mat med Flashcards
anti-D for PVB <12/40
ectopic, molar or TOP only: 250 iu
BCSH says for all
anti-D for PVB 12-20/40
250iu within 72h
anti-D for PVB >20/40
500iu + kleihauer
if >4ml on kleihauer, f/u sample ____
at 48h if given IV
at 72h if given IM
cell salvage in anti-D
cord blood –> RhD+ –> 1500iu
Kleihauer 30-40min post Tx
anti D for recurrent PVB 12-20/40
250iu q6/52
anti D for recurrent PVB >20/40
500iu q6/52 + kleihauer q2/52
additional doses 125iu/ml IM, 100iu/ml IV
AFLP: proportion of pts developing AKI
14%
AFLP: proportion of pts requiring renal replacement
3.5%
enzyme enducing AEDs
phenobarbital, phenytoin
Oxcarbazepine
Topiramate
Carbamazepine
Infliximab: stop or continue?
Stop by 16/40
Etanercept: stop or continue?
Stop by 3rd trimester
Certolizumab: stop or continue?
Continue
Adalimubab: stop or continue?
Stop by 3rd trimester
autonomic dysreflexia-
what level?
what symptoms?
above T6
Hypertension (rise of 20-40mmHg) and bradycardia
injury at what spinal level associated with increased risk of malpresentation at term
above T12
injury at what spinal level alters perceptions of FM and unable to feel labor pains
above T10
also associated with later preterm labour and UTI
quad test
AFP
bHCG
Inhibin A
Unconjugated estriol
most common solid benign liver lesion
hepatic hemangioma (present in about 10% of healthy individuals)
appearance of hepatic hemangioma on USS
well circumscribed, solid, hyper echoic
lifetime risk of haemorrhage of hepatic adenoma
27%
highest risk with larger lesions and THIRD trimester
lifetime risk of rupture of hepatic adenoma with intraperitoneal bleeding
17%
risk of malignant transformation of hepatic adenoma
5%
toxoplasmosis: risk of fetal transmission <4/40
1%
toxoplasmosis: risk of fetal transmission 13/40
10%
toxoplasmosis: risk of fetal transmission 36/40
> 60%
zika: avoid pregnancy for ?? if male partner traveled
3 months
zika: avoid pregnancy for ?? if only female partner traveled
8 weeks
high risk thrombophilias (asymptomatic) and management
- asymptomatic antithrombin deficiency
- protein C or S deficiency
- homozygous factor V leiden (or compound heterozygote)
- homozygous prothrombin gene mutation
refer to a local expert and consider antennal LMWH.
Recommend 6 weeks postnatal LMWH
low risk thrombophilia (asymptomatic)
- list (3)
- management
- heterozygous factor V leiden
- heterozygous prothrombin gene mutation
- antiphospholipid antibodies only
Management:
consider for antenatal thromboprophylaxis in presence of other RFs
10 days LMWH if one other RF present
antithrombin deficiency
very high risk
manage by local expert
epilepsy: treat as low risk if
seizure free >10y
Off AED for >5y
Resolved childhood epilepsy (seizure and treatment free in adulthood)
lamotrigine lowest risk dose and associated risk of congenital abnormality
<300mg/day (<2% risk)
*normal neurodevelopment
carbamazepine lowest risk dose and associated risk of congenital abnormality
<400mg/day (<3.4% risk)
*normal neurodevelopment
risk of congenital abnormalities on polytherapy (epilepsy)
16.8%
background risk of congenital abnormality
2-3%
valproate for epilepsy:
1) risk of congenital abnormality
2) risk of neurodevelopmental impairment
1) 10.7%
2) 40% (decreased IQ, Increased autism, reduced verbal and memory skills)
valproate for epilepsy: most common associated congenital defects
NTD
Facial cleft
Hypospadias
Phenytoin and carbamazepine: most commonly associated congenital defects
cleft palate
phenobarbital and phenytoin: most commonly associated congenital defects
cardiac abnormalities
risk of recurrent congenital abnormality if WWE with previous affected child with congenital abnormality
16.8%
effect of pregnancy on seizures
2/3 will not have deterioration
10% will have reduction
30% will have increase in seizure frequency
(focal epilepsy has a lower seizure-free rate)
how to terminate epileptic seizure intrapartum if no IV access (first line)
Diazepam 10-20mg PR, q15min
alternative = midazolam buccal
how to terminate epileptic seizure intrapartum if IV access present (first line)
Lorazepam 0.1mg/kg (4mg bolus + 10-20min)
intrapartum epileptic seizure: second line if not controlled
phenytoin 10-15mg/kg IV
**if FH not recovered in 5min of recurrent seizures, expedite delivery
side effects of antiepileptic drugs
depression, anxiety, neuropsychology sx
risk of FGR for WWE (off or on AED)
off: OR 1.26
on: OR 3.56
WWE: general risks
FGR Misc IOL PPH/APH C/S
risk of intrapartum epileptic seizures
1-2%
+1-2% within 24h PN
risk of status epilepticus intrapartum
1%
reliable contraception for WWE
