OB Flashcards
What are the causes of early pregnancy bleeding?
How to w/u early pregnancy bleeding?
b-hCG
CBC (anemia)
speculum exam
vaginal U/S (look for viability/nml pregnancy)
blood type and screen (for Rhogam if need D&C)
antibodies (looking for alloimmunization)
What are the 2 causes of early pregnancy bleeding with a closed cervical os?
missed (non-viable pregnancy) or threatened (pregnancy viable) abortion
What is the best for dating pregnancy?
last menstrual date
U/S in first trimester - crown to rump length +/- 5 days
How do you manage a missed abortion?
- wait to see if happens spontaneously
- misoprostol to stim contractions and explusion
- D&C
How do manage early pregnancy bleeding with an open cervical os?
inevitable abortion - wait, misoprostol, or D&C
incomplete abrotion - some tissue is out, same management (D&C if heavy bleeding)
completed abortion - everthing already out, conservative management
What is a hydatidiform mole?
placental tumor - looks like “snowstorm” or “grape-like” vesicles on US in uterus
b-cHG very high, can beneign or malignant
What fetal abnormalities is valproic acid in pregnancy associated with?
neural tube defects (ancephaly and spina bifida)
How to screen an pt >35 yo for genetic screening?
US for nuchal translucency (12 wks)
quadruple marker screen (12-15 wks)
cell-free DNA testing (10-12 wks)
chorionic villus sampling to confirm (15-20 wks)
How does the quadruple screen work for pregnancy?
maternal serum AFP, hCG, inhibin A, estriol
tri 21: high hCG and ihibin, low AFP and estriol
tri 18: all low
What anatomical anomalies are seen in tri 21?
endocardial cushion defect
duodenal atresia
What is the atypical antibody titer?
indirect coombs test
What antibodies are cocerning for hemolytic disease of the newborn and what has to be true to be danagerous to the fetus?
Anti-kell antibodies (Kell kills)
Anti-duffy antibodies (Duffy dies)
Fetus has to have blood type that is antigen-positive to the concerning antibodies
When concerned about alloimmunization in a pregnancy due to positive testing, what are the next steps?
- find out if dad is positive for the antibody to determine if baby could be positive
*or check baby’s blood with percutanoues umbiical cord sampling
- determine antibody titer (if low - okay), follow monthly, if rises to >1:8, may need early delivery
Who should get rhogam?
any pregnant woman who is Rh- (A-, B-, AB-, O-) at 28 wks and after delivery if baby is Rh +
other times when there is risk for fetal-maternal blood mixing (ectopic, amniocentesis…)
What is normal fetal movement?
10 times in 2 hours
What tests do you do when worried about fetal status in pregnancy?
NST - looking for fetal heart rate accelerations
amniotic fluid - checking how much is there
How do you report the NST?
reactive - presence of fetal heart rate accelerations
non-reactive - absence of fetal heart rate accelerations
if >/= 2 accelerations within 20 mins
What causes late decelerations?
uteroplacental insufficiency
*baby in state where can’t tolerate contractions/lack of blood flow for a short period
What is the biophysical profile?
test of fetal well-being
*always start with NST and amniotic fluid assessment (if good, don’t need to do the rest)
*score of 8-10 is reassuring (2 pts per line)
*score 4-6: worrisome, deliver if >36 wks or follow frequently
*score of 0 or 2 - fetal hypoxia - get baby out no matter age
How to differentiate preterm labor from preterm contractions?
labor - cervical changes (dilation or effacement)
contractions - no cervical changes
What is the ddx for preterm contractions?
What is a fetal fibronectin test and when shoudl it be done?
predicts if will deliver in next few days, if neg, very low chance (not that helpful if pos)
do the test before any other part of speculum exam or cervial exam
How to evaluate preterm labor?
digital cervical exam (dialtion, effacement, fetal station)
bedside US (fetal position and cervical length)
GBS swab
What should be offered to women who had a previous preterm delivery and normal cervical length in a next pregnancy?
