Part 3 Flashcards
(137 cards)
1
Q
When can you defer WinRho?
A
Spotting 2 weeks after WinRho administration
2
Q
Changes with HRT to lipids?
A
- High triglycerides (bad)
- Increased HDL and decreased LDL (good)
3
Q
Treatment for PMDD?
A
Mild symptoms = supportive, exercise, vitamins
Moderate sympmtoms
1. SSRI (first line if not desiring contraception)
2. OCP or GnRH agonist (may also require SSRI)
4
Q
Medications causing galactorrhea
A
Maxeran (high risk), many antipsychotics, SSRIs, antihypertensives (methyldopa, verapamil), methadone
5
Q
Most common cause of chromosomal abnormality of RPL?
A
Balanced/reciprocal translocation
6
Q
Collateral blood supply to the uterus after internal iliac artery ligation
A
Lumbar artery
7
Q
Most common bacterial cause of postpartum mastitis?
A
Staph aureus
8
Q
Previous PPH and secondary amenorrhea - MRI finding?
A
Empty sella
9
Q
Other name for hemabate?
A
Carboprost / 15-methyl PGF2-alpha
10
Q
What is the mechanism of action for polyhydramnios?
A
- Not swallowing (neurologic or upper GI obstruction)
2. Peeing too much
11
Q
Oomphalocele is associated with what 3 things? (if it is not an isolated finding)
A
- Aneuploidy
- Cardiac defects
- Increased AFP
12
Q
Most common cardiac lesion with Turners?
A
Bicuspid aortic valve
13
Q
Most common identifiable cause of fetal demise?
A
Abruption
14
Q
How to deliver:
A) Brow
B) Face - mentum anterior and mantum posterior
A
A) C/S (due to risk of c-spine injury)
B) Mentum anterior - SVD
Mentum posterior - C/S (gets caught on coccyx)
15
Q
Embryonic origin of the vagina?
A
Upper - paramesonephric ducts
Lower - urogenital sinus
16
Q
Ducts forming embryonic structures (memory aids)
A
Mesonephric ducts = Wolfian (wolf -> men)
Paramesonephric ducts = uterus (P=pregnant -> uterus, P=pink -> girls)
17
Q
What SSRI is teratogenic?
A
Paroxetine (P = bad in Pregnancy)
18
Q
Work-up for POI
A
- Adrenal antibodies
- Thyroid
- FSH/LH/estradiol
- Karyotype
- FMR-1 gene mutation
- Imaging
- Bone mineral density
19
Q
Treatment for day 4 of a recurrent HSV outbreak
A
Topical lidocaine
20
Q
Anti-epileptic medications with lowest risk of teratogenicity (2)
A
Lamotrigine + Levetiracetam (Keppra)
21
Q
Delayed cord clamping in preterm infants prevents what?
A
- Anemia / transfusions
- IVH
- NEC
22
Q
What has the best evidence to prevent PPH after SVD (and dose)?
A
Oxytocin 10u IM
23
Q
26 weeks with no FM after accident, first move?
A
Assess FHR
24
Q
What decreases risk of incomplete TA at 18 weeks?
A
Dilating to 19 weeks with Hegar
25
Benefits of diagnosing vasa previa antenatally?
- Decreased neonatal transfusions
| - Decreased neonatal mortality
26
Cardiac arrest, when do you do a perimortem C/S?
At 4 minutes
27
What is the risk of stillbirth after previous stillbirth?
5-10x higher (OR 5.5)
28
What factor is the most predictive of successful ECV?
```
#1 Complete vs. incomplete breech
#2 Amniotic fluid
```
29
What is the most important factor contributing to an AIDS defining illness?
CD4 Count
30
What are the risks of indomethacin?
>30 weeks = premature closure of the PDA, oligohydramnios, IVH
31
Route of oxygenated blood to fetal brain
Umbilical vein -> ductus venosus -> foramen ovale -> brain
32
Nerve root of sensation to uterus
T10
33
Shunt in fetus with most oxygenated blood?
Ductus venosus
34
Pulmonary edema is caused by which OB drug? Why?
