Lecture 13 Flashcards
What is Melasma (colasma)?
Mask of pregnancy
What is PUPP?
Pruritic urticarial papules and plaques of pregnancy
How do you treat PUPP?
Not many- maybe run ice cubes across stomach, take a Benadryl
What is the ratio of the plasma to RBC?
3:1 (no blood loss, just a dilution effect)
Under what levels of Hb is considered non-physiologic anemia?
<10-11 g/dL
What is the name for the proportion of blood composed of RBCs?
Hematocrit
What hematocrit (Hct) is considered non-physiologic anemia?
<30%
Hemoglobin multiplied by what gives you about an average of what you see on the Hct?
3
What will anemia look like on a smear?
Pale, hollowed out in center
microcystic, hypochromic
What are the three main types of neural tube defects?
Spina bifida
Encephalocele
Anencephaly
What chains of Hb are normal in the adult
2 alpha
2 beta
What type Hb does a fetus up to about 24 weeks makes?
Hb F
What is the name of alpha thalassemia where they are missing all 4 genes? incompartible with life, in utero fetal demise
Bart’s Hb
In sickle cell HB A is replaced with what?
Hb S
What type crises do people with sickle cell anemia have?
Vaso-occlusive crisis
How do you diagnosis sickle cell disorders?
Hb electrophoresis
What number of colonies are considered asymptomatic bacteruria?
> 10^5 colonies bacteria of urine culture
What can asymptomatic bacteruria develop into?
Cystitis (UTI) –> pyelonephritis
When do you do a urine culture?
Every first prenatal visit
If a mom has asymptomatic bacturia what do you do? (same for if they develop UTI)
3 days worth of antibiotics (ampicillin, cephalexin, or nitrofurantoin) and monitor w/ periodic culture
What is a good way in the urine to tell if mom is dehydrated?
Ketones
How do you treat pyeloneprhitis in a pregnant women?
Hospitalized (at risk of premature labor)
If a patient has the following what do you think they have: CVA tenderness, microhematuria, malaise, dehydration, no fever?
Calculi
How do you treat renal calculi
hydration, strain urine, watch for infection or obstruction
How much should a women with a normal weight gain in pregnancy?
25-35 lbs
How much should an underweight patient gain during pregnancy?
28-40 lbs
How much should an overweight women gain during pregnancy?
15-25 lbs
How much weight should an obese women gain during pregnancy?
11-20 lbs
How much water should a pregnant women drink?
six 8 oz glasses plus an additional 8 oz for every hour of activity
How much caffeine should pregnant women have?
<150-300 mg/day
What weeks does morning sickness usually occur?
4-14 weeks (peaks at 7-12)
What can help w/ morning sickness?
Ice chips, popsicles, small frequent meals, avoid triggers, ginger (crystallized) 250 mg capsules, only take 1/2 of prenatal vitamins at a time
To help with N/V what vitamin can a pregnant women take?
B6 BID-TID (10-50 mg)
What is the name for when a pregnant women has N/V and starts to lose weight (>5%) ?
Hyperemesis gravidarum
How do you treat hyperemesis gravidarum?
IV hydration, possible hospitalization
What should you R/O with hyperemesis gravidarum?
Acute fatty liver of pregnancy
What is the ddx for N/V with weight loss?
appendicitis, calculi, pyelonephritis, hepatitis, GB, hyperthyroid
If a pregnant women has Reflux what recommendations can you give?
Don’t lie down after eating
Avoid ETOH, citrus, caffeine, carbonated drinks
Take OTC antacids if dietary changes not helpful
What are symptoms of cholecystitis?
F/V/RUQ pain
How do you treat cholecystitis?
Supportive or surgical w/ obstruction or acute abdomen
If a women has itching, particularly on hands and feet what should you suspect?
Intrahepatic cholestasis of pregnancy
What are some physical symptoms of intrahepatic cholestasis of pregnancy?
Dark urine color light color BM fatigue or exhaustion Loss of appetite Depression itching on hands and feet
How do you treat intrahepatic cholestasis of pregnancy?
Ursodeoxycholic acid
What do you need to monitor w/ intrahepatic cholestasis of pregnancy?
NSTs, serum bile and LFTs
What are some risk factors of intrahepatic cholestasis of pregnancy?
multi-fetal gestations, previous liver damage or prior IUP w/cholestasis
What is the biggest concern w/ MVA & DV?
Placental abruption
What is the test for Rh status?
Kleihauer-Betke test (looks for fetal cells in maternal circulation)
IF a women has : fever, tachycardia, altered MS, V/D, arrhythmia and a history of hyperthyroidism what do you think of?
