OB Flashcards
- A low PAPP-A value has a positive predictive value for ____.
- Elevations in maternal serum β-hCG and alpha-fetoprotein levels (ie, both levels are greater than 2.0 MoM) in the second trimester are associated with what pregnancy complications?
- Small-for-gestational-age fetus; IUGR, preE, PTL, abruption
- Late fetal loss, PreE, intrauterine growth restriction, preterm delivery
75g 2hr GTT for GDM Dx Values
F: 92
1hr: 180
2hr: 153
Defintion of Chorio:
Define isolated mat fever:
2 g of cefazolin in patients weighing more than __ kg.
3 g in patients weighing more than __ kg.
If allergic to a PCN and allergy not severe, can you still give ancef?
When do we redose ancef?
Azithro at the time of CD has been shown to dec rate of __.
Ampicillin is added to the endometritis treatment regimen in a patient who has not improved after 48–72 hours of gentamicin and clindamycin for coverage of ___.
Fever plus one more: Discharge, WBC, fetal tachy (no mat tachy or ut ttp anymore)
Isolated mat fever: > 100.4 and still high in 30 min, or 102.2 x1. ACOG recommends administration of intrapartum antibiotics for patients with isolated maternal fever unless a source other than intraamniotic infection is identified.
1g of cefazolin in patients weighing
2 g of cefazolin in patients weighing > = 80 kg
3 g in patients weighing > 120 kg.
Yes. Less than 1% of patients with penicillin allergy are allergic to cephalosporins. Unless severe alergy to PCN, can give.
EBL > 1500, 4hrs
endometritis and SSI
Ampicillin is added to the endometritis treatment regimen in a patient who has not improved after 48–72 hours of gentamicin and clindamycin for coverage of Enterococcus species.
ACE inhibitors are associated with what fetal outcomes?
- Neonatal renal failure (anuria, oligohydramnios, arterial hypotension)
- intrauterine growth restriction
- limb defects
- Respiratory distress syndrome, pulmonary hypoplasia
- death
- Accreta US Findings
- State % Risk of acretta w/ Previa and history of cesarean delivery.
- Endometrial ablation, age, uterine manipulation, and IVF all inc risk of accreta. T or F
- Ultrasonographic findings strongly associated with placenta accreta include
- lacunae (MOST SENSITIVE, hypoechoic spaces) within the placenta;
- hypervascularity in the myometrium or placenta;
- loss of the retroplacental hypoechogenic zones, which represents an absence of the normal decidua basalis between the myometrium and placenta;
- myometrial thinning at the placental bed
- placenta bulging into the bladder.
Previa + h/o CD
1 CS 3% (if no previa .03%)
2 CD 11%
3 CD 40%
4 CD 61%
5 CD 67% (no previa .8%)
True
Neonatal signs of an acute intrapartum event include…
- Apgar score of less than 5 at 5 minutes and 10 minutes;
- fetal umbilical artery acidemia with fetal umbilical artery pH less than 7 or a
- base excess of more than 12 mmol/L;
- magnetic resonance imaging consistent with hypoxic-ischemic changes
- multisystem organ failure
- Most common sign of an amnioti fluic embolus?
- Hypoxemia
- Regarding care for a patient with prior alloimmunization, how do you interpret titers? so then what do you do?
- If first affected pregnancy, how often and when do you start to titer?
- What antigens do we worry about?
- Which do we NOT worry about?
- You cannot. Start MCA dopplers at 18 weeks GA.
————
- Start monthly when known, and at 24 weeks switch to every weeks.
If you reach a critical titter (1:16 antiD or 1:8 Kell) start MCA dopplers.
If those elevated, fetal Hg determination.
- D, Kell (K), Duffy (Fy), E, Kidd (Jk) c
————————-
- Lewis and I
Anemia w/up Algorith from ACOG.
What are the common features of the following chromosomal defects?
(A) 45,XO
(B) 47,XXY
(C) 47,XX,+21
(D) 47,XY,+18
(E) 47,XX,+13
a) Turner’s: cystic hygroma (specially 2nd tri), hydrops fetalis, short femur, coarctation of the aorta, hypoplastic left heart, and renal anomalies.
b) Kleinfelter: Klinefelter syndrome (47,XXY) is only detected prenatally in 10% of cases. There are no characteristic prenatal ultrasound findings for Klinefelter syndrome.
c) T21: duodenal atresia, cardiac anomalies, cystic hygroma, inc NT, hypoplastic or absent nasal bone, echogenic intracardiac foci, pyelectasis, short femur length, choroid plexus cysts, echogenic bowel, thickened nuchal skin fold, and ventriculomegaly. Most common cause is non-dysjunction.
d) T18: choroid plexus cysts, clinodactily, rocker bottom feet, hypoplastic nails, prominent occiput, low set ears, horshoe kidney.
e) T13: THINK MIDLINE DEFECT (midface, eye, forebrain), holoprosecephaly, microcephaly, low set ears, polydact,cleft lip/palette, cystic kidney
Risk of anorexia in pregnancy?
low birth weight, small for gestational age, hemorrhage.
- MOA of UFH and side effects.
- MOA of LMWH.
- MOA of Warfarin.
- Fetal warfarin syndrome characteristics.
- Warfarin is considered safe in women who are breast feeding. T or F.
