Keeler: Obstetrical hemorrhage, GDM and PPROM Flashcards

Question

pre-eclampsia DELIVERY - WHEN

Answer 1

Once the Dx is made, it becomes “all about” “how soon can we get this baby delivered?”. Factoring in: prematurity, fetal condition, maternal condition When does risk (of waiting) become > the risk of ACTING?

Answer 2

BP > 160/110 Platelets < 100,000 Liver impairment (RUQ pain or 2x ↑ in transaminases) Renal impairment (creatinine > 1.1 mg/dl) Pulmonary edema (New) cerebral or visual disturbances

Answer 3

hemolysis elevated liver-function tests low Platelet count

Answer 4

The FUSE is LIT DELIVERY is indicated ! May or may not be “time” for steroids Get MFM consult liberally May or may not be time for IOL

Answer 5

Remember – ultimate TX = delivery Seizure prophylaxis = MgSO4 through delivery + 24-48 hours after Hypertension control – hydralazine IV – don’t “bottom it out” HTN control – labetolol PO

Answer 6

A big goal of prenatal care is to find this complication EARLY – if you suspect it: More frequent visits Rest US for growth Baseline labs – CBC, LFT’s, Cr, 24 hr urine Counseling as to Sx to watch for, esp HA and RUQ/epigastric pain

Answer 7

HA’s = very common This Sx should always → check BP Ask about vision – scotomata, blurry, double? HA, esp w/ visual disturbances may be a sign of cerebral edema and a warning about impending ECLAMPSIA

Answer 8

“Swelling” is very common and normal Sudden-onset of new swelling and weight gain is a warning sign – see patient that day! Rest may help A/C in summer may help “NAS” diet = borderline help

Answer 9

``` Acid reflux (GERD) and GB sx are common Reported RUQ or epigastric pain should be treated as an emergency! ``` See pt immediately A potential WARNING SIGN of expansion of liver capsule and impending RUPTURE. = The worst-imaginable catastrophe.

Answer 10

Delivery is great, but…… The DANGER is not over!!!! Pre-eclampsia can seem to be getting better, only to WORSEN after patient goes home *** Some cases do not even begin until post-partum

Answer 11

Usually a disease of First term pregnancy Usually does not mean HTN-for-life Usually OK to use OCP’s after

Answer 12

write it out in hand-written notes so as not so confuse with MSO4, morphine sulfate

Answer 13

Reduce birth defects Reduce/dx early – pre-eclampsia Reduce hydramnios (aka “polyhydramnios”) Reduce/eliminate stillbirths Reduce macrosomia (→ a ↓ in C/S, shoulder dystocia) Reduce neonatal hypoglycemia/hypocalcemia

Answer 14

Gestational = “GDM” “Pre-existing” DM White classifications – no test questions Pre-conception control + planning = critical

Answer 15

``` GDM in prior pregnancy High BMI Prior large infant (> 9 lbs) Prior shoulder dystocia Family Hx of (any) DM Older age (30? 35? 40?) ```

Answer 16

``` “Challenge” test all by 28 weeks “GCT” = glucose challenge test 50 gm glucose, get plasma glucose = “BS” one hour later Fasting/special diet not necessary (Limiting conc. CHO’s may ↓ false +) under 130-140 = normal ```

Answer 17

If GCT is abnormal………. If ≥ 140 but < 200 ----- do 3 hour GTT If > 200, do NOT do GTT – may get ↑↑ BS If > 200, you have your dx If + dx: LFT’s, BMP, HgbA1C

Answer 18

Strongly consider med endocrinology consult Diet ~ 2500 Cal Self-monitoring FBS HgbA1C each visit Dietitian/nutritionist, endocrinol NP Diet may not be enough: insulin, glyburide po

Answer 19

Serial US to assess growth (not absolute) FM chart Warn about pre-eclampsia sx NST’s weekly, biweekly – when to start? (34) IOL at term (C/S if EFW > 4000 gm)

Answer 20

``` Control is the goal 2 week visits, weekly in 3rd tri Monitoring (FM, NST, US) starts sooner Assess FLM Role of “early” delivery ```

Answer 21

GDM moms are @ higher risk of DM later FBS + HgbA1C @ 6 week PP appt Recheck annually

Answer 22

it is a VITAL SIGN

Answer 23

PPROM Urinary incontinence Vaginal discharge Perspiration

Answer 24

alkaline pH | Estrogen causes salt in fluid to crystallize in a unique pattern: fern testing

Answer 25

accounts for ~1/2 of preterm births ``` PROM = Premature Rupture of Membranes (defined as prior to onset of labor) PPROM = Preterm PROM (<37 weeks) ``` “mid-trimester PROM” = PROM between 14 and 26 weeks (pre-viable)

Answer 26

``` Genital tract infections Previous PPROM Antepartum bleeding Cigarette smoking/cocaine Mechanical Stress Most patients have no identifiable risk factors ```

Answer 27

``` About 1/3 of women with PPROM develop potentially serious intrauterine infections Increased risk of: - Placental abruption - Umbilical cord prolapse - Pulmonary hypoplasia ``` Tx = Expeditious delivery, esp if after 34 weeks

Answer 28

If < 24-26 weeks – delivery If 26-34 weeks – expectant If 34+ weeks - delivery

Answer 29

It’s all about SURFACE TENSION Soap bubble effect in the ALVEOLI HMD = hyaline membrane disease = collapse of alveoli due to low surface tension Surfactant in alveoli keeps them expanded!!

Answer 30

Liggins and Howe, British physiologists Late 1960’s Fetal lambs, intentional premature delivery Steroids to ewe = much less premature lung disease in her premature lambs “Fools” alveolar lining into producing surfactant UC inhibitors used to allow steroids to work