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01 Family Medicine > Maternity Care > Flashcards

Maternity Care Flashcards

AAFP Board Review: Maternity Care Parts 1 & 2

1
Q

What is the first line treatment for early pregnancy nausea (morning sickness)?

A

Vitamin B6 10-50 mg PO with

Doxylamine 12.5 mg PO

q6-8 hours

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2
Q

When does morning sickness in pregnancy usually start and end?

A

Starts around 4 - 8 weeks

Begins to improve around 13 -14 weeks

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3
Q

What are some ways to reduce the risk of developing hyperemesis gravidarum in pregnancy?

A

Early treatment of nausea and vomting (Morning sickness)

Being on a multivitamin at time of conception reduces risk of developing nausea/vomiting

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4
Q

What are some non-pharmacological treatments of morning sickness in pregnancy?

A

Eating frequent small meals

Avoiding triggers (certain smells or foods)

Bland, high carb, low fat diet

Salty foods tolerated better in AM

Sour/tart liquids tolerated better than water

Emotional support

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5
Q

Over the counter treatments for morning sickness in pregnancy?

A

Switch from prenatal vitamin to folic acid only suppliment

Ginger capsules 250 mg QID

P6 acupressure with wrist bands

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6
Q

Do pregnant women get HSV testing in initial prenatal labs?

A

No

HSV is based on clinical history

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7
Q

How does PAP/HPV screening change with pregnancy?

A

No changes, follow USPTF guidelines

Pregnancy does not change cervical cancer risk

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8
Q

What are the initial prenatal labs?

A

Blood group/Rh/antibody

CBC

Rubella

RPR/HIV/Hep B

GC/Chlamydia

UA/Urine culture

*get whether its day of conception or day of delivery

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9
Q

When is GDM screening done in pregnant women?

A

24-28 weeks

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10
Q

When is screening for asymptomatic bacteriruria done in pregnant women?

A

Urine culture at 11-16 weeks

*or first visit if past 16 weeks

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11
Q

What two common genetic screens should patients consider prior to conception or early in pregnancy?

A

Sickle cell

Cystic fibrosis

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12
Q

What are the ACOG recommendations for anemia in pregnancy?

A

All pregnant women should be screened for anemia

(Hb <11 treat with additional iron supplimentation)

Iron supplimentation decreases prevalence of anemia at delivery

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13
Q

What are the USPTF recommendations for anemia in pregnancy?

A

Insufficient evidence to screen for or treat iron deficiency anemia

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14
Q

A pregnant women presents to the hospital in labor, she has had no documented prenatal care. A rapid HIV test is positive. What is the next step in managment?

A

Get consent to initiate antiretroviral prophylaxis

Treat without waiting for confirmatory testing

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15
Q

What is the definition of asymptomatic bacteriuria? What bugs are most commonly involved?

A

Greater than 100,000 of any single bacterial species

E. coli most common

Lactobaccilli and staph (not including saprophyticus) may be presumed contaminants

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16
Q

Pregnant women with what disease should have asymptomatic bacteriuria screening each trimester?

A

Sickle cell trait

*it is unusual for women who do not have asymptomatic bacteriuria in the first trimester to develop it later (unless sickle cell trait)

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17
Q

Why is asymptomatic bacteriuria screened for?

A

Higher risk of preterm delivery

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18
Q

What is the treatment for asymptomatic bacteriuria?

A

Cephalexin 250 mg QID x7 days

Clindamycin, erythromycin, amoxacillin, ampicillin

Nitrofurantoin and sulfonamides (ok in 2nd and 3rd trimester, if only option can use in first trimester)

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19
Q

What is the treatment for pregnant women >36 weeks with active recurrent HSV?

A

Suppressive therapy

Acyclovir 400 mg TID until delivery

or

Valacyclovir 500 mg BID until delivery

*decreases risk of outbreak at delivery, need for C section, lowers viral detection at delivery

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20
Q

How to screen for varicella immunity in pregnant women?

A

Clinical history: vaccine or illness

Could get titer if unsure

Vaccine postpartum if nonimmune

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21
Q

Who should be screened for hepatitis C in pregnancy?

A

Only women at increased risk

Not routine

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22
Q

How does Parvovirus B 19 affect pregnancy?

A

Embryotoxic virus

1st trimester- miscarriage

2nd trimester- fetal anemia, hydrops fetalis, still birth

Greatest risk 3-6 weeks after maternal infection

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23
Q

How to screen for and monitor Parvo B19 in pregnancy?

A

Maternal IgG and IgM testing

Fetal monitoring with sonogram and middle cerebral artery doppler

(may need RBC transfusion if hydrops and anemia are present)

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24
Q

Who should be screened for intimate partner violence?

