OB Flashcards
1
Q
Goodell’s Sign
A
Softening of cervix at 4-6wk
2
Q
Chadwick’s Sign
A
Bluish discolouration of cervix and vagina due to pelvic vasculature engorgement at 6wk
3
Q
Hegar’s sign
A
Softening of cervical isthmus at 6-8wks
4
Q
beta-hCG
A
Peptide hormone composed of alpha and beta subunits produced by placental trophoblastic cells
Maintains corpus luteum during pregnancy
5
Q
beta hCG positive levels at…
A
9d post-conception in serum
28d after first day of LMP in urine
6
Q
beta-hCG plasma level pattern
A
Doubles every 1.4-2d for first 4 weeks, then by 6-7wks may take 3d to double, peaks at 8-10wks then falls to plateau until delivery
7
Q
beta-hCG levels less than expected suggest
A
Ectopic
Abortion
Inaccurate dates
May be normal
8
Q
beta-hCG levels higher than expected suggest
A
Multiple gestation
Molar pregnancy
Trisomy 21
Inaccurate dates
9
Q
beta-hCG rule of 10s
A
10IU = time of missed menses
100 000 IU = 10wk (peak)
10 000 IU = term
10
Q
Transvaginal U/S finding at 5wks
A
Gestational sac
11
Q
Transvaginal U/S finding at 6 wk
A
Fetal pole
12
Q
Transvaginal U/S finding at 7-8wks
A
Fetal heart activity
13
Q
Transabdominal U/S finding at 6-8wk
A
Intrauterine pregnancy visible
14
Q
First trimester
A
1-14wks
15
Q
Second trimester
A
14-28wks
16
Q
Third trimester
A
28-42wks
17
Q
Change in Hb and Hct in pregnancy
A
Decrease (physiologic anemia secondary to hemodilution)
18
Q
Leukocyte count change in pregnancy
A
Increase but with impaired function
19
Q
Gestational thrombocytopenia
A
Mild (plt >70 000) and asymptomatic, normalizes within 2-12wk
20
Q
Hormone involved with delayed gastric emptying
A
Progesterone
Causes GERD, gallstones, constipation
21
Q
Ureters and renal pelvis dilation in pregnancy
A
R>L
Secondary to progesterone induced sooth muscle relaxation and uterine enlargement
22
Q
Renal function changes in pregnancy
A
Increased CO --> increased GFR Decreased Cr (35-44mmol/L), uric acid and BUN
23
Q
Thyroid changes in pregnancy
A
Increased total thyroxine and thyroxine binding globulin
TSH levels are normal
24
Q
Cortisol levels in pregnancy
A
Rise throughout
25
Calcium levels in pregnancy
Decreased total Calcium due to decreased albumin (free ionized Ca2+ remains the same due to parathyroid hormone)
26
Folic acid
8-12wks preconception until end of T1
Prevent NTDs
0.4-1mg daily in all women
5mg if previous NTD, antieplieptic meds, DM or BMI > 35kg/m2
27
Naegle's Rule of dating
1st day of LMP + 1yr + 7d - 3mo
28
Dates should change if T1 U/S differs by...
>5d in difference from LMP due date
29
Diclectin
10mg doxylamine succinate with Vitamin B6
4 tabs PO daily (1 qAM, 1qlunch, 2 qhs)
Up to max of 8 tabs/d
30
OB causes associated with hyperemesis
Multiple gestation
GTN
HELLP Syndrome
31
Kleihauer-Betke test
Extent of fetomaternal hemorrhage by estimating volume of fetal blood that entered maternal circulation
32
Situations when Rhogam is given to Rh neg women
Routinely at 28wk GA (protection for 12wk)
Within 72h of birth of an Rh+ fetus
Invasive procedure in pregnancy (CVS, amnio)
Ectopic preg
Miscarriage or therapeutic abortion
Antepartum hemorrhage
trauma
33
Tx for Rh neg and Ab pos mom
Follow serial monthly Ab titres throughout pregnancy, U/S +/- serial amnios as needed
34
Fetal hydrops
Edema in at least 2 fetal compartments due to fetal HF secondary to anemia
35
Erythroblastosis fetalis
Mod-severe immune-mediated hemolytic anemia
36
Risk factors for NTD
GRIMM
Genetics (risk of 2nd child having NTD is 2-5%, increased from baseline risk of 0.1%)
Race: Europeans>Africans, 3x higher in hispanics
Insufficient folate and zinc
Maternal chronic dz
maternal use of antiepileptics
37
Primigravidas feel fetal mvmt at
18-20wks
38
Normal EFM tracing
Baseline: 110-160bpm
