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Résidence - FM Learner > 79. Pregnancy > Flashcards

79. Pregnancy Flashcards

1
Q

In preconception counselling, describe Risk assessment (9)

A
  • Age
  • Chronic medical problems
  • Medications known to be teratogens
  • Reproductive history
  • Genetic conditions/family history
  • Substance use
  • Infection and vaccinations
  • Environmental hazards/toxins (occupational, heavy metals, pesticides, Zika)
  • Social and mental health concerns
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2
Q

In preconception counselling, describe lifestyle recommendations (5)

A
  • Smoking cessation
  • Weight control (under or overweight)
  • Avoid alcohol/drugs
  • Avoid consumption of undercooked meats and unpasteurized foods (risk of toxoplasmosis, CMV, listeria)
  • Avoid mosquito (clothing, repellents)
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3
Q

In preconception counselling, what’s the folic acide dose ?

A

Folic acid 0.4-1mg/d (high risk 5mg daily)

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4
Q

How to optimize natural fertility ? (5)

A

Intercourse timing
* Simple = 3x/week
* Fertile during 5 days prior to ovulation until ovulation (14 days prior to onset of menses)
* So take longest and shortest cycles (eg. 28-32 days) so ovulation on D14-18, so intercourse D9-18 q2-3d
* >10 days of abstinence can decrease sperm quality
* Avoid lubricants

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5
Q

What medications to stop during pregnancy ? (9)

A
  • Stop retinoids / Vitamin A >10,000 units/day (risk of malformations in T1)
  • Stop ACE-i/ARB (risk of fetal kidney disease in T2/T3). => Change to methyldopa, labetalol, calcium channel blocker (Nifedipine XL)
  • Stop oral anti-hyperglycemic => Consider metformin or glyburide
  • Stop warfarin (risk of malformations in T1) => Consider heparin/LMWH
  • Avoid lithium (very low risk of Ebstein anomaly and malformations in T1)
  • Avoid valproic acid/anticonvulsants (risk of malformations in T1)
  • Avoid Sulpha drugs and Trimethoprim (anti-folate risk in T1, and kernicterus in T3)
  • Avoid tetracycline (bone development, teeth staining)
  • Avoid NSAIDs (cardiac defects, spontaneous abortion)
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6
Q

Describe risk of untreated depression vs use of antidepressants

A
  • Risks of untreated depression often outweigh risks of antidepressants
  • Low risk of teratogenicity (some data suggests paroxetine may have small increase in congenital heart defects, other studies have not found this association)
  • May be associated with a small reduction in gestational age at birth that is not clinically significant
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7
Q

Describe what to cover during first vist in pregnancy (8)

A
  • Confirm pregnancy with urine or serum bhCG
  • Accurate dates by LMP : (1) Confirm with T1 dating ultrasound; (2) Requisition for 20w morphology ultrasound
  • Establish desirability of pregnancy (pregnancy termination, adoption, other)
  • Paternal risk factors (medical, social, occupational)
  • Prenatal Care Flow Sheets
  • Counselling
  • Routine prenatal bloodwork
  • Discuss trisomy 21 screening
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8
Q
A

Add questions regarding visits

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9
Q

Name risks : Prelabour Rupture of Membranes (PROM) (10)

A
  • Amniocentesis
  • Cervical insuff/cerclage
  • Prior conization/LEEP
  • PPROM, preterm
  • Vaginal bleed, Placental Abruption
  • Polyhydramnios
  • Multiple pregnancy
  • Smoking
  • STI, BV
  • Low SES
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10
Q

Name investigations : Prelabour Rupture of Membranes (PROM) (4)

A
  • No Digital
  • Sterile speculum
  • Culture for STI and GBS
  • Ultrasound for low AFI (Max vertical pocket <2cm or AFI ≤5 cm)
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11
Q

What to look in sterile speculum for PROM?