- For patients who are on low-molecular-weight heparin for anticoagulation during pregnancy, transitioning to unfractionated heparin is recommended at approximately __ weeks of gestation.
- After delivery, when do we start anticoag for Vaginal Del and Csections? what if has an epidural?
- If on ppx or theraptic anticoag, how long b4 delivery do we discontinue?
- Inactivating thrombin and activated factor X (factor Xa).The risk of heparin-induced thrombocytopenia is 2.6%. Use of unfractionated heparin for 1 month or more has been associated with a 2–3% risk of symptomatic vertebral fractures.
- Predominately binds to antithrombin, and functions as a factor Xa inhibitor. The risk of heparin- induced thrombocytopenia is 0.2%. The risks of osteoporosis and decreased bone mineral density are significantly lower among those patients treated with low-molecular- weight heparin than with unfractionated heparin.
- Inhibition of Vit K dep factors.
- Fetal warfarin syndrome is caused by exposure to war- farin between 6 weeks and 12 weeks of gestation. Fetal warfarin syndrome can be characterized by nasal hypoplasia, stippled bone epiphyses, chondrodysplasia, hydrocephaly, microcephaly, ophthalmologic abnormalities, IUGR, and developmental delay. There also is an increased risk of spontaneous abortion, stillbirth, and neonatal death in pregnancies exposed to warfarin.
5. Warfarin is considered safe in women who are breastfeeding because it does not accumulate in the breast milk.
- Transitioning to unfractionated heparin is recommended at approximately 36–37 weeks of gestation.
7. For women with a high risk of thrombosis, anticoagulation should be restarted following delivery. For a vaginal delivery, anticoagulation may be restarted 4–6 hours after delivery. Anticoagulation can be restarted 6–12 hours after a cesarean delivery. If the patient had neuraxial anesthesia, anticoagulation should be restarted 24 hours afterward and 4 hours after the removal of the epidural.
8. 12h for ppx, 24 for therapeutic
Pearl:
Low-molecular weight heparin has a longer half-life, a more predictable therapeutic response, less bone mineral density loss, and a lower risk of heparin-induced thrombocytopenia. Neither can cross the placenta.
What malformations are the following antiepileptics at risk for?
- Valproic Acid
- Carbamazepine
- Phenytoin
- Tricyclic antidep.
- Drug of choice for bipolar disorder med while breastfeeding?
- NTD (WORST): highest risk of fetal malformations of the antiepileptic medications and is associated with neural tube defects, heart defects, cleft palate, hypospadias, polydactyly, craniosynostosis, limb anomalies, facial dysmorphism, neurodevelopmental delay, and autism spectrum.
- NTD
- Hypoplastic nails, flat facies, IUGR, VSD, cleft palette
- Limb anomalies
- valproic acid
APGAR stands for?
Assign scoreS:
A newborn girl is pink; the soles of her feet and hands are blue; and her heart rate is 99 beats per minute (bpm). She is crying with active motion and good respiratory efforts.
A newborn boy is pale and has a weak cry, grimaces, and some flexion. His heart rate is 160 bpm.
A newborn boy is completely pink and his heart rate is 120 bpm. He has a weak cry, flexes somewhat, and grimaces in response to stimulation.
Appearance, Pulse, Grimace, Activity, Respirations
8
5
7
Who gets baby ASA in pregnancy?
Low-dose aspirin (81 mg/day) prophylaxis is recommended in women at high risk of preeclampsia and should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery.
One of these:
- Hx of Preeclampsia
- Twins
- autoimmune disease (lupus, antiphopholipid)
- Hypertention
- Diab type 1 or 2
- Renal disease
Two or more of thesE:
- First pregnancy
- Obese
- Adv mat age
- low socioecomic status
- mom os sister with h/o preE
- Personal hx (low birth weight, preior poor outcome)
- What are the Asthma Severity Categories.
- Examples of inhaled corticosteroids? Long acting beta agonists?
- What happends to FeV1 and FEV1 / FVC in asthma?
- See Photo
- Corticosteroids: Budesinide, beclomethasone, fluticasone
LABA: salmeterol
- Both go down (in restricitve, FEV!/FVC normal)
When can you use bactrim? What is the fetal risk?
How about Macrobid? What is the fetal risk?
Bactrim
- 2nd tri only (risk: kernicterus in preterm or < 2m age)
Macrobid
- avoid 1st tri or if preterm or <1m age (risk hemolytic anemia)
- Citrate in blood products chelates __ and __. What about K?
- Blood transfusions resulst in what pH change ___.
- Calcium (mostly) and Mag (less so).
Contains K!
- Citrate is metabolized and used to generate bicarbonates. If the latter is not adequately excreted in the urine, metabolic alkalosis can occur.
- T or F: Termination of pregnancy has been shown to improve the prognosis of pregnant women with breast cancer.
- During what trimesters can chemo for breast cancer be administered in pregnant women?
- False
- Adjuvant chemotherapy is known to decrease the risk of breast cancer recurrence. Because of its teratogenic effects, chemotherapy in the first trimester is contraindicated. Chemotherapeutic agents used for the treatment of breast cancer can be used in the second and third trimesters without increased risk of fetal malformations.
- Strict contraindications to brestfeeding…
- Stage 1 vs stage 2 lactogenesis…how do they differ?