Variability: 6-25bpm (< / = 5bpm for < 40min)
Decels: None, early decels, occasional uncomplicated, variable decels
Accels (term): Spontaneous, accels of >/= 15bpm lasting 15s
Accels (preterm): accels of > / = 10bpm last 10s
Accels present with scalp stim
39
Atypical EFM tracing
Baseline: 100-110 or >160 for <30min to < 80min
Variability: < / = 5bpm (absent or minimal) for 40-80min
Decels: Repetitive (> / = 3) uncomplicated variable decels. Occasional late decels. Single prolonged deceleration > 2 min but < 3 min
Accels: absence with fetal scalp stimulation
40
Abnormal EFM tracing
Baseline: Brady <100, tachy >160 for >80min
Variability: < 5 for > 80min, sinusoidal, >/=25bpm for >10min
Decels: Repetitive (> / = 3) complicated variable decels, late decels, any prolonged decel (> / = 3)
Accels: Nearly absent
41
Biophysical profile
U/S assessment +/- NST
Scoring: 2 points for each if reassuring
Tone (at least one epi of limb extension followed by flexion)
Movement (3 discrete mvmts)
breathing (at least one epi of breathing lasting at least 30s)
Amniotic fluid volume (fluid pocket of 2cm in 2 axes)
```
LAMB
Limb extension and flexion
AFV
Movement
Breathing
```
```
8-10 = normal
6 = unequivocal
=4 = deliver
```
42
Daily caloric intake during pregnancy
100cal/d in 1st trimester
300 cal/d in 2nd and 3rd trimester
450 cal/d during lactation
43
Only nutrient for which requirements during pregnancy can't be met by diet alone
Iron
44
Absolute C/I to exercise
```
Ruptured membranes
preterm labour
HTN d/o of preg
Incompetent cervix
IUGR
Multiple gestations (>3)
Placenta previa after 28th wk
Persistent 2nd or 3rd trimester bleeding
Unctrolled Type 1 DM
Uncontrolled thyroid dz
Other srs CV, resp or systemic d/o
```
45
Relative C/I to exercise
```
Previous preterm birth
Mild/mod cv or resp d/o
anemia (=100g/L)
Malnutrition or eating d/o
Twin preg after 28th wk
```
46
Smoking in pregnancy associated with
```
Decreased birth weight
Placenta previa/abruption
Spontaneous abortion
Preterm labour
Stillbirth
```
47
Cocaine in pregnancy associated with
Microcephaly
Growth retardation
Prematurity
Abruptio placentae
48
Marijuana in pregnancy associated with
Low birth weight
49
NSAIDs in pregnancy associated with
Premature closure of the ductus arteriosus after 30wks GA
50
Vaccines safe in pregnancy
```
Tetanus
Diphtheria
Influenza
Hep B
Pertussis
```
51
Vaccines recommended in pregnancy
Influenza
| Tdap (irrespective of immunization hx) ideally btwn 27-32wks
52
Hepatitis B if maternal status unknown or positive
Hep B Vaccine and HBIG should be given to infant within 12h of birth with F/U doses at 1 and 6mo
53
Most common pathological etiology of obstetrical hemorrhage in T3
Abruptio placentae
54
Placenta previa
Abnormal location of placenta near, partially or completely over the internal cervical os
0.5-0.8% of all pregnancies
Painless bleeding
55
Abruptio placentae
Premature separation of a normally implanted placenta after 20wk GA
1-2% of all pregnancies
Painful bleeding
56
Placenta previa risk factors
* Hx of placenta prevue (4-8% recurrence risk)
* Multiparity
* Increased maternal age
* Multiple gestation
* Uterine tumour (ie. fibroids) to other uterine anomalies
* Uterine scar due to previous abortion, C/S, D&C, myomectomy
57
Abruptio placenta risk factors
* Previous abruption (recurrence rate 5-16%)
* Maternal HTN (chronic or gestational HTN in 50% of abruptions) or vascular dz
* Cigarette smoking (>1 pack/d), excessive EtOH consumption, cocaine
* Multiparity and/or maternal age >35yr
* PPROM
* Rapid decompression of a distended uterus (polyhydramnios, multiple gestation)
* Uterine anomaly, fibroids
* Trauma
58
Spontaneous resolution of placenta previa is likely if...
