MFM Flashcards
(108 cards)
1
Q
Gestational HTN is defined as
A
> 140/90 after 20 weeks of pregnancy
2
Q
Gestational HTN investigations
A
Look for preeclampsia
1) proteinuria 2) severe features of preeclampsia 3) assess fetal status
3
Q
Severe Gestational HTN
A
≥160/110
4
Q
Postpartrum Hypertensive mgmt
A
Oral or IV medications, similar to those used in non-pregnant patients
5
Q
Pathogenesis of preeclampsia
A
Preeclampsia occurs because of placental circulation abnormalities, where the large spinal arteries fail to penetrate the myometrial portion, instead the vessels of the myometrium are narrowing, resulting in hypoperfusion and ischemia.
An exaggerated state of oxidative stress develops in the placenta which in turns adversely affects angiogenesis. As the pregnancy develops, anti-angiogenesis factors are released into maternal blood resulting in wide spread vascular inflammation, endothelial dysfunction leading to HTN and preeclampsia
6
Q
Severe preeclampsia defined as
A
- 160/110 with
- proteinura >3g/dL
- end organ dysfunction
- fetal effects - Onset <34 weeks
7
Q
Dx of Preeclampsia and definition of pre-eclampsia
A
Definition:
Preeclampsia refers to the new onset of HTN with proteinuria OR the new onset HTN with significant end-organ dysfunction with or without proteinuria after 20 weeks gestation
- two readings of ≥140/90 plus
- proteinuria
- end organ dysfunction (elevated AST/ALT, BUN,CR, Pulmonary edema)
- fetal effects
8
Q
women with preeclampsia are at risk for life-threatening events such as
A
CVA Retinal injury Placental abruption AKI ICH Hepatic failure pulmonary edema eclampsia thrombocytopenia MI ARDS
9
Q
the fetus in preeclampsia is at increased risk of
A
IGUR, oligohydraminos
10
Q
Approach to preeclampsia
A
- Acute BP target: <160/110 (reduction by ~25% in minutes to hours)
Labetalol 20mg over 20 minutes, then 40, 80mg to max 300 or infusion 2-3mg/min
Nifedipine 5-10mg q 30-45, max 80mg/d
Hydralazine 5-10mg to max 20mg - Magnesium 4g over 20 minutes then 1g/hr infusion for 24 hours
- Betamethasone 12mg q 24hr (x2) (in addition to lung maturity, it improves UA diastolic flow of the placenta - if suspect to deliver within the next 7 days)
- Fluid restrict for 80ml/hr
10
Q
Approach to Eclampsia
A
- Magnesium 4g/20minutes then 1g/hr.
2. for status, use Benzos
11
Q
HELLP syndrome dx
A
- Hemolysis - peripheral smear abnormalities, serum bili elevated, low hepatoglobin, or severe anemia
- elavated AST/ALT x 2
- platelets <100
12
Q
Approach to HELLP
A
- Severe gestational HTN mgmt
- Delivery
○ Stabilize mother and assess fetal status
○ Transfer to a tertiary centre due to risk of rapid complication development
○ Severe gestation HTN should be treated with Labetalol
○ Women with complications list above should promptly deliver
○ Manage hepatic hematoma with volume replacement and transfusion as necessary
○ RBC threshold - varies, UTD 70g/L
○ PLT threshold - <50 = if c-section impending, <20 Otherwise
12
Q
Phone Assessment:
A
- Cervix (dilation/effacement/length)
- contractions (frequency, durations and strength)
- membrane (intact/rupture, if ruptured how long and abx)
- baby (FHR -good variability)
- medications given - betamethasone, abx, tocolytics
- maternal (GDM, PIH, GBS, GTPAL)
13
Q
Placental Abruption refers to
A
partial or complete separation of the placenta prior to delivery of the fetus. Which can be concealed or revealed
14
Q
Is placental abruption blood maternal or fetal?
A
Maternal Hemorrhage, from the decidua basalis
Maternal vasculature may be arterial or venous
15
Q
Approach to placental abruption
A
- maternal hemodynamic assessment (manage coags)
- If fetal HR is non-reassuring, expeditious delivery is indicated
- If fetus <34 weeks and mother is stable - conservative mgmt until 37 weeks is recommended with tocolytics and antenatal steroids
- If fetus 34-36 weeks GA and mother are stable, expectant delivery is appropriate
- All pregnancies with acute abruption ≥36 weeks GA should be delivered
16
Q
Placental Previa definition
A
Placenta previa refers to the presence of placental tissue that extends over the internal cervical os.
