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LMCC > OB > Flashcards

OB Flashcards

1
Q

Goodell’s Sign

A

Softening of cervix at 4-6wk

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2
Q

Chadwick’s Sign

A

Bluish discolouration of cervix and vagina due to pelvic vasculature engorgement at 6wk

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3
Q

Hegar’s sign

A

Softening of cervical isthmus at 6-8wks

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4
Q

beta-hCG

A

Peptide hormone composed of alpha and beta subunits produced by placental trophoblastic cells
Maintains corpus luteum during pregnancy

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5
Q

beta hCG positive levels at…

A

9d post-conception in serum

28d after first day of LMP in urine

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6
Q

beta-hCG plasma level pattern

A

Doubles every 1.4-2d for first 4 weeks, then by 6-7wks may take 3d to double, peaks at 8-10wks then falls to plateau until delivery

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7
Q

beta-hCG levels less than expected suggest

A

Ectopic
Abortion
Inaccurate dates
May be normal

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8
Q

beta-hCG levels higher than expected suggest

A

Multiple gestation
Molar pregnancy
Trisomy 21
Inaccurate dates

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9
Q

beta-hCG rule of 10s

A

10IU = time of missed menses
100 000 IU = 10wk (peak)
10 000 IU = term

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10
Q

Transvaginal U/S finding at 5wks

A

Gestational sac

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11
Q

Transvaginal U/S finding at 6 wk

A

Fetal pole

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12
Q

Transvaginal U/S finding at 7-8wks

A

Fetal heart activity

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13
Q

Transabdominal U/S finding at 6-8wk

A

Intrauterine pregnancy visible

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14
Q

First trimester

A

1-14wks

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15
Q

Second trimester

A

14-28wks

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16
Q

Third trimester

A

28-42wks

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17
Q

Change in Hb and Hct in pregnancy

A

Decrease (physiologic anemia secondary to hemodilution)

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18
Q

Leukocyte count change in pregnancy

A

Increase but with impaired function

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19
Q

Gestational thrombocytopenia

A

Mild (plt >70 000) and asymptomatic, normalizes within 2-12wk

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20
Q

Hormone involved with delayed gastric emptying

A

Progesterone

Causes GERD, gallstones, constipation

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21
Q

Ureters and renal pelvis dilation in pregnancy

A

R>L

Secondary to progesterone induced sooth muscle relaxation and uterine enlargement

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22
Q

Renal function changes in pregnancy

A 
Increased CO --> increased GFR 
Decreased Cr (35-44mmol/L), uric acid and BUN
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23
Q

Thyroid changes in pregnancy

A

Increased total thyroxine and thyroxine binding globulin

TSH levels are normal

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24
Q

Cortisol levels in pregnancy

A

Rise throughout

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25
Q

Calcium levels in pregnancy

A

Decreased total Calcium due to decreased albumin (free ionized Ca2+ remains the same due to parathyroid hormone)

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26
Q

Folic acid

A

8-12wks preconception until end of T1
Prevent NTDs
0.4-1mg daily in all women
5mg if previous NTD, antieplieptic meds, DM or BMI > 35kg/m2

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27
Q

Naegle’s Rule of dating

A

1st day of LMP + 1yr + 7d - 3mo

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28
Q

Dates should change if T1 U/S differs by…

A

> 5d in difference from LMP due date

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29
Q

Diclectin

A

10mg doxylamine succinate with Vitamin B6
4 tabs PO daily (1 qAM, 1qlunch, 2 qhs)
Up to max of 8 tabs/d

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30
Q

OB causes associated with hyperemesis

A

Multiple gestation
GTN
HELLP Syndrome

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31
Q

Kleihauer-Betke test

A

Extent of fetomaternal hemorrhage by estimating volume of fetal blood that entered maternal circulation

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32
Q

Situations when Rhogam is given to Rh neg women

A

Routinely at 28wk GA (protection for 12wk)
Within 72h of birth of an Rh+ fetus
Invasive procedure in pregnancy (CVS, amnio)
Ectopic preg
Miscarriage or therapeutic abortion
Antepartum hemorrhage
trauma

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33
Q

Tx for Rh neg and Ab pos mom

A

Follow serial monthly Ab titres throughout pregnancy, U/S +/- serial amnios as needed

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34
Q

Fetal hydrops

A

Edema in at least 2 fetal compartments due to fetal HF secondary to anemia

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35
Q

Erythroblastosis fetalis

A

Mod-severe immune-mediated hemolytic anemia

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36
Q

Risk factors for NTD

A

GRIMM
Genetics (risk of 2nd child having NTD is 2-5%, increased from baseline risk of 0.1%)
Race: Europeans>Africans, 3x higher in hispanics
Insufficient folate and zinc
Maternal chronic dz
maternal use of antiepileptics

