OB pathology Flashcards
(182 cards)
1
Q
Antpartum bleeding -
A
placenta previa placenta abruption fetal vessel rupture uterine ruptute cervicitis, polyps, dysplasia, lacerations, varices, hemorroids, bleeding disorder
2
Q
1st trimester bleeding
A
SAB, ectopic pregnancues, notmal pregnancy
3
Q
Placenta previa and 4 types
A
abnormal implant of placenta over internal cervical os.
Complete- covers; partial- portion of internal os, marginal- edge reaches the margin of os, low lying placenta - implanted in lower uttering segment but not extending
Rare - vasa previa - overling fetal vessel
20% of antepartum bleeds, bleed w. normal movement and disruption of attachment
4
Q
placenta increta
A
placenta in myometrium
5
Q
placenta percreta
A
through myometrium into uterine serosa
6
Q
placenta acceta
A
placenta attaches to superficial endometrium/myometrium,
common peripartum hystorectomy cause
c section and anterior placement raises risk (15-30%)->(25-50%)>(29-67%),
MRI to image
7
Q
complications of placenta previa
A
preterm delivery, PROM, IUGR, vasa prevue, malpresentation, congenital abnormalities
increase risk w/ myomectomy, utterine abnormalities, mtpl gestation, multiparty, advanced age, smoking, prior Hx
8
Q
Painless vaginal bleeding, 1st episode after 28wks think of?
do not do what?
A
placenta previa
no vaginal exam until US to r/o, repeat USin 3rd trimester to determine if resolved if found earlier than 3rd, transvaginal better
9
Q
Hx of c section and placenta prevue suspect what?
A
placenta accreta
10
Q
Tx of placenta previa
A
pelvic rest(no intercourse, modified bed rest), after sentenial bleed
unstoppable labor, fetal distress and hemorrhage -> c section
>2cm away fro internal os may deliver vaginally
wk 36 just deliver c section post amniocentesis, 38 w/o lung maturity
11
Q
placenta abruption
A
premature seperation - 50% occur before labor and afte3 30wks, 15% during L
30% of all antepartum bleeding
-> premature, uterine tetany, DIC, hypovolemic shock
12
Q
Placental abruption predisposing factors
A
maternal HTN, prior Hx, cocaine use**
trauma, multiparitty, agr, polyhydraminps, DM, collagen vascular disease, meth ise. alchol >14drinks/wk, MVA
13
Q
Concealed hemorrhage
A
20% where placental separations confined to uterine cavity-> cervix and then becomes revealed/external hemorrhage
14
Q
Presentation of placental abruption
A
3rd trimester bleeding, severe ab pain and strong contractions, fetal distress, 30% are small w/ few or no symptoms
Negative findings on US do NOT r/o
15
Q
Tx of placental abruption
A
depends on size, small do not need to deliver emergently
C section if vaginal not imminent, blood products, fluids,
Stabilize the Pt, prepare for future hemorrhage, prepare for preterm delivery, deliver if life threatening
16
Q
uterine rupture
A
maternal and fetal death risk
90% have prior uterine scar, otherwise ab trauma, L and d w/ imptoper oxytocin, grand multiparty, mole, choriocarcinoma
need laparotomy
hemorrhage and hypovolemic shock
17
Q
uterine rupture Tx
A
repair if possible otherwise hysterectomy
discourage pregancy, and subsequent c sections only
18
Q
Fetal vessel rupture
A
2/2 velamentous cord insertion where blood vessels insert between the amnion and chorion away from the placneta instead of directly into chorionic plate. unprotected-> risk of rupture; possible vasa previa
risk fetal exsanguination
Tx w/ C section, presumptive at 35wks if previously diagnosed w/ vasa prevue
19
Q
succenturinate lobe
A
bulk of placenta is implanted in one portion of uterine wall but small lobe is implanted in another. vessels between are unprotected -. fetalvessl rupture
20
Q
Apt test
A
diluting blood w/ water and adding NaOH looking for fetal RBCs in fetal vessel rupture
21
Q
Sinusoidal pattern on fetal monitoring suggests
A
fetal anemia
22
Q
low birth weight
A
<2500g
23
Q
Pre term labor associated w/
A
PROM, chorioamnionitis, multiple gestations, uterine anomalies, previous preterm, prepreganancy weight <50kg, placental abruption, preeclampsia, infection, intra-ab disease, low SES
10% of all deliveries
24
Q
beta mimetic tocolytics
A
ritodrine- beta mimetic - IV contin
Terbutamine - beta 2 agonist - SC q20m x3 load g3-4h
- increase conversion of ATP ->cAMP -> less Ca
-SFX: HA, Tachy, anxiety
last only 48hrs, allow for steroids to help w/ fetal lung immaturity
- hydration also lowers contractions (less ADH ~oxytocin)
25
Reduce risk of respiratory distress syndrome
betamethasone, prior to 34 wks need to weigh risk of steroids vs prolonging pregnancy (prelim, chorizo, etc)
26
black box on terbutaline
maternal death, cardiac events, tachy, hyperglycemia, MI, pulm edema, hypokalemia
if used longer than 24-48hrs
27
magnesium in pregnancy
decreases uterine tone and contraction as a Ca antagonist and membrane stabilise, does NOT change age despite stoppin contractions
flushing, fatigue, diplopia, -> resp depression, hypoxemia, cardiac arrest. DTR depression is a clue prior to >10mg/dL toxic
6g bolus + 2-3g/hr infusion
28
Calcium channel blosckers in pregnancy
nifedipine - comparible to ritodrine and magnesium
HA, flushing, dizziness
given oral at 10mg dose 1st hr -> 10-30mg q4-6h
29
Indomethacin in pregnancy
Prostaglandins increase intracell levels of Ca-> more contractions. NSAIDs stop this and has limited maternal but variety of fetal SFx (closure of acute arterioles, pulm HTN, oligohydraminos 2/2 renal failure, neck enterocolitis risk,
use only before 32wks
30
Preterm vs premature rupture of membranes
preterm = rupture before wk 37
premature = before onset of labor
lasting longer 18hrs = prolonged PROM(PPROM)
50% of ROM -> labor in 24 hrs
31
Antibiotics w/ ruptured membranes?