Sequelae include the need for c-section as well as the potential for severe antepartum bleeding, preterm birth and postpartum hemorrhage.
17
Q
placental previa mgmt
A
- achieve and/or maintain maternal hemodynamic stability
2. determine if emergency c-section is indicated.
18
Q
placenta accrete
A
is the growth of the placenta into uterine scarring. Its a surgical emergency with immediate removal and possible hysterectomy.
19
Q
Preterm Labour pathogenesis
A
- premature activation of the maternal or fetal HPA axis related to stress
- exaggerated inflammatory response/infection
- abruption
- pathologic uterine distention
20
Q
The goal of delaying PTL is to
A
allow for antenatal corticosteroid administration, and allow for safe transfer.
21
Q
PTL mgmt:
A
- Betamethasone if between 24-34 weeks (lung/gut/neuro protection)
- tocolytic for 48 hours (nifedipine, Indocin)
- Abx (GBS)
- Magnesium (neuro protection)
22
Q
Tocolytic use in PTL:
A
- Nifedipine = loading dose of
10mg PO q 30 until contractions stop (max 40mg/2hours) then 1 hour after loading dose q12 hours for 48 hours - Indocin (only if <28 weeks) 100mg PR then 25mg PO q 6 hours x 48
23
PPROM refers to
Rupture of membranes prior to the onset of labour in pregnancy <37
24
complications of PROM
- PTL/PTB
- fetal/neonatal infection
- maternal infection
- umbilical cord compression/prolapse
- failed induction resulting in c-section
- pulmonary hypoplasia
25
Chorioamniotis dx is suspected when
- maternal fever >38 degrees
- fetal HR >160
- signs of maternal sepsis
Dx is confirmed with placental histopathology
26
Zygocity refers to
the description of number of eggs fertilized
27
Chorionocity is
the number of placentas
28
amniocity is the description of
number of amniotic sacs
29
Diachorionic twins
DI-achorionic twins (two placenta) could be dizygotic (fraternal) or monozygotic (identical) twins
safest forms of twins
30
monochorionic twins
One placenta
- always monozygotic (identical)
- amnioicity depends on timing of division of fertilized ovum
- monochoro twins are the most complicated version of twins
31
Monochorionic twins complications
- twin to twin transfusion syndrome
- twin anemia polychythemia sequence
- selevtive intrauterine growth restrictions
- twin reversed arterial perfusion
- dual damage of monochorionic twins
32
Cord gas UV and UA equals who's blood
```
UV = placental
UA= Babies
```
33
Maternal assessment questions:
- Age
- GA
- Maternal Hx: (GTPALS)
- Contractions (x in 10 with mod/mild/severe strength)
- passage (dilation/effacemnt/consistency)
- Last VE (dilation/length/position)
- TESTS (urine, ferrying, GBS)
- fetal assessments
- fetal problems
- antenatal problems
- antenatal treatment
34
Factors that promote or imitate labour
1. fetus
2. myometrial activation
3. membrane rupture
4. hormones
(prostaglandin, progesterone, estrogen, oxytocin)
35
Tocolytics are
medications used to suppress premature labour
36
Examples of tocolytics are
indomethacin and nifedipine (adalat)
37
Tocolytics are administered to allow
for prelabour growth. they also allow for administration of betamethasone to allow fetal production of surfactant
38
Which tocolytic is preferred
Nifedipine is typically used first because it has less adverse effects on PDA and NEC
39
MOA of Adalat
is a CCB that blocks calcium influx to inhibit labour contraction
40
Indomethacin drug classification/moa
NSAID and tocolytic. It functions by inhibiting prostaglandin synthestase.
