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1

What is the first clinical diamond?

A pregnant woman with acute chest pain should have an immediate CT angiogram.

2

•A pregnant woman with acute chest pain should have an immediate CT angiogram.  Why?

Risk of Pulomary Embolism

3

What should be done for a post partum mom up to 6 weeks out with acute chest pain?

•A pregnant woman with acute chest pain should have an immediate CT angiogram, include in this category post partum up to 6 weeks

 

4

What is the second diamond?

•A patient with preeclampsia and shortness of breath should have a chest X-ray immediately

5

  • A patient with preeclampsia and shortness of breath should have a chest X-ray immediately, for what reason?
  • What is another thing you can do here?

  1. Pulmonary edema
  2. Central line

6

What is the third diamond?

•A hospitalized patient with preeclampsia and a systolic blood pressure of 160 or a diastolic pressure of 110 should receive an IV antihypertensive within 15 minutes

7

•A hospitalized patient with preeclampsia and a systolic blood pressure of 160 or a diastolic pressure of 110 should receive an IV antihypertensive within 15 minutes.  Why?

rapidly rising BP can lead to stroke

8

What is the fourth diamond?

•Angiographic embolization should not be used for acute, massive postpartum hemorrhage

9

Angiographic embolization should not be used for acute, massive postpartum hemorrhage.  Why?

Bleeding is too fast, takes close to half hour to get set up and that is too long.

 

10

What is the 5th diamond?

•Any woman with cardiac disease gets a maternal–fetal medicine consult (perinatologist)

 

11

•Any woman with cardiac disease gets a maternal–fetal medicine consult.  Why?

•Pregnancy has 50% ↑ in maternal blood vol. causing increased strain on abnormal heart and can lead to CHF, etc

12

When in the course of her pregnancy should a woman with cardiac disease get a maternal-fetal medicine consult?

8 weeks.

 

13

What is the 6th diamond?

•If more than one dose of medication is needed to treat uterine atony, go to the patient’s bedside until the atony has resolved

14

If more than one dose of medication is needed to treat uterine atony, go to the patient’s bedside until the atony has resolved.  Why?

This causes post partum hemorrhage, and they can bleed out very quickly.

 

15

What is the 7th diamond?

•Never treat “postpartum hemorrhage” without simultaneously pursuing an actual clinical diagnosis

16

Never treat “postpartum hemorrhage” without simultaneously pursuing an actual clinical diagnosis.  Why?

Must understand why the bleed is occuring otherwise you may make things worse.  Also there can be multiple reasons behind the bleed.

 

 

17

What is the 8th diamond?

•A postpartum patient who is bleeding or who recently has stopped bleeding and is oliguric, should not receive diuretics

18

•A postpartum patient who is bleeding or who recently has stopped bleeding and is oliguric, should not receive diuretics

Why not?

The oliguria is d/t hypovolemia, thus the diuretic will make the volume problems worse.

 

19

What is the 9th diamond?

Any woman with placenta previa and even one previous Cesarean should be delivered in a tertiary care hospital

20

Any woman with placenta previa and even one previous Cesarean should be delivered in a tertiary care hospital.  Why?

The scar from the previous c section is no longer functional endometrium, as a result, the placenta will burrow into the scar/myometrium.  

 

21

What is the tenth diamond?

Every labor and delivery unit should have a recently updated massive transfusion protocol

22

Ok, now what are the ten clinical diamonds for OB world?

  1. A pregnant woman with acute chest pain should have an immediate CT angiogram
  2. A patient with preeclampsia and shortness of breath should have a chest X-ray immediately
  3. A hospitalized patient with preeclampsia and a systolic blood pressure of 160 or a diastolic pressure of 110 should receive an IV antihypertensive within 15 minutes
  4. Angiographic embolization should not be used for acute, massive postpartum hemorrhage
  5. Any woman with cardiac disease gets a maternal–fetal medicine consult
  6. If more than one dose of medication is needed to treat uterine atony, go to the patient’s bedside until the atony has resolved
  7. Never treat “postpartum hemorrhage” without simultaneously pursuing an actual clinical diagnosis
  8. A postpartum patient who is bleeding or who recently has stopped bleeding and is oliguric, should not receive diuretics
  9. Any woman with placenta previa and even one previous Cesarean should be delivered in a tertiary care hospital
  10. Every labor and delivery unit should have a recently updated massive transfusion protocol

 

23

Is patient sexually active?  “Are you involved with a sexual partner?” are questions you as an OB or PCP should be asking female patients.  Should they respond yes, but deny using BCM, what should you ask them?

