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R3 Orals > OB > Flashcards

OB Flashcards

1
Q

Gestational age of PTL

A

20w - 36w6d

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2
Q

What is the leading cause of neonatal morbidity?

A

PTD

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3
Q

If a patient presents in PTL, what is the chance that she will have a PTD within 7 days?

A

10%

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4
Q

What are some risk factors for PTB?

A 
h/o
short CXL
?h/o LEEP or D&C
VB
UTI
STI
peridontal dz
low BMI
smoking
drugs
short interval pregnancy
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5
Q

If a patient has a h/o PTD, how much is her risk of a subsequent PTD increased?

A

1.5 - 2 fold

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6
Q

What is the definition of a short cervix?

A

<25mm (can intervene at <24w)

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7
Q

What is the definition of a short interval pregnancy?

A

<6 months, recommended to wait 18 months in between

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8
Q

What is fetal fibronectin?

A

chemical in the adhesion between the placenta and the uterine decidua

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9
Q

How is CXL measured?

A

TVUS, not too much pressure (falsely long), shortest of 3 measurements

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10
Q

When is use of FFN and CXL appropriate?

A

Only when patient has acute symptoms

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11
Q

When is tocolysis appropriate?

A

Use up to 48h to get BMZ and mag for FNP on board, only up to 34w

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12
Q

What are contraindications to tocolysis?

A 
IUFD
lethal anomaly
NR-FHT
severe PreE/eclampsia
PPROM
Hemodynamic instability
Chorio
Abruption
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13
Q

How does magnesium act as a tocolytic?

A

Blocks calcium to inhibit uterine contractility

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14
Q

When should nifedipine be used for tocolysis?

A

NOT with Mag, so after 32w. (again blocks Ca, blocks contractility)

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15
Q

When should indocin be used for tocolysis?

A

Prior to 32 weeks

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16
Q

What are the doses of steroids for lung maturity?

A

Metamethasone 12 mg q24h x2

Dexamethasone 6mg q12h x4

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17
Q

When is a standard dose of steroids indicated?

A

24-34w when delivery is anticipated within 7 days

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18
Q

What are the benefits of steroids?

A

decreased respiratory distress
decreased intracranial hemorrhage
decreased NEC
decreased death

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19
Q

When are late preterm steroids indicated?

A

34-36w when the patient has not previously received steroids. shown to decreased respiratory distress

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20
Q

When is a theoretical risk of late preterm steroids?

A

neonatal hypoglycemia

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21
Q

When are “rescue” steroids indicated?

A

24-34w if first course was 14+ days prior (can consider at 7 days)

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22
Q

Are rescue steroids indicated in PPROM?

A

There is insufficient evidence to support this

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23
Q

When is magnesium for fetal neuroprotection indicated?

A

<32w

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24
Q

What is the benefit of magnesium for FNP?

A

Decreased CP and death

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25
Q

When should vaginal progesterone be offered to a patient?

A

If they have a h/o PTD, start at 16-24w

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26
Q

What is a hx indicated cerclage and when should it be placed?

A

h/o 2T loss or h/o cerclage. Place at 13-14w

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27
Q

What is a US indicated cerclage and when should it be placed?

A

h/o PTB <34w AND CXL <25mm. Place at <24w

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28
Q

Should cerclages be used in twins?

A

No! increases chance of PTD x2

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29
Q

In a patient with a h/o PTD, when and how often should CLX be measured?

A

q2w from 16-23w

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30
Q

What are the doses of progesterone to prevent PTL?

A

Vaginal 200mg nightly

IM 250mg weekly 16w-36w

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31
Q

How does cerclage decrease you chance of PTD?

A

Decreases delivery before 35w by 30%

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32
Q

How does PIH affect lifetime disk of cardivascular disease?

A

Increase x5

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33
Q

What percentage of pregnancies have PreE?

A

2-8%

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34
Q

What are RF for PIH?

A 
Nulliparity
Twins
H/o
cHTN
T2DM/gDM
Thrombphilia
Lupus
BMI>30
APAS
AMA
CKD
ART
OSA
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35
Q

What percentage of gHTN go on to develop PreE?

A

50% (esp if dx before 32w)

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36
Q

How is proteinuria defined?

