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CCFP 3 > Pregnancy *** > Flashcards

Pregnancy *** Flashcards

1
Q

What to cover in Preconception Counselling

A

Review previous pregnancies
Mental health
Family + genetic hx
Optimise chronic medical conditions + meds
CI in pregnancy: ACEi, valproic acid, lithium, topiramate, methotrexate, warfarin
Better anticonvulsants: carbamazepine or lamotrigine
Immunizations
Screen for STIs
Lifestyle: smoking cessation, stop alcohol and substance use
Supplementation: folic acid, calcium, omega 3s, vit D, vit B12
Nutrition: Avoid undercooked or raw meat + fish, unpasteurized milk, fish high in mercury (tuna steak, swordfish, shellfish)

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2
Q

Recommended dose of folic acid

A

0.4 to 1mg daily
5mg for people with RF

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3
Q

Sx associated with pre-eclampsia

A

RUQ Pain
Visual Changes (blurring/scotoma)
Headaches
Edema
Nausea
Vomiting
Somnolence
Irritability
Hyperreflexia

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4
Q

Indications for Rhogam

A

In negative women

Routinely at 28 weeks gestational age
Within 72 hours of birth of a Rh positive infant
Miscarriage
Antepartum Hemorrhage
Ectopic Pregnancy
Invasive Procedures During Pregnancy
Positive Kleinhauer-Betke Test

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5
Q

Tests performed in maternal serum screen

A

Alpha-Feto Protein
B-hCG
Estriol (unconjugated estrogen)

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6
Q

First visit content to cover

A

Is pregnancy desirable?
Assess risk factors (teens, substance use, DV victims, single moms, HIV, diabetes, epilepsy)
Establish dates
Advise pt about ongoing care (include SW as needed)
Bloods:
bHCG
Blood type + Rh status
CBC (Hb + MCV)
TSH
HIV, rubella, varicella, HBsAg, Syphilis, Hep C (if RFs)
Urine: midstream C+S
Swabs: GC + CT, pap if out of date

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7
Q

What to cover at 10-14 weeks

A

Dating US
SIPS1
IPS (SIPS1 + NT) for women 35-39

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8
Q

What to cover at 12 weeks

A

GDM screen if high risk
SFH

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9
Q

What to cover at 15-21 weeks

A

SIPS2 or Quad screen

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10
Q

What to cover at 18-20 wks

A

Anatomy, gender + placenta US

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11
Q

What to cover at 24-26 wks

A

Repeat blood type + Rh status in Rh negative pts
GDM screening: 1 hour 50g OGTT screen, 75g 2 hour test for confirmation

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12
Q

What to cover at 28 wks

A

Rh Ig to Rh negative
Edinburgh PDS
Repeat CBC, consider iron
Tdap

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13
Q

What to cover at 34 wks

A

Assess presentation, ECV if necessary

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14
Q

What to cover at 35-37

A

GBS screen
Suppression therapy for current HSV

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15
Q

Recommended vax + CI in pregnancy

A

Flu shot if during flu season
Tdap between 21-32w for every pregnancy
Hep A, B, meningococcal and pneumococcal if high risk
Contraindicated: live influenza, herpes, MMR, polio, rubella, varicalla

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16
Q

What is the 1st stage of labour?

A

regular contractions causing cervical dilatation and effacement
Latent: complete when nulliparous >4cm, parous 4-5cm
Active: starts at >4cm NP and 4-5cm MP

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17
Q

What is the 2nd stage of labour?

A

full dilatation to delivery of baby
Passive = no pushing
Active = pushing

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18
Q

What is the 3rd + 4th stage of labour?

