Week 7 pt 2 Flashcards
(143 cards)
1
Q
Interpret a transcranial doppler for fetal anemia
A
1) If velocity not high = no immediate workup
2) If velocity is high = make decision about delivery based on gestational age
Age < 34 weeks = stay in the womb, but PUBS (percutaneous umbilical blood sample), transfuse as needed
Age > 34 weeks = delivery
2
Q
Define chronic HTN
A
Hypertension present before pregnancy or before the 20th week of gestation or persists longer than 12 weeks after delivery.
3
Q
Define mild/moderate chronic HTN and severe chronic HTN
A
1) Mild/Moderate
140-159mmHg Systolic
90-109mmHg Diastolic
2) Severe
>160mmHg Systolic
>110mmHg Diastolic
4
Q
List the risks of chronic HTN
A
1) Development of preeclampsia
-Acute onset of proteinuria and worsening HTN
2) Development of eclampsia later in pregnancy
5
Q
50% of those with _____________________ will develop preeclampsia
A
gestational HTN
6
Q
List risk factors for preeclampsia
A
Nulliparity, multifetal gestation, maternal age 40 years or older, preeclampsia in previous pregnancy, diabetes, antiphospholipid syndrome, obesity, in vitro fertilization
7
Q
List the severe features of preeclampsia (1 or more req. to Dx)
A
≥160mmHg systolic of ≥110 mmHg diastolic
Serum creatinine >1.1mg/dl or doubling of baseline
Vision disturbances
Pulmonary edema
RUQ pain
Hepatic dysfunction (LFTs 2x normal)
Platelet count<100,000/microliter
8
Q
Describe the epidemiology of eclampsia
A
1) 0.5%-4% of patients with preeclampsia
2) Uncommon (1.5-10/10,000 deliveries) in high-resource countries
9
Q
What is the Tx for HELLP syndrome?
A
If less than 34 weeks, steroids and if stable delivery in 24-48 hours
Otherwise, immediate delivery.
10
Q
What should your H&P include for an HTN eval?
A
Vision disturbances, headache, RUQ pain, edema, fundoscopic exam, hyperreflexia, clonus
11
Q
List 2 fetal studies that should be done for HTN and why they’re done
A
1) Ultrasound
-Intrauterine growth restriction
-Oligohydramnios
2) Nonstress test +/- Biophysical profile (BPP)
-Uteroplacental insufficiency
12
Q
HTN management:
1) What is the goal?
2) How do you Tx chronic HTN if ≥160/105?
A
1) Balance the management of fetus and mother
2) PO Labetalol and CCBs (nifedipine or amlodipine) considered 1st line.
*No ACEis and ARBs (fetal malformations)
13
Q
How do you Tx preeclampsia if:
1) No severe features
2) Severe features but <34wks
3) Diagnosed at term or beyond
4) If severe features
A
1) If NO severe features: rest, frequent monitoring (u/s q 3swks, weekly labs, twice weekly NSTs, BPPs)
2) If severe features but <34wks, select patients may be managed expectantly inpt with frequent assessments.
3) If diagnosed at term or beyond, delivery.
4) If severe features, Magnesium sulfate IM or IV (4-6 mg/dL) to prevent or treat eclamptic seizures, steroids for fetal lung maturation if <37wks, delivery if worsening.
14
Q
How do you manage and Tx HELLP?
A
1) High-risk obstetric center
2) Correction of coagulation abnormalities
-Platelet transfusion if less than 20 (or 50 before csection)
3) Two doses steroids (if less than 34 weeks) then deliver within 48 hours unless worsening
15
Q
DM occurs in _______% of pregnancies (gestational or pregestational)
A
6-9%
16
Q
List the 3 classifications of DM
A
Type I DM: Destruction of pancreatic cells
Type II DM: Insulin resistance and exhaustion of cells
Gestational DM (GDM): identified during pregnancy and usually subsides postpartum
17
Q
What occurs with DM after pregnancy?