A

P:C 0.3
24h urine protein 300g
If no other labs, urine dip with 2+ protein

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37
Q

What is the pattern of LFT’s in PreE?

A

AST>ALT

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38
Q

What does PreE put you at risk of?

A 
MI
Pulmonary edema
Stroke
ARDs
Renal failure
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39
Q

What value of LDH is concerning for HELLP?

A

LDH >600

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40
Q

How much are PLT expected to drop a day in HELLP? When is the nadir?

A

PLT drop 40% a day, nadir at 23h PP, if still dropping on PPD#4- not likely due to HELLP

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41
Q

What percentage of HELLP occur in PP period?

A

30%

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42
Q

What percentage of HELLP won’t have underlying HTN or proteinuria?

A

15%

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43
Q

How does HELLP normally present?

A

90% present with RUQ/malaise

50% present with only n/v

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44
Q

What does PRES stand for and how does it present?

A

Posterior Reversible Encephalopathy syndrome, presents as vision loss/deficit, HA, AMS

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45
Q

How is PRES shown on MRI?

A

vasogenic edema, hyperintensities on posterior brain

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46
Q

What are some markers of early onset PreE?

A

sFlt-1 and PIGF (although neither is sensitive or specific)

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47
Q

What can we do to prevent PIH in pregnancy?

A

Start 81mg ASA (optimally by 16w) can start anytime between 12-28w

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48
Q

What is the mechanism of ASA?

A

inhibits thromboxane A2

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49
Q

How does death occur in eclampsia?

A

hypoxia, trauma, aspiration PNA

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50
Q

When is a seizure not likely d/t eclampsia?

A

h/o seixure d/o, if starts 48-72h PP, if happens when already on mag

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51
Q

What long term deficits do patients with eclampsia have?

A

None! However will show up as white matter loss on MRI

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52
Q

How is eclampsia normally preceded?

A

Occipital/frontal HA
Blurred vision
Photophobia
AMS

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53
Q

What percentage of eclamptics won’t have classic PreE?

A

20-38%

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54
Q

What is the chance of seizing if not on mag?

A

w/o SF: 1.9%

w/ SF: 3.2%

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55
Q

What is the therapeutic range of Mag?

A

4.8-9.6 mg/dL

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56
Q

What is the number needed to treat with magnesium for symptomatic severe pre-eclamptics?

A

36!

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57
Q

What are the mag toxicities and at what level do they occur?

A

loss of DTR’s >9
respiratory paralysis >12
cardiac arrest >30

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58
Q

What are contraindications to mag?

A

Myasthenia gravis
Hypocalcemia
Renal failure
MI

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59
Q

What is the onset of hydralazine and why?

A

10-20 minutes, must be metabolized after attachment to vessel wall

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60
Q

What is the onset of IV labetalol?

A

1-2 minutes

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61
Q

What is the onset of PO nifed?

A

5-10 minutes

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62
Q

Max dose of PO labetalol in one day?

A

2400mg

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63
Q

Max dose of IV labetalol in one day?

A

300mg

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64
Q

Max dose of IV hydral in one day?

A

20mg

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65
Q

Max dose of PO nifed in one day?

A

180 mg

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66
Q

What is the normal physiology in PP period in terms of BP?

A

extravascular fluid goes intravascularly, increase in BP normal

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67
Q

What is the proposed mechanism of how NSAIDs can raise BP?

A

NSAIDs block PG which normally cause vasodilation, so potentially could block vasodilation

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68
Q

Why don’t we use methyldopa in PP period?

A

potentially can exacerbate PP depression

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69
Q

What BP do we start anti-HTNives in PP period?

A

150/100

70
Q

cHTN affects what percentage of pregnancies?

A

1%

71
Q

When does the SVR nadir in pregnancy?

A

16-18 weeks, diastolic drops more than systolic

72
Q

What percentage of cHTN will develop PreE?

A

20-50%

73
Q

What are signs a cHTN developed PreE?

A

sudden increase in BP or increase in proteinuria, decreasing PLT is unique to PreE; sometime Uric Acid can be helpful!

74
Q

What is the relative risk of perinatal mortality when comparing cHTN w/o PreE to cHTN w/ si PreE?