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37
Q

Primigravidas feel fetal mvmt at

A

18-20wks

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38
Q

Normal EFM tracing

A

Baseline: 110-160bpm
Variability: 6-25bpm (< / = 5bpm for < 40min)
Decels: None, early decels, occasional uncomplicated, variable decels
Accels (term): Spontaneous, accels of >/= 15bpm lasting 15s
Accels (preterm): accels of > / = 10bpm last 10s
Accels present with scalp stim

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39
Q

Atypical EFM tracing

A

Baseline: 100-110 or >160 for <30min to < 80min
Variability: < / = 5bpm (absent or minimal) for 40-80min
Decels: Repetitive (> / = 3) uncomplicated variable decels. Occasional late decels. Single prolonged deceleration > 2 min but < 3 min
Accels: absence with fetal scalp stimulation

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40
Q

Abnormal EFM tracing

A

Baseline: Brady <100, tachy >160 for >80min
Variability: < 5 for > 80min, sinusoidal, >/=25bpm for >10min
Decels: Repetitive (> / = 3) complicated variable decels, late decels, any prolonged decel (> / = 3)
Accels: Nearly absent

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41
Q

Biophysical profile

A

U/S assessment +/- NST
Scoring: 2 points for each if reassuring
Tone (at least one epi of limb extension followed by flexion)
Movement (3 discrete mvmts)
breathing (at least one epi of breathing lasting at least 30s)
Amniotic fluid volume (fluid pocket of 2cm in 2 axes)

LAMB 
Limb extension and flexion
AFV 
Movement 
Breathing 
8-10 = normal
6 = unequivocal
=4 = deliver
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42
Q

Daily caloric intake during pregnancy

A

100cal/d in 1st trimester
300 cal/d in 2nd and 3rd trimester
450 cal/d during lactation

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43
Q

Only nutrient for which requirements during pregnancy can’t be met by diet alone

A

Iron

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44
Q

Absolute C/I to exercise

A 
Ruptured membranes 
preterm labour 
HTN d/o of preg 
Incompetent cervix
IUGR
Multiple gestations (>3) 
Placenta previa after 28th wk 
Persistent 2nd or 3rd trimester bleeding 
Unctrolled Type 1 DM 
Uncontrolled thyroid dz 
Other srs CV, resp or systemic d/o
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45
Q

Relative C/I to exercise

A 
Previous preterm birth
Mild/mod cv or resp d/o
anemia (=100g/L)
Malnutrition or eating d/o
Twin preg after 28th wk
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46
Q

Smoking in pregnancy associated with

A 
Decreased birth weight
Placenta previa/abruption
Spontaneous abortion
Preterm labour
Stillbirth
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47
Q

Cocaine in pregnancy associated with

A

Microcephaly
Growth retardation
Prematurity
Abruptio placentae

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48
Q

Marijuana in pregnancy associated with

A

Low birth weight

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49
Q

NSAIDs in pregnancy associated with

A

Premature closure of the ductus arteriosus after 30wks GA

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50
Q

Vaccines safe in pregnancy

A 
Tetanus 
Diphtheria 
Influenza
Hep B
Pertussis
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51
Q

Vaccines recommended in pregnancy

A

Influenza

Tdap (irrespective of immunization hx) ideally btwn 27-32wks

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52
Q

Hepatitis B if maternal status unknown or positive

A

Hep B Vaccine and HBIG should be given to infant within 12h of birth with F/U doses at 1 and 6mo

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53
Q

Most common pathological etiology of obstetrical hemorrhage in T3

A

Abruptio placentae

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54
Q

Placenta previa

A

Abnormal location of placenta near, partially or completely over the internal cervical os
0.5-0.8% of all pregnancies
Painless bleeding

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55
Q

Abruptio placentae

A

Premature separation of a normally implanted placenta after 20wk GA
1-2% of all pregnancies
Painful bleeding

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56
Q

Placenta previa risk factors

A
  • Hx of placenta prevue (4-8% recurrence risk)
  • Multiparity
  • Increased maternal age
  • Multiple gestation
  • Uterine tumour (ie. fibroids) to other uterine anomalies
  • Uterine scar due to previous abortion, C/S, D&C, myomectomy
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57
Q

Abruptio placenta risk factors

A
  • Previous abruption (recurrence rate 5-16%)
  • Maternal HTN (chronic or gestational HTN in 50% of abruptions) or vascular dz
  • Cigarette smoking (>1 pack/d), excessive EtOH consumption, cocaine
  • Multiparity and/or maternal age >35yr
  • PPROM
  • Rapid decompression of a distended uterus (polyhydramnios, multiple gestation)
  • Uterine anomaly, fibroids
  • Trauma
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58
Q

Spontaneous resolution of placenta previa is likely if…

A

placenta obscures internal os by <20mm at 20wk GA

Transvaginal U/S should be repeated in third trimester

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59
Q

NIPT

A

Analyzes blood for circulating cell free fetal DNA at 9-10wk GA onwards
Highly sensitive/specific for Trisomy 21 (can also look for tri 18, 13 and some X and Y disorders)
Doesn’t screen for ONTD