A
95% of mothers will return to normal immediately
70% will develop Type II DM later in life
18
Q
Describe the physiology of DM in pregnancy
A
hPL: Human placental lactogen
Produced by placenta
Promotes lipolysis: increased fatty acids circulating and decreased glucose uptake so “anti-insulin”
Estrogen and Progesterone
Also affects glucose metabolism
Insulinase
Produced by placenta
Degrades insulin
Glucosuria of pregnancy: 300mg/day = normal
19
Q
Describe the fetal complications of DM in pregnancy
A
1) Most common deformities: Cardiac, CNS, renal and limb
2) Congenital Anomalies: Sacral agenesis
3) Spontaneous Abortion and Stillbirth
4) Macrosomia (>4000-4500g)
5) Polyhydramnios
6) Hypoglycemia (especially soon after delivery)
7) HgbA1c
-5-6% malformation rate= 2-3% (close to normal)
->9.5% malformation rate = 22%
20
Q
A pts Hgb A1C obtained before conception shows elevation. Interpret it based on numeric value
A
> 6.5 = diabetes
< 5.7 = NOT diabetes
In between these two values = prediabetes
21
Q
Describe screening for gestational DM
A
24-28 weeks: 1 hour glucose tolerance test (50g drink)
If “failed” (>140), 3-hour glucose tolerance test (100g drink)
Dx: GDM
If positive, test again after pregnancy (4-12 weeks after delivery)
22
Q
What are the numeric goals of DM management?
A
Fasting glucose <95mg/dL
1hr post prandial: <140mg/dL
3hr GTT: 1hr <180mg/dL; 2hr <155; 3hr <140
Diet control first!
23
Q
What should you do if diet doesn’t control blood sugar?
A
If diet does not control BS, insulin.
Insulin does not cross the placenta (but glucose dose
24
Q
What should you do for diabetic patients before they get pregnant?
A
Control glucose prior to pregnancy if already dx with DM
Switch medications to insulin
25
DM delivery; when do you deliver if:
1) BG controlled without medication
2) BG controlled with medication
1) Spontaneous delivery week 39-end of 40 (before week 41)
2) Spontaneous delivery start of 39 to end of 39 (before week 40)
26
DM delivery; when do you deliver if:
1) BG controlled with inpatient meds
2) BG not controlled
1) Induce delivery if baby is term
-week 37 to end of week 38 (before week 39)
2) Induce, even if baby is late preterm
-start of week 34 to end of week 36 (before week 37)
27
Describe the 1hr and 3 hour glucose tests in detail
1) 1-hour test: Screens women at 24-28 weeks for “gestational DM”
2) 3-hour test: Used as follow up to positive 1-hour test
Done with three values: fasting after one hour, after two hours, after three hours
Positive if two or more values are above the thresholds you were shown
28
hCG has a weak _______________ effect on the thyroid because the alpha subgroup is similar to TSH.
stimulating
29
List the indications for thyroid testing in pregnancy (chart)
30
Hyperthyroidism/Grave’s disease: What are the Txs? Explain
1) Tx: PTU in 1st trimester (risk of liver failure)
2) 2nd and 3rd: methimazole.
*Avoid 1st trimester.
31
1) What do you need to know abt thyroid storm?
2) What should you do for Hypothyroidism/Hashimoto’s thyroiditis in pregnancy?
1) Medical emergency. Send to ER.
2) TSH monitored each trimester
Tx: Levothyroxine (Synthroid)
Increase dose 25-30% during pregnancy (from the start)
32
Describe Postpartum thyroiditis (5-10% people w no hx of thyroid dz)
1) Autoimmune inflammation; Hyper or hypo
2) Most resolve on own
33
List some ddxs for N/v in pregnancy
Gastroenteritis
Bowel Obstruction
Pancreatitis
Appendicitis
Pyelonephritis
DKA
Pseudotumor cerebri
Drug Toxicity
Cholecystitis
34
What are the Txs for n/v in pregnancy?
first line: Vit B6 (pyridoxime); Zofran, etc.
35
How common is hyperemesis gravidarum (HG)? What 3 things increase risk?
1) .3-3%
2) Multiple gestation
Molar pregnancy
Family history
36
What are some complications of HG?
Hypokalemia/hyponatremia
Encephalopathy
Vitamin B6/B12 deficiency
Mallory-Weiss tears
Fetal growth restriction
Metabolic alkalosis
37
How do you Tx HG?