Ampicllin +/- erythromycin rec in PPROM
also in unknown GBS status,
may induce after 34-36wks due to risk of infection waiting
32
4 types of pelvis
Gynecoid
Android
Anthropoid
Platypelloid
33
cephalopelvic disproportion
most common cause of failure to progress in labor, pelvis too small, presenting fetal part too big
34
obstetric conjugate
distance between the sacral promontory and midpoint of symphysis pubis, shorts distance in pelvis
9.5-11.5cm
35
3 types of breech presentation
3-4% of all deliveries w/ uterine ab, polyhydraminos, oligohydraminos, mtpl gestation, PPROM, hydrocephaly, anecephaley
Frank - butt, extended knees; complete - indian style, flexed knees; incomplete- have a foot
36
Tx of breech
external cephalic version- manipulation, rare before 36-37wks, try2nd time at 39 if fail w/epidural
trial breech vaginal delivery- rare in the US, need: flexed head 2kg-3.8kg, and incomplete breech
elective c section
37
Vertex malpresentations
face, brow, compound(extremity w/), shoulder (transverse lie)
38
fetal position that optimizes fetal had passing through pelvis
occiput anterior - OA, LOA and R OA are also normal
OT or OP is malpositioned in 1st-2nd stage of labor (OT rare to vaginal deliver, OP 50%)
more common in platypelloid pelvis
rotation fail or operative bag delivery fail -> c section
39
Prolonged deceleration
HR < 100-110 for longer than 2 min
longer than 10 min = bradycardia
associated w/ abruption, cord prolapse, uterine titanic contraction, uterine rupture, PE, amniotic fluid embolus, seizure
40
Tx of fetal HR decel
patient moved to L or R lateral decubitus to resolve FHR 2/2 compression of IVC
oxygen administered
txbased on etiology
tetanic uterine contracttion -> nitro, terbutaline
C section?, moved to OR after 4-5min of decl
41
Shoulder dystocia
impaction of anterior shoulder behind pubic symphysis
Risk- macrosomia (4000g), DM, previosu Hx, maternal obesiity, postterm, prolonged 2nd stage, perative vaginal delivery
42
Complications of shoulder dystocia
fractured clavicle/humerus, brachial plexus injury (erb palsy), phrenic nerve palsy, hypoxic brain injury
90% no long term sequela
43
Tx:of shoulder dystocia 5 maneuvers
delivery in c section
44
Maternal hypotension
common to have BP 90/50 but less than 80/40 unusual
vasovagal, regional anesthesia, antihypertensive drugs, hemorrhage, anaphylaxis, AFE
GIVe IV hydration and arenergic drugs
45
Mom seizing give
magnesiom sulfate IV or IM
46
SGA
fetal growth disrupted but cause is unknown. higher morbidity and mortality. however do better than babies of similar weight but premies.
either decreased growth potential of intrauterine growth restrictin
47
Decreased growth potential
10% of SGA , Downs, edwards, Patau, Turner. osteogenesis imperfecta, achondroplasia, neural tube defects,
CMV and Rubella
teratogens/Chemo/alcohol/cigarettes
48
IUGR
hyper plastic growth 1st 20 wks (increase cells)
hypertrophic 2nd 20 wks (increase size)
insult early -> symmetric vs later asymmetric growth defect
less nutrition and oxygen from: HTN, anemia, renal disease, antiphopholipis, SLE, malnutrition; placenta factors - previa, abruption, infarct, mtpl gestation
49
fundal height less than 3 cm expected do what?
