
- W/o macrosomia
- W/ macrosomia
- W/ macrosomia & DM
A
- 1.5%
- 15%
- 25%
3
Q
Risk of brachial plexus injury
- W/o macrosomia
- W/ macrosomia
A
- 0.1%
2. 5%
4
Q
Risk factors for macrosomia (6)
A
- h/o macrosomia
- excessive weight gain
- maternal obesity
- gest age > 40 wks
- pos 1hr GTT and neg 3 hr GTT
- DM
5
Q
When is fetal macrosomia an indication for IOL
A
> 5000g, 4500g if diabetic
6
Q
Medication to consider for shoulder dystocia
- onset
- duration
- SE
A
Nitroglycerine (50-100mcg)
onset- 30-90 sec
lasts 2-3 mins
SE: mild hypotension
7
Q
Maneuvers to reduce shoulder dystocia
A
- Suprapubic pressure
- McRoberts maneuver
- Deliver Posterior arm
- Rubin Maneuver
- Woods corkscrew maneuver
- Episiotomy (only to make room for hand)
- Intentional clavicular fracture
- Zavanelli maneuver
- Symphysiotomy
- Laparotomy
8
Q
Rubin Maneuver
A
- pressure on posterior of the most accessible shoulder
- rotate fetus <180 to dis-impact the shoulder from the symphysis
- decreases the bis-acromial diameter
9
Q
Woods Corkscew maneuver
A
- pressure on the front of the posterior shoulder
- rotate fetus <180
- increases the bis-acromial diameter
10
Q
Zavaneli Maneuver
A
cephalic replacement reverse cardinal movements of labor do c-section (consider tocolytic) LAST RESORT
11
Q
Intentional Clavicular Fracture
A
Anterior fracture
12
Q
Risks of Clavicular Fracture
A
Penumothrox
Hemothorax
Subclavian vessel injury
Brachial plexus injury
13
Q
Erb’s Palsy
A
C5-C6 Arm hangs at side medially rotated Forearm extended & pronated Wrist flexed Grasp reflex intact (waiter's tip)
14
Q
Klumpke’s Palsy
A
Flaccid Arm C8-T1 Hand & wrist paralysis arm hangs flaccidly at side Grasp reflex lost
15
Q
Cardinal movements
A
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- External rotation
- Expulsion
16
Q
NPV for NST, CST, BPP, modified BPP, umbilical artery doppler
A
> 99.8%
17
Q
PPV for NST
A
10%
18
Q
Contraindications for ECV
A
- Multiple gestation
- IUGR
- Indication for elective c/s
- Placenta previa
- Maternal cardiac disease
- Gestational Hypertension
- Previous classical c/s
- Utero-placental insufficiency
- Congenital uterine malformations
- Oligohydramnios
- Major fetal anomaly
- NRFHT
- PROM
- Unexplained uterine bleeding
19
Q
Ideal time for ECV
A
37 weeks
20
Q
Vaginal Breech Delivery Prerequisites
A
- Call for help (extra OB, pediatrician, nurse and anethesiologist)
- Have Piper forceps in delivery room
- Empty bladder & rectum
- Functional IV line
- Oxygen for mother
21
Q
Vaginal Breech Delivery Motions
A
- Hands off, only apply rotational force to achieve backup position
- Deliver legs with Pinaud’s maneuver (pressure on popliteal fossa)
- Wrap body in towel
- Lovset’s maneuver for delivery of arms
(slide hand from back over shoulder, onto anterior surface of humerus, place pressure in cubital fossa & sweep arm over over chest to the side and out of the vagina - Wrap arms in body in towel
- Make sure the back rotates anteriorly (persistent back down=disaster for trapped head)
- Delivery of head
22
Q
Delivery of Head in Vaginal Breech Delivery
A
- Suprapubic pressure (promote flexion)
- Bracht Maneuver (only after back of neck firmly tucked under symphysis pubis)-baby’s body is held against pubic symphysis
- Mauriceau-Smellie-Veit Maneuver
- Piper forceps for after-coming head
- Consider possible need for Duhrssen incision (2,6, and 10 o’clock)
23
Q
Max amount of lidocaine w/ and w/o epinepherine
A
w/ epi: 7mg/kg 0.5% (max 60cc)
w/o epi: 4mg/kg 0.5% w/o epi (max 30cc)
24
Q
Side Effects of Epinepherine in order of increasing toxicity
A
Metallic taste in mouth Perioral numbness Tinnitis Slurred speech & blurred vision Altered consciousness Convulsions Cardiac arrhythmias Cardiac arrest
25
During an emergency c/s which layers must be infiltrated with local anesthesia?
