OB Flashcards
What is alpha fetoprotein? When is measured?
Protein produced in the yolk sac, GI tract, liver. Measured at 15-20 weeks gestation (ideally between 16-18 weeks) to screen for fetal anomalies
AFP is mostly elevated in what conditions?
Screen for neural tube defects (anencephaly, spina bifida). Ventral wall defects (gastroschisis, omphalocele) and multiple gestation. Less commonly increased MSAFP can be seen in fetal congenital nephrosis and benign uropathy. MSAFP is decreased in aneuploidies
Down syndrome hormone profile
Low AFP, low estriol, elevated bHCG and inhibin A
Trisomy 18 hormone profile
Low AFP, very low estriol, very low bHCG and normal inhibin A
How does rhogam work
Anti D immunoglobulins given to the mother. They take out any fetal RhD positive erythrocytes that have entered the maternal blood stream before the mom’s immune system can get sensitized to it. Rho D Ig is composed of IgG antibodies and can cross the placenta and in rare cases can cause the baby to have positive direct antiglobulin test due to sensitization of fetal cells from mothers who have received multiple doses of RhoD immune globlulin.
ABO incompatibility often occurs when?
O moms have group A or group B babies but the degree of hemolytic diseae is much less severe compared to RH incomability
ABO incompatbility can occur during the first pregnancy because?
both A and B antigens are found in food and bacteria in the environment. These can produce various degrees of antibodies in group O individuals.
Hormone responsible for milk synthesis and hormone responsible for milk letdown
Prolactin responsible for synthesis and oxytocin - contraction of lactiferous glands and ducts resulting in the excretion of milk. Note that during pregnancy, estrogen and progesterone interfere with prolactin. Upon delivery, estrogen and progesterone decrease sharply, allowing prolactin to work
Bromocriptine is?
Dopamine agonist that acts by inhibiting prolactin secretion by the anterior pituitary thus suppressing lactation.
Causes of fetal growth restriction (
Asymmetric (maternal factors) - vascular disease (htn, PEC, diabetes), antiphospholipid antibody syndrome, autoimmune disease (SLE), cyanotic cardiac disease, substance abuse (tobacco, alcohol, cocaine). Symmetric (fetal factors) - genetic disorders, congental heart disease, intrauterine infection
IUGR predisposes child to
obesity, cognitive delay in childhood, diabetes, coronary artery disease, stroke
Sheehan Syndrome
Anterior pituitary infarction. Occurs when there is massive post partum hemorrhage and hypotension leading to hypoperfusion of the anterior pituitary gland. Can also occur after a normal delivery and may lead to deficiency of any of the anterior pituitary hormones (LH, FSH, TSH, ACTH, growth hormone, prolactin)
Sheehan syndrome initial prsentation
initial failure of postpartum lactation due to prolactin deficiency. Can also develop, persistent hypotension, amenorrhea, loss of sexual hair, weight loss, lethargy
Chorioamniotis diagnosed based on
Maternal fever, maternal and fetal tachycardia, uterine tenderness
Placental abruption symptoms/signs
80% present with bleeding but 10-20% don’t have bleeding. No bleeding does not rule out. abdominal or back pain, high-frequency, low-intensity contractions. Presents with uterine stiffness (blood is uterotonic). Significant abruption compromises fetal oxygenation so will show nonreassuring fetal heart rate tracings (variable declerations, late decelerations, or fetal bradycardia). Does not improve with intrauterine resuscitation measures.
Greatest risk factor for placental abruption
Maternal hypertension, PEC/eclampsia, other risk factors include cocaine or tobacco abuse, abdominal trauma, excessive uterine distension, previous placenta abruption
Tx for placental abruption
Unstable maternal VS or non reassuring fetal HR tracing => emergency section. If stable maternal VS, ok FHR tracing, >= 34 weeks, no placenta previa = trial of vaginal delivery
Dx of placental abruption
Mostly by clinical presentation but also use U/S to rule out placenta previa. Side note: maternal fever and leukocytosis are not typically a/w placental abruption
What is the Kleihauer-Batke test?
Used to measure the amount of fetal hemoglobin transferred into the maternal bloodstream.
Kleihauer-Batke test is performed on what women?
Rh negative women with Rh positive fetus to determine the dose of Rh immnoglobulin that should be given to the mother.
Pelvic exam is contraindicated in patients with antepartum hemorrhage until
Placenta previa is ruled out
Placenta previa clinical ppt?
usually PAINLESS Vaginal bleeding in third trimester with 2/3 cases presenting at 30 weeks gestation.
