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2022 - MFM ORAL BOARDS ALL > OB and Surgical Complications > Flashcards

OB and Surgical Complications Flashcards

1
Q

Describe ultrasound features characteristic for dichorinic twin gestation

A

Thick intertwin membrane (>2mm)
Sex discordance
Lambda / Twin peak signs

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2
Q

When is ultrasound the most accurate at establishing chorionicity in multiple gestation?

A

1st trimester

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3
Q

How do you counsel a patient about the maternal risks of pregnancy with dichorionic twins?

Fetal risks?

A 
Maternal:
Hyperemesis
Gestational diabetes
Hypertensive disorders
Anemia
Hemorrhage
C/S
Postpartum depression

Fetal:
Preterm delivery
Stillbirth
FGR

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4
Q

How do you follow Di/di twins throughout gestation?

A

Serial growth ultrasound

Weekly testing at 36 weeks

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5
Q

Do you follow/perform cervical length screening in twins?

A

No

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6
Q

What are the options for aneuploidy screening in twins?

A

NT
NIPT
Quad screen, sequential, integrated, etc.

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7
Q

When do you recommend delivery of uncomlicated di-di twins?

A

38w0d-38w6d

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8
Q

What are the indications for cesarean in a di/di twin pregnancy?

A

Twin A breech
<32 weeks Twin A cephalic, twin B noncephalic
Usual obstetric indications
Twin A cephalic, twin B noncephalic and OB provider not trained in management of breech 2nd twin

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9
Q

How do you counsel a patient about risk following a dichorionic cotwin demise in the first trimester?

A

It can happen fairly commonly

Not usually associated with increased morbidity or mortality of the cotwin

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10
Q

How do you counsel a patient about risk following a dichorionic cotwin demise in the second trimester?

A

3% -22% risk of cotwin death

1% risk of neurologic abnormality

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11
Q

How do you counsel a patient about risk following a dichorionic cotwin demise in the third trimester?

A

3-22% risk of cotwin death

1% risk of neurologic abnormality

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12
Q

How do you follow a patient following a dichorionic co twin demise in the first trimester?

A

Routine obstetric care

But would not use cell free-DNA or serum screens for aneuploidy (NT alone or invasive testing)

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13
Q

How do you follow a patient following a dichorionic co twin demise in the second trimester?

A

Monitor growth of surviving twin
Antenatal testing
Do not deliver surviving twin as it does not decrease brain injury in 2nd twin

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14
Q

How do you follow a patient following a dichorionic co twin demise in the third trimester?

A

Monitor growth of surviving twin
Antenatal testing
Do not deliver surviving twin as it does not decrease brain injury in 2nd twin

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15
Q

Do di/di twins run in families?

A

Yes, on the moms side (more likely to release two eggs, for a non-identical twin)

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16
Q

How do you manage a patient with twins and history of a prior spontaneous preterm birth?

A

Routine obstetric care

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17
Q

What pregnancy complications are unique to monochorionic twins compared to dichorionic twins?

A 
Twin-to-twin transfusion syndrome
Twin anemia polycthemia sequence
Acardiac twin (TRAP)
Conjoined twins
Fetal anomalies
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18
Q

Describe ultrasound features characteristic for a mo/di twin pregnancy?

A

T-sign
Thin intertwin membrane (<2mm)
Sex concordance

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19
Q

How do you follow mo/di twins during pregnancy?

A

1st trimester US for dating/chorionicity
TTTS Monitoring (Ultrasound every 2 weeks for fluid and growth, if abnormal –> UA Dopplers)
TAPS monitoring (MCA Doppler velocimetry q2 weeks starting at 26 weeks)
Fetal echocardiogram at 18-22 weeks
Serial growth ultrasounds
Weekly antenatal testing at 32 weeks

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20
Q

When do you recommend delivery of uncomplicated monochorionic twin gestation?

A

Mono/Di : 34w0d-37w6d (but usually say 36-37 weeks)

Mono/Mono: 32w0d-34w0d

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21
Q

How do you counsel a patient about risks follow a monochorionic cotwin demise in the first trimester?

A

Unclear whether there can be an increased risk of neurologic abnormality

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22
Q

How do you counsel a patient about risks follow a monochorionic cotwin demise in the second trimester?

A

15%-40% risk of cotwin death
18%-30% risk of neurologic abnormality
Also if previable offer termination due to the increased risk of neurological abnormality
immediate delivery of the co-twin has not been demonstrated to be of benefit

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23
Q

How do you counsel a patient about risks follow a monochorionic cotwin demise in the third trimester?

A

15%-40% risk of cotwin death
18%-30% risk of neurologic abnornality
immediate delivery of the co-twin has not been demonstrated to be of benefit

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24
Q

How do you follow a patient following a monochorionic cotwin demise in the first trimester?

A

Routine obstetric care

But would not use cell free-DNA or serum screens for aneuploidy (NT alone or invasive testing)

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25
Q

How do you follow a patient following a monochorionic cotwin demise in the second trimester?

A

Monitor growth of surviving twin
Antenatal testing
Do not deliver surviving twin as it does not decrease brain injury in 2nd twin

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26
Q

How do you follow a patient following a monochorionic cotwin demise in the third trimester?

A

If occurs in late 2nd or in 3rd trimester
Admit for steroids, magnesium sulfate and continuous monitoring
Monitor growth of surviving twin
Antenatal testing
Do not deliver surviving twin as it does not decrease brain injury in 2nd twin

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27
Q

If an intertwin dividing membrane cannot be visualized, what is your differential diagnosis?

A

TTTS with stuck twin
Monochorionic-monoamniotic twin pregnancy
Rupture of membranes

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28
Q

What is the likelihood of developing TTTS in a mo/di twin pregnancy?

A

10-15%

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29
Q

What is TTTS?

A

Complication of Mono-di pregnancies where there is unequal balance of blood flow via A-V connections in the placenta that results in one twin donating blood (donor) to the other twin (recipient) resulting in increased morbidity and mortality.

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30
Q

What are the US features leading you to suspect TTTS?

A

Donor: volume depleted, growth restricted, oligohydramnios
Recipient: polycythemic, heart failure, polyhydramnios, hypervolemic, hydrops

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31
Q

What are the Quintero stages of TTTS?

A 
I: Poly-Oli
II: Poly-Oli + Absent bladder in donor
III: Absent/reversed UA diastolic flow, reversed ductus venosus, pulsatile UV flow
IV: Hydrops fetalis in one or both twins
V: Fetal demise
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32
Q

When do you refer a patient for possible laser surgery for TTTS?

A

II, III, and IV TTTS in continuing pregnancies at <26 weeks

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33
Q

Why do we not perform laser on Stage I TTTS?

A

> 75% will regress / remain stable

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34
Q

How do you counsel the patient regarding the benefits of laser therapy for TTTS?

A

Improved survival at 6 months
Improved neurologic outcomes
Later ga at delivery

Single procedure vs. multiple procedures

80% survival of at least 1 twin
50% survival of both twins

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35
Q

How do you follow a patient after laser surgery for TTTS?

A 
Weekly for 2-3 weeks
q 2 weeks if stable
Growths q 4
Antenatal testing at 28 weeks
Delivery at 34-36 weeks
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36
Q

What are the potential comlications that can occur post laser for TTTS?

A 
PPROM 
Iatrogenic Mono mono twinning
Fetal demise (1 or 2)
Brain lesions 
PVLM
Persistent cardiac disease (pulmonary valve)
TAPS 
TTTS recurrence 
TTTS reversal
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37
Q

When do you recommend delivery following laser surgery for TTTS?

A

Goal of 34-36 weeks

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38
Q

What is TAPS?

A

Unbalanced blood distribution between twins w/o amniotic fluid discordance; Likely through small (< 1mm) vessels
Unidirectional, unreciprocated artery and vein anastamoses near periphery of placenta

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39
Q

How do you define TAPS?

A

MCA PSV> 1.5 MoM in one twin and < 1.0 MoM in the other twin

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40
Q

Do you screen for TAPS?

A

MCA PSV starting at >26 weeks

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41
Q

How is TAPS detected?

A

MCA PSV> 1.5 MoM in one twin and < 1.0 MoM in the other twin

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42
Q

What is the likelihood of developing TAPS in a mo/di twin gestation?

A

5%

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43
Q

What is the likelhood of developing TAPS following laser surgery for TTTS?

A

10-15%

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44
Q

If TAPS is detected, how will you manage the patient?

A

??Expectant management, delivery (stage I), selective feticide, IUT (may be short duration, may worsen polycythemia hyperviscosity syndrome in the recipient, skin necrosis of LE reported)-donor IV vs IP, partial exchange IUT or laser ???

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45
Q

Describe US features of monoamniotic twin gestation

A

Cord entanglement
No intertwin membrane
Sex concordance
One placenta

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46
Q

How do you counsel a patient about the pregnancy risks of a monoamniotic twin gestation?

A

Cord entanglement
TTTS
Congenital malformations

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47
Q

How do you manage a monoamniotic twin gestation?

A

Offer early inpatient management (beginning at 24–28 weeks of gestation) with daily fetal surveillance
Regular assessment of fetal growth

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48
Q

When do you recommend delivery for a monoamniotic twin gestation?

A

32-34 weeks

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49
Q

How do you manage cotwin demise with a monoamniotic twin gestation?

A

Consider delaying delivery to allow steroids

Delivery after 30 weeks, but can consider continued monitoring until 32

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50
Q

What is a placental abruption?

A

When a normally implanted placenta prematurely separates from the uterus

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51
Q

What are risk factors for a placental abruption?

A 
Prior history
Hypertensive disorders
Trauma
Cocaine / Smoking
Polyhydramnios
Multiple gestation
PPROM
Infection
Uterine anomalies/fibroids
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52
Q

What would make you suspect an abruption?

A

Painful vaginal bleeding

Nonreassuring fetal heart tracing with tachysystole

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53
Q

If an abruption is seen on US, describe the US characteristics?

A

Hyperechoic or isoechoic collections that turn hypoechoic 2 weeks after event

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54
Q

Does a normal US exclude the possibility of abruption?

A

50% of abruptions are not seen on ultrasound

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55
Q

What is a concealed abruption?

A

An abruption that doesnt communicate with cervix and therefore you dont see vaginal bleeding

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56
Q

What are the maternal risks if an abruption occurs?

A

Hemorrhage, hypovolemia, shock
Coagulopathy
Need for hysterectomy

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57
Q

What are the fetal risks if an abruption occurs?