A

3.6

75
Q

How do ACE/ARBs affect pregnancy?

A

fetopathic, cause malformations in first tri, esp in women who have used these >4 years

76
Q

Why is it important not to tank the BP in pregnant women?

A

Because the placenta does not auto-regulate blood flow

77
Q

What are some maternal risks of cHTN?

A 
Stroke
Pulmonary edema
Renal failue
gDM (maybe confounded)
C/s (1.8 fold)
PPH (2x)
78
Q

What are some fetal risks of cHTN?

A 
low birth weight
PTD (medically indicated)
IUGR (2x)
Mortality (increased by 2-4x)
Abruption
Congenital anomalies
79
Q

What congenital anomalies are associated with cHTN?

A

Heart defects
Hypospadius
Esophageal atresia

80
Q

When is delivery indicated for cHTN?

A

without medications: 38-39w

with medications: 37-39w

81
Q

What is thrombocytopenia of pregnancy?

A

PLT <150

82
Q

What percentage of women are affected by thrombocytopenia of pregnancy?

A

7-12%

83
Q

How does thrombocytopenia of pregnancy present?

A 
Petechiae
Ecchymosis
Epistaxis
Gingival bleeding
AUB (heavy or intermenstrual)
84
Q

What percentage of thrombocytopenia of pregnancy are due to gestational thrombocytopenia?

A

80%

85
Q

What percentage of women will have gestational thrombocytopenia?

A

5-10%

86
Q

When does gestational thrombocytopenia normally present?

A

2nd or 3rd trimester

87
Q

What level of PLT is usually associated with gestational thrombocytopenia?

A

PLT>75

88
Q

What symptoms do women with gestational thrombocytopenia have?

A

None, they are normally asymptomatic

89
Q

How long does it take for PLT to return to normal in a woman with gestational thrombocytopenia?

A

Usually 2-3 months PP

90
Q

What percentage of thrombocytopenia of pregnancy is due to PIH?

A

5-20%

91
Q

If a pregnant woman’s PLT<100, what is the most likely dx?

A

ITP, likely not gestational if <100

92
Q

What is fetal-neonatal alloimmunie thrombocytopenia?

A

Like the PLT equivalent of Rh dz, however can occur in G1. Maternal immune system attacks di-allele antigen on PLT causing destruction of fetal PLT

93
Q

What level of fetal PLT necessitates CS?

A

Fetal PLT<50

94
Q

What percentage of fetuses of mothers with ITP will have thrombocytopenia and why?

A

25% due to IgG crossing placenta

95
Q

When is a PLT transfusion indicated?

A

pre-operatively if PLT<50 or if in DIC (although consumptive and will drop PLT quickly)

96
Q

What level of PLT in ITP warrants treatment?

A

ITP when PLT <30

97
Q

What is the treatment for ITP when PLT are low?

A

Prednisone (0.5-2 mg/kg/day) although normally 10-20mg daily x 21 days, then taper
Can use IVIG (1g/kg) in refractory cases

98
Q

What is contraindicated during L&D in patients with ITP?

A

operative delivery or FSE d/t increased risk of fetal thrombocytopenia and subsequent hemorrhage

99
Q

How much more likely is a pregnant women to get a DVT vs a non-pregnant woman?

A

4-5 times more likely

100
Q

Which layer of the uterus is important in causing alterations in the clotting pathway?

A

the decidual layer

101
Q

What is the incidence of DVT’s in pregnant women?

A

0.5-2/1,000

102
Q

What percentage of pregnancy related deaths are due to DVT’s?

A

10%

103
Q

What percentage of DVT’s in pregnancy are due to factor V Leiden heterosygosity?

A

40%

104
Q

What percentage of DVT’s in pregnancy are due to prothrombin G202010A?

A

17%

105
Q

How much does anti-thrombin deficiency increase the risk of DVT in pregnant women?

A

25x the risk!

106
Q

Which thrombophilias need anticoagulation in the antepartum and postpartum periods?

A

Factor V Leiden
prothrombin 20210A
Anti-thrombin deficiency

107
Q

Who needs a thrombophilia workup?

A

person h/o DVT or high risk first degree relative

108
Q

Which tests should be done in a thrombophilia workup?