US
R/o oligohydraminos and SGA vs IUGR
IUGR falls of curve, SGA starts small and stays small
IUGR may have abnormal doppler of umbilical artery reversal (with calcifications or thromboses) and are delivered early
50
Tx of SGA in placental insufficency/preeclampsia?
antiphosphipid/thrombophilas
Aspirin, low dose
corticosteriods and heparin
51
macrosomia
Risk factors
weight >4500g
offer c sections if >5000g in women w/o GDM to 4500 w/ GDM
prexisting or GDM**, maternal obesity(BMI>30) is associated, posters pregnancies, multpariety, advance age
52
AFI normally
amniotic fluid index - measures largest vertical pocket in cm. AFI20-25 is polyhydraminos
peak fluid level is 800mL tapers to 500mL wk 40
53
oligohydraminos
Risk:
40x increase in perinatal mortality 2/2 cord compression risk-> fetal asphyxiation; congenital anomalies (GU system and growth restricted)
Chronic Uteroplacental insufficiency, congenital abnormalities of GU -> decrease urine output (potters/renal agenesis), Polycystic kidneys, obstruction)
ROM* most common
54
Tx of olgohydraminos
depends, BPP, umbilical artery dp[ler,GA
| Term -> deliver; ROM if not in labor, amnioinfusion if meconium or decelerations,
55
Polyhydraminos
Risk:
AFI greater than 20 or 25; 2-3% of pregnancies,
Maternal DM(baby's pee more), neurotube defects, obstruction of fetal alimentary canal (tracheoesophageal fistula, duodenal atresia) and hydrops, mtpl gestation
not as omnious as oligo
56
Tx of polyhydraminos
Prevent
risk malpresentation, increased risk of cord prolapse
ROM in controlled setting and head engaged
57
ABO incompatibility w/ Rh sensitization
decreases the risk of Rh sensitization as a result of destruction of fetal cells by anti A or anti B antibodies
58
Erythroblastosis fetalis
fetal hydrops -accumulation of fluid in the extracellular space in at least 2 body compartments
hyperdynamic state, heart failure, diffuse edema, ascities, pericardial effusion due to serious anemia
59
sensitized Rh negative patient and pregnant
antibody screen on initial screen
RhoGAM administered at 28wks and postpartum if neonate is Rh positive
0.3mg Rh IgG eradicated 15mL of fetal RBC
60
Kleihauer Betke test
amount of fetal RBCs in the maternal circulation
61
Sensitized Rh negative patient
can get paternal blood to test risk
antibody titre followed every 4 wks remaining it <1:16;
- serial amniocentesis is greater as early as 16-20 wks
-Amniocentesis fetal cells can be analyzed if further mgmt needed
-serial MCA doppler* to assess fetal anemia
62
Percutaneous umbilical blood sampling (PUBS); Intrauterine transfusion tx for fetal enamia
PUBS - fetal hematocrit to verify anemia and preform an IUT
63
Other RBC antigens
ABO bloodtype; CDE (Rh is D); Kell, Duffy, Lewis
Kell and Duffy - fetal hydrops
ABO and Lewis - mild hemolysis
64
Anti kell antibodies complications
hemolytic anemia, suppression of bone marrow, decreased RBC production
65
IUFD risk increases w/
abruption, congenital abnormalities, infection, posterm pregnancies
chronic placental insufficiency** secondary to rheumatologic, vascular or HTN
unknown cause = cord accident
retained > 3-4 wks can lead to hypofibrinogenemia secondary to the release of thromboplastic substances from decomposing fetus -> DIC
66
after 20wks fetal demise suspected w?
lack of movement, absence of uterine growth
confirmed w. US by 2 clinicians
67
To prevent risk of DIC w/IUFD treat w?
Delivery.
Early: have D and E or Mifepristone and misoprostol
After 20 wks: terminated by induced labor w/ protaglandine or high dose oxytocin
68
Posterm pregnancy
most common cause?
GA > 42 wks; more common in overweight/obese
many women induced at 41 wks
Due to inaccurate dating*, also ancephaly, fetal adrenal hypoplasia, absent fetal pituitary -all less estrogen
69
Mtpl gestations
Complications?