IM 17-OH-progesterone weekly to decrease likelihood of preterm delivery starting in 2nd trimester - 36 wks
What are risks for preterm delivery?
hx of previous preterm delivery (that wasn’t induced or for another indication)
cervical length < 25 mm
What should be offered to a pregnant woman who is found to have cervical length <20 mm?
daily vaginal progesterone tx until 36 wks
What are the criteria for preterm labor?
gestational age 20-36 wks
>2 contractions in 30 mins
cervix atleast 2 cm dilated on exam or cervix showing signs of change
How to monitor pt in labor?
external FHR monitor
tocometer for contractions
vitals…etc
What interventions do you need to do to protect the preterm fetus?
- IV MgSO4 for fetal neuroprotection if < 32 wks
- IM betamethasone (2 doses 24 hours apart) for pulm maturity if <34 wks
- abx for GBS prophylaxis (pen G, clindamycin, vancomycin, erythromycin need at least 4 hours prior to birth)
- tocolytic agents (delay delivery by 48 hours) -
*Magnesium sulfate (need to keep deep tendon reflexes, don’t give for renal insuff or myasthenia gravis)
*terbutaline (don’t give if CV disease, DM, or uncontrolled hyperthyroidism)
*nifedipine (CCB), don’t give if hypotension, tachycardia, CV disease
*indomethacin (decr prostaglandin production), can cause oligohydramnios, or PDA in pt >32 wks (contraindicated if >32 wks)
What are risks for preterm labor?
How do you screen for gestational diabetes?
1 hr 50 g oral glucose tolerance test
if abnormal go to 3 hr 100g test (fasting)
How do you initially manage gestational diabetes?
small frequent meals, diet change
home glucose monitoring
weekly office visits
monthly US for fetal growth
deliver at 40 wks
How do you manage gestational DM if diet not working?
insulin
glyburide (does not cross placenta)
monitor with NSTs and maionitic fluid indexes BID from 32 wk to
delivery at 39 wks
How do you manage shoulder dystocia?
suprapubic pressure
flex maternal thighs and rotate legs out laterally
deliver posterior shoulder
rotate the shoulders
What are common complications for infants of diabetic moms?
How to manage GDM postpartum?
watch for postpartum hemorrhage (uterine atony or laceration)
check 2 fasting blood sugars after 6 wks
How to monitor for preeclampsia?
BP - >140/90 on repeated measurments at least 4 hrs apart
UA for protein (if not protein, not preeclampsia)
CBC (incr hgb)
PLT (thrombocytopenia)
ALT/AST,
BUN/Cr, Uric acid (high if hemoconcentrated)
urine drug screen
Ddx for HTN in pregnancy?
What is the difference between mild and severe HTN in pregnancy?
mild >140/90
severe > 160/110
How to dx preecclampsia with severe pts?
severe HTN
PLTs < 100k
incr AST/ALT
incr Cr >1.1
pul edema
new onset cerebral or visual disturbances
How do you monitor a pt with preeclampsia without severe features?
if <37 wks, inpt obs and follow maternal and fetal status
*give IM steroids if <34 wks
deliver at 37 weeks (induce)
How do you monitor a pt with preeclampsia with severe features?
start IV continuous Mg sulfate to prevent seizures
lower bp with IV hydralazine or IV labetalol
start IV oxytocin to induce labor (if have time/depends on how severe and what cervix looks like)
deliver!
How to manage Mg toxicity on pregnant mom who is delvering?
stop continuous Mg!
*never give mg in myasthenia gravis - can cause respirtory arrest
How to manage gestational hypertension?
monitor for sings of preeclampsia
deliver at 37 wks
(No mg sulfate needed0
How to manage chronic HTN in pregnancy?
meds if BP >160/105 with labetalol, nifedipine, or methyldopa
deliver at 38 wks
How do you work up post-partum hemorrhage?
try to determine cause of bleeding
2 large bore IVs and bolus NS
foley catheter to monitor urine output
CBC, type and cross, 2 untis of red blood,
do bimanual uterine massage
give IV oxtocin, if no response, IM methylergonovine, if no response give IV prostaglandin E1
How to induce labor?
place foley ballon in the cervix to soften
start IV oxytocin (continuous)
*can do an amniotomy to further move things along
