16 OB Flashcards
GBS
- when to give mom ppx (4)
- how to tx baby
Penicillin:
- any positive screen at weeks 35-38
- asx bactiuria
- GBS+ in the past, ever
- prolonged ROM
newborn sepsis, assume GBS, give ampicillin
ROM, spontaneous
- means how long before delivery (normally)
- do what to confirm (3)
signals <1h to delivery, usu
- confirm with speculum exam looking for fluid pooling
- confirm with nitrazine test (paper turns blue) or fern sign
- confirm with U/S to make sure now oligohydramnios
Bloody show
bloody show (mucus plug released), happens beginning of labor, before/after contractions start
Immigrant pregnant female, going into labor at 35wks
-think what
GBS unknown
Do Penicillin in pROM or ppROM with unknown GBS status
When are tocolytics contraindicated?
think 3 categories
- maternal: Preeclampsia
- fetal: fetal distress
- high OB risk: pROM for infxn, abruption
Obviously premature baby must be delivered now, going to NICU
Pregnant mom, maternal serum AFP is low.
think what
What if high AFP?
low AFP, think Downs.
high AFP, think neural tube
But, get U/S to make sure dates correct. MCC abnormal AFP is wrong dates.
Sxs, congential:
Toxo
CMV
triad:
diffuse calcifications
hydrocephalus
chorioreitinitis
periventricular calcifications
IUGR
microcephaly
twin twin transfusion
-what twin types
smaller twin does better (reduced bili load)
mono/di and mono/mono
Pt with hypothyroidism on levothyroxine, presents for prenatal visit.
What to do for following thyroid
Increase levothyroxine dose now because need to make more thyroid hormone. Follow TSH but change dose now
Prolonged/Arrested active phase
- dx
- do what
Prime: >5h (1.2 cm/h), Multip: >4h (1.5cm/h)
Prolonged: slow change
Arrest: no change
Think causes as 3 P’s:
Power–check contractions (3 in 10, 40mm)
Passenger
Pelvis
- If contractions weak, do oxytocin. C/S if no improvement after 2h
- If contractions adequate, consider C/S
Hyperthyroid dz diagnosed in pregnancy
-how to tx
Can’t do RAIU or anything radioactive
Surgery, wait until 2nd trimester (fetus already developed)
episiotomy
medial vs mediolateral
Medial: heals, hurts, possible recto-vag fistula
mediolat: no heal, no hurt
Postdates
- what is postdates, what dangers (which most likely)
- how to manage/approach
> 42weeks. danger of dystocia, macrosomia.
most likely is oligohydramnios
If dates correct:
If cervix good, induce. If cervix not good, C/S
If dates unsure: wait and C/S when baby ready/distress (follow baby with BPP NST, 2x/week U/S to check for oligohydramnios)
How does TSH/T4 change in pregnancy
TBG increases, so:
higher total T4, but normal free T4 and TSH
Pregnant mom has Hep B Ag+
-do what for birth
Hep B acquired through birth canal
- C/S
- IVIG to baby, day of delivery
- Hep B vaccine to baby, day of delivery
Pregnant mother 32 weeks. Has edema of legs. think preeclampsia.
leg edema can be normal late in pregnancy b/c uterus pressing on IVC
Normal labor, describe all stages/phases:
Remember graph
Stage 1, Latent phase–regular contractions causing dilation/effacement. to 4cm cervix
Stage 1, active phase–4cm - full 10cm dilation
Stage 2–full dilation to delivery finishes
Stage 3–end of delivery to delivery of placenta
HELLP syndrome
- what is it
- do what
Hemolysis
Elevated LFTs
Low Platelets (petichiae)
Mg, Deliver now!!
Think of HELLP as a ‘Curable DIC’
fetal monitoring: what are the accel/decel types
VEAL CHOP
variable–cord
early–head
accels–OK
late–placental insuff (BAD)
Prolonged latent phase
- dx
- MCC
- do what
cervix <4cm. >20h in prime, >14h in multip
-MCC is analgesics (opioids given too soon, wait it out)
-once dx’d, check if contractions are adequate:
3 in 10min, and >40mm each
You can rest/wait. Or, speed things up with ripening (balloon) or oxytocin for stronger contractions
postpartum bleeding
-MCC
-uterine atony
gest diabetes
- what meds
- how do you know it is controlled
no oral meds!