A
  • Look for fluid from cervix, cord
  • Pooling in posterior fornix of vaginal vault
  • Ferning on microscopic examination
  • Liquid pH (>6) will turn nitrazine test blue (positive)
  • Commericial tests (AmniSure, Actim PROM, ROM Plus)
  • Consider collect fluid for lung maturity (fibronectin)
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12
Q

Name complications PROM (2)

A
  • Infection (fetal/maternal),
  • umbilical cord prolapes/compression
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13
Q

Describe management : TERM PROM (4)

A
  • Admit and regular vitals with daily BPP and WBC
  • Avoid Digital until labour/induction
  • Consider antibiotics if indicated (no evidence in term PROM)
  • IV Oxytocin for induction of labour in all term PROM
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14
Q

Describe use of oxytocin in induction of labour (3)

A
  • Vaginal Prostaglandin higher chorio rates (but consider in unfavourable cervix)
  • PO Misoprostol easier to administer
  • If patient chooses expectant management >24h, need to evaluate for infection, avoid digital exams
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15
Q

Describe tx : Preterm <37w (PPROM)

A
  • Unclear if expectant vs IOL (preterm vs infectious risks)
  • If <34w generally expectant, prophylaxis with antibiotics (prolongs latency)
  • Glucocorticoids (betamethasone x2) <34w
  • Magnesium sulphate for neuroprotection <32w
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16
Q

Describe : Chronic (preexisting) hypertension

A
  • prior to pregnancy or onset <20w gestation)
  • sBP ≥140 or dBP ≥90 on two measurements at least four hours apart
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17
Q

Describe : Gestational Hypertension (onset >20w gestation) (3)

A
  • sBP ≥140 or dBP ≥90 on two measurements at least four hours apart
  • No proteinuria
  • No severe features of preeclampsia
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18
Q
A
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18
Q

Describe : Preeclampsia

A

sBP ≥140 or dBP ≥90 on two measurements at least four hours apart, or sBP ≥160 or dBP ≥110 confirmed within shorter interval

AND
Proteinuria (eg. Urine PCR ≥0.3, or ≥0.3g protein in 24h urine )

OR
Severe features of preeclampsia

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19
Q

Describe : Preeclampsia on chronic hypertension

A

Sudden increase in blood pressure, or sudden increase or new onset proteinuria

OR

Severe features of preeclampsia

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20
Q

Describe : Eclampsia

A

Generalized seizures due to preeclampsia

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21
Q

Describe : HELLP syndrome

A
  • Hemolysis, Elevated Liver enzymes, Low Platelets
  • May have hypertension
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22
Q

Name severe features of preeclampsia (5)

A
  • Symptoms of CNS dysfunction
  • Hepatic abnormality. Severe RUQ or epigastric pain unresponsive to medication and no alternative diagnosis. Serum transaminase ≥2 x ULN
  • Severe hypertension. sBP ≥ 160 or dBP ≥ 110.
  • Thrombocytopenia. Platelets <100,000 platelets/microL
  • Renal failure. Creat >97.2 micrmol/L or doubling of concentration (in absence of other renal disease)
  • Pulmonary edema
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23
Q

Name risk HIGH factors : Preeclampsia (4)

A
  • Previous preeclampsia (especially early onset with adverse outcome)
  • Multifetal gestation
  • Pre-existing medical conditions (hypertension, diabetes, renal disease)
  • Autoimmune disease (anti-phospholipid syndrome, SLE)
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24
Q

Name risk MODERATE factors : Preeclampsia (6)

A
  • Nulliparity
  • Obesity (BMI>30)
  • Family history of preeclampsia (mother/sister)
  • Age ≥ 35y
  • Low SES
  • African American
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25
Q

Name prevention of preeclampsia if LOW RISK (2)

A
  • Low-dose aspirin NOT helpful
  • Calcium supplement >1g/d or increase dietary calcium
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26
Q

Name prevention of preeclampsia if HIGH RISK (3)

A
  • Low-dose aspirin (75-160mg daily) small decrease in risk (~10%). Earlier = better (<16w)
  • High dose calcium 1-2g calcium
  • Note: If already established preeclampsia, no difference if given aspirin/Calcium
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27
Q

Name investigations : Hypertensive disorders (7)

A
  • Vitals (including Oxygen saturation)
  • UA (≥1+ proteinuria without RBC or casts). Urine protein:creatinine ratio ≥0.3 (may consider confirming ≥0.3g protein in a 24-hour urine specimen)
  • CBC (decreased Hb/plat)
  • INR/aPTT, fibrinogen (increased INR/aPTT, decreased fibrinogen)
  • Serum creat, uric acid, glucose, AST/ALT, LDH, Bili, Alb
  • Blood type and crossmatch (if suspect will need transfusion)
  • Fetal status (NST, BPP). Consider ultrasound for amniotic fluid volume and fetal weight (risk of oligohydramnios and fetal growth restriction)
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28
Q

Describe management : Acute HTA >160/110 (4)