Nifedipine -> calcium channel blocker -> negative inotrope -> increased preload = pulmonary edema
35
Childhood manifestations after being an IUGR baby
Overweight & T2DM
36
Mode/timing of delivery for previa?
1. Previa
a) risk factors - 36+0 to 36+6
b) no risk factors - 37+0 to 37+6
2. Low-lying placenta
a) placental edge <1cm from os
i. risk factors - CS at 37+0 to 37+6
ii. no risk factors - CS at 38+0 to 38+6
b) placental edge >1cm from os
- trial of labour
- CS at 39+0 to 40+6 per maternal request
37
Management of vasa previa
- serial TVUS (15% will regress)
- goal of pre-labour pre-ROM CS
- if PVB/ROM -> to BU for EFM, +/- test for fetal blood -> CS if abnormal
- hospitalization (consider at 30-32 weeks)
- steroids (at 28-32 weeks for all)
- place of delivery (chart note, have O- irradiated blood ready for baby)
- timing: 35-36 weeks
38
What is the cutoff value of CPR and why is it significant?
- CPR <1
- late onset IUGR (>34wks)
- increased risk of IUFD
39
When to deliver based on Dopplers?
AEDF = 34 weeks
REDF = 30 weeks
Reversed a wave = 26 weeks
40
Risk factors for PAS disorders? (8)
- Age >35
- IVF
- Previa
- Prior C/S
- Previous uterine surgery (hysteroscopy, D&C)
- Myomectomy
- Fibroid embolization
- Intrauterine adhesions
41
Who gets ASA?
```
one of:
- hx PET
- twins
- chronic HTN
- renal disease
- SLE, APLAS
- DM1 or 2
2 of: nulliparity, obesity, low SES, age >35, fam hx PET, personal hx RF (prev SGA, adverse outcome, pregnancy interval >10yrs)
```
42
Risk factors for placenta previa? (9)
- AMA
- Multiparity
- Previous CS
- Previous placenta previa
- Chronic HTN
- DM
- Smoking / cocaine
- Multiple gestation
- ART
43
Risk factors for vasa previa? (9)
- Velementous cord insertion (pre-req)
- Bilobed placenta
- Succenturiate lobe
- IVF
- T2 placenta previa
- Anomalies
- Prematurity
- APH
- IUGR
44
Timing of delivery with PAS disorder?
- 34-36 weeks
- want controlled elective surgery
- remember steroids if <34+6
45
Risk of recurrence of PAS?
Overall 17-29%
46
Risk of PAS if previa & __ CS (1-4)
```
1 CS - 11%
2 CS - 40%
3 CS - 61%
4 CS - 67%
5+ CS - 67%
```
Elective CS guideline table
47
Risk of leaving placenta in situ and PAS
Infection (50%)
Emergency hysterectomy (50%)
Bleeding
Coagulopathy
48
What is the progression of least bad to worst fetal findings for IUFD?
```
Low growth
Early redistribution
Minimal growth
Abnormal umbilical artery doppler
Low AFI
Abnormal venous doppler
Abnormal FHR
IUFD
```
49
Management of early CS ectopic (i.e. early PAS)
Type 1 can be managed expectantly KCl into embryo
IM methotrexate = wait 2-3 days
Hysteroscopic resection +/- laparoscopy
50
Definition of placenta previa and low-lying placenta
```
Previa = placenta lies directly over cervix
Low-lying = placenta is within 2cm of cervical os
```
51
What type/location of placenta previa is most likely to resolve?
Anterior
52
What percent of previa will resolve by term if diagnosed in T2?
90-98%
53
How to confirm previa diagnosis
Ultrasound >32 weeks
54
When to hospitalize a placenta previa
Risk factors or remote location / lack of access
55
When to give steroids with a previa
Only if risk of delivery within 7 days (1 of 8 risk factors at <34+6)
56
When to make final diagnosis of placenta previa
If no risk factors and degree of cervical overlap minimal -> wait until repeat US at 36 weeks
57
Risk factors in the presence of a previa for APH? (6)
- History of APH (first episode <29 weeks, recurrent 3+)
- Thick placenta edge (>1cm)
- Marginal sinus
- Short cervical length (<3cm with previa, <2cm if low-lying)
- Previous CS
- Evidence of invasive placentation
58
HIV drugs teratogenic or contraindicated?