A

All women of childbearing age

*physcial, sexual, verbal and/or pyschological abuse

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25
What are the risks of having gestational diabetes in pregnancy?
Increased risk of: Gestational hypertension Preeclampsia Need for C section Developing diabetes later in life
26
What glucose level is considered elevated in a one hour glucose tolerance test?
\>135 or \>140 Either cutoff acceptable
27
What levels are considered elevated in a 3 hour glucose tolerance test?
Fasting \> 95 1 hour \> 180 2 hour \> 155 3 hour \> 140 2 or more abnormal values
28
Compare levels of alpha fetoprotein, hCG, estriol, inhibin A in Trisomy 21 v. Trisomy 18 v. neural tube defects
Trisomy 21 : low alpha fetoprotein, high hCG, low estriol, high inhibin A Trisomy 18: all levels low Neural tube defects: high alpha fetoprotein
29
When should in the Quad screen be completed in pregnancy?
Between 16-18 weeks Incorrect gestational age estimation can result in false positives
30
What is the recommended amount of folic acid for childbearing women?
0.4 mg per day 4 mg daily if hx of neural tube defect, taking valproate or carbamazepine 0.8 mg per day if on other antiepileptics \*1-3 months prior to pregnancy through first 3 months of pregnancy
31
When and how is Group B strep screened for in pregnancy?
36- 37 6/7 weeks Swab vaginal and rectum
32
Which pregnant women do NOT get screened for Group B strep?
Hx of infant with early onset GBS sepsis Any urine culture during pregnancy grows GBS
33
What is the treatment for Group B strep positive pregnant women at delivery?
Penicillin G for at least 4 hours If allergic can use clindamycin, vancomycin, possibly cefazolin
34
What are the risk factors for ectopic pregnancy?
Hx of prior ectopic pregnancy Hx of tubal surgery Hx of PID IUD in place Advance maternal age Smoking
35
How is ectopic pregnancy diagnosed?
Presentation: abdominal pain, vaginal bleeding about 7 weeks after LMP B hCG \>3500 and no sac seen on transabdominal US B hCG \>1800 and no sac seen on transvaginal US
36
Treatment of ectopic pregnancy?
Unstable patient: Laparotomy Stable: laparoscopic salpingostomy or Methotrexate (singe or multiple doses)
37
What medication is most common used for treating ectopic pregnancy? How does it work?
Methotrexate Folic acid antagonist Inhibits DNA synthesis and cell replication Kills cytotrophoblasts (rapidly dividing cells)
38
A woman with an ectopic pregnancy is treated with one dose of Methotrexate, how is treatment effectiveness measured?
Check B hCG on days 4 and 7 - if greater than 15% decrease repeat weekly hCG until undetectable - If decrease is less than 15% or increasing, repeat methotrexate - Consider surgery if hCG not decreasing or fetal cardiac activity persists after 3 methotrexate doses
39
What is the risk of having a salpingostomy v. salpingectomy?
Salpingostomy may not completely remove products of conception Check hCG weekly until undetectable
40
What is the differential diagnosis for first trimester bleeding?
Ectopic pregnancy Spontaneous pregnancy loss Idiopathic bleeding in viable pregnancy Cervical abnormalities Vaginal or cervical infection Subchorionic hemorrhage Trauma Molar pregnancy
41
When does an unsensitized, D-negative woman need anti-D immune globulin?
At 28 weeks gestation unless father is confirmed Rh negative Within 72 hours of delivery of Rh + infant After a first trimester pregnancy loss After invasive procedures like chorionic villus sampling, amniocentesis, fetal blood sampling
42
Women who experience Preeclampsia during a pregnancy are at higher risk for what illness later in life?
Ischemic Heart Disease HTN Stroke Venous embolism
43
What is the definition of gestational hypertension?
Elevated blood pressure after 20 weeks gestation \>140/90, two recordings more than 4 hours apart or \>160 SBP or \>110 DBP
44
What is the definition of Preeclampsia?
Gestational BP elevation after 20 weeks gestation with Proteinuria \>0.3 g in 24 hour urine collection or protein:creatinine ratio 0.3 or higher or HTN and one or more severe features
45
What are the risk factors of preeclampsia?
Personal or family hx of preeclampsia in previous pregnancy Multiple gestations Age \<20 and \>35 Nulliparity, first time father Chronic medical conditions Black race
46
Define chronic hypertension in the context of pregnancy
Blood pressure elevation before 20 weeks or HTN diagnosed during pregnancy that does not resolve postpartum
47
What are the severe features of preeclampsia?