IUCD, LNG-IUS, DMPA
when to do PN f/u for WWE if medications changed antenatally
day 10
pregnancy after breast ca: how long to recommend prior to conception
at least 2y
tamoxifen needs to be stopped 3/12 prior to conception
incidence of breast ca in pregnancy
1/3000 pregnancies
if having chemo:
1) what interval from last chemo to birth
2) what interval from last chemo to BF
1) at least 2-3 weeks
2) allow 14 days
risks of obstetric cholestasis: SB (untreated)
1-4%
risk of PTL in OC
iatrogenic 7-25%
Spontaneous 4-12%
risk of C/S in OC
10-36%
risk of meconium passage in OC
25% (more likely if severe)
risk of adverse fetal outcome in OC
1-2% for every 1umol/L increase in BA
recurrence of AFLP
25%
target FT4 in treatment of hyperthyroid
1.2-1.8
targets TSH in treatment hypothyroid (by trimester)
1st = 0.5-2.5 2nd = 0.2-3.0 3rd = 0.3-3.0
incidence of hyperthyroidism in pregnancy
1% (Graves in Pregnancy according to TOG)
(??0.2% according to stratOG??)
Gestational thyrotoxicosis (1-3%) is most common cause of biochemical hyperthyroidism in 1st trimester (present in 45% of hyperemesis)
risk of neonatal thyrotoxicosis in graves disease
1-5%
Mortality 12-20%
Lasts 2-3 months
if history of graves, when to measure TRab
20-24 weeks
incidence of overt hypothyroidism in pregnancy
0.5% (~2-10/1000)
incidence of subclinical hypothyroidism in pregnancy
2-5%
defined as TSH 2.5-10
risks of hyperthyroidism (maternal)
PET FGR SB miscarriage Prematurity
risks of overt hypothyroidism
Misc PET PIH PPH LBW Low IQ
Risks of subclinical hypothyroidism
pregnancy loss
abruption
PPROM
NND
**but rule of thyroxine replacement not clear
perinatal mortality rate for pre-existing DM
28/100 000
DM: avoid pregnancy at what threshold level
HbA1C >10% (86mmol)
DM: targets preconception
HbA1c <6.5 (48mmol)
Fasting 5-7mmol
Premeal 4-7mmol
DM: what renal threshold to refer to nephrology
creat >120
eGFR<45
or ACR >30
DM: timing of delivery for T1/T2
37-38+6/40 if uncomplicated,
otherwise <37/40
DM: intrapartum care BM targets
4-7mmol
who gets a GTT (24-28/40)
- BMI>30
- Previous macrosomia
- Previous GDM
- FH of DM
- Minority ethnic group
- Glycosuria (2+ x1 ,or 1+ x2)
DKA diagnosis
BM >11
Acidosis ph<7.3 (or HCO3 <15)
Ketones: capillary >3mmol; urine >2+
DM: timing of delivery for GDM
by 40+6
*planned C/S if DM + EFW >4.5kg
% of GDM on lifestyle changes requiring further treatment ie. metformin
10-20%
SCD: timing of delivery
38-40/40, IOL or C/S
SCD: fetal risks
IUGR
IOL or C/S
Fetal distress
PTL
SCD: what medication should be stopped and when
hydroxyurea >3/12 prior to conception
SCD: incidence of painful crises
27-50%
25% postpartum
SCD: incidence of ACS
7-20%
treatment of uncomplicated malaria (falciparum)
PO quinine 600mg TDS + clindamycin 450mg TDS
alternative riamet or malerone (atorvaquone -proguanil, 4 tablets daily x3/7)
treatment of uncomplicated malaria (vivax, vale, malaria)
PO chloroquine 600mg,
then 300mg 68h later
then on day 2 and again on day 3
treatment of complicated malaria (any species)
IV artesunate 2.4mg/kg - 12, 24h, then daily
when can tolerate oral, switch to PO artesunate + clindamycin
if PO artesunate not available, 3 day course of riamet or malerone;
alternative IV quinine 20mg/kg in dextrose + clindamycin IV 450mg TDS; switching to PO
treatment of uncomplicated malaria with vomiting
quinine IV 10mg/kg in 5% dextrose over 4h
+ clindamycin IV 450mg TDS
when can tolerate oral, switch to:
PO quinine 600mg TDS x 5-7 days
+/- PO clindamycin 450mg TDS x 7 days
prevention of malaria relapse (non-falciparum)
chloroquine 300mg once weekly until delivery
resistant plasmodium vivax treatment
as for uncomplicated falciparum
treatment of P vale
primaquine 15mg OD x 14/7
treatment of P vivax
primaquine 30mg OD x 14/7
treatment of non-falciparum malaria in presence of G6PD deficiency
primaquine 45-60mg once a week for 8 weeks
risk of contracting malaria in oceania
1:20
risk of contracting malaria in sub-saharan africa
1:50
risk of contracting malaria in Indian subcontinent
1:500
risk of contracting malaria in southeast asia
1:500
risk of contracting malaria in south america
1:2500
risk of contracting malaria in central america/caribbean
1:10 000
dosing for malaria chemoprophylaxis
mefloquine 1 table (250mg) weekly
HIV: if unknown viral load/not on treatment; what to give if presents term labour
nevirapine stat dose
start ZDV and lamivudine and raltegravir PO
give ZDV IV for duration of labour
under what circumstances would you start cART in 1st trimester
viral load >100 000
CD4 <200
if HBV/HIV co-infection, what should be given?
