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Grossesse Flashcards

1
Q

Indications prise aspirine

A

if either 1 high risk factor or 2 moderate risk factors:

1 high risk factor: history of preeclampsia, multifetal gestation, chronic hypertension, DM1 or DM2, renal disease, autoimmune disease (SLE, antiphospholipid)

2 moderate risk factors: Nulliparity, Obesity (BMI≥30), family history of preeclampsia, age 35 years and older, sociodemographic risk factors (low socioeconomic status, etc), or personal history factors (fetus is small for gestational age, previous adverse pregnancy outcomes, etc)

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2
Q

Dose et durée prise Aspirine

A

80-160mg ASA at bedtime ideally before 16 weeks gestation

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3
Q

Bilan prénatal T1

A

Blood type and screen (Rh and Ab)
CBC
HIV
Rubella
Syphilis
HepBsAg
HepCAb
UA, UCx
Gono chlam
Consider VZV, TSH (Target <2.5, then <3 for third trimester), ferritin, Hb electrophoresis, random glucose/HbA1c/fasting glucose

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4
Q

Exemples de femmes enceintes à risque élevé (psychosocial)

A

adolescentes,
victimes de violence familiale, famille monoparentale,
consommation de drogues, milieu de vie défavorisé

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5
Q

À quelle semaine donner winhro chez femmes Rh deg

A

28 semaines

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6
Q

Quand faire test 50g ou 75 g Glucose

A

24-28 semaines (Avant si haut risque)

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7
Q

Quand faire dépistage SGB ?

A

Entre 35 et 37e semaine

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8
Q

Antibiotiques empiriques pour cystite chez femme enceinte

A

Amoxicillin 500mg PO TID x7d
Amoxicillin-clavulanate 500mg PO BID x7d
Nitrofurantoin 100mg PO BID x 7d (avoid at labour because of hemolytic anemia)
Cephaléxine 250-500 mg QID x 4-7 jours
TMP-SMX 1 DS tab BID x 3d (avoid in first trimester and near term)

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9
Q

ATB pour couvrir SGB en travail

A

IV Pen G 5mill units + 2.5 units q4h
(cefazolin if low risk, clinda if high risk and sensitive or vanco if not sensitive)

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10
Q

Quels critères pour ATB lors travail pour prévention infection SGB ?

A

Previous infant with GBS
GBS bacteriuria during current pregnancy
Positive screen
GBS unknown and one of: Preterm or ROM>18h or T>38C

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11
Q

Exemples de femmes enceintes à risque élevé (médical)

A

femme infectée par le virus
de l’immunodéficience humaine, utilisatrices de drogues
intraveineuses, femmes diabétiques ou épileptiques

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12
Q

Calcul de la DPA avec la DDM

A

Premier jour de la dernière période menstruelle + 9 mois + 7 jours

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13
Q

DDX saignement T1

A

Implantation bleed
Abnormal pregnant (Ectopic/molar)
Abortion (threatened, inevitable, incomplete, complete, missed, septic)
Non-Obstetrical (Uterine, Cervical Vaginal Pathology)

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14
Q

Investigations saignement T1

A

CBC
Blood type
Serial b-hCG
- Rising b-hCG >35% over 48h consistent with viable IUP (but ectopic may also display rising hCG)
- hCG <35% over 48h suggest ectopic or abnormal IUP

Abdominal Ultrasound
-IUP if b-hCG >6000 IU/L

Transvaginal Ultrasound
-Gestational sac and yolk sac at 5w gestation
-Cardiac activity at 6w gestation
-IUP if b-hCG >2000 IU/L

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15
Q

DDX saignement T2

A

Bloody show (onset 72h prior to labor, PPROM)
Placenta previa (20%)
Placental abruption (30%)
Uterine rupture (rare)
Vasa previa (rare)
Non-Obstetrical (Uterine, Cervical, Vaginal Pathology)

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16
Q

Types d’HTA en grossesse

A

Chronic (preexisting) hypertension (prior to pregnancy or onset <20w gestation)

Gestational Hypertension (onset >20w gestation)
Preeclampsia
Eclampsia

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17
Q

Critère pré éclampsie (incluant Valeur HTA pour pré-éclampsie)

A

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

+ Présence protéinurie
OU
Symptômes sévères de pré éclampsie

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18
Q

Symptômes de pré éclampsie sévère

A

Symptoms of CNS dysfunction
Photopsia, scotomata, cortical blindness, retinal vasospasm
Severe headache (ie, incapacitating, “the worst headache I’ve ever had”) or headache that persists and progresses despite analgesic therapy
Altered mental status

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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19
Q

FdeR Pré éclampsie

A

High risk:
Previous preeclampsia (especially early onset with adverse outcome)
Multifetal gestation
Pre-existing medical conditions (hypertension, diabetes, renal disease)
Autoimmune disease (anti-phospholipid syndrome, SLE)

Moderate risk:
Nulliparity
Obesity (BMI>30)
Family history of preeclampsia (mother/sister)
Age ≥ 35y
Low SES
African American

20
Q

Investigations à demander pour pré éclampsie

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)

21
Q

Tx HTA en pré éclampsie

A

Aigu (si plus de 160/110):
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)