A

Fetal growth restriction
PPROM
Prematurity and associated morbidity/mortality
Fetal death

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58
Q

What lab tests will you order if you suspect an abruption?

A 
CBC
PT/PTT
Fibrinogen
Type and cross
KB if Rh negative
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59
Q

How do you evaluate a patient if you suspect an abruption?

A 
Vital signs
Evaluate for bleeding (speculum)
CBC
PT/PTT
Fibrinogen
Type and cross
KB if Rh negative
Ultrasound
FHR/Toco
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60
Q

How do you manage a patient if an abruption is diagnosed?

A

If >2 bleeds or >34 weeks deliver

<34 weeks and hemodynamically stable without further bleeding, surveillance with delivery at 37 weeks

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61
Q

What is a placenta previa?

A

When the placenta is covering the internal cervical os

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62
Q

How is a placenta previa diagnosed?

A

Transvaginal ultrasound

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63
Q

If a placenta previa is identified at <20 weeks on ultrasound, how likely is it to resolve?

A

90%

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64
Q

If a placenta previa is seen on mid trimester US, how will you follow this patient?

A

Repeat ultrasound at 32 weeks

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65
Q

How do you counsel a patient if a placenta previa is noted on her 32 weeks US?

A

That it still has the possibility to resolve, though the likelihood is smaller now than before
Reevaluate at 36 weeks, if still previa, recommend delivery by C/section.

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66
Q

When is delivery recommended for placenta previa?

A

36w0d-37w6d

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67
Q

How do you manage a patient who presents with a bleeding placenta previa?

A

Assess maternal / fetal status
Consider betamethasone / magnesium sulfate if viable/appropriate
Rhogam if Rh negative
Consider delivery if >34 weeks

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68
Q

When do you recommend hospitalization for patients with a placenta previa?

A

3+ bleeding episodes

Long distance from hospital

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69
Q

Do you recommend bedrest for patients with a placenta previa?

A

No

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70
Q

What are the maternal risks with a placenta previa?

A 
Hemorrhage, need for blood transfusion 
Need for cesarean section 
Increased hospitalization 
Need for hysterectomy particularly if associated with history of cesarean section and MAP 
Maternal death
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71
Q

What are the fetal risks with a placenta previa?

A

Preterm delivery

Increased neonatal morbidity/mortality due to prematurity

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72
Q 
What is the chance of invasive placentation in patients with a previa and 
0 prior uterine surgeries?
1 prior c/s?
2 prior c/s?
3 prior c/s?
A

0: 3%
1: 11%
2: 40%
3: 61%

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73
Q

What is a vasa previa?

A

Type 1: Velamentous cord insertion with umbilical vessels inserted into the membranes near or directly Over the internal cervical os
Type 2: Umbilical vessels coursing over membranes between a succenturiate lobe and main lobe near or over the cervix

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74
Q

How is a vasa previa diagnosed?

A

Transvaginal ultrasound: Uumbilical vessels crossing within 1-2cm of the endocervical os with color doppler

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75
Q

What are the maternal risks with a vasa previa?

A

hemorrhage
need for blood transfusion
need for cesarean section

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76
Q

When do you recommend hospitalization for patients with a vasa previa?

A

30-34 weeks

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77
Q

Do you recommend bedrest for patients with a vasa previa?

A

No, but I recommend pelvic rest

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78
Q

When do you recommend delivery for patients with a vasa previa?

A

34-35 weeks

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79
Q

What is placenta accreta spectrum disorder?

A

Where the placenta has invaded to/beyond the myometrium

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80
Q

What are the US findings suggestive of placenta accreta spectrum?

A

(1) Loss of normal hypoechoic retroplacental zone
(2) Multiple vascular lacunae in placenta (swiss cheese placenta)
(3) Blood vessels or placenta tissue bridging uterine-placental margin, myometrial bladder interface or crossing uterine serosa (disruption of serosa/bladder interface)
(4) Retroplacenta myometrial thickness <1mm
(5) bulging of placenta beyond or distorting the uterine contour

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81
Q

What is the role of MRI in the diagnosis of placenta accreta spectrum?

A

Unable to adequately visualize the uteroplacental interface (obesity)
Suspected percreta

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82
Q

Is MRI superior to US for the diagnosis of placenta accreta spectrum?

A

Not superior to ultrasound

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83
Q

What are the risk factors for placenta accreta spectrum?

A

previa
prior c/section
prior myomectomy

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84
Q

If placenta accreta spectrum is suspected, how do you counsel the patient?

A 
Increased risk of: 
Hemorrhage (life threatening)
Preterm birth w/ need for cesarean hysterectomy
Morbidity d/t cesarean hysterectomy
Risk of mortality
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85
Q

How will you manage the pregnancy if placenta accreta spectrum is diagnosed on US?

A

Planned cesarean hysterectomy at 34-35 weeks

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86
Q

Describe your delivery plan for a patient with placenta accreta spectrum?

A

Cesarean hysterectomy at 34-35w
Steroids for fetal lung maturity in week prior
Maximize preop Hb (iron if indicated)
Multidisciplinary approach
Plan for intraoperative hemorrhage / transfusion (cell saver and blood product availability)
Central lines

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87
Q

What are the risks of cesarean hysterectomy?

A

Hemorrhage
Risk of ICU admission due to hemorrhage
Damage to GI/GU systems/Ovaries

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88
Q

Describe your surgical approach for cesarean hysterectomy for placenta accreta spectrum?

A 
Consult with NICU, Gyn Onc or Gen surgery and anesthesia
Blood products on hold
Lithotomy position
Midline abdominal incision
Fundal uterine incision
No attempted removal of placenta
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89
Q

What are the risk factors for hypertensive disorders in pregnancy?

A 
High risk factors: 
Prior Hx 
CHTN
Diabetes
Multiple gestation
Renal disease
Autoimmune disease (SLE, APS)
Moderate risk factors: Age, Weight, Nulliparity, Fam hx, Socioeconomic status, Hx of LBW
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90
Q

Who do you consider to be a candidate for baby ASA to prevent preeclampsia?

A

1 high risk factor or 2+ moderate risk factors

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91
Q

How do you define GHTN?

A

SBP >= 140 or DBP >= 90 after 20 weeks
two occasions 4 hours apart
without proteinuria or severe features

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92
Q

What is severe GHTN?

A

SBP >= 160 or DBP >= 110 after 20 weeks on two occasions 4 hours apart without proteinuria

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93
Q

How do you manage a patient with severe GHTN?

A

The same as preeclampsia WITH severe features
Admit to hospital
Mag / Steroids
BP control (Goal <160/110)
Delivery at 34 weeks or sooner if contraindications arise

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94
Q

What are the pregnancy risks with GHTN?

A 
Abruption
Preeclampsia with severe features
Stroke
Seizure
Pulmonary Edema
End-organ damage (Kidney, liver, brain)
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95
Q

How do you screen for preeclampsia?

A

History

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96
Q

Do you perform Uterine Artery Dopplers to assess risk for preeclampsia?

A

No, low positive predictive value, so I currently use history for screening

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97
Q

What are criteria to diagnose preeclampsia?

A

SBP >= 140 or DBP >= 90 after 20 weeks on two occasions 4 hours apart
WITH proteinuria
OR WITH severe features

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98
Q

How do you diagnose preeclampsia w/ severe features?

A

SBP >= 160 or DBP >= 110 after 20 weeks on two occasions 4 hours apart
WITH proteinuria
OR WITH severe features

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99
Q

What are the severe features of preeclampsia?

A

SBP >=160 or DBP >= 110 after 20 weeks on 2 occasions at least 4 hours apart
Visual changes/Persistent HA not relieved by meds
Creatinine >=1.1 or 2X baseline
LFTs >= 2X ULN, or persistent RUQ/epigastric pain not relieved by conservative management or explained by alternative dx
Pulmonary edema
Platelets < 100

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100
Q

Can a patient have preeclampsia without proteinuria? Example?

A

Yes, Patient presenting with new hypertension and abnormal lab findings

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101
Q

How do you define proteinuria?

A

300mg in a 24 hour urine protein collection
Protein creatinine ratio of >0.3
2+ protein on a dipstick if no other testing is available

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102
Q

How do you manage a patient with preeclampsia WITHOUT severe features diagnosed after 24 weeks?

A 
Outpatient management
Home BP checks / evaluation for signs/symptoms of preeclampsia
Betamethasone
Weekly labs
Antenatal testing
Serial growth ultrasounds
Timing of delivery: 37 weeks
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103
Q

How do you manage a patient with preeclampsia WITH severe features diagnosed prior to 24 weeks?

A

Supportive care, magnesium sulfate and delivery

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104
Q

How do you manage a patient with preeclampsia WITH severe features diagnosed in the third trimester?

A 
Inpatient management:
Betamethasone
Magnesium sulfate
Antihypertensives to keep BP out of severe range
Serial labs
Antenatal testing
Serial growth ultrasounds
Timing of delivery: 34 weeks, or earlier if contraindications to expectant management
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105
Q

What preeclamptic patients are a candidate for mag sulfate?

A

Severe features

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106
Q

How do you administer mag sulfate?

A

4g bolus / 2g/hr

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107
Q

What is a therapeutic mag level?

A

4.8 - 9.6mg/dL

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108
Q

What is the role of magnesium levels?

A

Monitor that magnesium is in therapeutic range, especially in patients at high risk for mag toxicity (elevated creatinine, low urine output, symptoms of mag toxicity)

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109
Q

How do you manage magnesium in a patient with renal insufficiency?

A

Decrease maintenance from 2g/hr to 1g/hr
Monitor magnesium levels
Monitor for signs/symptoms of mag toxicity

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110
Q

What are signs and symptoms of mangesium toxicity?

At what levels do changes occur?

A 
Flushing
Headache
Loss of reflexes (9mg/dL)
Respiratory depression (12mg/dL)
Cardiovascular collapse (at 30mg/dL)
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111
Q

How do you manage mag toxicity?

A

1g Calcium gluconate 10% IV, 10mL given over 3 minutes

Furosemide to promote renal clearance

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112
Q

Why is Calcium gluconate administered over 3 minutes?

A

Risk of respiratory depression or acute hypertension if pushed too fast

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113
Q

When are indications for delivery in a patient with preeclampsia w/out severe features?

A

37 weeks of gestation

The usual obstetric indications

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114
Q

What are the MATERNAL contraindications for expectant management in preeclampsia WITH severe features?

