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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
Q

What are the risks of having gestational diabetes in pregnancy?

A

Increased risk of:

Gestational hypertension

Preeclampsia

Need for C section

Developing diabetes later in life

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26
Q

What glucose level is considered elevated in a one hour glucose tolerance test?

A

>135 or >140

Either cutoff acceptable

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27
Q

What levels are considered elevated in a 3 hour glucose tolerance test?

A

Fasting > 95

1 hour > 180

2 hour > 155

3 hour > 140

2 or more abnormal values

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28
Q

Compare levels of alpha fetoprotein, hCG, estriol, inhibin A in Trisomy 21 v. Trisomy 18 v. neural tube defects

A

Trisomy 21 : low alpha fetoprotein, high hCG, low estriol, high inhibin A

Trisomy 18: all levels low

Neural tube defects: high alpha fetoprotein

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29
Q

When should in the Quad screen be completed in pregnancy?

A

Between 16-18 weeks

Incorrect gestational age estimation can result in false positives

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30
Q

What is the recommended amount of folic acid for childbearing women?

A

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

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31
Q

When and how is Group B strep screened for in pregnancy?

A

36- 37 6/7 weeks

Swab vaginal and rectum

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32
Q

Which pregnant women do NOT get screened for Group B strep?

A

Hx of infant with early onset GBS sepsis

Any urine culture during pregnancy grows GBS

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33
Q

What is the treatment for Group B strep positive pregnant women at delivery?

A

Penicillin G for at least 4 hours

If allergic can use clindamycin, vancomycin, possibly cefazolin

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34
Q

What are the risk factors for ectopic pregnancy?

A

Hx of prior ectopic pregnancy

Hx of tubal surgery

Hx of PID

IUD in place

Advance maternal age

Smoking

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35
Q

How is ectopic pregnancy diagnosed?

A

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

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36
Q

Treatment of ectopic pregnancy?

A

Unstable patient: Laparotomy

Stable: laparoscopic salpingostomy or Methotrexate (singe or multiple doses)

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37
Q

What medication is most common used for treating ectopic pregnancy? How does it work?

A

Methotrexate

Folic acid antagonist

Inhibits DNA synthesis and cell replication

Kills cytotrophoblasts (rapidly dividing cells)

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38
Q

A woman with an ectopic pregnancy is treated with one dose of Methotrexate, how is treatment effectiveness measured?

A

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
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39
Q

What is the risk of having a salpingostomy v. salpingectomy?

A

Salpingostomy may not completely remove products of conception

Check hCG weekly until undetectable

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40
Q

What is the differential diagnosis for first trimester bleeding?

A

Ectopic pregnancy

Spontaneous pregnancy loss

Idiopathic bleeding in viable pregnancy

Cervical abnormalities

Vaginal or cervical infection

Subchorionic hemorrhage

Trauma

Molar pregnancy

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41
Q

When does an unsensitized, D-negative woman need anti-D immune globulin?

A

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
Q

Women who experience Preeclampsia during a pregnancy are at higher risk for what illness later in life?

A

Ischemic Heart Disease

HTN

Stroke

Venous embolism

43
Q

What is the definition of gestational hypertension?

A

Elevated blood pressure after 20 weeks gestation

>140/90, two recordings more than 4 hours apart

or

>160 SBP or >110 DBP

44
Q

What is the definition of Preeclampsia?

A

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
Q

What are the risk factors of preeclampsia?

A

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
Q

Define chronic hypertension in the context of pregnancy

A

Blood pressure elevation before 20 weeks

or

HTN diagnosed during pregnancy that does not resolve postpartum

47
Q

What are the severe features of preeclampsia?

A

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
Q

What is the most common cause of intrauterine growth restriction?

A

Chronic hypertension

49
Q

In pregnant patients with chronic hypertension, how many will go on to develop preeclampsia?

A

About 25%

50
Q

What labs should be monitored in pregnant patients with hypertension?