3. How is a clogged duct different from a galatocele?
- There is no contraindication to breastfeeding after gadolinium administration for an MRI. T or F
- HIV, HTLV, active TB, galactosemia, illicit drug use, cancer chemotherapy, radiation, antiretrovirals, methotrexate
- Stage 1 during the second half of pregnancy. Stage 2 triggered by decrease in Progesterone and increase in Prolactin.
- Galactoceles are not painful.
- T
- Mechanism of action of bupenorphine vs methadone.
- Suboxone (bupe+naloxone) is usually not used in preg. T or F
3. Can women breastfeed on these?
- Bupenorp: partial agonist & Methadone: full agonist
- True!
- Yes. ACOG recomends so!
Salient points:
the first-line medications for the treatment of opioid use disorder during pregnancy are methadone and buprenorphine opioid agonists, which have been shown to be safe in pregnancy, decrease the use of illicit drugs during pregnancy, improve maternal health and nutrition, improve compliance with prenatal care, and reduce maternal and neonatal morbidity and mortality. For pregnant women, pharmacotherapy for opioid use disorder is typically administered via an induction and maintenance regimen. This regimen consists of medication initiation, the incremental uptitration of medication dose until the patient’s withdrawal symptoms are eliminated, and the continuation of medication through the postpartum period and as long as needed.
Indications for Cerclage
History
- History of one or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labor or placental abruption
- Prior cerclage due to painless cervical dilation in the second trimester
Physical Examination
• Painless cervical dilation in the second trimester
Ultrasonographic Finding With a History of Prior Preterm Birth
Ultrasonographic Finding With a History of Prior Preterm Birth
•Current singleton pregnancy, prior spontaneous preterm birth at less than 34 weeks of gestation, and short cervical length (25 mm or less) before 24 weeks of gestation.
Cystic Fibrosis
- Inheritance pattern?
- What is the next step if a couple in which male has no vas def and had a neg panel?
- AR
- Assume that the male is a positive carrier of a denovo mutation and test mother.
Cholecystitis management in pregnancy.
Who goes to the OR, always?
In the absence of such indications for urgent or emergency surgery, the optimal treatment for acute cholecystitis depends on the gestational age:
- If 1st or 2nd tri: __
- If 3rd tri: __
Definitive, prompt surgical therapy is required for any patient with cholecystitis and signs of sepsis, suspected gangrene, or perforation, as well as disease progression while on antibiotic therapy.
- Operating Room! (OR)
- OR
3. Antibiotics, Fluid
Cholestasis:
Maternal characteristics associated with a higher risk…
Maternal characteristics associated with a higher risk of ICP include multiple gestation, in vitro fertilization treatment, hepatitis C positive status, and advanced maternal age
Potential benefits fo circumcision..
Decreased urinaty tract infections, decreased HIV, decreased penile cancer, decrease cervical CA, increased hygiene
- CMV is the most common congenital viral infection. T or F
- T or F. CMV is the leading cause of non-hereditary hearing loss.
- What are the symptoms of infection?
- How do we test mom? Fetus?
- When interpreting IgG, a new finding of positive IgG or a 4x increase in titer is indicative of new infection. T or F
- Fetal sequelae include…
- Neonatal squelae include…
- Fetus most vulnerable during what trimester?
- T (2% of all neonates)
- True
- Often asymptomatic (90%) in adults, but symptoms of infection may include fever, chills, myalgias, and malaise (flu like).
- IgM & IgG. We Use avidity testing (low =new). CANNOT use IgM alone, must always use IgG avidity to help you. PCR of amniotic fluid for infant.
- T
- Echogenic bowel**, **IUGR, periventricular calcifications, hepatosplenomegaly
- Hearing loss**, **neurodev delay, microcephaly, retinopathy, cns, hepatosplenomegaly, dec visual acuity
- 2nd
- Criteria for confirmation of term pregnancy include…(3)
- US measurement at less than 22 wk supporting a diagnosis of >39 weeks
- FHT present for 30 weeks by doppler
- 36 weeks elapsed since +UPT/HCG
- Normal cord blood gases.
- What component of the umbilical cord blood that is most consistent with a neurologic injury that is a result of an acute intrapartum event?
- Ph 7.28, CO2 50, Bicarb 23, Bace defecit -3.6
- Base excess!
What is the preferred treatment for a C-section scar ectopic?
Intrasac MTX + KCL
When a D&C is performed, it should be preceded by uterine artery embolization to minimize risk of bleeding.
How does one interpret a CST?
What does one do with an equivoval CST?
T or F: CST has good negative predictive value.
+ (lates w/ >50% CTX)
neg (no decels)
eq (some lates or variables) -> repeat in 24 hrs
True
Delivery timing:
- Poly
- Oli
- Mono-mono twins, mono di twins, didi twins
- Prior Classical
- Prior myomectomy
- Prior rupture
- Vasa previa
- Accreta, increta, percreta
- Previa
- Poly: 39w0d
- Oli: as early as 36w0d
3. Mo-Mo 32 (admit at 28 wk) 2. Mo-di 34 3. di-di 38
- Prior Classical: 36w0d
- Prior myomectomy: 37w0d
- Prior rupture: 36w0d
- Vasa previa: 34w0d
- Accreta, increta, percreta: 34w0d
- Previa: 36w0d
Depression:
- Blues vs Depression
- Score for + scale: ___
- Score for ED referral: __
- In non pregnant pts, what is the initial SSRI of choice?
