Pregnancy and Childbirth Flashcards

Question

Drugs and Vaccine during Pregnancy

Answer 1

Most drugs in pregnancy are FDA category B drugs - FDA Pregnancy and Lactation Labeling Rule (PLLR) will eventually replace the pregnancy letter categories w/ new labeling

Answer 2

Animal and human data show no risk to pregnant woman - Prenatal vitamins (high-dose multivitamins are not used during pregnancy) - Insulin - Thyroid hormone (levothyroxine) - Folic acid (vitamin B9), pyridoxine (vitamin B6)

Answer 3

Animal studies show no risk, no human data available - Antacids (Tums, Maalox) are safe for pregnant women - Docusate sodium (Colace); a stool softener and is approved for pregnant women; it is NOT a laxative - Analgesics (acetaminophen preferred to NSAIDs) esp in 3rd trimester * Avoid laxatives (e.g., ex-lax, Bisacodyl), esp in 3rd trimester (may induce labor)

Answer 4

- Amoxicillin (Amoxil) - Penicillin - Dicloxacillin

Answer 5

First Generation: - Cephalexin (Keflex) - cefadroxil (Duricef) Second Gen - Cefuroxine axetil (Ceftin) - Cefaclor (Ceclor) - Cefproxzil (Cefzil) 3rd Gen - Ceftriaxone (Rocephin) injections - Cefdinir (Omnicef) - Cefixime (Suprax) 4th Gen - Cefepime (Maxipime) injection/IV (used mainly in hospitals)

Answer 6

- Erythromycins - Erythromycin ethylsuccinate (E-mycin), erythromycin vase, erythromycin stearate, erythromycin estolate (EES) - Azithromycin (Zithromax) * Clarithromycin (Biaxin) is the only macrolide that is a category C; AVOID use during pregnancy; consult w/ physician before use and discuss risk vs benefits

Answer 7

Nitrofurantoin (Furadantin, Macrobid) - Do NOT use w/ G6PD anemia → causes hemolysis (anemia, jaundice, dark urine) Contraindication: - during labor and delivery (or near term) d/t ↑ risk of hemolytic anemia (infant) d/t immature erythrocyte enzyme system (glutathione instability)

Answer 8

Nitrofurantoin (Furadantin, Macrobid) - Do NOT use w/ G6PD anemia → causes hemolysis (anemia, jaundice, dark urine) Contraindication: - during labor and delivery (or near term) d/t ↑ risk of hemolytic anemia (infant) d/t- Nutrofuration (Furadantin, Macrobid) immature erythrocyte enzyme system (glutathione instability)

Answer 9

Used for women w/ preexisting HTN or for mod-severe preeclampsia or eclampsia - Use of antihypertensive drugs to control mild HTN does NOT alter course of ds or ↓ perinatal morbidity or mortality of preeclampsia → Refer to obstetrician - Methyldopa (Aldomet) - CCB (Procardia) - Labetalol (Normodyne)

Answer 10

Adverse effects seen in animal studies No human data available Sulfa Drugs - Considered category C in 3rd trimester d/t can cause hemolytic anemia in fetus/infant → hyperbilirubinemia - displaces bilirubin from albumin - high blood levels of unconjugated bilirubin can cross blood-brain barrier and cause brain damage (kernicterus) Trimethoprim-Sulfamethoxazole (e.g., Bactrim DS, Septra) - Clarithromycin (Biaxin) is the only category C macrolide abx - Avoid use in pregnant women - Consult w/ physician before using category C drugs during pregnancy Pseudoephedrine (Sudafed) - ↑ risk of gastroschisis - Ideally, it should NOT be used in pregnancy and breast feeding (repeated doses may interfere w/ lactation, as it crosses breastmilk)

Answer 11

When high blood levels of unconjugated bilirubin crosses blood-brain barrier and causes brain damage

Answer 12

Intestines protrude through abdominal wall defect

Answer 13

Evidence of fetal risk - Benefits should outweigh risk of using drug ACEi and ARBs - causes fetal renal abnormalities, renal failure, and hypotension - Captopril (Capoten) and losartan (Hyzaar) - Category C in 1st trimester - Category D in 2nd/3rd trimester Fluoroquinolones - Affect fetal cartilage development - a rare side effect is Achilles tendon rupture in athlete; CONTRAINDICATED in pregnant or lactating women and children 18 years - Ciprofloxacin (Cipro) - Ofloxacin (Floxin) - Gram+ activity → Levofloxacin (Levaquin), gemifloxacin (Factive), moxifloxacin (Avelox) Tetracyclines - Stain growing tooth enamel - Tetracycline, minocycline (Minocin) - Avoid in 3rd trimester NSAIDs - Block prostaglandins and may cause premature labor - avoid using esp in last 2 weeks of pregnancy - Category D in 3rd trimester, but category B during 1st/2nd trimester (ibuprofen, naproxen, other NSAIDs) Sulfa drugs - Risk of hyperbilirubinemia (neonatal jaundice or kernicterus) - displace bilirubin from albumin → high levels of unconjugated bilirubin will cross blood-brain barrier and cause brain damage (mental retardation, seziures, deafness, etc)