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60
Q

NIPT indications

A

> 35 yo
Abnormal prenatal screen (IPS, FTS or MSS)
Past hx of fam hx of: chromosomal anomaly or genetic dz, either parent a known carrier of a genetic d/o, consanguinity, >3 spontaneous abortions

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61
Q

Amniocentesis

A

U/S guided transabdominal extraction of amniotic fluid performed as early as 15wks GA
Screens for genetic anomalies and ONTD
Assessment of fetal lung maturity (T3) via L/S ratio (lecitihin:sphingomyelin), if >2:1 RDS is less likely to occur

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62
Q

Amniocentesis indications

A

Confirmation of positive NIPT

Positive FTS/IPS

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63
Q

Chorionic villus sampling

A

Biopsy of fetal derived chorion using transabdominal needle or transcervical catheter at 10-12wk
Screens for genetic d/o (rapid karyotyping and biocehmcial assay)
Does not screen for ONTD

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64
Q

Most common cause of DIC in pregnancy

A

Abruptio placentae

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65
Q

Dx of abruptio placentae

A

Clinical

U/S not sensitive for dx abruption

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66
Q

Stable abruption <37wk GA

A

Use serial Hct to assess concealed bleeding, deliver when feetus mature or when hemorrhage dictates

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67
Q

Stable abruption >/= 37wk

A

Deliver

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68
Q

Unstable abruption

A

Deliver (vaginal if no C/I, C/S otherwise)

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69
Q

Vasa previa

A
  • Unprotected fetal vessels pass over cervical os
  • A/W velamentous insertion of cord into membranes of placenta or accessory (succenturiate) lobe
  • 1 in 500 deliveries
  • Higher in twin pregnancies
  • PAINLESS vaginal bleeding and fetal distress
  • 50% perinatal mortality, increases to 75% if membranes rupture
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70
Q

Dx of vasa previa

A

Apt test

Wright stain on blood smear

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71
Q

Apt test

A

NaOH mixed with blood
Supernatant turns pink = fetal blood
Supernatant turns yellow = maternal blood

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72
Q

Wright stain on blood smear

A

Nucleated cells indicate cord blood

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73
Q

Tx of vasa previa

A

Planned C/s at 35-36wk

If bleeding, emergency C/S

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74
Q

Preterm labour

A

20-37wks GA

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75
Q

Most important risk factor for preterm labour

A

Previous history of spontaneous PTL

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76
Q

Cervical cerclage

A

Placement of cervical sutures at level of internal os, usually at end of first trimester (usually 12-12wk) or in second trimester and removed in third trimester

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77
Q

Progesterone to prevent preterm labour

A
  • If previous PTL: 17-alphahydroxyprogesterone 250mg IM weekly from 16 - 36wks GA
  • If short cervix: 200mg daily vaginally from time of dx to 36wks GA
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78
Q

Fetal fibronectin

A

Glycoprotein in amniotic fluid and placental tissue
+ve if >50ng/mL
Done only if 24-34wks, intact membranes, <3cm dilated, establish fetal well being
C/I if : cerclage, active vaginal bleeding, vag exam or sex in last 24h
If -ve: not likely to deliver in 7-14d
If +ve: increased risk of delivery

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79
Q

Tocolysis

A

Delays delivery for at least 48h for betamethasone valerate to work or for transfer to appropriate care centre
Only to be given if live, immature fetus, intact membranes, cervical dilatation of <4cm

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80
Q

Tocolytic agents

A

Nifedipine (20mg PO loading dose followed by 20mg PO 90min later, 20mg can be continued q3-8h for 72h or to a max of 180mg, 10mg PO q20min x 4doses)
Indomethacin = prostaglandin synthesis inhibitor, 1st line for early preterm labour (50-100mg PR loading dose followed by 50mg q6h x 8 doses for 48h)

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81
Q

Antenatal corticosteroids

A

Betamethasone valerate (12mg IM q24h x 2 doses)
Dexamethasone (6mg IM q12h x 4 doses)
Given btwn 24-36+6wks GA
Specific maternal C/I: Active TB

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82
Q

Prolonged ROM

A

> 24h elapsed btwn rupture of membranes and onset of labour

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83
Q

PPROM

A

<37wks GA and premature rupture of membranes

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84
Q

PPROM investigations

A 
Pooling
Cough test
Nitrizine (blue) 
Ferning 
U/S
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85
Q

Antibiotics in PPROM

A

Give if there are no signs of immediate labour
Increases latency and decreases chorioamniotis
Ampicillin IV + Erythro IV x 48h then Amox PO x 5d + erythro PO x 5d OR just erythro PO x 10d

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86
Q

Postterm pregnancy IOL

A

> 39wks GA in advanced maternal age

>41wks GA if vagian ldelivery not C/I

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87
Q

Fetal demise

A

Fetal death after 20wks GA

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88
Q

Obstetrical causes of DIC

A

Abruption
Gestational HTN
Fetal demise
PPH

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89
Q

DIC specific b/w

A

Plt
aPTT and PT
FDP
Fibrinogen

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90
Q

DIC tx

A 
Treat underlying cause 
Supportive
Fluids
Blood products 
FFP, plt, cryoprecipitate 
Consider anti-coagulation as VTE prophylaxis
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91
Q