twins; occurs 1:80 w/o assited fertilizaation - 30% monozygotic
preterm labor, placenta previa, cord prolapse, postpartum hemorrhage, cervical incompetence GDM, preeclampsia; SGA, malpresentation
70
monozygotic twins
fertilized ovum divided 2 separate ova; does not followan inheritable pattern
71
dizygotic twins
2 ova; tends to run in families
72
Mo-Di
monochorionic (1 placenta) diamniotic (2 amniotic sacs) twins
after trophoblast differentiation and before amnion formation - days 3-8
73
Twin to twin transfusion syndrome
placental vascular communication in Mo-Di twins,
one small anemic twin and another large, plethoric, polycythemic and occasional hydropic twin
assess q2wks w/ US
Tx serial amnio reduction
74
Di-Di
2 chorions(placentas), and 2 amnions(sacs);
Day 1-3 (earliest)
75
Mo- Mo
have high mortality rate (division after amnion formation leads to 1 sac 1 placenta)
Day 8-12
76
Delivery of Twins attempts
Vertex vertex - deliver 1st
Vertex breech - try and switch but c section if need be
Breech breech - c secition
also no discordance >20%
77
fetal macrosomia complicated by
hypoglycemia, birth trauma, jaundice and hypocalcemia, childhood cancers- whilms, leukemia, osteosarcoma
78
Dating in US 1st, 2nd and 3rd? off by how much
1st tri - 1 week
2nd - 2 wks
3rd - 3 weeks
79
Start normal NST monitoring at?
41 wk, 2x in 42nd week
80
BP in pregancy normally?
decreases- 2/2 decreased systemic vascular resistance, during the later half of the 1st tri, 3rd tri back to baseline
81
Elv liver enzymes seen in preeclampsia is seen w/ 2 disease etiologies
HELLP (10% of preeclamptic)-> high still born rates
Acute fatty liver of pregnancies
Tx w. delivery
82
Presentation of preeclampsia
nondependent edema, HTN* at least >140/90 2x), proteinuria*(>300mg/day)
(or rise in 30 systolic be concerned)
```
3rd tri( after 20wks) (5% of all live births)
2/2 intravascular spasm and constriction; imbalanced prostacyclin and thromboxane
```
83
Maternal complications of preeclampsia
2/2 generalixed arteriolar vasoconstriction: Seizure, cerebral hemorrhage, DIC/thrombocytopenia, renal failure, hepatic rupture, pulm edema, placental abruptio, prematue delivery, c sectiion
84
HTN in 14-20 wks think of
hydratidiform mole or undiagnosed chronic HTN
85
Major chief complaint of HEELP
RUG pain
see epigastric pain or N/V need to r/oHEELP
86
Risk of preeclampsia
Immunologic nature
- family Hx, mother of father
- live w. father 1 yr leads to lass effect
- nullparity,
- AA race
manifestations of disease
- collagen vasc disease
- HTN
- Obesity
- type 2 DM
- 35
Multifarious and smoking decreases risk
87
Fetal complications of preeclampsia
Acute uteroplacenal insufficiency: placental infart, intrapartum fetal distress, stillbirth
Chronic: asymmetrical/symmetric SGA fetus, IUGR
Oligohydraminos
88
Severe preeclampsia is
BP>160/110; proteinuria >5g/day
AMS, HA/vision change, RUQ/epigastric pain, impaired livers, oliguria (<100,000)
89
HELLP is?
rapidly deteriorating liver function
concern for hepatic rupture,
hemolysis(schistocytes/elv lactate dehydrogenase/elv t bili) , elv. liver enzymes, Low platelets
espectant mgmt 28-32 wks w/ betamethazoen vs delivery
90
acute fatty liver of pregnancy
AFLP -> fetuses w. long chain hydroxyacyl co A dehydrogenase def
Elv ammonia and glucose< 50, low fibrinogen and antithrombin III differentiates from HELLP
91
Tx of mild preeclampsia
delivery
prostaglandin, foley bulb, oxytocin, amniotomy
c sectin
bed rest expectant mgmt( inpatient) -> 37 wks
Magnesium PPx(4g load w/ 1/hr)-> 12-24hrs postpartum
92
Severe preeclampsia Tx
control maternal BP - hydralazine(direct dialator) or lobetalol (alpha and beta blocker)
deliver fetus - 32 wh goal
magnesium for seizure ppx
93
Lower subsequent risk of preeclampsia w/
asprin
| 25-33% risk
94
Eclampsia
grand mal siezure in preeclamptic pts
- w or w/o aura- 15% before labor, 50% during, 25% after
can occur w/o proteinuria
deliver after seizures controlled and mom's stable
95
overdose on magnesium Tx?
>10mg/mL
| give calcium chloride or calcium
96
Chronic HTN in pregnancy
HTN before conception, <20 wks, or persist 6 wks post part - vs Gestatational HTN in 3rd tri
fetus may have IUGR, risk of preeclampsia, prematurity, abruption
get baseline ECG and 24 urine protein/Cr
97
Tx of HTN in pregnancy
elv BP >140/90
use labetalol - beta blocker w/ alpha blockage
nifedipine- peripheral CCB
Methyldopa - central alpha 2 adrenergic agonist (not as good)
can have preeclampsia superimposed, 1/3 of Pts, (+30/15 increase over baseline BP) proteinuria
- elv uric acid of 6-6.5
98
Seizure algorythim in eclampsia
Assess ABCs
10g IM of Mg load
IV benzo - midazolam may break seizure
99
Gestational HTN
HTN after 20 wks in the absence go proteinuria and returns to normal post partum
25% of HG -> preeclampsia
100
GDM
| - hormone?