A 
Severe BPs not responsive to meds
Persistent headaches, refractory to tx
Epigastric/ruq pain unresponsive to tx
Visual disturbances, altered sensorium
HELLP syndrome
New/worse renal dysfunction
Pulmonary edema
Stroke
Myocardial infarction
Eclampsia
DIC
Abruption or VB w/out previa
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115
Q

What are the FETAL contraindications for expectant management in preeclampsia WITH severe features?

A

Abnormal fetal testing
Fetal death
Fetus without expectation for survival (eg, lethal anomaly, extreme prematurity)
Persistent rEDV in umbilical artery

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116
Q

Is there a role for outpatient management of preeclampsia?

A

Yes WITHOUT severe features

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117
Q

What blood pressure requires antihypertensive therapy?

A

> =160/110

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118
Q

Describe your approach to a patient with severe hypertension?

A

Treat acutely to get BP <160/110
Regimen 1: Labetalol: 20,40,80 Hydralazine: 10
OR
Regimen 2: Hydralazine 10, 10 Labetalol: 20,40
OR
Regimen 3: Oral nifedipine 10, 20, 20 Labetalol: 20
Repeating BP at 10 mins for Labetalol, 20 mins for hydralazine, nifedipine

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119
Q

What is your first line medication for treatment of severe hypertension?

A

IV labetalol

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120
Q

What is your goal of therapy for treatment of hypertension?

A

BP <160/110

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121
Q

How will you manage the patient who has not responded to IV labetalol and hydralazine therapy?

A

ICU transfer - IV infusion with nicardipine or esmolol

Arterial line

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122
Q

What are indications for an arterial line in preeclampsia?

A

pulmonary edema

requiring antihypertensive drip

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123
Q

What would make you suspect that your preeclamptic patient is developing pulmonary edema?

A

Shortness of breath
O2 saturation < 95%
Decreased urine output

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124
Q

In preeclampsia, If the patient develops hypoxemia, how will you evaluate her?

A 
Listen to lungs
Continuous pulsox
CXR
Urine output
Check for mag toxicity
Labs including mag level and creatinine
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125
Q

In preeclampsia, what is your differential diagnosis for hypoxemia?

A

Pulmonary edema
Mag toxicity
Pulmonary embolism
Pneumonia

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126
Q

How will you manage anesthesia and analgesia in a preeclamptic patient with platelet count of 90,000?

A

Neuraxial anesthesia

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127
Q

How will you manage anesthesia and analgesia in a preeclamptic patient with platelet count of 60,000?

A

General anesthesia

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128
Q

How will you manage anesthesia and analgesia in a preeclamptic patient with platelet count of 30,000?

A

General anesthesia

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129
Q

How do you manage a patient who present within 7 days postpartum with hypertension?

A

Admission to hospital
Magnesium sulfate x 24 hours
Antihypertensives

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130
Q

How do you follow your patient postpartum if she was delivered for preeclampsia?

A

Control BP in hospital prior to discharge
Home BP monitoring
Preeclampsia precautions (specifically headache)
BP check in office in 1 week

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131
Q

How do you counsel a patient with preeclampsia about her risk of cardiovascular disease?

A

Women with a history of preeclampsia continue to have an elevated risk of cardiovascular disease in subsequent years
Hypertension
Myocardial infarction
Congestive heart failure
Cerebrovascular events (stroke)
Peripheral arterial disease
and Cardiovascular mortality later in life
May warrant closer long-term follow-up and lifestyle modifications to better manage risk factors for cardiovascular disease (eg, achieving healthful weight, exercise, diet, smoking cessation)

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132
Q

What is the risk of recurrent hypertensive disorder in a subsequent pregnancy?

A

Approximately 15% (higher if early and severe, lower if later and non-severe)

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133
Q

What is eclampsia?

A

Convulsive manifestation of the hypertensive disorders of pregnancy
New onset tonic clonic, focal or multifocal seizure in the absence of other causes (epilepsy, infarction, hemorrhage, drugs)

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134
Q

What are the risks to the patient of having an eclamptic seizure?

A

Hypoxia
Aspiration pneumonia
Trauma

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135
Q

Describe how you will manage a patient having an eclamptic seizure?

A

Call for help
Prevent maternal injury (Padding railings)
Prevent aspiration (Lateral decubitus position)
Supplemental oxygen
Monitor vital signs
Magnesium sulfate
Delivery once stable (does not need to be c/s)

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136
Q

What is the risk of seizure in preeclampia?

A

Severe: 1/50

Non-severe: 1/200

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137
Q

When do you recommend brain imaging in eclampsia?

A

Refractory Seizure or while on mag
Vision loss
Altered mental status
Focal symptoms

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138
Q

How will you proceed with delivery following an eclamptic seizure?

A

Cesarean is not required, but at <28 weeks approximately 97% risk, decreases to 65% from 28-32 weeks

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139
Q

How do you manage the patient with an intractable seizure?

A

A further 2-4g magnesium bolus over 5 minutes
If still seizing at 20 mins after bolus, or >2 recurrences:
Sodium amobarbitol (250mg IV in 3 mins)
Thiopental
Phenytoin (1250mg IV at 50mg/minute)
ICU admission and consider intubation

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140
Q

What are the fetal risks during a seizure?

A

Hypoxemia
abruption,
fetal demise

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141
Q

When do you recommend head CT vs MRI in eclampsia?

A

If suspect hemorrhage -> CT

If suspect PRES -> MRI

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142
Q

How is HELLP syndrome defined?

A

LDH >600 IU/L
AST/ALT >2x ULN
Platelet <100 x 10^9/L

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143
Q

How do you manage a patient with HELLP syndrome?

A

Delivery regardless of gestational age (consider trying to complete steroids if stable)
Supportive care
Serial labs

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144
Q

What are maternal/fetal risks from HELLP syndrome?

A 
DIC
Abruption
Acute kidney injury
Pulmonary edema
subcapsular or intraparenchymal liver hematoma
Retinal detachment 
Small for gestational age
Stillbirth / neonatal death 
Maternal death
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145
Q

Is there a role for steroids in the management of HELLP syndrome?

A

Only for the usual fetal indications

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146
Q

What would make you suspect a subcapsular hematoma?

A

Severe RUQ/epigastric pain
Abnormal LFTs
Nausea/vomitting

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147
Q

If a subcapsular hematoma is identified how will you manage the patient?

A

Obtain CT/MRI
Assess vitals/coags
Transfuse / volume replete
Delivery once hemodynamically stable and anemia / coagulopathy are corrected
Consult ICU / Surgery (liver trauma experienced)

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148
Q

What are the risks of a subcapsular hematoma?

A

Capsular rupture -> hemorrhage -> Severe anemia
DIC
Maternal death

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149
Q

How do you manage a patient with a ruptured subcapsular hematoma?

A

Massive transfusion protocol
Consultation for anesthesia and trauma surgery
Delivery via c/s

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150
Q

How do you counsel patient about recurrence risks following a pregnancy complicated by HELLP syndrome?

A

7%

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151
Q

Differential diagnosis for HELLP?

A

Acute fatty liver of pregnancy
thrombotic thrombocytopenic purpura
pregnancy-related hemolytic-uremic syndrome
systemic lupus erythematosus

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152
Q

How do you define preterm labor?

A

Regular contractions with cervical change

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153
Q

What are risk factors for preterm labor?

A 
Prior preterm birth
PPROM
Short cervix 
Infection
Multiple gestation
Polyhydramnios
Smoking / Drugs
Medical conditions
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154
Q

How do you evaluate a patient presenting with suspected preterm labor?

A 
H&P 
Assess frequency of contractions and history of preterm delivery
Labs: UA, UDS, GBS, GC, wet mount
SSE w/ FFN collection
Cervical length
>3, sent home
<2 dont sent FFN, check cervix and admit for PTL management
2-3cm I would send an FFN
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155
Q

How do you manage preterm labor?

A

Betamethasone
Magnesium sulfate for neuroprotection
FHR / Toco
I consider tocolytics for 48 hours in patients <34 weeks for the purpose of administration of steroids

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156
Q

How do you manage a patient admitted for PTL at 36 weeks?

A 
Admit to hospital
UA, Urine culture
Antibiotics for GBS prophylaxis if positive or unknown
Steroids 
No tocolytics
Expectant management
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157
Q

What tocolytic do you use for PTL treatment?

A

Indomethacin

Procardia

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158
Q

What is the role of terbutaline in the management of preterm labor?

A

I do not use it, but it can be used for short duration for the purpose of getting steroids on board

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159
Q

What are the contraindications to tocolysis?

A 
Intrauterine fetal demise
Lethal fetal anomaly
Nonreassuring fetal status
Severe preeclampsia or eclampsia
Maternal bleeding w/ hemodynamic instability
Chorioamnionitis
PPROM
Maternal contraindications to specific medications
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160
Q

Specific contraindications for procardia?

A

Hypotension

Preload depending cardiac lesions (aortic insufficiency)

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161
Q

Specific contraindications for Indomethacin?

A 
Platelet dysfunction / bleeding disorder
Hepatic dysfunction
GI Ulcer
Renal dysfunction
Asthma (in women with hypersensitivity to aspirin)
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162
Q

Specific contraindications for terbutaline?

A

Tachycardia sensitive maternal cardiac disease

Poorly controlled DM

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163
Q

What are potential complications of prolonged terbutaline use in a pregnant woman?

A 
Death 
Arrhythmias / Tachycardia 
Hyperglycemia
Hypokalemia
Pulmonary edema
Myocardial ischemia
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164
Q

Who do you consider a candidate for tocolysis?

A

Women at <34 week receiving corticosteroids due to increaed risk of preterm delivery
Women with uterine tachysystole
Women undergoing cerclage

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165
Q

What are the risks of chronic NSAID use in pregnancy at/or beyond 32 weeks gestation?

A

In utero constriction of ductus arteriosus (PDA)
Oligohydramnios
Necrotizing enterocolitis in preterm newborns

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166
Q

Will you tocolyze a previable gestation?

A

Not for preterm labor, though it can be used after a procedure (like abdominal surgery or cerclage placement)

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167
Q

How long do you continue tocolysis?

A

48 hours

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168
Q

Is there a role for oral tocolysis beyond 48-72 hours?

A

No

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169
Q

Who is a candidate for corticosteroids for fetal benefit?

A

Women that are at increased risk of delivery in the next 7 days that are less than 37 weeks

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170
Q

Who is a candidate for “rescue steroids?