placenta obscures internal os by <20mm at 20wk GA
| Transvaginal U/S should be repeated in third trimester
59
NIPT
Analyzes blood for circulating cell free fetal DNA at 9-10wk GA onwards
Highly sensitive/specific for Trisomy 21 (can also look for tri 18, 13 and some X and Y disorders)
Doesn't screen for ONTD
60
NIPT indications
>35 yo
Abnormal prenatal screen (IPS, FTS or MSS)
Past hx of fam hx of: chromosomal anomaly or genetic dz, either parent a known carrier of a genetic d/o, consanguinity, >3 spontaneous abortions
61
Amniocentesis
U/S guided transabdominal extraction of amniotic fluid performed as early as 15wks GA
Screens for genetic anomalies and ONTD
Assessment of fetal lung maturity (T3) via L/S ratio (lecitihin:sphingomyelin), if >2:1 RDS is less likely to occur
62
Amniocentesis indications
Confirmation of positive NIPT
| Positive FTS/IPS
63
Chorionic villus sampling
Biopsy of fetal derived chorion using transabdominal needle or transcervical catheter at 10-12wk
Screens for genetic d/o (rapid karyotyping and biocehmcial assay)
Does not screen for ONTD
64
Most common cause of DIC in pregnancy
Abruptio placentae
65
Dx of abruptio placentae
Clinical
| U/S not sensitive for dx abruption
66
Stable abruption <37wk GA
Use serial Hct to assess concealed bleeding, deliver when feetus mature or when hemorrhage dictates
67
Stable abruption >/= 37wk
Deliver
68
Unstable abruption
Deliver (vaginal if no C/I, C/S otherwise)
69
Vasa previa
* Unprotected fetal vessels pass over cervical os
* A/W velamentous insertion of cord into membranes of placenta or accessory (succenturiate) lobe
* 1 in 500 deliveries
* Higher in twin pregnancies
* PAINLESS vaginal bleeding and fetal distress
* 50% perinatal mortality, increases to 75% if membranes rupture
70
Dx of vasa previa
Apt test
| Wright stain on blood smear
71
Apt test
NaOH mixed with blood
Supernatant turns pink = fetal blood
Supernatant turns yellow = maternal blood
72
Wright stain on blood smear
Nucleated cells indicate cord blood
73
Tx of vasa previa
Planned C/s at 35-36wk
| If bleeding, emergency C/S
74
Preterm labour
20-37wks GA
75
Most important risk factor for preterm labour
Previous history of spontaneous PTL
76
Cervical cerclage
Placement of cervical sutures at level of internal os, usually at end of first trimester (usually 12-12wk) or in second trimester and removed in third trimester
77
Progesterone to prevent preterm labour
* If previous PTL: 17-alphahydroxyprogesterone 250mg IM weekly from 16 - 36wks GA
* If short cervix: 200mg daily vaginally from time of dx to 36wks GA
78
Fetal fibronectin
Glycoprotein in amniotic fluid and placental tissue
+ve if >50ng/mL
Done only if 24-34wks, intact membranes, <3cm dilated, establish fetal well being
C/I if : cerclage, active vaginal bleeding, vag exam or sex in last 24h
If -ve: not likely to deliver in 7-14d
If +ve: increased risk of delivery
79
Tocolysis
Delays delivery for at least 48h for betamethasone valerate to work or for transfer to appropriate care centre
Only to be given if live, immature fetus, intact membranes, cervical dilatation of <4cm
80
Tocolytic agents
Nifedipine (20mg PO loading dose followed by 20mg PO 90min later, 20mg can be continued q3-8h for 72h or to a max of 180mg, 10mg PO q20min x 4doses)
Indomethacin = prostaglandin synthesis inhibitor, 1st line for early preterm labour (50-100mg PR loading dose followed by 50mg q6h x 8 doses for 48h)
81
Antenatal corticosteroids
Betamethasone valerate (12mg IM q24h x 2 doses)
Dexamethasone (6mg IM q12h x 4 doses)
Given btwn 24-36+6wks GA
Specific maternal C/I: Active TB
82
Prolonged ROM
>24h elapsed btwn rupture of membranes and onset of labour
83
PPROM
<37wks GA and premature rupture of membranes
84
PPROM investigations
```
Pooling
Cough test
Nitrizine (blue)
Ferning
U/S
```
85
Antibiotics in PPROM
Give if there are no signs of immediate labour
Increases latency and decreases chorioamniotis
Ampicillin IV + Erythro IV x 48h then Amox PO x 5d + erythro PO x 5d OR just erythro PO x 10d
86
Postterm pregnancy IOL