Skin
Parietal peritoneum
Visceral peritoneum
26
Signs of Uterine Rupture
- Most consistent (70%)- abrupt FHR abnormality
- Abrupt change in uterine ctx pattern
- loss of station
- vaginal bleeding (not consistent)
- pelvic/abdominal pain (not consistent)
27
Peri-mortem C/S
- within what time period
- relationship to CPR
1. within 4 minutes, (survival diminishes after 5 min)
2. CPR should not be initiated in lieu of immediate delivery
(not sufficiently effective in maintaining CO, delays optimal window for delivery, compressions less effective w/ lg ut)
28
Contraindications to TOLAC
1. Previous uterine rupture
2. previous classical or T-incision
3. Extensive transfundal surgery
29
Candidates for TOLAC
1. 1 or 2 previous LTCD
2. Previous low vertical CD
3. Previous CD w/ unknown scar unless there is strong suspicion of a classical CD
4. Twin gestation
30
Requirements for TOLAC
1. Adequate pelvis
2. Continuous EFM recommended
3. Appropriately trained MD available throughout labor
4. Hospital/facility support for emergency c/d
31
Rupture risk during TOLAC for
1. Background risk
2. Undocumented scar
3. Twins
4. Previous lower segment rupture
5. Previous upper segment rupture
6. Classical CD
7. Induction w/ PGE1
8. PG induction for 2nd TM loss
Rupture risk during TOLAC for
1. Background risk (1%)
2. Undocumented scar (1%)
3. Twins (1%)
4. Previous lower segment rupture (6%)
5. Previous upper segment rupture (32%)
6. Classical CD (10%)
7. Induction w/ PGE1 (15%)
8. PG induction for 2nd TM loss (1%)
32
VBAC success rates
1. previous CD for CPD
2. previous CD not for CPD
1. previous CD for CPD (66%)
| 2. previous CD not for CPD (75%)
33
Risks to infant from Parvovirus
1st TM-Spontaneous Abortion
| 2nd TM- Hydrops, anemia, heart failure, IUFD
34
How do you diagnose B19?
ELISA for IgG & IgM or
| PCR (more sensitive)
35
Mother tests positive for Parvovirus. How do you follow?
Serial weekly u/s for fetal well-being and to r/o hydrops for 2 moths after exposure/infection
-PUBS looking for fetal anemia, transfusion if hydrops is present
36
Maternal effects from Varicella
- pneumonia (20%), more common in 3rd TM, mortality 5%, tx w/ Acyclovir IV, ICU admit
- Encephalitis-rare
- Shingles
37
Fetal effects from Varicella
- Spontaneous abortion
- IUFD
- Varicella embryopathy (risk 13-20 wks--> 2%)
38
Neonatal effect of Varicella
increased mortality if maternal infection is <5 days from delivery (no passive maternal IgG)
39
Varicella Post-exposure prophylaxis
VariZIG - 60-80% effective in preventing infx
40
Varicella vaccine
2 doses SQ 4-8 wks apart
Live attenuated, contraindicated in pregnancy
Not teratogenic, not indicated for termination
Defer pregnancy for 3 months post vaccination
41
Incidence of Listeria in pregnant patients
13x greater for pregnant women
42
Symptoms of Listeria
mild GI /flu-like sx (mayalgia, N&V, diairrhea)
43
Listeria: Fetal effects
fetal loss
| PTL
44
Listeria: Neonatal effects
sepsis
meningitis
death
45
Listeria: dx
Blood cultures (not stool)
46
Management of pregnant pt who consumes recalled or implicated food product
- Asymptomatic- no testing, no tx, observe for sx for 2 months
- Mildly symptomatic- no fever
- manage as for asymptomatic
- send blood cx, only tx if cx+
- Febrile-w/ or w/o symptoms-test and tx simultaneously
47
Tx of Listeria
-high dose IV ampicillin (at least 6gm/day) for 14d, may add gentamicin
(Bactrim w/ PCN allergy)