A

<34 weeks of gestation AND at risk of preterm delivery within the next 7 days
AND whose prior course was >14 days prior (but can be considered within 7 days)
Unclear if beneficial in patients with PPROM

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171
Q

Who is a candidate for corticosteroids between 34-36w6d?

A

Singleton
No prior antenatal steroids
Not in patients likely to deliver in 12 hours
Not in patients with pregestational diabetes

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172
Q

Benefit of late preterm steroids?

A

Decreased need for respiratory support in 72 hours

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173
Q

Do you give more than 2 courses of steroids for fetal benefit?

A

No

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174
Q

What is the earliest gestational age you will give steroids for fetal benefit?

A

22 weeks if neonatal resuscitation is planned as it may help with mortality

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175
Q

What is the latest gestational age you will give steroids for fetal benefit?

A

36w6d

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176
Q

How does magnesium provide fetal benefit?

A

reduces the severity and risk of cerebral palsy, possibly via decreased excitotoxicity in the brain

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177
Q

Who is a candidate for magnesium for fetal neuroprotection?

A

Increased risk of imminent preterm delivery and gestational age>23 weeks but <32 weeks

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178
Q

Describe your regimen for mangesium for fetal neuroprotection.

A

4-6g loading dose, 1-2g/hour maintenance dose

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179
Q

Who should receive GBS prophylaxis

A 
GBS positive in labor
GBS bacteriuria in this pregnancy
GBS unknown and preterm
GBS unknown and >18 hours ruptured
GBS unknown and prior pregnancy with GBS colonization
GBS unknown and maternal fever >=100.4
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180
Q

How do you manage a patient with PTL and unknown GBS?

A

GBS culture

then treat them

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181
Q

How do you manage GBS prophylaxis in a patient with a low-risk allergy to penicillin?

A

Treat with cephalosporin

Cefazolin 2g iv, 1g q8h

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182
Q

How do you manage GBS prophylaxis in a patient with a high-risk allergy to penicillin?

A

Clindamycin and erythro susceptible: Clindamycin 900 mg IV every 8 hrs until delivery
Isolate not clindamycin susceptible: Vancomycin 1g q12 hours

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183
Q

When is a patient a candidate for discharge from the hospital following treatment for PTL?

A

Depends on the clinical picture and distance from hospital

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184
Q

What is the role of bedrest in the management of PTL?

A

No role, increases risk of thrombosis

185
Q

Do you manage twin gestation with PTL differently from singletons?

A

No

186
Q

How do you counsel a patient about future pregnancy risk and management if she delivers prematurely due to PTL?

A

This puts her at an increased risk of it happening again (35%)
She can help decrease that risk with IM progesterone or vaginal progesterone
We can perform serial cervical lengths from 16-24 weeks with consideration for cerclage if cervix is <2.5cm

187
Q

Which patients are candidates for 17 OHPC in pregnancy?

A

Singleton with history of prior spontaneous preterm birth

188
Q

How do you manage a patient with asymptomatic preterm cervical dilation found on exam at 18 weeks?

A

assess for infection (urine cx, vag cx, +/- amnio)
assess for uterine contractions
Offer exam indicated cerclage

189
Q

How do you manage a patient with asymptomatic preterm cervical dilation found on exam at 22 weeks?

A

assess for infection (urine cx, vag cx, +/- amnio)
assess for uterine contractions
Offer exam indicated cerclage

190
Q

How do you manage a patient with asymptomatic preterm cervical dilation found on exam at 25 weeks?

A

assess for infection
assess for uterine contractions
GBS prophylaxis, betamethasone, magnesium sulfate

191
Q

What questions will you ask the patient if she is found to have preterm cervical dilation?

A 
Has she felt contractions
Any recent fevers / chills
Any foul smelling vaginal discharge
Abdominal pain
Any recent trauma
Any bleeding
Prior history of preterm delivery?
Prior history of cervical procedures
192
Q

How do you manage a patient with symptomatic (contractions or spotting) preterm cervical dilation found on examination at 18 weeks gestation?

A

Assess for infection / abruption
Stabilize mom
Supportive care

193
Q

How do you manage a patient with symptomatic (contractions or spotting) preterm cervical dilation found on examination at 22 weeks gestation?

A 
Assess for infection / abruption
Rh status / Rhogam if applicable
Stabilize mom
Discuss periviable period, can offer steroids
Supportive care
194
Q

How do you manage a patient with symptomatic (contractions or spotting) preterm cervical dilation found on examination at 25 weeks gestation?

A 
Detailed H&P
Labs: UA, UDS, GBS, GC swab, wet mount
Rh status / Rhogam if applicable
Stabilize mom
Fetal monitoring / toco
Collect FFN, perform cervical length
Depending on evaluation +/- Steroids, tocolysis, magnesium sulfate, antibiotics for GBS prophylaxis
195
Q

How do you use an fFN to guide management in suspected preterm labor?

A

Collect FFN for anyone with suspected preterm labor <34 weeks
Then perform a cervical length
If >3, I dont send fFN and consider discharge
If <2, I dont send fFN and admit for continue management of PTL
If 2-3, I send fFN, if negative I consider discharge, if positive I consider admitting and continue managment for PTL

196
Q

In whom do you perform an fFN?

A

I send an FFN on any patient with symptoms of preterm labor with a cervical length between 2.0cm - 3.0cm.

197
Q

When do you recommend amniocentesis in the setting of preterm cervical dilation?

A

If planning for an exam indicated cerclage

198
Q

What studies do you send on amniotic fluid to evaluate for intra-amniotic infection?

A

Gram staining
Culture for aerobic and anaerobic bacteria
Glucose
WBC

199
Q

How do you interpret results of amniotic fluid studies for intrauterine infection?

A

Gram stain (positive)
Culture (positive)
Glucose <14 : suggestive of infection (high specificity /sensitivity, PPV 62.5%)
WBC: >50 cells/mm^3 (

200
Q

How common is intra-amniotic infection present in patients with preterm cervical dilation?

A

10% if no PPROM

Up to 35% if PPROM

201
Q

Do you screen / treat for BV to prevent PTB?

A

Not in asymptomatic women, I would test and treat if symptomatic

202
Q

What is the definition of a short cervix?

A

Cervical length <2.5 cm at <24w0d

203
Q

Describe how you measure a cervical length?

A 
Transvaginal ultrasound
Empty bladder
Cervix occupying 2/3 of the screen
Seeing internal and external os
Equal thickness of anterior and posterior parts of cervix
204
Q

Do you perform universal cervical length screening?

A

Yes

205
Q

When in gestation do you recommend screening cervical length be performed?

A

18-22 weeks

206
Q

What is the role of an abdominal cervical length assessment?

A

To screen for short cervix, if short –> transvaginal ultrasound

207
Q

Do you do cervical length screening in TWINS?

A

Yes as part of the routine assessment of anatomy at 18-22w6d

If on routine it is suspected to be short, I perform transvaginal ultrasound to better assess cervix.

208
Q

When in gestation should a cervical length surveillance be performed?

A

16 weeks - 23w6d

209
Q

How do you manage a patient with a short cervix at 20 weeks and no prior history of preterm birth?

A

I would review her OB and GYN history in detail

Vaginal progesterone

210
Q

How do you manage a patient with a short cervix at 20 weeks and a prior history of preterm birth?

A

I would review her OB and GYN history in detail

Offer cerclage or vaginal progesterone

211
Q

How do you manage a patient with a short cervix at 20 weeks and no prior history of preterm birth, that was placed on progesterone and now returns with a cervical length of 0.8cm?

A

I offer cerclage for patients on vaginal progesterone due to short cervix when cervical length is <1.0cm

212
Q

What are the benefits of treatment with vagibal progesterone in the management of a patient with a SINGLETON and a short cervix?

A

Decreases neonatal mortality
Decreases neonatal morbidity
Decreases risk of preterm birth by approximately 30%

213
Q

How do you counsel a patient with a SINGLETON and a history of prior spontaneous preterm delivery?

A

Increased risk of preterm birth in a future pregnancy

And there are ways to help decrease that risk (progesterone, cerclage if short cervix)

214
Q

How do you manage a patient with a SINGLETON and a history of a prior spontaneous preterm delivery?

A

I would review her OB and GYN history in detail
Vaginal progesterone or IM progesterone from 16-36 weeks
Cervical length surveillance (16-23w6d) with plan for cerclage for cervical length <2.5cm

215
Q

How do you manage a patient with TWINS with a history of a prior spontaneous preterm birth?

A

No additional management

216
Q

Do you use 17 OHPC in TWINS with a prior history of spontaneous preterm birth?

A

No, though some benefit has been shown in limited studies

217
Q

Do you use vaginal progesterone in TWIN pregnancy with a short cervix?

A

No, though some benefit has been shown in limited studies (data is of such quality to make definitive recommendations difficult)

218
Q

How do you manage a patient with TWINS and previable short cervix?

A

Offer physical exam to assess dilation
If dilated I offer exam indicated cerclage
If not dilated, I manage expectantly

219
Q

How do you manage a patient with TWINS and previable painless cervical dilation?

A

I offer exam indicated cerclage

220
Q

How do you manage a patient with TWINS and a short cervix with a prior history of a spontaneous preterm birth <34 weeks?

A

I do not offer cerclage or vaginal progesterone
I offer a vaginal exam to assess for cervical dilation and consider cerclage if it I find painless cervical dilation prior to 24 weeks.

221
Q

How do you evaluate patients for PPROM?

A

H&P
Sterile speculum exam: ferning, nitrazine, pooling
AFI

222
Q

Significance of nitrazine?

A

Amniotic fluid is more basic (7.1-7.3) then vagina, if positive, suspicious for rupture of membranes

223
Q

False positive for nitrazine?

A

Blood, semen, BV

224
Q

How do you manage a pregnant woman with PPROM after 24 weeks gestation?

A

Admission to hospital
Betamethasone
Antibiotics for latency
Magnesium sulfate for fetal neuroprotection
FHR/Toco
Delivery at 34 weeks, or later with shared decision making

225
Q

How do you counsel a patient about potential complications of PPROM?

A 
Infection
Preterm labor
Abruption
Cord prolapse
Nonreassuring FHR
Increased neonatal morbidity (RDS, IVH, NEC, sepsis)
226
Q

What percent of PPROM patients deliver within 48 hours (previable vs viable)?

A

Previable: 20% in 48 hrs, 40-50% in 1 week

24-34: 50% in 48 hrs, 70-80% in 1 week

227
Q

What are the most common complications following PPROM?

