Case Files Flashcards
What’s needed to make formal diagnosis of preeclampsia?`
after 20 weeks gestation, 2 elevated BP readings 6 hours apart.
Complications of preeclampsia
placental abruption
ecalmpsia with possible intracerrebral hemorrhage
coagulopathies
renal failure
hepatic subscapular hematoma
hepatic rupture
uteroplacental insufficiency
Fetal growth restriction
Oligohydramnios
low APGAR score
fetal acidiosis
Risk factors for preeclampsia
nulliparity
extremes of age
AA race
personal hx of severe preE
fam hx of preE
chronic htn
chronic renal disease
obesity
antiphopholipid syndrome
DM
multifetal gestation
when to evaluate BP in pregnancy?
befre and after 20 weeks–do serial bp readings along with urinalysis.
sudden increase in weight in pregnany can indicate what?
edema
Lab tests to order for PreE
CBC – check platelet count and hemoconcentration
Urinalysis and 24 hour urine protein collection
liver function tests - CMP
LDH and uric acid
**BPP for uteroplacental insufficiency.
Management of PreE in GA >37wks
Mag sulfate and deliver
Management of PreE in preterm, GA <37
Watch closely and expectant management if mild PreE until term or severe
-If severe disease present then give mag and deliver
when is the greatest risk of Eclampsia in a preeclamptic patient?
prior to delivery
during labor (intrapartum)
within the first 24 hours postpartum.
If patient given magnesium, what needs to be monitored?
urne output bc it’s excreted renally
respiratory depression and dyspnea (side effect f mag is pulm edema)
abolition of deep tendon reflexes (frst sign of toxic effect is hyporeflexia)
What htn meds given to pregnant patients?
hydralazine or labetalol.
when is mag discontinued?
when should preeclamptic patients f/u after delivery?
approx. 24 hours postpartum.
f/u 1-2 weeks to check bp and proteinuria.
early vs late onset preE?
early onset may be due to abnormal placental factors–see nothcing of uterine artery on doppler. These patients have worse and earlier onset disease
late onset d/t constitutional factors like obesity. These pts have a more favorable course. Bariatric surgery prior to pregnancy in obese pts can help reduce risk of preE and the risks of obesity
Ddx in abnormal LFTs in pregnancy?
preeclampsia- LFTs 100-300 IU/L range, htn, proteinuria
AFLP- n/v, icteric, hypoglycemia, coagulopathy
HELLP- hemolysis, lfts up to 1000 IU/L, plt <100k uL
ICP- generalized itching, mildly elevated LFTs, elevated bile salts.
MC mechanism by which eclampsia causes mortality?
intracerebral hemorrhage
preterm patient with mild preE, management?``
expectant management until severe criteria noted or pregnancy reaches term.
most appropriate reason for delivery in preE at preterm gestation?
pulmonary edema.
Preterm labor workup
hx ass for risk factors
PE with speculum for ruptured membranes
serial digital cervical exams
CBC
UDS
UA, U CULTURE AND SENSITIVITY
cervical tests for gonnorhea and possibly chalm
vag culture for GBS
US for fetal weight and presentation
vaginal fluid test increase risk for preterm delivery ?
other objective test for preterm delivery?
fetal fibronectin assay. Negative FFN indicate that delivery will not occur within 1 week.
- transvaginal cervical length US measurement.
most significant risk factor for preterm labor?
hx of prior spontaneous preterm birth
Tx for preterm labor
- tocolysis unless contraindicated (intraamniotic infection or severe preE)
- IM antenatal steroids if less than 34 weeks for fetal pulmonary maturity
- cause of preterm labor such as UTI, infection ,bv
- IV ab like penicillin
- if less than 31 and 6/7, then give mag for neurodevelopment of preterm baby reducing CP.
-
tocolytic agents used?
mag- Competitive inhibitor of calcium
terbutaline/ritodrine - beta agonist- relax smooth muscle
nifedipine - inibt ca ion influx into vascular smooth muscle
indomethacin - decrease prostaglandin synthesis
17alpha pregogesterone - synthetic progesterone hormone – give 16-36 weeks to prevent preterm labor in people with hx of preterm labor.
Side effects and contraindications to tocoltic agents?
mag- pulm edema side effect
terbutaline/ritodrine- pulm edema, increase puplse preesure, HYPERglycemia, HYPOkalemia, and trachycardia side effect
nifedipine- HTN is a contraindication. dont give mag sulfate with it
indomethacin- dont give in third trimester– close fetus ducuts arteriosus which would lead to pulm htn and oligohydramnios.
is gonorrhea or chalmydia or both associated with preterm delivery?
gonoccoal cervicitis but not so much chalmydial infection.
What’s a contraindication for tocolysis and why?
abruption bc it can extend and cause complete shearing of placenta in which case delivery would bethe best treatment.