SBP \>160, DBP \>110, 2 measurements at least 4 hours apart Platelets less than 100,000 Impaired liver function- LFTs x2 upper limit of normal, severe RUQ or epigastric pain (no other cause found) Progressive renal insufficiency- Cr \> 1.1 or doubling Pulmonary edema New onset cerebral or visual disturbance (ex: headache)
48
What is the most common cause of intrauterine growth restriction?
Chronic hypertension
49
In pregnant patients with chronic hypertension, how many will go on to develop preeclampsia?
About 25%
50
What labs should be monitored in pregnant patients with hypertension?
Uric acid CBC AST/ALT Protein/Creatinine ratio or 24 hour total urine protein
51
What is the blood pressure goal for pregnant women with hypertension?
BP between 120/80 and 160/110
52
What is the treatment for pregnant women with hypertension not at goal?
Labetalol or Nifedipine Get US screening for fetal growth restriction
53
What is one preventative treatment to reduce the risk of preeclampsia in high risk pregnant women?
Aspirin 81 mg Start after 12 weeks
54
What is the timing of delivery in women with gestational hypertension or preeclampsia without severe features?
Planned delivery at 37 weeks
55
What is the timing of delivery for women with chronic hypertension (no other pregnancy complications)?
If no medications needed: Delivery before 38 weeks, not recommended If on an antihypertensive medication: Delivery before 37 weeks not recommended
56
What is the treatment for women with preeclampsia with severe features or eclampsia at time of delivery?
MgSO4- reduces risk of first or subsequent seizures Antihypertensive therapy Vaginal delivery prefered
57
What is the BP threshold to treat pregnant women for hypertension?
BPs persistently greater than 160/110
58
What is the postpartum managment for women with gestational hypertension or preeclampsia?
Monitor BP for 72 hours after delivery and 7-10 days later
59
What are the maternal risks of gestational diabetes?
Increased risk of: Hypertension C section Intrauterine fetal demise in last 4-8 weeks of gestation
60
What are the fetal risks of gestational diabetes?
Increased risk of: Excessive fetal growth Operative delivery Shoulder dystocia Birth trauma Neonatal: hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia
61
What is the treatment for gestational diabetes?
Nutrition counseling, exercise First line tx: Insulin Second line tx: Metformin, glyburide
62
What are the target glucose levels for gestational diabetes?
Fasting or preprandial \< 95 1 hour post prandial \< 140 2 hour post prandial \< 120
63
In managment of gestational diabetes when should pharmacologic treatment be initiated?
If on 3 or more occaisons, fasting \> 95 and/or 2 hour post prandial \> 120
64
Timing of delivery for women with controlled A1GDM v. A2GDM?
A1GDM (diet controlled): do not deliver before 39 weeks, expectant management up to 40 6/7 weeks A2GDM (medication controlled): deliver between 39 0/7 to 39 6/7 weeks
65
Timing of delivery for women with poorly controlled diabetes?
Insufficent evidence, consider delivery between 37 0/7 to 38 6/7 If EFW \> 4500g, council on scheduling C section
66
What are the long term risks for women with gestational diabetes?
Increased risk of: GDM in future pregnancies Developing diabetes after pregnancy Offspring with obestiy, early diagnosis of glucose intolerance/diabetes
67
How often should women who had gestational diabetes be screened post partum?
- 6 week 2 hour glucose tolerance test - Then screening every 1 to 3 years
68
How might intrahepatic cholestasis of pregnancy present?
Pruritus at night Continuous pruritus (no rash) Jaundice More common after 25 weeks Higher risk of ICP if infected with Hep C
69
What lab values would indicate intrahepatic cholestasis of pregnancy?
Serum bile acids \> 3 times upper limit of normal AST/ALT usually normal Bilirubin elevated (conjugated GGT normal or mild elevation Alkaline phosphatase \> 5-10 times upper limit of normal
70
What is the treatment of intrahepatic cholestasis of pregnancy?
1# choice: Ursodeoxycholic acid Hydroxyzine, Dexamethasone, Epomediol
71
What are the maternal and fetal outcomes of intrahepatic cholestatis of pregnancy?
Maternal- Benign, resolves in 1-2 weeks of delivery Fetal- Can be serious: Increase risk of preterm labor/delivery, fetal compromise, need for C section, meconium staining, IUFD
72
Differential for bleeding in late pregnancy?
Placenta previa Placental abruption Vasa Previa Cervical trauma (intercourse) Vaginal infections Bloody show
73
What is the most serious complication of placental abruption?
Hypovolemia leading to acute renal failure
74
What is placenta previa and how does it present?
Placenta implanted over the cervical os Painless bleeding
75
How is placenta previa diagnosed?
