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Infant Transport Team > MFM > Flashcards

MFM Flashcards

1
Q

Gestational HTN is defined as

A

> 140/90 after 20 weeks of pregnancy

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2
Q

Gestational HTN investigations

A

Look for preeclampsia

1) proteinuria 2) severe features of preeclampsia 3) assess fetal status

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3
Q

Severe Gestational HTN

A

≥160/110

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4
Q

Postpartrum Hypertensive mgmt

A

Oral or IV medications, similar to those used in non-pregnant patients

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5
Q

Pathogenesis of preeclampsia

A

Preeclampsia occurs because of placental circulation abnormalities, where the large spinal arteries fail to penetrate the myometrial portion, instead the vessels of the myometrium are narrowing, resulting in hypoperfusion and ischemia.

An exaggerated state of oxidative stress develops in the placenta which in turns adversely affects angiogenesis. As the pregnancy develops, anti-angiogenesis factors are released into maternal blood resulting in wide spread vascular inflammation, endothelial dysfunction leading to HTN and preeclampsia

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6
Q

Severe preeclampsia defined as

A
  1. 160/110 with
    - proteinura >3g/dL
    - end organ dysfunction
    - fetal effects
  2. Onset <34 weeks
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7
Q

Dx of Preeclampsia and definition of pre-eclampsia

A

Definition:
Preeclampsia refers to the new onset of HTN with proteinuria OR the new onset HTN with significant end-organ dysfunction with or without proteinuria after 20 weeks gestation

  1. two readings of ≥140/90 plus
  2. proteinuria
  3. end organ dysfunction (elevated AST/ALT, BUN,CR, Pulmonary edema)
  4. fetal effects
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8
Q

women with preeclampsia are at risk for life-threatening events such as

A 
CVA
Retinal injury
Placental abruption
AKI
ICH
Hepatic failure
pulmonary edema
eclampsia
thrombocytopenia
MI 
ARDS
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9
Q

the fetus in preeclampsia is at increased risk of

A

IGUR, oligohydraminos

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10
Q

Approach to preeclampsia

A
  1. Acute BP target: <160/110 (reduction by ~25% in minutes to hours)
    Labetalol 20mg over 20 minutes, then 40, 80mg to max 300 or infusion 2-3mg/min
    Nifedipine 5-10mg q 30-45, max 80mg/d
    Hydralazine 5-10mg to max 20mg
  2. Magnesium 4g over 20 minutes then 1g/hr infusion for 24 hours
  3. Betamethasone 12mg q 24hr (x2) (in addition to lung maturity, it improves UA diastolic flow of the placenta - if suspect to deliver within the next 7 days)
  4. Fluid restrict for 80ml/hr
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10
Q

Approach to Eclampsia

A
  1. Magnesium 4g/20minutes then 1g/hr.

2. for status, use Benzos

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11
Q

HELLP syndrome dx

A
  1. Hemolysis - peripheral smear abnormalities, serum bili elevated, low hepatoglobin, or severe anemia
  2. elavated AST/ALT x 2
  3. platelets <100
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12
Q

Approach to HELLP

A
  1. Severe gestational HTN mgmt
  2. Delivery
    ○ Stabilize mother and assess fetal status
    ○ Transfer to a tertiary centre due to risk of rapid complication development
    ○ Severe gestation HTN should be treated with Labetalol
    ○ Women with complications list above should promptly deliver
    ○ Manage hepatic hematoma with volume replacement and transfusion as necessary
    ○ RBC threshold - varies, UTD 70g/L
    ○ PLT threshold - <50 = if c-section impending, <20 Otherwise
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12
Q

Phone Assessment:

A
  1. Cervix (dilation/effacement/length)
  2. contractions (frequency, durations and strength)
  3. membrane (intact/rupture, if ruptured how long and abx)
  4. baby (FHR -good variability)
  5. medications given - betamethasone, abx, tocolytics
  6. maternal (GDM, PIH, GBS, GTPAL)
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13
Q

Placental Abruption refers to

A

partial or complete separation of the placenta prior to delivery of the fetus. Which can be concealed or revealed

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14
Q

Is placental abruption blood maternal or fetal?

A

Maternal Hemorrhage, from the decidua basalis

Maternal vasculature may be arterial or venous

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15
Q

Approach to placental abruption

A
  1. maternal hemodynamic assessment (manage coags)
  2. If fetal HR is non-reassuring, expeditious delivery is indicated
  3. If fetus <34 weeks and mother is stable - conservative mgmt until 37 weeks is recommended with tocolytics and antenatal steroids
  4. If fetus 34-36 weeks GA and mother are stable, expectant delivery is appropriate
  5. All pregnancies with acute abruption ≥36 weeks GA should be delivered
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16
Q

Placental Previa definition

A

Placenta previa refers to the presence of placental tissue that extends over the internal cervical os.
Sequelae include the need for c-section as well as the potential for severe antepartum bleeding, preterm birth and postpartum hemorrhage.