>39wks GA in advanced maternal age
| >41wks GA if vagian ldelivery not C/I
87
Fetal demise
Fetal death after 20wks GA
88
Obstetrical causes of DIC
Abruption
Gestational HTN
Fetal demise
PPH
89
DIC specific b/w
Plt
aPTT and PT
FDP
Fibrinogen
90
DIC tx
```
Treat underlying cause
Supportive
Fluids
Blood products
FFP, plt, cryoprecipitate
Consider anti-coagulation as VTE prophylaxis
```
91
IUGR
Estimated fetal weight <10th percentile for GA on U/S
92
TORCH infections
```
Toxoplasmosis
Others (ie. syphilis)
Rubella
CMV
HSV
```
93
Most important risk factor for IUGR
Previous IUGR
94
Symmetric/Type I IUGR
25-30%
Occurs early in pregnancy
* Reduced growth of both head and abdominal
* Head:Abdo ratio may be normal
* Usually a/w with congenital anomalies or TORCH infections
95
Asymmetric/Type II IUGR
70%
Occurs late in pregnancy
* Fetal abdo is disproportionately smaller than fetal head
* Brain is spared (Head:abdo ratio is increased)
* Usually a/w placental insufficiency
* More favourable prognosis than type I
96
Macrosomia
Infant weight >/=90th percentile for a particular GA or >4000g
97
U/S predictors of macrosomia
Polyhydramnios
Third trimester AC > 1.5cm/wk
HC/AC ratio <10th percentile
FL/AC ratio <20th percentile
98
Prophylactic C/S for macrosomia
EFW > 5000g in non-diabetic woman
| EFW > 4500g in diabetic woman
99
Polyhydramnios
AFI>25cm
U/S deepest pocket >8cm
Management: mild-mod require no tx, severe should be hospitalized and consider therapeutic amnio
100
Oligohydramnios
AFI <5cm
U/S deepest pocket =2cm
Management: Admit, investigate, maternal hydration PO or IV, inject fluid via amnio, consider delivery
101
Med associated with oligohydramnios
ACEi
102
U/S frequency for multiple gestation
Serial U/S q2-3wk from 24wk GA to assess growth (uncomplicated didi)
Increased freq in monodi and monomono)
103
Vaginal delivery possible for twins if...
Twin A presents vertex
104
Time of cleavage for monoamniotic monochorionic twins
9-12d
105
Time of cleavage for diamniotic dichorionic twins
0-72h
106
Time of cleavage for diamnionic monochorionic twin
4-8d
107
Twin-Twin transfusion syndrome
Formation of placental intertwin vascular anastomoses causing arterial blood from donor twin to pass into veins of recipient twin
108
ECV
Has to be >36wk, singleton, unengaged presenting part, reactive NST, not in labour
If pt Rh neg, give Rhogam prior to procedure
109
Criteria for vaginal breech delivery
Frank or complete breech, GA > 36 wk
EFW 2500-3800g based on clinical and U/S assessment
Fetal head flexed
Continuous fetal monitoring
experienced clinicians
Ability to perform emergency C/S within 30min if required
110
Pre-existing HTN
BP >140/90 PRIOR TO 20wk GA, persisting >7wk postpartum
111
Gestational HTN
sBP >/= 140 or dBP >/= 90 after 20wk GA without proteinuria in a previously normotensive pt
More common in primigravida pts
112
Pre-eclampsia
Pre-existing or gestational HTN with new onset proteinuria or adverse conditions (end organ dysfunction)
113
Eclampsia
>/=1 generalized convulsions and/or coma in setting of preeclampsia and in absence of other neuro conditions
1/3 of cases have no proteinuria or BP > 140/90 prior to seizure
114
Ominous symptoms of HTN in pregnancy
RUQ pain
Headache
Visual disturbances
115
Placental growth factor (PIGF)
Lab test recommended to help rule out preeclampsia, insufficient evidence to recommend its use to rule in preeclampsia
116
Management of HTN
Labetalol 100-400mg PO BID-TID
or Nifedipine 20-60mg PO daily
or Alpha methyldopa 250-500mg PO BID-QID
117
Management of severe HTN
Labetalol 20mg IV t hen 20-80mg IV q30min (max 300mg) then switch to oral
Nifedipine 5-10mg capsule q30min
Hydralazine 5mg IV rpt q5-10mg IV q30min or 0.5-10mg/h IV to max of 20mg IV
118
Drugs to avoid to tx HTN in pregnancy
```
ACEi
ARBs
Diuretics
Prazosin
Atenolol
```
119
HELLP Syndrome
Hemolysis
Elevated Liver enzymes
Low Platelets
120
Seizure prevention/tx
MgSO4: 4g IV loading dose, followed by 1g/h (2g/h for treatment)
Risk of seizure highest in first 24h postpartum (cont MgSO4 for 12-24h after delivery)