1) Antiemetics and hydration
2) Corticosteroids (only if severe)
IV Hydrocortisone or Methylprednisolone
Followed by two-week taper.
*Do not use during first 10 weeks of gestation (oral clefts)
38
Intrahepatic Cholestasis of Pregnancy (ICP): Describe the prevalence of cholestasis without inflammation and when it occurs
0.2%-1% of pregnancies in the US (4% in South America)
2nd half of pregnancy
Risk of intrauterine fetal demise
39
Intrahepatic Cholestasis of Pregnancy (ICP): What are the S/Sx?
3rd trimester mom with pruritus (esp. hands and feet)
elevation of fasting total serum bile acid
40
ICP: How do you Dx?
Elevated bile acid concentration
Possible elevation in AST and ALT
GGT usually normal
No abnormality on imaging
41
ICP: How do you Tx?
Repeat bile acid test
Treat with ursodeoxycholic acid
Deliver at 37wk
If bile acid level is > 100 micromole/L at any point in pregnancy, deliver at 36 weeks
*High risk of stillbirth
42
Describe acute fatty liver
Uncommon but most common cause of acute liver failure in pregnancy
Microvascular fatty infiltration of hepatocytes
Typically, presents in 3rd trimester
43
List the Sx of acute fatty liver
Persistent nausea and vomiting
Malaise
Anorexia
Abdominal pain
Edema
Jaundice
44
Most common cause of dyspepsia is what?
GERD
45
GERD: What are the recommendations for pts?
Drink 8oz of non-caffeinated fluid daily
Avoid milk products toward the end of the day
Avoid fatty foods
Tobacco cessation (prior to pregnancy!)
No eating 2-3 hours before bedtime
Elevate head of bed 30 degrees
46
How do you Tx GERD in pregnancy?
Lifestyle modifications antacids (Tums, etc) H2 blockers (Pepcid) PPI
47
What Can mimic hyperemesis gravidarum?
PUD
48
Describe Tx of PUD in pregnancy
Acid suppression with PPI (omeprazole or pantoprazole)
H.pylori: antimicrobial treatment deferred until after delivery if mild symptoms
Bismuth, Metronidazole, levofloxacin contraindicated in pregnancy
49
What should you do before pregnancy for pts with IBD?
400 mcg folic acid supplementation
Stop smoking/limit caffeine
Review med list: most IBD meds are low risk
Sulfasalazine and mesalamine can be continued during pregnancy
In most cases, a flare during pregnancy is higher risk to baby than medication
50
What are the effects of IBD on pregnancy?
1) If in remission = continued remission is likely during pregnancy
2) If active at the time of conception = likely to have active disease during pregnancy
51
Describe asthma severity classification in pregnancy
52
List asthma mgmt for:
1) Mild- intermittent
2) Mild-persistent
3) Moderate-persistent
Mild- intermittent
Albuterol PRN for rescue
Mild-persistent
Inhaled low-dose corticosteroid therapy
Moderate-persistent
Low-dose + salmeterol OR medium dose inhaled corticosteroid
53
List asthma mgmt for Severe-persistent pts
1) High-dose inhaled corticosteroid + salmeterol + (if needed) oral corticosteroid
2) Severe pregnant patients cared for same as non-pregnant
PFTs, ABG, supplemental oxygen, treatment with nebulized β-agonists, corticosteroids (oral or IV), or intubation
54
Describe Asymptomatic Bacteriuria and Acute Cystitis
Increased risk due to urinary stasis and glucosuria
25-30% not treated will progress
Most common organism is E. coli.
Treat with...
Fosfomycin
Cefpodixime
Augmentin
Ampicillin/Amoxicillin
Nitrofurantoin
Cephalexin
55
Pyelonephritis:
1) How common/ uncommon is it?
2) What are the Sx?
1) 2% of all pregnant pts
2) Acutely ill:
Fever
Costovertebral tenderness
Malaise
Dehydration
Bacteriemia
Septic shock!
56
What is the Tx for pyelonephritis in pregnancy?
IV hydration and abx are the Tx
ceftriaxone/cefepime are first line,
or
ampicillin
+
gentamycin
Expect definite improvement by 48hrs
57
Nephrolithiasis and Urinary Calculi:
1) How common/ uncommon?