- insulin
- very tight control in gest diabetes. <95 fasting glucoses.
ppROM
- what is it
- do what
preterm, premature ROM: “Both Baby and Mom not ready”
24-36 weeks. If <24, nonviable
Dilemna of delivering now (lower infxn risk) vs keeping inside (develop lungs)
Get L/S ratio. If >2, lungs OK, deliver.
If <2, steroids, Amp-Gent. NO TOCOLYTICS b/c already ROM
Twin types:
-what each is at risk for?
Risks are added from one above:
Di/Di, dizygotic–breech, preterm, placenta previa
Di/Di, monozygotic
Mono/Di–twin-twin transfusion
Mono/mono–conjoined twins, cord entanglement
3rd trimester labs
-what main things (3)
- gest diabetes
- anemia
- Rh
Non stress test
- what is it, looking for what
- how often get it
Fetal heart rate monitoring
first test to assess fetus and r/o fetal demise
Looking for 15,15,2 in 20
15 sec of 15bpm increase, 2x in 20 min
high risk OB pts get NST q1week until delivery (from the time of low fetal mvmnt)
Prolonged 3rd stage
- definition
- do what
Should be 30min for placenta to come out. Dx is always power issue (uterus too tired to push)
- uterine massage, then
- oxytocin, then
- manual manipulation if all else fails
Prolonged 2nd stage
- definition
- do what things
No epidural 2h, epidural 3h
Still assess Power (3 in 10, 40mm), Passenger, Pelvis. Increase power (oxytocin) if not strong enough.
If station 0 to -2, do C/S
If station 1,2: do Vacuum or Forceps
Postpartum bleeding, algorithm
-ddx (5), their sxs/tx
> 500ml vaginal, >1000ml C/S
Uterine palpation:
Boggy–uterine atony. massage, oxytocin
Absence–uterine inversion. speculum exam, push back in or surgery to tack
Firm–retained placenta. D+C/Surgery (accreta, increta, percreta)
Normal–vag lac
Normal–DIC
3rd trimester bleeding
- how to separate life threatening causes
- do what for each
Painless:
placenta previa–U/S (transverse lie), NST, then C/S
vasa previa–NST, then C/S
Painful:
uterine rupture–Crash C/S!
placental abruption–you have time for U/S and NST, then C/S
Quad screen: what levels:
Down’s
Trisomy 18
Neural tube defects
maternal serum: AFP Estriol (E3) B-HCG Inhibin A
Down’s: low AFP, low E3,high HCG
T-18: low,low,low
Neural: high AFP
Inhibin A: high in Downs, low in T18
biophysical profile
-what looking for
BPP: Do U/S
- breathing
- muscle tone
- movement
- AFI (amniotic fluid index)–looking at all 4 quadrants deepest fluid measurement
- NST
All max score 2. 8+ is reassuring. <8 do CST
Normal labor max times:
Latent phase, prime
Latent, multip
Active phase, prime
Active, multip
Latent phase, prime–20h
Latent, multip–14h
Active:
Prime: >5h (1.2 cm/h)
Multip: >4h (1.5cm/h)
Pregnant mother delivers, then goes into DIC
-think what
placental embolism
also, amniotic embolism can cause PE and then DIC
Pregnant mother in 3rd trimester is concerned about decreased fetal movement.
-What tests, what order?
- NST (fetal HR monitor) looking for 15,15,2 in 20. vibrate if not reactive
If not reactive: - BPP (U/S criteria)
If 0-2: deliver now, C/S. baby dying.
8-10: leave in, reassuring.
If 2-8 and <36wks: - CST–this is rarely done anymore as next step.
All twins:
increased risk of what? (3)
breech birth, malpresentation
preterm delivery (-4 weeks each)
placenta previa
Preeclamptic pregnant mother, gets sz
-do what
Eclampsia.
Give Mg, deliver now, no waiting. C/S if necessary
placental abruption
-risk factors (3)
painful 3rd trimester bleeding
HTN
trauma
cocaine
Pregnant mother 32 weeks. Has BP 160/110, HA and vision change.
think what, do what things?
- labs
- give what meds
- what else
severe preeclampsia. Mg+urgent delivery
Get: CBC, DIC panel, LFTs
Give: Mg to ppx sz, labetalol/hydralazine to lower BP
Goal: stabilize and deliver, induce if necessary
Pregnant female with non-gestational diabetes
-how to manage
no orals, do insulin
-goal <150 fasting. Compared to gestational <95
Postpartum hemorrhage, unexplained. Do what in what order
Arterial ligation:
uterine a,
hypogastric a,
hysterectomy
U/S degree of error in dx fetal age
trimester 1: +/- 1 week
so on.
