OB - 2 Flashcards
When are antibiotics recommended for ppx use for endocarditis?
No longer recommended!
May consider if hx endocarditis, unrepaired cyanotic disease, or prosthetic valve
Ampicillin 2g
What factors convey Risk Of Heart Attack?
Race, Obesity, HTN, Age
What are most common cardiac illnesses in pregnancy and postpartum?
Heart failure, MI, arrhythmia, aortic dissection
NYHA Classification of Heart Disease
Class 1 - no compromise
Class 2 - mild fatigue with activity
Class 3 - fatigue with less than normal activity
Class 4 - fatigue at rest
What is the most common rheumatic heart lesion?
Mitral stenosis
What pathology does mitral stenosis have?
Fixed cardiac output d/t narrowed valve
Blood accumulates in L atrium, backs up into lungs, causes heart failure
What is the treatment for mitral stenosis?
Prevent tachycardia with beta blockers
What strategies are employed in laboring patient with cardiac disease?
Vaginal delivery preferred
- Except Marfan’s > CS!
Allow to labor down
Shorten 2nd stage with OVD
What is the treatment of thyroid storm?
PTU followed by iodide
Steroids, beta blockers
What are the risks of epilepsy in pregnancy?
IUGR, IUFD, PEC
What are some of the adverse effects of anti-epileptics?
Decreased folate (give 4mg)
Decreased Vit K (give upon delivery)
Decreased Vit D
What are the drugs of choice for epilepsy in pregnancy?
Lamotrigine (textbook)
Keppra (reality)
What are the effects of valproate on pregnancy?
NTD
What is fetal hydantoin syndrome?
Growth restriction
Microcephaly
Mental retardation
Phalangeal hypoplasia
What are the clinical criteria for APLS?
Vascular
- Venous or arterial thrombosis
Pregnancy
- Loss > 10w
- SAB x3 < 10w
- Delivery at <34w for PEC/IUGR
What are the lab criteria for APLS?
On 2 occasions >= 12w apart
- Beta-2 glycoprotein
- Anti-cardiolipin
- LA
With APLS, what is the (percent) risk of: fetal loss?
50%
With APLS, what is the (percent) risk of: PEC?
50%
With APLS, what is the (percent) risk of: IUGR?
25%
With APLS, what is the (percent) risk of: thrombosis?
10%
What are antepartum considerations for APLS?
ASA + ppx AC
Surveillance for PEC and thrombosis
Growth US in 3rd tri for risk of IUGR
NST surveillance
Postpartum AC x6w
What are some causes of symmetric IUGR?
Genetics, TORCH, malaria, syphilis, congenital anomalies
What are some causes of asymmetric IUGR?
Placental insufficiency
When to deliver: uncomplicated IUGR (3-10%ile)?
38-39w
When to deliver: complicated IUGR (oligo, abn doppler, maternal conditions)?
34-38w
When to deliver: severe IUGR (<3%ile)?
37w
When to deliver: IUGR DCDA twins (uncomplicated)?
36-38w
When to deliver: IUGR DCDA twins (complicated)?
32-35w
What are some causes of TCP in pregnancy?
Gestational
Immune (ITP, TTP)
PEC
Drugs (SQH, AZT)
HIV
When do you treat TCP in pregnancy?
Plt < 50k or bleeding diathesis
What is the antigen implicated in NAIT?
HPA-1a, Plt antigen
When to deliver: DCDA twins (uncomplicated)?
38-39w
When to deliver: MCDA twins (uncomplicated)?
34-38w
When to deliver: MCMA twins (uncomplicated)?
32-34w
What are some maternal complications of twin gestation?
Hyperemesis
Anemia
DVT/PE
Pyelo
CS
What are some OB complications of twin gestation?
PPROM, PTL
HTN/PEC/HELLP
Acute fatty liver
GDM
Placenta previa
PPH
What are some fetal complications of twin gestation?
IUGR, Congenital anomalies /Hydramnios, Cerebral palsy, cord accident (MCMA), TT Transfusion (MCDA, MCMA)
What are some complications of preterm labor? (RIPNS)
RDS, IVH, PDA, NEC, Sepsis
When is IM progesterone (17-OHP) recommended?
For women with hx PTD, give 16-26w
When is vaginal progesterone recommended?
Short cervix <= 20mm before 20w
What are the criteria for US indicated cerclage?
<25mm before 24w GA and hx PTD < 34/mid tri loss
What are the criteria for history indicated cerclage?
Hx one or more 2nd tri delivery (without labor)
What are the criteria for exam indicated cerclage?
Advanced cervical dilation without labor, abruption, or infection evident
Post term pregnancy is associated with:
Perinatal mortality, meconium aspiration, convulsions, low 5-min Apgars, low cord PH, oligo, dysmaturity syndrome, macrosomia
If you don’t know the gestational age of a patient, how can you determine if they are term?