impaired carb metabolism during pregnancy
- human chorionic somatomammotropin (human placental lactogen) and other hormones by placenta are anti-insulin agents - more in 2nd-3rd trimester
beta cell hypertrophy in 1st half of pregnancy
101
Risk of congenital anomalies in GDM vs pre gestational DM
less in GDM since not apparent till 2-3rd trip
still have neonatal hypocalcemia, hypocalcemia, hyper bill, and policy
4-10x increase in T2DM
102
Risks for GDM
AMA, obesity, family Hx of DM, previous infant of 4000g, stillborn HX
Ethnicity +/-
103
Screen for GDM @
24-28 wks in low risk
1st prenatal visit if risk for T2DM
50g glucose load - 1hr < 140
+ f/u with GTT (glucose tolerance test): 100g after 8 hr fast and 3 day special carb dietand 3hrs and measure qhr. >2 elv ->GDM,
-3h-145; 2h-165; 1hr-190; fast-105
104
GDM Class A1, A2, B, C, D, F, RF, H, T
```
A1- GDM w/ diet control
A2- GDM w/insulin
B - Onset age> 20s and dur20y
D - Onset 20y
F- Diabet nephropathy
R Proliferative retinopathy
RF- retinopathy, nephropathy
H - ischemic heart diesase
T-Renal transplant
```
105
Postprandial glucose goals in GDM
25-20% are elv need insulin or oral hypoglycemics
106
Induce labor in GDM PTs at?
39 wks if A2 GDM
concern for hypoglycemia towards end of pregnancy- dextrose and insulin drips maintain
107
Risk of GDM subsequent pregnancies
50% risk GDM
| 25-35% risk T@DM, screen at post part and annually
108
Maternal complications of DM
polyhydraminos, preeclampsia(4x), miscarriage(2x), infection, postpartum, C section, Hypoglycemia, j=ketoacidosis, diabetic coma, cardiac/renal/opthalmic/peripheral vascular, peripheral neuropathy and GI disturbacnce
109
fetal complications of DM
dramatic delivery, shoulder dystocia, erb palsy, delayed growth go pulm, hepatic, neurologic, PT axis, congenital malformed: cardiovasc, neural tube(4g of folate), caudal regression, situs inverts, duplex renal ureter, IUGR, death
110
Labs for pregestational DM pregnancy
A1c, ECG, 24hr urine (Cr and protein), TSH/free T4, ophthalmologist apt
weekly NSts at 32-36 wks, BPP 2x, IS for fetal growth
111
insulin control in labor
have dextrose and insulin running to maintain glucose between 100-120
112
UTI in pregnancy
common - 20%; 2-11% have ASB
asymptomatic bacteriuria(>100,000 colonies) in early reg are 20-30x likely to developing into pylo
progesterone -> smooth muscle relaxation and less bladder tone and arterial and pelvis dilation and less peristalsis
113
cystitis
urinary urgency, frequency, dysuria, suprpubic discomfor and NO fever and CVA
+/- gross hematuria
Tx if quant culture >100,000 CFU
114
UTI bugs and tx
E coli, klebsiella, proteus, Staph, GBS and enteroccos
amoxicillin, nitrofurantoin, trimethoprim and sulfamthoxazole, cephalexin
- Phenazopyridine (pyridium) - orange pee
3- 7 days, w/ test to cure 1-2 weeks after
115
Plyelonephritis concerns if
fever, chills, flank pain, N/V, CVA, pyuria, WBC casts
116
Pyelonephritis risks in pregnacy
preterm labor, septic shock, ARDS(hypoxemia, dyspnea, tachypnea, pulm edema),
20% -> multiorgan 2/2 endotoxemia, increase capillary permeability and decreased vital organ perfusion
117
Tx of pyelonephritis in pregnancy
hospital Admission
IV hydration
IV ABx until 48 hrs afebrile - cefazolin, cefotetan, ceftriaxone, ampicillan w/ gentamycin,
Tx 10-14 days IV and oral
PPx Abx if 2+ recurrences
118
Bacterial vaginosis increases risk of?
increase PPROM, preterm delivery, puerperal infections(chorioamnionitis, endometritis)
Thus treat is symptomatic, do not need to screen
119
Dx of Bacterial vaginosis
malodorous d/c; vaginal ittitation; asymptomatic?;
Need 2/4: thin, white grey homogenous d/c coating vaginal walls; amine/fishy odor w/ 10% KOH added; pH > 4.5; presence of >20% clue cells
Gardenella vaginosis, bacteriodes, mycoplasma hominis
120
Tx BV w/
oral metronidazole (flagyl) for 1 week. Clinda (oral) for 1 wk is an option
121
GBS causes?