121
Definitive treatment of eclampsia
Delivery
122
Tx for T2DM in pregnancy
Insulin
123
Targets in T2DM in pregnancy
FPG = 5.3mmol/L
1h post prandial PG = 7.8mmol/L
2h post prandial PG = 6.7 mmol/L
Monthly A1c
124
T2DM labour
Induce by 38-39wks
Consider elective C/S for predicted birthweight >4500g
Monitor blood glucose q1h with pt on insulin and dextrose drip
Aim for blood glucose 3.9-7mmol/L to reduce risk of neonatal hypoglycemia
125
Diabetes screening period
24-28wk GA
126
Diabetes screening options in pregnancy
1. Fasting 75g OGTT; GDM if >/=1 of FPG >/= 5.1, 1h PG >/= 10, 2h PG >/= 8.5
2. Random non-fasting 50g OGCT; GDM if 1h PG >/= 11.1, if 7.8-11 perform fasting 75g OGTT, GDM if >/=1 of FPG >/= 5.3, 1h PG >/= 10.6, 2h PG >/= 9
127
Postpartum followup for GDM
75g OGTT 6wk to 6mo postpartum
128
Congenital anomalies a/w diabetes in pregnancy
2-7x increased risk of congenital anomalies due to hyperglycemia from T1DM or T2DM
**NOT in GDM b/c it develops after critical period of organogenesis
129
GDM risk of progression to T2DM
50% in the next 20yr
130
GBS screening period
35-37wks GA
131
Risk factors for GBS
```
GBS bacteriuria
Previous infant with invasive GBS infection
Unkown GBS status with:
- PTL <37wk
- ROM >/= 18h before delivery
- Intrapartum mat temp >/= 38C
Positive GBS screen at 35-37wks
```
132
Indications for GBS abx prophylaxis
+ve GBS screen
GBS in urine
Previous infant with GBS
GBS unknown + one other risk factor
133
Abx for GBS
Give 4h prior to delivery
Pen G 5 million IU IV then 2.5 million IU IV q4h until delivery
If pen allergic but not anaphylactic: Cefazolin 2g IV then 1g q8h
If anaphylactically allergic to pen: Vanco 1g IV q12h until delivery
134
Tx of UTI in pregnancy
* 1st line: Amoxicillin 250-500mg PO q8h x 7d
* Alternatives: Nitrofurantoin 100mg PO BID x 7d or cephalosporins
* Follow with monthly urine cultures (recurrence is common)
135
Varicella vaccine during pregnancy
DO NOT administer
Live attenuated
Give VZIG if mother exposed to reduce congenital varicella syndrome
136
Congenital varicella syndrome
```
Limb aplasia
Chorioretinitis
Cataracts
Cutaneous scars
Cortical atrophy
IUGR
Hydrops
```
137
CMV implications to fetus
5-10% develops CNS involvement
138
Rubella vaccine during pregnancy
DO NOT administer
Live attenuated
No specific treatment during pregnancy
139
Congenital rubella syndrome
hearing loss, cataracts, CV lesions, MR, IUGR, hepatitis, CNS defects, osseous changes
140
Syphilis treatment
Pen G 2.4 million U IM x 1 dose if early, 3 doses if late
| Monitor VDRL monthly
141
Congenital toxoplasmosis
Chorioretinitis, hydrocephaly, intracranial calcification, MR, microcephaly
142
Highest risk of DVT in pregancy
Third trimester and postpartum
143
Highest risk of PE in pregnancy
Postpartum (first 6wk)
144
Management of VTE in pregnancy
UFH 5000IU bolus followed by 30000IU/24h infusion
Measure aPTT 6h after bolus, maintain at therapeutic level (1.5-2x normal)
LMWH can also be used
Warfarin is C/I due to potential tertaogenic effects
145
Women with non-active PMHx of VTE mgmt during pregnancy
Unfractionated heparin regimens suggested
146
Preterm
>/=20 - = 36+6wk GA
147
Term
37 - 41+6wk GA
148
Postterm
>/= 42wk GA
149
Components of Bishop Score
```
Dilatation
Effacement
Consistency
Position
Station
```
150
Most common fetal position
Left OA
151
First stage of labour
0-10cm cervical dilation
152
Second stage of labour
10cm dilation - delivery of baby
153
Third stage of labour
Delivery of baby - delivery of placenta
154
Time limit for third stage of labour before interventions required
30min
155
Mgmt of placenta delivery
Oxytocin IV
156
Fourth stage of labour
First postpartum hour
157
Arteries and veins in placenta
2 arteries 1 vein
158
Early deceleration
Mirrors contraction
Benign
Due to vagal response to head compression
159
Variable deceleration
Often abrupt drop in FHR >15bpm below baseline with no effecto n baseline FHR (>15s for <2 min)
Due to cord compression or in second stage pushing with contractions
160