2) S/Sx?
1) 1 in 1500 pregnant patients
2) Hematuria
Acute flank pain radiating to groin or lower abdomen
2nd-3rd trimester
Pyuria (40%)
58
Preexisting Renal Disease: List the risk stratification based on Cl/Cr
1) <1.5mg/dL: Little/no risk
2) 1.5-3.0: Likely deterioration of renal function
3) >3.0: Serious complications
Hypertension
Intrauterine growth restriction (IUGR)
59
Superficial thrombosis: Describe the pathophys
Occlusion of superficial veins
Usually in lower extremities
Risk is increased in pregnancy
60
Superficial thrombosis:
1) How does it present?
2) How do you Dx?
3) How do you Tx?
1) “my leg hurts and it’s a little red right here”
2) Clinical; probably don’t need US, but you could get one to ensure it’s not a DVT
3) Usually NSAID, but not in pregnant patients…
Instead, choose other pain control and monitor (acetaminophen)
61
DVT:
1) Why is pregnancy hypercoagulable?
2) How do you Dx? Where is it most commonly found?
1) Increased coagulation factors
-Endothelial damage
-Venous stasis
2) D-dimer, Doppler US or venography, VQ scan or CTA of chest
-90% of pregnant DVT patients will have it in the left leg
62
How should you counsel patient on risks of pregnancy on anti-seizure meds?
1) Meds have risks of congenital defects
2) But uncontrolled epilepsy can be life-threatening
Fetal risk of injury (e.g., placental abruption) or oxygen deprivation from a prolonged maternal seizure
63
Seizures:
1) What should you take before conception?
2) What abt after 36wks?
1) Take folic acid 4mg QD before conception
2) Vitamin K 10mg po QD after 36 weeks (w certain meds)
64
Seizures:
1) What are preferred meds?
2) What meds do you need to avoid?
3) What kind of dose should you use? Explain
1) Lamotrigine and Levetiracetam preferred
2) Valproate and carbamazepine
3) Use lowest possible dose
Measure drug level before delivery, each trimester and 4-8 weeks post-delivery
65
How do you Tx Tension Headaches/Migraine Headaches in pregnancy?
Tylenol/Reglan/Caffeine
Compazine or Phenergan (vomiting)
IV fluids (can add dextrose)
Avoid triptans in 1st trimester
66
How do you Tx Post dural puncture headaches in pregnancy?
Can occur after epidural placement
Most resolve spontaneously in 24-48 hours
Bed rest, hydration, epidural blood patch
67
What may the headache red flags be telling you about in pregnancy? How do you Tx this?
Preeclampsia
Tx: magnesium IV
68
Describe MS in pregnancy
1) Diagnosis ~ 30 years old
2) Fewer relapses during pregnancy
If relapse
3) IV methylprednisolone
Lower birth weight of infant and a higher cesarean delivery rate have been noted in patients with MS
69
Systemic Lupus Erythematosus (SLE): Why is there a 20 fold increased risk for maternal mortality?
Thrombosis
Infection
Transfusion
C-section
preterm labor
Preeclampsia
70
SLE in pregnancy: What should you continue and discontinue?
Continue aspirin and corticosteroids
*Discontinue cyclophosphamide and methotrexate
71
Neonatal lupus:
1) What can Antigen-antibody complexes cause?
2) How do you Tx?
1) Skin lesions
Hepatosplenomegaly
Leukopenia/Thrombocytopenia/Hemolytic anemia
2) Corticosteroids, plasmapheresis and IV immunoglobulin
72
Antiphospholipid Antibody Syndrome: What are the 3 indications for evaluation?
1) Two or more failed clinical pregnancies documented by ultrasound
2) Three consecutive pregnancy losses
3) Recurrent thrombosis of any size vessel
73
Antiphospholipid Antibody Syndrome:
1) Autoantibodies are present in ___% of healthy patients
2) __________________ antibody IgG and IgM and lupus anticoagulant
1) 5%
2) Anticardiolipin
74
Describe Bell's palsy in pregnancy
Increased chance in pregnancy
Third trimester or postpartum
Increased chance of permanent paralysis
75
Depression and anxiety:
1) Affects 1 in __ women
2) What are the risk factors?