IUGR

A

Estimated fetal weight <10th percentile for GA on U/S

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92
Q

TORCH infections

A 
Toxoplasmosis 
Others (ie. syphilis)
Rubella 
CMV 
HSV
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93
Q

Most important risk factor for IUGR

A

Previous IUGR

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94
Q

Symmetric/Type I IUGR

A

25-30%
Occurs early in pregnancy
* Reduced growth of both head and abdominal
* Head:Abdo ratio may be normal
* Usually a/w with congenital anomalies or TORCH infections

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95
Q

Asymmetric/Type II IUGR

A

70%
Occurs late in pregnancy
* Fetal abdo is disproportionately smaller than fetal head
* Brain is spared (Head:abdo ratio is increased)
* Usually a/w placental insufficiency
* More favourable prognosis than type I

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96
Q

Macrosomia

A

Infant weight >/=90th percentile for a particular GA or >4000g

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97
Q

U/S predictors of macrosomia

A

Polyhydramnios
Third trimester AC > 1.5cm/wk
HC/AC ratio <10th percentile
FL/AC ratio <20th percentile

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98
Q

Prophylactic C/S for macrosomia

A

EFW > 5000g in non-diabetic woman

EFW > 4500g in diabetic woman

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99
Q

Polyhydramnios

A

AFI>25cm
U/S deepest pocket >8cm
Management: mild-mod require no tx, severe should be hospitalized and consider therapeutic amnio

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100
Q

Oligohydramnios

A

AFI <5cm
U/S deepest pocket =2cm
Management: Admit, investigate, maternal hydration PO or IV, inject fluid via amnio, consider delivery

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101
Q

Med associated with oligohydramnios

A

ACEi

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102
Q

U/S frequency for multiple gestation

A

Serial U/S q2-3wk from 24wk GA to assess growth (uncomplicated didi)
Increased freq in monodi and monomono)

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103
Q

Vaginal delivery possible for twins if…

A

Twin A presents vertex

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104
Q

Time of cleavage for monoamniotic monochorionic twins

A

9-12d

105
Q

Time of cleavage for diamniotic dichorionic twins

A

0-72h

106
Q

Time of cleavage for diamnionic monochorionic twin

A

4-8d

107
Q

Twin-Twin transfusion syndrome

A

Formation of placental intertwin vascular anastomoses causing arterial blood from donor twin to pass into veins of recipient twin

108
Q

ECV

A

Has to be >36wk, singleton, unengaged presenting part, reactive NST, not in labour
If pt Rh neg, give Rhogam prior to procedure

109
Q

Criteria for vaginal breech delivery

A

Frank or complete breech, GA > 36 wk
EFW 2500-3800g based on clinical and U/S assessment
Fetal head flexed
Continuous fetal monitoring
experienced clinicians
Ability to perform emergency C/S within 30min if required

110
Q

Pre-existing HTN

A

BP >140/90 PRIOR TO 20wk GA, persisting >7wk postpartum

111
Q

Gestational HTN

A

sBP >/= 140 or dBP >/= 90 after 20wk GA without proteinuria in a previously normotensive pt
More common in primigravida pts

112
Q

Pre-eclampsia

A

Pre-existing or gestational HTN with new onset proteinuria or adverse conditions (end organ dysfunction)

113
Q

Eclampsia

A

> /=1 generalized convulsions and/or coma in setting of preeclampsia and in absence of other neuro conditions
1/3 of cases have no proteinuria or BP > 140/90 prior to seizure

114
Q

Ominous symptoms of HTN in pregnancy

A

RUQ pain
Headache
Visual disturbances

115
Q

Placental growth factor (PIGF)

A

Lab test recommended to help rule out preeclampsia, insufficient evidence to recommend its use to rule in preeclampsia

116
Q

Management of HTN

A

Labetalol 100-400mg PO BID-TID
or Nifedipine 20-60mg PO daily
or Alpha methyldopa 250-500mg PO BID-QID

117
Q

Management of severe HTN

A

Labetalol 20mg IV t hen 20-80mg IV q30min (max 300mg) then switch to oral
Nifedipine 5-10mg capsule q30min
Hydralazine 5mg IV rpt q5-10mg IV q30min or 0.5-10mg/h IV to max of 20mg IV

118
Q

Drugs to avoid to tx HTN in pregnancy

A 
ACEi 
ARBs
Diuretics 
Prazosin
Atenolol
119
Q

HELLP Syndrome

A

Hemolysis
Elevated Liver enzymes
Low Platelets

120
Q

Seizure prevention/tx

A

MgSO4: 4g IV loading dose, followed by 1g/h (2g/h for treatment)
Risk of seizure highest in first 24h postpartum (cont MgSO4 for 12-24h after delivery)