Tocolysis would increase the motehr’s chance of hemorrhage after delivery.
change in fetal heart rate tracing after tocolysis showing variable decels?
variable decels = cord compression
can occur in oligohydranios
indometahacine is assocated oligohydramnios
side effect of many tocolytic therapy esp beta agonists?
Tx?
pulmonary edema.
Tx- Oxygen and IV furosemide to decrease intravascular fluid.
PPROM management?
in the absence of infection give corticosteroids to decrease risk of RDS.
broad spectrum antibiotics to decrease risk of asending infections.
aka expectant management
pprom–> expectant management –> chorioamnionitis. tx?
- give IV antibiotics such as ampicillin and gentamicin
and
induction of labor and vaginal delivery
early isgn of chorio?
fetal tachycardia.
when should antenatal steroids be given for pprom?
before 32 weeks gestation
for PPROM when is delivery the treatment after expectant management?
34/35 weeks
or if evdece of fetal lung maturity by presence of phosphatidyl glycerol (PG) in the vaginal pool amniotic fluid.
most accurate methd to confirm intra-amniortic infection?
amniocentesis revealing organisms on gram stain are diagnostic of infection
what organism can induce chorioamnionitis w/o rupture of membranes?
organisms most likley affecting neonates?
chorio w/o ROM– b. listeria
- fbs and gram neg enteric orgs like e coli are most common orgs to affect neonates
most common finding with PPROM?
variable decels bc of oligo –> cord compression
tx with changing the patient’s position.
difference in parvo b19 infection in adults and childre
adults- malaise, arthralgia, myalgia, reticular/lacy rash
children- slapped cheek with high fever
what kind of organism is parvo b19?
infection in pregnancy can cause?
how to diagnose parvo b19 infection?
SS DNA virus.
infection in pregnancy can cause hydrops fetalis d/t severe fetal anemia since it inhibits bone marrow erythrocyte production
diagnose with serology
FHRT in severe fetal anemia?
sinusoidal HR pattern
signs of fetal hydrops?
how to confirm?
excess hydramnios –> uterine size greater than predicted by dates and fetal parts that are difficult to palpate.
confirm with US
- igm and igg both negative for parvo?
- if more than 20 days then suscpetible but not infected –> counsel and stay away from infected places
- if less than 20 days then possible early infection vs not infected –> repeat igg and igm in 1-2 weeks.
how to follow pregnant women infected with parvo b19?
if hydrops?
weekly fetal US for 10 weeks assessing for fetal hydrops.
if hydrop then intrauterine transfusion may be necessary.
is there a vaccine for parvo b19?
no!
parvo 19 infection complications?
fetal abortio, stillbirth and hdyrops.
ways to assess for possible fetal anemia?
result?
fetal MCA doppler and if anemia it’ll show elevated systolic veolocity.
mcc of nonimmune hydrops?
cardiac abnormalities like SVT but doesnt affect bone marrow,.
fetal dudenal atresia diagnosis?
- double bubble on US a/w hydramnios.
chlamydia test positive next step?
oral erythromycin, azithromycin or amoxicillin
screening and diagnostic test for HIV test?
screening test : ELISA or rapid antigen test
diagnostic: western blot or an IFA.
treatment of HIV in pregnancy?
- assess stage of HIV infection
initiation of HAART
offer elective C section
oral zidovudine to neonate
is chalmydia or gonorrhea infections more common?
chlamydia!
complications of chlamydial infection in pregnancy?
tx?
conjunctivitis and pneumonia.
conjunctivitis: erythromycin eye ointment DOES NOT HELP–only helps in gonorrheal conjunctivitis. Chalmydial ophtlamic infections given ORAL ERYTHROMYCIN X 14 days.
when to screen for chlaymidia?
tx?
third trimester since e’re worried about it affecting neonate so close to time of delivery is when we want to check.
Tx with erythromycin or amoxicillin x 7 days
OR
1 time dose of azithromycin
which antibiotics is contraindicated in pregnancy and why?
- tetracycline like doxy can cause fetal teeth yellow staining
- cipro associated with neonatal musculoskeletal problems
what kind of organism is chlaymida?
obligate intracellular organism with several serotypes.
MCC of conjunctivitis in first month of life?
chlamydial conjunctivitis
gonococcal infection associated with?
abortion, preterm labor, PPROM, chorio, neonatal sesis, and postpartum infection.
Tx of gonococcoal cervicitis?
IM ceftriaxone and add erythromycin bc c. trachomatis is commonly infected with it
when should antibodies for HIV detected?
1 month usually and def 3 months
how to monitor health status of HIV infected preggo woman?
viral load and CD4 T cell tesing
whats the goal in pregnancy in term of viral load for HIV?
under 1000 RNA copies
MC mode of HIV transmission in women?
heterosexual contact
seen esp in AA women.