48
Hepatitis B in pregnancy
1. Incidence
2. Risk of vertical transmission
3. Breast feeding recommendations?
4. Prevention
Hepatitis B in pregnancy
1. Incidence-40%
2. Risk of vertical transmission- HBsAg+ (20%), HBsAg & HBeAg+ (90%)
3. Breast feeding recommendations? Ok in preg but needs vaccine 0, 1 , 6 m)
4. Prevention- Vaccine and HBIG w/in 24 hrs of exposure
49
Significance of HBcAg and HBeAg
HBcAg-found in hepatocyts, positive w/ natural but not vaccine based immunity
HBeAg- High infectivity, active replication, cirrhosis and liver cancer association
50
Risk of Vertical Transmission of Hepatitis B:
1. 1st TM vs. 2nd TM
2. How do majority of transmission occur?
3. Risk of transmission during amniocentesis? Hi/Lo?
4. Which method of delivery has lower risk of transmission?
Risk of Vertical Transmission:
1. 1st TM-10% vs. 2nd TM-90%
2. How do majority of transmission occur? during delivery
3. Risk of transmission during amniocentesis? Hi/Lo?
4. Which method of delivery has lower risk of transmission? Transmission rate not affected by mode of delivery.
51
C-section Abx prophylaxis for c-section
Cefazolin (Ancef) 1gm
Cefazolin 2gm IV if BMI>30 or >100kg
Clindamycin 900mg w/ aminoglycoside (eg. gentamycin)
52
Latency Abx
```
Ampicillin 2gm q6 hr x 48 hr
Erythromycin 250 mg q6 x 48 hr
then
Amoxicillin 250mg q 8 hr x 5 d
Erythromycin 333g q8 hr x 5 d
```
53
Incidence of GBS pos cx in population
20%
54
1. How long is GBS cx valid for?
| 2. When should routine cx be taken?
1. 5 wks
| 2. 35-37 wks
55
What affect does GBS prophylaxis have on early GBS infx?
80% reduction in early onset GBS
56
GBS prophylaxis
-Pen G 5 mil u, then 2.5 mil u q4 hr until delivery or
-Amp 2gm bolus then 1gm IV q4 hr to delivery
PCN Allergy:
Low risk: Cefazolin 2gm iv then 1gm q8 hr
High risk: Clindamycin 900 mg Q8 hr (if susceptible to both clinda and erythromycin) or
Vancomycin 1gm IV q12 hr (if no sus testing/ resistant to erythro)
57
Clinical features of CMV
- Chorioretinitis
- Hepatosplenomegaly
- IUGR
- Fetal hydrops
- Echogenic bowel
- Congenital deafness
- Microcephaly
- Ventriculomegaly
58
CMV Vertical Transmission
More common in 3rd TM but more severe in 1TM
59
Causes of Recurrent Pregnancy Loss
```
Uterine anomalies
Genetic
Luteal phase deficiency
Infection (TORCH, B19, Syphilis)
Immune d/o (APLA, alloimmune)
```
60
Which congenital uterine abnormality carries the worse prognosis?
Septate
61
W/up for recurrent preg loss
1. Hx- family, PMH, exposure
2. Examination (placenta, autopsy, HSG/SHG)
3. Tests: CBC, Utox, TORCH, RPR, AclAb, Lupus anticoag, KB, Karyotype, TSH, HBA1c
62
Incidence of recurrent preg loss?
1-2%
63
Definition of recurrent pregnancy loss?
3 or more spontaneous pregnancy losses
| testing should begin after 2, risk of another is just as high as after 3rd
64
Baseline incidence of SAB?
20% (40% of these are genetically abnormal)
65
Isoimmunization w/up
-If ab screen positive-> titer =/> 16-Doppler MCA to assess anemia (replaces amnio to measure delta OD 450)
66
Prevention of isoimmunization
- 50 micrograms for 1TM bleeding/loss
- 300 micrograms
- covers up to 15 ml fetal blood cell transfusion (30ml whole blood)
67
How much blood does normal dose of Rho GAM cover?
-up to 15 ml of fetal blood cell transfusion (30ml or whole blood)
68
How long is regular dose of Rho GAM effective?
10-12 weeks
69
What is the name of the test used to determine dose of RhoGAM necessary postpartum?
