OB

Question 1

Diagnostic criteria for HTN in pregnancy, office and ambulatory.

Answer 1

Office:
SBP ≥ 140 or DBP ≥ 90mmHg
Ambulatory BP monitor:
SBP ≥ 135 or DBP ≥ 85mmHg

Question 2

Severe hypertension in pregnancy

Answer 2

SBP ≥ 160 or DBP ≥ 110 mmHg

Question 3

DBP target for hypertension in pregnancy

Answer 3

DBP < 85 mmHg

Question 4

Symptoms and management of Mg Sulfate toxicity

Answer 4

– Symptoms: respiratory suppression, bradycardia, hypotension, reduced GCS
– Monitoring: decreased reflexes, decreased urine output, NOT Mg levels
– Treatment: stop Mg, calcium gluconate, dialysis

Question 5

Fetal complications of warfarin in first and second trimester

Answer 5

– First trimester: warfarin embryopathy (mid facial and limb hypoplasia and stippled bone)
Second/third trimesters: CNS malformations, microcephaly, and optic atropy

Question 6

Which oral hyperglycemics are safe UNTIL pregnancy?

Answer 6

Metformin and Glyburide safe in pre-conception. STOP when pregnant and switch to insulin.

if on other oral antihyperglycemic agents, switch to insulin prior to conception

*If pt is refusing insulin, can use Metformin and Glyburide in pregnancy but does cross placenta (so does Insulin). Also safe in breastfeeding

Question 7

Blood glucose targets in pregnancy?

Answer 7

Fasting <5.3
1h post-prandial <7.8
2h post-prandial <6.7

Question 8

Cut offs for 50g 1hr OGCT in pregnancy?

Answer 8

> =11.1 GDM diagnosed
7.8-11.1 Borderline – move to OGTT
<=7.8 Normal

Question 9

Cut offs for 75g 2hr OGTT in pregnancy?

Answer 9

Cutoff if used as 2nd step (e.g. after borderline 50g)
FPG ≧5.3
1hr ≧10.6
2hr ≧9.0

Question 10

When to screen for GDM?

Answer 10

24-28 weeks

Question 11

Plt threshold for delivery (vaginal, c, neuroaxial) in ITP and pregnancy?

Answer 11

Vaginal delivery >30
C-section >50
Neuraxial anesthesia >80

Question 12

Plt threshold for delivery (vaginal, c, neuroaxial) in HELLP/Preeclampsia and pregnancy?

Answer 12

<20 transfuse all
<50 +C section–> transfuse
>50 – transfuse if actively hemorrhaging or rapidly falling counts with other coagulopathy

Question 13

Changes to PFTs in pregnancy

Answer 13

1. No change in TLC
2. Increased tidal volume
3. Increased Inspiratory Volume
4. Decreased FRC, ERV
5. No change in vital capacity

Question 14

3 antihypertensives to avoid in pregnancy?

Answer 14

1. ACE/ARB
2. Atenolol
3. Prazosin

Question 15

RFs for pre-eclampsia in pregnancy? Hint: Split into Epidemiological, maternal and fetal

Answer 15

Epidemiological

• First pregnancy
• New partner or IVF
• Family history (OR 6)
• Age < 20 or > 35

Maternal

• Previous pre-eclampsia
• Chronic HTN, Diabetes, CK, obesity
• Auto-immune disorders (SLE, APLA)

Fetal

• Multiple gestation
• Hydrops fetalis
• Molar pregnancy

Question 16

Who needs ASA for pre-clampsia prevention?

Answer 16

• Previous pre-eclampsia
• Chronic hypertension
• Type 1 or 2 diabete
• CKD
• SLE
• APLA syndrome
• multiple gestation
• Two or more minor factors (ex. Nulliparous, Age >40, BMI>30, IVF…)

Give 81-162mg daily, start before 16wks and continue until 36 weeks.

Question 17

If you suspect DVT in pregnancy, what is your approach to imaging and treatment?

Answer 17

1. If you suspect DVT–> anticoagulate on spec
2. Perform bilateral Dopplers, if you suspect isolated iliac vein and doppler negative, get MR
3. If ultrasound is negative, REPEAT in 7 days!

Question 18

If you suspect PE in pregnancy, what is your approach to imaging and treatment?

Answer 18

1. If you suspect PE–> anticoagulate on spec
2. Perform bilateral Dopplers, if negative…
3. CXR first then V/Q
4. If non diagnostic:
   Low pre-test prob–> Perform serial dopplers
   High pre-test prob–> Spiral CTA

Question 19

What is the upper limit of radiation you tolerate in pregnancy?

Answer 19

<5 rad (or 50 milligray)

For reference:
Maternal radiation: CTPA <0.5 rads, VQ 0.007-0.03 rads, CXR 0.005 rads

Question 20

How much folate is required pre-pregnancy? When do you start and how long do you continue?

Answer 20

Folate 1 mg for 3 months pre- and 3 months post-conception

Question 21

In DM1 patients, what endocrinopathy should you screen for in the post-partum period?

Answer 21

Post-partum thyroiditis

Question 22

In patients with Gestational DM, when should you screen for diabetes post-partum? How do you screen?

Answer 22

75g OGTT at 6 weeks – 6 months postpartum to rule out T2DM

50% will have GDM in subsequent pregnancies;
20% of women will develop T2DM in 10 years

Question 23

How do you treat cholestatis of pregnancy?

Answer 23

Urso!

Question 24

How to treat ITP in Pregnancy?

Answer 24

Prednisone and IVIG

Question 25

How do you treat CAP in pregnancy?

Answer 25

Macrolide or Beta-lactam
Levo- questionable data

NO sulfa-kernicterus
NO Tetracycline- teeth staining and bone formation issues.

Question 26

Which 6 vaccines are fine to give in pregnancy?

Answer 26

1. Hepatitis B
2. Hepatitis A
3. Influenza
4. Tdap (give to all 27-32 weeks)
5. Meningococcus
6. Pneumococcus

Question 27

Which 5 vaccines are contraindicated in pregnancy?

Answer 27

1. Yellow Fever
2. MMR
3. Nasal Influenza
4. Rabies
5. Varicella

Question 28

Pre- conception doses of folate for low-risk, moderate risk and high-risk?

Answer 28

• Low risk (0.4mg daily, in multivitamin)
• Moderate risk (1mg daily): family history of NTD, maternal type 1 or 2 diabetes, anti-epileptic drugs, GI malabsorption disorders
• High risk (4mg daily): personal history of NTD (maternal or paternal), previous pregnancy with NTD

Question 29

Which liver enzymes go up and down in pregnancy?

Answer 29

Goes Up:
ALP made by the placenta, normally elevated 2nd, 3rd trimester

No change:
AST, ALT
INR
LDH

Down:
GGT (?)
Albumin, Protein (dilutional) Bilirubin
If concerned about cholestasis – check BILE ACID LEVEL (not covered in ON by OHIP)