OB Flashcards
What is the effect of teratogens?
First two weeks: either kill baby…or nothing
2-12 weeks: abnormal organ formation
Does blood pressure go up or down with pregnancy?
Both systolic and diastolic pressures go down
What causes increased tidal volume/minute ventilation during pregnancy?
Progesterone
What happens to the stomach with pregnancy?
Decreased motility
How many calories should a pregnant woman take in per day?
2500
How much weight should a pregnant woman gain?
BMI less than 19.8…28-40lbs
BMI less 19.8-26…25-35lbs
BMI greater than 26…15-25
How much folate is recommend for non-risk pregnancies?
0.8-1mg/day to prevent neural tube defects
How much calcium is recommended for pregnancies? What can happen with hypocalcemia?
1000-1300mg/day (50% increase)
Impaired maternal bone mineralization or HTN
Premature birth or low birth weight
How much iron is recommended for pregnancies?
30mg/day (100% increase)
How much protein is recommended for pregnancies?
60g/day (30% increase)
A Full Integrated Test is done during the first trimester for mothers who desire noninvasive testing with the lowest false-positive risk. What is all on it?
PAPP-A (Pregnancy-Associated Plasma Protein A)
hCG
NT (Nuchal Translucency)
A Full Integrated Test comes back with decreased PAPP-A, increased hCG, and increased NT. What is the likely defect?
Trisomy 21…only one with elevated hCG
How can trisomy 18 and 13 be told apart on Full Integrated Test?
Trisomy 18 has really low hCG
Trisomy 13 has only low hCG
When is a quadruple screen checked? What is all on it?
16-18wk appointment
AFP, hCG, unconjugated estriol, inhibin A
How can it be determined on quad screen that the baby has trisomy 21?
Increased hCG and Inhibin A
How can trisomy 18 and 13 be told apart on quad screen?
Trisomy 18 everything is low except inhibin A…which is normal
Trisomy 13 everything is normal
When is glucose challenge done?
24-28 weeks
When are N. gonorrhea, Chlamydia, and GBS screened for?
32-37 weeks
When can an amniocentesis be done? What does it check for? What is the risk?
16 weeks
Amniotic AFP and determine karyotype (detects neural tube defects and chromosome abnormalities)
1% increased risk of spontaneous abortion
When is chorionic villi sampling done?
9-12 weeks for early detection in higher risk patients
When is percutaneous umbilical blood sampling done?
After 18 weeks to identify chromosomal defects, fetal infection, and Rh sensitization
RECAP: Maternal serum AFP can be checked from weeks 16-18 to determine what?
Neural tube defects (if high)
Trisomy 18 or 21 (if low)
What is considered an abnormal 1hr glucose tolerance test? 3hr glucose tolerance test?
1 hr:
>130mg/dL
3hr: 2+ of the following
Fasting: 95+mg/dL
1hr: 180+mg/dL
2hr: 150+mg/dL
3hr: 140+mg/dL
What are the goal glucose levels in pregnant women with gestational diabetes?
Fasting glucose less than 90
1 hour post-prandial less than 120
What are some fetal complications from gestational diabetes?
Macrosomia, polyhydramnios delayed pulmonary maturity, uteroplacental insufficiency –> IUGR or intrauterine fetal demise
What are some perinatal/postnatal complications from gestational diabetes?
Traumatic delivery, delayed neurologic maturity, RDS, hypoglycemia (secondary to therapy), hypocalcemia
What are maternal complications from normal diabetes?
Preeclampsia, renal insufficiency, retinopathy, DKA, hyperosmolar hyperglycemic nonketotic state
What are fetal complications from normal diabetes?
Cardiac defects (TGA and ToF), neural tube defects, sacral agenesis, renal agenesis, polyhdramnios, macrosomia, IUGR, intrauterine fetal demise
A pregnant woman has HTN, proteinuria, and edema. What does she have? What is seen on labs
Preeclampsia
Decreased platelets, normal/high Cr, increased ALT and AST, decreased GFR
What are some complications of preeclampsia? What is the cure for preeclampsia?
Eclampsia, stroke, IUGR, pulmonary edema, maternal organ dysfunction, HELLP…can cause abruptio placentae, renal insufficiency, encephalopathy, DIC
Deliver
What is done for preeclampsia if far from term?
If mild: restricted activity and frequent assessments
If severe: inpatient, BP less than 155/105 with diastolic >90, MgSO4 (prevent seizure)
A mother has preeclampsia and delivers the baby. Now what?
Continue anti-HTN meds and MgSO4 and continue to monitor
What is eclampsia?