3) What should you avoid in treatment?
1) 7
2) Hx of depression or anxiety, lack of social support, unintended pregnancy, lower education/socioeconomic status, smoking and substance abuse, traumatic birth experience, problems with breastfeeding
3) Paroxetine
76
1) Define bipolar disorders
2) Postpartum Psychosis occurs when? In who?
1) Episodes of mania/hypomania with depression
2) 2-3 days postpartum
Usually in pts with previous dx bipolar, schizophrenia
77
Postpartum Psychosis:
1) S/Sx?
2) How do you Dx?
1) Delusions, hallucinations, thought disorganization
2) Primary mood disorder + peripartum onset
78
Surgery:
1) What increases risk of fetal loss?
2) What leads to delays?
1) Surgery (esp. abdominal surgery) increases the risk of fetal loss
2) Reluctance leads to delays which increases morbidity/mortality for mother and fetus
79
Describe the timing of surgery in pregnancy
Elective surgery should be avoided
Acute/emergent: safest in 2nd trimester
80
Is anesthesia teratogenic?
Little evidence of teratogenesis from anesthesia
81
Pulmonary aspiration:
1) Define it
2) Pregnant women should be treated as if they have a full stomach, so what do you need to premedicate with?
1) Gastric contents regurgitated into trachea and lungs leading to injury
Potentially fatal
2) Citrate: antacid, increases pH
Histamine blockers: increase pH, decrease volume of gastric contents
82
Appendicitis:
1) Define it
2) What are the Sx?
1) Inflammation of the appendix secondary to obstruction
2) Usual symptoms of appendicitis are less obvious in pregnancy
-Epigastric pain, nausea, vomiting
RLQ pain is still the most common presentation
-Location is different slightly different due to enlarging uterus displacing the appendix superolaterally
83
Describe imaging of appendicitis
1) Ultrasound often initial
“Noncompressible tubular structure” in the region of the pain
2) MRI is widely used for diagnosing appendicitis in pregnant women if u/s inconclusive
3) CT Scan
-Involves radiation exposure
Fetal exposure: 0.025 Grays (Gy)
Exposure to less than 0.05 Gy not associated with fetal anomalies
84
List and describe the 2 approaches to appendectomy
1) Laparotomy
Open the abdomen: quicker but more traumatic and pain
Better fetal outcomes
2) Laparoscopy
Cameras and tubes: less trauma, fewer complication rates but CO2 from insufflation can cross into placenta and lead to fetal respiratory acidosis
85
Acute Cholecystitis / Cholelithiasis:
1) What is it?
2) What are the Sx?
3) What imaging? What will it show?
1) Gallbladder inflammation secondary to obstruction
2) Nausea, vomiting, RUQ pain
3) U/S: increased thickness of gallbladder wall
86
Acute Cholecystitis / Cholelithiasis: How do you manage it?
1st line medical: IV fluids, pain control, and gastric decompression
2nd line surgical: laparoscopic cholecystectomy is safe
87
Describe the mgmt of acute pancreatitis
Management = Admit
1) Medical: 1 – 10 days of rest, IV fluids, NG suction
If not improving, move to surgical options
Maternal and fetal risk is high
2) Surgical:
Peritoneal lavage, operative draining, partial pancreatic resection
Or some combination of these
88
Bowel obstruction
1) What is it?
2) What are the Sx?
1) Obstruction of intestines that prevents the flow of digestive products
Usually due to postoperative adhesions
2) Cramping, abdominal pain, obstipation
89
Bowel Obstruction:
1) What is the diagnostic testing?
2) How do you manage it?
1) XR: dilated loops of bowel and air-fluid levels
2) Medical: NG suction and IV fluids for 2 – 4 days
Surgical: exploratory laparotomy
90
Adnexal torsion:
1) What is it?
2) What are the symptoms?
