Antepartum abnormal Flashcards

1
Q

Transient HTN

A

BP >= 140/90 for first time w/o proteinuria if preeclampsia does not develop and the BP has returned to normal by 12 wks pp

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2
Q

Preeclampsia

A

BP >=140/90 after 20 wks GA with proteinuria (>=300mg/24hr or persistent 30mg/dL or 1+ on urine dipstick

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3
Q

Theories of etiology of preeclampsia (7)

A
Abnormal trophoblast invasion 
Coagulation abnormalities
Vascular endothelial damage
Cardiovascular maladaptation
Immunologic phenomena
Genetic pre-disposition
Dietary deficiencies or excesses
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4
Q

Eclampsia

A

Clonic-tonic seizures before, during or up to 10 days pp that are not attributable to other causes.

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5
Q

Superimposed Preeclampsia

A

New onset proteinuria in HTN after 20 wks GA

Sudden increase in proteinuria and BP and decrease in platelets <100K in women with proteinuria before 20wks GA.

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6
Q

HELLP Syndrome

A

Hemolysis, Elevated Liver enzymes, Low Platelets

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7
Q

HTN risk factors (8)

A
Nulliparous
New father
Adverse med hx
Fam hx of preeclampsia
Multiple gestation, fetal hydrops 
Race
Obesity
>35 y/o
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8
Q

S/S of abnormal HTN disorders (7)

A
HTN: BP >= 140/90
Proteinuria: 30mg/dL random, 1-2+ on dipstick; >300mg/24hr
Thrombocytopenia (Platelets > 100K)
Headache (resistant to meds)
Visual distrubances
Decreased urine output
Epigastric/right upper quadrant pain
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9
Q

Management plan: Early, mild hypertension (home care) (7)

A
Left lateral bedrest 2hrs am and pm
Daily BP checks
Daily weight
Daily urine dipsticks
Bi-weekly office visits
Daily fetal kick counts
Consult and education pt
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10
Q

Preeclamsia in-patient management (9)

A
Bed rest
decreased environmental stimulation
24hr I&Os
Labs: 24hr urine for protein and creatinine clearance
Liver function tests (AST/ALT)
High Protein dit
NSTs bi-weekly
US if  <36 weeks ega to assess IUGR
BP q2-4hrs, routine VS and FHT  otherwise
Deliver at term
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11
Q

Eclampsia management (4)

A

Call for help (notify physician stat)
Observe seizure
Prevent injury (side rails up, turn to left side, don’t restrain)
Mag sulfate IV

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12
Q

What to do after eclampsia seizure (7)

A
Clear airway
Oxygen 8L/min
EFM
Evaluate Contractions and labor
Examine for injury
Maternal Blood gasses, electrolytes and serum
Magnesium levels
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13
Q

CMV

A

most common congenital virus from the herpes family.

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14
Q

Clinical signs of CMV maternal (4)

A

Adenopathy
Mono symptoms
Rare fever or hepatitis
More severe if immunocompromised

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15
Q

Neonatal signs CMV (8)

A
SGA
Microcephaly (fetal hydrops),
thrombocytopenia
petechiae
jaundice
retinitis
hyperbilirubinemia
splenomegaly
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16
Q

Long term sequelae of CMV (neonate) (5)

A
Hearing loss (most common)
Various neurological symptoms
Mental retardation
Retinitis
Developmental delay
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17
Q

Fetal transmission by trimester

A

1st and early 2nd = more serious (eg microcephaly)

3rd trimester = fetal hepatitis and thrombocytopenia

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18
Q

Toxoplasmosis transmission

A

more likely to have transmission as pregnancy increases but severity is less
1st = 15%
2nd = 25%
3rd = 60%
May slightly increase risk of stillbirths

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19
Q

Toxoplasmosis for neonate

A
75% asymptomatic; if symptomatic 10-12% mortality
IUGR,
Retinitis
Jaundice
hepatosplenomegaly
pneumonia
adenopathy
anemia
thrombocytopenia
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20
Q

Treatment/Management with toxoplasmosis

A

Pyrimethanine, folic acid and sulfadiazine

Prevention: No raw meat, cat litter handling, hand wash foods from contaminated soil

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21
Q

Varicella (Chicken Pox)

A

A herpes virus transmitted via arosol with perinatal transmission usually within 1st 20 weeks

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22
Q

S/S of varicella

A

Fever, chills, cough
Rash (starts maculopapular on trunk, progress to vessicles and crust)
possible development of pneumonia (with high risk of mortality
Increased risk of Preterm birth

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23
Q

Fetal congenital infection of Varicella (8)

A
Greatest risk 13-20wks
Skin scarring
Microcephaly and micro-ophthalmia
Limb reduction
Growth restriction
Polyhydramnios
Dextrocardia
30% neonatal mortality rate if infected near birth
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24
Q

