10. Obstetrics Flashcards
Describe : Spontaneous abortion
Pregnancy loss < 20 w GA
Differenciate spontaneous abortions
* Inevitable
* Incomplete
* Complete
* Missed
* Recurrent / Habitual
* Septic
- Inevitable: cervix dilated, no products expelled
- Incomplete: some but not all products expelled, retained products
- Complete: all products of conception expelled
- Missed: fetal demise but no uterine activity
- Recurrent / Habitual: ≥ 3 consecutive pregnancy losses
- Septic: Spontaneous abortion complicated by uterine infection
Name signs and symptoms : Spontaneous Abortion (5)
- signs of blood loss (syncope, CP, SOB)
- signs of sepsis (fever/chills, postural vitals, increased HR, boggy uterus)
- cramping
- uterus size
- cervix - bleeding, open/closed
Name investigations : Spontaneous abortion (5)
- Beta-hCG (if ⬆️66% in 48hr - likely viable)
- CBC (anaemic?)
- Group and Screen (Rho?) : if Rh neg administer Anti-D (<12 w GA = 120 IM, >12 w GA = 300 IM)
- ?consider gonorrhea + Chlamydia
- Ultrasound (FHR, tissue)
Describe management : Spontaneous abortion (4)
- Expectant management (effective 82-96% within 14days)
- Misoprostol 800 mcg vaginally and then 24 -72 hrs later if no bleeding (po less effective and has more s/e)
- RhoGAM given if Rh negative : <12 weeks = 120mcg IM OR >12 weeks = 300mcg IM
- Vacuum aspiration if hemodynamically unstable (ex. peritoneal signs) or septic (ex. fever), or by patient choice (risk = uterine adhesions/perforation, Anesthetic risks ; benefit = effective 97%, often less bleeding)
Describe tx : Septis Spontaneous abortions (2)
- IV wide spectrum (gentamicin, clindamycin)
- O2
Name regimen for medical abortions (2)
if Rh neg & 49d preg, Rh immunoglobulin 24hr prior to MA
* Day 1: mifepristone
* Day 2-3: Misoprostol
* Day 14: F/U (clinical exam or u/s or beta hCG (⬇️ 80%)) and contraception
Name risks of medical abortions (6)
- bleeding
- cramping/pelvic pain
- gastrointestinal symptoms (nausea/vomiting/diarrhea)
- headaches
- fever or chills, and
- pelvic/lower genital infection, mortality (0.3 per 100,000 usually from infection or undiagnosed ectopic)
Name absolute CI : Medical abortion (4)
- ectopic
- chronic adrenal failure
- inherited porphyria
- uncontrolled asthma
Name relative CI : Medical abortion (4)
- unconfirmed GA
- IUD
- concurrent systemic corticosteroids
- hemorrhagic disorder or concurrent anticoagulation
Name complications : Medical Abortion (4)
- retained products (may need 2nd dose of miso)
- ongoing pregnancy
- post-abortion infection
- toxic shock syndrome
When to screen : Group B Streptococcal Disease (1)
Screen (+/- susceptibility testing if penicillin anaphylaxis) at 35-37w GA w/ vaginal/rectal swab even if planned c/s
Describe tx : Group B Streptococcal Disease (2)
- typically w/ IV penicillin
- often cefazolin if penicillin allergy)
When to give prophylactic ATB : Group B Streptococcal Disease (3)
- Give prophylactic IV abx and immediate obstetrical delivery if PROM / in labour ≥37w GA and any of the following (1) GBS swab+ (2) previous infant w/ GBS, (3) GBS bacteriuria in current pregnancy
- Give prophylactic IV abx if ≥37w GA, unknown GBS & ROM >18hr
- Give 48hr of IV abx if ROM / in labour <37w GA and unknown or +GBS
Name orders for induction of labour (3)
Cervical ripening (bishop <6) :
* Intracervical/intravaginal PGE Prepidil 0.5mg q6-12hrs up to 3 doses (I) (intravaginal = “more timely vaginal delivery”) -> do NOT use in VBAC
* Foley catheter - frate needed for oxytocin (Il-2B) can VBAC, is
slower than PGE
Labour induction: oxytocin augmentation: +q30min
* Risks include fetal compromise, uterine rupture, hypotension
* If uterine activity ⬆️ (>5 contractions in 10min or lasting >120sec),
normal FHR, ⬇️ dose
* If uterine activity + NRFH: reposition mom, BP, ⬆️IVF, r/o prolapse, O2, discontinue oxytocin
Artificial ROM: wait until active labour + head engaged
Describe : Labour dystocia (3)
- cannot be diagnosed prior to active labour or cervix < 4cm
- During active first stage >4 hrs of < 0.5cm / hr dilatation or 0 cm / 2hr
- During second stage >1hr with no descent during active pushing, nulliparous >3hr w/ regional anesthetic or >2hr w/out, parous >2hr w/ regional anesthetic or >1hr w/lout
Name etiologies : Labour dystocia
Etiology: the 4 Ps
* Power = leading cause, contractions hypotonic or in coordinate, inadequate maternal effort
* Passenger = fetal position, attitude, size, anomalies
* Passage = pelvic structure, maternal soft tissue factors (septum, fibroids)
* Psyche = pain, anxiety, stress hormones
* Other factors that impact it: maternal age (⬆️ complications /interventions), obesity (⬆️ 1st stage)
Describe management : Labour dystocia (3)
- Prolonged latent phase - think maybe false labour or premature /excess use of sedation / analgesia
- Oxytocin augmentation useful in protraction of dilation or descent if contractions are inadequate. Risks include fetal compromise, uterine rupture, hypotension. Use lowest dose necessary to produce normal progression
- not recommended to do operative delivery after <2 hr of pushing
Define : Placental Abruption
- premature separation of placenta after 20w
Name signs and symptoms : Placental Abruption (6)
- painful vaginal bleeding
- sudden onset
- constant
- localized to lower back + uterus
- +/-fetal distress
- 15% present with fetal demise
Describe invetigations : Placental Abruption (5)
- clinical
- u/s only 15% sensitive
- CBC
- fibrinogen
- type + cross
Describe management : Placental Abruption (5)
- stabilize (IVF, 02)
- monitors
- blood products
- RhoGAM
- may need c/s
Describe : Premature Rupture of Membranes (4)
- History: gush or continuous leakage
- DDx = urinary incontinence.