- Postpartum blues is a transient condition characterized by several mild depressive symptoms such as sadness, crying, irritability, anxiety, insomnia, exhaustion, and decreased concentration, as well as mood lability that may include elation. Symptoms typically develop within two to three days of delivery, peak over the next few days, and resolve within two weeks of onset.
The two disorders are distinguished in that the diagnosis of postpartum blues does not require a minimum number of symptoms, whereas major depression requires a minimum of five symptoms. In addition, the symptoms of postpartum blues are generally self-limited and resolve within two weeks of onset.
>=12 or 10
>=20 / HI/SI
Although scores of 12 and above identifies most women with postpartum depression, a cut-off of 10 or more is preferred in many practices. Patients with a score between 5 and 9 should be re-evaluated within a month
Sertraline
(A) Atopic eruption of pregnancy
(B) Intrahepatic cholestasis of pregnancy
(C) Pemphigoid gestationis
(D) Polymorphic eruption of pregnancy (PUPPS)
(E) Psoriasis
(A) Atopic eruption of pregnancy: the most common pruritic skin condition of pregnancy. Pruritus, prurigo lesions/ excoriations, and eczematous-like skin lesions; secondary infection due to excoriations. 66% present with widespread eczematous changes affecting typical atopic sites; 33% have small pruritic, erythematous papules on trunk and limbs.
(B) Intrahepatic cholestasis of pregnancy: Severe pruritus with no primary skin lesions occurring with or without jaundice. Onset on palms and soles to later become generalized; secondary lesions such as excoriations, scratch marks, and prurigo nodules might develop.
(C) Pemphigoid gestationis: Pruritic urticarial papules and annular plaques followed by vesicles and finally large tense bullae on an erythematous background. Eruption site is the periumbilical area (most common),
rest of the abdomen, thighs, palms, and soles. Rx: Oral and topical corticosteroids. Risk of premature birth and small-for-gestational-age infants.
(D) Polymorphic eruption of pregnancy (PUPPS): Intensely pruritic urticarial rash with erythema- tous, edematous papules, and plaques, developing into polymorphic features such as papulovesicles, erythema, and annular wheals. Onset on the abdomen with sparing of the umbilical region as a characteristic finding, which later spreads to thighs, buttocks, and back. Topical corticosteroids; oral antihistamines; oral corticosteroids. 3rd tri. Primes. inc mat weight gain. multifetal gest.
(E) Psoriasis: silvery, scaled plaque with an erythematous base that is itchy and painful, and may crack or bleed. The majority of patients with psoriasis will have improvement in their symptoms during pregnancy, but the symptoms appear to worsen in approximately 20% of pregnant patients. Initial management is accomplished with topical corticosteroids.
- Most common cause of adult diarrheal illness:
- Most common cause of child diarrheal illness:
- Treatment for giardia:
- Treatment for shigella, salmonella, ecoli:
- Treatment for campylobacter:
- Travelers diarrhea cause and treatment? prophylaxis?
- C. Diff treatment.
- Most common cause of adult diarrheal illness: norovirus
- Most commonca use of child diarrheal illness: rotavirus
- Treatment for giardia: metronidazole
- Treatment for shigella, salmonella, ecoli: cipro
- Treatment for campylobacter: erythro
- Enterotoxigenic e coli; Cipro or Azithro (pregnant); Antimicrobial prophylaxis is not routinely recommended but may be indicated in patients at high risk of complications from diarrheal illness. Rifaximin is the prophylactic drug of choice.
- PO Vanc or oral fidaxomicin are first line! PO flagyl is second line
Degeorge is casued by a deletion in 22q11
What are its features?
Mode of inheritance?
CATCH22
Cardiac anomalies
Abnormal facies
Thymic abnormalities
Cleft palete
HypoCalcemia
22
Autosomal dominant
T or F: complete breech position is associated with greater ECV succes (compared to frank breech).
True
Echogenic Intracardiac Focus
- How to manage in preg with normal genentics?
- If no prior genetic testing or AMA?
- Routine follow-up
- Offer dx testing + targetted anatomy scan
Hydralazine, Labetalol, Nifedipine are the drugs of choice for hypertensive emergencies….what are the:
- Doses
- Timing intervals for administration
- Side effects
- Mechanism of action
Hydral (10mg–>10mg–>labetalol 20mg) (mat hypotenison, HA, tremor) Measure q20min
peripheral smooth muscle relaxant.
Lab (20/40/80) (avoid if asthma, heart diseasez, heart failure) Measure q10min
Nonselective beta + and Alpha 1 Blocker.
Nifedipine (10/20/20) (reflex tachy, HA) Measure q20min
Ca channel blocker.
Prophylaxis against infective endocarditis is not recommended for non-dental procedures in the absence of active infection. T or F
Prophylaxis against infective endocarditis is reasonable for the following patients at highest risk of adverse outcomes from infective endocarditis:
True
- -Patients with prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- -Patients with previous infective endocarditis
- -Patients with CHD:
- –Unrepaired cyanotic CHD, including palliative shunts and conduits
- –Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure.