121
Q

Definitive treatment of eclampsia

A

Delivery

122
Q

Tx for T2DM in pregnancy

A

Insulin

123
Q

Targets in T2DM in pregnancy

A

FPG = 5.3mmol/L
1h post prandial PG = 7.8mmol/L
2h post prandial PG = 6.7 mmol/L
Monthly A1c

124
Q

T2DM labour

A

Induce by 38-39wks
Consider elective C/S for predicted birthweight >4500g
Monitor blood glucose q1h with pt on insulin and dextrose drip
Aim for blood glucose 3.9-7mmol/L to reduce risk of neonatal hypoglycemia

125
Q

Diabetes screening period

A

24-28wk GA

126
Q

Diabetes screening options in pregnancy

A
  1. Fasting 75g OGTT; GDM if >/=1 of FPG >/= 5.1, 1h PG >/= 10, 2h PG >/= 8.5
  2. Random non-fasting 50g OGCT; GDM if 1h PG >/= 11.1, if 7.8-11 perform fasting 75g OGTT, GDM if >/=1 of FPG >/= 5.3, 1h PG >/= 10.6, 2h PG >/= 9
127
Q

Postpartum followup for GDM

A

75g OGTT 6wk to 6mo postpartum

128
Q

Congenital anomalies a/w diabetes in pregnancy

A

2-7x increased risk of congenital anomalies due to hyperglycemia from T1DM or T2DM
**NOT in GDM b/c it develops after critical period of organogenesis

129
Q

GDM risk of progression to T2DM

A

50% in the next 20yr

130
Q

GBS screening period

A

35-37wks GA

131
Q

Risk factors for GBS

A 
GBS bacteriuria 
Previous infant with invasive GBS infection
Unkown GBS status with: 
- PTL <37wk
- ROM >/= 18h before delivery
- Intrapartum mat temp >/= 38C
Positive GBS screen at 35-37wks
132
Q

Indications for GBS abx prophylaxis

A

+ve GBS screen
GBS in urine
Previous infant with GBS
GBS unknown + one other risk factor

133
Q

Abx for GBS

A

Give 4h prior to delivery
Pen G 5 million IU IV then 2.5 million IU IV q4h until delivery
If pen allergic but not anaphylactic: Cefazolin 2g IV then 1g q8h
If anaphylactically allergic to pen: Vanco 1g IV q12h until delivery

134
Q

Tx of UTI in pregnancy

A
  • 1st line: Amoxicillin 250-500mg PO q8h x 7d
  • Alternatives: Nitrofurantoin 100mg PO BID x 7d or cephalosporins
  • Follow with monthly urine cultures (recurrence is common)
135
Q

Varicella vaccine during pregnancy

A

DO NOT administer
Live attenuated
Give VZIG if mother exposed to reduce congenital varicella syndrome

136
Q

Congenital varicella syndrome

A 
Limb aplasia
Chorioretinitis 
Cataracts 
Cutaneous scars
Cortical atrophy 
IUGR
Hydrops
137
Q

CMV implications to fetus

A

5-10% develops CNS involvement

138
Q

Rubella vaccine during pregnancy

A

DO NOT administer
Live attenuated
No specific treatment during pregnancy

139
Q

Congenital rubella syndrome

A

hearing loss, cataracts, CV lesions, MR, IUGR, hepatitis, CNS defects, osseous changes

140
Q

Syphilis treatment

A

Pen G 2.4 million U IM x 1 dose if early, 3 doses if late

Monitor VDRL monthly

141
Q

Congenital toxoplasmosis

A

Chorioretinitis, hydrocephaly, intracranial calcification, MR, microcephaly

142
Q

Highest risk of DVT in pregancy

A

Third trimester and postpartum

143
Q

Highest risk of PE in pregnancy

A

Postpartum (first 6wk)

144
Q

Management of VTE in pregnancy

A

UFH 5000IU bolus followed by 30000IU/24h infusion
Measure aPTT 6h after bolus, maintain at therapeutic level (1.5-2x normal)
LMWH can also be used
Warfarin is C/I due to potential tertaogenic effects

145
Q

Women with non-active PMHx of VTE mgmt during pregnancy

A

Unfractionated heparin regimens suggested

146
Q

Preterm

A

> /=20 - = 36+6wk GA

147
Q

Term

A

37 - 41+6wk GA

148
Q

Postterm

A

> /= 42wk GA

149
Q

Components of Bishop Score

A 
Dilatation 
Effacement
Consistency 
Position 
Station
150
Q

Most common fetal position

A

Left OA

151
Q

First stage of labour

A

0-10cm cervical dilation

152
Q

Second stage of labour

A

10cm dilation - delivery of baby

153
Q

Third stage of labour

A

Delivery of baby - delivery of placenta

154
Q

Time limit for third stage of labour before interventions required

A

30min

155
Q

Mgmt of placenta delivery

A

Oxytocin IV

156
Q

Fourth stage of labour

A

First postpartum hour

157
Q

Arteries and veins in placenta

A

2 arteries 1 vein

158
Q

Early deceleration

A

Mirrors contraction
Benign
Due to vagal response to head compression

159
Q

Variable deceleration

A

Often abrupt drop in FHR >15bpm below baseline with no effecto n baseline FHR (>15s for <2 min)
Due to cord compression or in second stage pushing with contractions

