Differential And Steps Flashcards
Management of placenta previa?
- Bedrest
- C-section if unstoppable labor, fetal distress, life-threatening hemorrhage
- If bleeding, venous access, HCT, type and screen, PT/PTT, Kleinhauer-Betke,
- tocolysis and steroids if under 34 weeks
Patient with antepartum bleeding – differential?
OBSTETRIC causes
- Placental – previa, abruption, vasa previa
- Maternal – uterine rupture
- Fetal – fetal vessels rupture
NON-OBSTETRIC causes
- Cervical – cervicitis, polyps, cancer
- Vaginal – lacerations, varices, cancer
- Other – bleeding disorder, trauma
Placental abruption - management?
- IV access, type and screen, CBC, PT/PTT, fibrin split products, RhoGAM
- Prepare for preterm deliver
- C-section if life-threatening bleed, and non-reassuring tracing
Uterine rupture - management?
- Laparotomy and delivery of the fetus
- Hysterectomy if repair not possible
- Discourage future pregnancies, at minimum no trial of labor in future
ruptured fetal vessel - management?
emergent c-section
Suspect Preterm rupture of membranes - diagnosis?
- Pooling, nitrazine, and ferning
- if evoquivical, use ultrasound for AFI
- If still unconfirmed, inject dye into amnionic sac and examine vaginal for leakage
Preterm rupture of membranes - management?
- If under 32, prolong with ampicillin, give steroids (tocolysis has little benefit)
- If 32-36, physician decision
- If over 36, deliver (longer wait increase risk for Chorioamnionitis)
- If signs of infection or fetal distress, deliver
Labor fails to progress - Ddx?
- Pelvis - too small?
- Power - IUPC and ptosin
- Passenger - macrosomia?
Cephalopelvic Disproportion - management?
- Trial of labor unless US has documented fetal head larger than pelvis
Breech presentation - management?
- External version if after 37 weeks (earlier and it will revert back)
- Trial of breech vaginal delivery (if favorable pelvis, weight 2000-3800, and not foot/compound breech)
- If compound breech, watch for umbilical cord prolapse
- C-section
Vasa previa - management?
- Do NOT artificially rupture membranes
2. If vasa previa, can undergo a trial of labor if they wish
Fetal bradycardia - tx?
- Move pt to side (may be due to IVC compression)
- O2 to mother
- Vaginal exam (for blood, uterine tetany, rapid descent)
- If hypotensive, hydration and ephedrine
- For tetany, give nitroglycerin and terbutaline
- If umbilical cord prolapse, c-section
Shoulder dystocia - management?
- McRoberts
- Wood’s corkscrew
- Delivery of posterior arm
- Suprapubic pressure
- Zavanelli
Pregnant with seizure - management?
- ABCs
- Assess fetal status
- Mag sulfate
4 lorazepam
5 phenytoin - If no response, phenobarbital
7.
SGA - Ddx?
- Decreased growth potential - trisomies, congenital infections, teratogens
- IUGR with symmetric restriction - insults <20 weeks gestation (malnutrition, maternal anemia, renal disease, hypertension, SLE, twins)
- IUGR with asymmetric restriction - insults over 20 weeks
Risk factors for SGA vs LGA
- Trisomies vs other chromosomal (Beckwith-Wiedemann)
- Large vs small maternal stature
- Substance abuse vs food abuse (obesity/diabetes)
- IDDM vs gestational diabetes
- Females vs males
6 intrauterine infections vs old, multips
LGA fetus - management?
- Get good dating or assess lung maturity from amniocentesis
- Induced before fetus becomes macrosomic (over 4500g)
Oligohydramnios - causes?
- Uteroplacental insufficiency
- Renal agenesis/ GU obstruction
- Rupture of membranes/leakage
Oligohydramnios - management?
- Plan for Labor at term or post date or with rupture of membranes
- Frequent antenatal testing
- Amnioinfusion if meconium or cord compression
Polyhydramnios - Management?
- Expect Malrotation and Risk of cord prolapse so be careful after ROM
- RhoGAM to prevent Isoimmunization
Fetal demise - management?
- Delivery to prevent DIC (prostaglandins/oxytocin after 20 weeks)
- Test mother of CVD, hypercoagulable state, TORCH
Postterm pregnancy - management?
- Week 41 - NST
- Week 42 - BPP and NST
- After 42nd week, induce
Mild preeclampsia - management?
- If over 34 weeks, induce with ptosin, prostaglandins, amniotomy
- If stable preterm, steroids and bedrest
3 Mag sulfate during L&D
Severe preeclampsia – management?
- Magnesium sulfate for seizure prophylaxis (Continue 24 hours postpartum)
- Hydralazine for blood-pressure control
- If less than 32 weeks, steroids
- Beyond 32 weeks, delivery
Eclampsia – management?
- Seizure management with magnesium
- Blood pressure control with hydralazine
- Calcium chloride or calcium gluconate if magnesium toxicity
- No cesarean section unless obstetrics indications (nonreassuring fetal tracing, hemodynamic instability)
Patient with chronic hypertension in pregnancy – management?
- Labetalol
- Nifedipine
- Methyldopa less effective
PMS tx?
- Exercise and vitamin A, E, B6
- OCP
- SSRIs
Diabetes during pregnancy - evaluation?
- 50g 1 hour glucose tolerance at 24-28 weeks (positive if over 140)
- If positive 3 hour GTT (gestational diabetes if 2+ values are elevated)
Gestational diabetes - pregnancy management?
- Diabetic diet A1
- Insulin (short acting since fasting values usually normal while postprandial elevated) A2
- If A2, NST or BPP between 32-36 weeks
- US for macrosomia at 34-37 weeks
Gestational diabetes - delivery management?
- Induction at 39-40 weeks (if poor sugar control, at 37-39 weeks)
- C-section if over 4000-4500
Pt with diabetes - obstetric complications?
Polyhydramnios Preeclampsia (4x) Miscarriage (2x) Infection Postpartum hemorrhage
Regular diabetes during pregnancy - management?
- ECG, 24 urine analysis, HbA1c, TSH
- Tight Glucose control
- 4mg frolic acid daily (neural tube)
- After week 32, weekly NST. After week 36, biweekly
- After pregnancy, insulin requirements decrease due to removal of placenta (fewer insulin antagonists)
Ddx postpartum hemorrhage with vaginal delivery?
Vaginal - hematoma/lacerations
Cervical - lacerations
Uterus - atony, inversion, rupture
Placental - accreta, retained POCs
Ddx postpartum hemorrhage with c-section delivery
Placenta - accreta
Uterus - atony, rupture
Uterine atony - management?
- Oxyoxin with uterine massage
- If fails, methergine (unless HTN)
- If fails, prostaglandin F2a (unless asthmatic)
- If fails, D&C to r/o retained POC
- If fails, uterine artery embolization
- I fails, hysterectomy
Accreta management?
Laparoscopy