Ribavirin
Efavirenz (NTD in T1)
Nevirapine (SJS and hepatotoxicity)
*Don't stop drugs if patient is stable on them
59
Treatment for toxoplasmosis?
- If in mom / placenta only
- If confirmed in fetus
Mom / placenta: spiramycin 1g q8h PO (for duration of pregnancy)
Fetus: Pyrimethamin PO daily + sulfadiazine 75mg/kg PO then 50mg/kg PO q12h + folinic acid
60
Percent of women with parvovirus who will have an infected fetus
30%
61
Percent of fetuses with parvovirus that will develop anemia
1%
62
When to test for Zika?
2-3 weeks after last exposure (including unprotected intercourse)
63
Toxoplasmosis IgG+ and IgM+ next step?
- Repeat testing in 2-3 weeks to confirm or rule out false +
| - Diagnosis confirmed if 4-fold increase in titre (IgG)
64
When you repeat a toxoplasmosis serology you send it to who? What result confirms infection?
- Send to reference lab
| - 4 fold increase in titre
65
GBS prophylaxis treatment? Penicillin allergy?
- Pen G 5 million units IV, then 2.5 million units IV q4
- Allergy non-anaphylactic: Ancef 2g IV x1, then 1g q8h
- Anaphylactic: susceptibilities! Either clinda 900mg IV q8h or vanco 1g IV q12h
66
Risk of vertical transmission for Hep C is directly related to what? Other risks?
Related to viral load
| Other risk is co-HIV infection
67
Risk of vertical transmission of HIV
a) baseline
b) with PNC and ART
c) in Canada with at least 4 weeks of ART
d) overall with ART and no breastfeeding
a) 25%
b) <2%
c) 0.4%
d) <1%
68
What percent of maternal infection of CMV transfer to the baby?
30-40%
69
What percent of babies infected with CMV develop sequelae?
25%
70
What percent of babies infected with CMV will have US findings?
25%
71
Contraindications to vaccines (3)
1. Anaphylaxis to vaccine or components
2. Severe uncontrolled asthma
3. Hx of Guillan-Barre within 6 months of getting the vaccine previously
72
How long after acute toxoplasmosis infection should you wait to conceive?
6 months
73
Risk of Hep B vertical transmission with amniocentesis
| with and without Hep e antigen
1.4% without e antigen
| Up to 16% with e antigen
74
When and what Hep B prophylaxis is used in pregnancy
If HBV DNA >10^6 copies or 200,000 IU/ml start at 26-32 weeks
Tenofovir 300mg PO daily
75
Diffuse red raised patching rash on pregnant woman
Rubella
76
What is the treatment for syphilis?
Benzathine penicillin G
77
What reaction can pregnant women get with syphilis treatment?
Jarisch-Herxsheimer (causes contractions and fever)
78
When to do an amniocentesis for rubella
At least 6 weeks post-infection and after 20 weeks gestation
79
When to do an amniocentesis for CMV
7 weeks post infection and 21 weeks
| 7x3 = 21, 3 letters in CMV
80
CMV ultrasound findings
- IUGR
- Microcephaly
- Intracranial calcifications
- Hydrops
- Echogenic bowel
- Placentamegaly
- IUFD
- Hepatic calcifications
81
What do you do about varicella exposure in pregnancy?
VZIG!
- within 96 hours
- 125u/10kg IM
- need to get consent
82
Neonatal findings of CMV?
- IUGR
- Microcephaly
- Hepatosplenomegaly
- Petechiae
- Jaundice
- Anemia
- Sensorineural hearing loss*
- Visual impairment
- Developmental delay
83
When do you give GBS prophylaxis (7)
- GBS+
- Previous infant affected by GBS sepsis
- Current pregnancy GBS+ in urine (regardless of CFU)
- <37 weeks in labour (unless known GBS-)
- <37 weeks PPROM (at least 48hrs unless known GBS-)
- Intrapartum fever/chorio (regardless of GBS status)
- >37 weeks with ROM >18hrs and GBS unknown
84
Neonatal sequelae of rubella (6)
- IUGR
- Microcephaly
- Sensorineural hearing loss
- Eye abnormalities (cataracts, glaucoma)
- Cardiac abnormalities (PDA/PS)
- Neurologic sequelae (developmental delay)
85
Ddx for echogenic bowel
- Normal variant
- Aneuploidy
- IUGR
- APH
- CF
- Bowel obstruction
- CMV or toxoplasmosis
86
Treatment for listeria in pregnancy
- Culture (if fever)
| - IV ampicillin (erythromycin or vancomycin if allergy)
87
Sources of listeria in pregnancy?