Complicated variable decels
FHR drop <70bpm for >60s
Loss of variability or decrease in baseline after decel
Slow return to baseline
May be associated with fetal acidemia
161
Late decels
Decels occuring after peak of contraction, slow return to baseline
ay cause decreased variabilty and change in baseline FHR
162
pH measurement for fetal scalp blood sampling
>/=7.25, lactate <4.2 = normal, repeat if abnormal FHR persists
7.21-7.24, lactate 4.2-4.8 = repeat assessment in 30 min or consider delivery if rapid fall since last sample
= 7.20, lactate >4.8 = indicated fetal acidosis, delivery is indicated
163
Redistribution of fetal blood flow in response to hypoxia/asphyxia
Increased blood flow to brain, heart, adrenals
Decreased blood flow to kidneys, lungs, gut, liver, peripheral tissues
Increase in BP
164
Bishop score scoring
Cervix considered unfavourable if <6
Favourable if >/=6
9-13 = high likelihood of vaginal delivery
165
Maternal indications for labour induction
```
DM
Gestational HTN >/= 37wk
Preeclampsia
Other maternal medical problems (ie. renal or lung dz, chronic HTN, cholestasis)
Maternal age >40
```
166
Maternal-fetal factors for labour induction
Isoimmunization
PROM
Chorioamnionitis
167
Cervical ripening methods
Prostaglandins (PGE2)
PGE1 (Misoprostol)
Foley catheter placement
168
Opioid in labour management
Morphine in latent stage
| Fentanyl in active stage/second stage
169
Labour induction agent
Oxytocin
170
Labour augmentation agent
Oxytocin
171
4 Ps of dystocia
Power (leading cause)
Passenger
Passage
Psyche
172
Dystocia in active phase
> 4h of < 0.5cm/h
173
Dystocia in 2nd phase
> 1h with no descent during active pushing
174
Brachial plexus injury, Erb's palsy
C5-7
175
Brachial plexus injury, Klumpke's palsy
C8-T1
176
Most common presentation of uterine rupture
Prolonged fetal bradycardia
177
Placenta accreta
Placenta grows too deeply into uterine wall
178
Placental abruption
Placenta detaches from uterine wall before birth
179
Amniotic fluid embolus
Amniotic fluid debris in maternal circulation triggering an anaphylactoid immunologic response
Sudden onset resp distress, CV collapse, coagulopathy, sz in 10%
180
Leading cause of maternal death in induced abortions and miscarriages
Amniotic fluid embolus
181
Chorioamnionitis
Infection of chorion, amnion, amniotic fluid typically due to ascending infections by organisms of normal vaginal flora
182
Predominant microorganisms in chorioamnionitis
```
GBS
Bacteroides
Prevotella
E.Coli
Anaerobic streptococcus
```
183
Treatment for chorioamnionitis
```
Ampicillin 2g IV and gentamicin 2mg/kg load then 1.5mg/kg IV q8h or 5mg/kg IV q24h
Anaerobic coverage (ie. clindamycin 900mg IV q8h)
If at risk for endometritis, continue postpartum
NOT and indication for immediate delivery or C/S
```
184
Meconium
More common in postdate pregnancies
Always abnormal in preterm fetus
Likely due to cord compression +/- uterine hypertonia
185
Outlet forceps position
Head visible btwn labia in btwn contractions
186
Low forceps position
Presenting part at station +2 or greater
187
Mid-forceps position
Presenting part below spines but above station +2
188
Vacuum extraction C/I
<34wk GA (<2500g)
Fetal head deflexed
Fetus requires rotation
Fetal condition (ie. bleedng d/o)
189
Limits for trial of vacuum
After 3 pulls over 3 contractions with no progress
After 3 pop offs with no obvious cause
20min and delivery is not imminent
190
1st degree laceration
Skin and vaginal mucosa but not underlying fascia and muscle
191
2nd degree laceration
Fascia and muscles of perineal body but not anal sphincter
192
3rd degree laceration
Involves anal sphincter
| Single prophylactic dose of IV abx should be administered
193
4th degree laceration
Extends through anal sphincter into rectal mucosa
| Single prophylactic dose of IV abx should be administered
194
Episiotomy
Essentially controlled 2nd degree laceration
| Midline (heals better, increased risk of 3/4th degree tears) or mediolateral (less risk of tear, more painful)
195
7 layers to dissect through in C/S
```
