79. Pregnancy Flashcards
In preconception counselling, describe Risk assessment (9)
- 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
In preconception counselling, describe lifestyle recommendations (5)
- 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)
In preconception counselling, what’s the folic acide dose ?
Folic acid 0.4-1mg/d (high risk 5mg daily)
How to optimize natural fertility ? (5)
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
What medications to stop during pregnancy ? (9)
- 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)
Describe risk of untreated depression vs use of antidepressants
- 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
Describe what to cover during first vist in pregnancy (8)
- 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
Add questions regarding visits
Name risks : Prelabour Rupture of Membranes (PROM) (10)
- Amniocentesis
- Cervical insuff/cerclage
- Prior conization/LEEP
- PPROM, preterm
- Vaginal bleed, Placental Abruption
- Polyhydramnios
- Multiple pregnancy
- Smoking
- STI, BV
- Low SES
Name investigations : Prelabour Rupture of Membranes (PROM) (4)
- No Digital
- Sterile speculum
- Culture for STI and GBS
- Ultrasound for low AFI (Max vertical pocket <2cm or AFI ≤5 cm)
What to look in sterile speculum for PROM?
- 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)
Name complications PROM (2)
- Infection (fetal/maternal),
- umbilical cord prolapes/compression
Describe management : TERM PROM (4)
- 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
Describe use of oxytocin in induction of labour (3)
- 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
Describe tx : Preterm <37w (PPROM)
- 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
Describe : Chronic (preexisting) hypertension
- prior to pregnancy or onset <20w gestation)
- sBP ≥140 or dBP ≥90 on two measurements at least four hours apart
Describe : Gestational Hypertension (onset >20w gestation) (3)
- sBP ≥140 or dBP ≥90 on two measurements at least four hours apart
- No proteinuria
- No severe features of preeclampsia
Describe : Preeclampsia
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
Describe : Preeclampsia on chronic hypertension
Sudden increase in blood pressure, or sudden increase or new onset proteinuria
OR
Severe features of preeclampsia
Describe : Eclampsia
Generalized seizures due to preeclampsia
Describe : HELLP syndrome
- Hemolysis, Elevated Liver enzymes, Low Platelets
- May have hypertension
Name severe features of preeclampsia (5)
- 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
Name risk HIGH factors : Preeclampsia (4)
- Previous preeclampsia (especially early onset with adverse outcome)
- Multifetal gestation
- Pre-existing medical conditions (hypertension, diabetes, renal disease)
- Autoimmune disease (anti-phospholipid syndrome, SLE)
Name risk MODERATE factors : Preeclampsia (6)
- Nulliparity
- Obesity (BMI>30)
- Family history of preeclampsia (mother/sister)
- Age ≥ 35y
- Low SES
- African American
Name prevention of preeclampsia if LOW RISK (2)
- Low-dose aspirin NOT helpful
- Calcium supplement >1g/d or increase dietary calcium
Name prevention of preeclampsia if HIGH RISK (3)
- 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
Name investigations : Hypertensive disorders (7)
- 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)
Describe management : Acute HTA >160/110 (4)
- 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
Describe maintenance tx of HTA (3)
- 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)
Describe use of fluids in tx of HTA (3)
- Monitor O2. Beware of pulmonary edema
- Assess volume status, consider small bolus (500mL NS). Urine output <15mL/h tolerated for few hours
- Monitor Creatinine
Describe primary prevention of Seizure Prophylaxis
- 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
Describe magnesium toxicity (5)
- Loss of reflexes
- Respiration >12/min
- LOC
- urine output >100mL/4h
- If toxic consider 10mL of 10% calcium gluconate IV
Describe tx of Eclampsia (6)
- 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
What patients to deliver with HTA ?