1) Twisting of adnexa resulting in vascular compromise
2) Sudden, severe abdominal pain (may or may not radiate to flank or anterior thigh)
1st/early 2nd trimester: palpable mass
Nausea, vomiting
91
Adnexal/Ovarian Torsion:
1) Describe the diagnostic testing (4 things)
2) Describe the surgery
1) Fever
Leukocytosis
Increased creatine phosphokinase
Ultrasound: adnexal mass
2) Untwist to attempt to save viable appearing ovary
Removal of ovary
If it contains the corpus luteum, progesterone supplementation is necessary
92
True or false: Adnexal masses are not uncommon
True
93
What are the most common ovarian tumors?
Paraovarian cysts
Corpus luteal cysts
50-70% will resolve spontaneously
Risk of finding malignant ovarian tumor is 3-7%
94
How do you diagnose ovarian tumors in pregnancy?
Ultrasound
95
1) What can abd trauma lead to?
2) Describe GSWs (gunshot wounds) in pregnancy
1) Placental abruption + can also lead to uterine contusions and fetal skull fractures
2) Treated the same as in nonpregnant patients
Stop the bleeding and repair the injuries
As long as pregnancy is intact, uterus should not be disturbed
Consider the possibility of domestic violence
96
Describe the pathology of toxoplasmosis
1) Toxoplasmosis: protozoan Toxoplasma gondii
2) Pregnant woman in contact with cat feces (changing litter box) or soil (gardening)
3) Pregnant woman consumes undercooked lamb or pork
4) Virus passed to fetus through placenta during first 6 months of pregnancy
97
Describe the patient symptoms with toxoplasmosis
1) Mom: usually asymptomatic, but may have flu-like symptoms
-Baby: Congenital toxoplasmosis
2) Classic Triad:
-Chorioretinitis: Inflammation of choroid and retina seen on fundoscopic exam
-Hydrocephalus: ICF accumulates and enlarges ventricles macrocephaly
-Intracranial calcifications: White spots on CT
98
List the steps of toxoplasmosis screening
1) Step 1: Serum IgG antibodies
If positive, step 2
If negative, consider retest in 3 weeks
2) Step 2: Serum IgM antibodies
If positive, step 3 and treat
If negative, infection was greater than 6 months ago
3) Step 3: Serum IgG avidity status
If low, step 4
If high, infected 12 weeks or longer ago (chronic?)
4) Step 4: Resend IgG, IgM and avidity after 3 weeks
Go back to step one to interpret findings
If still not diagnostic, go to step 5
5) Step 5: Amniocentesis for Toxoplasmosis PCR
99
True or false: With toxoplasmosis, antimicrobial treatment offered to women diagnosed with recent infection to protect baby
True
100
Describe the early signs of hydrops fetalis (before 2 years)
Maculopapular rash > including palms and soles
“Snuffles”: rhinorrhea
101
Describe the later signs of hydrops fetalis (before 2 years)
Frontal bossing: bulging of frontal skull
Saddle nose
Short maxilla
Hutchinson teeth: small notched teeth
Saber shins: bending of LE long bones
Damage to CN VIII: deafness
102
Describe the diagnosing of syphilis
1) Part of routine screening with serologic testing
RPR (rapid plasma regain) or VDRL (venereal disease research laboratory)
2) If positive, confirm with FTA-ABS (fluorescent treponemal antibody absorption) or TPPA (t. pallidum particle agglutination assay)
103
Describe the treatment of syphilis
1) PCN G benzathine
If allergic, desensitize
2) Obtain serial post treatment titers (RPR or VDRL) and follow for one year
104
Describe the Sx of congenital rubella (“German Measles” or “3-day Measles”)
Patent ductus arteriosus
Microcephaly
Intellectual disability
Deafness
Cataracts
“Blueberry Muffin”
105
What are the screening and Tx for rubella?
Screening: IgG antibodies
Tx: supportive care
106
Do not give live ______ Vaccine to pregnant patient or 4 weeks before conception
MMR
107
Cytomegalovirus (CMV):
1) Describe the pathology
2) What are the Sx in mom?
1) Sexual contact or organ transplant
Passed to fetus via placenta
2) Usually asymptomatic, may have “mono” type sx
Fever, LAD, sore throat
108
Cytomegalovirus (CMV): Describe the Sx in baby
Deafness and eye abnormalities
Seizure and intellectual disability
Microcephaly
Periventricular calcifications (brain)
109
Cytomegalovirus: How is it diagnosed?