Maternal seizures…usually preceded by headaches, visual disturbances (scotomata), and upper abdominal pain
How should eclampsia be treated?
MgSO4 and diazepam
Stabilize with oxygen and BP control
Continue BP med and MgSO4 for 48hrs post-delivery
What are complications of eclampsia?
2% maternal death; 6-12% fetal death
65% of preeclampsia and 2% of eclampsia in subsequent pregnancies
What should be done with pregnant epileptic patients?
Continue normal meds + supplement vitamin K and folate
What are the risks for a pregnant asthma patient?
Preeclampsia, spontaneous abortion, intrauterine fetal demise, and IUGR with untreated severe disease
A pregnant woman requires anticoagulation. What cannot be used? When should it be stopped/restarted?
Warfarin is teratogenic (skeletal abnormalities)
Stop 24-36hrs prior to delivery and restart 6 hours after
What can be used to treat maternal UTIs?
Amoxicillin, nitrofurantoin, or cephalexin for 3-7days
NOT fluoroquinolones
Risks for pot baby? Momma?
Fetal risks: IUGR, prematurity
Maternal risks: minimal
Risks for coke baby? Momma?
Fetal risks: abruptio placentae*, IUGR, prematurity, facial abnormalities, delayed intellectual development, fetal demise
Maternal risks: Arrhythmia, MI, subarachnoid hemorrhage, seizures, stroke, abruptio placentae
Risks for alcohol baby? Momma?
Fetal risks: FAS (metnal retardation, IUGR, sensory and motor neuropathy, facial abnormalities), spontaneous abortion, intrauterine demise
Maternal risks: minimal
Risks for opioid baby? momma?
Fetal risks: Prematurity, IUGR, meconium aspiration, neonatal infections, narcotic withdrawal…can be fatal
Maternal risks: infection (from needles), narcotic withdrawal, PROM
Risks of stimulant baby? momma?
Fetal risks: IUGR, congenital heart defects, cleft lip
Maternal risks: lack of appetite and malnutrition, arrhythmia, withdrawal depression, hypertension
Risks of tobacco baby? momma?
Fetal risks: spontaneous aboriton, prematurity, IUGR*, intrauterine fetal demise, impaired intellectual development, higher risk of neonatal respiratory infections
Maternal risks: Abruptio placentae, placenta previa, PROM
Risks of hallucinogen baby? momma?
Fetal risks: possible developmental delays
Maternal risks: personal endangerment
Teratogenic effect of ACEI?
renal abnormalities
decreased skull ossification
Teratogenic effect of aminoglycosides?
CN VIII damage
Skeletal abnormalities
Renal defects
Teratogenic effect of carbamazepine?
Facial abnormalities IUGR Mental retardation CV abnormalities Neural tube defects
Teratogenic effect of Chemo drugs?
Intrauterine demise (30%) severe IUGR multiple anatomic defects mental retardation spontaneous abortion secondary neoplasms
Teratogenic effect of diazepam?
Cleft palate
Renal defects
Secondary neoplasms
Teratogenic effect of DES?
Vaginal and cervical cancer later in life (adenocarcinoma)
Teratogenic effect of fluoroquinolone?
cartilage abnormalities
Teratogenic effect of heparin?
Prematurity
intrauterine demise
Safer than warfarin
Teratogenic effect of lithium?
Ebstein’s anomaly (tricuspid valves are in ventricle…larger atrium and smaller ventricle)
Teratogenic effect of OCPs?
Spontaneous abortion
Ectopic pregnancy
Teratogenic effect of phenobarbital?
Neonatal withdrawal
Teratogenic effect of phenytoin?
Facial abnormalities
IUGR
Mental retardation
CV abnormalities
Teratogenic effect of retinoids (vitamin A analog used to treat acne)?
CNS abnormalities
CV abnormalities
Facial abnormalities
Spontaneous abortion
Teratogenic effect of sulfonamides?
Kernicterus (bile infiltration of brain)
Teratogenic effect of tetracycline?
Skeletal abnormalities
limb abnormalities
teeth discoloration
Teratogenic effect of thalidomide (for multiple myeloma)?
limb abnormalities
Teratogenic effect of valproic acid?
Neural tube defects (1% of pregnancies)
facial abnormalities
CV abnormalities
Skeletal abnormalities
Teratogenic effect of warfarin?
Spontaneous abortion IUGR CNS abnormalities Facial abnormalities mental retardation Dandy-Walker malformation (large 4th ventricle...absence of cerebellar vermis)
What does TORCH stand for?