Answer 14

Proven fetal risks outweigh the benefits Accutane (isotretinoin - Vit A derivative) - used for severe cystic and nodular scne recalcitrant to treatment; highly teratogenic - Also avoid vita A derivative topicals such as retinol/retinoid, tretinoin (Retin A), adapalene Methotrexate (antimetabolite) and anticancer drugs - used for some types of autoimmune ds (psoriasis, RA) and certain cancers Proscar (antiandrogen) - Used for BPH and prostate CA Misoprostol (prostaglandin analog) - used as one of the drugs in medical abortions (a component of the "abortion pill") Evista and tamoxifen (selective estrogen receptor modulator [SERM]) - use reduces risk of reoccurrence of estrogen receptor-positive breast CA - All hormonal drugs (natural or synthetic) are category X in pregnancy--all forms of estrogens, testosterone, finasteride (Proscar), mifepristone (RU-86) - Any drug that blocks hormone synthesis or binding (Depo Lupron) - Depo Lupron is used for infertility, hormone-dependent CAs, and endometriosis

Answer 15

- NSAIDs (blocks prostaglandin) - Aspirin and salicylates (affect platelets) - Bismuth subsalicylate (Pepto-Bismol) contains salicylates - Sulfa-containing drugs (trimethoprim0sulfamethoxazole, nitrofurantoin) near term → higher risk of hyperbilirubinemia, jaundice, kernicterus, oligohydramnios, premature closure ductus arteriosis

Answer 16

CONTRAINDICATED in Pregnancy: - MMR; oral polio; varicella; and FluMist - Live attenuated influenza virus (LAIV) Influenza vaccine is an inactivated virus and is safe to use in pregnant women - Recommended for pregnant women esp if pregnant during fall and winter seasons - only use injectable inactivated flu vaccine ** After a live virus vaccine, advise reproductive-aged women not to get pregnant (and use reliable birth control) in the next 4 weeks (MMR) or 3 months (varicella and shingles vaccine) - Inactivated flue vaccine and Tdap vaccines are recommended for pregnant women

Answer 17

Agents that can cause structural abnormalities during pregnancy - Paroxetine (Paxil) → increases risk of birth defects in 1st trimester; particularly heart defects (others are anencephaly, abdominal wall defects); FEDA category D drug - Fluoxetine (Prozac) → heart wall defects and craniosynostosis (premature closure of skill sutures) - Other SSRIs (citalopram, escitalopram, sertraline) → 1st trimester exposure may be associated w/ a low risk of teratogenicity - Alcohol → fetal alcohol syndrome - Cigarettes → Intrauterine growth retardation (IUGR), prematurity - Cocaine → CVAs, mental retardation, abruptio placentae - Isotretinoin (Accutane) → CNS/caraniofacial/ear/cardiovascular defects - Lithium → cardiac defects (Ebstein's anomalies are malformations of tricuspid valve and R atrium that can cause HF, sudden death, TIA, stroke; presentation is middle teenager years) - Chronic hyperglycemia during pregnancy (poorly controlled diabetes or gestational DM (GDM) is a teratogenic state → increases risk of neural tube defects and craniofacial defects

Answer 18

- Take prenatal vitamins w/ 400 mcg of folic acid daily (start 2-3 months before conception) - ALWAYS wear seatbelt (lap-style seatbelt below uterine fundus) - Avoid soft cheeses (blue cheese, brie), uncooked meats, raw milk (Listeria bacteria) - Sex is safe except during vaginal bleeding, incompetent cervix, placenta previa, or preterm labor - Catter litter or raw/undercooked meat can cause toxoplasmosis (congenital infection) - Do NOT eat raw shellfish or raw oysters (Vibrio vulnificus infection) - Be careful w/ cold cuts, uncooked hot dogs, and "deli" meat (Listeria bacteria) * Pregnant women 20x more likely to become infected and die from listeria monocytogenes - Smoking (vasoconstriction causes IUGR) and alcohol (fetal alcohol syndrome) are contraindicated -Regular coffee (8 oz/d) is okay; do NOT consume an excessive amount of caffeine (premature labor) - Do not use hot tubs or saunas or expose oneself to excessive heat

Answer 19

- can cause severe birth defects (eg, microcephaly) and neurodevelopmental abnormalities - the only way to completely prevent Zika infection during pregnancy is NOT travel to areas w/ Zika outbreak/risk & use condoms or avoid sex w/ someone who has recently traveled to a risk area - If travel is necessary, CDC recommends special precautions for pregnant women and women (and their partners) who are trying to become pregnant

Answer 20

- Use Environmental Protection Agency (EPA)-registered insect repellents and cover skin - Stay in places with AC, screens, and mosquito nets - Use condoms or abstain from sex during pregnancy - Be alert for sx after travel

Answer 21

Use condoms or abstain from sex according to the following time frames: - Both partners or only the male partner traveled to an outbreak/risk area → 3 months after return or from the start of symptoms or date of diagnosis - Only the female partner traveled to an outbreak/risk area → 2 months after return or from start of symptoms or date of diagnosis

Answer 22

1. In 3rd trimester (~1-2 lb [0.45-0.91 kg] per week) 2. Total gain of 25-35 lb (11.3-15.9 kg) if healthy weight before pregnancy (BMI 18.5-24.9) is ideal 3. BMI <18.5 → gain a total of 28-40 lb (12.7-18.1 kg) 4. BMI >30 → total of 11-20 lb (4.98-9.07 kg) 5. Loss of up to 15-20 lb (6.8-9.1 kg) in the first few weeks is appropriate 6. ↑ weight gain 37-54 (16.8-24.5 kg) is appropriate, but weight gain should NOT be double that for a single fetus