Kleihauer-Betke
70
Minor Antigens and effects
Kell =Kills (IgG)
Duffy = Dies (IgG)
Lewis = Lives (IgM)
71
Weak Rh+ treatment
treat as Rh +
72
1. Sickle Cell Heredity
| 2. Sickle Cell Trait Heredity
1. Autosomal Recessive, Homozygous (Hb AS)
| 2. Heterozygous (Hb AS)
73
Incidence of Sickle Cell Gene in African Americans
1:12 (AS)
74
Pathophysiology of Sickle Cell
Decreased pO2-> sickling -> microvascular obstruction-> decreased perfusion & organ damage (eg. auto splenectomy-> inc infx risk & acute chest syndrome)
75
Sx of Acute Chest Syndrome
1. Pulmonary infiltrate (vaso-occulsive dz)
2. Fever
3. Hypoxemia
4. Acidosis
76
Dx of Sickle Cell Disease on Hgb Electrophoresis
SS Dz: virtually all Hb is HbS w/ minimal HbA2/HbF
| SS Tr: Higher % if HbA & asymptomatic
77
Maternal Risks of SS Dz
1. Inc frequency of crises
2. Gest HTN
3. Infx
78
Fetal Risks of SS Dz
1. SAB
2. IUGR
3. IUFD
79
Management of SS Dz in pregnancy
1. Increased folic acid supplementation (4mg/day)
2. Transfusion (aim for HbS fraction <40%, Total Hb >10), controversial, some say transfuse if Hgb <6/7 w/ frequent crises
3. Increased fetal testing (US and FH monitoring)
80
Sickle Cell Crisis Managment
1. Pain management
2. Oxygen (if O2 Sat <95%)
3. Tx infx if there is one
81
Thalassemias-most common populations
1. Southeast Asian (a-thal cis form w/ elevated HbH)
2. Mediterranean
3. W. Indies
4. Hispanic
82
a-Thalassemia Types
Heredity of a-thal?
1. If 1 gene absent-clinically insignificant
2. If 2 genes absent- a-thal minor=carrier (trait)- Mild Anemia
3. If 3 genes absent Hb H Disease: Mod hemolytic anemia
4. If 4 genes absent- Bart's Disease (a-thal major)-Hydrops
Autosomal Recessive
83
a-Thal Minor Subsets
1. cis form- same chromosome, common in SE Asians more likely to have offspring w/ HbH
2. trans form-opposing chromosomes- less likely to have offspring w/ Hb H
84
b-Thalassemia
Heredity
- Decreased ability to make b-chains thus adult Hb (HbA)
| - Autosomal Recessive
85
b-thal minor
- heterozygous
| - asymptomatic mild anemia
86
b-thal major
- homozygous
- Cooley's anemia
- Severe anemia
- Death usually w/in 10 years
- Pregnancy extremely rare, pts need extensive MFM care
87
Composition of Adult Hgb
2 a chains +
2 b chains (Hb A) or
2 d chains (Hb A2) or
2 g chains ( Hb F- predominates in fetus at 12-24 w)
88
Effects of obesity antepartum?
1. GDM
2. VTE
3. pre-E
4. fatty liver dz
5. cardiac dysfxn
6. proteinuria
7. excess gestational wt gain
8. SAB
9. Recurrent AB
10. IUFD
11. macrosomia
12. congenital anomalies (cardiac, orofacial, limb)
89
Effects of obesity intrapartum?
1. Inc risk of CD
2. Failed 1st stage of labor
4. VTE
5. Blood loss
90
Effects of obesity postpartum
1. Inc risk of surg site infx
2. VTE
3. excess PP wt retention
91
Effects of obesity postpartum
1. Inc risk of surg site infx
2. VTE
3. excess PP wt retention
92
Target weight gain by BMI
Underweight BMI <18.5 30-40 lbs
Normal weight BMI 18.5-24.9 25-35 lbs
Over weight BMI 25-29.9 15-25 lbs
Obese BMI 30 10-20 lb
93
When do you perform early GDM screening?
1. BMI >30
2. prev GDM
3. Known glucose intolerance
94
Roux-en-Y can cause malabosorption of what?
```
folate
iron
Vit D
B12
protein
calcium
```
95
Special considerations about Roux-en-Y and 2TM testing.