- Physical: STERILE SPEC, R/O cord prolapse. no bimanual
- 1) pooling 2) Nitrazine blue 3) Ferning.
Describe management: Premature Rupture of Membranes (7)
If term + GBS + or unknown > abx + start induction
if term and GBS neg -> can wait 24hrs prior to induction
Preterm
* consider Celestone (betamethasone)
* assess for need for immediate delivery (infection (chorioamnionitis), placental abruption or fetal distress))
* get GBS
* hospitalize for at least a few days (likely to have preterm labour).
* If no indication for immediate delivery induce ~ 34-36w GA
Describe investigations : Preterm labour (2)
- Fetal fibronectin
- U/S for cervical length.
Describe management : Preterm labour (7)
- consider Celestone (betamethasone) (12mg IM q24 x2)
- no exams
- bed rest
- transfer to NICU place
- cerclage.
- Tocolytic = Nifedipine (CCB) and Indomethacin (block prostaglandins) have best evidence.
- If imminent preterm birth (>/= 4 cm or planned preterm birth) & </= 33+6 GA, d/c tocolytic + consider antenatal magnesium sulphate 4g/V loading dose over 30min +/- 1g/hr (max 12hr) for fetal neuroprotection. D/C if delivery no longer imminent
Describe sign : Shoulder Dystocia (1)
turtle sign - head retracting after delivery
Describe management : Shoulder Dystocia (7)
ALARMER
* Apply suprapubic pressure/Ask for help
* Legs in full flexion
* Anterior shoulder disimpaction
* Release posterior shoulder
* Manual corkscrew
* Episiotomy
* Roll over on hands and knees
Describe signs and symptoms : Uterine Rupture (4)
- acute onset abdo pain
- hyper/hypotonic uterine cox
- abnormal FHR
- vaginal bleeding
Describe management : Uterine Rupture (4)
r/o abruption, immediate delivery
Describe stages of labor
First Stage
* Regular contractions causing cervical dilatation +/- effacement
* Dystocia: >4 hrs of <0.5cm / hr dilatation or 0 cm / 2hr
* Latent : Complete when nulliparous ≥ 4 cm, parous 4-5cm, cervical length generally <1cm
* Active : Starts when nulliparous ≥ 4cm, parous 4-5cm
Second Stage
* Full dilatation to delivery of the baby
* Dystocia: > 1hr of active pushing w/out descent of presenting part
* Passive : Full dilatation w/out active pushing
* Active : Full dilatation w/ active pushing
Third Stage
* Immediately after delivery of the baby to delivery of the placenta
Fourth Stage
* Immediately after delivery of the placenta to 1 hr postpartum
When to use continuous EFM? (8)
- decelerations or abnormal intermittent auscultation
- single umbilical artery
- velamentous cord insertion
- 3 or more nuchal loops of cord
- combined spinal-epidural analgesia
- labour dystocia
- FHR arrhythmia
- pre pregnancy BMI >35
Describe : Comfort Measures / Pain relief during first stage of labor
Non-pharmacologic
* Benefit from self-hypnosis and acupuncture.
* Some evidence for water immersion to decrease need for epidural & duration of 1st stage.
* Weak evidence for TENS.
* No benefit from acupressure, aromatherapy, audio analgesia, or massage
**Systemic **
* Nitrous oxide: deep inhalation w/ contraction, short acting.
* Opioids: IM, Subcut, IV, can cause n/v, drowsiness, recommend one w/ short half-life to lower negative effects on newbom.
* Do NOT use meperidine (Demerol) due to long-acting active metabolites and negative effects on neonatal behaviours
Regional:
* pudendal nerve block (used for perineum during 2nd stage - 10 mL of 1% lidocaine in 2 locations, just inferior to the sacrospinal ligament, just medial to the ischial spine on each side)
- perineal infiltration (repair of laceration or episiotomy)
- epidural superior pain relief, 1 assisted delivery, maternal hypotension / fever, 1 length of second stage, 1 c/s for maternal distress. Encourage women to maintain mobility and flexibility
Describe fetal monitoring in second stage of labor (2)
- Intermittent auscultation ≤ q5min
- continuous electronic fetal monitoring equal or less q15min if caregiver present at all times
Describe : Active management of third stage
- (administering of all 3 (1) prophylactic uterotonic, (2) early cord clamping & (3) controlled cord traction) is no longer recommended for all women (⬇️ risk of maternal bleed, ⬆️ maternal hypertension, ⬆️ pain, ⬆️ return to hospital for bleed, ⬇️ neonatal blood volume.