 “Do you want to become pregnant?”

  • If no – assist with decision on BCM
  • If “yes” or “I’m fine with it if it happens

24

A preconception appointment is a consult only, and you should invite the father.  What are some benefits to this appointment?

Can educate the parents about appropriate steps to take, such as starting vitamins prior to conception, cutting out substance use, etc.

 

25

How should you approach the pre-conception appointment (and many other appointments)?

With a questionaire and a pre-developed document, that becomes part of the medical record and protects you from lawsuits.

 

 

26

During the preconception appointment, you need to cover the current and past state of health of BOTH partners.  What are some things to ask the man about?

  1. Mumps in his teens
  2. trauma
  3. meds
  4. Substances
  5. Family hist.
  6. marijuana - bad quality sperm

 

27

Apart from identifying significant medical conditions/social history, why else is taking a solid history important?

So that you can identify and consult with any other physicians who might be managing her care.

28

If your newly pregnant patient starts talking about going on their baby moon, what should you advise them of?

Advise them to avoid traveling at all, but especially avoid cruise ships and areas with known pathogens that cause problems in pregnancy.

 

29

A patients ethnicity can have significant impacts on the likliehood of problems arising in progeny.  What conditions are associated with the following?

–Ashkenazi Jews 

–African-American

–Northern European

–Ashkenazi Jews (Tay-Sachs)

–African-American (sickle cell anemia)

–Northern European (cystic fibrosis)

30

What are some important labs to get on your mom-to-be? 6

  1. TSH
  2. Rubella immunity
  3. CF carrier status
  4. Hgb electrophoresis (HgbS in A.A. popul)
  5. Consider doing HIV Ab
  6. Patient specific - HbA1C, FBS, renal function

31

What is the preferable approach to substances and medications when planning for pregnancy?

•Discontinue EVERYTHING, PREFERABLY PRIOR TO CONCEPTION.

Exceptions only for Rx provided by you or other physician, and then assess for risk and alternatives.

 

32

Folic acid should be supplemented for pregnant women, up to 400 mcg/day.  This reduces risk of anomalies such as spina bifida by up to 50%.  

When should the patient start taking this?

What should you inform them of as far as toxicities?

•Begin BEFORE CONCEPTION  - these anomalies occur within DAYS of conception.

•FA = water soluble – can’t have “too much”. (no toxicities)

33

Should a womans prenatals be over the counter?

yes, generally.

34

When trying to conceive, the patient should keep a calendar and record "day ONE" of each menses.  What is the estimated date of confinement (EDC)?

40 completed  weeks from day one of LNMP

35

When counseling patients on oral BCP who are planning to concieve, what should you tell them about the discontinuation process?

Ideally, stop BCP @ end of package and have that period (called a “pill period”) AND TWO MORE “natural” periods and THEN conceive.

This may help restore endometrium – and may reduce miscarriage risk.

36

When should a patients IUD be removed?

How long should they wait to concieve?

Remove on last day of a normal period.

Have one more period and then conceive

37

What is day one of a woman's cycle?

First day of normal menses

 

38

After ovulation how long is the ovum fertilizable?

Knowing this, what is the ideal strategy?

22-23 HOURS after ovulation.

Ideally, the ovulation would take place into a sperm rich environment, leading to fertilization right away.  

 

39

Sperm survive in the oviduct for roughly 72 hours.  How long does it take them to get there?

minutes only.

40

How often should a couple have intercourse when trying to concieve?  When in the cycle?

Coitus every OTHER day from about days 10-20 (daily ejaculation decreases sperm count gradually)

 

41

What is shettle's criteria for?

Method by which you can alter vaginal environment to “favor” one type of sperm over the other – “tilt” odds by 5-10%.