Best to avoid gtt at 24 weeks secondary to concerns for Dumping Syndrom (perform fasting & postprandial home glucose tests x 1 week instead)
96
Differential Dx of Fetal Hydrops
Immune-Rh Dz
Non-Immune
Infectious- B19, CMV
Congenital- Congenital Heart Defect, supra-
ventricular tachycardia
Placental- AV malformations (chorioangioma),
fetomaternal bleed
97
Teratogenicity of Tetracyclines
Dental discoloration
98
Teratogenicity of Chloramphenicol
Gray baby sydrome
99
Teratogenicity of Quinolones
Affects cartilage
100
Teratogenicity of Erythromycin estolate
Maternal hepatic toxicity
101
Teratogenicity of Retinoic Acid
CNS, craniofacial abnormalities
102
Teratogenicity of ACE inhibitors
Possible heart defects (1TM), Oliguria, renal failure (2nd/3rd)
103
Teratogenicity of MTX
Multiple anomalies, IUFD
104
Teratogenicity of Coumadin
Multiple anomalies, IUFD
105
Teratogenicity of Valproate
NTD
106
Fetal blood volume
80 ml/kg
107
When does corpus luteal/placental shift take place?
70 days
108
Effects of smoking in OB
```
Increased:
spontaneous abortion
IUGR
placental abruption
SIDS
infertility
PTD
stillbirth
ectopic pregnancy
```
109
NTD prohylaxis
Routine 0.4 mg/day
| History of NTD 4 mg/day ( also if on phenytoin, carbamazepine, valproate)
110
Acceptable Vaccines in Pregnancy
Tdap (27-36 weeks)
Hepatitis A & B
Pneumococcus
Influenza
111
Vaccines that are Contraindicated in Pregnancy
```
Measles (Rubeola)
Mumps (Paramyxovirus)
Chickenpox (Varicella)
Rubella (pregnancy should be delayed at least 3 m)
HPV
Intranasal Flu Vaccine
```
112
Causes of Oligohydramnios
```
ROM
IUGR
SGA
Idiopathic
TORCH ifx
Renal Agenesis
```
113
Causes of Polyhydramnios
```
Idiopathic
Maternal DM
Esophageal atresia
genetic anomalies
Infx: syphilis, TORCH
Hydrops fetalis
```
114
Definition of Polyhydramnios
>25/>8cm
Mild <30/12cm
Mod <35/16
SVR >35/>16
115
W/up for polyhydramnios
1. U/S: look for anomalies & hydrops
2. DM
3. Ab Screen
4. RPR
5. TORCH
116
Polyhydramnios increases the risk of what?
1. PTL
2. PPROM
3. macrosomia
4. malpresentation
5. cord prolapse
6. abruption
7. atony
8. PPH
117
Target Delivery w/ Polyhydramnios
Deliver at 39-40 weeks
118
Utility of Amnio-Reduction
- Alleviate maternal discomfort, difficulty breathing or sleeping
- only works temporarily
119
How should amnio-reduction be performed?
Remove 500cc/hr to a total of 1500cc: repeat every 1-2 weeks
120
Up until when does the corpus luteum of pregnancy persist?
12 weeks
121
Management of adnexal mass in pregnancy
Expectant Management: (Rationale)
Risk of acute complications <2%
Risk of malignancy low
122
Contraindications to breast feeding
1. Substance abuse
2. HIV pos
3. Untreated TB or varicella
4. HSV on breast
123
Management of nursing mother with Mastitis
1. Continue to breast feed
| 2. Dicloxacillin 500mg Q6 hrs x 10 days
124
Consideration for mother with von Willebrand Dz during delivery
Do not perform VAVD (baby may have dz) as this may cause a severe hematoma
125
Preconception counseling: when do you begin PNV?
1 month before conception
126
Fragile X:
1. Gene mutation?
2. Incidence?
3. Genetic Transmission?
4. Dx Testing?
5. Indications for screening?
Fragile X:
1. Gene mutation? FMR1 gene
2. Incidence? 1/4000
3. Genetic Transmission? X-linked Recessive
4. Dx Testing? PCR or southern blot
5. Indications for screening?
Fam hx of Fragile X, MR, Developmental delay, autism or Personal H/o Premature ovarian failure or patient request
127
Testing recommended by ACOG for Eastern European Jewish descent?
1. Tay-Sachs (1:30)
2. CF (1:30)
3. Familial dysautonomia (1:30)
4. Canavan Dz (1:40)
128
What intervertebral space would one aim for in order to place an epidural?
L2/3 or L3/4
129
Contraindications for Epidural?
1. Infx on overlying skin
2. Coagulopathy
3. Inc intracranial pressure
4. Local spinal anomaly
5. Uncooperative patient
6. Maternal hypovolemia
130
How would you treat Maternal hypotension caused by epidural?