- NO difference in length of 3rd stage, RPOC
Describe : Prophylactic Uterotonic during third stage of labor (4)
- oxytocin
- give routinely after delivery of baby to ⬇️ PPH
- Term - given with the delivery of the anterior shoulder
- Preterm - given after clamping to ⬇️ bolus of blood
Describe : Controlled cord traction during third stage of labor (2)
- Traction (once evidence of separation between placenta and uterus, apply umbilical cord traction and suprapubic counter pressure on uterus
- can be routinely offered if birth attendant has the skills
Describe : Timing of Cord Clamping during third stage of labor (2)
- for infants that do not require resuscitation, delayed clamping of 60 seconds is recommended (can keep babe warm with warm towel or on mother’s abdomen)
- Preterm - ideal delayed cord clamping ~60-120sec but at least 30sec
Delayed cord clamping beyond 60 seconds increases risk of what?
for
hyperbilirubinemia
Name C-I of delayed cord clamping ()
Absolute Contraindications
* fetal hydrops
* need for immediate resuscitation,
* disrupted utero-placental circulation (I.e. bleeding vasa previa)
* twin-to-twin transfusion
Relative Contraindications
* risk of hyperbilirubinemia (e.g., polycythemia, severe IUGR, pregestational DM)
Name postpartum complications (5)
- Postpartum Hemorrhage
- Retained Placenta
- Postpartum Fever
- Postpartum Hypothyroidism
- Postpartum Depression
Define : Postpartum Hemorrhage (3)
- blood loss at time of delivery >500 mL vaginal delivery
- > 1000mL C/S
- > can be early or late (after first 24hrs, up to 6 weeks)
Describe etiologies : cDefine : Postpartum Hemorrhage (4)
Etiology: 4 Ts
* Tone: uterine atony = most common cause, occurs w/in first 24 hrs, prevent by giving oxytocin w/ delivery of anterior shoulder. Atony
due to abnormal labour, infection, uterine distention, placental abruption, grand multip, halothane anesthesia
* Tissue: retained placenta or clots
* Trauma: laceration of cervix, vagina, uterus; episiotomy, hematoma, uterine rupture
* Thrombin: coagulopathy (hopefully identified prior to delivery), DIG, ITP, TP, therapeutic anticoagulation
Describe : Management PPH
Basics:
* ABCs, cross & type 4 units
* treat underlying cause
* 2 large
bore IVs and crystalloids,
Medical:
* oxytocin 20U/L NS IV continuous infusion
* ergotamine 0.25mg IM/MM q5min up to 125mg (may exacerbate HTN),
* Hemabate-0.25mg IM/MM g15min up to 2mg, (but
contraindicated in CV, pulm, renal, hepatic dysfunction)
Local:
* bimanual compression/uterine massage, uterine packing
Surgical:
* D&C
* laparotomy with bilateral ligation of uterine arteries, hysterectomy
* +/- angio embolization
Describe (definition, etiology,RF, clinical features) : Retained Placenta (4)
- Definition: undelivered placenta > 30min post-delivery of infant
- Etiology: separated, but not delivered versus abnormal implantation affecting separation (i.e. accreta, increta, percreta)
- RF : placenta previa, prior C/S, curettage, prior manual placental removal, uterine infection
- Clinical Features: placenta not delivering or incomplete placenta on delivery. Risk of PPH and infection.
Describe management : Retained Placenta (4)
- Explore uterus, assess degree of blood loss
- 2 large bore Vs
- type and screen
- firm traction on umbilical cord wi/suprapubic pressure -> oxytocin 10 IU in 20mL NS into umbilical vein > manual removal -> D&C
Describe : Postpartum Fever (1)
fever >38C on any 2 of the first 10 days postpartum, not
including the 1st day
Name etiologies : Postpartum Fever (6)
- Wind: atelectasis, pneumonia
- Water: UTI
- Wound: C/S incision or episiotomy site
- Walking: Pelvic Thrombophlebitis, DVT
- Womb: endometritis
- Breast: mastitis, engorgement
Describe investigations : Postpartum Fever (2)
- if suspect endometritis: blood and genital cultures.
- Otherwise relevant exam and cultures
Describe empiric treatment for
wound infections postpartum (1)
Clindamycin + gentamicin
Describe : Postpartum Hypothyroidism (2)
- History of Hypothyroidism: likely need to ⬇️ thyroxine dose
- New hypothyroidism: often occurs between 6-12 mon
Describe : Postpartum Blues (3)
- extension of normal hormonal changes and adjustment
- Incidence: 85% of new mothers
- Clinical Features: onset day 3-10 , self-limited, doesn’t last more than 2 weeks, mood lability, depressed affect, tearful, fatique, sensitive to criticism, irritable, poor concentration
Define : Postpartum Depression (1)
Major depression episode criteria occurring within 4 weeks or 6 mo of delivery
Describe management : Postpartum Depression (4)
- Screen w/ Edinburg Postnatal Depression Scale
- CBT. IPT
- citalopram, escitalopram, sertraline
- exercise, acupuncture, light therapy, bupropion, desvenlafaxine, duloxetine, fluoxetine, fluvoxamine, mirtazapine, TCA, venlafaxine, ECT (for severe, psychotic)
Describe relevance Pelvic floor exercises postpartum (1)
Pelvic floor exercises immediate postpartum period /risk of urinary incontinence
When to give RhoGAM postpartum?