Answer 23

Pregnancy age ≥35 years At higher risk of: - Chromosomal abnormalities (e.g., Down syndrome), birth defects - Preeclampsia - Low-birth-weight infants - Miscarriage, premature birth - Complications during delivery (e.g., stillbirth); more likely to have Cesarean delivery

Answer 24

- Palpation of fetus by health provider - US and visualization of fetus - Fetal heart tones (FHTs) auscultated by health provider * 10-12 weeks by Doppler/ Doptone * 20 weeks by fetoscope/stethoscope *** Memorize the 3 positive signs of pregnancy; this sit he shortest list to memorize; by the process of elimination, you can R/O (or in) the correct answer choice

Answer 25

- Goodell's sign (4 weeks): Cervical softening - Chadwick's sign (6-8 weeks): Blue coloration of cervix and vagina - Hegar's sign (6-8 weeks): Softening uterine isthmus - Enlarged uterus - Ballottement (seen in midpregnancy): when the fetus is pushed, it can be felt to bound back by tapping the palpating fingers inside vagina - Urine or blood pregnancy tests (beta HCG) ** The signs with surnames (Goodell, Chadwick, Hegar) are all probably signs ** Urine/serum pregnancy tests are considered probably sign s(do NOT confuse them as "positive signs); Beta HCG also presents in molar pregnancy and ovarian CA *** Exam questions asking for one of the signs will mix them up (e.g., mix a positive sign w/ a probable sign); ensure the answer option contains the two signs from the same category

Answer 26

4 weeks Cervical softening

Answer 27

6-8 weeks Blue coloration of cervix and vagina

Answer 28

6-8 weeks Softening uterine isthmus

Answer 29

- seen in midpregnancy - when the fetus is pushed, it can be felt to bound back by tapping the palpating fingers inside vagina

Answer 30

The following are "softest" and least objective signs (from mother); can be caused by many other conditions besides pregnancy - Amenorrhea - N/V (most common in 1st trimester in AM, usually disappears by 2nd trimester) - Breast changes (Swollen and tender) - Fatigue - urinary frequency - slight ↑ in body temp - "Quickening" → mother feels baby's movements for the first time; starts at 16 weeks

Answer 31

Mother feels baby's movements for the first time - starts at 16 weeks

Answer 32

1. Clinical Finding → amenorrhea, no uncommon to have spotting in first missed menses Time from conception → Approx 8-10 dyas after ovulation (earliest time that it can be detected w/ standard serum HCG test); serum HCG can detect it earlier 2. Clinical Finding: Cervical softening Time from conception: 4 weeks 3. Clinical Finding:Bluish discoloration of cervix/vagina Time from conception: 6-8 weeks 4. Clinical Finding: Softening of uterine isthmus Time from conception: 6-8 weeks

Answer 33

1. - Uterine fundus first rises above the symphysis pubis - FHTs are heard by Doppler by 10-12 weeks 2. - uterine fundus b/w symphysis pubis and umbilicus 3. - uterine fundus at level of umbilicus - FHTs are heard w/ fetoscope or stethoscopy by 20 weeks 4. - Measure distance b/t upper edge of pubic symphysis and top of uterine fundus using a paper tape measure - Fundal height in cm = # of weeks of gestation (+/- 2 cm) Ex: a 32-week-gestation fetus should have a fundal high of b/ww 30-24 cm

Answer 34

- Palpation of fetus by health provider - US and visualization of fetus - Fetal heart tones (FHTs) auscultated by health provider * 10-12 weeks by Doppler/ Doptone * 20 weeks by fetoscope/stethoscope *** Memorize the 3 positive signs of pregnancy; this is the shortest list to memorize; by the process of elimination, you can R/O (or in) the correct answer choice

Answer 35

The size of uterus does NOT match gestation age Defined: a difference of + or - 2 (or +/- 2) from # of weeks of gestation. - If uterine fundus is ≤2 cm (fetus smaller than expected), it can be caused by dating error, IUGR, or other problem - If fundus size ≥ 2 cm (fetus larger than expected), it may be d/t dating error, macrosomia, or other problem → Order an US * Screening US to check gestational age: At 10-14 weeks; gestation, will measure nuchal translucency, maternal serum beta HCG, and pregnancy-associated plasma protein0A (PAPP-A)

Answer 36

1. - Heart is shifted anteriorly toward left - Rotated toward a transverse position as uterus enlarges 2. - ↑ during pregnancy by 15-20 bpm - resting HR starts to rise during 1st trimester 3. - HS are louder in pregnancy - S3 heart sound is common (80%) but NOT S4 - Wide splitting of S1 - In 3rd trimester, splitting of S2 may be heard * S3 heart murmur is normal finding in pregnancy 4. - Systolic ejection murmur (grade II/Iv) over pulmonary and tricuspid area is common - A mammary souffle (systole or continuous) is heard over breasts later in pregnancy and during lactation (breastfeeding) 5. - ↑ by 30-50% and peaks at ~28-34 weeks' gestation - Reduction of SVR and SBP