A

immediately after delivery of baby to delivery of placenta

4th: immediately after delivery of placenta to 1hr postpartum

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19
Q

Indications for continuous FM

A

Decels, single umbilical artery, velamentous cord insertion, >3 nuchal loops of cord, spinal-epidural anesthesia, labour dystocia, FHR arrhythmia, BMI >35

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20
Q

Pain relief options

A

Non-pharmacologic (self-hypnosis, acupuncture, water immersion
Systemic: nitrous oxide, opioids
Regional: pudendal nerve block (inferior to sacrospinal ligament + medial to ischial spine bilaterally), epidural

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21
Q

3rd stage management

A

Prophylactic uterotonic (oxytocin)
Early cord clamping
Controlled cord traction

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22
Q

Bishops score characteristics

A

C-PEDS

Consistency
Position
Effacement
Dilatation
Station

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23
Q

What is the definition of decreased cervical length + what is the Rx

A

<25mm @ 16-24w GA
Rx: vaginal progesterone from 16-36w

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24
Q

What is normal and decreased fetal movements, and rx for decreased?

A

Normal = >26w = 6 movements / 2 hrs
<6 = NST, normal = daily movement counting, abnormal = biophysical

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25
Q

When would HTN be considered gestational?

A

> 20wks

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26
Q

RF for GHTN

A

<18 or >35, 1st pregnancy new partner, primip, >1 fetus

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27
Q

Maternal and fetal complications of GHTN

A

Maternal: sz, retinal detachment, stroke, TIA, HELLP
Fetal: placental abruption, IUGR, oligohydramino

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28
Q

Screening for HTN

A

UA + BP each visit

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29
Q

Ix if UA + for protein

A

CBC, INR, PTT, fibrinogen, BUN, Cr, lytes, glucose, AST, ALT, LDH, bili, albumin (low)
24hr urine
fetal movement count/ NST, US for growth, middle cerebral artery doppler

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30
Q

Prevention of GHTN

A

Calcium supplementation
No EtOH
Smoking cessation
High risk women: LMWH if prev placental complications

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31
Q

When to deliver in GHTN/ pre-eclampsia

A

Severe = immediate
Hemolysis + raised LFTs - deliver >35w
Non severe = >37w

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32
Q

Rx for GHTN

A

Labetalol or methyldopa 1st line, clonidine 2nd line
Nifedipine if severe
MgSO4 4g IV to prevent eclampsia
Corticosteroids for fetus if <34+6
HELLP management: consider blood or platelet transfusion

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33
Q

RF for GDM

A

prev GDM, fam hx, macrosomia, >25y/o, obese, PCOS, steroids, hispanic/ asian/ african

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34
Q

Complications of GDM

A

cephalo-pelvic disproportion, LGA, shoulder dystocia, VSD, NTD, neonatal hypoglycemia, Erb palsy, pyloric stenosis, premature

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35
Q

Ix + results for GDM

A

screen at 24-28w w/ 75g OGTT, GDM if FBG >5.1, >10 @ 1hr or >8.5 @ 2hrs

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36
Q

Rx of GDM

A

Nutritional counselling
Monitor fetal growth q4w from 24w
Weekly NST from 36w
Induce at 38w
Monitor newborn for hypoglycemia
Repeat 75g OGTT between 6w-6mo PP

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37
Q

Rx for hyperemesis

A

pyridoxine 10mg QID or diclectin 10mg QID
+ gravol 50mg Q4H
+ metoclopramide 5-10mg Q8H PO/ IM/ IV
+ ondansetron 8mg Q12H IV

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38
Q

IUGR definition

A

<10th % on US d/t pathological process

39
Q

Causes of IUGR

A

smoking, drugs, TORCH, genetic abnormalities

40
Q

Screening for IUGR

A

in trisomy 21, uterine dopplers @ 19-23w

41
Q

Rx for IUGR

A

Previable - monitor
Viable (>500g + >24w) - EFW, AFV, umbilical doppler, weekly BPP in 3rd trimester
If growth plateaus <34w = corticosteroids, consider hospitalisation, increased surveillance
If >34w + abnormal (AFV <5cm or DVP <2cm) BPP + doppler, consider delivering

42
Q

Polyhydraminos causes

A

GDM, fetal hydrops, genetics, GI problem

43
Q

Oligohydraminos causes

A

renal problem, placenta hypoxia, PROM

44
Q

TOLAC
Success rate
Rupture rate
Who is at increased risk
Who is likely to have reduced success

A

Success rate = 75%
Rupture rate = 1%
Increased risk: >2 CS, <18mo since CS, induction of labour
Reduced success: increasing age, BMI, GA >40w, BW >4000g, hx dystocia

45
Q

Rx for previa

A

Management: US at 32 + 26
No vaginal or anal sex, no insertion of FB into vagina

46
Q

What dose of Rhogam to give?