UTIs, chorioamnionitis, endomyometritis
| -> neonatal sepsis and mortality depending on GA
122
Screen for GBS at
35-37wks using a rectovaginal swab/culture
123
Tx of GBS
+ GBS cultures and GBS bacteriuria are Tx w/ IV penicillin G at time of labor or ROM
Unknown GBS status and labor 18 hrs Tx
Allergy to penicillin = cefazolin (Ancef) if low risk, High anaphylaxis risk use clindamycin
124
Chorioamnionitis:
infection of membranes and amniotic fluid
Associated w/ preterm and prolonged ROM
0. 5-10% of pregnancies
- > most common cause of neonatal sepsis (also resp distress, pneumonia, meningitis, periventricular leukomalacia, cerebral palsy)
uterine atony, postpart hemorrgage, C section, septic shock
125
Dx of chorioamnionitis
Need high suspicion
Maternal temp >100.4 (38). WBC. 15,000, uterine tenderness, tachycardia maternal/fetal, foul amniotic fluid smell
gold standard is culture, can also get glucose, WBC, protein, gram stain
126
Tx of choriamnionitis -
IV Abx and delivery of fetus
Broad spectrum - 2nd-3rd gen cephalosporin, or amp/genta; given intrapartum
127
HSV + pregnancy concerns
75% can expect at least one outbreak/recurrence, 14% have prodromal symptoms
c section if active lesion on labor, but not 100%; not indicates if Hc and active of lesions or prodromal symptoms
128
Testing for HSV
viral detection - Viral DNA in culture and HSV antigen PCR; negative does NOT r/o
antibody detection- antibodies to HSV1 or HSV2; especially HSV2
129
Tx of HSV w/ initial outbreak goals
Type
- acyclovir or valcyclovir
Used to recuce duration and severity of symptoms and reduce duration of training
offered acyclovir PPX from wk 36 until delivery if outbreak in pregnancy
130
HSV risk to neonate
exposed in vaginal tract - rare in utero and postnatal. 80% infected from mom's reporting no Hx of HSV
herpatic lesions, oropharynx or eyes.
Classified as: disseminated, CNS, limited to skin, eyes or mouth
-> viral sepsis, pneumonia, herpes encephalitis
131
varicella zoster
incubation 10-20 days, spread via close contact or respiratory droplets, infection 48 hrs before rash and lasts until crusting
VZV pneumonia in pregnancy, overall uncommon
Preconception should be given vaccine, contraindicated in pregnancy
132
Varicella in pregnancy
vertical transmission concern transplacentally, 1% fetal anomalies in 1st tri,
-Congenital varicella syndrome predominately in mothers infected between 8 and 20 wks: Skin scarring, limb hypoplasia, chorioretinitis and microcephaly
No increase of SAB.
133
Tx of Varicella near birth
infants of mom's with outbreaks 5 days before or 2 days after birth should get VZIG +/- treatment w/ antivirals
Tx susceptable mom's exposed w/in 72-96 hrs w/ VZIGor oral acyclovir/valcyclovir
134
Parvovirus B19 in pregnancy
DNA virus -> erythema infectiosum (5th disease)
respiratory droplets and infected blood- incubates 1--20 days
concern for maternal-fetal transmission -> infection and death. 1st tri- miscarriage but later -> fetal hydrops (5-1% decreasing
--> Virus attaches to anitgen on RBS stem cells -> suppression of erythropoesis (anemia and High output CHF)
135
Erythema infectiosum symptoms
low grade fever, malaise, myalgia, arthralgia, re macular "slapped cheeks". Erythematous, lace like rash onto torso and upper extremities
transient aplastic crisis
136
Test for Parvo b19 in moms
look for IgM for concerns of initial infection. if both IgG and IgM negative, susceptible
IgM (+/- IgG) - beyond 20 wks get serial US up to 8-10wks post infection. Doppler velocimetry to examine peak systolic flow in MCA (increase suspect anemia) get cordocentesis if positive and possible intrauterine transfusion
137
CMV
DNA herpes virus family (50-80% have had in past, but not protective)
- close contact needed: blood, sex, urine/saliva contact
- Vertical transmission w/ transplacental - genital, breastfeeding - any trimester, fatal > in 1st tri
Incubates 28-60days, subclinic, mild viral illness usually, rarely hepatitis or mono
Ultimately latent in cells
138
ID congenital CMV w/
ID in amniotic fluid by culture or PCR
US = microcephaly, ventriculomegaly, intercerebral calcification, fetal hydrops, growth restriction, oligohydraminos
fetal heart block , echogenic bowel, meconium peritonitis, renal dysplasia, ascots, pleural effusions
1-2% makes most common
139
Symptoms in congenital CMV
hearinglloss, cytomegalic inclusion disease -> hepatomegaly, splenomegalu, thrombocytopenia, jaundice, cerebral calcifications, chorioretinitis, interstitial pneumonitis
severe- hepatitis, 30% die and 80% survive w/ severe neuromuscular disorders
No Tx or propylaxiss
140
Reubella(german measles)
RNA virus -
Adults -> mild illness w/ widely disse,imated nonpurititic erythematous maculopapular rash, arthritis, arthralgias, diffuse LAD lasting 3-5 days
post auricular LAD and conjunctivas common
141
Congenital reubella infection
4 symptoms
may lead to congenital rubella syndrome
-virus crosses the placenta by hematogenous spread, before exposure 12wks gestation bad
deafness, eye defects (cataracts/retinopathy), CNS defects, cardiac abnormalities (patent ductus arteriosus, suprapvalvular pulm stenosis)
also: microceph, IUGR, hepatosplenomeg, hemolytic anemia, thrombocyto
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Diagnosis of maternal reubella
IgM for primary and reinfection. IgG elvated over time also supports
Fetal blood through cordocentesis technically dif <20wks, chorionic villi, amniotic samples as well forPCR antigen
No Tx
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MMR and pregnancy
wait 1 month before getting preganant
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Tx of chlamydia in pregnancy
NOT doxy or tetracycline
Use azithromycin, amoxicillin or erythromycin
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GC/Chlam n preg screening
everyone 1st and repeat 3rd if risk
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HIV C section viral load
>1000 get a c section, less than 1000 no difference than vaginal
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Untreated gonorrhea in neonates concern w/
corneal scaring, oropharynx infeciton, external eat anorectal mucosa
-> arthritis, meningitis and blindness
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Repeast testing after cure in?