Give RhoGAM 300ug IM with 72 hours of delivery if infant is Rh positive
Describe : Rubella / Varicella
If Nonimmune, Give MMR (may need to delay if pt has been given received immunoglobulin containing products such as RhoGAM or blood products) or Varicella 0.5mL IM
Can you do exercise when breastfeeding?
Moderate exercise during lactation, does NOT affect quantity or composition of breast milk
Describe post-partum contraception (3)
- Non-lactating: Can begin combination CP 3 weeks postpartum
- Lactating : Micronor 6 weeks postpartum and change to OCP when the patient introduces supplemental feeding OR begin OCP at 3 months if breastfeeding exclusively.
- Can give IUD 6w postpartum
Describe post-partum tests during follow-up 6 weeks ()
pregnancy complications (HT, DM, idiopathic preterm birth, IUGR, or placental abruption) can identify women w/ underlying, CVD risk factors
if any of the above complications:
* 6mo postpartum: BMI, BP, lipid, glucose, urinalysis
* 12mo postpartum: BMI + BP
If GDM: 75g OGTT 6w-Gmo postpartum & A1C q1-3vr
If HTN: BP q6-12mo
Counsel LSM: physical activity, heart healthy diet, monitor weight
Future Preg: consider aspirin starting at 12-16w GA & early DM screen
After a caesarea birth, advise to wait how long until next conception?
Advise to wait at least 18 months prior to conception
What’s the recommended interpregnancy interval?
> 18 and <59 months
Describe HIV and preconception (3)
- Transmission risk to fetus is -2% with antiretroviral therapy.
- Efavirenz is contraindicated.
- Refer to specialist.
Describe seizure disorder and preconception (5)
- Discuss potential pregnancy outcomes related to seizures and seizure medications.
- Moderate risk for folic acid (1mg 3mo prior to conception)
- Lowest dose of one medication recommended, when possible.
- Valproic acid, lithium, and topiramate are contraindicated.
- Less risk with Carbamazepine and lamotrigine.
Describe medication for Systemic Lupus Erythematosus, Rheumatoid Arthritis, and other autoimmune diseases during pregnancy (5)
- Delay conception until good control is achieved.
- Discuss natural history of disease during/after pregnancy.
- Cyclophosphamide, Methotrexate, and Leflunomide are contraindicated.
- Avoid estrogen-containing contraception options in women with SLE and positive/unknown antiphospholipid antibody.
- Discuss use of aspirin and heparin with rheumatologist for women with SLE and antiphospholipid antibody syndrome.
Describe Thromboembolic Disease in preconception (3)
- Counsel re: + risk for VTE during pregnancy and postpartum
- Many will require anticoagulation treatment.
- Coumadin is contraindicated.
Describe thyroid disease and preconception (4)
- Achieve euthyroid state prior to conception(preferably TSH <2.5 Prior to conception (poor evidence).
- Women with hypothyroidism should increase their dose of levothyroxine by 30% as soon as pregnancy occurs.
- Radioactive iodine is contraindicated.
- Screen all women for CBC and TSH, prior to conception.
Should you get pregnent if patient gets varicella, Varicella/ Measles / Mumps / Rubella ?
- Varicella (avoid pregnancy for 1 month)
- Measles / Mumps / Rubella (avoid pregnancy for 3 months)
Describe nutrition and supplements during pregnancy (8)
- Folic Acid
- calcium 1000mg daily through food ‡supplements.
- essential fatty acid rich diet, including omega 3 and 6.
- vitamin D 600 IU daily through supplementation
- vitamin B12 2.6 ug daily through supplement
- Caffeine <300mg /day
- avoiding raw/undercooked meat and fish and unpasteurized milk and cheese, fish high in mercury (avoid Tuna steak, shark, swordfish, marlin, shellfish)
- If at risk, screen for iron deficiency anemia
Describe folic acid intake during pregnancy
- Low risk 0.4-1.0mg daily
- **Mod Risk **(personal Hx of folate sensitive congenital anomaly, FamHx NTD, maternal DM, teratogenic meds anticonvulsant, metformin, methotrexate, Septral], maternal Gl malabsorption [celiac, BD, gastric bypass sx], liver dz, renal dialysis, EtOH over use): 1mg 3 mo prior to conception, if not preg in 6mo, ⬇️ folic acid to 0.4mg x 6mo
-
High risk: (personal NTD history [mom or dad or previous pregnancy w/ NTD): 4mg 3 mo prior to conception, if not preg in
6mo, ⬇️folic acid to 0.4mg x 6mo
Describe physical activity during pregnancy ()
- recommend at least 150 minutes of moderate to vigorous aerobic physical activity per week in episodes of 10 minutes or more.