Ephedrine 5mg and IV fluids
131
How long would you wait before placement of epidural if pt received prophylactic dose of LMWH?
12 hours
132
How long would you wait before placement of epidural if pt received therapeutic dose of LMWH?
24 hours
133
Which dermatome is associated with Nipple level?
T4
134
Which dermatome is associated with Xiphisternum?
T8
135
Which dermatome is associated with Umbilicus?
T10
136
Which dermatome is associated with Pubis?
T12
137
Classical female pelvic sup-type
Gynecoid
138
Male Type, heart shaped inlet w/ funnel shaped cavity
Android
139
Stretched inlet in AP diameter
Anthropoid
140
Stretched inlet in transverse diameter w/ shallow cavity
Platypelloid ("platty" pelloid is "flatty" pelloid)
141
Anatomy of the Ureter- Abdominal
15 cm long
commences at renal pelvis and descends over psoas from lat to med
Enters pelvic brim at bifurcation of common iliac vessels
142
Anatomy of the Ureter-Pelvic
15 cm
Descends pelvic side wall post to ov fossa
Corsses under cardinal lig from post-lat to antero-med
Crosses under uterine art (water under bridge) 1-2 cm from cervix
Continues anteriomedially to insert into bladder tangentially
143
Common locations of ureteral injury
1. Ligating ut art (under cardinal ligaments)
2. Ligating uterosacral ligaments (under uterosacral lig)
3. Ligating infundibular ligaments
4. Closing/over sewing the vault
144
Muscles cut in episiotomy
1. Bulbocavernosous muscle
2. transverse perineal muscle
3. deep transverse perineal muscle
145
Progress of dilation & descent for multip?
1.5cm/hr dilation & 1 cm/hr descent
146
Progress of dilation & descent for nulip?
1.2cm/hr dilation & 2 cm/hr descent
147
Failed IOL?
Failure to generate regular Q3 min ctx & cvx change after at least 24 hrs of oxytocin w/ AROM if possible
148
Arrest of dilation (first stage of labor)
Dilation =/>6 cm w/ AROM and no cervical change for =/>4 hrs of adequate contractions (MVU>200) or =/>6 hr of inadequate contractions
149
Arrest of descent (second stage of labor) for Multip
w/o epidural 2 hrs
| w/ epidural 3 hrs
150
Arrest of descent (second stage of labor) for Nulip
w/o epidural 3 hrs
| 2/ epidural 4 hrs
151
Indication for IUPC
Obesity (if ext monitor not effective)
Absence of 1:1 nursing care
Inadequate response to oxytocin
152
Indications for CD because safe vag delivery is problematic?
Face, mentum posterior
Breech, back down (back must rotate anteriorly: too late for CD if back rotates posteriorly)
Brow
Transverse lie, back down-requires classical CD not transverse lower segment)
153
Definition of Category III tracing
Sinusoidal pattern alone or absent variability plus any of the following:
- recurrent late decels
- recurrent variable decels
- bradycardia
154
Definition of tachysystole
>5 ctx in 10 min averaged over 30 mins
155
Management of BPP 6
Term-Deliver
| Preterm-Repeat in 24 hrs
156
Management of BPP of 4 or less
Deliver
157
Utility of Bishop score
=/>8- probability of vag del is same as pat in spont labor
| =/<6 unfavorable cervix (unripe) should not be done unless for medical reason
158
Dx of chronic HTN
HTN <20 wks, prior to preg or persists >12 wks PP w/ systolic >140/Diastolic >90 mmHg, BP should be measured on 2 occasions at least 4 hrs apart
159
Differential Dx of Primary (w/in 24 hrs) PPH
```
Atony
Retained POC
Lacerations
Uterine Inversion
Coagulopathy
Uterine Rupture
```
160
Differential Dx of Secondary (24hr-6wks) PPH
Infection
Placental site sub-involution
Retained placental fragments
Repair breakdown
161
Definition of GHTN
HTN >20 wks
BP normal at 12 wk PP
No proteinuria
162
Definition of Preeclampsia
```
GHTN + proteinuria
Proteinuria:
24 hr urine >300 mg
P:C =/>0.3
Random urine >30 mg/dL (1+or greater)
```
163
```
Protein Dipstick Indicators
+
++
+++
++++
```
```
Protein Dipstick Indicators
+ 30
++ 100
+++ 300
++++ >2000
```
164
Preeclampsia w/ severe features
```
Proteinuria not required.
