OB Flashcards
placenta abruption symptom triad
- uterine contraction
- hypertonic uterine
- painful vaginal bleeding/ constant abdo or back pain
- (non-reassuring FHR)
DDx of vaginal bleeding in 2nd to 3rd trimester
non-painful vaginal bleeding
- placenta previa (20% of bleeds)
- vasa previa
- bloody show (PPROM)
“Painful” vaginal bleeding
- placenta abruption (40% of bleeds)
- uterine rupture
placenta previa symptoms
- painless vaginal bleeding
- fetal distress
placenta abruption risk factors
- PPROM
- Multiparity
- previous abruption
- HTN
- T2DM
- smoking (not in otool’s book)
- thrombophilia (Fibrinogen)
- fibroid
- drugs
- age < 20 or > 35 y/o (not in FM note)
- trauma
placenta previa risk factors
- previous placenta previa
- previous c/s
- multiparity
- multiple gestations
- smoker
- fibroid
risk factors of vasa previa
- low lying placenta
- multi-lobed placenta
- IVF
< Placenta previa>
definition
placenta attached to the lower segment of uterus < 2cm from os
What are the symptoms of early show?
- effacement
- dilation of cervix
- mucous plug passes
< placenta abruption>
What are the work-ups of placenta abruption?
- u/s with decreased sensitivity (20% with no vaginal bleeding)
- Kleihauser-Betke (fetal cells in mat blood)
- fibrinogen
- CBC, BUN/CRE, Rh and ABO type and cross
- PT/aPTT (increased risk of DIC)
Vasa previa work-up investigation
and Management
- Apt test
(positive= fetal blood in vaginal blood; neg: only maternal blood) - Wright test/ stain
Management: urgent c/s
management
- OB emergency
- ABC, IVF, monitor for DIC
- Pre-term - admit + monitor
- term + stable: induced VD
- unstable: c/s
placenta previa management
- u/s to confirm type: accreta vs. increta vs. percreta
- c-section (try to wait until 37 wks)
- bed rest, Celestone (for lung maturation)
- serial CBC, fetal monitoring
DDx of vaginal bleeding in 1st to 2nd trimester
- Non-obstetrical ddx
Non-obstetrical ddx:
- trauma (post-coital, partner violence, sexual assault)
- genital lesions (cervical polyps, neoplasm)
- cervicitis/ vaginitis
- hemorrhagic cyst
- perineal lesions
- vulvar varicosities
- rectal bleeding (lower GI)
- UTI/ hematuria
DDx of vaginal bleeding in 1st to 2nd trimester
- Obstetrical ddx
- 20% of pregnancies will have bleeding before 20 w GA
- physiological bleeding - spotting, implantation bleed
- abnormal pregnancy (ectopic, molar)
- abortion
Investigation of vaginal bleeding in 1st to 2nd trimester
- CBC + blood type
- beta-hCG
- pap + swabs
- transvaginal us
Which types of abortion has cervix still closed?
How are they managed?
- threatened abortion (<5%): mild bleed +/- cramps
> u/s - viable fetus? FHR? ectopic? - missed abortion: fetal pole > 6mm w/ no FHR (fetal demise) - NO blood, no uterine activity
> D+C +/- Oxytocin 50% resolve in 2 wks - sepsis abortion (can be closed or open): spontaneous abortion complicated by uterine infection
> SIRS (temp<36 or>38, leuk<4 or >12, RR>20, HR>90)
> IV abx (gentamicin + clindamycin)
Def of recurrent/ habitual abortion
> or = 3 consecutive pregnancy losses
Def of spontaneous abortion
pregnancy loss < 20w GA
* 10% of known pregnancies will end in spontaneous abortion
Antiphospholipid syndrome (APS) diagnosis criteria
Clinical criteria (1) AND (2)
(1 ) vascular thrombosis: one or more clinical episodes of arterial, venous, or small-vessel thrombosis in any tissue or organ confirmed by findings from imaging studies, Doppler studies, or histopathology
(2) pregnancy morbidity
- One or more late-term (>10 weeks’ gestation) spontaneous abortions
- One or more premature births of a morphologically healthy neonate at or before 34 weeks’ gestation because of severe preeclampsia or eclampsia or severe placental insufficiency
- Three or more unexplained, consecutive, spontaneous abortions before 10 weeks’ gestation
—————————————————————————-
Laboratory criteria include any of the following:
- Medium to high levels of immunoglobulin G (IgG) or immunoglobulin M (IgM) anticardiolipin (aCL) Anti–beta-2 glycoprotein I
- Lupus anticoagulant on at least two occasions at least 12 weeks apart
absolute contraindication of medical abortion
- ectopic
- chronic adrenal failure
- inherited porphyria
- uncontrolled asthma
relative contraindication of medical abortion
- unconfirmed GA
- IUD
- concurrent systemic corticosteroid
- hemorrhagic disorder or concurrent anti-coagulation
Risks of medical/induced abortion
- bleeding
- cramping/pelvic pain
- GI symptoms (N/V/diarrhea)
- headache
- fever or chills
- pelvic/ lower genital infection
- mortality (0.3 per 100,000, most from infection or undiagnosed ectopic)
Efficacy of medical/induced abortion
Before 49d after LMP ( 7w GA): as effective as surgical abortion
up to 70d after LMP (10w GA): highly effective
Regimen of medical/ induced abortion
mifepristone 200mg oral AND
misoprostol 800 mcg
** Rh immunoglobulin (RhoGAM) given 24 hr prior to medical abortion
common s/e of medical/ induced abortion
- cramping
- bleeding
- n/v/d
- dizziness
- fever
- headache
complications of medical/ induced abortion
- retained products (may need 2nd dose of misoprostol)
- ongoing pregnancy
- post-abortion infection
- toxic shock syndrome
What is the cause of toxic shock syndrome
- toxin-mediated acute life-threatening illness
- precipitated by infection with either Staphylococcus aureus or group A Streptococcus (GAS) =Streptococcus pyogenes
What are the typical symptoms of toxic shock syndrome?
- high fever, rash, hypotension, multiorgan failure (involving at least 3 or more organ systems)
- desquamation, typically of the palms and soles, 1-2 weeks after the onset of acute illness
- can also include severe myalgia, vomiting, diarrhea, headache, and non-focal neurologic abnormalities
medical conditions likely cause toxic shock syndrome
Menstrual (tampon-used) toxic shock syndrome (50%) - most are staphylococcus infection
Non-menstrual Staph toxic shock syndrome: Surgical wound infections Postpartum infections Focal cutaneous and subcutaneous lesions Deep abscesses Empyema Peritonsillar abscess Sinusitis Osteomyelitis
Soft tissue infections from group A Streptococcus (GAS):
necrotizing fasciitis, myositis, or cellulitis
Oral contraceptive pill (combo hormonal) benefits
Cycle regulation decrease flow anemia increase BMD decrease dysmenorrhea/ pelvic pain decrease perimenopausal syndrome (PMS), acne, hirsutism, endometrial/ovarian/ colorectal ca decrease risk of fibroid decrease ovarian cyst, benign breast disease, salpingitis
Contraindication of oral contraceptive pill (combo hormonal)
- < 4wk postpartum (breastfeeding) or < 21d postpartum (no breastfeeding)
- Smoker (>=15 cigarette/d) > 35 y/o
- Vascular disease
- HTN (BP>=160/100)
- Active VTE
- Hx of VTE not on anticoagulants + high risk
- Major surgery with prolonged immobilization
- Thrombophilia
- CAD
- CVA
- Complicated valvular disease
- SLE w/ + /unknown APA
- Migraine w/ aura
- Peripartum cardiomyopathy
- Current breast CA
- Severe cirrhosis
- Hepatocellular adenoma
- Malignant hepatoma
Treatment target of pregnancy induced hypertension (PIH)
DBP < 85 mmHg
pharmacotherapy of PIH
Non severe: 140-160/90-110
- Labetalol (beta-blocker)
- methyldopa (central-acting alpha2 agonist)
- long acting nifedipine (CCB)
NOT ACEI or ARB
NOT atenolol or prazosin prior to delivery
Severe: BP > 160/110 “considered ob emergency”
tx in hospital + continuous FHR monitor
- nifedipine, parenteral labetalol/ hydralazine
recommendation for women at high risk of pre-eclampsia
The U.S. Preventive Services Task Force:
1) pregnant women at high risk of preeclampsia take low-dose aspirin (81 mg per day) after 12 weeks’ gestation
2) Delivery is generally indicated at 37 weeks’ gestation for women who have gestational hypertension or preeclampsia without severe features.