T-Toxoplasmosis O-Other (VZV, parvoB19, GBS, G&C) R-Rubella/Rubeola/RPR (syphilis) C-CMV H-HSV/HBV/HIV
Toxoplasmosis: How does it present? How is it diagnosed? How is it treated?
Hydrocephalus, intracranial calcifications, chorioretinitis, microcephaly, spontaneous abortion, seizures
Possible mono-like illness
Amniotic fluid PCR for Toxoplasma gondii or serum Ab screening
Pyrimethamine, sulfadiazine, and folic acid
Mother should avoid gardening, raw meat, cat litter boxes, and unpasteurized milk
Rubella: How does it present? How is it diagnosed? How is it treated?
Increased risk of spontaneous abortion
Skin lesions (blueberry muffin)
Congenital rubella syndrome (IUGR, deafness, CV abnormalities, vision abnorms, CNS abnorms, hepatitis)
Early prenatal IgG screening
Mother should be immunized prior to pregnancy
No treatment if infection develops during pregnancy
No proved benefit from rubella immune globulin
Rubeola: How does it present? How is it diagnosed? How is it treated?
Increased risk of prematurity, IUGR, and spontaneous abortion
High risk of neonatal death (20% term; 55% preterm)
Clinical diagnosis in mother confirmed by IgM or IgG
Mother should be immunized prior to pregnancy
Immune serum globulin given to mom if infection develops during pregnancy
Vaccine is contraindicated during pregnancy (live attenuated virus carries risk of fetal infection)
Syphilis: How does it present? How is it diagnosed? How is it treated?
Neonatal anemia, deafness, hepatosplenomegaly, pneumonia, hepatitis, osteodystrophy, rash followed by hand/foot desquamation
25% neonatal mortality
Early prenatal RPR or VDRL
Confirm with FTA-ABS (doesn’t go away)
maternal or neonatal PCN
CMV: How does it present? How is it diagnosed? How is it treated?
IUGR, chorioretinitis, CNS abnorms*, mental retardation, vision abnorms, deafness, hydrocephalus, seizures, hepatosplenomegaly
Possible mono-like illness
IgM antibody screening or PCR of viral DNA w/in first few weeks of life
No treatment if infection develops during pregnancy
Ganciclovir may decrease effects in neonates
Good hygiene reduces risk of transmission
HSV: How does it present? How is it diagnosed? How is it treated?
Increased risk of prematurity, IUGR, and spontaneous abortion
High risk of neonatal dither CNS abnorms
Clinical diagnosis confirmed with viral culture or immunoassays
Delivery by C-section* if active
Acyclovir may be beneficial in neonates
HBV: How does it present? How is it diagnosed? How is it treated?
Increased risk of prematurity and IUGR
Increased risk of neonatal death of acute disease develops
Prenatal HBsAg testing
Maternal vaccination
Neonatal passive and active vaccination
HIV: How does it present? How is it diagnosed? How is it treated?
Viral transmission in utero (5% risk)…rapid progression of AIDS
Early prenatal maternal blood screening (get consent)
AZT significantly reduces vertical transmission risk
Continue prescribed antiviral regimen, but avoid efavirenz, didanosine, stavudine, and nevirapine
G&C: How does it present? How is it diagnosed? How is it treated?
Increased risk of spontaneous abortion; neonatal sepsis; conjunctivitis*
Cervical cx and immunoassays
Erythromycin given to mother or neonate
VZV: How does it present? How is it diagnosed? How is it treated?
Prematurity, encephalitis, pneumonia, IUGR, CNS abnorms*, limb abnorms, blindness
High risk of neonatal death if birth occurs during active infection
IgG titer screening in women with NO known history
IgM and IgG can confirm diagnosis in neonates
Varicella Ig given to nominate mother w/in 96 hours of exposure and to neonate if born during active infection
Vaccin is contraindicated during pregnancy (live attenuated vaccine)
GBS: How does it present? How is it diagnosed? How is it treated?
Respiratory distress, pneumonia, meningitis*, sepsis
Antigen screening after 34wks
IV beta-lactams or cloned during labor or in infected neonates
ParvoB19: How does it present? How is it diagnosed? How is it treated?
Decreased RBC production, hemolytic anemia, hydrous fettles
IgM antibody screening or PCR of viral DNA
Monitor fetal Hgb by PUBS (Percutaneous Umbilical Blood Sampling) and give intrauterine transfusion for severe anemia
When can transabdominal US visualize a pregnancy? Transvaginal?
6500mIU/mL
1500mIU/mL
How is ectopic pregnancy treated?