- –Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (both of which inhibit endothelialization)
- -Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve.
The use of prophylactic antibiotic therapy be considered for vaginal delivery in patients with the highest risk of adverse outcomes from endocarditis. Those at highest risk are women with cyanotic cardiac disease, or prosthetic valves, or both. Mitral valve prolapse is not considered a lesion that ever needs infective endocarditis prophylaxis. For those not already receiving intrapartum antibiotic therapy for another indication that would also provide coverage against endocarditis, antibiotic regimens for endocarditis prophylaxis can be administered as close to 30–60 minutes before anticipated time of delivery as is feasible.
Epidural timing in the setting of anticoagulation. ACOG chart.
For prophylactic anticoagulation, 12hrs.
For therapeutic anticoagulation, 24hrs.
What is the most common preventive casue of intellectual dissability and its features?
Fetal Alcohol Syndrome:
short palpebral fissure, thin vermillion border, smooth philthrum
Fetal Head Injuries
- Caput sucedaneum
- Cephalohemoma
- Subgaleal
- Which is most common with vaccum?
- pitting edema that crosses suture lines
- over parietal bones, DOES NOT CORSS SUT lines
- crosses lines
- cephalohematoma
T or F: Cesarean delivery is the most common complication associated with myomas.
True
This increased rate is likely secondary to an increased rate of malpresenta- tion, dysfunctional labor, placental abruption, intrauterine growth restriction, placenta previa, and preterm prelabor rupture of membranes.
Flu
- What is the prophylaxis after exposure
- Treatment
- Treatment of pyelonephritis if admitted and pregnant
Postexposure antiviral chemoprophylaxis can be con- sidered for pregnant women and up to 2 weeks postpa tum for women who have close contact with someone likely infected with influenza.
- Chemoprophylaxis is oseltamivir phosphate 75 mg daily for 10 days.
- oseltamivir phosphate 75 mg BID x5days
- Pyelo: amp/gent or 3rd ger ceph
Specific uses for:
Piper
Kielland
SimpsOn
T or F: Moter vehicle accidents are the most common cause of trauma in pregnancy.
What is the diffetence between outlet, low, and mid forceps?
Pipper: Breech
Kielland: Rotation/Asynclitic
SimpsOn: mOlding
Domestic violence is the most common cause of trauma in pregnancy.
Low: +2 or greater
mid: less than +2
outlet: scalp visible at introitus
rotation f >45degree correction
- How do we treat Group A Strep?
- What if allergic? What is the microbiological description of the bacteria?
- What is the Rx for Necrotising fasciatis in addition to emergent surg debridement?
- Toxic shock syndrome is a life-threatening condition caused by the release of toxins from what bacteria?
- What is the difference between staphylococcal and streotococcal toxic shock syndrome?
- Penicilling + Clinda (Treats toxin)
(M Protein is the major virulence factor)
- Vanc if allerigic
G+ cocci in pairs and chains
- A Penem (or Zosyn) + Vanc + Clinda
- Toxic shock syndrome is a life-threatening condition caused by the release of toxins from the Staphylococcus aureus bacteria.
The casusative agent agent.
What are the approved Rxs for GBS+ in non-PCN allergic patients?
Penicillin G, 5 million units IV as initial dose, then 2.5–3 million units every 4 hours until delivery
OR
Ampicillin, 2 g IV as initial dose, then 1 g IV every 4 hours until delivery
- What should the diet of gestation diabetic consist of?
- What types of agents are glyburide and metformin?
Carbs: 40%
Fat: 40%
Protein: 20%
Generally will start with restricting daily caloric intake to approximately 2,000 calories per day depending on patient’s body mass index.
Metformin:biguanide that inhibits hepatic gluconeogenesis and glucose absorption and stimulates glucose uptake in peripheral tissue
Glyburide: sulfonylurea, increases insulin secretion, avoid if sulfa allergy!
Define:
- Plietropy
- Variable Expresivity
- Incomplete Penetrance
- Plietropy: The phenomenon in which a single gene disorder manifests in multiple organ systems or in multiple ways, such as in Marfan syndrome.
- Variable expressivity refers to a phenomenon in which all patients manifest the disease in some fashion, but patients are affected differently. An example is cystic fibrosis.
- Incomplete penetrance, in which some patients have no manifestations
Genetics Yield after IUFD
T or F Amniocentesis before delivery provides the greatest yield.
T or F Umbilical cord proximal to placenta if amniocentesis declined.
T or F Fluorescence in situ hybridization may be useful if fetal cells cannot be cultured.
All true
Fetal or embryonic tissue.
Hydatidiform swelling of chorionic villi.
Trophoblastic hyperplasia.
Trophoblastic stromal inclusions.
Genetic parentage.
Karyotype.
Persistent b-hCG.
- Diagnostic criteria for HELLP.
Hemolysis characterized by schistocytes on blood smear, total bilirubin of 1.2 mg/dL or more, lactate dehydrogenase greater than 600 international units/L, or serum haptoglobin concentration 25 mg/dL or less
Elevated liver enzymes with alanine aminotransferase and aspartate aminotransferase greater than 70 international units/L, or twice the upper limits of normal
Platelet count less than 100,000/mm3
***Unlike preeclampsia, proteinuria and hypertension are absent approximately 15% of the time in women diagnosed with HELLP syndrome.***
HepB
- At what VL do we treat and with what agent?