Management of placenta previa?
Depends on the severity of the bleeding and age of the pregnancy. If fetus at term, mother stable, scheduled section. If pregnancy is not yet term and fetus is stable,c lose monitoring. At 36 weeks do amniocentesis to assess lung maturity. If lungs are mature, elective C section. Complete placenta previa requires delivery by section.
Prolonged rupture of membranes
> 18 hours of rupture
Dx of intramniotic infection
Maternal fever + 1) uterine tenderness 2) maternal 3)fetal tachycardia 4) malodorous amniotic fluid/purulent vaginal discharge 5) WBC>15,000 cells
Tx of chorioamnionitis
IV broad spectrum antibiotics (ampicillin, gentamicin, clindamycin) and delivery. Labor should be accelerated with pitocin. C section is not standard for just chorioamnionitis. Antipyretics
Any attempt to convert breech into vertex before how many weeks is not indicated?
37 weeks
Definition of oligohydramnios
Amniotic fluid index
Components of the BPP
1) NST 2) Amniotic fluid volume 3) fetal movements (>3= general body movements) 4) fetal tone (>= 1 episode of flexion/extension) of fetal limbs or spine 5) fetal breathing movements (1 breathing episode for 30 seconds)
Scores for BPP
8-10 normal, 6 equivocal, =
What are the abnormalities seen with a metabolically compromised fetus?
Decelerations, decreased fetal movement followed by decreased fetal tone and decreased fetal breathing movement
Pre-eclampsia
New onset hypertension (140/90) + proteinuria (>=300mg/24 hr, protein:cr ratio >=0.3, or dipstick of >=1+) OR signs of end organ damage
Severe features of PEC important to recognize as they increase risk of morbitidy
160/110 4 hours apart on 2 separte occasions, thrombocytopenia (platelets 1.1 or doubling, transaminitis, pulmonary edema, new onset visual or cerebral sx
chronic HTN with superimposed PEC
Chronic HTN + 1 of the following: new onset proteinuria or worsening of existing proteinuria at >= weeks of gestation 2) sudden worsening HTN or 3) signs of end organ damage
Management /Tx of PEC
1) Delivery 2) for patients with PEC with severe features - A) seizure prophylaxis: Mg sulfate IV or IM B) antihypertensives for BP > 160/110 labetalol IV, hydralazine IV, or nifedipine PO
Eclampsia
Severe eclampsia + seizures
Clinical features of eclampsia
Maternal: visual distrubances, headaches, AMS, right upper quadrant or epigastric pain, SOB, AMS, 3-4 mins of tonic clonic seizures (usually self limited) fetal: bradycardia with compensatory tachycardia and loss of variability
Management of eclampsia
1) Prevent maternal trauma and hypoxia 2) prevent recurrent seizures with mg sulfate 3) prevent stroke, if severe htn, treat 4) evaluate for delivery with induction or section
If 2 boluses of IV mg sulfate don’t’ control eclamptic seizures, then give
diazepam or phenytoin
Predominant pathophysiologic finding of PEC
endothelial cell dysfunction or vasospasm. Problem is thought to originate from abnormal placental vasculature developed during early pregnancy.
Definitive treatment of PEC-eclampsia
Delivery. Assess patient and fetus to determine mode of delivery. Stabilize patient. If no signs of distress, augmentation of labor. Mg sulfate is given through the labor and post partum
Controversial pre-operative threshold for platelets for C section?
40-50K
Lithium a/w
ebstein’s anomaly. When if bipolar is stable
Isotretinoin
Dc. If using dudring reproductive age, need to make sure been on 2 working contraception for at least 1 month prior to tx initiation and also for another month after d/c
Why does hypotension sometimes occur after an epidural?
if the sympathetic nerves for vascular tone get blocked, then you experience vasodilation and pooling, leading to hypotension. Prolonged hypotension could lead to uterine hypoperfusion and cause fetal acidosis. Can prevent this by giving adequate fluids before prior to epidural palcement.
what is a wet tap? Symptoms of a wet tap?
dura gets inadvertently punctured and you get leadkage of CSF. Postural headaches. Better when lying down.