-reduction of inflammation inhibits production of labour
41
At what weeks is Indomethacin appropriate to give
Between 28-32 weeks (text book) but really, <28 weeks. or just dont fucking use it. plus who wants to give anything PR
42
Induction methods
- Membrane sweep
- Prostaglandin tampons
- Amniotomy
- Foley catheter in cervix
- Oxytocin
43
What does a membrane sweep mean
breaks the barrier of the cervix which beings the cascade of inflammation and uterine preparation for birthing
44
What is a prostaglandin tampon
They are used to apply prostaglandin to the cervix to initiate the birthing cascade. Prostaglandin is contraindication in women with uterine scarring from C-Section
45
Whats an amniotomy
Is a manual ROM by amniohook
46
Whats the role of 'Foley catheter in cervix'
To stimulate the release of inflammatory factors and also application of pressure on the internal os of the cervix which assists in thinning the cervix
47
Why is oxytocin used for induction
Oxytocin effectively works by increasing intracellular calcium.
Oxytocin is useless when the cervix is fully constricted
48
When and why is induction undertake before ___weeks
typically undertake before 41 + 3 because the risk of still birth steadily climbs beyond that point
49
The 5 P's of labour
1. passage
2. passenger
3. power
4. position
5. pscyhe/parter
50
When is transport not recommended in the setting of labour
When >4 cm (advised to birth in location)
51
Active labour is defined as
Progressive cervical dilation with contractions >30seconds with 2 constrictions in 10 minutes
52
Four stages of labour
1. onset of involuntary, painful contractions (cervic <3cm)
2. Full cervical dilation to delivery of fetus
3. delivery of baby to delivery of placenta
4. post-birth
53
Social abortion is allowed up to
24 weeks in BC
54
Genetic-abnormalities D&E can occur up to
~28 weeks GA
55
Abortions in the community setting aren't typically offered beyond
14 weeks
56
The four major hypertensive disorders related to pregnancy include
1. gestational HTN
2. Chronic HTN
3. Preeclampsia
4. preeclampsia super imposed upon chronic hypertension
57
When do you give midazolam in preeclampsia
When they're eclamptic and in status seizures, first line magnesium
58
Seizure prophylaxis in preeclampsia
4g of mag over 20minutes, followed by 1g/h for 24 hours
59
In addition to fetal lung maturity, and decreasing risk of IVH what do glucocorticoids improve in preeclampsia
Improve UA end-diastolic flow in the short term
60
Maintenance fluids of preeclampsia
80ml/hr
61
Whats the number 1 killer in preeclampsia
Pulmonary edema
62
Treatment for magnesium toxicity
calcium glutinate 15-30ml of 10% over 2-5 minutes
63
Is preeclampsia an indication for c-section
No. Not unless harm to mother or fetus
64
Why is Labetalol the only beta-blocker used in preeclampsia
Other beta blockers are teratogenic
65
In the setting of prevention, whats the only drug shown to reduce risk of preeclampsia
low dose asa
66
Eclampsia is a clinical diagnosis based on what
the occurrence of new-onset tonic-clonic, focal or multifocal seizures in a women with a hypertensive disorder of pregnancy
67
Whats the pathogenesis of eclampsia?
1. breakdown of the auto regulatory system of the cerebral circulation leading to hyperperfusion, endothelial dysfunction and vasogenic/cytotoxic edema
68
Diagnosis of HELLP is based on the presence of
Hemolysis (severe anemia, peripheral smear abnormalities)
Elevated liver enzymes (AST/ALT X 2 upper limit)
Low platelets (<100)
69
Complications of HELLP
```
placental abruption
AKI
hepatic rupture
pulmonary edema
retinal detachment
preterm with LBW
DIC
```
70
Pathophysiology of placental abruption
The immediate cause of placental separation is RUPTURE of maternal vessels in the decimal basalis. The ruptured maternal vessels may be an artery or a vein.
Thrombin (Factor 2) plays a key role in the clinical consequence of placental abruption.
71
Clinical features of placental abruption
- vaginal bleeding
- abdominal pain
- contractions with irregular pattern
- uterine rigidity and severe tenderness
- non-reassuring FHR
72
Dx of Abruption
clinical and based on the abrupt onset.
- kleighauer test is a blood that tests for present of fetal hemoglobin in maternal blood
- abruption is usually visible on US
73
In PTL when can we give steroids between?
24 and 34 weeks
74
Risk factors for PTL
- Prior PTL (Strongest risk factor)
- extreme maternal age
- multiple GA
- fetal disorder
- poly/oligohydraminos
- maternal medical conditions
- short cervix length
- positive fFN between 22-34 weeks
75
Tocolytics no longer used
Ventolin, magnesium, nitro patch, terbutaline
76
Dx of PROM
is clinical, based on visualization of amniotic fluid coming from cervical canal.