A

Preterm delivery
Infection
Abruption

228
Q

What is the role of antibiotics in the management of patients following PPROM?

A

Increase latency (time from rupture to delivery)

229
Q

What antibiotic regimen fo you utilize to prolong latency following PPROM?

A

Ampicillin 2g IV q6 x 48 hours -> Amoxicillin 250mg q8h x 5 days
AND
Azithromycin (1g, orally, once)

230
Q

What antibiotic regimen do you utilize for a patient with a high risk pencillin allergy following PPROM?

A

Azithromycin (1g, orally, once)
AND
Clinda / Genta

231
Q

What clinical findings are suspicious for intraamniotic infection ?

A 
Uterine tenderness
Foul smelling discharge
Fever
Maternal tachycardia
Fetal tachycardia
Leukocytosis
232
Q

What are the criteria for a presumptive diagnosis of intraamniotic infection?

A 
Fever >39
OR
Fever 38-38.9 
AND 
Fetal tachycardia
Maternal leukocytosis
Purulent fluid from the cervical Os
233
Q

How is intraamniotic infection diagnosis confirmed?

A 
Positive AF gram stain
Low AF glucose <14 mg/dL 
Positive AF culture
High WBC in AF in absence of bloody tap
Histopathologic evidence of triple I in placenta, fetal membranes or umbilical cord vessels.
234
Q

How do you confirm or exclude ruptured membranes in the setting of inconvlusive initial examination?

A

Indigo carmine amnioinfusion (1ml in 9mL of NS)

Assess for leakage of blue-stained fluid into the vagina 20-30 minutes

235
Q

What are complications of previable PPROM?

A 
Preterm birth
Maternal infection (sepsis in 5% of PPROM between 20-24 weeks)
Fetal/neonatal infection
Placental abruption
Umbilical cord prolapse
Fetal/neonatal deformation
Fetal/neonatal death
Retained placenta
Need for C/s via a classical hysterotomy
236
Q

How do you manage a patient following previable PPROM?

A

Counsel
Offer induction of labor vs expectant management
Monitor for infection, abruption, PTL
D/c if stable
Plan to readmit when viability is reached

237
Q

How do you counsel a patient regarding likelihood of fetal pulmonary hypoplasia following PPROM?

A

There is an increased risk of problems due to oligohydramnios as amniotic fluid is critical to the production and function of the pneumocytes and lungs are still developing in a preterm fetus

238
Q

How do you define recurrent pregnancy loss?

A

2 or more failed pregnancies prior to 20 weeks gestation

239
Q

When should recurrent pregnancy loss be worked up?

A

> =3 pregnancy failures
or 2 pregnancy failures and (AMA, difficulty in conception, familial history for pregnancy loss/aneuploidy, fetal cardiac activity seen prior to loss)

240
Q

What percentage of RPL is unexplained? and what percentage of these women go on to achieve a successful pregnancy?

A

50-75% unexplained

75% achieve a successful pregnancy

241
Q

What is your differential diagnosis for the causes of recurrent pregnancy loss?

A

Genetic (balanced translocations, other genetic disorders)
Autoimmune
Anatomic (didelphy / bicornuate / septated uterus)
Maternal Disease
Endocrine
Unexplained

242
Q

What clues are suggestive of a genetic etiology of RPL?

A

Repetitive first trimester losses
Anembryonic pregnancies
AMA
Family history of congenital malformations, MR or xlinked conditions

243
Q

How do you workup products of conception?

A

Chromosomal microarray (higher yield, no growth of cells needed)

244
Q

Limitations of microarray?

A

Cannot see balanced translocations

245
Q

What are the types of translocations?

A

Reciprocal (piece of one chromosome switches with a piece of another)
Robertsonian (acrocentric (13,14,15,21,22) chromosomes that merge long arms)

246
Q

What are the structural causes of RPL?

A

Congenital uterine anomalies (didelphy / bicornuate / septated uterus)
Leiomyomas
Synechiae (asherman’s)
Uterine polyps

247
Q

What is a bicornuate uterus?

A

one cervix, 2 cavities/uterine horns due to lack/incomplete canalization

248
Q

What is a didelphys uterus?

A

2 cervices, 2 cavities/uterine horns due to lack merging / fusion

249
Q

What is a septate uterus?

A

Lack of septal reabsorption

Most common mullein anomaly 3-7% in general population

250
Q

What does bicollis mean?

A

Double cervix

251
Q

How does a bicornuate uterus differe from a didelphys uterus?

A

One cervix in bicornuate

2 cervices in didelphys (may also have vaginal septum)

252
Q

Describe how Mullerian anomalies occur embryologically?

A

Failure of elongation, fusion and canalization or septal reabsorption occurs around 9 weeks gestation

253
Q

How do you counsel a patient about pregnancy risks in the presence of a Mullerian anomaly?

A

Increased risk of malpresentation, miscarriage, growth restriction, preterm birth

254
Q

What is the incidence of maternal renal anomalies if she has a Mullerian anomaly?

A

Up to 30%

255
Q

How do you manage delivery in a patient with a vaginal septum?

A

Can deliver through it

256
Q

How can you improve pregnancy chances in patients with Septate uterus?

A

Hysteroscopic septum resection

257
Q

What are the endocrine causes of RPL?

A 
Luteal phase defect
PCOS
HyperPRL
Poorly controlled DM
Hypothyroidism
258
Q

How is PCOS treated?

A

Metformin

259
Q

What workup do you perform in patients with a history of recurrent pregnancy loss?

A

H&P (family history of pregnancy loss, history of birth defects/genetic abnormalities, history of thrombosis, comorbidities, toxin exposure)
Parental karyotype
Sonohysterogram or 3D ultrasound
Antiphospholipid antibodies (if criteria met)
TSH / Prolactin
HbA1c

260
Q

What are the indications for a cerclage?

A

Exam - indicated
History - indicated
Ultrasound with a history - indicated

261
Q

How do you define cervical insufficiency?

A

Inability of the uterine cervix to retain a pregnancy
In the absence of the contractions / labor
In the second trimester (typically before 24 weeks).

262
Q

How do you counsel a patient with a history of cervical insufficiency?

A

Increased risk of it happening again
Discuss history indicated cerclage at 13-14 weeks
VS
Cervical length surveillance with cerclage for CL<2.5cm

263
Q

Who do you consider to be a candidate for an exam indicated cerclage?

A

Physical exam showing painless cervical dilation in the second trimester

264
Q

Who do you consider to be a candidate for a history indicated cerclage?

A

History of 1+ second trimester losses from painless cervical dilation (without abruption or labor) or that had a cerclage placed due to painless cervical dilation in the 2nd trimester.

265
Q

Who do you consider to be a candidate for an ultrasound indicated cerclage?

A

Patients with a history of a prior spontaneous preterm delivery at <34 weeks
AND
Cervical length <2.5cm before 24 weeks gestation

266
Q

Who do you consider to be a candidate for an abdominal cerclage?

A

Failed cerclage, or history of trachelectomy

267
Q

Describe how you place a McDonald cerclage?

A

Empty bladder
Place speculum and retractor
use ring forcep to grab anterior lip of cervix and place clockwise suture in purse string fashion
5mm mersilene

268
Q

How do you counsel a patient with a history of cervical insufficiency and a short cervix at 18 weeks gestation?

A

Vaginal progesterone or cerclage

269
Q

Do you follow cervical length ultrasounds post cerclage placement? If so, how often?

A

No

270
Q

What are the risk factors for fetal demise?

A 
Prior fetal demise
Prior preeclampsia, abruption, FGR
African american race
nulliparity
advanced maternal age
obesity
preexisting diabetes
chronic hypertension
smoking
alcohol use
ART 
Multiple gestations
271
Q

Risk of stillbirth?

Risk of recurrent stillbirth?

A
  1. 5% , 1/200

2. 5%, 1/40

272
Q

What is your differential diagnosis for a fetal demise?

A 
Placental / Umbilical cord issues
Infection
Genetic causes
HTN
Antiphospholipid antibodies
Hemorrhage
Anomalies
273
Q

What initial workup do you perform following a fetal demise?

A 
Fetal autopsy
placental pathology
karyotype or microarray
antiphospholipid antibody testing
Kleihauer betke
CBC, type and screen
Syphilis screen
274
Q

What additional findings would make you send other testing on a fetal demise and what tests would you send?

A 
Macrosomia: FBS, HbA1c
FGR: APS, CHTN evaluation, autoimmune
Drug use/abruption: tox screen
Hydrops: Parvovirus, Antibody screen, Hb electrophoresis
Viral infection: viral serology
275
Q

Following a fetal demise in the second or third trimester, which evaluations offer the greatest yield?

A

Fetal autopsy
Examination of the placenta, cord and membranes
Karyotype / Microarray analysis
Antiphospholipid antibody testing

276
Q

How would you counsel a patient regarding route of delivery following a second or third trimester fetal demise and prior c/s?

A

No fetal benefit for hysterotomy

277
Q

How would you induce labor in a patient with a fetal demise and a prior cesarean section in the second trimester vs third trimester?

A

2nd trimester: cytotec

3rd trimester: pitocin

278
Q

How do you counsel a patient about the risks of anesthesia during pregnancy?

A

No evidence that in-utero exposure to anesthetics has any effect on the developing brain of the fetus
No anesthetic agent with known teratogenic effects in humans when used at standard concentration at any gestational age

279
Q

Do you perform continuous fetal monitoring during surgery?

A

Can assist in maternal positioning and cardiopulmonary management
Can be considered if fetus is viable, physically possible during procedure, presence of OB with privileges and personnel able to translate the monitoring result and c-section consent obtained prior to delivery

280
Q

How do you counsel a patient about whether fetal monitoring should be performed during surgery in pregnancy?

A

Can be considered if fetus is viable,
However, in most surgery, risks to the fetus are low, ability to interrupt surgery to perform a C/s is limited and monitoring is not always technically possible
testing pre and post procedure is a good option

281
Q

What are the risks of abdominal surgery during pregnancy?

A

Damage to surrounding organs, blood loss, infection, preterm contractions
However, usually risk to fetus is minimal

282
Q

If continuous monitoring is not planned how do you assess the fetus pre and postoperatively during surgery in the first trimester?

A

Doppler

283
Q

If continuous monitoring is not planned how do you assess the fetus pre and postoperatively during surgery in the second trimester?

