OB Meded Flashcards
CV changes in pregnancy
DECREASED MAP (BP) overall
^HR and ^Preload but decreased SVR due to placental circulation
decreased Hgb (^RBC but ^^plasma volume)
^IVC compression, turn on Left side!
respiratory changes in pregnancy
^tidal volume, decreased FRC (she takes deeper breaths but is unable to “store” as much air)
FEV1 and RR is SAME
coagulatory changes in pregnancy
HYPERCOAGULABLE
^vWF, ^fibrinogen and d-dimer, ^Factors 7, 8, 10, ^tPa-inhibitor
decrease protein C, S
good for preventing hemorrhage, ^risk DVT/PE
renal changes in pregnancy
^GFR (more blood flow overall) decreased Cr (0.4-0.8) obstructive uropathy at pelvic brim
weight changes in pregnancy
BMI less than 18.5: 28-40 lbs
18.5-25: 25-35
25-30: 15-25
30+: 10-15
GI changes in pregnancy
GERD, nausea, constipation, Fe deficiency
pre-conception visit
safety
folate
vaccines: flu (IM), Hep B, MMRV (live attenuated, can’t give after pregnant)
lifestyle: smoking, etOH, drugs
optimization of disease: DM, HTN, hypothyroid (may need to increase dose)
1st trimester evaluation
10 weeks vitals, weight, safety Gs and Ps, History, risk factors dx: UCG, U/S, intrauterine, gestational age, multiple do not need serum hCG
Gs and Ps
G TPAL
Gravid (# pregnancies)
Term, Preterm, Abortions, Living
blood tests to get at 1st trimester visit
ABO, Rh-Ab, Hbg/Hct
HIB, Hep B, RPR
titers: varicella, rubella
urine tests to get at 1st trimester visit
U/A and urine culture
tx asymptomatic bacteruria
proteinuria baselines (eclampsia)
Gc/Chlamydia
cytology at 1st trimester visit
pap smear
genetic screens at 1st trimester visit
CF
HgbSS (SCD)
how often to see pregnant female
q4 weeks until 28 weeks
q2 weeks until 36 weeks
q1 weeks until delivery
aneuploidy
Down’s: 21
Edward’s: 18
Patau’s: 13
^risk in AMA, but prevalence highest in younger women
aneuploidy screening test
1st trim: U/S for nuchal translucency (less than 3 mm), PAPP-A, hCG
2nd trim: triple: hCG, AFP, Estriol +Inhibin-A for quad
Down’s quad screen
^hCG, low AFP, low estriol, ^Inhibin-A
Edward’s quad screen
LOW hCG, low AFP, low estriol, LOW Inhibin-A
ALL LOW
new genetic screen
cell-free DNA:
fetal DNA in maternal blood
disease to look for at 20-28 weeks of preganancy
Gestational DM
Alloimmunization
Maternal Anemia
Gestational DM
DM +20 weeks gestation
^risk: BMI 30+, GDM hx, pre-diabetic
GDM tests
1-hr glucose tolerance test (50g) positive if 140+ move onto 3-hr GTT: fasting: 90+ 1 hr: 180+ 2 hr: 155+ 3 hr: 140+ need any 2 to be + NOT HbA1C or 2 hr GTT
GDM tx
insulin
post-prandial sugars less than 180
some oral hypoglycemics starting to be used
how mom becomes alloimmunized
Rh-Ag - with previous Rh-Ag+ baby, mom is now Rh-AB +
will attack next Rh-Ag+ baby and cause fetal anemia
screen for Rh-Ab+
if Rh-Ab- and baby could be Rh-Ag+, give RhoGAM at 28 weeks and within 72 hrs of delivery
if mom has Rh-AB+ and baby could be Rh-Ag+ and mom has ^titers and right type, what to do to assess for fetal anemia
transcranial doppler (TCD) PUBS is incorrect (used to transfuse baby)- percutaneous umbilical blood sampling
normal Hgb/Hct at 28 weeks
10/30
may have iron deficiency, get CBC at 28 weeks
folate does not typically cause anemia in pregnant women
reasons to get U/S in pregnancy
1st trimester: determine IUP, GA, multiple preg.
3rd: fetal well being, lie/orientation, oligo/polyhydramnios
accuracy of U/S in predicting gestational age
1st trimester: GA +/- 1 wk
2nd: GA +/- 2 wks
3rd: GA +/- 3 wks
when transcranial doppler used
\+20 weeks in setting of fetal anemia no risk (u/s) ^velocity of blood: anemia, sensitive but does not provide dx and tx
when to get amniocentesis
only reliable +16 wks
confirm genetic disorders
loss is about 1/300
(used to use for fetal anemia and lung maturity, no longer)
CVS
used at 10+ weeks
genetic disorders: karyotypes and genes
loss about 1/500
good for early detection and termination
PUBS
percutaneous umbilical blood sampling 20+ wks, less than 34 wks if fetal anemia on +TCD used for diagnosis and fix get Hgb and can transfuse but typically just deliver if +TCD
treatment of asymptomatic bacteriuria and cystitis in pregnancy
AMOXICILLIN
2nd line: nitrofurantoin (macrobid) if PCN-allergic
NO bactrim or cipro!