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17
Q

placental previa mgmt

A
  1. achieve and/or maintain maternal hemodynamic stability

2. determine if emergency c-section is indicated.

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18
Q

placenta accrete

A

is the growth of the placenta into uterine scarring. Its a surgical emergency with immediate removal and possible hysterectomy.

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19
Q

Preterm Labour pathogenesis

A
  1. premature activation of the maternal or fetal HPA axis related to stress
  2. exaggerated inflammatory response/infection
  3. abruption
  4. pathologic uterine distention
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20
Q

The goal of delaying PTL is to

A

allow for antenatal corticosteroid administration, and allow for safe transfer.

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21
Q

PTL mgmt:

A
  1. Betamethasone if between 24-34 weeks (lung/gut/neuro protection)
  2. tocolytic for 48 hours (nifedipine, Indocin)
  3. Abx (GBS)
  4. Magnesium (neuro protection)
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22
Q

Tocolytic use in PTL:

A
  1. Nifedipine = loading dose of
    10mg PO q 30 until contractions stop (max 40mg/2hours) then 1 hour after loading dose q12 hours for 48 hours
  2. Indocin (only if <28 weeks) 100mg PR then 25mg PO q 6 hours x 48
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23
Q

PPROM refers to

A

Rupture of membranes prior to the onset of labour in pregnancy <37

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24
Q

complications of PROM

A
  • PTL/PTB
  • fetal/neonatal infection
  • maternal infection
  • umbilical cord compression/prolapse
  • failed induction resulting in c-section
  • pulmonary hypoplasia
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25
Q

Chorioamniotis dx is suspected when

A
  • maternal fever >38 degrees
  • fetal HR >160
  • signs of maternal sepsis

Dx is confirmed with placental histopathology

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26
Q

Zygocity refers to

A

the description of number of eggs fertilized

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27
Q

Chorionocity is

A

the number of placentas

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28
Q

amniocity is the description of

A

number of amniotic sacs

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29
Q

Diachorionic twins

A

DI-achorionic twins (two placenta) could be dizygotic (fraternal) or monozygotic (identical) twins

safest forms of twins

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30
Q

monochorionic twins

A

One placenta

  • always monozygotic (identical)
  • amnioicity depends on timing of division of fertilized ovum
  • monochoro twins are the most complicated version of twins
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31
Q

Monochorionic twins complications

A
  • twin to twin transfusion syndrome
  • twin anemia polychythemia sequence
  • selevtive intrauterine growth restrictions
  • twin reversed arterial perfusion
  • dual damage of monochorionic twins
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32
Q

Cord gas UV and UA equals who’s blood

A 
UV = placental
UA= Babies
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33
Q

Maternal assessment questions:

A
  • Age
  • GA
  • Maternal Hx: (GTPALS)
  • Contractions (x in 10 with mod/mild/severe strength)
  • passage (dilation/effacemnt/consistency)
  • Last VE (dilation/length/position)
  • TESTS (urine, ferrying, GBS)
  • fetal assessments
  • fetal problems
  • antenatal problems
  • antenatal treatment
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34
Q

Factors that promote or imitate labour

A
  1. fetus
  2. myometrial activation
  3. membrane rupture
  4. hormones
    (prostaglandin, progesterone, estrogen, oxytocin)
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35
Q

Tocolytics are

A

medications used to suppress premature labour

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36
Q

Examples of tocolytics are

A

indomethacin and nifedipine (adalat)

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37
Q

Tocolytics are administered to allow

A

for prelabour growth. they also allow for administration of betamethasone to allow fetal production of surfactant

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38
Q

Which tocolytic is preferred

A

Nifedipine is typically used first because it has less adverse effects on PDA and NEC

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39
Q

MOA of Adalat

A

is a CCB that blocks calcium influx to inhibit labour contraction

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40
Q

Indomethacin drug classification/moa

A

NSAID and tocolytic. It functions by inhibiting prostaglandin synthestase.
-reduction of inflammation inhibits production of labour

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41
Q

At what weeks is Indomethacin appropriate to give

A

Between 28-32 weeks (text book) but really, <28 weeks. or just dont fucking use it. plus who wants to give anything PR

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42
Q

Induction methods

A
  • Membrane sweep
  • Prostaglandin tampons
  • Amniotomy
  • Foley catheter in cervix
  • Oxytocin
43
Q

What does a membrane sweep mean

A

breaks the barrier of the cervix which beings the cascade of inflammation and uterine preparation for birthing

44
Q

What is a prostaglandin tampon

A

They are used to apply prostaglandin to the cervix to initiate the birthing cascade. Prostaglandin is contraindication in women with uterine scarring from C-Section