A

Doppler, NST if viable

284
Q

If continuous monitoring is not planned how do you assess the fetus pre and postoperatively during surgery in the third trimester?

A

NST

285
Q

30 yo G4P3 at 34 weeks presents due to Minor MVA. +spotting, +cramping.
BP 138/84, HR 104, RR 18 , SVE 3/80/-2
How do you evaluate?

A

IVF
EFM/Toco
CBC, Fibrinogen, Coags, Type and screen
Ultrasound

286
Q

30 yo G4P3 at 34 weeks presents due to Minor MVA. +spotting, +cramping.
BP 138/84, HR 104, RR 18 , SVE 3/80/-2
Do you tocolyze?

A

No, you dont tocolyze a suspected abruption

287
Q

30 yo G4P3 at 34 weeks presents due to Minor MVA. +spotting, +cramping.
BP 138/84, HR 104, RR 18 , SVE 3/80/-2
On monitor you see recurrent decels and prep for c/s
Her BP is now 88/40 p 130 and she is drowsy. What is happening?
What do you do?

A 
Suspect a concealed abruption with massive blood loss
Prepare for massive transfusion
2 large bore IVs, Transfusion
IV hydration
Stat C/s with general anesthesia
288
Q

“30 yo G4P3 at 34 weeks presents due to Minor MVA. +spotting, +cramping.
BP 138/84, HR 104, RR 18 , SVE 3/80/-2
On monitor you see recurrent decels and prep for c/s
Her BP is now 88/40 p 130 and she is drowsy. And you go for Stat C/s and activate massive transfusion protocol.
Once on the table, the anesthesiologist reports that she is in Cardiac arrest. What do you do?

A

Call a code
Continue massive transfusion
Perform resuscitative cesarean section (Can do it before 4 minutes if prepared)

289
Q

How do you counsel the patient about risks to the pregnancy following a minor motor vehicle crash or fall?

A

Discuss shearing forces and risk of placental abruption and maternal hemorrhage
In a minor crash, the overall risk is low
But we will monitor FHR, contractions and maternal vital signs for a few hours

290
Q

What labs do you order on the patient following a minor trauma?

A

CBC, Type and screen
KB if Rh negative
If there is bleeding or a lot of contracting -> Coags/Fibrinogen

291
Q

How long do you perform continuous fetal monitoring and contraction monitoring on a patient following minor trauma?

A

4-6 hours post accident if no contractions

24 hours if contracting or direct abdominal trauma

292
Q

What clinical and laboratory signs would make you suspect placental abruption?

A

Tachycardia / Hypotension
Recurrent painful contractions
Bleeding
Dropping fibrinogen, CBC

293
Q

What is the role of Kleihauer Betke screening in the management of a pregnant patient post trauma?

A

Assess for amount of Rhogam if maternal fetal hemorrhage is present

294
Q

How often does an abruption occur in a pregnant woman following minor trauma?
How about in major trauma?

A

<1%

Can be as high in 40% in major trauma

295
Q

What is the accuracy of ultrasound in detecting placental abruption?

A

Not very sensitive

Though high positive predictive value if seen with symptoms

296
Q

Describe your initial assessment of a pregnant woman following major trauma?

A 
(A) airway / cervical spine control
(B) breathing
(C) circulation
(D) disability
(E) exposure- consult with trauma team- consult with NICU- displace uterus > 20 weeks
297
Q

If you are called to the ER for a pregnant woman folloiwng a major traums, what are your initial steps in her evaluation?

A

Assess to see if she is stable: Vitals, Bleeding
If Fetus viable, monitoring
Ultrasound of pregnancy
FAST scan
CBC, Type and cross, Coags, Fibrinogen
Consider steroids if viable, consider magnesium sulfate if <32 weeks

298
Q

What fetal monitoring findings would make you suspect abruption in the patient following trauma, minor or major?

A

Greater than six (6) contractions in an hour

Fetal decelerations

299
Q

Describe how a fibrinogen level can alart you to a concealed abruption?

A

Fibrinogen is consumed to make fibrin clot in the setting of acute bleeding. In the event of preplacental bleed, the bleed may not be seen by ultrasound or vaginally but the fibrinogen would be low suggesting an acute bleed that cannot be seen

300
Q

How can you do a cesarean under local anesthesia?

A

Lidocaine 4mg/kg of 1% lidocaine without epi (30mL)

301
Q

What are the most common causes of cardiac arrest in pregnancy?

A 
Bleeding/ DIC
Embolism (AFE, PE)
Anesthesia complication
Uterine atony
Cardiac complications (MI, cardiomyopathy, arrhythmia)
Hypertension/preeclampsia/eclampsia
Other (5Hs and 4Ts)
Placenta abruption/Previa
Sepsis
302
Q

When do you perform a perimortem cesarean delivery?

A

Maternal cardiac arrest

303
Q

What are the reversible causes of PEA?

A 
Hypovolemia
Hypoxemia
Hyper/Hypokalemia
H+ excess (Acidosis)
Hypothermia
Tension pneumo
Tamponade
Thrombosis (PE)
Thrombosis (MI)
Toxins
304
Q

Describe how you perform a perimortem cessarean delivery?

A

Remain in place where arrest occurred (Do not move to an OR)
Uterus will be manually displaced
Chest compressions continue while CD initiated
No anesthesia necessary
No abdominal prep necessary
Vertical or pfannenstiel
Close uterus while ACLS/CPR continues
Continue palpating aorta to confirm pulse

305
Q

If a pregnant woman develops cardiac arrest at 28 weeks, describe how you will handle the situation?

A 
CABUD
Call code and begin resuscitation
Circulation
Airway and breathing
Uterine displacement (LUD)
Delivery
306
Q

How do you monitor the fetus during CPR?

A

Detach monitors, and prepare for perimortem c/s

307
Q

WHat is the 4 or 5 minute rule in resuscitation in pregnancy?

A

Resuscitative cesarean section after 4 minutes
because it relieves aortocaval obstruction
Improves ability to perform CPR
Improves maternal survival
Improves neonatal outcomes

308
Q

Describe how chest compressions are performed.

A

100 compressions / minute
30:2 compressions to ventillations (Changing every 2 minutes)
No pause for breaths once intubated

309
Q

When do you stop chest compressions for a patient in cardiac arrest?

A

No return of spontaneous circulation after resuscitative hysterotomy

310
Q

Do you recommend relocating the patient to an OR for perimorterm cesarean delivery. Why or why not?

A

No, you do not delay, you deliver whereever you are

311
Q

What are the most common reasons for ICU admission in the pregnant and postpartum patient?

A 
Hypertension
Hemorrhage
Respiratory Failure
Sepsis
Cardiac disease
312
Q

What is preload?

A

Amount of fluid being returned to heart

Left ventricular EDV

313
Q

What is afterload?

A

Resistance to blood flow exiting the heart

314
Q

What are the determinants of Cardiac Output? And what are they determined by? And how can they be estimated?

A

HR X SV (amount of blood pumped out in 1 minute)
SV determined by:
Preload (historically measured with wedge pressure and CVP)
Afterload (PVR and SVR)
Contractility (LVSWI - left ventricular stroke work index)

315
Q

Determinants of BP?

A

SVR X SV X HR

316
Q

Physiologic changes to Cardiac output, SVR and Colloid Oncotic pressure in pregnancy?

A

Cardiac Output increases
SVR decreases
Colloid oncotic pressure decreases

317
Q

Treatment for preload problems?

A

If low Expand volume (fluids)

If high Diurese / Vasodilate

318
Q

Treatment for afterload problems?

A

If low give vasopressors

If high give vasodilators

319
Q

Treatment for contractility?

A

If low give inotropes (digoxin)

320
Q

Treatment for bradycardia / tachycardia?

A

bradycardia: atropine
tachycardia: beta blocker, calcium channel blocker

321
Q

Mnemonic for alpha and beta receptors?

A

1 Heart, 2 Lungs 1: constrict, 2: dilate
Alpha: arteries
Beta: beats/breaths

322
Q

What are indications for invasive hemodynamic monitoring?

A 
Unresponsive shock 
ARDS 
Cardiac failure 
Left heart obstruction 
AFE
323
Q

What are the indications for an arterial line

A 
ARDS
Hypovolemic shock
Septic shock with hypotension
Severe preeclampsia with pulmonary edema 
Cardiac failure
324
Q

What are the types of central lines? And what are they used for?

A 
Arterial line (radial artery) - used for continuous BP and frequent ABG
CVP (central access via jugular or subclavian vein) - Assess volume, RV function, give meds, high volume fluids
PICC line
325
Q

Mixed venous saturation?

A

Mixed venous saturation - (central access via jugular or subclavian vein) - used in sepsis, assess tissue oxygen extraction

If it’s increasing, means body is compensating by extracting more oxygen, which is not a good sign.

326
Q

PA catheter measures?

A

PA Catheter (central access via jugular or subclavian) - Measure CVP, PAP, CO, SVR, PCOP and SvO2

327
Q

What does pulmonary capillary occlusion pressure assess

A

Left sided preload (not used much anymore)

328
Q

What does central venous pressure assess?

A

Right sided preload

329
Q

What is gapped acidosis?

A

Acidosis with an increased anion gap

330
Q

How do you determine if acidosis is gapped or non-gapped?

A

Measure anion gap (Na - Cl - HCO3)

331
Q

What are the risk factors for hemorrhage?

A 
Prolonged labor
LGA fetus
Polyhydramnios
Chorioamnionitis
Twins
Fibroids
Multiparity
332
Q

What is hemorrhagic shock?

A

Reduced intravascular volume from blood loss

  • > inadequate oxygen delivery to meet cellular needs
  • > producing cellular and tissue hypoxia
333
Q

What is the definition of massive transfusion?

A

10u of blood in 24 hours

3u of blood in 1 hour

334
Q

What are the goals of massive transfusion?

A

(1) Hemodynamic stability (fluids)
(2) Oxygenate tissues (red cells)
Hb > 7
Plt > 50,000
Fibrinogen >100 mg/dL
PT/PTT <= 1.5 times control

335
Q

What are risks of massive transfusion?

A

Hypothermia
Coagulopathies
Electrolyte imbalances
Transfusion reactions (Acute lung injury)
Pulmonary edema (cardiogenic if from volume, or non cardiogenic if from DIC or TRALI)

336
Q

What is the lethal triad in management of massive hemorrhage and transfusion? What does it mean when its present?

A

Hypothermia
Coagulopathy
Acidosis
When all 3 are present mortality is as high as >65%

337
Q

How does citrate in blood products effect a patient?