A
  • Antihypertensive goal <160/110 for strokes (does not help with eclampsia)
  • First line: Nifedipine 5-10mg PO q30 mins for response or Labetalol 20-40mg IV q30mins (max 220mg/day)
  • Second line: Hydralazine 5mg IV q30mins (max 20mg/day)
  • Consider inpatient admission
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29
Q

Describe maintenance tx of HTA (3)

A
  • Target BP <140/90
  • First line oral labetalol, oral methyldopa, Nifedipine PA or XL
  • Note: ACE-i/ARB and atenolol are contraindicated (IUGR, prematurity, oligohydramnios, anomalies)
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30
Q

Describe use of fluids in tx of HTA (3)

A
  • Monitor O2. Beware of pulmonary edema
  • Assess volume status, consider small bolus (500mL NS). Urine output <15mL/h tolerated for few hours
  • Monitor Creatinine
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31
Q

Describe primary prevention of Seizure Prophylaxis

A
  • Severe preeclampsia, non-severe preeclampsia with symptoms, HELLP
  • If requires seizure prophylaxis, treat MgSO4 4g IV during labour and first 24h
  • Secondary prevention of recurrent seizures in eclampsia
  • Monitor for magnesium toxicity
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32
Q

Describe magnesium toxicity (5)

A
  • Loss of reflexes
  • Respiration >12/min
  • LOC
  • urine output >100mL/4h
  • If toxic consider 10mL of 10% calcium gluconate IV
33
Q

Describe tx of Eclampsia (6)

A
  • Call for help
  • Turn woman to side
  • Protect airway
  • Start MgSO4 4g IV over 30 mins then maintenance
  • Administer oxygen when seizures stops, take vitals
  • Assess for placental abruption, DVT, CVA, cardiomyopathy
34
Q

What patients to deliver with HTA ?

A
  • Pre-existing HTN without complications - 38w
  • Gestational HTN without complications - 37w
  • Preeclampsia without severe complications - 37w
  • Preeclampsia with severe features - deliver regardless of age
35
Q

Describe tx : HELLP (4)

A
  • Consider BP control and MgSO4 as above
  • If platelets <50, consider corticosteroids. Increases platelets
  • If platelets <50, falling or coagulopathy consider transfusion
  • If platelets <20, transfuse prior to C/S or vaginal deliver
36
Q

Describe tx HTA in post-partum (3)

A
  • HTN and complications may worsen during first few postpartum days
  • Consider furosemide to postpartum medication
  • Monitor until improving, BP<160/100 for 24h
37
Q

Describe : First stage dystocia (2)

A
  • First stage (active) 4h of <0.5cm/hr dilation or no cervical dilation>2h
  • Obstructed (lack of dilation/descent) if evidence of strong contractions
38
Q

Describe : Second stage dystocia

A

Second stage (active) >1h active pushing without descent

39
Q

Name causes of dystocia

A
  • Power (50-60mm Hg above baseline by IUPC, >60 seconds) -oxytocin
  • Passenger (fetal position, attitude, size, abnormalities) - reposition
  • Passage (pelvic/soft tissue factors) - ensure bladder empty
  • Psyche (pain/anxiety)
40
Q

Name management : Dystocia (6)

A
  • Prevent. If epidural analgesia, augment ARM/oxytocin early
  • Analgesia, hydration, rest
  • Amniotomy
  • Oxytocin augmentation, IUPC to assess contractions,
  • Assisted vaginal Birth
  • C-section
41
Q

Describe : Shoulder Dystocia (2)

A
  • Impaction of anterior shoulder on symphysis pubis (AP diameter)
  • See turtle sign (head delivered but retracts)
42
Q

Name risks : Shoulder Dystocia

A
  • Antepartum: Suspected macrosomia (induction does not prevent risk), diabetes, GA>42w, multiparity, previous hx dystocia, previous macrosomia, weight gain, obesity
  • Intrapartum: Prolonged labour, operative vaginal delivery, labour induction, epidural anesthesia
43
Q

Name complications : Shoulder Dystocia

A
  • Fetal: Hypoxia/asphyxia, fractures, brachial plexus palsy, death
  • Brachial plexus injury most common at C5-6 (forearm flexor/supinator) → waiter’s tip = Erb-Duchenne, most recover. C8-T1 = Klumpke (claw-hand) is rare
  • Maternal: PPH, uterine rupture, 4th degree tears
  • Avoid the 4 P’s (Pull, push, panic, pivot head)
44
Q

Describe management : Shoulder Dystocia (7)