GC/chlam in 3 wks
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Testing for syphilis in pregnancy
Screen w/ VRDL or RPR
confirm w/ FTA-ABS or TP-PA
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Tx of syphillis if allergic
desensitization because it is the best
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Congenital infection of syphillis
can occur as early as 6 wks
early - late abortion, preterm delivery,
2/3 asympotmatic at birth-> maculopapular rash, LAD, snuffles, hepatosplenomegaly, hemolysis, LAD, jaundice, pseudo paralysis of Prrot
ID IgM antitreponemal Ans
LAte congenital - saber shins, mulberry molars, Hutchinsons teeth, saddle nose, neuro defects
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Congenital toxo infection -
fevers, seizures, chorioretinitis, hydro/microcephaly, hepatosplenomegalu
Disseminated pupuritic rash, uveitis, periventricular calcifications
Lack og IgM does not r/o infection, also IgM lasts awhile and may not be active, need amniocentesis w. DNA PCR
Tx - Spiramycin
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Hyperemesis gravidum
persistent vomiting _> 5% pre pregnancy body weight and ketonuria
common in molar pregnancies
-> hypochloremic alkalosis gibve IV hydration
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Morning sickness
common - 88% of pregnancies (elv b HCG, thyroid, gut hormones)
Resolve by week 16
small frequent meals to prevent hypoglycemia to help
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Tx of hyperemesis gravidarum
antiemetics - Phenergan 1st, then Reglan, compassion, tigon. Droperidol and zofran also option
Vit B6 and doxylamine
Ginger w/B12
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Seizure disorders in preg
risk - miscarriage, prenatal death and increased seizures(more estrogen and increased P450 activity, increased renal function
Change in volume distribution of drug and lower adherence
Switch to mono therapy prior to conception and later down
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Antiepileptics in pregnancy effects
Phenytoin, phenobarbitol, primidone -> all folate antagonists (Give folate)
valproate, carbamexapine, trimethadione
cleft lips, cardiac anomalies, neural tube defects, abnormal EEG, developmental delay, lower IQ, microcephaly, low set ears, short nose, long philtrum. ptosis, IUGR
Higher risk of spntaneous hemorrhage - inhibition of Vit K clot factors (II, VII, IX, X) aggressive Vit K sup at end of pegancy
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Siezure med f/u in pregnancy
Level II fetal survey at 19-20wks
alpha fetoprotein (MSAFP)
Amniocentesis if FHx of NTDs or w/ valproc acid or carbamezapine
total and free leels of AED monthly
Supplement oral Vit K 10mg qD at 37 wks
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Drug of choice if known seizure PT is delivering and seizing
Phenytoin instead of Mg
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Maternal cardiac disease and pregnancy
50% increase in blood volume, decrease in vascular resistance and increase in stroke volume and remodeling of myocardium to accomifate
Primary pulm HTN, Eisenmenger physiology, severe mitral/aortic stenosis, marfans at higher risk
post partum changes dangerous - increase venous return and uterus clamps and demands less circulation
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Cardiac drugs contraindicated in pregnancy
ACE inhibitors, diuretics, warfarin
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Eisenmenger and Pulm HTN in pregnancy
PDAs, VSD which have reversed biggest risk
-> increased flow -> scar formation and pulm cap destruction
encouraged to terminate 2/2 chronic hypoxia, follow w/ serial echo, c section if continued, risk 2-4wks post partum
163
Marfan and pregnancy
concern of aortic dissection/rupture give beta blockers and encourage sedentary life
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peripartum caridomyopathy
HF 2/2 pregnancy. usually baseline cardiomyopathy exacerbated, EF
165
Maternal renal disease
mild Cr2.8
- in general increase CR clearance in pregnancy w/o disease; mod-severe face increased risk of dialysis
preeclampsia, preterm delivery IUGR
Screen once/trimester w/ 24 Cr:Protein
166
Coag disorders in pregnancy
hypercoaguable in general
higher risk of DVT and Pulm embolism