A 
Factr V Leiden
Prothrombin20210A
AT3 deficiency
Protein C and S deficiency
APAS
109
Q

Which thrombophilia should not be tested for during pregnancy and when should it be tested?

A 
Protein S (some will be bound during pregnancy making levels falsely low)
Test at least 6w after a clot, not while pregnant, on AC or on hormonal therapy
110
Q

At what risk level should someone be started on AS antenatally?

A

3% risk of DVT

111
Q

When should antenatal anticoagulation be started?

A

first trimester through 6w PP

112
Q

How to handle AC around delivery?

A

Hold 12 hours before induction (for neuraxial anesthesia)- can check aPTT to make sure it’s ok
Restart 4-6h after Vag delivery, 6-12h after CS

113
Q

When is an Rh negative woman exposed to the rh antigen?

A 
miscarriage 
ectopic
antenatal bleeding
delivery
amniocentesis
D&amp;C for missed 
ECV
114
Q

Where does rhogam come from?

A

Anti-D Ig from donated plasma

115
Q

How much is in the standard dose of rhogam and how much fetal blood will that cover?

A

300mcg, covers 30ml whole fetal blood or 15ml fetal RBC

116
Q

When should women recieve rhogam?

A

When exposed to Antigen (bleeding), at delivery and at 28w

117
Q

How long is rhogam hypothetically covering the mother for?

A

12w

118
Q

At what GA is RhD present in a fetus?

A

7w3d

119
Q

When would you give a microdose of rhogam (50 mcg)

A

SAB <12w, if >12w give 30mcg

120
Q

What is “weak D”?

A

A variant of Rh D some people have on their RBC’s

121
Q

How should “weak D” be treated?

A

treat like Rh negative in pregnancy

If donating blood treat like Rh positive

122
Q

What percentage of neonates born to Rh neg mothers will be Rh negative as well?

A

40%

123
Q

how much fetal blood can the “rosette” test detect?

A

> 2 ml fetal blood

124
Q

What is the rosette test?

A 
Put Rh-D Ig into Rh neg maternal blood. 
Will bind to Rh on fetal cells
Will clump (form rosette)
125
Q

What test comes after the rosette test and how does this work?

A

K-B after rosette, looks for percentage of fetal blood in mom’s blood by Hgb F

126
Q

What diseases may have false positive KB and why?

A

Sickle cell and some thalessemias

increased HgB F in normal maternal blood

127
Q

What percentage of pregnancies will have VB in the 3rd tri?

A

4-5%

128
Q

What is bloody show?

A

blood from sheering of small vessels in cervix, can precede labor by 72h

129
Q

What are some RF of placenta previa?

A 
Increased parity
AMA
ART
h/o termination
h/o Uterine surgery
smoking
cocaine
non-white
male fetus
130
Q

What is recommended for placenta previa?

A

pelvic rest, no orgasms

Delivery at 36-37w by CS

131
Q

What is a low lying placenta?

A

placenta within 2cm of os

132
Q

Chance of accreta in patient with previa and h/o 1,2,3,4 c/s

A

1 CS = 11%
2 CS = 40%
3 CS= 61%
4 CS = 67%

133
Q

Risk factors for placental abruption

A 
h/o
trauma
smoking
cocaine
HTN
PPROM
134
Q

How does placental abruption present?

A

80% have VB

70% have ab pn

135
Q

what is the cause of abdominal pain in abruption and what is this finding called?

A

bleeding into myometrium: Couvelaire uterus

136
Q

How much of the placenta needs to abrupt to cause a demise?

A

50%

137
Q

What is a blood marker that can predict abruption?

A

AFP > 280

138
Q

Types of vasa previa?

A

Type 1: villamentous cord insertion, vessels near os
Type 2: bi-lobed or succenturiate placenta, vessels over os
Type 3: atrophy of placenta near os, vessels at edge exposed

139
Q

How much blodd is running through spiral arteries per minute at term?

A

600cc blood per minute

140
Q

What is required for hemostasis as the placenta detaches?

A

Needs to coagulate and need to contract to help tamponade

141
Q

What is the chance of acquiring an infxn from a blood transfusion?

