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1

Incidence of macrosomia?

1.5%

2

Risk of shoulder dystocia
1. W/o macrosomia
2. W/ macrosomia
3. W/ macrosomia & DM

1. 1.5%
2. 15%
3. 25%

3

Risk of brachial plexus injury
1. W/o macrosomia
2. W/ macrosomia

1. 0.1%
2. 5%

4

Risk factors for macrosomia (6)

1. h/o macrosomia
2. excessive weight gain
3. maternal obesity
4. gest age > 40 wks
5. pos 1hr GTT and neg 3 hr GTT
6. DM

5

When is fetal macrosomia an indication for IOL

>5000g, 4500g if diabetic

6

Medication to consider for shoulder dystocia
-onset
-duration
-SE

Nitroglycerine (50-100mcg)
onset- 30-90 sec
lasts 2-3 mins
SE: mild hypotension

7

Maneuvers to reduce shoulder dystocia

1. Suprapubic pressure
2. McRoberts maneuver
3. Deliver Posterior arm
4. Rubin Maneuver
5. Woods corkscrew maneuver
6. Episiotomy (only to make room for hand)
7. Intentional clavicular fracture
8. Zavanelli maneuver
9. Symphysiotomy
10. Laparotomy

8

Rubin Maneuver

-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

Woods Corkscew maneuver

-pressure on the front of the posterior shoulder
-rotate fetus <180
-increases the bis-acromial diameter

10

Zavaneli Maneuver

cephalic replacement
reverse cardinal movements of labor
do c-section
(consider tocolytic)
LAST RESORT

11

Intentional Clavicular Fracture

Anterior fracture

12

Risks of Clavicular Fracture

Penumothrox
Hemothorax
Subclavian vessel injury
Brachial plexus injury

13

Erb's Palsy

C5-C6
Arm hangs at side medially rotated
Forearm extended & pronated
Wrist flexed
Grasp reflex intact (waiter's tip)

14

Klumpke's Palsy

Flaccid Arm
C8-T1
Hand & wrist paralysis
arm hangs flaccidly at side
Grasp reflex lost

15

Cardinal movements

1. Engagement
2. Descent
3. Flexion
4. Internal rotation
5. Extension
6. External rotation
7. Expulsion

16

NPV for NST, CST, BPP, modified BPP, umbilical artery doppler

>99.8%

17

PPV for NST

10%

18

Contraindications for ECV

1. Multiple gestation
2. IUGR
3. Indication for elective c/s
4. Placenta previa
5. Maternal cardiac disease
6. Gestational Hypertension
7. Previous classical c/s
8. Utero-placental insufficiency
9. Congenital uterine malformations
10. Oligohydramnios
11. Major fetal anomaly
12. NRFHT
13. PROM
14. Unexplained uterine bleeding

19

Ideal time for ECV

37 weeks

20

Vaginal Breech Delivery Prerequisites

-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

Vaginal Breech Delivery Motions

1. Hands off, only apply rotational force to achieve backup position
2. Deliver legs with Pinaud's maneuver (pressure on popliteal fossa)
3. Wrap body in towel
4. 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
5. Wrap arms in body in towel
6. Make sure the back rotates anteriorly (persistent back down=disaster for trapped head)
7. Delivery of head

22

Delivery of Head in Vaginal Breech Delivery

1. Suprapubic pressure (promote flexion)
2. Bracht Maneuver (only after back of neck firmly tucked under symphysis pubis)-baby's body is held against pubic symphysis
3. Mauriceau-Smellie-Veit Maneuver
4. Piper forceps for after-coming head
5. Consider possible need for Duhrssen incision (2,6, and 10 o'clock)

23

Max amount of lidocaine w/ and w/o epinepherine

w/ epi: 7mg/kg 0.5% (max 60cc)
w/o epi: 4mg/kg 0.5% w/o epi (max 30cc)

24

Side Effects of Epinepherine in order of increasing toxicity

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