Ectopic pregnancy
Amenorrhea, vaginal bleeding, abdominal pain. 2) orthostatic changes and hypovolemic shock 3) normal/slightly enlarged uterus 4) cervical motion tenderness/abdominal tenderness 5) +/- palpable adnexal mass. If ruptured = pooling of blood and irritation of nearby structures can cause adnexal tenderness, diffuse abdominal pain, shoulder pain (Referred from diaphragm), and urge to defecate (blood in posterior cul de sac)
Ectopic pregnancy management
Medical (MTX) or surgical management based on patient presentation
Early deceleration
Symmetric to contraction, >= 30 seconds from onset to nadir, nadir correponds with peak of contraction, etiology: fetal head compression, can be normal fetal tracing
Late deceleration
Delayed compared to contraction (onset of the decel starts around the peak of contraction), nadirs in >= 30s, nadir of decel corresponds with after the contraction, gradual, etiology: uteroplacental insufficiency
Variable deceleration
can be but not necessarily related to contraction, abrupt (=15/min; duration is >= 15 seconds but
What is a reactive (normal) stress teat
If in 20 minutes, there are >=2 accelerations (>15 beats/min lasting for 15 seconds)
Maternal hyperglycemia leads to
1st trimester: congenital fetal heart defects, neural tube defects, small left colon syndrome. spontaneous abortion. 2nd trimester: fetal hyperglycemia => fetal hyperinsulinemia => 1) increased metabolic demand leading to fetal hypoxia leading to erythopoeisis leading to polyctyemia 2) organomegaly 3) macrosomia leading to shouler dystocia, brachial plexus injury, clavicule fracture and 4) neonatal hypoglycemia
D&C for stillbirth
up to 24 weeks?
Normal result in contraction stress test
FHR during spontaneous or induced stress test. Normal result: no late or recurrent variable decelerations.
Fetal lung maturity assessment
lecithin:sphingomeylin ratio and other things
Confirm IUFD with
Real time u/s to check for lack of fetal cardiac movement
Types of spontaneous abortion
1) missed 2) inevitable 3) incomplete 4) threateneed 5) septic
MTX moa
folic acid antagnoist, disrupts rapidly dividing cells
How do you manage threatened abortion?
Expectant management until 1 of the following 1) symptom resolution or 2) progression to incomplete, inevitable or missed abortion
How do you manage inevitable, incomplete or missed abortion?
If hemodynamically unstable, heavy bleeding: surgical evacuation (D&C). If hemodynamically stable with mild bleeding: expectant management, prostaglandins, or surgical evacauation
How do you manage septic abortions?
Blood and endometrial cultures, broad spectrum abx, surgical evacuation of uterine contents
Normal result in NST
(t’s external FHR for 20-40 mins). Normal result is: Reactive meaning >= 2 accelerations. Abnormal results: If less than 2 (non-reactive) or recurrent variable or late decerations.
How often should NSTs be practiced in third-trimester pregnancies that require ongoing antenal surveillance
Weekly
Most common sx of appendicitis in pregnancy
right LQ pain. Depending on GA, the pain can be displaced upward by the gravid uterus. May or may not have fever. Elevated white count is also present in pregnancy so is not necessarily indicative of pregnancy
When is anti-D administration indicated
In unsensitized Rh negative women at 28 weeks or within 72 hours of any procedure or incident in which there could be feto-maternal blood mixing (amniocentesis, CVS, 72 hours of a spontaneous, threatened or induced abortion), 2nd/third trimster bleeding, external cephalic version, abodminal trauma, ectopic pregnancy, hyadtidiform molar pregnancy
Risk factors for hyperemesis gravidarum
Hyperemesis gravidarum in prior pregnancy, multifetal gestation, gestational trophoblastic disease
Gestational trophoblastic disease is caused by?
Abnormal trophoblastic proliferation, resulting in an abnormal placenta that can be seen on U/S. A/w bilateral ovarian enlargement secondary to elevated bHCG induced hyperstimulation and ovarian cyst formation (Theca lutein cysts)
Clinical presentation of molar pregnancy
1) Uterinze size > gestational size 2) abnormal bleeding +/- passage of hydropic tissue 3) theca lutein ovarian cysts 4) hyperemesis gravidarum 5) abnormally high beta HCG levels for GA 6) hyperthyroidism
What does HELLP stand for?
Hemolysis, elevated liver enzymes and low platelet count
When is surgical management preferred in patient with inevitable abortion?
Low hg, or excessive bleeding
Early sign of mag sulftate toxicity?
Depressed deep tendon reflexes
What should you do if you suspect mg sulfate toxicity?