A

Uric acid

CBC

AST/ALT

Protein/Creatinine ratio or 24 hour total urine protein

51
Q

What is the blood pressure goal for pregnant women with hypertension?

A

BP between 120/80 and 160/110

52
Q

What is the treatment for pregnant women with hypertension not at goal?

A

Labetalol or Nifedipine

Get US screening for fetal growth restriction

53
Q

What is one preventative treatment to reduce the risk of preeclampsia in high risk pregnant women?

A

Aspirin 81 mg

Start after 12 weeks

54
Q

What is the timing of delivery in women with gestational hypertension or preeclampsia without severe features?

A

Planned delivery at 37 weeks

55
Q

What is the timing of delivery for women with chronic hypertension (no other pregnancy complications)?

A

If no medications needed: Delivery before 38 weeks, not recommended

If on an antihypertensive medication: Delivery before 37 weeks not recommended

56
Q

What is the treatment for women with preeclampsia with severe features or eclampsia at time of delivery?

A

MgSO4- reduces risk of first or subsequent seizures

Antihypertensive therapy

Vaginal delivery prefered

57
Q

What is the BP threshold to treat pregnant women for hypertension?

A

BPs persistently greater than 160/110

58
Q

What is the postpartum managment for women with gestational hypertension or preeclampsia?

A

Monitor BP for 72 hours after delivery and 7-10 days later

59
Q

What are the maternal risks of gestational diabetes?

A

Increased risk of:

Hypertension

C section

Intrauterine fetal demise in last 4-8 weeks of gestation

60
Q

What are the fetal risks of gestational diabetes?

A

Increased risk of:

Excessive fetal growth

Operative delivery

Shoulder dystocia

Birth trauma

Neonatal: hypoglycemia, hypocalcemia, hyperbilirubinemia, polycythemia

61
Q

What is the treatment for gestational diabetes?

A

Nutrition counseling, exercise

First line tx: Insulin

Second line tx: Metformin, glyburide

62
Q

What are the target glucose levels for gestational diabetes?

A

Fasting or preprandial < 95

1 hour post prandial < 140

2 hour post prandial < 120

63
Q

In managment of gestational diabetes when should pharmacologic treatment be initiated?

A

If on 3 or more occaisons,

fasting > 95

and/or

2 hour post prandial > 120

64
Q

Timing of delivery for women with controlled A1GDM v. A2GDM?

A

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
Q

Timing of delivery for women with poorly controlled diabetes?

A

Insufficent evidence, consider delivery between 37 0/7 to 38 6/7

If EFW > 4500g, council on scheduling C section

66
Q

What are the long term risks for women with gestational diabetes?

A

Increased risk of:

GDM in future pregnancies

Developing diabetes after pregnancy

Offspring with obestiy, early diagnosis of glucose intolerance/diabetes

67
Q

How often should women who had gestational diabetes be screened post partum?

A
  • 6 week 2 hour glucose tolerance test
  • Then screening every 1 to 3 years
68
Q

How might intrahepatic cholestasis of pregnancy present?

A

Pruritus at night

Continuous pruritus (no rash)

Jaundice

More common after 25 weeks

Higher risk of ICP if infected with Hep C

69
Q

What lab values would indicate intrahepatic cholestasis of pregnancy?

A

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
Q

What is the treatment of intrahepatic cholestasis of pregnancy?

A

1# choice: Ursodeoxycholic acid

Hydroxyzine, Dexamethasone, Epomediol

71
Q

What are the maternal and fetal outcomes of intrahepatic cholestatis of pregnancy?

A

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
Q

Differential for bleeding in late pregnancy?

A

Placenta previa

Placental abruption

Vasa Previa

Cervical trauma (intercourse)

Vaginal infections

Bloody show

73
Q

What is the most serious complication of placental abruption?

A

Hypovolemia leading to acute renal failure

74
Q

What is placenta previa and how does it present?