Entretien:
oral labetalol, oral methyldopa, Nifedipine PA or XL

22
Q

PEC éclampsie

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

23
Q

Quand prévoir accouchement pour:
Hypertensionn chronique, hypertension gestationnelle, pré éclampsie et éclampsie

A

Pre-existing HTN without complications - 38w

Gestational HTN without complications - 37w

Preeclampsia without severe complications - 37w

Preeclampsia with severe features / Eclampsia - deliver regardless of age

24
Q

Définition HELLP

A

Hemolysis, Elevated Liver enzymes (AST, ALT, LDH), Low Platelets

May have hypertension

25
FdeR PROM
Amniocentesis Cervical insuff/cerclage Prior conization/LEEP PPROM, preterm Vaginal bleed, Placental Abruption Polyhydramnios Multiple pregnancy Smoking STI, BV Low SES
26
Investigations pour confirmer PROM
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) Ultrasound for low AFI
27
PEC PROM à terme
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 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
28
PEC PROM pré terme
Unclear if expectant vs IOL -Induction of labor (preterm vs infectious risks) If <34w generally expectant, prophylaxis with antibiotics (prolongs latency) Glucocorticoids (betamethasone x2) <34w Magnesium sulphate for neuroprotection <32w
29
FdeR Diabète gestationnel
Obesity Previous pregnancy with GDM or IGT Family history of DM
30
Complications Diabète gestationnel (Maternel)
Hypertension Polyhydramnios Retinopathy Hypoglycemia Pyelonephritis/UTI
31
Complications Diabète gestationnel (Foetal)
Macrosomia IUGR (= RCIU en français) Hypoglycemia Polycythemia Fetal lung immaturity
32
PEC diabète gestationnel
Dietary advice Pharmacotherapy (insulin, metformin, glyburide) Target A1C ≤6.5 (ideally ≤6.1) Blood glucose targets: Prepandial <5.3, 1h Postprandial <7.5 (or <7.8), 2h Postprandial <6.7mmol/L Serial ultrasound to monitor growth Induce by 40w gestation Blood sugars hourly during labour Follow-up with repeat 75g OGTT between 6 weeks and 6 months postpartum (risk of DM2)
33
Stades du travail
First stage - regular contractions + cervical change (dilation/effacement) Latent (days): Nulliparous up to 3-4cm dilation Parous up to 4-5cm Active Contractions leading to cervical change after above cervical change Second stage - Full dilation to delivery (active = pushing) Third stage - Delivery of baby to placenta Fourth stage - Placenta to one hour postpartum
34
Définition / critère Dystocie
First stage (active) 4h of <0.5cm/hr dilation or no cervical dilation>2h Obstructed (lack of dilation/descent) if evidence of strong contractions Second stage (active) >1h active pushing without descent
35
Cause dystocie (les 4 P)
Puissance (50-60mm Hg above baseline by IUPC, >60 seconds) -oxytocin Passager (fetal position, attitude, size, abnormalities) - reposition Passage (pelvic/soft tissue factors) - ensure bladder empty Psyché (pain/anxiety)
36
FdeR dystocie épaule
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
37
Complications dystocie épaule
Fetal: Hypoxia/asphyxia, fractures, brachial plexus palsy, death Maternal: PPH (Hémorragie post partum), uterine rupture, 4th degree tears
38
PEC dystocie épaule
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) If steady pressure not working, try rocking pressure Adduct anterior shoulder by applying pressure to posterior shoulder (Rubin) to push towards chest of baby 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
39
Dx chorioamnionite
Fever (T (≥39°C or ≥38°C on two occasions 30mins apart) + 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
40
PEC chorioamnionite
Broad-spectrum antibiotics, eg. Ampicillin 2g IV 6h and Gentamicin 5mg/kg once daily Prompt induction or augmentation of labor (cesarean only for standard obstetrical indications)
41
Signes au tracé qui ne sont pas normaux
Tahy (Plus de 160 pour 10 min) Bragy (Moins de 110 pour 10 min) Décélérations tardives ou Variables compliquées) Variabilité faible (moins de 5 ppm) Contractions utérines (Plus de 5 en 10 min, durée plus de 90 sec, pas de retour à état de base) Pas d'accélération (devrait avoir 2 de plus de 15 ppm durant plus de 15 sec)
42
Cause d'hémorragie post partum
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)
43
Médicaments à donner en HPP
Oxytocin 10 units IM, then 20-40 units/1L NS infusion 200-500mL/h titrated to uterine tone and hemorrhage control Tranexamic acid 1g IV over 10 mins, repeat after 30 mins if needed Consider other uterotonics Carboprost (Hemabate) 0.25mg IM q15mins (max 2mg) -Avoid in asthma Misoprostol 800mcg sublingual or rectal Methylergonovine 0.2mg IM q2-4h -Avoid if hypertensive, Raynaud syndrome, scleroderma
44
PEC non pharmaco de HPP
Bimanual fundal massage Call 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) Consider intrauterine tamponade (packing, condom + foley, Bakri balloon), emergency embolization, emergency laparotomy, emergency hysterectomy
45
DDX fièvre PP
Endometritis Rising fever, uterine tenderness (usually postpartum day 2-3) Treat with antibiotics with anaerobic coverage (eg. clinda/genta IV until improved x 24-48h) Wound infection Mastitis/engorgement 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 UTI Pneumonia DVT

Examen Med fam (4 decks)

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