- Add muscle and bone strengthening activities at least 2 days per week
Describe : Decreased Fetal Movements (2)
- Normal fetal movement = >26w GA > 6 movements / 2 hours
- If <6/hrs: Non stress test: if normal = daily movement counting -> if normal & risk IUGR OR nonstress test abnormal = biophysical
Describe investigations : Gestational Diabetes (GDM) ()
screen ALL between 24-28w GA w/ non fasting 50g OGCT
- If 50g OGCT < 7.8 mmol / L, no further testing needed
- If 50g OGCT 7.8 - 11, order a 2hr 75g OGTT
- Diagnose GDM if FBG 25.3, 1hr ≥ 10.6, 2hr 29.0
- If 50g OGCT ≥11.1 mmol / L, GDM diagnosed
- Altemative: only 75g OGTT, dx GDM if FBG ≥ 5.1, 1hr ≥ 10, 2hr ≥ 8.5
Describe tx : GDM (8)
- Target A1C<6%, FBG 3.8-5.3, 1hr postprandial <7.8, 2hr <6.7
- Monitor Fasting + postprandial 4/d on insulin, 4/d every 2d not on insulin
- Nutritional counseling, if not in target in 1-2w, then start insulin
- Starting at 24w GA, Monitor fetal growth 03-4w & ⬆️ control if concern for macrosomia, ⬇️ control if concern for SGA (order Dopplers)
- at 36w GA order weekly test, NST or NST + AFI or biophysical (more frequent if obese, poor glycemic control, LGA, PIH, SGA)
- Offer induction 38-40w GA
- Postpartum- monitor newborn for hypoglycemia (breastfeed to ⬇️ risk)
- Repeat 75g OGGT between 6w + 6mo postpartum (15-50% risk of DM) normal FBG<6.1, 2hr 7.8, A1C <6%. dx DM FBG ≥ 7, A1C ≥ 6.5%
Describe tx : Nausea + Vomiting in Pregnancy
- Encourage dietary / lifestyle changes, eat anything appealing (II-C)
- If NO iron deficiency, stop prenatal vitamin w/ iron. Take folic acid in T1
- ** Pyridoxine Vit Bc) 10mg°D or Diclectin 10mg 0D (max 8 tabs / d)
- ADD Gravo/ 50mg g4-6hr (max 200 mg/d)***
Altemative:
* acupressure (3 finger breadths above wrist between 2 tendons
* ginger 250mgQD (NNT =3 after 6d), not to be used close to labour, hx vaginal bleed or miscarriage or clotting disorder (risk of hemorrhage)
* mindfulness-based cognitive therapy as adjunct to pyridoxine
adjuncts: treat GERD (antacid / H2blocker / PPI), mood disorder, H Pylori
Describe : Hypothyroidism during pregnancy
- Targets: Trimester 1 TSH 0.2-2.5, after 20w GA 0.2-3.5
- Known Hx: TSH <2.5 Prior to conception (poor evidence). TSH when pregnancy confirmed (1dose 30-40% by 4-6w/ GA)
Hypothyroidism dx in pregnancy: Stabilize TSH ASAP
* Monitor TSH q2-3 w vs. 4-6 w (controversial) until 20w GA
* Likely need to ⬇️dose / pre pregnancy dose postpartum
Describe : Intrauterine Growth Restriction
Definition : small for gestational age > fetus < or = 10% on u/s (Il)
* IUGR -> fetus < or = 10:% on u/s b/c pathologic process (IlI)
* Diagnosis: based on u/s (Do NOT rely on SFH)
Types: “symmetrical vs. “asymmetrical” less important than evaluating
fetal anatomy, uterine and umbilical artery
* Asymmetry: brain is spared,
* Symmetry: TORCH, genetics
Etiology: cigarettes, drugs, TORCH, genetic anomalies
Screening: Trisomy 21, if + > uterine dopplers@19-23w GA
* SF is less than GA by >3 -> biophysical +/- umbilical doppler
Describe management : Intrauterine Growth Restriction
- lx: amniocentesis if ⬆️ risk aneuploidy, Consider TORCH screen
- Maternal: ongoing monitoring for preeclampsia + no smoking. Consider adding low dose asa
Fetal:
* If previable (<500g +/- <24w GA) > monitor
* If viable (>500g + >24w GA) -> EFW, AFV, umbilical Doppler,
in 3%9 trimester - weekly biophysical profile
* If growth continues along the curve -> weekly biophysical + umbilical artery Doppler.
* Consider delivery 38-40w GA
If growth plateaus <34w GA -> corticosteroids, ⬆️surveillance 2-
3/w, consider hospitalization / consulting MFM + peds
* If >34w GA + normal studies -> continue weekly surveillance + consider delivery after 37 weeks
* If >34W GA + abnormal (AFV<5cm or DVP<2cm): BPP+
Doppler study, consider delivery
Describe : Polyhydramnios (2)
- big for dates, u/s, consider amnio, refer
- Maternal: GDM, Fetal: fetal hydrops, genetics, Gl problem
Describe : Oligohydramnios: (2)
- small for dates, u/s, IVF, vesico amnionic shunt
- Renal problem, placenta hypoxia, PROM
Describe opioid use disorder and rpegnancy ()
- In opioid use disorder, use opioid agonist (i.e. methadone /buprenorphine).