45
Q

Whats an amniotomy

A

Is a manual ROM by amniohook

46
Q

Whats the role of ‘Foley catheter in cervix’

A

To stimulate the release of inflammatory factors and also application of pressure on the internal os of the cervix which assists in thinning the cervix

47
Q

Why is oxytocin used for induction

A

Oxytocin effectively works by increasing intracellular calcium.
Oxytocin is useless when the cervix is fully constricted

48
Q

When and why is induction undertake before ___weeks

A

typically undertake before 41 + 3 because the risk of still birth steadily climbs beyond that point

49
Q

The 5 P’s of labour

A
  1. passage
  2. passenger
  3. power
  4. position
  5. pscyhe/parter
50
Q

When is transport not recommended in the setting of labour

A

When >4 cm (advised to birth in location)

51
Q

Active labour is defined as

A

Progressive cervical dilation with contractions >30seconds with 2 constrictions in 10 minutes

52
Q

Four stages of labour

A
  1. onset of involuntary, painful contractions (cervic <3cm)
  2. Full cervical dilation to delivery of fetus
  3. delivery of baby to delivery of placenta
  4. post-birth
53
Q

Social abortion is allowed up to

A

24 weeks in BC

54
Q

Genetic-abnormalities D&E can occur up to

A

~28 weeks GA

55
Q

Abortions in the community setting aren’t typically offered beyond

A

14 weeks

56
Q

The four major hypertensive disorders related to pregnancy include

A
  1. gestational HTN
  2. Chronic HTN
  3. Preeclampsia
  4. preeclampsia super imposed upon chronic hypertension
57
Q

When do you give midazolam in preeclampsia

A

When they’re eclamptic and in status seizures, first line magnesium

58
Q

Seizure prophylaxis in preeclampsia

A

4g of mag over 20minutes, followed by 1g/h for 24 hours

59
Q

In addition to fetal lung maturity, and decreasing risk of IVH what do glucocorticoids improve in preeclampsia

A

Improve UA end-diastolic flow in the short term

60
Q

Maintenance fluids of preeclampsia

A

80ml/hr

61
Q

Whats the number 1 killer in preeclampsia

A

Pulmonary edema

62
Q

Treatment for magnesium toxicity

A

calcium glutinate 15-30ml of 10% over 2-5 minutes

63
Q

Is preeclampsia an indication for c-section

A

No. Not unless harm to mother or fetus

64
Q

Why is Labetalol the only beta-blocker used in preeclampsia

A

Other beta blockers are teratogenic

65
Q

In the setting of prevention, whats the only drug shown to reduce risk of preeclampsia

A

low dose asa

66
Q

Eclampsia is a clinical diagnosis based on what

A

the occurrence of new-onset tonic-clonic, focal or multifocal seizures in a women with a hypertensive disorder of pregnancy

67
Q

Whats the pathogenesis of eclampsia?

A
  1. breakdown of the auto regulatory system of the cerebral circulation leading to hyperperfusion, endothelial dysfunction and vasogenic/cytotoxic edema
68
Q

Diagnosis of HELLP is based on the presence of

A

Hemolysis (severe anemia, peripheral smear abnormalities)

Elevated liver enzymes (AST/ALT X 2 upper limit)

Low platelets (<100)

69
Q

Complications of HELLP

A 
placental abruption
AKI
hepatic rupture
pulmonary edema
retinal detachment
preterm with LBW
DIC
70
Q

Pathophysiology of placental abruption

A

The immediate cause of placental separation is RUPTURE of maternal vessels in the decimal basalis. The ruptured maternal vessels may be an artery or a vein.

Thrombin (Factor 2) plays a key role in the clinical consequence of placental abruption.

71
Q

Clinical features of placental abruption

A
  • vaginal bleeding
  • abdominal pain
  • contractions with irregular pattern
  • uterine rigidity and severe tenderness
  • non-reassuring FHR
72
Q

Dx of Abruption

A

clinical and based on the abrupt onset.

  • kleighauer test is a blood that tests for present of fetal hemoglobin in maternal blood
  • abruption is usually visible on US
73
Q

In PTL when can we give steroids between?

A

24 and 34 weeks

74
Q

Risk factors for PTL

A
  • Prior PTL (Strongest risk factor)
  • extreme maternal age
  • multiple GA
  • fetal disorder
  • poly/oligohydraminos
  • maternal medical conditions
  • short cervix length
  • positive fFN between 22-34 weeks
75
Q

Tocolytics no longer used

A

Ventolin, magnesium, nitro patch, terbutaline

76
Q

Dx of PROM

A

is clinical, based on visualization of amniotic fluid coming from cervical canal.