Answer 37

6. - ↑ almost 50% by end of 2nd trimester - Hemodilution → physiologic anemia or pregnancy (hematocrit ↓) 7. - most obvious from 6-9 months (2nd/3rd trimester) - Hgb & Hct ↓ d/t hemodilution from ↑ plasma volume; Hgb can ↓ to as low as 10.5 g/dL 8. - Preload ↑ d/t higher blood volume - Afterload ↓ d/t ↓ in PVR that occurs during pregnancy 9. - SBP and DBP starts ↓ in 1st trimester and continues in 2nd trimester; many m others who are hypertensive before pregnancy can be off prescription antihypertensives at this time - By 3rd trimester, BP gradually returns back to prepregnancy levels → antihypertensives used for pregnant women are methyldopa (Aldomet) and labetalol (Noirmodyne; beta-blocker)

Answer 38

10. - Compression by enlarged uterus (20 weeks' gestation til labor) of IVC ↓ blood return to the brain, → orthostatic hypotension (postural hypotensive syndrome) - advise women to lie on left side and change positions slowly 11. - Pregnancy is a hypercoagulable state (clotting factors go up) esp after labor (puerperium or postpartum period) 12. - varicose veins become more severe during pregnancy 13. - Peripheral edema is considered normal in pregnancy - mild edema of LE and feet is most noticeable in 3rd trimester

Answer 39

- Presence of basal rales that disappear w/ coughing or deep breathing - Feeling of breathlessness (innocent hyperpnea) and ↓ exercise tolerance - Physiologic dyspnea in pregnancy has slow onset; ** Sudden-onset dyspnea is abnormal → R/O PE (pleuritic chest pain, tachypnea, hemoptysis) - Gravid uterus pushes up diaphragm as it gets larger; diameter of thorax is ↑ - No change in FEV1, but TLC ↓ slightly from 4.2 to 4 L

Answer 40

- diffusely enlarged (size up to 15% larger), w/ higher metabolic activity

Answer 41

- ↓ peristalsis from progesterone effects (constipation, heartburn)

Answer 42

1. - Pigmentary changes from ↑ in m elanocyte-stimulating hormone from higher levels of estrogen → causes linea nigra (dark pigmented "line" that extends from mons pubis to umbilicus located midline) - nipples and areola darken 2. Melasma - blotchy hyperpigmentation on forehead, cheeks, noise,a nd upper lip seen in pregnant women and some birth control pill users - usually gets lighter and regressed within 1 years; however, in some women, hyperpigmentation may be permanent - Condition is more common in darker skins (olive skins and darker) * Cholasma/melasma is d/t high estrogen levels

Answer 43

dark pigmented "line" that extends from mons pubis to umbilicus located midline

Answer 44

3. Stretch Marks - Most common locations are abdomen, breasts, and thighs - Other less common areas: upper arms, lower back, and buttocks 4. Hair Loss - During postpartum period, hair loss may accelerate, but it is temporary

Answer 45

- Kidney size ↑ - ureters and renal pelvis become dilated (physiologic hydronephrosis) - GFR is much ↑ in pregnancy d/t higher CO and renal blood flow

Answer 46

- Kidney size ↑ - ureters and renal pelvis become dilated (physiologic hydronephrosis) - GFR is much ↑ in pregnancy d/t higher CO and renal blood flow

Answer 47

- Some women develop nasal congestion and/or epistaxis d/t ↑ blood flow to nasopharynx during pregnancy - R/O acute sinusitis if purulent mucus seen in posterior pharynx

Answer 48

- Weight gain, enlarged uterus, and hormonal changes contribute to joint ligamentous laxity and exaggerated lordosis of lumbar spine - Up to 60% of pregnant women experience back pain (not r/t labor) - Gait change sot wider stance

Answer 49

- Used to estimate date of delivery (EDD) during 1st trimester - Assumes regularly 28- to 30-day menstrual cycle; not as useful for irregular menstrual cycles * A full-term pregnancy is 40 weeks (280 days) 2 different ways to use Naegele's rule. They are equivalent; pick the one w/ which you feel most comfortable 1 → LMP + 9 months + 7 days 2 → LMP - 3 months + 7 days LMP = Last menstrual period

Answer 50

Method 1: LMP 2/20/2021 1. Add 9 months to Feb: 2+9=11 (November) 2. Add 7 days to date of LMP: 20+7=27 3. EDD = November 27, 2021 Method 2: LMP 2/20/2021 1. Subtract 2 months from Feb = November 2. Add 7 days to date of LMP: 20+7=27 3. EDD = November 27, 2021 Exam Tip: There is usually one question about the EDD (use Naegele's rule). - TheLMP month on exam will either by Jan, Feb, or March If LMP is: LMP → EDD Jan → Oct Feb → Nov Mar → Dec

Answer 51

Placenta previa: vaginal bleeding (bright red) without hypertonic tender uterus Placenta abruptio: vaginal bleeding, intermittent w/ hypertonic, hard, and tender uterus

Answer 52

12 weeks → above symphysis pubis 16 weeks → between symphysis pubis and umbilicus 20 weeks → at the umbilicus

Answer 53

European Jews Should be screened for Tay-Sachs disease

Answer 54

ACEi and ARBs to treat HRN → Category C/D

Answer 55

- methyldopa (Aldomet) - labetalol (beta-blocker) - hydralazine - long-acting nifedipine

Answer 56

Check LEFTs at baseline and periodically CONTRAINDICATED if active hepatic disease Discontinue med if jaundice, abnormal LFTs, or unexplained fever