Ultrasound If seen before 24 weeks, high chance of moving away from the os at term, recheck with US in 3rd trimester If bulk of placenta is over os at or after 24 weeks, less likely to clear os at term
76
What is placental abruption and how does it present?
Separation of the placenta from the implantation site Painful bleeding
77
What is the etiology of placental abruption?
Trauma, hypertension, cocaine, preterm rupture, tobacco use, hx of abruption
78
How is placental abruption managed?
- Assess fetal viability - If live fetus and rigid uterus get C section - If live fetus and soft uterus can induce labor If detachment \> 50% very high risk of fetal demise -If fetal demise, deliver fetus, blood transfusion for mom
79
Compare pain, contractions, blood, coagulation and hemorrhage between Placenta previa and placental abruption
PP minimal pain, PA severe pain PP mild or no contractions, PA severe rapid contractions PP bright red blood, PA port wine blood PP normal coagulation, PA abnormal PP rare for concealed hemorrhage, PA concealed hemorrhage \> 20 % of the time
80
Define preterm labor
Between 24 and 37 weeks +contractions and cervical change
81
What are risk factors for preterm labor?
Hx of prior preterm birth Multiple gestation Short cervical length (\<25 mm at 18-25 weeks) Less than 6 months between pregnancies Infection Tobacco use Black race
82
What is the efficacy of bed rest and hydration in the prevention of preterm labor?
Not effective
83
What is the purpose of tocolytic agents in managing preterm labor?
First line: Beta agonists Calcium chanel blockers, NSAIDs Can help with short term prolongation of pregnancy Not effective as maintenance therapy for prevention
84
When should corticosteroids be given in the setting of preterm labor?
Single course between 24 and 34 weeks Give within 7 days if at high risk of preterm delivery
85
What is the role of antibiotics in managing preterm labor?
Do not use to prolong gestation Do not improve neonatal outcomes in women with intact membranes
86
What is the role of magnesium sulfate in managing preterm labor?
Reduces severity and risk of cerebral palsy in surviving infants if given when birth is anticipated prior to 32 weeks gestation
87
How can preterm labor be prevented and who can get it?
GIve 17-hydroxyprogesterone caproate weekly starting at 16-20 weeks until at 36 weeks Only indicated for women with a history of spontaneous preterm birth
88
What testing should be done in pregnant women with a hx of spontaneous preterm birth?
Check cervical length with US every 2 weeks starting at 16-20 weeks Consider cerclage for cervical length \< 25 mm
89
What are the causes of postpartum hemorrhage?`
Tone- Uterine atony Tissue- Retained placenta fragments Trauma- Lacerations, uterine rupture, uterine inversion Thrombin- Coagulopathy (hereditary, DIC, HELLP)
90
What are the risk factors for uterine atony?
Overdistention (hydramnios, multi-gestation, fetal macrosomia) Oxytocin use High parity Rapid or prolonged labor Infection
91
How is postpartum hemorrhage treated?
Bimanual uterine massage Oxytocics Inspect for lacerations and repair Last resort: Hysterectomy
92
What are the medications used to treat postpartum hemorrhage?
Oxytocin Misoprostol (Cytotec) Methylergonovine (Methergen) Carboprost or Hemabate (15-methyl PGF- alpha) Dinoprostone (PGE2)
93
If a pregnant woman has a history of asthma which uterotonic medication can she NOT recieve?
Carbaprost or Hemabate
94
What are some ways to prevent postpartum hemorrhage?
Correct anemia Avoid routine episiotomy Infant to breast after delivery Oxytocin with shoulder delivery Clamp and cut cord early (2-3 minutes) Controlled cord traction
95
How does oxytocin work to treat postpartum hemorrhage?
Stimulate upper segment of uterus to contract Constricts spiral arteries, decreasing uterine blood flow
96
How does Misoprostol (Cytotec) treat postpartum hemhorrage? What is one common side effect?
Smooth muscle contraction Diarrhea
97
Define postdates pregnancy
After 42 weeks \*Most women scheduled for induction at 41w0d
98
Define Macrosomia and risk factors
Greater than 4500 g Risk factors: hx of macromia, maternal hyperglycemia
99
Is macrosomia an indication for labor before 39 0/7?
Not an indication \*suspected macrosomia is NOT a contraindication to trying labor after a C section
100
What medication can be used to promote cervical ripening and induce labor?
Prostaglandins
101
What are the risks of iron deficiency anemia in pregnancy?
Increased risk of: low birth weight preterm delivery perinatal mortality

01 Family Medicine (16 decks)

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