- Pre-existing HTN without complications - 38w
- Gestational HTN without complications - 37w
- Preeclampsia without severe complications - 37w
- Preeclampsia with severe features - deliver regardless of age
Describe tx : HELLP (4)
- 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
Describe tx HTA in post-partum (3)
- HTN and complications may worsen during first few postpartum days
- Consider furosemide to postpartum medication
- Monitor until improving, BP<160/100 for 24h
Describe : First stage dystocia (2)
- First stage (active) 4h of <0.5cm/hr dilation or no cervical dilation>2h
- Obstructed (lack of dilation/descent) if evidence of strong contractions
Describe : Second stage dystocia
Second stage (active) >1h active pushing without descent
Name causes of dystocia
- 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)
Name management : Dystocia (6)
- Prevent. If epidural analgesia, augment ARM/oxytocin early
- Analgesia, hydration, rest
- Amniotomy
- Oxytocin augmentation, IUPC to assess contractions,
- Assisted vaginal Birth
- C-section
Describe : Shoulder Dystocia (2)
- Impaction of anterior shoulder on symphysis pubis (AP diameter)
- See turtle sign (head delivered but retracts)
Name risks : Shoulder Dystocia
- 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
Name complications : Shoulder Dystocia
- 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)
Describe management : Shoulder Dystocia (7)
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
Describe dx : Chorioamnionitis
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
Describe tx : Chorioamnionitis (3)
- 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)
Describe normal Fetal Heart Rate Monitoring (2)
- Normal FHR baseline 110-160
- at least 2 accelerations (≥15bpm lasting ≥15s) in 40mins strip
Describe ABNORMAL Fetal Heart Rate Monitoring (3)
- 160 for 10 mins or <110 for 10 mins
- changing FHR baseline
- decelerations
What to think of in tachy in fetal heart rate monitoring (3)
- Reposition (alleviate cord compression)
- Rule out fever/dehydration/drug/prematurity, IV fluids
- Maternal pulse/BP
What to think of in brady in fetal heart rate monitoring (1)
check for cord prolapse
What to do if decelerations in fetal heart rate monitoring (2)
- check amniotic fluid for meconium
- oxygen if mother hypoxic or hypovolemic
Describe early decelerations (2)
- Early: gradual decrease, usually same time beginning, peak and ending
- Due to fetal head compression
Describe late decelerations (2)
- Gradual decrease, peak after contraction peak
- Uteroplacental insufficiency
Describe variable decelerations (2)
- Abrupt decrease (onset to nadir <30 seconds)
- Complicated : <70bpm for >60 seconds, loss of variability, biphasic, prolonged secondary acceleration, fetal tachy/brady
- Cord compression
What’s normal variabiltiy
5 - 25 bpm
Describe : Normal uterine contractions
- 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
Describe : Fetal resuscitation (7)
- 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
Describe : Postpartum Hemorrhage (3)
- 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
Name etiologies of postpartum hemorrhage
- 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)
Describe : Active management of 3rd stage of labour (10)
- 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)
Describe management : Postpartum Hemorrhage (8)
- 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
Name uterotonics (4)
- 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
Describe : Postpartum Pyrexia
Fever >38C on any 2 of first 10d postpartum (except first day)
Name DDX : Postpartum Pyrexia (6)
- Endometritis
- Wound infection
- Mastitis/engorgement
- UTI
- Pneumonia
- DVT
Describe : Endometritis (3)
- Rising fever
- Uterine tenderness
- Usually postpartum day 2-3
Describe tx : Mastitis/engorgement (4)
- 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
Describe : Postpartum Blues (2)
- Onset day 3-10, increased anxiety, irritability, decreased concentration, sleep disturbance
- Mild and self-limited, < 2w
Describe : Postpartum Depression (2)
- Within 1y of delivery
- Suspect if >2w or severe (r/o psychosis)
Describe tx : Postpartum Depression
Treat SSRI (eg. sertraline) and psychotherapy
Name risks of Postpartum depression (3)
- Previous depression
- Poor social/financial support
- Stressful life events during pregnancy or after delivery (domestic violence, abuse)
Mothers should breastfeed when ? (3)
- when infant shows signs of hunger or q2 hours
- max 5 hour break once/day
- aim for minimum of 8-12 feeds.
What’s normal quantity of urine voids for infants ?
Infant should urinate one void per number of days of life until 6-8 times daily by day 5
Suspect inadeqaute milk intake when ?
if >7% weight loss or if the infant does not regain their weight by 2w
Name categoies of Inadequate Milk Intake (2)
- Inadequate milk production
- Poor milk extraction
Name reasons for Inadequate milk production (4)
- 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
Name reasons for Poor milk extraction (5)
- 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
Name DDX : Nipple and Breast Pain (7)
- Trauma
- Vasoconstriction
- Engorgement/Excessive milk supply
- “Plugged ducts”, ie. Ductal Narrowing
- Infection (bacterial, candidal)
- Dermatitis/psoriasis
- Mammary dysbiosis (subacute mastitis)
Describe general tx : Dysfunctional breastfeeding (4)
- 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