Answer 57

G: Gravida → # of pregnancies (twins or multiples counted as 1 pregnancy) T: Term → # of deliveries after 37 weeks P: Preterm → # of deliveries after 20 weeks (up to 38 weeks) A: Abortion → # of deliveries before 20 weeks (induced or spontaneous) L: Living → # of living children

Answer 58

G: 5 pregnancies total T: 3 pregnancies full term P: 1 One twin pregnancy preterm born at 34 weeks A: 1 abortion L: 5 living children

Answer 59

Occurs immediately after delivery and generally lasts ~6 weeks

Answer 60

Occurs immediately after delivery and generally lasts ~6 weeks

Answer 61

- Normal for postpartum women to have uterine contractions (spontaneous or w/ breast feeding) during the first 2-3 days after giving birth - After delivery, uterus is size of a 20-week pregnancy (fundi at the umbilicus) - A soft boggy uterus accompanied by heavy vaginal bleeding is a sign of atony (inadequate contraction) - Uterine involution takes ~ 16 weeks

Answer 62

- Amniotic fluid volume < than expected for gestational age - usually diagnosed by US and measured as amniotic fluid index (AFI <5 cm) or the deepest vertical pocket (DVP) AFI - Normal rage: 5-25 cm The uterus is smaller in size than expected At higher risk of: - fetal malformation - pulmonary hypoplasia - umbilical cord compression - fetal or neonatal death - may occur in 1st, 2nd, or 3rd trimester Multiple causes: - idiopathic - maternal, fetal, or placental causes → Refer to obstetrician for management

Answer 63

- Excessive volume of amniotic fluid, more than expected for gestational age - occurs in ~1% of pregnancies - Fetal anomalies usually associated w/ genetic abnormality or syndrome are most common causes → Refer to obstetrician for management

Answer 64

- In Rh-negative mothers w/ Rh-positive fetuses, maternal immune system develops antibodies against Rh-positive blood if not given RhoGAM (gamma globulin against Rh factor) - Give RhoGAM for all pregnancies of Rh-negative mothers--even if they terminate in miscarriages, abortions, or tubal or ectropic pregnancies

Answer 65

- AKA anti-D immune globulin - made from pooled IgG antibodies against Rh (rhesus) factor - an immunoglobulin that helps prevent maternal isoimmunization (self-immunization) or alloimmunization (immunity against another individual of the same species) - If RhoGAM is not given to Rh-negative pregnant women, → fetal hemolysis and fetal anemia in her future pregnancies - Coombs test: Detects presence of Rh antibodies in the mother (indirect Coombs test) and the infant (direct Coombs test); test is done as part of labs performed early in pregnancy RhoGAM 300 mcg IM first dose is at 28 weeks - Give 2nd dose within 72 hrs (or sooner) after delivery - RhoGAM ↓ risk of isoimmunization of maternal immune system by destroying fetal Rh-positive RBCs that have crossed placenta

Answer 66

Detects presence of Rh antibodies in the mother (indirect Coombs test) and the infant (direct Coombs test) - test is done as part of labs performed early in pregnancy

Answer 67

1. - diabetes occurring during pregnancy - GDM mothers are at high risk for DM2 - high rates of reoccurrence (33-50%) in future pregnancies - concomitant higher rates of neural tube defects (anencephaly, microcephaly), congenital heart ds, birth trauma (shoulder dystocia), preeclampsia, and neonatal hypoglycemia RF: - Hx of GDM in previous pregnancy - obesity - ethnicity (Asian, American Indian, Pacific Islander, African American, Hispanic) - Macrosomic infant (>9 lbs) - age >35 years - If hx of GDM, check for prediabetes or diabetes at 4-12 weeks postpartum and advise lifelong screening at least Q3 years 2. - Screen at the first visit of hx of GDM and/or presence of RF - If not high risk, screen at 24-28 weeks' gestation - 2 mothers of testing for GDM (one-step or two-step strategy) ** Diagnosed in the 2nd/3rd trimester - A woman w/ diabetes in the first trimester has DM2 - An A1C <6% (2nd/3rd trimester) has the lowest risk for large-for-gestational-age infants → lowest rates of adverse fetal outcomes (large-for-gestational age infant, preterm delivery, preeclampsia) occur with A1C <6% - 6.5%

Answer 68

- Administer 75 g oral glucose tolerance test (OGTT) - check fasting, 1 hour, and 2 hours - Overnight fast of at least 8 hours - Perform test in the morning - Diagnostic Criteria * Fasting: ≥ 92 mg/dL * 1 hour: ≥ 180 mg/dL * 2 hours: ≥ 153 mg/dL - If one value is elevated in this test, it is diagnostic of GDM - The 75 g OGTT is the preferred test * Used for screening and diagnosis

Answer 69

- Screening: 50 g glucose load (nonfasting), check plasma glucose at 1 hour - If ≥140 mg/dL → R/O GDM - Order 100 g OFTT (fasting, 1 hour, 2 hours, and 3 hours) Diagnostic Criteria * Fasting: ≥ 95 mg/dL * 1 hour: ≥ 180 m g/dL * 2 hours: ≥155 mg/dL * 3 hours≥ 140 mg/dL - If 50 g OGTT is abnormal (postprandial >140 mg/dL or fasting > 95 g/dL), follow-up test is 100 g OGTT (must fast for at least 8 hours)