diagnosis of preeclampsia
New-onset hypertension after 20 weeks’ gestation (a systolic BP of at least 140 mm Hg or a diastolic BP of at least 90 mm H g on at least two occasions, taken at least four hours apart, plus new-onset proteinuria or a severe feature) PLUS 1 of the following:
proteinuria thrombocytopenia renal insufficiency impaired liver function pulmonary edema cerebral or visual symptoms
management of eclampsia
MgSO4
risk factors of PIH
HTN in previous pregnancy CKD autoimmune DM HTN 1st pregnancy > 40 y/o BMI > 35 family history of pre-eclampsia multiple pregnancy interval > 10 yr
Definition of IUGR
small for gestational age SGA: fetus < 10th % on u/s
IUGR: fetus < 10th percentile on u/s b/c pathologic process
etiology of IUGR
Asymmetry: brain is spared
Symmetry: TORCH, genetics
Etiology: cigarette, drugs, TORCH, genetic anomalies
contraindication of VBAC (vaginal birth after C-section)
- Hx of uterine rupture
- uterine reconstruction
- classic/inverted T uterine scar
- placenta previa/ malpresentation
Risk factors of GDM
- previous GDM
- family hx
- hx of macrosomnia
- > 25 y/o
- obese
- PCOS
- steroid
- aboriginal/ hispanic/ asian/ african
Test for GDM
24-28w GA with non-fasting 50g OGCT
`1) Normal: < 7.8
2) Needs 2hr 75g OGCT: 7.8-11
3) GDM confirmed: = or > 11.1 mmol/L
For 2hr 75g OGCC: Diagnose GDM if FBG =/> 5.3, 1hr =/> 10.6, 2hr=/> 9.0
treatment target of GDM
1) A1C < 6%
2) FBG 3.8-5.3
3) 1 hr postprandial < 7.8
4) 2 hr postprandial < 6.7
Management of GDM
offer induction 38-40 wk GA
repeat 75 OGTT between 6w to 6 mo postpartum
management of hyperemesis gravida
pyridoxine (Vit B6) or Diclectin 10mg (max 8 tabs/d)
can add gravol
monitor if dehydration
dietary/lifestyle changes, eat anything appealing
treat GERD (antacid/H2 blocker/ PPI), mood disorder, H. Pylori
management of placenta previous
C/S at 36-38 GA
timing of Tdap in pregnancy
offer 21-32w GA for every pregnancy regardless of hx
Complications of Varicella infection in pregnancy
Maternal: - pneumonitis (5-10% among pregnancy varicella) --- treated with antiviral (acyclovir) - intubation, death Newborn: - congenital varicella - congenital malformation: > chorioretinitis > cerebral cortical atrophy > hydronephrosis > cutaneous and bone leg defects
Management of pregnancy Varicella infection
- DO NOT immunize during pregnancy
- if exposed to suspected infection:
do maternal serology- if no available in 96 hr, or non-immune
==> give varicella zoster immunoglobulin
- if no available in 96 hr, or non-immune
Conceiving with HIV + counseling
- antiviral > 3mo & 2 undetected viral load 1/mo
- PrEP if serodiscordant & can’t confirm adherence/ viral suppression
Mgt of preg/postpartum with HIV+ women
- antiretroviral regardless of CD4
- monitor plasma viral load q4-8w + drug toxicity
- if viral load < 1000c/ml: SVD; if increased: C/S
- newborn:
»_space;> 6w antiretroviral therapy
»_space;> HIV test @ 1, 3, 18 mo - NO breastfeeding
Counseling for postpartum contraception
- Non-lactating:
»_space;> can begin combination OCP 3 weeks postpartum - Lactating:
1) Micronor 6 weeks postpartum and change to OCP when introducing supplemental feeding2) can begin OCP at 3 months if breastfeeding exclusively
3) can give IUD 6 weeks postpartum
Etiology of postpartum fever (> 38 degree on any 2 of the first 10 days postpartum, not including the 1st day)
Wind: atelectasis, pneumonia Water: UTI Wound: C/S incision or episiotomy site Walking: pelvic thrombophlebitis, DVT Womb: endometritis breast: mastitis, engorgement
Ix: blood and genital culture
Mgt: clindamycin + gentamicin = empiric treatment for wound infection
risk factors of uterine atony
- abnormal labour
- infection
- uterine distension
- placental abruption
- grand multip
- halothane anesthesia
Etiology of post-partum hemorrhage
At the time of delivery, > 500ml vaginal delivery OR > 1000ml C/S, can be late (after first 24 hrs, up to 6 weeks)
4T -
» Tone: uterine atony (most common) occurs within 24 hr
» Tissue: retained placeta or clots
» Trauma: laceration of cervix, vagina, uterus, episiotomy, hematoma, uterine rupture
» Thrombin: coagulopathy, DIC, ITP, TTP, on anticoagulation