A

ALARMER
* Ask for help, Tell patient to STOP pushing until manoeuvre completed
* Lift legs in McRoberts. Flatten head of bead and hyperflex legs
* Anterior Shoulder disimpaction (apply suprapubic pressure to the posterior anterior shoulder)
* Rotate posterior shoulder like screw (Wood’s)
* Manual removal posterior arm - Grab posterior hand and sweep across chest and deliver (can lead to fracture)
* Roll onto all fours - allows easier access for rotation and removal of posterior arm
* Episiotomy can facilitate above maneuvers but does not relieve dystocia

45
Q

Describe dx : Chorioamnionitis

A

Presumptive diagnosis

(1) Fever (T (≥39°C or ≥38°C on two occasions 30mins apart)

(2) One of :
* Baseline FHR >160/min for ≥10 mins (excluding periods of variability)
* Maternal WBC >15 in absence of corticosteroids (ideally showing left shift)
* Purulent fluid from cervical os visualized by speculum

46
Q

Describe tx : Chorioamnionitis (3)

A
  • Broad-spectrum antibiotics, eg. Ampicillin and Gentamicin
  • Consider Clindamycin or Metronidazole to cover aneaerobes if undergoing surgery
  • Prompt induction or augmentation of labor (cesarean only for standard obstetrical indications)
47
Q

Describe normal Fetal Heart Rate Monitoring (2)

A
  • Normal FHR baseline 110-160
  • at least 2 accelerations (≥15bpm lasting ≥15s) in 40mins strip
48
Q

Describe ABNORMAL Fetal Heart Rate Monitoring (3)

A
  • 160 for 10 mins or <110 for 10 mins
  • changing FHR baseline
  • decelerations
49
Q

What to think of in tachy in fetal heart rate monitoring (3)

A
  • Reposition (alleviate cord compression)
  • Rule out fever/dehydration/drug/prematurity, IV fluids
  • Maternal pulse/BP
50
Q

What to think of in brady in fetal heart rate monitoring (1)

A

check for cord prolapse

51
Q

What to do if decelerations in fetal heart rate monitoring (2)

A
  • check amniotic fluid for meconium
  • oxygen if mother hypoxic or hypovolemic
52
Q

Describe early decelerations (2)

A
  • Early: gradual decrease, usually same time beginning, peak and ending
  • Due to fetal head compression
53
Q

Describe late decelerations (2)

A
  • Gradual decrease, peak after contraction peak
  • Uteroplacental insufficiency
54
Q

Describe variable decelerations (2)

A
  • Abrupt decrease (onset to nadir <30 seconds)
  • Complicated : <70bpm for >60 seconds, loss of variability, biphasic, prolonged secondary acceleration, fetal tachy/brady
  • Cord compression
55
Q

What’s normal variabiltiy

A

5 - 25 bpm

56
Q

Describe : Normal uterine contractions

A
  • Uterine activity (frequency averaged over 30 mins, duration, intensity, resting tone)
  • Normal uterine contractions = <5 in 10 minutes, lasting <90 seconds between 25-75 mmHg, resting tone <7-25mmHg
57
Q

Describe : Fetal resuscitation (7)

A
  • Stop/decrease oxytocin
  • Change position (left/right lateral)
  • Improve hydration with IV fluids
  • Vaginal exam r/o cord
  • Amnioinfusion if variable decelerations
  • Reduce maternal anxiety
  • Consider oxygen if needed
58
Q

Describe : Postpartum Hemorrhage (3)

A
  • Any blood loss causing hemodynamic instability (eg. >0.5L vaginal, >1L in C-section)
  • Primary (immediate <24h of delivery) usually due to uterine atony
  • Secondary (late >24h) usually due to retained products of conception or infection
59
Q

Name etiologies of postpartum hemorrhage

A
  • Tone - uterine atony, distended bladder, infection
  • Trauma - uterine, cervical, vaginal
  • Tissue - retained placenta/clots. Manual removal or D&C
  • Thrombin - coagulopathy (pre-existing or acquired)
60
Q

Describe : Active management of 3rd stage of labour (10)

A
  • Oxytocin after delivery of anterior shoulder, eg. 10 units IM
  • Controlled cord traction (decrease duration)
  • Wait for signs of placental separation before delivery of placenta (vaginal bleeding, laxity)
  • Delivery of placenta
  • Assess uterine fundus
  • Inspect placenta for completeness
  • Inspect for uterine inversion (uterus into vagina)
  • Inspect for trauma (genital tract, vaginal)
  • Inspect for hematoma
  • Inspect for IV sites (ongoing bleeding may suggest DIC)
61
Q