Methotrexate
IV fluids and surgery if ruptured
What causes the majority of 1st trimester spontaneous abortions?
Chromosome abnormalities (especially trisomies)
What is intrauterine fetal demise?
Intrauterine fetal death that occurs after 20 weeks gestation and before onset of labor
Caused by placental or cord abnorms secondary to maternal cv or hematologic conditions, maternal HTN infection poor maternal health, or fetal congenital abnorms
What can happen if fetus is retained for a prolonged period of time?
DIC
What causes symmetric IUGR?
Symmetric is 20% of cases
Caused by congenital infection, chromosomal abnorms, maternal drug use
What is asymmetric IUGR? What causes it?
Decreased abdominal size…normal head and limbs (80% of cases)
Multiple gestation, poor maternal health, or placental insufficiency
How can IUGR be diagnosed on exam?
Fundal height 3+cm shorter than expected
What happens with first trimester oligohydramnios?
Frequently spontaneous abortion
What typically causes second trimester oligohydramnios?
Fetal renal abnorms
Maternal preeclampsia, renal disease, HTN, collagen-vascular disease
Placental thrombosis
What is associated with third trimester oligohydramnios?
PROM, preeclampsia, abruptio placentae, idiopathic cause
What is seen on US that would diagnose oligohydramnios?
Amniotic fluid index less than 5cm with no pockets greater than 2cm
What is polyhydramnios? What causes it?
Amniotic fluid index >25cm or a pocket >8cm
Insufficient swallowing, increased fetal urination (maternal DM), multiple gestation, fetal anemia, or chromosomal abnorms
Besides amnioreduction, what else is done if less than 32 weeks?
Tapered indomethacin
You suspect PROM. What can be done to confirm? What else should be done with the fluid?
Microscopic exam shows “ferning”
Nitrazine paper will turn blue
Culture fluid to detect infection
PROM is confirmed. Now what?
Prophylactic antibiotics and…
Less than 32wks: give corticosteroid…induce when lungs are viable
32-34wks: check lung viability…do what is necessary
>34wks: induce labor
What are examples of tocolytics?
MgSO4, terbutaline, indomethacin, or nifedipine
What is a big difference between bleeding with placenta previa and bleeding with placental abruption?
Previa…painless
Abruption…painful (increased uterine tone)
What is a normal reactive acceleration?
15bpm increase for 15s
What is taken into consideration for a biophysical profile?
A second nonstress test Amniotic fluid index Fetal breathing rate Fetal movement Fetal one
Score of 8 or 10 is reassuring (scored 0 or 2…not 1)
What are early decelerations? What causes them?
Decels begin and end with uterine contraction
Caused by head compression…not a sign of fetal distress
What are late decelerations? What cause them? What should be done?
Begin after and end after uterine contraction
Uteroplacental insufficiency, maternal venous compression, materna hypotension, or abruptio placentae
May suggest fetal hypoxia
Fetal scalp blood sampling (hypoxia or acidosis)
Recurrent late decels –> prompt delivery
What are variable decelerations? What causes them? What should be done?
Inconsistent onset, duration, and degree of decelerations
Umbilical cord compression
Reposition mom
How long does the first stage of pregnancy last for nulliparous women? Multiparous?
Nulliparous: less than 20 hours (2/3 latent; 1/3 active)
Multiparous: less than 14 hours
How long does it usually take form full cervical dilation to delivery (stage 2)?
Nulliparous: less than 2 hours (3 w/epidural)
Multiparous: less than 1 hour (2 w/epidural)
How long does it usually take after the kid is born to deliver the placenta?
0-30 minutes
What can be used to induce labor?
Oxytocin, misoprostol
Which immunoglobulin is passed in colostrum (early breast milk)?
IgA
A postpartum mother has a lot of bleeding. What could be going on? What might be felt on exam?
Retained placental tissue
Soft, boggy uterus
An US shows snowstorm pattern in the uterus. What could be going on? What might be expelled from the uterus?
Hydatidiform mole
Grape-like vesicles
A pregnant woman has preeclampsia in first 20wks of pregnancy. What should be considered?
Get an ultrasound to confirm hydatidiform mole
A woman gets pregnancy that runs whatever course it runs…and now has vaginal bleeding and possible hemoptysis, dyspnea, headache, dizziness, or rectal bleeding. On exam, she has an enlarged uterus with bleeding from her cervical os. What lab should be ordered? What is likely going on?
Check beta-hCG
Choriocarcinoma (50% post hydatidiform mole)…can metastasize