1) Discovered on US screen
Ventricular calcifications
Microcephaly, fetal growth restriction
Ascites
Hydrops
Many others. . .
2) Antibodies can be obtained to confirmed
110
How is CMV treated?
-Usually, supportive care only
-If you discover infection in mom early, you can treat with valacyclovir or hyperimmune globulin to prevent fetal disease
111
Describe primary herpes
no evidence of prior HSV infection
Greatest risk to the fetus
Meningoencephalitis
Neonatal infection 50%
112
Herpes:
1) What does recurrent mean?
2) What are the 2 relevant forms?
1) Prior infections or serologic evidence
2) HSV 1 (“oral”) and HSV 2 (“genital”)
113
How do you Tx herpes?
1) If mom has history of HSV but no flare = normal pregnancy
2) If mom does not have a history of HSV and there's concern she has a new infection = start acyclovir
3) If history of HSV and a flare during pregnancy start acyclovir at week 36 and continue until term
4) If active lesion at labor = cesarean delivery
If you can’t do C-section = IV acyclovir
114
Describe the pathogenesis of varicella zoster
1) Respiratory droplets (incubation 10-21 days)
2) Direct contact with oral or skin lesions
Rash (chicken pox) = secondary reactivation (shingles)
3) Mom is unvaccinated with no history of infection
Transmits to baby through placenta during 1st or 2nd trimester
Low rate of transmission ~2%
115
How do you diagnose varicella?
Maternal = clinical
Prenatal = PCR
Postnatal diagnosis is made with the following criteria:
History of maternal varicella during 1st or 2nd trimester
Presence of compatible fetal abnormalities
Evidence of intrauterine VZV infection
Detection of VZV DNA or of antibody
116
Describe the 4 modalities of varicella treatment
1) Mother with characteristic varicella rash can be given oral acyclovir within 24 hours of rash to decrease symptoms, however it has not been shown to decrease rate of fetal transmission
2) If clinical infection manifests in mother from 5 days prior to delivery or 2 days after delivery, severe and deadly neonatal infection can occur: Varicella zoster Ig (VZIG) is given to infants in these cases
3) Varicella pneumonia is serious for MOM and can lead to maternal mortality: IV acyclovir is given in this situation plus admission
4) If neonate shows symptoms of congenital varicella syndrome, IV acyclovir
117
When is a neonate at a high risk for Gonorrhea and Chlamydia?
High risk with vaginal delivery
Neonatal sepsis
Scalp abscess
Meningitis
Neonatal conjunctivitis (ophthalmia neonatorum)
Conjunctival inflammation
Mucopurulent Eye discharge
Can lead to blindness
118
How do you Tx gonorrhea and chlamydia?
screen/treat mother BEFORE delivery
Ceftriaxone 500mg IM (1gm if >150kg)
Azithromycin 2gm PO x1
Retest in 1 week to confirm clearance
119
Hepatitis B:
1) How is it transmitted?
2) What does HBeAg indicate? Explain
1) Vertical/Blood/Sexual contact
2) If + HBeAg = higher viral load
Highest risk if contracted in 3rd trimester
Can transmit through breastmilk
120
Hep B:
1) You can vax in pregnancy, but when else can you vax?
2) What should you do if exposed in pregnancy
3) When do you Tx with tenofovir?
1) Infants: initial injection 2 day- 2 months old
Within 12 hours of birth if mom Hep B+.
2) If exposed during pregnancy, HBIg ASAP then start vaccination series.
3) if chronic carrier and high viral load to decreased risk of intrauterine fetal infection
121
Hep C:
1) How is it transmitted?
2) How is it diagnosed?
1) Sexual, parenteral and vertical
2) anti-HCV IgG
May not be detectable until up to 10 weeks after onset of clinical illness
50% of infected individuals go on to have chronic infection
122
Hep C: When is breastfeeding contrandicated?
If mother has cracked or bleeding nipples
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List the risk factors for routine screening of Hep C
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Hep D:
1) How common is chronic infection?
2) What abt vertical transmission?
1) Chronic infection can occur
25% mortality rate
2) Vertical transmission rare
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Hep D:
1) How do you Dx?
2) Is there a vax?