Answer 70

* Glycemic targets in pregnancy: - Preprandial: ≤95 mg/dL - 1-hour postmeal: ≤140 mg/dL - 2-hour postmeal: ≤120- mg/dL - A1C goal: <6% First-line treatment: lifestyle - follow meal place and schedule physical activity - Eat 3 meals/day + 2-3 snacks; Limit carbohydrates - Exercise 30 mins/day at least 5 days/week ((total of 2 hrs/wk) Low-impact exercises such as walking and swimming are preferred - Perform frequent home glucose monitoring, 4-6 x/day - If med needed, human insulin is preferred agent; insulin infections needed if unable to control blood glucose w/ diet and exercise - May need to self-inject insulin from 3-6 x/day - ADA and ACOG have endorsed use of oral antihyperglycemic drugs glyburide and metformin Glucose monitoring: check BG at least QID (fasting, 1 or 2 hours after first bite of each meal) Follow-up: Test of prediabetes or diabetes at 24-12 weeks postpartum and at least Q3 years afterward (future)

Answer 71

1. Acute cystitis can occur alone, or may be complicated by acute pyelonephritis - Higher risk of preterm birth and low birth weight Most common organism: E. coli (75-95%) S/Sx: - dysuria - frequency - urgency - nocturia 2. Pregnant women w/ asymptomatic bacteriuria are ALWAYS tx because they are at high risk for acute pyelonephritis (25%) - Diagnosis is based on midstream urine C&S results - Obtain specimens before antibiotic tx and after (to check fo eradication of infection) - UTIs ↑ risk of preterm birth, low birth weight, and piernatal mortality 3. - Urine dipstick ► WBCs (leukocyte esterase): Positive ► Nitrate: may be positive or negative - Send midstream urine for urinalysis (UA) and urine C&S - Document resolution of infection by ordering posttreatment urine C&S 1 week after completing antibiotic therapy - If suspect pyelonephritis → Refer to ED/physician

Answer 72

1. Acute cystitis can occur alone, or may be complicated by acute pyelonephritis - Higher risk of preterm birth and low birth weight ** UTIs in pregnant women are classified as "complicated UTIs" Most common organism: E. coli (75-95%) - Lab: urine WBC ≥10^3 CFU/mL → considered UTI - Normal nonpregnant health adult, UTI is defined as >100,000 CFU or 10^5 CFU, of one organism S/Sx (same as those in nonpregnant state): - dysuria - frequency - urgency - nocturia 2. Pregnant women w/ asymptomatic bacteriuria are ALWAYS tx because they are at high risk for acute pyelonephritis (25%) - Diagnosis is based on midstream urine C&S results - Obtain specimens before antibiotic tx and after (to check for eradication of infection) - UTIs ↑ risk of preterm birth, low birth weight, and perinatal mortality ** ALWAYS treat asymptomatic bacteriruia and UTIs in pregnant women 3. - Urine dipstick ► WBCs (leukocyte esterase): Positive ► Nitrate: may be positive or negative - Send midstreaPregnancy: Urinary Tract Infections urine for urinalysis (UA) and urine C&S - Document resolution of infection by ordering posttreatment urine C&S 1 week after completing antibiotic therapy - If suspect pyelonephritis → Refer to ED/physician

Answer 73

4. - Nitrofuratoin (Macrobid) BID x 5-7 days (avoid during last trimester) → Do NOT use sulfa drugs (e.g., Bactrim) or nitrofurantoin near term because of risk of hyperbilirubinemia; causes hemolysis if mother (or both mother and baby) has G6PD anemia - Amoxicillin-clavulanate (Augmentin) BID 3-7 days - Amoxicillin BID x 3-7 days - Cephalexin BID x 3-7 days - Fosfomycin 3g single dose ** Amoxicillin is NOT the first-line drug for empiric UTI treatment d/t high resistance rates 6. - Avoid near term (38-42 weeks), during labor, and during delivery - Also CONTRAINDICATED in neonates <4 weeks of age - These drugs ↑ risk of hyperbilirubinemia (bilirubin is toxic to nerves and CNS) - Complication of hyperbilirubinemia is called "kernicterus" (serious nerve/brain damage) - Do NOT use of G6PD anemia is suspected (causes hemolysis) - Nitrofurantoin causes serious adverse effects: pulmonary reactions (interstitial pneumonitis, pulmonary fibrosis), liver damage, neuropathy, others Exam Tip: There are usually only a few questions that address pregnancy. Do NOT overstudy this subject area for the exam /dt ↓ # of questions over past few years

Answer 74

AKA miscarriage - Spontaneous loss of the fetus before viable (<20 weeks)

Answer 75

Vaginal bleeding occurs, but cervical os remains closed - Most of these cases will result in an ongoing pregnancy

Answer 76

Cercix is dilated and unable to stop process - Fetus will be aborted

Answer 77

Vaginal bleeding w/ cramping occurs - Placenta and fetus are expelled completely - Cervical oss will close and bleeding stops

Answer 78

Vaginal bleeding w/ cramping occurs - placental products remain in uterus - cervical os remains dilated - bleeding persists -pieces of tissue may be seen at the cervical os - vaginal discharge is fould smelling 9bacterial vaginosis) TX: dilation and curettage (D&C) and antibiotics

Answer 79

Pregnancy loss that occurs at 20 weeks' gestation or later or weight of ≥ 350 grams