  1. ferning is the other gold standard
  2. amnisure is a POC used to determine PPROM
  3. Nitrazine testing (pH testing of fluid)
77
Q

Extreme Preterm age

A

<27 weeks

78
Q

very prerm age rage

A

27-31 weeks GA

79
Q

Moderate to late preterm

A

32-36+6

80
Q

Whats the survival rate of Premies born at 24 weeks

A

59%

81
Q

Interventions of reduced PTB

A 
vaginal progesterone 
cerclage of cervix
low dose asa
removal of large fibroids
prevention of multifetal gestations
82
Q

Whats the number 1 complication of multiple gestation

A

preterm birth

83
Q

What does Di-Di pregnancy mean?

A

Dichorionic-Diamniotic

two separate placentas
two separate amniotic sacs

84
Q

What does Mono-Di mean?

A

Monochorionic-Diamniotic

1 shared placenta, 2 amniotic sacs

85
Q

What does mono-mono twins mean

A

Monochorionic-Monoamniotic

1 shared placenta, 1 share amniotic sac

86
Q

What is Twin-to-Twin transfusion syndrome

A

fetal to fetal transfusion of a large volume of blood causes fluid discordance.

Baby A becomes anemic and has oligohydramnios, where baby B becomes polycythemic and develops CHD and polyhyradminos

87
Q

whats Twin anemia polycythemia sequence (TAPS)

A

Baby A born with 2x hemoglobin than baby B.

Small volumes of RBCs feto-fetal transfusion causes discordant hemoglobin

More insidious because some volumes are being transfused over a slower period of tie.

88
Q

What is true labour

A

Progressive cervical dilation, effacement or both resulting from regular uterine contractions (2 or more in 10 minutes lasting 30-60s)

89
Q

What does prostaglandins have to do with labour

A

Inflammatory response creating arachidonic acid prostaglandin syntheses

90
Q

What does progesterone inhibit?

A

Prostaglandin production

91
Q

Indocin (indomethacin) inhibits the production of?

A

Arachnoidic acid, which inhibits prostaglandin synthesis

92
Q

Labour is a continuous process of contractions altering with relaxation by increasing and decreasing…

A

intracellular calcium

93
Q

Four T’s of post-partum bleeding

A

tissue (placenta retention)
trauma (tearing vessels)
tone (inability of the uterus to self-contract)
thrombin (bleeding disorders)

94
Q

Initial assessment for < 34 weeks gestation with symptoms of PTL

A
  1. check GA AGE
  2. Palpate contractions
  3. sterile sepeculum exams; (cultures, R/O ROM, take FFN swab)
  4. perform digital assessment of cervix
95
Q

Whats cervical incompetence/insufficiency

A

the inability of the uterine cervix to retain pregnancy in the absence of the signs and symptoms of clinical contractions or labour or both in 2nd trimester

96
Q

Whats the timeline for first, second and 3rd trimester?

A
  1. 1-12
  2. 13-26
  3. 27 +
97
Q

Corticosteroid prophylaxis benefits are seen as early as

A

4 hours

98
Q

Maximum effect of corticosteroids in PTL

A

48 hours - 7 days after first dose

99
Q

Maternal cardiovascular differences

A
  1. increased CO
  2. dilution anemia, but increased RBC production
  3. increased blood volume
  4. increase preload, decrease afterload from declining SVR
  5. declining SVR from prostaglandin
  6. increased hR by 20
  7. left axis deviation
  8. increase in Pao2
100
Q

maternal Resp differences

A
  1. respiratory alkalosis (pH >7.4 decrease CO2 30-32mmHg)
  2. decreased FRC 2nd to babe/diaphragm
  3. decreased chest compliance
  4. decrease v/Q
  5. progesterone stimulation produces an increased resp drive
101
Q

maternal GI/GU differences

A

higher risk of gastric aspiration 2nd to lower esophageal sphincter tone

increased grr with increased renal BF , decreased CR to 35-45

102
Q

What are dizygotic twins

A

non-identical twins. 2 eggs, 2 sperms

103
Q

what are monozygotic twins

A

identical. 1 egg 1 sperm

104
Q

Three differentials for HELLP

A
  1. Acute fatty liver of pregnancy
  2. Thrombotic thrombocytopenia purpura
  3. Pregnancy induced hemolytic ureic syndrome
105
Q

Pathophysiology of HELLP syndrome

A

It probably represents a severe form of preeclampsia but to relationship between the two disorders remain controversial.
Microangiopathy and activation of intravascular coagulopathy can account for all the laboratory findings of HELLP syndrome

106
Q

Benefits of delayed cord clamping

A
  • decreases the need for transfusion, increase blood
  • volume 20-40ml/kg increase
  • increase stem cells
  • decrease risk of NEC and IVH

Infant Transport Team (14 decks)

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