- How are newborns of mothers with hepB treated?
6–8 log10 copies/mL (>200,000 Copies).
Tenofovir has been suggested as the first-line agent for this antiviral therapy.
Newborns get the vaccine + IVIG.
- Immune due to natural infection.
- Immune due to vaccination
- Acutely Infected
- Chronic Infection
- The risk of vertical transmission of hepatitis C is approximately 2-8%. The top 2 risk factors are:
- High maternal titer and prolonged rupture of the membranes (OR 9.3).
Drug of choice for anticoagulation if history of HIT and pregnant? What is the mechanism of action?
MOA of:
Dabigatran.
Edoxaban, betrixaban, and rivaroxaban.
Fondaparinux is the drug of choice for anticoagulation in patients with a history of heparin-induced thrombocytopenia. Fondaparinux binds to antithrombin III and accelerates the inhibition of factor Xa.
Dabigatran is an oral thrombin inhibitor.
Edoxaban, betrixaban, and rivaroxaban are anti-Xa inhibitors.
These medications should be avoided in pregnancy because there is inadequate information on safety. These medications do cross the placenta and may compromise fetal coagulation.
- Why do we avoid efavirenz in pregnancy?
- What do we do with patients on Stavudine or Didanosine?
- The concomitant use of methergine and protease inhibitors has been associated with what?
- If VL > 1000, what are the recommendations?
- Artificial rupture of membranes and duration of rupture of membranes are not associated with an increased risk of perinatal transmission when VL < 1000. T or F
- Studies have shown that the risk of HIV transmission from breastfeeding is up to approximately 15%. In the USA is is alwasy contraindicated to BF. T or F.
- What is the risk for vertical transmission w/ viral load >1000 and:
- AZT+SVD
- CD + AZT
- SVD VL<1000
- No Efavirenz before 8 weeks of gestation because of the medication’s increased risk of neural tube defects.
- Those on a combination of stavudine and didanosine before pregnancy should be switched to a different regimen because of this combination’s adverse effect of lactic acidosis in pregnant women.
- Exaggerated vasoconstrictive response!
- Intravenous zidovudine at least 3 hours before cesarean delivery. Additionally, cesarean delivery should be performed at 38 weeks of gestation before onset of labor, or rupture of amniotic membranes (and without an amniocentesis for fetal lung maturity), or both.
- True
- True
- risk for VT w/ VL >1000 and
- AZT+SVD 25%
- CD + AZT 5%
- SVD VL<1000 2%
- For women with a CD4 count less than 200, what vaccines are contraindicated?
- What is the next step following a 4th gen positive HIV test?
- What is the preferred regimen for HIV treatment in preg?
- If using __, delay pregnancy 8 weeks.
- Live ones such as Varicella, zoster, and MMR
- HIV1/2 differentiation assay -> if neg, RNA levels sent
- x2 NRTI (usually zidovudine/lamividine)+ 1 protease inhibitor
- efavirenz
How is HSIL cytology managed in pregnancy?
Colpo, no ECC, with biopsy.
If CIN2-3, surveillance colpo Q12 weeks is preferred.
Repeat biopsy if invasion suspected or lesion appearance worsens
Do not RX!
Hyperemesis gravidarum
- 1st line treatment? if this fails, how to escalate?
- Why was high dose ondansetron removed from the market? What is the risk of methylpref before 10wk GA?
- The first-line treatment for nutritional support should be:
- Why include thiamine in the IVF?
- Pressure points, convert PNV to just folic acid, ginger capsules. If fails, Pyridoxine (vitamin B6) as monotherapy, or in combination with doxylamine, is safe and effective.
NEXT: benadryl, compazine (prochloperazine), phenergan (promthazine).
Next: Zofran or trimethobenzaprine
Worst: methylpred or thorazine (chlorpromazine)
Ondansetron is associated with maternal risk of arrhythmia, in particular prolongation of the QT interval
Methylprednisolone use in the first trimester has been associated with fetal oral clefts so this medication should be avoided before 10 weeks.
The first-line treatment for nutritional support should be enteral tube feeding through either nasogastric or nasoduodenal tube while continuing with antiemetic pharmacotherapy.
Thiamine should be included with the intravenous hydration for the described patient to prevent Wernicke encephalopathy.
Isotretinoin
Thalidomide
Fetal hydrocephaly and microtia, craniofacial, cardiovascular, neurologic, and thymic.
The pharmacokinetics of elimination varies among patients, so there is not a clear recommendation for the duration of contraception after therapy, but 3 months has been suggested.
Phocomelia is the most dramatic birth defect associated with prenatal use of thalidomide.
- When do we deliver IUGR in general?
- How do doppler results affect delivery timing?
- 38w0d-39w6d
- Types of Labor Anesthesia (Photo)
- Into what space is the spinal needle placed?
- Pudendal Nerve roots.
- see photo
- subarachnoid
- S2-S4 (vs T10-L1)
Sx of Listeria…
How is Listeria managed if:
- Exposed and no symptoms…
- Symptoms but no fever…
- Symptoms and fever
In pregnant patients, the disease course is usually mild, with symptoms similar to influenza, but the fetal effects may be severe. Preterm birth, neonatal sepsis, meningitis, death, and intrauterine fetal demise have all been reported in association with listeriosis in pregnancy.