- Detox reserved for select patients. Counsel about neonatal withdrawal + monitoring.
- Can still breastfeed on opioid agonist
Name C-I : Trial of Labour After C-Section (4)
- Hx uterine rupture, uterine reconstruction
- classic /inverted T uterine scar
- placenta previa
- malpresentation
Describe : Trial of Labour After C-Section (5)
- rupture rate<1%
- Success 75%
- Allowed but ⬆️ risk : ≥ 2 c/s, <18mo of c/s, induction of labour
- Not contraindicated : multiple gestation, GDM, postdates
- Needs continuous fetal monitoring, avoid PGE, use foley for induction
Name factors that lower success for trial of labour after C-Section (5)
- ↑ age
- ↑BMI
- GA>40w
- BW>4000g
- hx dystocia
Can use a VBAC calculator tool to calculate odds of success
Define : Placenta Previa / Low lying placenta
- Previa = covering os
- lowing lying = ≤ 20mm from os
Define : Placenta Previa / Low lying placenta (5)
- note placenta position during anatomy scan >18-20w
- If ≤ 20mm = u/s ≥ 32w GA. If still ≤ 20mm @ 32w GA = u/s 36w GA
- no vaginal / anal sex, insertion of foreign body into vagina/rectum
- If 11-20mm @ 36w GA (or ≤ 10mm & no risk factors)- trial spontaneous vaginal delivery.
- Otherwise C/S (POCUS prior to sx) 36-38w (previa), 37-39w (low)
When to give RhoGAM? (5)
Give RhoGAM to Rh neg women at
- <12wGA, abortion/threatened/ectopic/ molar /CVS ->120mcg IM
- > 12wGA, abortion/threatened/ectopic/molar /CVS -> 300mcg IM
- Amniocentesis > 300 mcg IM
- 28w GA w/ fetal Rh unknown or positive > 300 mcg IM (alternative is 120 mcg IM @28 + 34 w GA)
- 72hrs after delivery of Rh-positive baby (if NOT given, give as soon as recognized up to 28d) -> 300 mcg IM
Describe delivery of women with obesity ()
- BMI 240-delivery at 39-40wGA
- elective c/s if projected BW 25000g (0 DM) ≥ 4500g (DM)
Describe frequency appointments for adolescents + pregnancy
↑ frequency T2 + T3 b/c ↑risk preterm labour
Name types of pregnancy HTA (10)
- HTN : office/hospital BP ≥140/90mmHg, confirm w/ home BP 2135/85
- Transient HTN : BP ≥ 140/90 that is NOT confirmed on retest
- Masked HTN : BP <140/90 in office and ambulatory ≥135/85
- Resistant HTN : 3 antihypertensives for BP control at 220 weeks GA
- Non severe HTN: 140/90 to 160/110 mmHg, consider confirming persistent HTN w/ home or ambulalory BP
- Severe HTN : ≥160/110mmHg **repeat in 15 min, OB emergency
- Chronic HTN / Pre-existing HTN: <20 weeks GA (no ACEi / ARB). Dx pre-eclampsia if resistant HTN or worsening proteinuria or >1 adverse condition (see signs + symptoms + complications)
- Gestational hypertension : new dx >20 weeks GA
- Eclampsia : new seizure activity in preg/postpartum w/out olher cause
- HELP : preeclampsia w/ hemolysis, ↑ LFTs, ↓ platelets
Name complications of pregnancy induced HTA
Matemal:
* Convulsion / retinal detachment, stroke, TIA
* Thrombocytopenia / DIC / HELLP (hemolysis, elevated liver enzymes, low platelets)
* Pulmonary edema / oliguria / AKI
Fetal:
* Placental abruption
* IUGR, Oligohydramnios
* Fetal hydrops
* Absent / reversed umbilical artery
Describe : Prevention for LOW-Risk Women for Pregnancy Induced Hypertension (3)
- Calcium supplement (>500g/d) If low (<200mg/d) dietary calcium
- No EIOH (II-2), smoking cessation to prevent low weight (-E)
- exercise (I-A), + folic acid to prevent neural tube defect (1-A),
Describe : Prevention for Women at INCREASED Risk for Pregnancy Induced Hypertension (7)
- High risk = hx pre-eclampsia, BMI> 30, chronic HTN, DM, CKD, SLE, assisted reproduclive therapy, antiphospholipid antibody syndrome
- Mod risk = prior abruption / still birth, age >40, nulliparity, multifetal preg, hx SGA
- IF 1 high risk or 22 mod risk factors: ASA 81mg -162 mg QHS starting after 12w GA (per USPSTF), before 16w (per SOGC) and dc at 36w
- Calcium supplement (>500g/d) if low calcium intake (<900mg/d)
- NO high dose folic acid beyond first trimester
- exercise (I-A), and if overweight provide dietary counseling
- NOT recommended: vit C+E
What’s the delivery TIming for pre-eclampsia?
discuss at 34-35+6w GA, consider at 36-36+6w
What’s the delivery TIming for Gestational HTN?
w/out preeclampsia: delivery 38 and 39+ 6 w GA.