Skin
Fat
Fascia
Rectus abdominus
Peritoneum
Bladder flap
Uterus
```
196
Layers of rectus sheath
Above arcuate line: External oblique, external internal oblique, internal oblique, rectus abdominis, internal internal oblique, transversus abdominis
Below arcuate line: External oblique, internal oblique, transversus abdominis, rectus abdominis
197
Name of obliterated umbilical ligament
Urachus
198
C/I to VBAC
Previous classical, inverted T or unknown uterine incisions or complete transection of uterus
Hx of uterine surgery (ie. myomectomy) or previous uterine rupture
Multiple gestation
Non-vertex presentation or placenta previa
Inadequate facilities or personnel for emergency C/S
199
Puerperium
6wk post partum
200
Postpartum hemorrhage
Loss of >1000mL of blood within 24h of birthing process regardless of mode of delivery
Primary = within first 24h
Secondary = after 24h but within first 12wk
201
4 Ts of PPH
Tone (most common cause)
Tissue
Thrombin (vDW = most common)
Trauma
202
Avoid tone causing PPH via:
1. Oxytocin 10U IM or 20-40IU in 1000cc crystalloid at 150mL/h
2. Uterine massage
3. Umbilical cord traction
203
Carbetocin
Long-acting oxytocin
| Consider as alternative to continuous infusion in elective C/S or vaginal deliveries with 1 risk factor for PPH
204
Ergotamine/Methylergonavine maleate
0.25mg IM q15min up to 1.25mg
Can be given as IV bolus of 0.125mg
May exacerbate HTN (avoid in HTN pts or pts on HIV meds)
205
Hemabate/Carboprost
Synthetic PGF-1alpha analog
250ug IM q15min to max 2mg
C/I in CV, pulmonary, renal, and hepatic dysfunction (ie. asthma)
206
Misoprostol for PPH
600-800ug PO/SL or PR/PV
| Not as effective
207
TXA for PPH
Antifibrinolytic
| 1g IV
208
Bakri balloon
Used to tamponade PPH to slow hemorrhage
209
Surgical tx for intractable PPH
D&C
Embolization of uterine artery or internal iliac artery
laparatomy with bilateral ligation of uterine artery, ovarian artery or hypogastric artery
Hysterectomy as last option
210
Retained placenta
Placenta undelivered after 30min postpartum
211
Retained placenta mgmt
Brant maneuver (traction on cord while applying suprapubic pressure to avoid uterine inversion)
Oxytocin 10IU in 20mL NS into umbilical vein
Manual removal or D&C if all else fails
Cefazole 2g IV if manual removal or D&C
212
Endometritis treatment
Clindamycin and gentamicin IV
213
Mastitis
Cloxacillin or cephalexin
Continue nursing
If abscess develops, d/c nursing and start IV abx (oxacillin) + I&D
214
Postpartum blues
Self limited
| Resolves by 2 weeks
215
Postpartum depression
Major depression occuring in a woman within 6mo of childbirth
216
Postpartum psychosis
Onset of psychotic symptoms over 24-72h within first month postpartum
217
Time for ovulation to resume
~45d for non-lactating women
| 3-6mo for lactating women and sometimes later
218
Galactogogues
DA antagonists
| Domperidone, metoclopramide
219
Meds C/I when BF
```
Cyclophosphamides
Sulphonamides (in G6PD deficiency)
Nitrofurantoin (in G6PD deficiency)
Tetracycline
Lithium
Bromocriptine
Antineoplastic and immunosuppressants
Psychotropic drugs
```
220
Uterine rupture presentation during labour
Repetitive variable decels
Vaginal bleeding
Presenting part no longer palpable
Persistent pelvic pain
221
Most common cause of jaundice in pregnancy
Viral hepatitis
| Accounts for 50% of all cases
222
Cholestasis of pregnancy
```
Pruritus often worse on palms and soles at night
RUQ pain
Nausea
Jaundice RARE
High serum bile acid concentrations (>/= 40 increased risk to fetus, >/= 100 risk for fetal demise)
Typically late 2nd or 3rd trimester
Resolves rapidly after delivery
Most common liver disease in pregnancy
```
223
Cholestasis of pregnancy mgmt
Treat all
If suspected but labwork normal, tx empirically OR rpt lab tests weekly
Ursodeoxycholic acid 300mg BID-TID until delivery
Follow with modified BPP 2x/wk
May have increased NSTs
Deliver usually at 36 - 36+6wks
Recheck LFTs/bile acids 6-8wks after delivery
224
Velamentous cord insertion
Umbilical cord inserts into choriamniotic membranes then travels within membranes to placenta (btwn amnion and chorion)