A

If Rh neg, repeat at 28w
Give RhoGAM:
<12w = 120mcg
>12w = 300mcg
Amniocentesis = 300mcg ;

47
Q

How do you test for parvovirus in pregnancy?

A

Parvovirus B19 IgG (positive indicates past infection and immunity)
Parvovirus B19 IgM (positive indicates recent infection)

48
Q

Rx for Group B strep

A

Rx w/ IV penicillin

49
Q

Reasons + risks of inducing

A

Reasons: spontaneous ROM, IUGR, reduced fetal movement, postdates, pre-eclampsia, maternal conditions
Risks: increased risk of operative delivery, abnormal FHR, uterine rupture, cord prolapse

50
Q

Pre-requisites + CI to induction

A

CI: prev uterine rupture, fetal transverse lie, placenta previa, invasive cervical cancer, active genital herpes
Pre-requisites: Bishop >6

51
Q

How to ripen cervix

A

vaginal prostaglandin (Prepidil 0.5mg q12H x 3 doses), foley catheter

52
Q

Oxytocin risks

A

fetal compromise, uterine rupture, hypotension

53
Q

When can you perform ARM

A

active labour + head engaged

54
Q

Definition of dystocia in 1st + 2nd stage

A

Active first stage >4hrs w/ <0.5cm/hr dilatation
2nd stage >1hr w/ no descent

55
Q

Causes + rx of dystocia

A

Causes:
Power
Passenger
Passage
Psyche
Management:
Oxytocin augmentation

56
Q

RF for placental abruption

A

previous abruption, HTN, vascular dz, smoking, alcohol use, multiparity, increasing maternal age, PPROM

57
Q

Sx of placental abruption

A

painful vaginal bleeding, sudden onset, constant, lower back + uterus, fetal distress

58
Q

Complications of placental abruption

A

prematurity, hypoxia, DIC, anemia, shock, amniotic fluid embolism

59
Q

RF for uterine rupture

A

prev uterine scar, oxytocin, grand multip, previous uterine manipulation

60
Q

Sx of uterine rupture

A

acute onset abdo pain, abnormal FHR, vaginal bleeding

61
Q

Complications of uterine rupture

A

hemorrhage, shock, DIC, amniotic fluid embolism, fetal distress

62
Q

Premature rupture of membranes management

A

sterile spec, r/o cord prolapse, looking for 1) pooling, 2) nitrazine blue 3) ferning. Determine GBS status.

63
Q

Preterm labour Ix + Rx

A

Ix: fetal fibronectin, US for cervical length
Management:
- betamethasone 12mg IM q24 x2,
- transfer to NICU place
- nifedipine
- magnesium sulphate 4g IV

64
Q

RF for shoulder dystocia

A

obesity, DM, multiparity, macrosomia, longer gestation, long 2nd stage, advanced maternal age, male newborn, induction

65
Q

Sx of shoulder dystocia

A

Turtle sign (head retracting after delivery)

66
Q

Complications of shoulder dystocia

A

PPH, uterine rupture, newborn brachial plexus injury/ clavicle fracture, hypoxia

67
Q

Rx for shoulder dystocia

A

ALARMER: apply suprapubic pressure, legs in full flexion, anterior shoulder disimpaction, release posterior shoulder, manual corkscrew, episiotomy, roll over onto hands and knees

68
Q

Rx of Non-reassuring FHR

A

Management: ensure fetal tracing, call for help, LLD position, 100% O2, stop oxy, give fluids, r/o cord prolapse