If new HTN ≥37 GA, discuss initiating delivery
What’s the delivery TIming for pre-existing HTN?
delivery between 38 and 39+6 w GA
What’s the tx of non-severe HTA in pregnancy
Non severe = BP 140-159 / 90-109 mmHg,
- Labetalol 100-400mg 80-TID, methyldopa 250-500mg BID-®0, long acting (XL) oral nifedipine 20-60mg OD, other beta-blocker (acebutolol, metoprolol, pindolol, propranolol). Do not use labetalol in asthma, caution in DM. no nifedipine in aortic stenosis, methyldopa may cause depression
- Clonidine, Hydralazine, Thiazide diuretics
NOT ACE or ARB, NOT Atenolol or prazosin prior to delivery
What’s the tx of SEVERE HTA in pregnancy (5)
Severe: BP >160/110 * tx in hospital + continuous FHR monitor
1. nifedipine capsule, parenteral labetalol, parenteral hydralazine
2. nitro infusion, methyldopa po, labetalol po, clonidine po
3. refractory: sodium nitroprusside
NOT MgSO, as monotherapy but add it to prevent eclampsia in
severe HTN or adverse / end-organ damage
Describe fetal corticosteroids in pregnancy (3)
- Administered for pre-eclampsia + ≤ 34+6 weeks GA
- Consider if gestational HTN ≤ 34+6 w/ GA if planned delivery in 7d
- Consider if delivered by elective c/s ≤ 38+6 w GA
Describe : Management of Eclampsia
MgSO; 4g IV over 20min then 1g/hr
MgSO, for prophylaxis in severe pre-eclampsia, and consider in non- severe pre-eclampsia
Treatment for HELP syndrome
- Platelets ≥50 w/ hemolysis + ↑ LFTs: blood products prior to delivery IF ↑bleeding, platelet dysfunction, rapidly ↓platelets
- Platelets 20 - 50 w/ hemolysis + ↑ LFTs: platelet transfusion prior C-section and consider prior transfusion prior to vaginal delivery IF excessive bleeding, platelet dysfunction, rapidly ↓ platelets
- Platelets ≤ 20 w/ hemolysis + ↑ LFTs: transfusion prior to delivery
Describe HTA management postpartum (8)
- Measure BP daily on day 3 to 7 postpartum
- Target <140/90
- Nifedipine XL, labetalol, methyldopa, captopnil, enalapril
- Consider thrombo prophylaxis if pre-eclampsia
- Confirm resolution of end-organ damage
- Avoid NSAIDs (especially if oliguria, ↑Cr, platelets <50)
> > 6 weeks postpartum (expect to normalize in 6-12mo)
* Screen pts with pre-existing HTN or persistent postpartum HTN -> urinalysis, Cr, lytes, FBG, cholesterol, ECG
* Healthy diet + exercise
Avoid pregnancy × 4 w if vaccinated with ___
w/ / live or live-attenuated
Name recommended, consider offering, allowed and contraindicated vaccines
Describe : Cytomegalovirus
- Symptoms: fever, fatigue, sore throat, hepatitis
- Complications: 15% newborns w/ CMV have permanent neuro issues
- Prevention: hand washing, toy washing, no sharing drinks / kissing kids
Describe investigations : Cytomegalovirus
CMV IgG + IgM, amniocentesis for CMV. newborn test for CMV
Describe tx : Cytomegalovirus
Tx: inconsistent evidence for antivirals
Describe breastfeeding with Cytomegalovirus
safe
Describe : Group B Streptococcus Bacteruria (4)
- if colony 2100,000CFU/mL - treat
- if <100,000 CFU/mL - not treat
- Regardless of colony size, use prophylactic abx at delivery
- If +bacteruria, regardless colony size, do NOT retest w/ GBS swab
Describe management Herpes Simplex Virus (HSV) during pregnancy (7)
- Document hx of genital herpes early in preg
- If no personal Hx of HSV but partner has HSV - do type specific serology early in preg & again at 32-34w GA. Can offer antiviral suppression to partner in conjunction w/ condoms
- Can tx severe maternal symptoms throughout peg w/ acyclovir
- If 1° HSV in 3rd trimester ( greatest risk transmission 30-50%), offer C-section + do neonatal cultures after delivery
- If recurrent HSV (low risk transmission 2-5% if lesion) : acyclovir 400mgTID or valacyclovir 500mgBID @ 36w GA
- If pt has prodrome or lesions at delivery - offer C-section
- Congenital / neonatal infection -> IV antiviral therapy (acyclovir)
Describe conceiving with HIV
- antiviral ≥ 3mo (prefer ≥ 6mo) & 2 undetected viral load 1/mo
- PrEP if serodiscordant & can’t confirm adherence / viral suppression
- If trial condomless sex, ensure no genital infections (ex. BV, ulcers) + do regular HIV testing for seroconversion. Refer if not preg in 6-12mo. ♀♂
Serodiscordant w/ virologic suppression - condomless sex or referral
* ♀+HIV and ♂-HIV > can try 6 mo home insemination
* ♀-HIV and **♂+HIV **> consider sperm washing w/ IUI
- ♀+HIV single /same sex partner > IUI preferred (increase success)
- ♂+HIV single / same sex partner > refer to fertility clinic
- ♀♂+HIV w/ virologic suppression > 6mo timed condomless sex (risk HIV super-infection + drug resistant strains) or sperm wash lUl