Thyroid storm
What is the Rx for hypothyroid?
Levothyroxine (Synthroid)
How often should you check TSH with a pregnant women?
once per trimester after TSH levels stable
What is thyroiditis usually associated w/
IUP loss
hypothyroid
When does GDM usually occur?
2nd trimester
What does the placenta produce that causes mom’s tissues to be less receptive to insulin?
HPL
With GDM what else does mom have more of?
TG and FFA (free fatty acids) and more of these go to the fetus
What are some risk factors of GDM?
AA< hispanic or Latin American, native american, family hx DM
What do you do to test GDM?
1 hour glucose challenge
What is the fetus as risk w/ GDM?
Sacral agenesis, cardiac anomalies, stillbrith, neonata hypoglycemia
WHat is the name to describe a neonate >4000 gm?
Macrosomia
What is the mom at risk for w/ GDM?
ecalmpsia, preterm delivery, C-sec, uterine atony/inertia –> PP hemorrhage
What do you want Hgb A1c under in women w/ DM?
<6%
When is the glucose challenge done if no risk factors?
24-28 weeks
How many grams of sugar do you give w/ the glucose challenge test (non-fasting)?
50 grams oral soluation and draw 1 hour later
What is an abnormal level for a 1 hour glucose challenge?
> 140 mg/DL (indication of 3 HGTT)
For a women with GDM what do you want plasma fasting to be at?
90-100
What do you want post-prandial for GDM?
120-140
Do diabetic patients deliver past their due dates?
No, they will be scheduled before then
When do you recheck maternal glucose levels?
after delivery and 6-12 weeks after
What is the rule of 3 with asthma?
1/3 of women get better
1/3 worsen
1/3 stay the same
What is monitored in pregnant women w/ asthma?
Monitor peak expiratory flow rate or FEV1 & symptoms
With asthma patients when do you do Serial US & antenatal testing ?
> 32 weeks
What does the NYHA classification used for?
Cardiac Disease classifications to show level of decompensation
What position for L&D do you like for women w/ cardiac disease?
Lateral position
What type of prophylaxis may be needed in pregnant women w/ cardiac disease?
Anticoagulation and antibiotic prophylaxis
What is the most common arrhythmia in pregnant women?
PAT (paroxysmal atrial tachycardia)
What should you suspect if a patient presents with fatigue, palpitations, nocturia, ankle edema, DOE, SOB/supine
Peri-partum cardiomyopathy
When do you screen for Group B Strep?
35-37 weeks
If a pregnant women has a positive culture for GBS what do you do?
antibiotic prophylaxis 4 hours pre-delivery through ROM and Labor and Delivery
If you have unknown status of GBS and a women is in labor what should you do?
Antibiotic prophylaxis
What happens to a baby w/ GBS?
Septic shock: Early onset: 1st week; late onset: >6 days-3 months
What should a women who has a partner with herpes simplex do?
Abstinence 3rd trimester w/ prodrome or lesions
When should you do a C-section with women w/ herpes simplex?
prodrome
active lesions or positive HSV glycoprotein at L&D
What can happen if a fetus is exposed to rubella the first trimester?
congenital reubella syndrome (deafness, cataracts, heart defects (PDA), mental retardation) or SAB
What labs do you for rubella?
IgM and IgG antibodies (if these are present = have infection)
Is immunization for Hep A ok when pregnant?
Yes since it is inactivated viral protein
What can you give if a women has been exposed to Hep A?
HAV Ig (immune globulin)
Can a women w/ Hep A breastfeed?
Yes, with proper hygiene precautions
Which is more serious, Hep B or Hep A?
Hep B can progress to chronic carrier state and can affect liver more
What lab do you check for for Hep B?
HBsAG (hep B surface antigen)
What transmission model is Hep B?
Vertical
If a neonate is thought to have Hep B what do you do?
IZ and HB Ig w/in 12 hours of birth
What reduces antepartum transmission of HIV/AIDS?
HIV + Antiretroviral, C-section
minimize duration ROM and fetal exposure to maternal blood
Can you vaccinate for HPV while pregnant?
No
How can you treat condyloma acuminata if present?
cyro, laster, TCA (Trichloroacetic acid)
If a women has an abnormal PAP during pregnancy what do you do?
Treat post partum
What may happen to the neonata if the mom has HPV (rare)?
rare laryngal papillomatosis (C-section not prevent)
Does syphilis cross the placenta?
Yes
If a women has a low titer w/ positive FTA for syphilis what has probably happened?
They are seroconverted
What do you use to treat syphilis in pregnant women?
Benzathien LA 2.4 single or weekly x 3
With the Jarisch-Herxheimer rxn what risk is there to the fetus?