Sxs, congenital:
Syphilis
Rubella
saddle nose, saber shins, rhinitis
deafness, cataracts, heart dz
uterine rupture
-story to know
Mom in labor, gets epidural. Suddenly, contractions stop. Uterus is boggy, FHR goes down, fetal distress. No pain, no vaginal bleeding. Crash C/S now!
No pain with epidural
Bleeding not always occur
emergency contraception
- what is it
- use within how many days
levonorgestrel is Plan B. High dose hormones, prevent implantation
Use within 5 days of sex
can also use high dose OCPs
Preeclampsia pt, now breathing shallow and hyporeflexia
-think what, do what
Mg toxicity
Give Ca carbonate, stop Mg
3rd trimester bleeding:
what ddx
4 deadly: placenta previa vasa previa uterine rupture abruption
2 MCC
polps
cervical lesions
Alarm sxs for severe eclampsia? (3)
HA
vision change
epigastric pain
Amniocentesis vs CVS
- what are each, what weeks
- when to do each
CVS: 6-12 weeks, higher risk loss
Amnio: 16 wks+ (2nd trimester). Too late to do easy abortion (now needs suction curettage if unwanted fetus)
Consider CVS in high risk (moms 35+, hx of trisomies)
Female just delivered baby 8h ago. Has 38 fever, continued bloody discharge, and firm nontender uterus
Think what?
Lochia rubra. (sounds like endometritis though)
Normal red vaginal d/c after delivery. Nontender uterus Low grade fever without overt signs of toxicity is normal.
Endometritis: think toxic pt, foul smelling d/c, leukocytosis, tender uterus
Mg toxcity
- sxs
- antidote
Think of Mg like Ca.
HyperMg:
- hyporeflexia
- resp depression
- death
Give Ca carbonate
Anemia screening in pregnant mom
-why and when to act
Anemia is normal. Nadir 28-30wks, can be 10
If Hgb<10 or Hct<30, check MCV and ferritin to see if Fe def. If not, then might have to do bone marrow bx to diff ACD from Fe def.
Pregnant female, 32 weeks. You measure BP 145/92.
Now think what, do what
preeclampsia?
Look at edema of hands–earliest sign of PreE getting bad. Ask abd pain
Get:
CBC, looking for hemoconcentration (2/2 3rd spacing)
UA: protein
postpartum hemorrhage from Uterine atony
-treatment escalation ladder (5)
massage oxytocin packing arterial embolization hysterectomy
prolonged ROM, mom has fever, septic
-think what, do what
This is chorioamnionitis (endometritis if 8h after delivery)
Broad spectrum: Amp+Gent+MTZ, or Zosyn
Deliver if haven’t!
Down’s prenatal quad screen:
AFP low
E3 low
B HCG high
Inhibian A high
Preeclampsia
mild, severe, eclampsia
-criteria
Mild preeclampsia:
BP>140/90
urine>300mg/24h
Severe:
>160/110 (same as fetal HR), protein >5g/24h
OR alarm sx
Eclampsia:
-with seizures
female with chronic HTN gets pregnant
- how to know if preeclampsia
- what meds to use
can’t use BP
get UA for protein, U/S for IUGR
HTN in pregnancy: H,M,L,N
Station
how far physically baby is -2 -1 0--entering vagina (?) 1 2--vaginal entrance now, about to crown
Fetal anemia
- how to screen, confirm, when, and tx
- who at risk
screen: transcranial doppler after 20 weeks. At risk includes isoimmunization risk
confirm dx and tx requires PUBS (percutaneous umbilical blood sampling)–putting IV in fetus to transfuse blood. Do >20wks
Varicella in pregnancy
- what to know, careful for what
- What if mom gets chickenpox during pregnancy
Secondary reactivation (shingles): give acyclovir to mom
Primary viremia is most dangerous!! If mom never had chickenpox or vaccine, then get vaccine before pregnancy. But NO VACCINE during pregnancy, causes viremia. ISOLATE mom from any kids that might have chickenpox.