Answer 80

Pregnancy-Induced HTN - older name: "toxemia" - Exact etiology: unknown - If seizures develop → eclampsia 1 & 2. Most causes occur in late 3rd trimester (≥ 34 weeks) - Can occur up to 4 weeks after childbirth (postpartum period) - Mild cases of preeclampsia may not have symptoms (e.g., headaches, blurred vision, or RUQ abdominal pain) RF: - primigravida - multipara - >35 years - obesity - prior hx of preeclampsia - HTN - kidney ds Will cause multiorgan damage: - brain → stroke - kidneys → acute renal failure - lungs → pulmonary edema - liver → hepatic rupture - DIC - fetal and/or maternal death 3. Classic triad: HTN, proteinuria, and edema occurring after 20 weeks' gestation and up to 4 weeks postpartum - Take at least 2 separate readings (at least 6 hours apart) - SBP ≥140, DBP ≥ 90 - Proteinuria: >0.3 g protein in a 24-hr urine specimen * Proteinuria ranges from trace to 1+ to 4+ (severe cases) - Rapid weight gain of 2-5 lb/week - Edema is most obvious in face, around eyes, and on hands 4. - Refer to obstetrician for management - Only definitive "cure" for preeclampsia and eclampsia is delivery of placenta/fetus

Answer 81

- Defined as presence of an elevated BP (>140/90) before 20th week of gestation - Do NOT confuse this condition w/ preeclampsia - may be on a prescription - If on ACEi/ARB, discontinue ASAP and monitor BP closely - Most pregnant women w/ preexisting HTN can usually get off BP meds (temporarily) during 1st-2nd trimester d/t ↓ BP during pregnancy (less PVR)

Answer 82

Placental Abruption 1. premature partial to complete separation of a normally implanted placenta from uterine bed - rupture of maternal blood vessels from decidua basalis - bleeding ranges from mild to hemorrhage - controllable RF: smoking, cocaine use, HTN, and encouraged seatbelt use 2. - sudden onset of vaginal bleeding (mild to hemorrhage) - abdominal and/or back pain - painful uterine contractions - Uterus is rigid (hypertonic) and very tender 3. → Refer to ED - Initial ED labs: CBC, PT/PTT, blood type, cross-match, Rh factor, etc - Abdominal US and blood transfusion PRN - If mild contractions, give magnesium sulfate IV; strict bed rest is needed - Deliver fetus by C-section if mother's life is threatened, give steroids if fetus is viable

Answer 83

1. abnormally implanted placenta - placenta implants too low either on top of cervix or on cervical isthmus/neck - most cases get better spontaneously (will reimplant) some cases are asymptomatic - high risk of if hx of placenta previa or C-section, multipara, older age, smoking, fibroids, or cocaine use 2. - late 2nd/3rd trimester or pregnancy - sudden onset of bright-red vaginal bleeding (light to heavy) - accompanied by mild contractions - uterus feels soft and is NOT tender 3. - Refer to ED - Avoid bimanual exam d/t palpation of uterus may cause severe hemorrhage - use abdominal US only; NO intravaginal US - NO rectal exams - avoid any vaginal/rectal sexual intercourse - bed rest required - close fetal and manteral monitoring - if contractions, give magnesium sulfate IV - If mild case, pregnancy can be salvaged, and placenta will reimplant - Perform C-section if mother's life is in danger

Answer 84

First few days (days 1-2) → colostrum is produced (thick yellow color), which contains maternal antibodies (passive immunity) By 3rd-4th day → mature breast milk is produced (contains fat, sugar/lactose, water, protein, and antibodies) Full-term healthy infant can be exclusively breastfed for the first 6 months w/ no supplemental fluids unless ill or dehydrated

Answer 85

- all breastfed infants need vit D supplementation started within first few days - formula-fed infants should only be given iron-fortified formula (has vit D)

Answer 86

- All exclusively breastfed infants require iron (ferrous sulfate) supplementation at 4 months at dose of 1 mg/kg - Breast milk contains very little iron - Most full-term newborns have sufficient iron stores in their bodies for at least 4 months - At ~6 months, infants' iron needs can be met through introduction of iron-rich foods, iron-fortified cereals, or iron supplement drops - If on iron-fortified formula, do not need additional iron supplementation

Answer 87

- Breastfeed within 1st hr of birth → provides baby with colostrum and helps uterus contract - a new mother should be taught proper breastfeeding technique → Refer to lactation specialist if having problems, follow up at home - If noisy, assess for improper latch on (check positioning, sucking, clicking noises) - Swallowing noises are normal, but not clicking noises - For clicking, advise mother to us index finger to pull down baby's chin so the baby's lower lip will be outside → baby should have entire nipple and most of areola inside its mouth - Newborns will nurse about 8-12 times/24 hrs

Answer 88

1. Infants' chest and stomach should rest against body; head is straight and not turned to side 2. Tickle infant's lips w/ nipple and aim nipple just above infant's top lip 3. Ensure nipple and areola are inside infant's mouth (baby's tongue will cup under breast w/ lip turns out) 4. May hear/see swallowing; infant's ears may wiggle slightly 5. Breast soreness is normal the first few days; a proper latch will help make it more comfortable 6. If improper latch on, gently place a clean finger in corner of infant's mouth to break seal (suction) and start again ** Swallowing noises may be heard in breastfeeding esp in younger babies → normal ** Clicking noises are abnormal → advise mother to use index finger to pull down baby's chin so baby's lower lip will latch better onto areola