Describe HIV postpartum (6)
- antiretroviral regardless of CD4 (do NOT delay start)
- Immunize: Hep B, Pneumococcal, Flu
- Monitor plasma viral load q 4-8 w + drug toxicities
- If viral load <1000c/ml. = SVD, if ↑ viral load = c/s
- Newborn: 6w antiretroviral therapy, HIV test at 1, 3, 18 mo
- no breastfeeding
Describe pregnancy if unknown HIV status
if high risk + unknown status = tx w/ prophylaxis during
delivery & to infant postpartum & defer breastfeeding until testing done
Name clinical manifestations of rubella in pregnancy (8)
- Asymptomatic 25-50%
- fever
- conjunctivitis,
- sore throat, coryza
- H/A
- malaise
- lymphadenopathy
- polyarthritis
- Rash: face, spread to trunk + extremities, resolves in 3d
Name complications of rubella in pregnancy (10)
- newborn deafness
- pulmonary stenosis / PDA / VSD
- retinopathy
- cataracts
- mental retardation
- microcephaly
- thrombocytopenia
- DM
- thyroiditis
- behavioural problems
Destribe serology for rubella :
* IgM-, IgG-
* IgM-, IgG+
* IgM+, IgG+
* IgM+, IgG-
- IgM-, IgG- = susceptible: repeat 4w after contact or 7d symptom
- IgM-, IgG+ = immune: repeat 4w after contact or 7d symptoms
- IgM+, IgG+ = reinfection if repeat 2-3w ↑ IgG(×4) - consider fetal testing or u/s surveillance
- IgM+, IgG- = infection: repeat, if IgG- immunize after delivery, if
IgG+ (seroconversion) then rubella infection in pregnancy
Describe management : Rubella during pregnancy (6)
- Do NOT immunize during pregnancy (Il-B)
- If exposure or suspected infection (confirm DA) - matemal serology
- 1-12wGA: infection/congenital defect 80%, consider termination
- 13-16wGA: infection54%, defect 35%, fetal testing + termination
- 17-22wGA: infection36%, min defect, u/s surveillance
- 23-40wGA: infection progressing 30-100%: u/s surveillance
Describe : Parvovirus B19 Infection in Pregnancy (5)
- Clinical: asymptomatic, fever / rash (slapped cheeks) / arthralgia
- Transmission: respiratory secretions, usually in spring, viremia 4-14d after exposure, 50-70% of reproductive ♀ have immunity
- At Risk Population: day care / elementary school teachers
- Screening: NOT recommended in low-risk pregnancy
- Complications: fetal transmission, fetal loss (risk 13% if <20w GA, 0.5% if >20w GA), hydrops (3%),
Describe investigation : Parvovirus B19 Infection in Pregnancy (4)
- exposure to Parvovirus or symptoms
- if fetal hydrops or intrauterine fetal death
- Immune: parvovirus Pos |gG, neg IgM, repeat in 2-4w
- Susceptible: neg parvovirus IgG and IgM
Describe clinical, transmission, prevention and screen : Toxoplasmosis in Pregnancy (4)
- Clinical: 90% asymptomatic, flu-like symptoms. Incubation 5-18d
- Transmission: ingestions raw / undercooked meat (contaminated H2O, oocyst-infected cat feces (gardening w/out gloves), vertical transmission
- Prevention: avoid preg x6mo if infected. Ø raw meat / egg, wear gloves w/ soil / cat litter, disinfect litter box, keep cat inside, Ø raw cat food
- Screen: Screen only if at risk (immunocompromised, HIV positive)
Describe testing : Toxoplasmosis in Pregnancy (4)
+|gG & IgM, repeat in2-4w if: TORCH u/s (severe IUGR
intracranial calcification, micro/hydrocephaly, ascites, ↑ liver / spleen
Describe epidemiology, sx, transmission and complications: Varicella in Pregnancy
- Epi: >90% antennal population is +VZV IgG antibody (immune), incubation 10-21d, infectious 48hrs prior to rash until vesicles crust
- Symptoms: Fever, malaise, pruritic maculopapular rash becomes vesicular & crusts
- Transmission; droplet, effects ~0.2-0.3% pregnancies
Complications:
* pneumonitis (5-10% of infected pregnancy 9), intubation (~50% of pts w/ pneumonitis), death
* Newborn: congenital varicella, congenital malformation (chorioretinitis, cerebral cortical atrophy, hydronephrosis, and cutaneous and bony leg defects)
Describe management : Varicella in pregnancy
- Preconception counselling re: immunization -> immunize
non-immune women Pre pregnancy (II-3B) or if unable to, then postpartum - Do NOT immunize during pregnancy (I-3D)
- Document hx of previous infection, vaccination hx, or varicella IgG
- If exposure or suspected infection: Do maternal serology.
- If serology not available for 96 hrs, or patient Nonimmune -> administer varicella zoster immunoglobulin
If infected:
* Discuss risks / complications.
* Detailed u/s to assess for fetal consequences (Ill-B)
* If serious infection (ex. Pneumonitis) > treat w/ antiviral
(acyclovir 800mg 5/d)
Describe frequency of routine vists of pregnancy
- q4 weeks to 28 weeks
- then q2w until 36w GA
- then q1w until delivery