- Deli meats
- Unpasteurized cheese/dairy
- Pate
- Undercooked meat
88
HSV treatment (2 options for each)
a) Initial episode
b) Recurrent
c) Suppressive
a) Acyclovir 400mg TID x10d OR Valacyclovir 1g BID x10d
b) Acyclovir 800mg TID x2d OR Valacyclovir 1g daily x3d
c) Acyclovir 400mg TID OR Valacyclovir 500mg BID from 36 weeks until delivery
89
Treatment of known or suspected influenza in pregnancy
Tamiflu 75mg PO BID (ideally within 72hrs of symptom onset)
90
Screening and diagnostic testing for syphilis
```
Screening = VDRL (non-treponemal)
Diagnostic = Treponemal or dark field microscopy direct visualization
```
91
Symptoms of primary, secondary, early and late latent syphilis
Primary = chancre, papule, lymphadenopathy
Secondary = 6wks to 6 months, flu-like symptoms, rash on palms/soles, condylomata lata
Early latent = asymptomatic
Late latent = neuro, cardiac, or skin (gumma)
92
Findings of congenital syphilis
- IUFD
- IUGR
- Snuffles (rhinitis)
- Mulberry molars
- Hutchinson's teeth
- Saber shins (bowing of tibia)
93
Neonatal sequelae of listeria
- IUFD
- PPROM
- TPTL
- Abnormal FHR
94
Neonatal mortality (%) and morbidity with HSV infection
Mortality 60%
| Morbidity = microcephaly, microopthalmia, intracranial calcifications, chorioretinitis
95
What should you avoid in labour for a patient with HIV?
- FSE
- IUPC
- Scalp lactates/pH
- Prolonged ARM/SRM
- Operative delivery
- Episiotomy
- Ergot (worsens vasoconstriction with protease inhibitors)
96
HIV prophylaxis in labour? When do you start?
Zidovudine 2mg/kg/hr bolus, then 1mg/kg/hr until delivery
If no cART, can use nevirapine 200mg POx1
Start if...active labour, SRM, 2-3hrs pre-C/S
97
Mode of delivery with HIV?
```
Trial of VD if viral load <1000 within 4 weeks of delivery
C/S at 38-39 weeks if...
> no cART
> monotherapy with zidovudine
> viral load >1000
> unknown viral load
```
98
Antenatal risks of HIV (3)
- IUGR/SGA
- Oligohydramnios
- Preterm birth
99
Antenatal care for HIV in the first trimester
- Dating US
- MSS + NT (less risk for invasive testing)
- 1mg folic acid
- Labs: toxo, CMV, syphilis, Hep A/B/C, rubella, varicella
- Aggressive management of N/V
- Harm reduction
100
Antenatal care for HIV in the second trimester
- Part 2 MSS
- Routine anatomy US
- NIPT preferred over invasive testing
- CD4, viral load, LFTs, renal function
- Labs q4-8 weeks and 6 weeks PP
101
Antenatal care for HIV in the third trimester
- US q4wks for fluid/growth
- Risk of PTB (consider early GBS and HSV prophylaxis)
- Make formula feeding plan
102
Nausea/vomiting with HIV cART
- STOP all cART at once
| - Resume all at once once N/V resolved
103
Blueberry muffin baby?
Rubella
104
Congenital cataracts?
Rubella
105
Infectious causes of microcephaly (6)
- Zika
- CMV
- Toxoplasmosis
- Rubella
- HSV
- HIV
106
Avoid pregnancy for how many weeks post Zika-related travel? Protected intercourse for how many weeks?