Treatment Varicella

A

acyclovir IV if symptomatic with complications

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25
Rubella transmission
14-21 day incubation period through nasaopharyngeal secretions 1st timester exposure results in 20-80% congenital abnormalities No documented defecte beyond 20 wks
26
Fetal s/s of rubella (9)
``` Fetal growth restriction Cateracts Congenital Heart disease Bone lesions Hepatosplenomegaly Congenital deafness petechiae anmeia microcephaly ```
27
Late neonatal sequelae of rubella (5)
``` Mental retardation Diabetes Thyroid disease Visual Damage Encephalitis ```
28
Management of Rubella
Treatment is palliative Vaccination of children and susceptible women of childbearing age Vaccine contraindicated in pregnancy
29
Thyroid changes in preg
Moderate thyroid enlargement Fetus uses maternal iodide up to 20 wks GA Increased maternal renal clearance of iodide TSH does not change in pregnancy
30
Management of thyroid in preg
Sig increase in size, goiter or nodule requires evaluation. ACOG: Thyroid testing only performed on symptomatic women with personal hx of the disease or other conditions associated with disease (i.e. DM)
31
Thyroid storm
Medical emergency: extreme hypermatabolic state with risk of maternal heart failure; s/s = fever, tachycardia, changed mental status, vomiting, diarrhea, cardiac arrhythmia
32
Dizygotic twins
multiple ova fertilized by different sperm 2 separate placentas and 2 separate membranes Runs in families 69% of twins More likely in AA women
33
Monozygotic twins (identical)
31% of twins Data suggest small increase with ovulatory stimulants Relationship of # of placenta/membranes depends on timing of division monoamniotic/monochorionic diamniotic/monochorionic diamniotic/monoamniotic
34
Maternal risks of multiple gestation (4)
HTN (10-25%) Abruption (2-6%) PP hemorrhage (10-20%) Preterm birth (25-50%)
35
Fetal risks of multiple gestation
Growth restriction Preterm birth Demise of more than one twin (more common in mono twins) twin-twin transfusion
36
Genital Warts risks in preg
Potential lesions on vocal chords or in the upper airway and can result in rare respiratory papillomatosis
37
Management of Genital warts
``` Immiquimod (class B) or topical TriChloractic acid Podophyllin & podofilox are contraindicated ```
38
HSV risks in preg
Neonatal infection
39
HSV management in preg
C/S if active lesion or prodromal symptoms at onset of labor | Prophylaxis with acyclovir in last month of pregnancy
40
Gonorrhea risks in preg
Neonatal blindness
41
Gonorrhea management in preg
Neonatal prophylaxis at birth | maternal tx Ceftriaxone 250mg IM once
42
Chlamydia risks in preg
``` Opthalmia neonatorum (not liked to blindness) Neonatal pneumonia (tx during preg may reduce risk) ```
43
Chlamydia management in preg
Azithromycin 2g one time dose (maternal) | Neonatal eye prophylaxis at birth
44
Syphilis risks in preg
Congenital syph: cataracts, microcphaly, hutchinson's teeth (notched teeth), hepatoslenomegaly
45
Management of Syphilis in preg
Treat ASAP to minimize neonatal effects Treat as latent (3 injections of benzathine penicillin 1 each week for 3 wks). If allergic, desensitize with PCN, cuz erythromycin has poor placental crossing (woman may be treated, but not fetus)
46
HIV risks in preg
Perinatal transmissions may occur esp with vaginal birth or BF if viral load is not suppressed.
47
Management of HIV in preg
Antiretroviral therapy during preg and neonatal periods C/S recommended if viral load is not suppressed No BF
48
Bleeding in preg how often and how is it related to SAB
25% of women in 1st and 2nd trimesters will experience bleeding and approximately 13% or half will experience SAB ABs, Moles, ectopics, blighted ovums
49
Def of Threatened AB (4)
Continuation of preg is in doubt Does not always culminate in AB Usually pain is absent of minimal; if present, it is an ominous sign. The cervix is closed and not effaced
50
Inevitable AB (3)
Termination of preg is in progress Usually characterized by dilated cervix with accompanying pain, bleeding or rupture of membranes Inevitable abortion usually proceeds to complete or incomplete AB
51
Incomplete AB
Products of conception protrude through the cervical os | Bleeding is apt to be more severe than other types of abortions often necessitating a D & E
52
Missed AB
Fetal death occur w/o expulsion of POC for several weeks Bleeding may or may not occur and may be light if it does Uterus is smaller than expected
53
Blighted ovum (no embryo)
Unknown etiology Gestational sac develops, but no embryo Usually treated as inevitable or incomplete abortion
54
Ectopic Preg