160
Q

Complicated variable decels

A

FHR drop <70bpm for >60s
Loss of variability or decrease in baseline after decel
Slow return to baseline
May be associated with fetal acidemia

161
Q

Late decels

A

Decels occuring after peak of contraction, slow return to baseline
ay cause decreased variabilty and change in baseline FHR

162
Q

pH measurement for fetal scalp blood sampling

A

> /=7.25, lactate <4.2 = normal, repeat if abnormal FHR persists
7.21-7.24, lactate 4.2-4.8 = repeat assessment in 30 min or consider delivery if rapid fall since last sample
= 7.20, lactate >4.8 = indicated fetal acidosis, delivery is indicated

163
Q

Redistribution of fetal blood flow in response to hypoxia/asphyxia

A

Increased blood flow to brain, heart, adrenals
Decreased blood flow to kidneys, lungs, gut, liver, peripheral tissues
Increase in BP

164
Q

Bishop score scoring

A

Cervix considered unfavourable if <6
Favourable if >/=6
9-13 = high likelihood of vaginal delivery

165
Q

Maternal indications for labour induction

A 
DM 
Gestational HTN >/= 37wk 
Preeclampsia 
Other maternal medical problems (ie. renal or lung dz, chronic HTN, cholestasis)
Maternal age >40
166
Q

Maternal-fetal factors for labour induction

A

Isoimmunization
PROM
Chorioamnionitis

167
Q

Cervical ripening methods

A

Prostaglandins (PGE2)
PGE1 (Misoprostol)
Foley catheter placement

168
Q

Opioid in labour management

A

Morphine in latent stage

Fentanyl in active stage/second stage

169
Q

Labour induction agent

A

Oxytocin

170
Q

Labour augmentation agent

A

Oxytocin

171
Q

4 Ps of dystocia

A

Power (leading cause)
Passenger
Passage
Psyche

172
Q

Dystocia in active phase

A

> 4h of < 0.5cm/h

173
Q

Dystocia in 2nd phase

A

> 1h with no descent during active pushing

174
Q

Brachial plexus injury, Erb’s palsy

A

C5-7

175
Q

Brachial plexus injury, Klumpke’s palsy

A

C8-T1

176
Q

Most common presentation of uterine rupture

A

Prolonged fetal bradycardia

177
Q

Placenta accreta

A

Placenta grows too deeply into uterine wall

178
Q

Placental abruption

A

Placenta detaches from uterine wall before birth

179
Q

Amniotic fluid embolus

A

Amniotic fluid debris in maternal circulation triggering an anaphylactoid immunologic response
Sudden onset resp distress, CV collapse, coagulopathy, sz in 10%

180
Q

Leading cause of maternal death in induced abortions and miscarriages

A

Amniotic fluid embolus

181
Q

Chorioamnionitis

A

Infection of chorion, amnion, amniotic fluid typically due to ascending infections by organisms of normal vaginal flora

182
Q

Predominant microorganisms in chorioamnionitis

A 
GBS 
Bacteroides 
Prevotella 
E.Coli 
Anaerobic streptococcus
183
Q

Treatment for chorioamnionitis

A 
Ampicillin 2g IV and gentamicin 2mg/kg load then 1.5mg/kg IV q8h or 5mg/kg IV q24h 
Anaerobic coverage (ie. clindamycin 900mg IV q8h) 
If at risk for endometritis, continue postpartum 
NOT and indication for immediate  delivery or C/S
184
Q

Meconium

A

More common in postdate pregnancies
Always abnormal in preterm fetus
Likely due to cord compression +/- uterine hypertonia

185
Q

Outlet forceps position

A

Head visible btwn labia in btwn contractions

186
Q

Low forceps position

A

Presenting part at station +2 or greater

187
Q

Mid-forceps position

A

Presenting part below spines but above station +2

188
Q

Vacuum extraction C/I

A

<34wk GA (<2500g)
Fetal head deflexed
Fetus requires rotation
Fetal condition (ie. bleedng d/o)

189
Q

Limits for trial of vacuum

A

After 3 pulls over 3 contractions with no progress
After 3 pop offs with no obvious cause
20min and delivery is not imminent

190
Q

1st degree laceration

A

Skin and vaginal mucosa but not underlying fascia and muscle

191
Q

2nd degree laceration

A

Fascia and muscles of perineal body but not anal sphincter

192
Q

3rd degree laceration

A

Involves anal sphincter

Single prophylactic dose of IV abx should be administered

193
Q

4th degree laceration

A

Extends through anal sphincter into rectal mucosa

Single prophylactic dose of IV abx should be administered

194
Q

Episiotomy

A

Essentially controlled 2nd degree laceration

Midline (heals better, increased risk of 3/4th degree tears) or mediolateral (less risk of tear, more painful)

