MFM

Question 1

The biggest RF for PTL

Answer 1

Hx of spontaneous PTB, often occurs at the same GA or earlier

Question 2

interventions to reduce PTL

Answer 2

1. progesterone per vagina
2. cerclage of cervix
3. low dose asa
4. removal of large fibroids
5. ideally is 12-18m inter-pregnancy interval
6. smoking cessation
7. multifetal gestation

Question 3

Causes of PTL

Answer 3

1. Maternal stress
2. Infection/inflammation
3. Decidual Hemorrhage
4. Pathologic Uterine Distention (Polyhydraminos, multiples)

Question 4

True labour

Answer 4

Contractions that result in cervical change

Question 5

Cervical change is defined as

Answer 5

dilation, effacement, softening, moving anterior

rate of cervival change important

Question 6

Tocolytics are used for

Answer 6

Administration of a tocolytic rx can reduce the strength and frequency of uterine contraction

Question 7

Tocolytic indications

Answer 7

1. To try to reduce the strength/frequency of contractions.
2. To delay/halt/prevent PTL
3. To try to get to appropriate level of care for mother/fetus
4. Used for 48hrs in Canada

Question 8

Tocolytic medications

Answer 8

1. Adalat (Nifedipine)
2. indocid
3. ventolin
4. magnesum
5. nitro patch
6. terbutaline, ritodrine

Question 9

Nifedipine (adalat)

Answer 9

used as a tocolytic for PTL (calcium channel blocker)
used in preeclampsia
evidence of benefit
less fetal harm
material s/s: n,v, hypotension, dizziness, h/a
you can use Nifedipine and magnesium together

Question 10

Why use steroids in antenatal care?

Answer 10

Administration of antenatal corticosteroids to patients at risk for preterm birth reduces neonatal mortality when delivery occurs within 7 days help fetal lung develop

Question 11

What steroids are given?

Answer 11

Betamethasone and dexamethasone

Question 12

Chorioamnionitis definition

Answer 12

maternal fever >38 with tachycardia pulse signs of maternal sepsis
Tx: delivery and broad spectrum abx

Question 13

Definition of preeclampsia

Answer 13

Resistant HTN with new/worsening proteinuria and adverse effects (H/A, Blurred vision, epigastric pain, IUGR, Oligo) after 20 weeks GA

Question 14

Target organ damage in pre-eclampsia

Answer 14

maternal = eclampsia, ICH, Pulmonary edema, liver
fetal = IUGR, oligo, abnormal doppler, abnormal EFM

Question 15

criteria for blood pressure in preeclampsia

Answer 15

≥140/≥90 = HTN
≥160/≥110 = Severe HTN

Question 16

eclampsia is

Answer 16

a grand mal seizure with pre-eclampsia

Question 17

HELLP is

Answer 17

hemolysis elevated liver enzymes and low platelets. It represents a subtype of pre-eclampsia with severe features in which hemolysis, elevated liver enzyme and low platelets are the predominant features, rather than HTN or CNS/renal dysfunction.

Question 18

Preeclampsia indications for delivery

Answer 18

1. worsening maternal status:
   - increasing bp
   - HELLP syndrome
   - eclampsia
   - increasing serum cr
   - abruption/DIC
2. Compromised Fetal status
   - IUGR
   - Abnormal Doppler
   - oligohydramnios

Question 19

Treat pre-eclampsia with

Answer 19

Nefidapine, then labetalol

Question 20

Treat eclampsia with

Answer 20

4g of magnesium iv over 10-20 minutes

then 1g/hr for 24 hours

Question 21

important Hormones associated with maternal physiology

Answer 21

1. progesterone
2. prostaglandins
3. oxytocin
4. estrogen
5. relaxin/cytokines and para-thyrpod hormones

Question 22

Factors inducing of labour

Answer 22

1. fetus (HPA stress, cortisol)
2. myometrial activation
3. hormones
4. membrane rupture

Question 23

how does indocin (indomethacin) work and why is it used as a tocolytic

Answer 23

Indacin inhibits the production of arachnoidic acid, which inhibits prostagland synthesis (used as a tocolytic)

Question 24

Benefits of oxytocin

Answer 24

○ Precursor produced in hypothalamus
○ Secreted from posterior pituitary in active labour
○ Oxytocin receptors are present on myometrium
§ Receptor increase near term
§ Receptors increased estradiol
§ Receptors down-regulated by progesterone
○ Oxytocin causes contractions by increasing intracellular calcium

Question 25

Five P's of labor

Answer 25

``` passage passenger power position psyche/partners ```

Question 26

treatment for short cervix

Answer 26

• Progesterone • Cerclage ~Pessary

Question 27

Initial Assessment for <34 weeks gestation with symptoms of preterm labour

Answer 27

1. Check gestational age 2. Palpate contractions 3. Sterile speculum exam: a. Cultures b. Rule out preterm ROM c. Take FFN Swab Perform digital assessment of CX

Question 28

Tocolytic Therapy goals

Answer 28

* Delay delivery 24-48 hours if GA <34 weeks * Antibiotics: prevention of neonatal group B strep sepsis * Steroid therapy for prevention of neonatal RDS * Transport to appropriate centre for higher level of care if required

Question 29

Nifedipine MOA, dose and indications

Answer 29

MOA: calcium channel blocker Dose: PTL = Loading dose of 10mg q 15 until contractions stop (4 doses max). Then XL dose Indicated for: PTL, and for pre-eclampsia

Question 30

Preterm labour treatments:

Answer 30

1. Betamethasone (corticosteroid for lung/gut/neuro protection) 2. Tocoyltic (nifedipine, Indocin for meds to work/transport) 3. Abx (Group B strep) 4. Magnesium for fetal neuroprotection

Question 31

Consequences of PPROM

Answer 31

``` • Preterm delivery • Fetal pulmonary hypoplasia • Fetal skeletal maldevelopment • Ascending infection ○ Maternal sepsis ○ Neonatal sepsis Independent risk factor for cerebral palsy ```

Question 32

PPROM dx

Answer 32

Ferning and pH <7

Question 33

PPROM mgmt

Answer 33

• 24-34 weeks • Ampicillin 2G IV q 6 h, erythromycin 250mg IV q6 h for 48hr • Amoxicillin 250mg q 8h, erythromycin base 333mg q 8 hours for 5 days • Single course of corticosteroids • Monitor for signs of infection • Monitor for signs for preterm labour Deliver at 34-36 weeks, or when indicated

Question 34

difference between abx for PPROM and PTL or someone who has Group B strep

Answer 34

1. PPROM abx essentially are used to keep baby inside so corticosteroids can work 2. PTL/GROUP B strep is to prevent baby from getting septic during delivery from mom who has a high risk or has group b

Question 35

neonate risk of infection

Answer 35

• <37 weeks • >18 hours PROM • Intraamniotic infection Previous affected neonate

Question 36

labs in HELLP

Answer 36

``` • Hemolysis ○ Peripheral smear w/ schistocytes and burr cells ○ Bili >20mmol ○ Low LDH, Low heptaglobin ○ Severe anemia unrelated to blood loss • HELLP ○ Two x upper limit of normal Plts <100 ```

Question 37

severe preeclampsia

Answer 37

***>160/110*** ***preeclampsia before 34 weeks *** protein 3g/24h (spot urine, cr protein ratio 250g/mol)