Fetal demise
have patient check their temp/ make sure baby is still moving
If a baby has the following what should you suspect? Snuffles, HSM, jaundice, LAD, chorioretinitis, Hutchinson teeth, mulberry molars, saddle nose, saber shins
Congenital syphilis
What can happen with a neonate when the mom has chlamydia?
maternal azithromycin po
Neonate: purulent conjunctivitis at birth or pneumonia at 1-3 mos
If a patient has a short febrile illness or a clinical suspicion of CMV what should you do?
Test for presence of CMV antibodies: anti-CMV IgG
What can happen to the neonate with CMV?
Petechiae, HSM, jaundice, microcephaly, chorioretinitis, fetal hydrops
Long term: hearing loss, neurological disabilities
What is fetal hydrops?
Collect of excess fluid (can occur in many places)
Who do you mandatorily screen for toxoplasmosis?
moms with HIV/ AIDS
If a mom has a positive IgG for toxoplasmosis what does that mean?
Infection at some point in time
If a mom has a positive IgM for toxoplasmosis what does that mean?
Recent infection
What are some risks to the neonate with toxoplasmosis?
Infants infected before birth often show no symptoms at birth but develop them later in life w/potential blindness, mental retardation, chorioretinitis, hydrocephalus & seizures
Other risks: SAB, stillbirth, congenital issue
Can you be vaccinated for varicella while pregnant?
No
What can you give a mom exposed to varciella?
VZIG (immunoglobulins) w/in 72 hours but doesn’t protect fetus
For parvovirus what do you screen?
B19 igM and IgG
If a women has a positivei B19 IgM what should you do for parvovirus?
Do a US to r/o hydrops
What do you prescribe w/ a pregnant women w/ migraine?
Acetaminopehn w/ or w/o codeine
What type women may need more folate supplements?
Epileptic women
What are some risk factors for antenatal depression?
Unplanned/unwanted IUP, socioeconomic stressors, current/past depression, FHx
How long does PP blues last?
2-4 days post birth; come and go and gone 1-2 weeks
Asthma Severity Classification: Intermittent
Frequency: 2 days/week or less
Nighttime awakening: Twice/month or less
Asthma Severity Classification: Severe persistent
Frequency: symptoms throughout day
Nighttime awakening: 4 times/week or more
Asthma Severity Classification: Moderate persistent
Frequency: Daily Symptoms
Nighttime awakening: More than once per week
Asthma Severity Classification: Mild persistent
Frequency: more than 2 days/ week, but not daily
Nighttime awakening: More than twice per month
What do you need to confirm GDM?
Glucose Challenge Test (50g solution and draw 1 hour later)
If abnormal: 3 HGTT w/ 100g solution (2 of 4 values are abnormal = GDM)
NYHA: Class I
No cardiac decompensation
By NYHA, what class show no symptoms of cardiac decompensation at rest, but marked limitations of physical activity?
Class III
NHYA: Class IV
Symptoms of cardiac decompensation at rest, increased discomfort with any physical activity
BY NYHA, what class shows no symptoms of cardiac decompensation at rest and minor limitations of physical activity?
Class II
What do you do to help with maternal cardiac function and fetal well being with a CV problematic patient?
Prevent maternal stress (anemia, cardiac workload, weight gain, physical activity/work)
L&D (lateral position, shorten 2nd stage, epidural)
Anticoagulation and antibiotic prophylaxis as needed
Close monitoring post partum
What are risks of rheumatic heart disease?
maternal risk subacute bacterial endocarditis, heart failure, embolic events, fetal loss
When is it common to have peri-partum cardiomyopathy?
Last month of IUP or 1st 6 months PP
What signs and symptoms are common with peri-partum cardiomyopathy?
fatigue palpitations nocturia ankle edema DOE SOB/supine
If a mom gets the live attenuated rubella vaccine, how long should she wait to get pregnant?
4 weeks before attempting IUP
During the 1st prenatal visit, what test is done to confirm HIV/AIDS?
ELISA w/ Western blot
If the initial HIV/AIDS test is negative, when should you repeat it?
3rd trimester for high risk pt (contracts STD while pregnant, HIV+ partner, adds additional partners while pregnant, high HIV prevalent region)
What is the most likely hx for someone with toxoplasmosis?
cats in household and contact with infected cat feces
What is Congenital Varicella Syndrome?
1st or early 2nd trimester maternal infections causes LBW, scarring on skin, limb hypoplasia, microcephaly
If a baby has been exposed to Parvovirus and has hydrops, what should be done?
intrauterine transfusion and monitor fetal growth
What are the risks of parovirus?
SAB, hydrops, fetal death