Avoid pregnancy >3 months
| Protected intercourse for duration of pregnancy
107
Exposures for toxoplasmosis (4)
- Raw meat
- Water
- Animals (cats)
- Northern communities
108
Lots of black holes in head on US?
Toxoplasmosis
109
U/S findings with toxoplasmosis (6)
- Intracranial calcifications
- Ventriculomegaly
- Microcephaly
- IUGR
- IUFD
- Abnormal placenta
110
When do you give Tdap?
All pregnancies, ideally 21-32 weeks
111
Which infections require avidity testing? What does it mean?
- Toxo, CMV, Rubella
- Low avidity = more recent infection <3 months
- High avidity = more remote infection >5 months
112
Slap check / erythema infectiosum / fifths disease
Parvovirus B19
113
Fetal consequences of Parvovirus? How do you monitor?
Anemia - need MCA dopplers for 12 weeks
114
TORCH in general: early infection vs late infection risks
```
Early = lower vertical transmission but worse consequences
Late = higher vertical transmission but lower consequences
```
115
a) IgM - and IgG -
b) IgM - and IgG +
c) IgM + and IgG +
d) IgM + and IgG -
a) no evidence of infection, susceptible
b) past infection or immunization
c) possible primary infection
d) possible primary infection or false positive
116
How long to wait post-live vaccine to get pregnant
4 weeks (28 days)
117
What do you give a baby with a Hep B+ mom?
HBIG 0.5ml x3 doses (passive immunity)
Hep B vaccine (active immunity)
- Give within 12 hours, then complete vaccine series
118
Listeria symptoms
Nausea, vomiting, diarrhea, fever, myalgias
119
Treatment of CMV
No treatment
120
Investigations for echogenic bowel?
- MSS
- Genetic sonogram
- Amnio -> RAD
- NIPT
- CF testing
- TORCH screen
121
What infection is associated with Hutchinson's teeth and Mulberry molars?
Congenital syphilis
122
What is the risk of HSV transmission
a) Primary infection
b) Recurrent infection
c) Asymptomatic with positive history
a) 30-40%
b) 3-4%
c) 0.03-0.04%
“HSV is rules of 3”
123
Most common congenital infection?
CMV
124
Symptoms of CMV
Mono-like symptoms (fever, myalgias)
| Most commonly asymptomatic
125
Maternal risks of varicella
Pneumonia, death
126
What percent of congenitally infected infants with CMV will have symptoms at birth?
10-15%
127
What percent of infants infected with CMV who are asymptomatic at birth will develop symptoms? What will these symptoms be?
5-15%
| Deafness, psychomotor delay, blindness
128
What is the rate of asymptomatic shedding with HSV?
3% in the first year, 1% in the next 2 years
129
Mode of delivery for active HSV?
C/S if...
> Within 4 hours of ROM
> No benefit if imminent delivery
> Protective effect lost if prolonged ROM
If PPROM, suppression until delivery
130
When do you treat asymptomatic bacteruria in pregnancy?
If >100,000 CFU/hpf of any bacteria
131
What are maternal and perinatal risks of bacteriuria in pregnancy?
- Pyelonephritis
- LBW
- PTB
- Chorioamnionitis (GBS)
132
Treating asymptomatic bacteruria in pregnant woman decreases the risk of what?
Pyelonephritis and LBW
133
When do you do an amniocentesis for toxoplasmosis?
4 weeks post-infection and at least 18 weeks GA
| 4 letters in toxo = 4 weeks, 8 looks like two 0's and two 0's in toxo
134
In general terms, what drugs do you use to treat HIV?
Dual nucleoside reverse transcriptase inhibitors (NRTI) + protease inhibitors
135
What are the neonatal risks of varicella?
- Chorioretinitis
- Cerebral cortical atrophy
- Cutaneous scarring (cicatrial)
- Bony defects
- IUGR
136
When is the highest risk time for neonatal varicella?
2% risk in second trimester (of congenital varicella)
| Increased risk 5d prior and 2d postpartum (of neonatal varicella)
137
Rubella findings?
- Head, heart, eyes, ears
- Congenital cataracts
- Blueberry muffin