1) HDV antigen and anti-HDV IgM in acute disease, (IgG develops but not protective)
2) No vaccine available
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Hep E:
1) How is it transmitted? What is the risk of vertical transmission?
2) How do you Dx?
1) Waterborne
Risk of vertical transmission low; uncommon in the US
2) HEV antibodies
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Hep E:
1) How do you Tx?
2) Is there a vax?
1) Self-limited, higher risk of mortality in pregnant women (20%)
2) No vaccine available
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Describe the diagnosis of HIV
1) Routine screen at first neonatal visit: P24 antigen and HIV antibody screen
-Effective screen starting within 10 days of HIV infection
2) If not available = western blot
3) If positive = PCR for viral load and CD4 count
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Describe the Tx of HIV in pregnancy
1) Antiviral therapy > delivery
HIV antiviral therapy
Follow viral load levels
Should become undetectable in 3 months
*Target of therapy is low viral load before delivery between week 36-38
Baby may need antiviral after delivery
2) If viral load not adequately suppressed
C section + medication
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TB: Do you screen for it in pregnancy?
TB in pregnancy is common worldwide less so in the United States
Only screened if significant risk factors or exposure
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HPV:
1) Which are assoc with warts?
2) What abt dysplasia?
1) 6,11 associated with warts
2) 16,18 associated with dysplasia
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HPV:
1) How do you Dx in pregnancy?
2) How do you Tx?
1) clinical, only biopsy if uncertain
2) Indication for treatment the same as non-pregnant: bothersome symptoms or psychologic distress
-But additionally, remove warts that may obstruct delivery through the vaginal canal
-Podophyllin, podophyllotoxin, interferon, FU all contraindicated
-Can give topical imiquimod
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Should you have a C-section with HPV?
CDC does not recommend C-section unless they imped vagina
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Parvovirus (B19) (Fifth Disease)
1) What is the pathology?
2) Describe the Sx in the mother
3) Describe the Sx in the fetus
1) Respiratory droplets
Decreased production of RBCs = red blood cell aplasia
2) Arthritis: Symmetrical in small joints hands, wrists, knees, feet:
3) Anemia > Increased HR > Increased fetal blood pressure > Hydrops fetalis
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Parvovirus (B19) (Fifth Disease):
1) How do you Dx?
2) How do you Tx?
1) Antibody test looking for IgM/IgG
2) Monitor for anemia / hydrops with US
Fetal skin edema, ascites, pleural or pericardial effusion
-Monitor anemia with transcranial doppler
Percutaneous Umbilical Cord Sampling (PUBS) transfuse if necessary
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Listeria:
1) What type of bacteria?
2) Where is it contracted from?
1) Gram positive bacillus
2) Food:
Deli meat
Frozen vegetables (2016 outbreak)
Unpasteurized milk (including soft cheese)
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Listeria:
1) Where are the Sx in mom?
2) What abt baby?
1) Mom: Flu-like illness (can progress to sepsis)
2) Baby: Premature delivery, stillbirth, sepsis
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1) What is Zika? How/ when is it transmitted?
2) What are the S/Sx?
1) Identified in 2015, transmitted by mosquitoes or sexual contact
Vertical transmission highest 1st and 2nd trimester, but can happen anytime
2) Severe microcephaly
Misshapen skull
Scalp rugae
Intracranial calcifications
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Zika:
1) List the complications
2) How do you Dx?
3) How do you Tx?
1) Chorioretinal atrophy or scarring
Cognitive disorders
Hypertonia, spasticity, tremors
Seizures
Swallowing Disorders
Clubfoot
2) PCR
3) Supportive care
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Streptococcus agalactaie (group B Strep): Describe this condition
Asymptomatic
Colonization in up to 30% of pregnant women
50% of infants exposed will become colonized
GBS Sepsis occurs in approximately 1.7 infants per 1,000 live births
Septicemia/septic shock, pneumonia, meningitis
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Step B:
1) When does it occur early?
2) What abt late?
1) Early-Onset: Days 1-6
2) Late-Onset: >6 days-3months
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How do you Tx group B strep?
1) Will get antibiotics during delivery: Penicillin G
2) C-section not indication for GBS abx
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