Describe management : Postpartum Hemorrhage (8)

A
  • Bimanual fundal massage
  • Oxytocin titrated to uterine tone and hemorrhage control
  • all for help (Obstetrics/Surgery)
  • Vitals q5 mins, IV x2, Fluid resuscitation, O2 as needed. Consider Crossmatch, CBC, Coags (INR, fibrinogen, D-dimer)
  • Keep patient warm
  • Foley catheter (empty bladder)
  • Tranexamic acid 1g IV
  • Consider other uterotonics
62
Q

Name uterotonics (4)

A
  • Carboprost IM. Avoid in asthma.
  • Misoprostol sublingual or rectal.
  • Methylergonovine IM. Avoid if hypertensive, Raynaud syndrome, scleroderma
  • Consider intrauterine tamponade (packing, condom + foley, Bakri balloon), emergency embolization, emergency laparotomy, emergency hysterectomy
63
Q

Describe : Postpartum Pyrexia

A

Fever >38C on any 2 of first 10d postpartum (except first day)

64
Q

Name DDX : Postpartum Pyrexia (6)

A
  • Endometritis
  • Wound infection
  • Mastitis/engorgement
  • UTI
  • Pneumonia
  • DVT
65
Q

Describe : Endometritis (3)

A
  • Rising fever
  • Uterine tenderness
  • Usually postpartum day 2-3
66
Q

Describe tx : Mastitis/engorgement (4)

A
  • Empty breast (breastfeeding, pumping, expression)
  • Antibiotic coverage, eg. Cephalexin or cover MRSA if risk (TMP SMX, Clindamycin)
  • Ultrasound r/o abscess if does not respond in 72h
  • If non-lactational and mass does not resolve → FNA r/o inflammatory CA
67
Q

Describe : Postpartum Blues (2)

A
  • Onset day 3-10, increased anxiety, irritability, decreased concentration, sleep disturbance
  • Mild and self-limited, < 2w
68
Q

Describe : Postpartum Depression (2)

A
  • Within 1y of delivery
  • Suspect if >2w or severe (r/o psychosis)
69
Q

Describe tx : Postpartum Depression

A

Treat SSRI (eg. sertraline) and psychotherapy

70
Q

Name risks of Postpartum depression (3)

A
  • Previous depression
  • Poor social/financial support
  • Stressful life events during pregnancy or after delivery (domestic violence, abuse)
71
Q

Mothers should breastfeed when ? (3)

A
  • when infant shows signs of hunger or q2 hours
  • max 5 hour break once/day
  • aim for minimum of 8-12 feeds.
72
Q

What’s normal quantity of urine voids for infants ?

A

Infant should urinate one void per number of days of life until 6-8 times daily by day 5

73
Q

Suspect inadeqaute milk intake when ?

A

if >7% weight loss or if the infant does not regain their weight by 2w

74
Q

Name categoies of Inadequate Milk Intake (2)

A
  • Inadequate milk production
  • Poor milk extraction
75
Q

Name reasons for Inadequate milk production (4)

A
  • Breast development (previous surgery, radiation, endocrine -prolactinoma)
  • Delay in lactogenesis within first 5d. Usually due to obesity, hypertension, PCOS
  • Medications (oxytocin, SSRI, estrogen)
  • Offering only one side per feeding
76
Q

Name reasons for Poor milk extraction (5)

A
  • Infrequent feeding
  • Inadequate latch-on
  • Maternal-infant separation
  • Use of supplemental formula
  • Anatomical abnormalities, eg. Ankyloglossia (tongue-tie) may cause breastfeeding difficulties in some infants
77
Q

Name DDX : Nipple and Breast Pain (7)

A
  • Trauma
  • Vasoconstriction
  • Engorgement/Excessive milk supply
  • “Plugged ducts”, ie. Ductal Narrowing
  • Infection (bacterial, candidal)
  • Dermatitis/psoriasis
  • Mammary dysbiosis (subacute mastitis)
78
Q

Describe general tx : Dysfunctional breastfeeding (4)

A
  • Proper positioning and latch
  • Limited data for galactogogues (domperidone, metoclopramide, fenugreek) over breastfeeding technique interventions
  • Ointment with dressing on cracked nipples to keep wound moist, prevent infection and form a barrier
  • Cool or warm compresses, breastmilk to nipple
79
Q
A

Résidence - FM Learner (32 decks)

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