A

HepB: 1/200,000
HepC: 1/1.3 million
HepB: 1/2 million

142
Q

How much volume is in 1u pRBC?

A

300cc

143
Q

How much should 1u pRBC increased you hgb/hct?

A

hgb by 1 pt, hct by 3%

144
Q

what ratio of RBC:FFP:PLT should we use in obstetric hemorrhage?

A

1:1:1 (6 pack)

145
Q

When should you give cryo and why is it a good product?

A

Give cryo if fibrinogen <200

Good because it is concentrated (volume only 30cc)

146
Q

What is the blood volume of FFP?

A

250cc

147
Q

What is the blood volume of one 6-pack of PLT and how much should it increase your PLT?

A

300cc, should increase PLT 42

148
Q

What is the definition of massive transfusion protocol?

A

> 6u pRBC over 2 hours or >10u pRBC over 24h

149
Q

What are the classes of hemorrhage?

A

Class 1: 1L (15% of volume) feel dizzy
Class 2: 1.5L (25% of volume) tachycardic, orthostatic
Class 3: 2L (35% of volume) tachycardic, hypotensive
Class 4: >2.5L (>40% of volume) oliguric

150
Q

When should you consider repleting Calcium during a transfusion and why is this important?

A

after 4u pRBC, need Ca for uterus to contract and stop bleeding

151
Q

how much do you expect cryo and FFP to increase your fibrinogen

A

5-10 points

152
Q

How is sickle cell inherited?

A

Autosomal recessive

153
Q

If a patient has sickle cell in pregnancy what is she at risk of?

A 
PTL
PPROM
PP infection
IUGR
Low birth weight
SAB
Stillbirth
154
Q

What supplements do pregnant women with sickle cell need?

A

4 mg folic acid (due to increased RBC turnover)

155
Q

What is the normal treatment for sickle cell and why isn’t it used in pregnancy?

A

Hydroxyurea, it’s teratogenic

156
Q

What percentage of African Americans have Sickle cell trait?

A

50%

157
Q

How is sickle cell diagnosed?

A

HgB electrophoresis

158
Q

At what gestational ages can you do CVS and amnio?

A

CVS 10-12 weeks, amnio >15 weeks

159
Q

What qualifies as anemia in pregnancy?

A

1T: 11/33
2T: 10.5/32
3T: 11/33

160
Q

How much does blood volume and RBC mass increase in pregnancy?

A

Total blood volume expands 50%, RBC mass increased 25%

161
Q

What is the recommended daily allowance of Fe in normal pregnant lady?

A

27mg

162
Q

What is the most sensitive test for anemia of pregnancy and what is its normal value?

A

Serum ferritin, normal >10 mcg/dL

163
Q

What happens to a fetus if mom’s Hgb is below 6?

A

Abnormal fetal O2 > NR-FHT
Decreased amniotic fluid
Fital cerebral vasodilation
Fetal death

164
Q

Which is more effective? PO or IV iron

A

At days 5 and 14 IV was shown to have higher response in HgB, however at 40 days the responses were the same

165
Q

What is the daily recommended allowance of folic acid in a normal pregnant woman?

A

400 mcg/day

166
Q

Ddx for microcytic anemia

A

Iron deficiency
Thalessemia
Copper deficiency
Lead poinsoning

167
Q

Ddx for normocytic anemia

A 
Acute blood loss
Early iron def
Anemia of chronic dz
BM suppression
CKD
Autoimmune hemolytic anemia
168
Q

Ddx for macrocytic anemia

A

Folic acid deficiency
B12 deficiency
Liver dz or EtOH

169
Q

What is the pathophys of hemolytic dz of fetus/newborn?

A

IgG cross placenta to attack fetal RBC > intravscular hemolysis> dcreased oncotic pressure> extravisation of fluid and hydrops

170
Q

What are the 4 signs of fetal hydrops?

A

ascites
pericardial effusion
pleural effusion
skin edema

171
Q

How are Ab screened at first prenatal visit?

A

indirect coombs test
Known Rh+ RBC mixed with tested maternal plasma
Maternal Anti-D AB will adhere to these D+ RBCs
RBC’s are washed in Coomb’s serum (antihuman globulin) > RBC’s tht are coated will show up positive

R3 Orals (2 decks)

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