Early US suggesting EGA > 39w
Positive HCG x 36w
Fetal heart heard with Doppler x 30w
device x 20w
How do you treat GBS if pt PCN allergic?
Normally: PCN 5mil u f/b 2.5mil u q4 hrs
If not true allergy: ancef 2g q6
If susceptible to clinda + erythromycin:
Clindamycin 900mg q8 hrs
If not: Vancomycin 20mg/kg q8 hrs
When do you treat a pt who is GBS unk?
Preterm
ROM => 18 hrs
Fever => 100.4
Known GBS pos in prior pregnancy
What is the risk of transmission for and severity of toxoplasmosis in each trimester?
1 - 15% (severe)
2 - 30% (mod)
3 - 60% (mild)
What is the clinical presentation of fetal toxoplasmosis?
Intracranial calcifications, chorioretinitis, hearing loss, mental retardations, HSM
What is the prevalence of acute primary CMV and risk of vertical transmission, neonatal disease, death?
Prevalence 3%
Vertical transmission 30% of these 3%
Neonatal disease: 30%
Death: 30%
What is the clinical presentation of fetal CMV?
Chorioretinitis, HSM, IUGR, Hydrops
What is the vertical transmission rate of Parvovirus, and what occurs in each trimester?
25%
1st tri - SAB
2nd/3rd tri - Hydrops, IUFD 2/2 anemia
What fetal surveillance is required once mom tests positive for Parvovirus?
Serials weekly US for 2 mo after maternal infection to evaluate fetal wellbeing and signs of hydrops.
What is the rate of survival with fetal Parvovirus?
With treatment - 80%
Without treatment - 20%
What is this clinical presentation of maternal Parvovirus?
Rash, arthritis, flu-like illness, mostly asymptomatic
What is the clinical presentation of maternal Varicella?
Primary rash or shingles, PNA, Encephalitis
What is the clinical presentation of fetal Varicella?
SAB, Varicella embryopathy (eyes, limbs, skin, CNS effects), IUFD (high risk if <5d prior to delivery)
What is PEP for Varicella?
Varicella immunoglobulin and Acyclovir 800mg 5x daily x7d
What are the symptoms of Zika virus?
Fever, maculopapular rash, arthralgia, conjunctivitis, myalgias, pruritis, vomiting
How do you screen for Zika virus?
Potential exposure, travel to endemic area by patient or partner, symptoms
What testing is performed for Zika virus?
Test symptomatic pregnant people with possible exposure, up to 12w after symptoms onset, with concurrent IgM and NAT testing
If ongoing exposure, testing 3 times during pregnancy with Zika NAT of serum and urine
If considering conception, how long must you wait after a Zika exposure?
Female partner - 8w
Male partner - 6mo
What is the clinical presentation of maternal Listeria?
GI illness and flu-like symptoms (myalgia, N/V, diarrhea), fever
What are the fetal and neonatal effects of Listeria?
Fetal - IUFD, PTL
Neonatal - Meningitis, Sepsis, Death
How do you manage a patient exposed to a recalled Listeria product?
Asymptomatic - nothing, observe
Mild sx no fever - manage as asymptomatic or send blood cx, only treat if cx+
Fever +/- other sx - test and treat simultaneously (ampicillin or bactrim)
What is the definition of AIDS?
HIV+ and CD4< 200
What are the rates of vertical transmission of HSV with:
- Primary infection
- Non-primary 1st episode
- Recurrent infection?
- Primary: 50%
- Non-primary 1st: 33%
- Recurrent: 3%
What is the dose of Valacyclovir for
- Primary infection + non-primary 1st episode
- Recurrent infection
- Suppression?
- Primary + non-p 1st: 1000mg bid x10d
- Recurrent 500mg bid x3d
- Suppression 500mg bid from 36w
What the effects of obesity on pregnancy?
Increased risk of SAB and recurrent SAB, IUFD, PEC, macrosomia, congenital anomalies (cardiac, orofacial, limb, NTD), childhood obesity and asthma, ADHD, autism spectrum
What micronutrients should be monitored after bariatric surgery?
Folate, Fe, Vit D, B12, Ca
What is the different diagnosis of fetal hydrops?
Immune (Rh disease)
Non-immune
- Anemia
- Parvo or CMV
- Congenital heart defects
- Placenta problems: AV malformations, fetal maternal hemorrhage
What vaccines are acceptable in pregnancy?
Tdap, Flu, Hep A + B, Pneumococcus
What vaccines are contraindicated in pregnancy?
MMR, Varicella, HPV, Intranasal Flu
What is the ddx of oligohydramnios?
ROM, IUGR, SGA, TORCH, renal agenesis, Idiopathic
What is the ddx of polyhydramnios?
Diabetes, esophageal atresia, duodenal atresia, TORCH, syphilis, hydrops, genetic anomalies, idiopathic