42

In what scenarios would you want to consider trying for a particular gender?

Where a family history of a particular disorder is present.  For example a history of hemophilia.

43

When should a "new OB" appointment occur if planned pregnancy?

If unplanned?

•If had preconception appointment, at 6-7 weeks.

•If unplanned or no pre-appointment, at 5-6 weeks or ASAP after + Pg test.

44

What is a safe dose of alcohol?

None, that is the best chance to prevent FAS.

 

45

HgbA1C should be roughly 5-6% before conception.  

What is the increased risk of anomalies if the HbA1C is 7-8%?

How about for 11-12%?

•> 7-8 % = doubles risk of anomalies

•11-12% = very high risk

46

What do the following mean?

•FHT or FHR =

•SVE = 

•SSE = 

•PIH = 

•DT = 

•FS =

•FOC =

MOC = 

  1. FHT or FHR = fetal heart tones / rate
  2. SVE = sterile vaginal exam
  3. SSE = sterile speculum exam
  4. PIH = pregnancy-induced hypertension
  5. DT = Doptone (doppler)
  6. FS = fetoscope
  7. FOC = father of child   
  8. MOC = mother of child

 

47

What do the following mean?

ROM = 

•AROM = 

•PROM = 

•PPROM = 

•SROM = 

•BOW = 

•IBOW =

•BBOW = 

•ROM = rupture of membranes

•AROM = artificial ROM

•PROM = premature (prior to onset of labor) ROM

•PPROM = Pre-term PROM (<37 weeks)

•SROM = spontaneous ROM

•BOW = “bag of waters”

•IBOW = intact BOW

•BBOW = “bulging” BOW

48

What do the following mean?

•FH = 

•GDM = 

•IDM = 

•UC = 

•GBS = 

•TOCO = 

•FH = fundal height (in cm – SP to top of fundus) – only valid after 20 weeks

•GDM = gestational diabetes

•IDM = infant of a diabetic mother

•UC = uterine contraction

•GBS = group B beta-hemolytic streptococcus

•TOCO = tocodynamometer – records UC’s

49

What do the following mean?

•CX or Cx = 

•NST = 

•CST = 

•VTX or Vtx = 

•Vtx can also mean

•BPD = 

•EFW = 

•CX or Cx = cervix

•NST = non-stress test

•CST = contraction stress test

•VTX or Vtx = baby’s occipital region

•Vtx can also mean baby is coming “head first”

•BPD = biparietal diameter

•EFW = estimated fetal weight

50

What do the following mean?

•EDC = 

•EGA = 

•QHCG = 

•LBW = 

•IOL = 

•LGA, SGA = 

•EDC = estimated date of “confinement” = the “due date”

•EGA = estimated gestational age (in weeks)

•QHCG = quantitative human chorionic gonadotropin

•LBW = low birth weight (<2500 gm)

•IOL = induction of labor

•LGA, SGA = large/small for gestational age

51

What do the following mean?

•SOOL = 

•FLM =

•IAI =

•SOOL = spontaneous onset of labor

•FLM = fetal lung maturity

•IAI = intraamniotic infection - chorioamnionitis

52

Weeks gestation = ?

•COMPLETED weeks from the first day of the LNMP

53

When considering the weeks gestation, accepted notation is to use a “sevenths” fraction:    31 weeks, 5 days = 31 5/7 weeks.  Verbally this would be stated how?

•“31 and 5”

54

What does the term "station" refer to?

What are the positions?

•baby’s head relative to ischial spine

•-1, -2, -3, -4 = cm ABOVE the spine

•+1, +2, +3, +4 = cm BELOW the spine

0 = at the spine

55

At what measurement is the cervix fully dilated?

10 cm

 

56

“Effacement” is expressed as a %, and describes what?

Degree of thinning or shortening of cervix

57

What is the normal "length" of a cervix?

2+ cms in “length” (= 0 % effaced)

58

Presentation describes what?

what part is “presenting” = “coming first”.  Vtx = usual.  Also:  breech, hand, brow, face

59

What is the position of the baby?

•orientation of presenting part – if Vtx, is baby “facing” up, down, sideways, e.g.