D/c mag and start calcium gluconate
Pathophysiology of abruptio placenta
Poor perfusion of the placenta => disrupts vascular integrity => results in hemorrhage of the decidua basalis => premature separation of the placenta from the uterus
Agents of choice for chronic htn
Labetalol (non selective beta blocker), nifedipine (calcicum channel blocker), methyldopa (alpha 2 adrenergic agonist)
Abnormal proteinuria in PEC is defined as
> 300mg/24 hours = 3+ on urine dipstick
What is the importance of human placental lactogen? How does it work?
Produced by the placenta. Serum levels decrease after the expulsion of the placenta. Insulin antagonist that promotes insulin resistance in the mother as well as lipolysis, thereby enhancing delivery of fatty acids and glucose to the fetus.
How does prolactin cause amenorrhea
Elevated prolactin suppresses GnRH release, therefore, supressing FSH and Lh which is required for ovulation
After diagnosis of IUFD, what should be drawn?
Coagulation prifle to detect incipient DIC. Retention fo a dead fetus can cause chronic consumptic coagulopathy
What abx should be avoided in treating UTIs/acute cystitis in pregnancy?
Avoid aminoglycosides in all trimesters, avoid bactrim in 1st and 3rd trimesters. Avoid fluoroquinolones in 1st trimester.
What is the management for asymtpomatic bacteriuria and acute cystitis in pregnancy?
1) nitrofurantoin for 5-7 days or amoxiciliin or augmentin for 3-7 days or fosfomycin as single dose
Screening for UTI is usually done at
12-16 weeks
Treatment for acute pyelonephritis
Flank pain, CVA tenderness, N/V, fever. May or may not have cystitis sx (urinary frequency, urinary urgency,dysuria). Admit and give IV antibx. Switch to oral meds after afebrile for 24 hours. Avoid aminoglycosides unless other agents can’t be used.
Acute fatty liver of pregnancy sx/signs
Similar to HELLP but also has leukocytosis, hypoglycemia and AKI
Fetal hydantoin syndrome
Most commonly associated meds include phentyoin and carbamazepine. Small size, midfacial hypoplasia, microcephaly, cleft lip and palate, digital hypoplasia, hirsutism and developmental delay
Pathophysiology of PCOS
Abnormal GnrH release leading to increased LH and insufficient FSH. Increased LH leads to excess androgen production by ovarian theca cells resulting in hirsutism, male escutcheon, acne and androgenic alopecia.
Intrahepatic cholestasis of pregnancy manifests as
Generalized pruritus, hyperbilirubinemia, and transaminitis due to elevation of serum bile acid and conentration from impaired bile acid flow.
Pathophysiology of HELLP
Abnormal placentation => systemic inflammation => activation of coagulation system/complement cascade => circulating platelets consumed, microangiopathic hemolytic anemia =>this is particularly bad for the liver = causes liver swelling, distenstion of liver capsule, transaminatis. Half of womenw ith HELLP => DIC
Tx for HELLP
Immediately delivery in >=34 weeks gestation or with deteriorating maternal/fetal status. Vaginal delivery is preferred if cervix is favorable or if the woman is in labor, fetus is vertex and otherwise clinical status is stable
Lochia
Vaginal discharge after birth
Changes in lochia
Lochia rubra => after 3-4 days lochia serosa (color becomes pale) => lochia alba (white or yellow)
If lochia is malodorous, suspect?
Endometritis
What are the target glucose levels for gestational DM?
Fasting
What is the tx for gestational DM?
1st line: dietary modifications 2nd line: insulin, oral agents like glyburide, metformin
When do you screen for gestational DM?
24-28 weeks. If woman is at high risk (obesity or hx of GDM), then screen earlier in pregnancy.
Arrest of labor in the first stage is diagnosed when
dilation is >=6cm with ruptured membranes and 1 of the following: 1) no cervical change for >=4 hours despite adequate contractions or 2) no cervical change for >= 6 hours with inadequate contractions
Misoprostol
Synthetic prostaglandin used with mifepristone to terminate pregnancies for
Indications for GBS prophylaxis when GBS status is unknown
Delivery at =18hrs, GBS bacteriuria in any concentration during pregnancy, prior hx of delivery of infant with GBS sepsis
Prolactin is stimulated / inhibited by?
Stimulated by TRH and serotonin. Inhibited by dopamine.