A

Binds calcium -> leading to hypocalcemia -> arrhythmias
Citrate metabolism results in HCO3, which is excreted in urine, if the insulit is enough to decrease removal then the result is Hypokalemia and Alkalosis

338
Q

If you anticipated high risk for inctraoperative hemorrhage, how will you prepare?

A 
Large bore IVs
Type and cross 
Make sure patient is warmed
Hydrate
Baseline labs
If very high risk, central line
339
Q

What is dose and potential side effects of misoprostol?

A

600-1000mcg PO/PR
Fever
Shivering

340
Q

What is dose and potential side effects of hemabate?

A

0.25mg IM q 15-90 max dose 2mg

Diarrhea

341
Q

What is dose and potential side effects of methergine?

A

0.2mg IM

Hypertension

342
Q

How does tranexamic acid work?

A

Reducing bleeding by decreasing fibrinolysis by inhibiting the enzymatic breakdown by plasmin

343
Q

Dose and when should tranexamic acid be used?

A

1g IV, within 3 hours of hemorrhage, and after initial attempts of medical management have failed.

344
Q

Describe how you perform a B-Lynch suture

A

1) A large Mayo needle with # 1 or 2 chromic catgut is used to enter and exit 3 cm below the anterior uterine incision and exit 3 cm above the uterine incision anteriorly
2) then looped over and around to the posterior uterine segment
3) insert a horizontal suture at the posterior lower segment of the uterus which allows you to cross to the other side of the uterus posteriorly
4) loop the suture over and around the uterus again
5) insert the suture 3 cm above and below the incision and tied securely with uterine compression

345
Q

Explain how you manage uterine atony?

A 
Uterine massage
Bimanual pelvic exam
Remove intrauterine clots
Empty bladder
Oxytocin plus second agent 
If unsuccessful then: Uterine tamponade Bakri balloon 300-500mL of saline
346
Q

What are indications for a cesarean hysterectomy?

A 
??Uterine hemorrhage
Infection
Fibroids
Cervical cancer
Adnexal disease??
347
Q

When will you proceed with hysterectomy in a patient who is having active uterine bleeding postpartum?

A

Abnormal vital signs not responding to transfusion

348
Q

What is your management for PPH?

A

Alert OB team
Uterine massage
Bimanual pelvic exam -> remove intrauterine clots
Oxytocin plus second agentIf unsuccessful
Empty bladder
Uterine tamponade Bakri balloon 300-500mL of saline

349
Q

What are your goals for resuscitation in postpartum hemorrhage?

A 
Correct coagulopathy
Correct acidosis
SBP>100
Stop bleeding 
Maintain oxygenation
350
Q

How do you monitor response to resuscitation in PPH?

A

BP/Pulse
Pulse pressure
UOP
SpO2

351
Q

What are triggers for initiating a massive transfusion protocol?

A

acute blood loss and hemodynamic instability

352
Q

Describe how you will manage bleeding from the cuff and peritoneal surfaces post hysterectomy?

A

Topical hemostatics
Packing
Embolization if stable

353
Q

What is the role of IR in the management of hemorrhage?

A

Only for stable patients

354
Q

What is D.I.C?

A

Consumption of clotting factors so that you cant clot anymore

355
Q

How is DIC defined?

A

Acquired complication resulting in widespread formation of clots in the microcirculation

356
Q

Signs/symptoms of DIC?

A

Bleeding
Ecchymosis, petechiae and purpura
Hematuria
Shock out of proportion to blood loss

357
Q

What are some examples of causes of DIC?

A 
Shock
Trauma
Infections
Abruption
Fetal death
Malignancies
358
Q

What is the pathology that occurs in DIC?

A

Endothelial disruption -> Platelet activation (plug formations) ->Intrinsic clotting cascade -> Fibrin mesh work (screen doors to cover holes) -> Plasmin (remodels and trims the meshwork) -> FSP (fibrin split products) fly through circulation and cause damage -> endothelial disruption…

359
Q

What damage do fibrin split products cause?

A 
RBC damage (hemolysis)
Damage to endothelial lining of pulmonary capillary bed (acute lung injury)
Plugs microcirculation (Tissue necrosiss / organ injury)
Leads to platelet dysfunction -> bleeding
360
Q

What laboratory workup to you perform?

A 
Fibrinogen
PT (prolongs before PTT)
361
Q

What is your differential diagnosis of a patient in DIC?

A 
Massive blood loss
HIT
Vitamin K Deficiency
Liver Insufficiency
Thrombotic microangiopathy
362
Q

What are fibrin split products?

A

Pieces of clot from remodeling that can fly thru vasculature and cause problems

363
Q

What is a normal fibrinogen level in a pregnant patient?

A

> 300mg

364
Q

What are complications of DIC?

A

Hemorrhage
Tissue necrosis / Organ injury
Lung injury
Hemolysis

365
Q

How do you manage DIC in a patient due to hemorrhage?

A

Massive transfusion protocol

Control bleeding

366
Q

What is FFP? Volume?

A

Plasma (Fibrinogen, clotting factors) 250mL

367
Q

What is in FFP?

A

Fibrinogen, plasma, clotting factors

368
Q

How much will a single unit of FFP raise fibrinogen levels?

A

10-15

369
Q

What is cryoprecipitate? Volume?

A

Distilled FFP, with smaller volume but more concentrated factors 40mL

370
Q

Whats in cryoprecipitate?

A

Fibrinogen, Factor 8, Factor XIII, VWF

371
Q

How much wll a single unit of cryoprecitate raise fibrinogen levels?

A

10-15

372
Q

What are the lab targets for massive transfusion?

A

Hb > 7
Plt > 50,000
Fibrinogen >100 mg/dL
PT/PTT <= 1.5 times control

373
Q

Why do patient get acidotic and hypothermic in the setting of massive transfusion?

A

Hypothermia: decreased blood volume and open abdomen allowing escape of warmth
Acidotic: Hypoperfusion

374
Q

What is transfusion related acute lung injury (TRALI)?

A

Transfusion related acute lung injury

Fluid build-up in the lungs/acute injury following transfusion with no other explanation

375
Q

How is TRALI diagnosed?

A

new acute respiratory distress syndrome (ARDS) within six hours after blood product administration documented by hypoxemia and abnormal chest imaging.

376
Q

How is TRALI managed?

A

Stop transfusion
WBC
CXR
Notify blood bank to screen for anti leukocyte antibodies

377
Q

How is oxygen carried in your blood?

A

It saturates Hb first, and then whats left over is dissolved in plasma
Attached to Hb (SaO2) - 98-99%
Dissolved in plasma (PaO2) - 1-2% of it

378
Q

What is the normal PaO2?

A

80-100mmHg

379
Q

What is the respiratory alkalosis of pregnancy?

A

Alkalosis due to changes during pregnancy
Minute ventillation (Tidal volume * RR) goes up due to an increase in TV
As a result, mom Breathes off extra CO2 -> Decreased CO2 levels
This allows for the gradient to be from fetus to mom to get rid of CO2
Decreased maternal PaCO2 leads to chronic alkalosis, and the compensatory process is kidney excreting Bicarbonate

380
Q

What are the key changes seen on an ABG in pregnancy?

A 
pH increases slightly 
CO2 decreases (from 35-45 -> 25-30) - SHOULD NEVER BE IN NORMAL RANGE DURING PREGNANCY
HCO3 decreases (22-26 -> 18-26)
381
Q

How does supplemental oxygen affect ABG results in a patient with healthy lungs?

A

??

382
Q

What is your differential diagnosis for a patient who presents with hypoxemia?

A

Asthma
Pneumonia
Pulmonary edema
Pulmonary embolism

383
Q

If a patient presents with hypoxemia, describe your initial assessment?

A 
H&P (history of asthma, what medications they are, increased risk of clotting, BP or signs of preeclampsia. listen to lungs)
Give O2 
CXR 
ABG
If asthma (bronchodilators)
If PE suspected CTPA or LE Dopplers 
If Pulmonary edema suspected (Echo)
If fetus is viable, evaluate fetus (FHR / Toco)
384
Q

Describe how you will escalate oxygen supplementation if he patient’s hypoxemia is not improving?

A 
Nasal canula (24-40%)
Face mask (45-55%)
Nonrebreather (70%)
High flow (100%)
CPAP
BiPap
Mechanical Ventillation
ECMO
385
Q

What is your goal of oxygen supplementation?

A

> =95%

386
Q

What are in indications for intubation?

A

Failure to oxygenate (O2 sat<95% or PaO2 <80-100)
Failure to ventillate (High PCO2 on ABG, eg. asthma)
Unable to maintain the work of breathing (High RR, uncooperative, despite O2 is okay)
Unable to protect airway (seizure, trauma)

387
Q

Goals for Ventillation settings?

A

Tidal volume increases in pregnancy (6-10mL /kg)
Goal PaO2 >60mmHg
Goal SaO2 >95%
Goal PaCO2 27-32

388
Q

If the patient is in respiratory failure and pregnant with a viable fetus, how do you assess the fetus?

A

Continuous FHR until stable

389
Q

If the patient is in respiratory failure and pregnant with a previable fetus, how do you assess the fetus?

A

FH check

390
Q

What are the indications for delivery in the setting of respiratory failure?

A

Evidence for delivery to improve maternal condition is conflicting and not compelling
Fetal benefit
Individualize care

391
Q

General management for: Cardiogenic pulmonary edema

A

Decrease preload / afterload (diuresis, BP control)

Improve contractility

392
Q

General management for: Noncardiogenic pulmonary edema

A

Diuresis

Treat primary cause

393
Q

Targeted therapy for: Asthma

A

Bronchodilator

394
Q

Targeted therapy for: Pneumonia

A

Antibiotics

395
Q

Targeted therapy for: Pulmonary embolism

A

Anticoagulation

396
Q

Targeted therapy for: ARDS

A

Supportive care

Address the underlying cause

397
Q

What factors do you take into consideration when deciding whether or not to proceed with delivery in a patient in respiratory failure and pregnant with a viable fetus?

A

Gestational age of the fetus?
Will delivery improve maternal status?
Is mom stable for delivery?

398
Q

What factors do you take into consideration when deciding whether or not to proceed with delivery in a patient in respiratory failure and pregnant with a previable fetus?

A

Will delivery improve maternal status?

Is mom stable for delivery?

399
Q

What is cardiogenic pulmonary edema?