A

Placenta implanted over the cervical os

Painless bleeding

75
Q

How is placenta previa diagnosed?

A

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
Q

What is placental abruption and how does it present?

A

Separation of the placenta from the implantation site

Painful bleeding

77
Q

What is the etiology of placental abruption?

A

Trauma, hypertension, cocaine, preterm rupture, tobacco use, hx of abruption

78
Q

How is placental abruption managed?

A
  • 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
Q

Compare pain, contractions, blood, coagulation and hemorrhage between Placenta previa and placental abruption

A

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
Q

Define preterm labor

A

Between 24 and 37 weeks

+contractions and cervical change

81
Q

What are risk factors for preterm labor?

A

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
Q

What is the efficacy of bed rest and hydration in the prevention of preterm labor?

A

Not effective

83
Q

What is the purpose of tocolytic agents in managing preterm labor?

A

First line: Beta agonists

Calcium chanel blockers, NSAIDs

Can help with short term prolongation of pregnancy

Not effective as maintenance therapy for prevention

84
Q

When should corticosteroids be given in the setting of preterm labor?

A

Single course between 24 and 34 weeks

Give within 7 days if at high risk of preterm delivery

85
Q

What is the role of antibiotics in managing preterm labor?

A

Do not use to prolong gestation

Do not improve neonatal outcomes in women with intact membranes

86
Q

What is the role of magnesium sulfate in managing preterm labor?

A

Reduces severity and risk of cerebral palsy in surviving infants if given when birth is anticipated prior to 32 weeks gestation

87
Q

How can preterm labor be prevented and who can get it?

A

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
Q

What testing should be done in pregnant women with a hx of spontaneous preterm birth?

A

Check cervical length with US every 2 weeks starting at 16-20 weeks

Consider cerclage for cervical length < 25 mm

89
Q

What are the causes of postpartum hemorrhage?`

A

Tone- Uterine atony

Tissue- Retained placenta fragments

Trauma- Lacerations, uterine rupture, uterine inversion

Thrombin- Coagulopathy (hereditary, DIC, HELLP)

90
Q

What are the risk factors for uterine atony?

A

Overdistention (hydramnios, multi-gestation, fetal macrosomia)

Oxytocin use

High parity

Rapid or prolonged labor

Infection

91
Q

How is postpartum hemorrhage treated?

A

Bimanual uterine massage

Oxytocics

Inspect for lacerations and repair

Last resort: Hysterectomy

92
Q

What are the medications used to treat postpartum hemorrhage?

A

Oxytocin

Misoprostol (Cytotec)

Methylergonovine (Methergen)

Carboprost or Hemabate (15-methyl PGF- alpha)

Dinoprostone (PGE2)

93
Q

If a pregnant woman has a history of asthma which uterotonic medication can she NOT recieve?

A

Carbaprost or Hemabate

94
Q

What are some ways to prevent postpartum hemorrhage?

A

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
Q

How does oxytocin work to treat postpartum hemorrhage?

A

Stimulate upper segment of uterus to contract

Constricts spiral arteries, decreasing uterine blood flow

96
Q

How does Misoprostol (Cytotec) treat postpartum hemhorrage?

What is one common side effect?

A

Smooth muscle contraction

Diarrhea

97
Q

Define postdates pregnancy

A

After 42 weeks

*Most women scheduled for induction at 41w0d

98
Q

Define Macrosomia and risk factors

A

Greater than 4500 g

Risk factors: hx of macromia, maternal hyperglycemia

99
Q

Is macrosomia an indication for labor before 39 0/7?

A

Not an indication

*suspected macrosomia is NOT a contraindication to trying labor after a C section

100
Q

What medication can be used to promote cervical ripening and induce labor?

A

Prostaglandins

101
Q

What are the risks of iron deficiency anemia in pregnancy?

A

Increased risk of:

low birth weight

preterm delivery

perinatal mortality

01 Family Medicine (16 decks)

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