PreE + any:
Vascular- BP>160/110 mmHG
- Pulmonary edema
Renal- Serum creatinine >1.1 mg/dL
-doubling of Cr w/o renal dz
Cerebral- HA & vis disturbances
Hematologic- Hemolysis/thrombocytopenia (HELLP)
Hepatic- elevated enzymes (twice normal)
-RUQ or epigastric pain
- Fatty liver of pregnancy
-Low glucose
-Liver Dysfunction
-Prolonged PTT
*High maternal and fetal mortality
```
165
MgSO4 dilution solution
40 gm in 1000ml which provides 4gm/100ml
166
Dose of MgSO4
2-4gm bolus over 20 minutes then 2gm/hr
167
Therapeutic range of MgSO4
4-8 mg/dL
168
MgSO4 Level of 10
Loss of Reflexes
169
MgSO4 Level of 16
Respiratory Arrest
170
MgSO4 Level of 22
Cardiac Arrest
171
Antidote of Magnesium sulfate Toxicity
Calcium gluconate 1gm IV over 2 minutes
172
What condition is contraindicated w/ use of MgSO4? What medication can you use instead for seizure prophylaxis?
Myasthenia Gravis
Phenytoin (monitor w/ EKG)
Diazepam (be able to intubate)
173
HTN emergency protocol?
160/110
Labetalol 20 mg, 40 mg, 80 mg (Q10 min) ->Hydralazine 10 mg
Hydralazine 5mg, 10mg, 20mg (Q20 min)
->Labetalol 40 mg
Nifedipine oral 10mg, 20mg, 20mg (Q20m)
->Labetalol 40 mg
174
3 Hr GTT cutoff
105/190/165/145
Carpenter Coustan: 95/180/155/140
175
Early 1 hr GTT (Indications)
```
Obesity
Fam H/o DM
Previous macrosomic infant
Previous GDM
Previous macrosomic stillbirth
```
176
White Classification for DM
```
A1-GDM-diet controlled
A2-GDM- drug tx
B- Onset >age 20, Duration <10 yrs
C- Onset 10-20, Duration 10-20
D- Onset <10, Duration >20
F- Ne "F" ropathy
H- Heart involvement
R- Retinopathy
```
177
Effects of DM on pregnancy 1st TM
1TM- SAB
Congenital malformations 2-6 fold
Cardiac (ASD, VSD, transposition) 38%
Skeletal
CNS (NTD, holoporcencephaly)
Caudal regression-rare but nearly all 2/2
DM
CONGENITAL ANOMALIES & SAB NOT ASSOCIATED W/ GESTATIONAL DM SINCE BLOOD SUGARS BECOME ELEVATED LONG AFTER ORGANOGENESIS
178
Effects of DM of pregnancy 3rd TM
LGA/macrosomia
IUGR
IUFD
179
Effects of DM on neonatal period
Low- glucose, calcium, temperature, mg
| High- bilirubin, RBC, +RDS
180
Dietary requirements w/ DM
30kcal/kg/day (typically 2200-2400) using prepregnant weight
20 kcal/kg/day if BMI >30
181
Critical antibody titer
16 or greater, Doppler the MCA to access level of anemia, this replaces amnio to measure DeltaOD450
182
80% of new HSV cases are of which subtype? Which subtype recurs less frequently?
HSV-1
183
Dx of HSV?
Serology w/ PCR (cultures have false + rate of 20%
184
Vertical Transmission Rate of HSV Primary Infection? Serology results?
50%, Ab neg
185
Vertical Transmission Rate of Non-primary, 1st episode? Serology results?
33%, Ab+ but Ab & clinical type don't match
186
Vertical transmission of Recurrent infection? Serology results?
3%, Ab +: Ab and clinical type do match.
187
MOA of Acyclovir?
Inhibits viral thymidine kinase and thus viral replication.
188
MOA of Famiclovir?
Converted to pencyclovir in liver (>bioavailability than acyclovir)
189
MOA of Valacyclovir?
Converted to acyclovir in the liver (>bioavailability than acyclovir)
190
How would you treat primary or non-primary 1st herpes episode?
Valacyclovir 1000mg BID x 10 days
191
How would you treat recurrent herpes episode?
Valacyclovir 500mg BID x 5 days
192
Suppression of Herpes?
Valacyclovir 1000mg daily