Answer 89

- advise mother not to stop breastfeeding → causes breast engorgement (painful) - If poor latch, infant may have to suck harder, which causes pain - This results from babies having difficulty "latching on" to an engorged breast - Nipple pain is worse during 1stweek and usually disappears by 2nd week - If nipple pain persists, assess nipples for fissures and infection - start nursing on less painful breast first - initiate "letdown reflex" of milk by massage/warm shower - Apply lanolin or breast milk to nipple after nursing to protect from skin breakdown - Avoid using plastic nipple shields, alcohol, and soap; wear nursing bras w/ good support - may need referral to lactation specialist (e.g., La Leche League) Exam tip! If a question describes a mother who complains of sore nipples, do NOT advise her to stop breastfeeding, to supplement w/ formula, or to use formula at nighttime feedings - BEST answer is to advise mother that it is a common problem during the first 2 weeks and will resolve and to continue breastfeeding

Answer 90

- stimulates uterine contractions (speeds up uterine involution after delivery) - ↑ maternal bonding w/ infant (oxytocin effect) - Speeds up weight loss after pregnancy - ↓ risk of breast/ovarian CA - can delay ovulation if mother breastfeeds exclusively

Answer 91

- ↓ risk of infections (necrotizing enterocolitis, acute otitis media) - ↓ risk of bacterial/viral infections such as otitis media and diarrhea - ↓ incidence of asthma and allergies in breastfed babies - Young infants who are exclusively breastfed get enough fluids and do not need extra water; juices should be avoided; ↑ risk of dental caries - ↓ risk of sudden infant death syndrome and future obesity

Answer 92

1. - most common in first 2 months - skin fissures on nipple(s) allowing bacterial entry - most common organism: Staph aureus (Gram+) - Consider MRSA bacterial infection (becoming more common) - If severe or toxic → Refer to ED or admit to hospital 2. - frequent and complete emptying of breast and proper breastfeeding technique - Breast engorgement and poor technique ↑ risk of mastitis 3. - c/o sudden onset of red, firm, and tender area (induration) on one breast - may also have fever/chills - malaise (flu-like sx) - may have adenopathy on axilla be affected breast - most common in first 3 months of breast feeding

Answer 93

4. - usually not needed; clinical diagnosis - CBC shows leukocytosis; C&S of milk is usually not required, but can be useful to guide antibiotic esp if hospitalization or not responding to antibiotic tx - US may be useful if mastitis does not respond in 48-72 hrs 5. If low risk of MRSA - Dicloxacillin 500 mg PO QID or cephalexin (Keflex) 500 mg PO QID for 10-14 days - Do NOT use sulfas during newborn period d/t ↑ risk of kernicterus If high risk of MRSA - Trimethoprim-sulfamethoxazole (Bactrim) 1-2 tablets PO BID (can be used if healthy infant is 1 month or older, no jaundice) OR clindaymycin 300 mg PO QID for 10-14 days - Continue to breastfeed on affected breast during antibiotic tx - If unable to breastfeed, pump milk from infected breast and discard to prevent engorgement - complete emptying of breast is important during infection - If breast abscess is suspected, order US and refer for I&D - NSAID for pain and fever PRN; apply cold compresses on indurated breast area - Refer to lactation consultant if suspect poor breastfeeding technique

Answer 94

Cervicitis, urethritis 1. - Treating chlamydia trachomatis infection in mother will help prevent transmission (vertical transmission) of infection to NB through birth canal - Ex: Trachoma ( or inclusion conjunctivitis of NB) and PNA 2. - obtain NAATs such as Gen-Probe, Amplicor, or ProbeTec - Gen-Probe can only be used on cervix and urethra → Do NOT collect specimens from eyes - Test of cure needed in 3 weeks after completing treatment 3. - FIRST-Line: Azithromycin 1 g PO (single dose) - Alternative: Amoxicillin 500 mg PO TID x 7 days (lower cure rate than azithromycin) 4. - FIRST-Line: Azithromycin 1 g PO (single dose) - Doxycycline 100 mg PO BID x 7 days (do NOT use if breastfeeding stains tooth enamel, category D) - Avoid sex activity for 7 days - Avoid unprotected intercourse until both partners are treated - test for other STDs (gonorrhea, syphilis, HIV)

Answer 95

- Women who exclusively breastfeed (at least Q4hr daily) with amenorrhea and who are <6 months postpartum are much less likely to ovulate than woman who doe snot breastfeed exclusively (lactational amenorrhea method) - In women who do not breastfeed ovulation resumes (average) at 39 days postpartum - During postpartum period and w/ breastfeeding, BC pills or any contraceptive method containing estrogen (pregnancy category X) is contraindicated - Postpartum women or women who cannot take estrogens can use methods such as IUDs (copper or levonorgestrel) or progesterone-only contraception such as etonogestrel (Nexplanon), depot medroxyprogesterone (Depo-Provera), progestin-only pills, or barrier methods (condoms, diaphragm, cervical cap) → progestin-only contraceptive pill norethindrone (Micronor) contains 28 active pills that are taken daily (no pill-free week) → For max effectiveness, pill must be taken at the same time each day (very important) → If >3 hours late, take dose ASAP and use backup (condom) for the next 2 days; will probably have vaginal spotting for the next few days

Pregnancy and Childbirth Flashcards

(119 cards)