A

Hydrostatic pulmonary edema
Heart is not able to keep up with the volume, so overflows into the lungs
Doesnt need to have a primary heart problem, can be increased fluid volume

400
Q

Examples of cardiogenic pulmonary edema?

A 
CHF
Cardiomyopathy
Hypertension
Arrhythmias
Volume overload
401
Q

What is non-cardiogenic pulmonary edema?

A

Non-hydrostatic pulmonary edema
Heart is not the problem,
NOT an overflow problem, a leaky vessel problem

402
Q

Examples of noncardiogenic pulmonary edema?

A 
Pre-eclampsia
ARDS
Sepsis
DIC
TRALI
Amniotic fluid embolism
Aspiration Pneumonia
403
Q

How do you differentiate between cardiogenic and non-cardiogenic pulmonary edema?

A

Cardiogenic
Patchy infiltrates at lung bases
BNP elevated
Decreased LV function on Echo

Non-cardiogenic
homogenous fluffy shadows
BNP <100
High WBC
Normal LV function
404
Q

What clinical signs and symptoms suggest pulmonary edema?

A 
Hypoxemia
Dyspnea
Tachypnea
Tachycardia
Crackles
Chest pain
Cough
405
Q

What physiologic changes in pregnancy predispose her to cardiogenic pulmonary edema?

A

Increased intravascular volume
Increased vascular permeability ???
Lower serum colloid osmotic (oncotic) pressure ??

406
Q

How do you diagnose pulmonary edema?

A

Clinical suspicion

CXR

407
Q

Describe your management of pulmonary edema?

A

Monitor the fetus
O2 (Goal SaO2 >=95%)
Sit patient up to recruit lower alveoli
Diuresis
Assess volume status (Cardiogenic vs. Noncardiogenic)
BNP or Echo
Decrease Afterload (depending on etiology)

408
Q

How do you gauge appropriate response to your management of pulmonary edema?

A

Assess oxygenation, ventillation and work of breathing

409
Q

If the patient continues to have worsening hypoxemia despite diuretic therapy, how will you manage her?

A

Consider stepping up in oxygen delivery methods
Contine diuresing
Consider intubation

410
Q

What is the role of positive pressure ventilation in the management of respiratory failure?

A

CPAP and BiPap

Keeps airways open by hi flow air

411
Q

What is high flow nasal canula?

A

Heated/Humidified
Inspiratory demands met better
FRC increases via delivery of PEEP
Lighter than CPAP or BiPap)
Oxygen dilution minimized by meeting flow demands
Washout of dead space due to hihg flow rates

412
Q

What is ARDS?

A

Decreased lung compliance and intrapulmonary shunting

413
Q

What are the risk factors for developing ARDS?

A 
Sepsis
Trauma
Aspiration
Massive transfusion
Pneumonia
414
Q

How do you diagnose ARDS?

A

Symptoms within 1 week of a clinical insult
B/l opacities
Rule out cardiac failure and fluid overload with echo
P/F < 300

415
Q

What is the PF ratio?

A

PaO2 / FiO2, tells us how well oxygen exchange is
Low = poor
High = good

416
Q

What are the key management principles for ARDS?

A

Treat underlying cause (sepsis, trauma) and give supportive measures
O2
Vitals & I/Os
Elevat head of bed / prone (recruit the lower alveoli of lung)
Sedation if needed
Monitor for need to intubate

417
Q

How is sepsis defined?

A

Life threatening organ dysfunction caused by a dysregulated host reponse to infection

418
Q

What is septic shock?

A

Sepsis with persistent hypotension requiring vasopressors to maintain a MAP > 65mmHg
AND
Lactate level >2mmol/L despite adequate fluid resuscitation

419
Q

How do you assess for septic shock?

A

BP
lactate level
Assess volume status
Assess urine output

420
Q

What are the most common sources for sepsis in the pregnant and postpartum patient?

A 
Chorioamnionitis
Septic abortion
Wound infection
Endometritis
Pyelonephritis
Pneumonia
421
Q

What are the most common organisms that cause sepsis in the pregnant and postpartum patient?

A

E.coli
Group A strep
Group B strep

422
Q

What is your initial antibiotic of choice in the septic pregnant patient?

A 
Depends on the suspected infection
Pneumonia: ceftriaxone and azithromycin
Chorioamnionitis: amp/gent
Endometritis: amp/gent/clinda
Pyelonephritis: ceftriaxone
423
Q

What is a SOFA score?

A

An objective assesment score for organ dysfunction

424
Q

Components of SOFA scoore?

A 
PaO2/FiO2
Platelets
Bilirubin
MAP
Glasgow coma scale
Creatinine
425
Q

Components of qSOFA?

A

SBP <100
RR >22
Altered mental status

426
Q

Describe the key principles of sepsis management?

A 
Maintain BP (Hydration/pressors)
Source control
427
Q

What is your initial management of a patient suspected to be septic?

A 
Obtain cultures
Obtain lactate
Administer broad spectrum antibiotics
Initiate fluid therapy (30mL/kg of crystalloid) to maintain MAP of >65 mmHg
Evaluate fetus
Search for localizing features
428
Q

What are the objective goals of sepsis resuscitation?

A

MAP >= 65mmHg
Normal lactate
Urine output > 0.5mL / kg / hour

429
Q

28 week patient in triage with pyelonephritis and suspected sepsis.
She received 4L IV fluid, is getting amp and gent infusion.
Vital signs 90/50, HR 128 T39 O2sat 92%
EFM Cat 2 with baseline tachycardia and moderate variability with occasional decels.
What are your next steps?

A

Suspicious that she is hypovolemic (4L still hypotensive)
Lactate level
Assess urine output
Assess volume status (discuss how with intensivist, Bedside Cardiovascular ultrasound, passive leg raise)

430
Q

What should be performed within 1 hour of suspected sepsis diagnosis?

A

Obtain cultures
Obtain lactate
Administer broad spectrum antibiotics
Initiate fluid therapy (30mL/kg of crystalloid) to maintain MAP of >65 mmHg

431
Q

What labs do you draw in a septic patient?

A 
Cultures
UA
Lactate
CBC
CMP
432
Q

What vital sign abnormalities are most commonly abnormal in the septic pregnant patient?

A 
Heart rate (tachycardia)
BP (hypotension)
433
Q

What is the role of lactate in the septic patient management? What does it mean when it’s elevated ?

A

Help assess perfusion, if elevating , means poorly perfusing

Tissue hypoxia
>2 increases risk for ICU admission
>4 increases risk of death

434
Q

How do you correct an elevated lactate level?

A

Improve perfusion:

IV fluids, vasopressors

435
Q

How do you assess response to fluid resuscitation?

A

Urine output and Blood pressure

436
Q

What are complications that may develop with a septic patient broken down by systems?

A 
CNS: Altered mental status
CV: Hypotension / Heart failure
Pulm: ARDS
GI: Ileus
Hepatic: Hepatic failure
Renal: Oliguria/Acute kidney injury
Hematologic: Thrombocytopenia / DIC
Endocrine: Adrenal dysfunction / Insulin resistance
437
Q

How can you assess respiratory function in a septic patient?

A

Using a P/F Ratio

438
Q

What is the PF ratio?

A

PaO2 / FiO2, tells us how well oxygen exchange is
Low = poor
High = good

439
Q

How do you assess renal function in a septic patient?

A

Creatinine, Urine output

440
Q

If the patient is in the ICU with sepsis, how will you assess the fetus?

A

If viable, fetal monitoring

441
Q

What are indications for delivery in a septic patient?

A 
Intrauterine infection
IUFD
GA a low risk for neonatal complications
DIC (after stabilization)
Respiratory failure (ARDS)
Hepatic failure
Renal failure
Cardiac arrest
Fails to respond to therapy
Maternal condition expected to improve with delivery
442
Q

Do you recommend tocolysis in a septic pregnant patient who is contracting at 24 weeks?
At 30 weeks?
At 36 weeks?

A

No

443
Q

Do you recommend steroids for fetal benefit in a septic patient who is contracting at 24 weeks?
At 30 weeks?
At 36 weeks?

A

Yes, for the usual obstetric indications

444
Q

Do you recommend magnesium for neuroprotection in a septic patient who is contracting at 24 weeks?
At 30 weeks?
At 36 weeks?

A

Yes, if I think she is at high risk of imminent delivery

But not after 32 weeks.

445
Q

What is severe hypertension?

A

> = 160 SBP

OR >= 110 DBP

446
Q

What are your goals of treatment of hypertension?

A

<160 SBP

<110 DBP

447
Q

What is your first-line antihypertensive in a patient with severe hypertension?

A

Labetalol

448
Q

How will you escalate if she does not respond?

A

Treat acutely to get BP <160/110
Regimen 1: Labetalol: 20,40,80 Hydralazine: 10
OR
Regimen 2: Hydralazine 10, 10 Labetalol: 20,40
OR
Regimen 3: Oral nifedipine 10, 20, 20 Labetalol: 20
Repeating BP at 10 mins for Labetalol, 20 mins for hydralazine, nifedipine

449
Q

How do you manage the patient who remains severely hypertensive despite IV labetalol, IV hydralazine and PO nifedipine?

A

ICU transfer - IV infusion with nicardipine or esmolol

Arterial line

450
Q

What are the maternal risks of untreated severe hypertension?

A

Stroke

Heart failure

451
Q

What are the fetal risks of untreated severe hypertension?

A

Abruption
Fetal growth restriction
Fetal death

452
Q

What is posterior reversible encephalopathy syndrome (PRES)?

What are some features of it?

A 
Vasogenic edema in brain leading to clinical findings like: 
Altered mental status
Vision loss / deficit
Seizure
Headache
453
Q

How is PRES diagnosed?

A

MRI of the brain without intravenous (IV) contrast

Shows vasogenic edema in the posterior brain

454
Q

What is the prognosis for PRES?

A

Good prognosis

455
Q

How is PRES managed?

A

Delivery
Antihypertensives
Seizure meds

456
Q

What clinical findings are suggestive of intracranial hemorrhage?

A

sudden severe headaches
focal neurologic deficits
seizures with a prolonged postictal state
or atypical presentation for eclampsia

457
Q

When do you recommend brain imaging?

A

Worse headaches
AMS
focal neurologic deficits (vision loss, stroke like symptoms)
unexplained seizures or seizing on mag

458
Q

When do you recommend Head CT vs MRI?

A

If my concern is for Intracranial hemorrhage

2022 - MFM ORAL BOARDS ALL (6 decks)

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