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STEP 2CK Review > 16 OB > Flashcards

16 OB Flashcards

1
Q

GBS

  • when to give mom ppx (4)
  • how to tx baby
A

Penicillin:

  1. any positive screen at weeks 35-38
  2. asx bactiuria
  3. GBS+ in the past, ever
  4. prolonged ROM

newborn sepsis, assume GBS, give ampicillin

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2
Q

ROM, spontaneous

  • means how long before delivery (normally)
  • do what to confirm (3)
A

signals <1h to delivery, usu

  1. confirm with speculum exam looking for fluid pooling
  2. confirm with nitrazine test (paper turns blue) or fern sign
  3. confirm with U/S to make sure now oligohydramnios
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3
Q

Bloody show

A

bloody show (mucus plug released), happens beginning of labor, before/after contractions start

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4
Q

Immigrant pregnant female, going into labor at 35wks

-think what

A

GBS unknown

Do Penicillin in pROM or ppROM with unknown GBS status

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5
Q

When are tocolytics contraindicated?

think 3 categories

A
  1. maternal: Preeclampsia
  2. fetal: fetal distress
  3. high OB risk: pROM for infxn, abruption

Obviously premature baby must be delivered now, going to NICU

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6
Q

Pregnant mom, maternal serum AFP is low.
think what

What if high AFP?

A

low AFP, think Downs.
high AFP, think neural tube

But, get U/S to make sure dates correct. MCC abnormal AFP is wrong dates.

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7
Q

Sxs, congential:

Toxo
CMV

A

triad:
diffuse calcifications
hydrocephalus
chorioreitinitis

periventricular calcifications
IUGR
microcephaly

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8
Q

twin twin transfusion

-what twin types

A

smaller twin does better (reduced bili load)

mono/di and mono/mono

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9
Q

Pt with hypothyroidism on levothyroxine, presents for prenatal visit.
What to do for following thyroid

A

Increase levothyroxine dose now because need to make more thyroid hormone. Follow TSH but change dose now

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10
Q

Prolonged/Arrested active phase

  • dx
  • do what
A

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
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11
Q

Hyperthyroid dz diagnosed in pregnancy

-how to tx

A

Can’t do RAIU or anything radioactive

Surgery, wait until 2nd trimester (fetus already developed)

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12
Q

episiotomy

medial vs mediolateral

A

Medial: heals, hurts, possible recto-vag fistula
mediolat: no heal, no hurt

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13
Q

Postdates

  • what is postdates, what dangers (which most likely)
  • how to manage/approach
A

> 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)

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14
Q

How does TSH/T4 change in pregnancy

A

TBG increases, so:

higher total T4, but normal free T4 and TSH

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15
Q

Pregnant mom has Hep B Ag+

-do what for birth

A

Hep B acquired through birth canal

  1. C/S
  2. IVIG to baby, day of delivery
  3. Hep B vaccine to baby, day of delivery
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16
Q

Pregnant mother 32 weeks. Has edema of legs. think preeclampsia.

A

leg edema can be normal late in pregnancy b/c uterus pressing on IVC

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17
Q

Normal labor, describe all stages/phases:

A

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

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18
Q

HELLP syndrome

  • what is it
  • do what
A

Hemolysis
Elevated LFTs
Low Platelets (petichiae)

Mg, Deliver now!!

Think of HELLP as a ‘Curable DIC’

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19
Q

fetal monitoring: what are the accel/decel types

A

VEAL CHOP

variable–cord
early–head
accels–OK
late–placental insuff (BAD)

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20
Q

Prolonged latent phase

  • dx
  • MCC
  • do what
A

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

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21
Q

postpartum bleeding

-MCC

A

-uterine atony

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22
Q

gest diabetes

  • what meds
  • how do you know it is controlled
A

no oral meds!

  • insulin
  • very tight control in gest diabetes. <95 fasting glucoses.
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23
Q

ppROM

  • what is it
  • do what
A

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

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24
Q

Twin types:

-what each is at risk for?