Exposed vessels are not protected by Wharton's jelly
225
Triple screen
```
AFP, HCG, uE3
Considers age-related risk for aneuploidy for each of the markers --> predicts risk for both trisomy 21 and trisomy 18
All 3 are low in tri 18
Tri 21 has low AFP
Tri 13 can't be screened by low AFP
```
226
AFP in open neural tube defects
Elevated
227
Cervical insufficiency
Inability of uterine cervix to retain a pregnancy in the second trimester, in the absence of uterine contractions
228
Biochemical changes a/w cervical insufficiency
```
Decreased collagen concentration
Increased collagen solubility
Increased interleukin 8
Increased glycosaminoglycans
Increased tissue hydration
```
229
First step in assessing infertility
Sperm analysis
230
Normal sperm analysis
>2mL volume
Sperm motility >50%
Sperm density >20million
231
Ovulation and basal body temperature
Temp rises as progesterone is secreted just after ovulation
Ovulation occurs JUST BEFORE temperature rises
Sometimes there is a temperature drop during ovulation
232
Cholesterol in pregnancy
Increases
233
Albumin in pregnancy
Decreases due to dilution
234
Fasting glucose in pregnancy
Drops due to increased storage of tissue glycogen, increased peripheral glucose utilization, decreased hepatic glucose production, glucose consumption by fetus
235
Bicarb in pregnancy
Decreases as kidney excretes more to compensate for drop in CO2 (due to increase in minute ventilation)
236
Contraction stress test
Positive indicates late decels are present on at lesat 50% of contractions
237
Preventative measures for women at increased risk of eclampsia
ASA 75-162mg/d taken at bedtime, start BEFORE 16wks GA and continue until delivery
Calcium supplementation
No EtOH, peri-conceptual use of folate-containing multivitamin, smoking cessation
238
Personal risk factors for pre-eclampsia
```
First pregnancy
New partner
<18yo or >35yo
Hx of preeclampsia
Family hx of preeclampsia in 1st degree relative
Black race
Obesity
Interpreg interval <2y or >10y
```
239
Medical risk factors for pre-eclampsia
```
Chronic HTN
Pre-existing diabetes
Renal dz
SLE
Obesity
Thrombophilia
Hx of migraine
SSRI use beyond 1st trimester
```
240
2nd trimester DS lab results
AFP: 25% lower than normal
hCG: 2x higher than normal
241
Hormone responsible for development of milk producing alveolar cells in breast tissue during pregnancy
Progesterone
242
Hormone produced via suckling reflex to cause contraction of smooth muscle cells in ducts to eject milk from nipple
Oxytocin
243
Hormone responsible for stimulating alveolar cells to produce milk
Prolactin
| High progesterone during pregnancy inhibits prolactin from inducing milk synthesis
244
Hormone involved in gestational diabetes
Human Placental Lactogen
245
BMI < 18.5 can expect to gain...
<12.5-18kg
246
BMI 18.5-25 can expect to gain
11.6-16kg
247
BMI >18.5 can expect to gain
7-11.5kg
248
When to do Leopold maneuvers
>30wks
249
Factors a/w decreased success of VBAC:
```
BMI >/= 40
>/=2 C/S without vaginal delivery in the past
Previous C/S for failure to progress
Maternal age of >35yrs
Infant weight >/= 4000g
Requirement for induction of labour
```
250
Length of cervix that is considered short and would require cervical cerclage
<25mm
251
Missed abortion
Dead fetus with closed cervix and no passage of products
252
Complete abortion
Products of conception are passed and cervix is closed
253
Threatened abortion
Bleeding but closed cervix. No products of conception passed.
254
Incomplete abortion
Bleeding, open os, products of conceptions seen at os or vault
255
Antiphospholipid syndrome
A/w false +VDRL, prolonged PTT, thrombocytopenia
| Prophylaxis with low dose ASA, LMWH
256
Tx of Grave's in pregnancy
Propylthiouracil in first trimester
| Methimazole in 2nd and 3rd trimesters
257
Magnesium toxicity signs
Lack of patellar reflexes --> respiratory depression --> cardiac conduction changes --> cardiac arrest
258
Zika virus and pregnancy planning
Wait 2 mo for women
| Wait 6 mo for men