•ROA, LOA, OA, ROP, LOP, ROT, LOT

60

When should the first, or "NOB" appointment occur?

•8 weeks US – ensure single, viable  (gives also the most-reliable EDC)

61

What needs to be done at the 12 weeks appointment?

•BP, weight, UA (S,P,N)

•Use Doppler to find FHT’s

•Fundus is @ SP

•Genetics background finalized

62

What should be done at the 16 weeks appointment?

•BP, weight, UA

•Fundus ½ way between SP and umbilicus

•FHT’s with DT

•Hematocrit (Hct) or hemoglobin

•Order US for ~~ 19 weeks

63

What should be done at the 20 weeks appointment?

•BP, weight, UA

•Review US from 19 wks

•Counsel pt to choose physician for baby

•FHT’s with DT and FS

•Begin FH measurements

–Fundus @ umbilicus, FH = ~~20 cms

–Cms = weeks (+ or – 2cm) until ~~ 34 weeks

64

You need a “good” EDC to work from.  How should you calculate the "final EDC"?

From the 8 week ultrasound in most cases.  (Use the CRL)

Later = worse estimate

•LMP, LNMP, 19 week (or later) US = OK, but not as good

 

65

What should happen at the 24 weeks appointment?

•BP, weight, UA

•Measure FH

•FHT’s w/ DT

•Register for prenatal classes

•Vaccines?  (influenza + pertussis)

66

What should happen at the 28 weeks appointment?

•BP, weight, UA

•FHT’s w/ DT

•FH = ~28 cm

•Consider SVE - ? Prem. Dilation

•Test for GDM (1 hr BS)

•Hct

•Begin L&D counseling

67

What should happen at the 30 week appointment?

•Optional in normal case

•BP, weight, UA

•FHT’s w/ DT

•FH ~ 30 cms

•L&D counseling

68

What should happen at the 32 week appointment?

•BP, weight, UA

•FHT’s w/ DT

•FH = ~~ 32 cms

•Begin Leopold’s maneuvers

•L&D counseling

69

What should happen at the 34 week appointment?

•BP, weight, UA

•FHT’s w/ DT

•FH begins to “lag”

•Leopold’s to check lie/presentation

•L&D counseling, Q&A

70

What should happen at the 36 week appointment?

•BP, weight, UA

•FHT’s with DT

•FH lags

•Leopold’s

•Hct

•GBS culture

•SVE to check cervix status

•L&D discussion

71

What are some priorities for the 37 week appointment?

•BP, weight, UA

•FHT’s w/ DT

•FH – lags

•Leopold’s

•SVE

•L&D discussion

•Discuss future BCM (birth control method)

72

The 38 week appointment should include 

•BP, weight, UA

•FHT’s w/ DT

•FH – lags

•Leopold’s

•SVE

Just like the 37 week appointment.  What are two other topics to discuss?

•L&D discussion

•WTC (when to call)

73

What should be covered at the 39 week appointment?

•BP, weight, UA

•FHT’s w/ DT

•FH – lags

•Leopold’s

•SVE

•Q&A

74

What should happen at the 40 week appointment?

•BP, weight, UA

•FHT’s w/ DT

•FH – lags

•Leopold’s

•SVE

•“Post-dates” planning

•Q&A

75

How much weight should a pregnant woman gain before 20 weeks?

How about between 20-40 weeks?

10 lbs before 20 weeks

one lb. per week between 20 and 40 weeks.

(Total of 30 lbs)

 

76

Routine US should be done at weeks 8 and 19.  What type of ultrasound at each?

8 week: Transvaginal - assess viability, dates, fetal number

19 weeks: Transabdominal - anatomy scan, may tell fetal gender

 

77

For at risk patients, US of the cervix should be at 12 - 22 weeks.  What are you looking for?

What is a possible option if you see a problem?

Look for shortening or "funneling".

Cerclage - debatable, but suturing the cervix to keep it shut may help maintain pregnancy.

78

What type of US is used to assess growth?

What are you looking for?

Transabdominal

Looking for IUGR - assess via abdominal circumference and amniotic fluid volume

 

79