Preg outside the uterine cavity | usually assoc with pain, irregular bleeding and possible adenexal mass or fullness on one side
55
Gestational trophoblastic disease (molar preg)
Abnormal chorionic villi that form grape like vessicles, may occur with fetus (incomplete mole) or in absences of a fetus (complete mole) Uterus large or small for dates. No FHT if complete mole Assoc with early preeclampsia, hyperemesis gravidarum and very high HCG levels May progress to invasive mole or choriaocarcinoma
56
Incomplete mole & complete mole
IM =May be result of fertilization with diploid sperm | CM = only paternal genetic material, possibly from 2 sperm fertilizing an ovum with no maternal genetic material
57
Other reasons for bleeding in preg (more gyne related)
Chlamydia, cervical eversion causing more postcoital bleeding and with paps and cervical polyps
58
Normal HCG levels in preg
rises 66-100% every 48 hrs until about week 8; rises slowly until week 10 and plateaus at 24 weeks
59
HCG in abnormal conditions (3)
Ectopic: < 66%/48hrs GTD (mole): higher than expected SAB (complete): <5 mIU/mL or less; may take several weeks to go down
60
Bleeding in late preg (6)
Previa (20%) Abruption (30%) Other Causes (50%) Marginal placental separation, preterm labor, STI
61
Hypertonic uterus =
more likely due to abruption
62
Transvag US is best for identifying what condition
Preveia Placental abruption (inconsistently identifiable) No pelvic exam if previa
63
Emergency late preg bleeding
Emergency consult and obtain neonatal support if 1. Brisk vaginal bleeding 2. unstable vital signs 3. Fetal distress
64
management of bleeding in late preg
maternal O2, Trendelenburg position or at least pelvic tilt Immediate IV access: 2 large bore IV (16-18 gauge) Initiate IV LR solution Order type & Cross 2 units of whole blood.
65
Post dates complications
``` Maternal= Birth trauma due to macrosomia/shoulder dystocia, increased incidence of operative delivery, secondary infection or hemorrhage Neonatal= Meconium aspiration syndrome, polycythemia, hyperbilirubinemia, hypoglycemia ```
66
Fetal surveillance postdates per ACOG
Despite lack of evidence that monitoring improves outcomes, its reasonable to initiate fetal surveillance between 41 and 42 wks GA with NST and AFI, performed biweekly
67
Asthma in preg: Patient outcomes
28% improve; 33% no effect; 35% worsen | Consultation or collaboration is necessary depending on severity
68
Maternal complication with asthma in preg (5)
``` Hyperemesis Preeclampsia CHTN Vaginal bleeding Preterm labor and birth ```
69
Management of Asthma in preg (6)
Careful observation of fetal size Fetal kick counts Continue peak flow diary Condition likely to worsen at 29-36 wks GA Avoid beta adrenergics; use of Mag SO4 controversial for PTL
70
Acute treatment in preg (8)
``` Admit if peak flow is 95% Continuous pulse ox EFT Pulmonary function tests Beta Adrenergics Mortality >40% if asthma requires intubation ```
71
GDM causes
Preg is a diabetogenic state due to fasting hypoglycemia, post prandial hyperglycemia and hyperinsulinemia. hPL decreases insulin effectiveness Progesterone thought to increase basal levels of insulin Progesterone and Estrogen thought to have a role in increasing tissue resistance to insulin In GDM mother cannot produce enough insulin to overcome peripheral insulin resistance
72
Screening for GDM
Average risk: at 24-28 wks GA High risk: at first visit and repeat at 24-28wks GA. ACOG recommend all preg women be screened by pt hx, clinical risk factors or 1hr GTT at 24-28wks
73
3hr GTT cut offs
``` Fasting >105 1hr >190 2hr >165 3hr >145 GDM diagnosed when 2 or more are over the cut off. ```
74
PROM and PPROM
Spontaneous ROM prior to onset of regular uterine contrx. PPROM if earlier than 37 wks GA Assoc w/ complications such as PTL, chorio, prolapsed cord and malpresentation The earlier in preg PROM occurs the longer the latent period (time b/t rupture and contrx)
75
Causes of PROM
Infection (bacteria weaken collagen in membranes and initiate prostaglandin synthesis) Usually BV, Trich, GC/CT and GBS
76
Mgmt of PROM (induction vs expectant)
``` Induction = shortens latent period, avoid unnecessary vag exams, watch for s/s of infection Expectant = the longer latent period > chance of infection; 70% go into labor in 24h and 90% in 48hr; sterile spec exam, fetal kick counts, temps every 4 hrs, NST or BPP every 2 days; BPP <6 may mean amniomitis; pelvic rest ```
77
Mgmt of PPROM
Amnio to detect infection and assess fetal lung maturity; abx therapy; moreso expectant mgmt; admin of corticosteroids; prolong preg to 34 wks in absence of infection and fetal distress