1. ferning is the other gold standard
2. amnisure is a POC used to determine PPROM
3. Nitrazine testing (pH testing of fluid)
77
Extreme Preterm age
<27 weeks
78
very prerm age rage
27-31 weeks GA
79
Moderate to late preterm
32-36+6
80
Whats the survival rate of Premies born at 24 weeks
59%
81
Interventions of reduced PTB
```
vaginal progesterone
cerclage of cervix
low dose asa
removal of large fibroids
prevention of multifetal gestations
```
82
Whats the number 1 complication of multiple gestation
preterm birth
83
What does Di-Di pregnancy mean?
Dichorionic-Diamniotic
two separate placentas
two separate amniotic sacs
84
What does Mono-Di mean?
Monochorionic-Diamniotic
| 1 shared placenta, 2 amniotic sacs
85
What does mono-mono twins mean
Monochorionic-Monoamniotic
| 1 shared placenta, 1 share amniotic sac
86
What is Twin-to-Twin transfusion syndrome
fetal to fetal transfusion of a large volume of blood causes fluid discordance.
Baby A becomes anemic and has oligohydramnios, where baby B becomes polycythemic and develops CHD and polyhyradminos
87
whats Twin anemia polycythemia sequence (TAPS)
Baby A born with 2x hemoglobin than baby B.
Small volumes of RBCs feto-fetal transfusion causes discordant hemoglobin
More insidious because some volumes are being transfused over a slower period of tie.
88
What is true labour
Progressive cervical dilation, effacement or both resulting from regular uterine contractions (2 or more in 10 minutes lasting 30-60s)
89
What does prostaglandins have to do with labour
Inflammatory response creating arachidonic acid prostaglandin syntheses
90
What does progesterone inhibit?
Prostaglandin production
91
Indocin (indomethacin) inhibits the production of?
Arachnoidic acid, which inhibits prostaglandin synthesis
92
Labour is a continuous process of contractions altering with relaxation by increasing and decreasing...
intracellular calcium
93
Four T's of post-partum bleeding
tissue (placenta retention)
trauma (tearing vessels)
tone (inability of the uterus to self-contract)
thrombin (bleeding disorders)
94
Initial assessment for < 34 weeks gestation with symptoms of PTL
1. check GA AGE
2. Palpate contractions
3. sterile sepeculum exams; (cultures, R/O ROM, take FFN swab)
4. perform digital assessment of cervix
95
Whats cervical incompetence/insufficiency
the inability of the uterine cervix to retain pregnancy in the absence of the signs and symptoms of clinical contractions or labour or both in 2nd trimester
96
Whats the timeline for first, second and 3rd trimester?
1. 1-12
2. 13-26
3. 27 +
97
Corticosteroid prophylaxis benefits are seen as early as
4 hours
98
Maximum effect of corticosteroids in PTL
48 hours - 7 days after first dose
99
Maternal cardiovascular differences
1. increased CO
2. dilution anemia, but increased RBC production
3. increased blood volume
4. increase preload, decrease afterload from declining SVR
5. declining SVR from prostaglandin
6. increased hR by 20
7. left axis deviation
8. increase in Pao2
100
maternal Resp differences
1. respiratory alkalosis (pH >7.4 decrease CO2 30-32mmHg)
2. decreased FRC 2nd to babe/diaphragm
3. decreased chest compliance
4. decrease v/Q
5. progesterone stimulation produces an increased resp drive
101
maternal GI/GU differences
higher risk of gastric aspiration 2nd to lower esophageal sphincter tone
increased grr with increased renal BF , decreased CR to 35-45
102
What are dizygotic twins
non-identical twins. 2 eggs, 2 sperms
103
what are monozygotic twins
identical. 1 egg 1 sperm
104
Three differentials for HELLP
1. Acute fatty liver of pregnancy
2. Thrombotic thrombocytopenia purpura
3. Pregnancy induced hemolytic ureic syndrome
105
Pathophysiology of HELLP syndrome
It probably represents a severe form of preeclampsia but to relationship between the two disorders remain controversial.
Microangiopathy and activation of intravascular coagulopathy can account for all the laboratory findings of HELLP syndrome
106
Benefits of delayed cord clamping
- decreases the need for transfusion, increase blood
- volume 20-40ml/kg increase
- increase stem cells
- decrease risk of NEC and IVH