195
Q

7 layers to dissect through in C/S

A 
Skin
Fat
Fascia 
Rectus abdominus 
Peritoneum 
Bladder flap 
Uterus
196
Q

Layers of rectus sheath

A

Above arcuate line: External oblique, external internal oblique, internal oblique, rectus abdominis, internal internal oblique, transversus abdominis
Below arcuate line: External oblique, internal oblique, transversus abdominis, rectus abdominis

197
Q

Name of obliterated umbilical ligament

A

Urachus

198
Q

C/I to VBAC

A

Previous classical, inverted T or unknown uterine incisions or complete transection of uterus
Hx of uterine surgery (ie. myomectomy) or previous uterine rupture
Multiple gestation
Non-vertex presentation or placenta previa
Inadequate facilities or personnel for emergency C/S

199
Q

Puerperium

A

6wk post partum

200
Q

Postpartum hemorrhage

A

Loss of >1000mL of blood within 24h of birthing process regardless of mode of delivery
Primary = within first 24h
Secondary = after 24h but within first 12wk

201
Q

4 Ts of PPH

A

Tone (most common cause)
Tissue
Thrombin (vDW = most common)
Trauma

202
Q

Avoid tone causing PPH via:

A
  1. Oxytocin 10U IM or 20-40IU in 1000cc crystalloid at 150mL/h
  2. Uterine massage
  3. Umbilical cord traction
203
Q

Carbetocin

A

Long-acting oxytocin

Consider as alternative to continuous infusion in elective C/S or vaginal deliveries with 1 risk factor for PPH

204
Q

Ergotamine/Methylergonavine maleate

A

0.25mg IM q15min up to 1.25mg
Can be given as IV bolus of 0.125mg
May exacerbate HTN (avoid in HTN pts or pts on HIV meds)

205
Q

Hemabate/Carboprost

A

Synthetic PGF-1alpha analog
250ug IM q15min to max 2mg
C/I in CV, pulmonary, renal, and hepatic dysfunction (ie. asthma)

206
Q

Misoprostol for PPH

A

600-800ug PO/SL or PR/PV

Not as effective

207
Q

TXA for PPH

A

Antifibrinolytic

1g IV

208
Q

Bakri balloon

A

Used to tamponade PPH to slow hemorrhage

209
Q

Surgical tx for intractable PPH

A

D&C
Embolization of uterine artery or internal iliac artery
laparatomy with bilateral ligation of uterine artery, ovarian artery or hypogastric artery
Hysterectomy as last option

210
Q

Retained placenta

A

Placenta undelivered after 30min postpartum

211
Q

Retained placenta mgmt

A

Brant maneuver (traction on cord while applying suprapubic pressure to avoid uterine inversion)
Oxytocin 10IU in 20mL NS into umbilical vein
Manual removal or D&C if all else fails
Cefazole 2g IV if manual removal or D&C

212
Q

Endometritis treatment

A

Clindamycin and gentamicin IV

213
Q

Mastitis

A

Cloxacillin or cephalexin
Continue nursing
If abscess develops, d/c nursing and start IV abx (oxacillin) + I&D

214
Q

Postpartum blues

A

Self limited

Resolves by 2 weeks

215
Q

Postpartum depression

A

Major depression occuring in a woman within 6mo of childbirth

216
Q

Postpartum psychosis

A

Onset of psychotic symptoms over 24-72h within first month postpartum

217
Q

Time for ovulation to resume

A

~45d for non-lactating women

3-6mo for lactating women and sometimes later

218
Q

Galactogogues

A

DA antagonists

Domperidone, metoclopramide

219
Q

Meds C/I when BF

A 
Cyclophosphamides 
Sulphonamides (in G6PD deficiency) 
Nitrofurantoin (in G6PD deficiency) 
Tetracycline 
Lithium 
Bromocriptine 
Antineoplastic and immunosuppressants
Psychotropic drugs
220
Q

Uterine rupture presentation during labour

A

Repetitive variable decels
Vaginal bleeding
Presenting part no longer palpable
Persistent pelvic pain

221
Q

Most common cause of jaundice in pregnancy

A

Viral hepatitis

Accounts for 50% of all cases

222
Q

Cholestasis of pregnancy

A 
Pruritus often worse on palms and soles at night 
RUQ pain 
Nausea 
Jaundice RARE 
High serum bile acid concentrations (>/= 40 increased risk to fetus, >/= 100 risk for fetal demise) 
Typically late 2nd or 3rd trimester 
Resolves rapidly after delivery 
Most common liver disease in pregnancy
223
Q

Cholestasis of pregnancy mgmt

A

Treat all
If suspected but labwork normal, tx empirically OR rpt lab tests weekly
Ursodeoxycholic acid 300mg BID-TID until delivery
Follow with modified BPP 2x/wk
May have increased NSTs
Deliver usually at 36 - 36+6wks
Recheck LFTs/bile acids 6-8wks after delivery