How does hypothryoidism cause hyperprolactinemia
Hypothyroidism => Increased TRH and TSH => inhibits prolactin
Differential dx of antepartum hemorrhage
1) normal labor - intermittent pain with contractions, small amount of blood tinged-mucus 2) placental abruption - sudden onset vaginal bleeding, abdominal pain, hypertonic/ tender uterus 3) placenta previa - low lying placenta, painless vaginal bleeding 4) uterine rupture - sudden-onset vaginal bleeding, constant abdominal pain, cessation of uterine contractions, palpable fetal hearts 5) vasa previa - painless vaginal bleeding that occurs on rupture of membranes, fetal deterioration (sinusoidal tracing)
Vasa previa
Rare condition in which the fetal vessels transverse the fetal membranes across the lower uterus between the fetus and the internal cervical os. Here, the fetal vessels are vulnerable to tearing during contractions or AROM. Fetus is at significant risk for death by exsanguination. Maternal VS and abdominal exam are generally unchanged as bleeding originates from the fetus.
Gold standard for prenatal dx of vasa previa
antenatal abdominal and vaginal doppler U/S. When recognized, offer C section before onset of labor
Endometritis sx
Fever, uterine tenderness, foul smelling lochia and leukocytosis. Most common cause of puerperal fever on the 2nd or 3rd PPD
Endometritis is caused by
Polymicrobial infection (gram +, gram -, aerobic and anaeraobic)
Tx for endometritis
IV clindamycin + IV gentamicin
Risk factors for cervical insufficiency
LEEP, cone biopsy procedures, hx of maternal obstetrical trauma, DES exposure, multiple gestation. Previous hx of pret-term or second trimester pregnancy
cervix length less than what mm at 23-28 weeks is considered short?
25mm
What is placenta accreta
When the villi implant into the myometrium instead of the decidua
Normal bladder capacity and PVR
400-600ml, PVR of
First line tocolytics
beta adrenergic receptor agonists, calcium channel blockers, NSAIDS
Progesterone supplementation recommended when?
16-36 weeks with singleton pregnancy and hx of preterm births
Oral glucose tolerance testing should be done
24-28 weeks. If woman is at high risk (obesity or hx of GDM), then screen earlier in pregnancy.
Common approach to OGTT?
50g OGTT 1 hour followed by confirmation with a 3 hour 100g OGTT
When is anti-D given
At 28 weeks and at any other times during the pregnancy that it may be indicated (CVS, amniotcentisis, external cephalic version) and within 72 hours of delivery
What dose of rhogam do you know to give?
Kleihauer-Betke test. RBCs from maternal circulation is fixed on a slide. Exposed to acidic solution. Maternal RBCs lyse and become ghost cells. Fetal Hb remains stable. Dose of anti-d calculated by % of fetal Hg remaining.
Spontaneous abortion defn
Unintended loss of fetus/embryo at
What are the 1st, 2nd, 3rd line anti-hypertensives used in pregnancy
1st line (safe) - methyoldopa, beta blockers (labetolol), hydralazine, calcium channel blockers (nifedipine). 2nd line- thiazide diuretics, clonidine. CONTRAINDICATED - ace inhibitors, ARBs, aldosterone blockers, direct renin inhibiters, furosemide
What is pseudocyesis
Rare psychiatric disorder in which desire to be pregnant causes hormonal changes to show signs/sx of early pregnancy including amenorrhea, breast tenderness, morning sickness, weight gain, etc but u/s shows normal endometrial stripe
Cell free fetal DNA testing can be done when fetus GA?
> =10 weeks
When can you do CVS and amniocentesis
CVS = 10-12 weeks, amnio = 15-20 weeks
Uterine rupture presentation
intense abdominal pain, vaginal bleeding. Loss of fetal station is a red flag for uterine rupture. STAT C SECTION before mom exsanguinates to death. Also bad for baby
Risk factors of uterine rupture
Pre-existing uterine scar from section or abdominal trauma.
Amniotic fluid embolism
Cardiorespiratory failure. Rare. Presentions with hypotension, DIC, during labor or immediately post partum
Antibiotic use in pregnancy - acyclovir? cipro? Erythromycin?doxyclycine? Fluconazole
Acyclovir - benefits of treating HSV outweight risks; Cipro-teratogenic; erythyromycin - doesn’t cross the placenta; doxycycline - bad for bones/teeth of fetus; Fluconazole - safe for use in pregnancy
Tx of choice for bacterial vaginosis in pregnant and non pregnant women
Oral metronidazle 500mg BID for 7 days
Hyperandrogenism during pregnancy is usually caused by?