A

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

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25
Q

3rd trimester labs

-what main things (3)

A
  1. gest diabetes
  2. anemia
  3. Rh
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26
Q

Non stress test

  • what is it, looking for what
  • how often get it
A

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)

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27
Q

Prolonged 3rd stage

  • definition
  • do what
A

Should be 30min for placenta to come out. Dx is always power issue (uterus too tired to push)

  1. uterine massage, then
  2. oxytocin, then
  3. manual manipulation if all else fails
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28
Q

Prolonged 2nd stage

  • definition
  • do what things
A

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

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29
Q

Postpartum bleeding, algorithm

-ddx (5), their sxs/tx

A

> 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

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30
Q

3rd trimester bleeding

  • how to separate life threatening causes
  • do what for each
A

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

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31
Q

Quad screen: what levels:

Down’s
Trisomy 18
Neural tube defects

A 
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

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32
Q

biophysical profile

-what looking for

A

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

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33
Q

Normal labor max times:

Latent phase, prime
Latent, multip
Active phase, prime
Active, multip

A

Latent phase, prime–20h
Latent, multip–14h

Active:
Prime: >5h (1.2 cm/h)
Multip: >4h (1.5cm/h)

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34
Q

Pregnant mother delivers, then goes into DIC

-think what

A

placental embolism

also, amniotic embolism can cause PE and then DIC

35
Q

Pregnant mother in 3rd trimester is concerned about decreased fetal movement.
-What tests, what order?

A
  1. NST (fetal HR monitor) looking for 15,15,2 in 20. vibrate if not reactive
    If not reactive:
  2. BPP (U/S criteria)
    If 0-2: deliver now, C/S. baby dying.
    8-10: leave in, reassuring.
    If 2-8 and <36wks:
  3. CST–this is rarely done anymore as next step.
36
Q

All twins:

increased risk of what? (3)

A

breech birth, malpresentation
preterm delivery (-4 weeks each)
placenta previa

37
Q

Preeclamptic pregnant mother, gets sz

-do what

A

Eclampsia.

Give Mg, deliver now, no waiting. C/S if necessary

38
Q

placental abruption

-risk factors (3)

A

painful 3rd trimester bleeding

HTN
trauma
cocaine

39
Q

Pregnant mother 32 weeks. Has BP 160/110, HA and vision change.

think what, do what things?

  • labs
  • give what meds
  • what else
A

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

40
Q

Pregnant female with non-gestational diabetes

-how to manage

A

no orals, do insulin

-goal <150 fasting. Compared to gestational <95

41
Q

Postpartum hemorrhage, unexplained. Do what in what order

A

Arterial ligation:

uterine a,
hypogastric a,
hysterectomy

42
Q

U/S degree of error in dx fetal age

A

trimester 1: +/- 1 week

so on.

43
Q

Sxs, congenital:

Syphilis
Rubella

A

saddle nose, saber shins, rhinitis

deafness, cataracts, heart dz

44
Q

uterine rupture

-story to know

A

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

45
Q

emergency contraception

  • what is it
  • use within how many days
A

levonorgestrel is Plan B. High dose hormones, prevent implantation

Use within 5 days of sex

can also use high dose OCPs

46
Q

Preeclampsia pt, now breathing shallow and hyporeflexia

-think what, do what

A

Mg toxicity

Give Ca carbonate, stop Mg

47
Q

3rd trimester bleeding:

what ddx

A 
4 deadly:
placenta previa
vasa previa
uterine rupture
abruption

2 MCC
polps
cervical lesions

48
Q

Alarm sxs for severe eclampsia? (3)

A

HA
vision change
epigastric pain

49
Q

Amniocentesis vs CVS

  • what are each, what weeks
  • when to do each
A

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)

50
Q

Female just delivered baby 8h ago. Has 38 fever, continued bloody discharge, and firm nontender uterus

Think what?

A

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

51
Q

Mg toxcity

  • sxs
  • antidote
A

Think of Mg like Ca.

HyperMg:

  • hyporeflexia
  • resp depression
  • death

Give Ca carbonate

52
Q

Anemia screening in pregnant mom

-why and when to act

A

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.

53
Q

Pregnant female, 32 weeks. You measure BP 145/92.

Now think what, do what

A

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

54
Q

postpartum hemorrhage from Uterine atony

-treatment escalation ladder (5)

A 
massage
oxytocin
packing
arterial embolization
hysterectomy
55
Q

prolonged ROM, mom has fever, septic

-think what, do what

A

This is chorioamnionitis (endometritis if 8h after delivery)

Broad spectrum: Amp+Gent+MTZ, or Zosyn
Deliver if haven’t!