69
Q

Postpartum history

A

Brain: depression, psychosis, sleep, suicide, substances, support, sex
Breasts: feeding, concerns
BP
Bladder/ bowels: incontinence, UTI
Bleeding: colour, smell, clots
Baby: bonding, feeding, concerns

70
Q

Contraception options postpartum (lactating vs not)

A

Non lactating: OCP from 3wks
Lactating: micronor 6wks PP + change to OCP at 3mo or sooner if formula fed
IUD from 6w PP

71
Q

What to counsel parents on after birth

A

Transition to parenthood
Family violence + safety
Nutrition + healthy living
Contraception
Pelvic floor exercises
Community resources
Future pregnancies
Preconception planning
C/S: discuss VBAC + pregnancy spacing

72
Q

FU for pts w/ HTN, DM, preterm, IUGR, placental abruption after delivery

A

If HTN, DM, preterm, IUGR, placental abruption:
6mo: BMI, BP, lipids, glucose, UA
12mo: BMI + BP

73
Q

FU for GDM after delivery

A

75g OGTT 6w PP + a1c q1yr

74
Q

Definition of PPH

A

Blood loss >500ml for SVD or >1000ml for CS, up til 6wks

75
Q

Causes of PPH

A

uterine atony, retained placenta, laceration of cervix/ vagina/ uterus, coagulopathy, DIC, ITP, TTP

76
Q

Management of PPH

A

Cross match 4 units
Oxytocin infusion
Ergotamine 0.25mg IM q5 mins
Hemabate 0.25mg IM
Manual compression/ uterine massage
D+C, lap w/ ligation of uterine arteries

77
Q

Causes of postpartum fever

A

Wind (atelectasis, PNA), water (UTI), wound, walking (DVT), womb (endometritis)

78
Q

Ix for postpartum fever

A

Ix: blood + genital cultures if suspecting endometritis

79
Q

Definition + causes of retained placenta

A

Undelivered placenta >30 mins from delivery of baby
Causes: accreta, incret, percreta

80
Q

RF + Rx of retained placenta

A

RF: placenta previa, prior CS, curettage, uterine infection
Management: explore uterus, firm traction, oxytocin into umbilical vein, manual removal, D+C

81
Q

How to manage existing hypothyroidism

A

May need to decrease thyroxine dose in known hypothyroid pts

82
Q

Rx for endometritis

A

Management: clindamycin + gentamicin

83
Q

Blues vs depression

A

Blues: onset day 3-10, lasts <2wks
Depression: within 4wks - 6mo from delivery

84
Q

RF for depression

A

personal or fam hx, prenatal depression or anxiety, stressful life situation, poor support, unwanted pregnancy, sick infant

85
Q

How to offer abortion

A

confirm gestational age, exclude ectopic, assess for CI (uncontrolled asthma, chronic adrenal failure, chronic steroid use, hematological dz, remove IUD), advise on how to take meds, expect pain, FU - mifepristone/ misoprostil

86
Q

How to diagnose gestational HTN?

A

> 140/90 x2 >20 wks

87
Q

How to diagnose preterm labour?

A

Fetal fibronectin + serial vaginal exam

88
Q

RF for PPH

A

prior hx, rapid delivery, shoulder dystocia, instrumentation

89
Q

Causes of postpartum infection

A

endometritis, septic pelvic thrombophlebitis

90
Q

What supplements reduce sz occurrence in pregnant pts?

A

Calcium, folic acid

91
Q

Bipolar med advice in pregnancy

A

lowest effective dose, monotherapy, avoid valproate, psychosocial preferred over meds in 1st trimester

92
Q

Recommended wt gain per week in pregnancy

A

Underweight = 0.5kg/wk
Healthy = 0.4kg/wk
Overweight = 0.3kg/wk
Obese = 0.2kg/wk

93
Q

Recommended wt gain in pregnancy for obese women

A

5-9kg

94
Q

Bugs causing mastitis

A

staph aureus, beta hemolytic strep, e coli

CCFP 3 (67 decks)

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