Thought to be 2/2 increase of all clotting factors except II, V, and IX. Fibrinogen turn around time decreased. increased fibrinopeptide A. Placenta may secrete factor that decreases fibrinolysis. Increases exposure to sub endothelial collagen. Venous stasis (less tone and uterus compresses IVC, iliac and pelvic
167
Superficial vin thrombosis in pregnancy
painful complication, unlikely 2/2 emboli
- obvious, palpable and visible venous cord that is tender w/ erythema and edema
Not Tx other than warm compresses and analgesics
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DVTs in pregnancy
unilateral lower extremity pain and swelling
Edema, local erythema, tenderness, venous dissension and palpable cord underlying
-> get doppler, venography Gold standard but rare
Tx: adjusted LMWH (less HIT) or unfractionated heparin (PTT of 1.5-2.5)
NO warfarin (nasal hypoplasia and skeletal abnormalities, CNS abnormalitis (optic atrophy_
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Pulm Embolus in pregnancy Dx
Pulm HTN, hypoxia, Right sided heart failure and death
Acute SOB, onset of pleuritic chest pain, hemoptysis, tachycardia and DVT signs
CXR may be normal, can see: abrupt term of vessel, area of radiolucency in region beyond PE
ECG may be normal or sinus tachy occasional R heart strain, nonspecific ST change, peaked T
Spiral CT most common in preg/nonpregnant, risk weighed with health of mom
Pulm Angio is gold standard
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Tx of PE in pregnancy
LMW heparin - enoxaprin
If hypotensive/unstable IV heparin
Massive PE and unstable - streptokinase for thrombolysis - 6 months and check PTT/INR
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Most common cause of hyperthyroidism is?
MGMT?
Graves
Propylthiouracil (decreases peripheral conversion to T3) or methimazole - decreases production of T4 (PTU 1st, MMI 2nd and 3rd)
Check thyroid stimulating immunoglobulins - elv -> fetus at risk for fetal goiter, and survey at 18-20wks and US in 3rd tri
TSH closer 0.5 vs 2.5
Antenatal test w/ serial NSTs also
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Changes in thyroid mgmt in pregnancy
increase in thyroid binding globulin and total T3 and T4 but no change in free T3 and T4
increased metabolic demand in pregnancy -> TSH and FT4 monitored q6-8 wks
173
Hypothyroidism in pregnancy
most commonly 2/2 hashimotos and 2nd is ablation
increase levothyroxine 25-30%
TSH kept low normal
174
SLE in pregnancy
Higher risk of preeclampsia, IUGR(thrombosed placenta in 3rd tri), preterm delivery
1/3 improve, 1/3 stay same, 1/3 get worse
ASA and corticosteroids continued, STOP cyclophosphamide and methotrexate
175
Lupus flare vs preeclampsia
both have circulating antigen-antibody complexes or tissue specific antibodies -> vasculitis
Check complement levels, C3 and C4 reduced in lupus as well as active urine sediment
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neonatal lupus
2 complicaitons
- maternal antigen-antibody complexes that cross the placenta -> lupus; severe flares
- Irreversible congenital heart block. (also Sjogrens) produce anti Ro and La that affect fetal conduction and damage AV node
Tx: corticosteriods, plasmapheresis, IVIG
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Alcohol in pregnancy
FAS - spectrum of increasing severity w/ 2-5drinks/day
Growth retardation, CNS effects, abnormal facies in 1/2000
Cardiac defects are particularly associated
Barbs for withdrawal concerns given benzo teratogen
178
Caffeine in pregnancy
teratogenic at high levels in rat studies, not seen in humans
Higher risk of 1st and 2nd tri miscarriages w/ >150mg/day caffeine (cup of coffee is 150mg)
179
Cigarettes in pregnancy
increased risk of SAB, preterm births, abrupt placentae and decreased birth weight
increased risk for SIDS and resp illness
180
Cocaine in pregnancy
risk of abrupt placentae, IUGR, increased preterm labor and delivery 2/2 vasoconstriction and HTN
Risk CNS complications and dev delay
Tx: detox
181
Opiates in pregnancy
Oxycodone, heroin and methadone
No known teratogenic effects but withdrawal is a concern: miscarriage, preterm delivery, fetal death
methadone clinic preferred vs quiting
Buprennorphine (Suboxone) may be better
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leading cause of maternal death
PE