56
Q

Down’s prenatal quad screen:

A

AFP low
E3 low
B HCG high
Inhibian A high

57
Q

Preeclampsia
mild, severe, eclampsia
-criteria

A

Mild preeclampsia:
BP>140/90
urine>300mg/24h

Severe:
>160/110 (same as fetal HR), protein >5g/24h
OR alarm sx

Eclampsia:
-with seizures

58
Q

female with chronic HTN gets pregnant

  • how to know if preeclampsia
  • what meds to use
A

can’t use BP
get UA for protein, U/S for IUGR

HTN in pregnancy: H,M,L,N

59
Q

Station

A 
how far physically baby is
-2
-1
0--entering vagina (?)
1
2--vaginal entrance now, about to crown
60
Q

Fetal anemia

  • how to screen, confirm, when, and tx
  • who at risk
A

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

61
Q

Varicella in pregnancy

  • what to know, careful for what
  • What if mom gets chickenpox during pregnancy
A

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

62
Q

Baby in breech position

-do what

A

at 37 weeks, do Leopold maneuvers

-if fail, plan C/S

63
Q

Hyperemesis gravidarum

  • what is it
  • dx, check for what
  • tx
A

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

64
Q

Post partum hemorrhage: how much blood loss is too much

vaginal
C/S

A

vaginal: 500ml

C/S: 1000ml

65
Q

irregular contractions before labor

A

Braxton Hicks. not regular contractions. not labor

66
Q

When to suspect twin pregnancy

A
  • uterus is large for dates
  • AFP high on quad screen

Do U/S

67
Q

Effacement

A

cervical ripening. stim by:

  • fetal head engagement/balloon
  • PGE2 (so indomethacin is tocolytic)
68
Q

Pregnant mom has HIV

  • do what for birth
  • what if mom not on HAART
  • how to screen baby
A

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.

69
Q

Placenta accreta

-what are the different types

A

shallow-deep:

accreta–endometrium only
increta–to myometrium
percreta–to serosa

70
Q

Preterm labor

  • how to buy more time (4)
  • what else to give
A

You can only buy hours-days with tocolytics:

  1. Mag (best)
  2. B agonist (terbutaline)
  3. CCB (nifedipine)
  4. prostaglandins (indomethacin)

Give steroids for lung maturation, follow L/S ratio (>2, deliver)

71
Q

prolonged ROM

  • what is it
  • do what
A

ROM >18h before delivery

Risk of GBS goes way up. Give amoxicillin, watch closely for chorio and endometritis

72
Q

Pregnant mom, worried about her child with Downs or other abnormality. What to ask before doing CVS/amnio?

A

Does she intend to abort if positive result?? Otherwise, unnecessary risk

73
Q

chorioamnionitis

-do what

A

Abx and deliver!
Abx–Zosyn or amp-gent-MTZ

Deliver: induce if contractions started, otherwise C/S

74
Q

gestational diabetes

  • when to screen, what week
  • how to screen
A

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)
75
Q

cervical insufficiency

-what is this, do what

A

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.

76
Q

Give Rhogam within __hours of blood mixing

A

72h, for mother whose criteria fulfilled

also give at 28 weeks for those pts

77
Q

Herpes in pregnancy

  • do what
  • can herpes cross placenta?
A

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)

78
Q

Contraction stress test

  • what is adequate test?
  • when must deliver immediately?
A

IUPC
3 contractions in 10 min
look for accels/decels

  • late decels
  • fetal brady (<100)
79
Q

Pregnant mom:

how to screen Rh, when to give Rhogam

A

Screen:

  1. Rh of mom
  2. anti-Rh Ab if mom is Rh-

Give Rhogam at 28wks and delivery if:

  1. Dad is Rh+ or unknown,
  2. 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

80
Q

pROM

  • what is it
  • do what
A

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.

81
Q

vasa previa

-story

A

triad of: ROM, followed by painless bleeding, then fetal brady

Do NST, then U/S

82
Q

Postpartum hemorrhage from retained placenta after delivery

  • explain mech
  • who at risk
  • do what after dx and tx?
A

Placenta tears b/c

  1. Burrows deeply (accreta)
  2. 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

83
Q

variable decels

-think what, careful for what

A

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.

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