1) Luteomas 2) Theca lutein cysts 3) Krukenberg tumor
Are luteomas benign?
Yes
Patients with luteomas can experience? What can happen to the fetus?
New onset hirsuitism and acne due to increased levels of testosterone, androstenedione, and dihydrotestosterone. High risk of virilization.
Management of luteomas
Ultrasound monitoring - they appear as solid ovarian masses (large lutein cells) typically 6-10mm in diameter and bilateral in half of patients. Masses and sx typically regress after pregnancy
Theca lutein cysts arise due to?
High beta hcg levels, such as in molar pregnancy or multiple gestation. They are seen as bilateral ovarian cysts on U/S. Regress spontaneously after delivery. They are low risk.
Steroids are effective at what stage of the pregnancy in accelerating lung maturity
24-34 weeks.
Normal AFI
> 5 and
What is the management of abnormal pap smears in pregnant women
Women with HGSIL and CIN 2 or 3 during pregnancy show that these regress after pregnancy. If HGSIL pap => colposcopy. If not normal => biopsy. If CIN 2 or 3 => cytology and biopsy every 12 weeks. If colposcopy is normal => repeat pap and colpscopy after delivery.
Why are abnormal quadruple screening results like reliable in multiple gestation?
produce more m-AFP, other markers are averaged.
Increased MSAFP levels are a/w
neural tube defects and abdominal wall defects
What are the tests for all pregnant patients
Cervical cytology (at it fits with patient’s routine screening), rhesus type and screen, hematocrit/hg/mcv, rubella immunity, varicella immunity, hep b antigen, urine culture, syphillis testing, chlamydia testing, HIV, influenza, offer genetic screening for cystic fibrosis, offer down syndrome testing.
What are the additional tests for high risk patients
thyroid function ONLY if symptomatic, personal or family hx of dysfunction or associated condition (Eg, diabetes), TB for at-risk patients, toxoplasmosis serology for at risk patients, Hg electrophoresis for patients with high risk ethnic background or MCV
Liver disorders unique to pregnancy
Intrahepatic cholestasis of pregnancy, HELLP, AFLP
Presentation and lab abnormalities of ICP
Functional disorder of bile formation => intense pruritus especially on palms and soles that worses at night, elevated bile acids/elevated levels of liver aminotransferases, diagnosis of exclusion.
Presentation and lab abnormalities of AFLP
Malaise, rUQ pain, N/V, sequeelae of liver failure. Hypoglycemia, mildly elevated LFTs, elevated bilirubin, possible DIC
what happens to thyroid function T4 levels and TSH levels.
Pregnancy - high metabolic state with increased in thyroid hormone, resulting in increase T4 and T3 concentraions. Thyroid hormone production stimulated in first trimester due to rising levels of beta hcg which has same alpha subunit as TSH. Meanwhile, increased estrogen leads to more TBG rproduction which minds thryoid hormone in blood. Net effect, slight increase in free T4 and T3 despite significant increase in total thyroid hormone levels. Due to elevated thyrhoid hormone production => decrease in TSH.
Vaccines not recommended during pregnancy
In gneral, live vaccines such as MMR immediately before or during pregnancy. HPV, MMR, small pox, varicella, live attenuated intranasal influenza vaccines
What are the recommendations for evaluation of ASC-US?
for women 21-24 ASC-US or LSIL = repeat pap in 1 year. Colposcopy is not performed unless ASC for 3 consecutive years. Colposcopy is recommended for any ASC-H, atypical glandular cells, or high-grade squamous intraepithelial lesion. For woman over 25, HPV testing is recommended. if positive, colposcopy. If negative, repeate pap and HPV test in 3 years.
UTI abx in pregnancy. Recommended and contraindicated
1) nitrofurantoin, amoxicillin, amoxicillin-clavunate, cephalexin 2) tetracyclines, fluoroquinolines, bactrim
Why are fluoroquinolones and bactrim contraindicated in pregnancy
Fluoroquinolones = due to potential association with bone deformities and arthopathy; bactrim = contraindicated in first trimester because it interferes with folic acid metabolism. In third trimetester, increases risk of kernicterus
Indications for prophylactic anti-D immune globulin administration for unsensitized Rh negative pregnant patient
28-82 weeks, within 72 hours of delivery of rh+ infnant or spontaneous, threatened, induced abortion, ectopic pregnancy, hyatidiform molar pregnancy, CVS/amnio, abdominal trauma, 2nd an 3rd trimester bleeding, external cephail version.