224
Q

Velamentous cord insertion

A

Umbilical cord inserts into choriamniotic membranes then travels within membranes to placenta (btwn amnion and chorion)
Exposed vessels are not protected by Wharton’s jelly

225
Q

Triple screen

A 
AFP, HCG, uE3 
Considers age-related risk for aneuploidy for each of the markers --> predicts risk for both trisomy 21 and trisomy 18 
All 3 are low in tri 18 
Tri 21 has low AFP 
Tri 13 can't be screened by low AFP
226
Q

AFP in open neural tube defects

A

Elevated

227
Q

Cervical insufficiency

A

Inability of uterine cervix to retain a pregnancy in the second trimester, in the absence of uterine contractions

228
Q

Biochemical changes a/w cervical insufficiency

A 
Decreased collagen concentration 
Increased collagen solubility
Increased interleukin 8
Increased glycosaminoglycans 
Increased tissue hydration
229
Q

First step in assessing infertility

A

Sperm analysis

230
Q

Normal sperm analysis

A

> 2mL volume
Sperm motility >50%
Sperm density >20million

231
Q

Ovulation and basal body temperature

A

Temp rises as progesterone is secreted just after ovulation
Ovulation occurs JUST BEFORE temperature rises
Sometimes there is a temperature drop during ovulation

232
Q

Cholesterol in pregnancy

A

Increases

233
Q

Albumin in pregnancy

A

Decreases due to dilution

234
Q

Fasting glucose in pregnancy

A

Drops due to increased storage of tissue glycogen, increased peripheral glucose utilization, decreased hepatic glucose production, glucose consumption by fetus

235
Q

Bicarb in pregnancy

A

Decreases as kidney excretes more to compensate for drop in CO2 (due to increase in minute ventilation)

236
Q

Contraction stress test

A

Positive indicates late decels are present on at lesat 50% of contractions

237
Q

Preventative measures for women at increased risk of eclampsia

A

ASA 75-162mg/d taken at bedtime, start BEFORE 16wks GA and continue until delivery
Calcium supplementation
No EtOH, peri-conceptual use of folate-containing multivitamin, smoking cessation

238
Q

Personal risk factors for pre-eclampsia

A 
First pregnancy
New partner
<18yo or >35yo
Hx of preeclampsia 
Family hx of preeclampsia in 1st degree relative
Black race
Obesity 
Interpreg interval <2y or >10y
239
Q

Medical risk factors for pre-eclampsia

A 
Chronic HTN  
Pre-existing diabetes 
Renal dz 
SLE 
Obesity 
Thrombophilia
Hx of migraine 
SSRI use beyond 1st trimester
240
Q

2nd trimester DS lab results

A

AFP: 25% lower than normal
hCG: 2x higher than normal

241
Q

Hormone responsible for development of milk producing alveolar cells in breast tissue during pregnancy

A

Progesterone

242
Q

Hormone produced via suckling reflex to cause contraction of smooth muscle cells in ducts to eject milk from nipple

A

Oxytocin

243
Q

Hormone responsible for stimulating alveolar cells to produce milk

A

Prolactin

High progesterone during pregnancy inhibits prolactin from inducing milk synthesis

244
Q

Hormone involved in gestational diabetes

A

Human Placental Lactogen

245
Q

BMI < 18.5 can expect to gain…

A

<12.5-18kg

246
Q

BMI 18.5-25 can expect to gain

A

11.6-16kg

247
Q

BMI >18.5 can expect to gain

A

7-11.5kg

248
Q

When to do Leopold maneuvers

A

> 30wks

249
Q

Factors a/w decreased success of VBAC:

A 
BMI >/= 40
>/=2 C/S without vaginal delivery in the past 
Previous C/S for failure to progress
Maternal age of >35yrs 
Infant weight >/= 4000g 
Requirement for induction of labour
250
Q

Length of cervix that is considered short and would require cervical cerclage

A

<25mm

251
Q

Missed abortion

A

Dead fetus with closed cervix and no passage of products

252
Q

Complete abortion

A

Products of conception are passed and cervix is closed

253
Q

Threatened abortion

A

Bleeding but closed cervix. No products of conception passed.

254
Q

Incomplete abortion

A

Bleeding, open os, products of conceptions seen at os or vault

255
Q

Antiphospholipid syndrome

A

A/w false +VDRL, prolonged PTT, thrombocytopenia

Prophylaxis with low dose ASA, LMWH

256
Q

Tx of Grave’s in pregnancy

A

Propylthiouracil in first trimester

Methimazole in 2nd and 3rd trimesters

257
Q

Magnesium toxicity signs

A

Lack of patellar reflexes –> respiratory depression –> cardiac conduction changes –> cardiac arrest

258
Q

Zika virus and pregnancy planning

A

Wait 2 mo for women

Wait 6 mo for men

LMCC (22 decks)

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