Tenofovir as part of cART
if HCV/HIV co-infection, what drug should be avoided?
ribavirin
postnatal GDM followup
- test BM prior to discharge
- test fasting @ 6-13/52
- annual HbA1c thereafter
diabetes insipidus in pregnancy associated with what lab abnormalities
Blood Osm >285
Urine Osm <300
Hypernatremia
DM preconception BM target fasting
5-7
DM preconception BM target pre-meal
4-7
DM antenatal BM target fasting
<5.3
DM antenatal BM target 1h post meal
<7.8
DM antenatal BM target 3h post meal
<6.4
DM postnatal BM - normal/low risk
<6
DM postnatal BM - high risk
6.0 - 6.9
DM postnatal BM - likely T2DM
> 7.0
Hemophilia A: factor8/VWF ratio suggestive of carrier status?
<0.7
hemophilia, de novo mutations
30-50%
severe hemophilia, level below?
0.01
moderate hemophilia levels
0.01-0.05
mild hemophilia levels
0.06-0.40
risk of ICH and ECH in hemophilia affected male fetuses
- 2.5% ICH (OR 44)
- 3.7% ECH (OR 8)
when to do fetal sex determination for hemophilia (for severe carriers)
from 9/40 by cffDNA
when and what kind of PND to offer for hemophilia carriers pregnant with male fetus
CVS at 11-14 weeks;
can also be offered 3rd trimester amniocentesis if not previous done
which factor rises in pregnancy
- Factor 8, from 6/40, up to 2-3x baseline
- vWF
hemophilia: target factor level prior to surgical or invasive procedures or during spontaneous misc
> 0.5
what to give to raise Factor levels
- DDAVP 0.3mcg/kg booking weight IV or SC
- repeat 12-24h
- recombinant F8 or F9
+/- TXA
hemophilia: factor trget level with treatment
1.0
ECV in hemophilia?
avoid in all male fetuses, and any female who are obligate or possible carriers of severe hemophilias B
MOD for hemophilia
option of LSCS at 39/40 for affected male babies, or if status unknown.
Aim vaginal delivery otherwise. Avoid ventous and midcavity forceps for males.
FBS and FSE in hemophilia?
- NO in severe or moderate
- can consider if mild
hemophilia: level required for regional anaesthesia
> 0.5
hemophilia: how long to maintain levels postpartum
3 days if NVD, 5 days if instrumental or C/S.
Continue TA until lochia minimal, or at least 7 days post-c/s
hemophilia: what level to avoid VTE prophylaxis
<0.6
incidence of vWD
1/1000 - 10 000
Type I vWD
partial quantitative; <0.3
Type II vWD
qualitative; vWF activity: antigen <0.6
Type 3 vWD
severe quantitative, absent vWF and lowered F8
when do VWF and F8 decrease PP?
around day 3
vWD: PPH risk
15-30% primary, 25% secondary
vWD: need for RBCs
increased 5x
vWD: mortality rate
increased 10x
vWD: APH risk
increased 10x
which patients to avoid DDAVP
- PET
- known arterial disease
- uncontrolled HTN
type 3 vWD: regional anaesthesia
avoid completely
Type 1 vWD: regional anaesthesia
can have if normalized VWF activity
Type 2 vWD: regional anaeshesia
avoid unless levels >0.5
severe vWD: HB monitoring PP?
at 2/52
high risk bleeding disorders for mother
- type 3 vWD
- severe homozygous rare coagulopathies
- severe PLT function disorder
- hemophilia carriers with significant bleeding history
high risk bleeding disorders for neonate
- males with severe and moderate Hemophilia
- type 3 vWD
- severe homozygous coagulopathies
- severe PLT disorders
deficient factors in Hemophilia A and B?
A= 8, B = 9