The management of patients with exposure depends on subsequent symptoms.
Those who are asymptomatic do not need testing or treatment and should be instructed to report symptoms within 2 months of the suspected exposure.
Patients who have symptoms but no fever** may be managed expectantly or have blood cultures drawn. Health care providers can consider empiric antibiotics pending **blood culture results if the patient’s history is compelling for true illness.
Patients who have an exposure and develop symptoms and a fever (ie, temperature greater than 38.1°C [100.6°F]) should be tested and treated at the same time. Treatment typically is accomplished with intravenous ampicillin, often with (gentamicin) [use trimethoprim-sulfamethoxazole for penicillin-allergic patients]. Because listeriosis is a nationally reportable illness, health care providers should notify local health departments.
Granulomatosis infanticeptica (abcesses).
- Contraindications to Mg Sulfate? Alternatives?
- What is the order and the levels of Mg for toxicity? (loss of reflexes at __? resp depression at __? Cardiac toxcity at __?)
- Reversal agent?
- Intrmuscular Magnesium course is: 10g then __g Q4hours.
- myesthenia, hypoCa, renal failure, cardiac ischemia, heart block, myocarditis;
Alternatives: Keppra/Phenytoin/diazepam
- Photo
- Cagluconate 10% IV
- 5g q4
- How do you treat stage 1C germ cell ov cancer in pregnancy?
- BEP after 1st tri if > stage 1B.
__% of patients with penicillin allergy are allergic to cephalosporins.
What are the characteristics of SEVERE PCN allergy?
1%
Patients with type I reactions classically present with urticaria, angioedema, laryngeal edema, wheezing, and hypotension, with or without cardiorespiratory failure.
- OB conjugate vs diagonal conjugate.
- GYN, Anthro, android, plat
- OB (mid PS to sacrum), Dig (lower edge of PS to sacrum)
- Photo
Periviable Birth
- T or F: All interventions can be considered at >= ? weeks.
- T or F: All interventions are recommended at >= ?.
- At what GA is CD recommended for periviable birth?
- What can be ordered at 20-21weeks vs 22weeks?
- True
- True
- 25 weeks
- At 20 can consider ABX. At 22 weeks can consider ABX + Resusitation.
Post-term pregnancy risks
oligohydramnios, meconium, macrosomia, birth trauma, long nails, dry skin, lanugo, hypoglycemia, polycyhtemia, PPHTN, asphyxia, sezires, palsy, iufd
Values for the PP 75g GTT.
PPH Drugs and Dosing
MOA of:
- Methergine
- Carboprost
- Misoprostol
- Dinoprostone
See Photo
- Methergine: contraction of smooth uterus muscle via 5-HT2A serotonin receptors
- Carboprost: PGF2alpha
- Misoprostol: PGE1
- Dinoprostone: PGE2
Pulmonary Changes
- TLC
- Tidal Volume
- FRC
- Minute Ventilation
- End Residual Volume
- Resp Rate
- CO2
During pregnancy, both anatomical and physiological changes occur to the respiratory tract. As the uterus grows, the diaphragm rises and the thoracic circumference increases. As the diaphragm rises, the residual volume (RV) and expiratory reserve volume (ERV) decrease, which results in decreased functional residual capacity (FRC). There is an increased tidal volume (TV) and inspiratory capacity (IC). There is a small decrease to no change in the total lung capacity (TLC). The respiratory rate is unchanged, however, the increased tidal volume results in an increased minute ventilation. This is attributed primarily to progesterone, which increases respiratory effort by increasing the sensitivity of the chemoreceptors to carbon dioxide. The increased minute ventilation decreases PaCO₂, resulting in a state of respiratory alkalosis. The decreased partial pressure of carbon dioxide facilitates transfer of CO₂ away from the fetus, while the alkalotic state, through 2,3-diphosphoglycerate, shifts the oxygen dissociation curve to the right, enhancing oxygen release to the fetus.
- TLC: dec
- Tidal Volume: inc
- FRC: dec
- Minute Ventilation: inc
- End Residual Volume: dec
- Resp Rate: same
- Decreases (resp alkalosis)
- qSOFA Identifies high risk patients with suspected infections for in-hopsital morality
AMS
Syst BP < 100
RR 22
>=2: 3-14x mortality risk
Upper limit of normal for radiation exposure in pregnancy?
50 milliGrays (or 5 Rads)
- Criteria for redating pregnancy early on based on US.
Date preg with US if
> 5d & <9wk
>7d & 9-14 wk
- What are the maternal sx of rubella infection?
- How do we dignose it?
- Fetal sequelae…
- Neonatal sequelae…
- rash, head –> spreading to toes over 1-3 days; peiauricular adenopathy, conjunctivitis, flu-like sx.
- IgG/IgM. Rubella is a devastating infection during pregnancy, and patients should be vaccinated at least 1 month prior to pregnancy. Non-immune mothers who have known exposure should be watched carefully and if any symptoms of rubella develop, they should be offered maternal serum testing and amniocentesis. Eighty percent of women with rubella infection in the first 12 weeks of pregnancy have an affected fetus, and this decreases to 25% by the end of the second trimester.