If mom gets chickenpox, then give IVIG
Baby in breech position
-do what
at 37 weeks, do Leopold maneuvers
-if fail, plan C/S
Hyperemesis gravidarum
- what is it
- dx, check for what
- tx
think ‘Severe morning sickness’ that goes into 2nd trimester (morning sickness should not)
-N/V with volume depletion, so bad there is weight loss and starvation ketosis
-do B-HCG to make sure not molar
Tx: IVF, antiemetics
Post partum hemorrhage: how much blood loss is too much
vaginal
C/S
vaginal: 500ml
C/S: 1000ml
irregular contractions before labor
Braxton Hicks. not regular contractions. not labor
When to suspect twin pregnancy
- uterus is large for dates
- AFP high on quad screen
Do U/S
Effacement
cervical ripening. stim by:
- fetal head engagement/balloon
- PGE2 (so indomethacin is tocolytic)
Pregnant mom has HIV
- do what for birth
- what if mom not on HAART
- how to screen baby
HIV does not cross placenta; it is transmitted by blood-blood contact. So,
- C/S (reduce blood mingling)
- keep mom on HAART. If not, then give AZT at delivery
HIV Ab cross placenta, so baby will have HIV Ab+. Wait 6 months for Ab to go away, then can screen.
Placenta accreta
-what are the different types
shallow-deep:
accreta–endometrium only
increta–to myometrium
percreta–to serosa
Preterm labor
- how to buy more time (4)
- what else to give
You can only buy hours-days with tocolytics:
- Mag (best)
- B agonist (terbutaline)
- CCB (nifedipine)
- prostaglandins (indomethacin)
Give steroids for lung maturation, follow L/S ratio (>2, deliver)
prolonged ROM
- what is it
- do what
ROM >18h before delivery
Risk of GBS goes way up. Give amoxicillin, watch closely for chorio and endometritis
Pregnant mom, worried about her child with Downs or other abnormality. What to ask before doing CVS/amnio?
Does she intend to abort if positive result?? Otherwise, unnecessary risk
chorioamnionitis
-do what
Abx and deliver!
Abx–Zosyn or amp-gent-MTZ
Deliver: induce if contractions started, otherwise C/S
gestational diabetes
- when to screen, what week
- how to screen
3rd trimester (screen must be after week 20)
- 1h GTT. If >140, then:
- fasting glu. if >125, dx made. If <125, do:
- 3h-GTT. 2 criteria needs to be met (next several hrs)
cervical insufficiency
-what is this, do what
hx of cone bx or frequent GYN infections. Cervix not tight enough, placenta will fall out.
Do circlage at weeks 12-14
REMOVE before ripening.
Give Rhogam within __hours of blood mixing
72h, for mother whose criteria fulfilled
also give at 28 weeks for those pts
Herpes in pregnancy
- do what
- can herpes cross placenta?
Herpes spread by baby contact with ulcer. So do C/S, give mom acyclovir
Herpes secondary reactivation (ulcers) is not viremia, so no placental crossing. However, primary herpes viremia will cross placenta. (Varicella same way)
Contraction stress test
- what is adequate test?
- when must deliver immediately?
IUPC
3 contractions in 10 min
look for accels/decels
- late decels
- fetal brady (<100)
Pregnant mom:
how to screen Rh, when to give Rhogam
Screen:
- Rh of mom
- anti-Rh Ab if mom is Rh-
Give Rhogam at 28wks and delivery if:
- Dad is Rh+ or unknown,
- Mom is Rh- and anti-Rh negative
If mom already has anti-Rh, too late. Get trans-cranial doppler to see if baby is risk for fetal anemia
pROM
- what is it
- do what
premature ROM: “Baby’s ready, mom’s not.” >36wks
Rupture, but absence of uterine contractions!
Caused by ascending infxn (usu E Coli)
Confirm ROM (3 steps),
Empiric coverage: Amp+Gent,
then induce.
vasa previa
-story
triad of: ROM, followed by painless bleeding, then fetal brady
Do NST, then U/S
Postpartum hemorrhage from retained placenta after delivery
- explain mech
- who at risk
- do what after dx and tx?
Placenta tears b/c
- Burrows deeply (accreta)
- expands wide (accessory lobe). (blood vessels to placenta edge)
Moms with multiple pregnancies higher risk
Think oil drilling analogy
Afterwards, beware retained piece and CC! Follow B-HCG, give OCPS x1y
variable decels
-think what, careful for what
cord compression. No big deal b/c baby can compensate. Can try to reposition mom and give O2 but usu not necessary
Do NOT induce ROM, loss of fluid will increase cord compression.