- IUGR, hydrops, microcephaly, pulmonary stenosis, congenital cataracts
- Deafness, eye defects, cardiac malformation, CNS malformations
- What are the SIRS criteria?
- Define Sepsis, Severe Sepsis, Septic Shock, MOF
- ___ is the first-line single agent vasopressor in patients who remain hypotensive following initial management.
Norepinephrine is the first-line single agent vasopressor in patients who remain hypotensive following initial management.
SMA
- Inhearitace Pattern?
- Least sensitive in what racial group?
- Which chromosomal layout is most concerning?
- AR
- AA
- See Photo (-cis)
- What are the 5As?
- Nicotine Replacement ok in pregnancy?
- Wellbutrin: MOA, Contraindications
- Verenicline: MOA.
- What is the black box warning for both?
6. All should stop smoking prior to surgergery for at least __ wks.
7. Which can you use when BF?
- See Photo
- Not been sufficiently studied in pregnancy and lactation to determine safety or efficacy. Use of nicotine replacement therapy should be undertaken with close supervision and after a discussion with the patient of the known risks of continued smoking and the possible risks of nicotine replacement therapy.
- Norepinephrine-dopamine reuptake inhibitor, or NDRI. Contraindicated in patients with seizure disorders or prior diagnosis of eating disorders.
- Acts on nicotine receptors in the brain. Because of this drug’s association with worsening mental illness, clinicians must address psychiatric illness with patients before initiation and follow closely for changes in mood or behavior. nasuea, abn dreams
Cant use nic, or the pharm agents if BF.
Varenicline and buproCion both carry black box warnings regarding risk of psychiatric symptoms and suicide associated with their use.
4 wks
Buproprion ok with breastfeeding
- What Hg types are elevated in Beta thal?
- Alpha thal: AA vs asian (trans or cis)
- name:
aa/a-
aa/– or a-/a-
a-/–
–/–
- name:
b/-
b-/b-
- /-
5. pregnant patients with sickle cell anemia should be prescribed __ mg of folic acid per day.
- A2 and Fetal (Fetuses affected by beta-thalassemia major (Cooley anemia) are unaffected in utero because production of beta globin does not begin until infancy. The predominant form of hemoglobin in the fetus after 8 weeks gestation is Hb F, which consists of 2 alpha-chains and 2 gamma-chains.)
- AA (a-/a-)
Asian is Trans (–/aa)
- Trait, Minor, H disease, Barts
- Minor, intermedia, major
- 1mg
Who gets VTE testing?
High risk vs low risk thrombophilias?
T or F: Antepartum, prophylactic anticoagulation therapy may be withheld in women with prior venous thromboembolism in the context of a nonrecurrent risk factor and a negative inherited thrombophilia evaluation and no additional risk factors.
T or F: PPx anticoagulation therapy is recommended in all women with a prior venous thromboembolism.
What thrombophilias can you test for during an active clot?
Screening may be considered in patients with a personal history of venous thromboembolism(even if associated with a nonrecurrent risk factor such as a fracture or surgery). Also, patients with a first-degree relative with a history of high-risk thrombophilia may be tested.
Low-risk thrombophilias include factor V Leiden heterozygous; prothrombin G20210A heterozy- gous; and protein C and protein S deficiencies. High-risk thrombophilias include antithrombin deficiency; double heterozygous for prothrombin G20210A mutation and factor V Leiden; homozygous for factor V Leiden and prothrombin G20210A. LRTs with no prior hx of clot get no anticoag during preg, and PP they do IF they have risk factors (obesity, CD, prolonged immobility)
Both true.
What are the major and minor risk factors for VTE after CD?
T or F: For women undergoing cesarean delivery without additional risk factors for thrombosis, use of thromboprophylaxis is not recommended other than early mobilization.
T or F: For women with increased risk of thrombosis after cesarean delivery with one major or at least two minor risk factors, pharmacologic thromboprophylaxis or mechanical prophylaxis in those in whom anticoagulation is contraindicated is recommended while still in the hospital.
T or F: For women undergoing cesarean delivery with very high risk of venous thrombosis and who have addi- tional risk factors for thromboembolism in the post- partum period, prophylactic low-molecular-weight heparin combined with mechanical prophylaxis is recommended.
T or F: For women with significant risk factors for thrombosis that persist after delivery, extended prophylaxis for up to 6 weeks after delivery is recommended.
See Photo for Risk Factors.
- What are the symptoms of maternal Toxo?
- What do we use to diagnose maternal infection.
- Fetal sequelae
- Neonatal sequelae
- RX
- mom without fetal infection
- fetal infection
- In most adults, infection with toxoplasmosis is asymptomatic. When present, symptoms may include lymphadenopathy, malaise, and night sweats. Consuming undercooked pork and lamb products are the most likely causes of maternal toxoplasmosis infection.
- IgG/IgM
- inTracranial calcifications and microcephaly (cmV, periVentricular)
- chorioretinitis, hearing loss, and neurodevelopmental delay
- MOM alone (spiramycin)
Fetal: pyrimethamine + sulfadiazine + folinic acid
Doses and MOA:
- Oxy
- TXA
- Ergots
- Carboprost
- Miso
- Dino
- RF7a
Which is CI in pts on protease inhibitors?
Methergine CI in pts on pretease inhibitors.
Carboprost if PF2a