RESCREEN pt after treatment
treatment of pyelonephritis in pregnancy
admit, IV rocephin
reassess, if have improved over 3 days: 10 ds abx
if has not improved, think perinephric abscess: abx 14 days, U/S (can’t use CT) and drain
treatment of hyperthyroidism in pregnancy
PTU, surgical removal 2nd trimester
NO iodine/radiological ablation
NO methimazole
treatment of hypothyroidism in pregnancy
levothyroxine
^TBG, so may need 25%^ dose
get TSH q4wks
seizure treatment in pregancy
Leviteracetam, Lamotrigine, phenobarbital are safer
NO valproic acid, phenytoin, carbamezipine
BP goal in preg
medications to use
less than 140/80 safe meds: a-methyldopa, labetalol, hydrazine, nifedipine "HTN moms love nifedipine" no ACE-i, ARBs, CCB, diuretics tight ecclampsia screening
insulin requirements in pregnancy
increase (with increased hormones)
basal-bolus insulin (transition before becoming pregnancy)
target post-prandial sugars
decrease insulin after delivery (need sugars!)
uncontrolled sugars early on
transposition of great vessels
uncontrolled sugars later on
macrosomia, shoulder dystocia, delivery complications
Labor stage 1
latent: dilation 0 cm to 6 cm (6 cm is critical point, after which cervix will rapidly dilate to 10 cm)
active: dilation from 6 cm to 10 cm
20 hrs nulli (1.2 cm/hr)
14 hrs multi (1.5 cm/hr)
Labor stage 2
10 cm (max) to delivery of fetus
3 hrs nulli
2 hrs multi
Labor stage 3
delivery of fetus to delivery of placenta
30 minutes
cervical change
breakage of disulfide bonds with infusion of water
softening, effacement (shorter), dilation (wider), position
happen in response to fetal head engagement
fetal station
use ischial spine (point 0)
- 5: 5 cm deeper than ischial spine
5: 5 cm out
fetal position
longitudinal cephalic
aligned with mom, head down
malalignment: longitudinal breech or transverse
how to determine fetal position
how to move baby
Leopold maneuver
can also use u/s
external version to move baby, if fails to align consider C-section
breech definitions
frank: hips flexed, knees extended
complete: hips and knees flexed
footling: either
delay in active labor
no change in 4 hrs or progress takes longer than 5 hrs
how to engage cervix in latent phase
balloon
amniotomy (rupture sac)
misoprostal (prostaglandin)
oxytocin* (used in active phase as well)
3 Ps
passenger
pelvis
power: can augment with oxytocin
adequate contractions
200 mV units in 10 minutes measured with IUPC
augmentation (oxy) not likely to help if sufficient
(good: 3 in 10 minutes, bad: less than 3 in 30 minutes)
if oxytocin fails in active phase?
if in stage III?
C-section
if stage 3, may use forceps or vacuum if baby is positive position, C-section if negative
delay of stage 3
is a problem with power (just placenta coming out)
start with uterine massage, then try oxytocin, THEN manual extraction (not D&C)
delivery ranges
nonviable: 0-20/24 weeks
preterm: 24-37 weeks
term: 37-42 weeks
post-dates: +42 weeks
“treatment age”: 34 weeks
PROM
Premature ROM:
term, before contractions (think GBS) if GBS+ or unknown give ampicillin
and wait for delivery
duration of labor should not exceed
18 hrs
if +18: prolonged rupture of membranes
how to determine ROM
nitralazine blue test : amniotic fluid turns it blue
slide shows ferning
U/S: oligo (less fluid)
P-PROM
preterm premature ROM: before term, no contractions
if +34 weeks: deliver
if less than 24: abortion
in between: give steroids for lung maturity
may lead to prolonged ROM
prolonged ROM
18+ hrs worry about GBS endometritis (baby out) and chorioamnionitis (baby in) mom will be feverish and toxic Do NOT get vaginal cx get U/A, CXR, blood CX tx: amp and gent WITH clindamycin
risk factors for prematurity (defined by contractions AND cervical change and before term)
smoking, young maternal age, multiple gestations, preterm ROM, anatomical abnormalities
if preterm and between 20 and 34 weeks
give steroids and tocolytics
post-date problems
40+ weeks by conception
42+ weeks by dates
macrosomia, dystocia, dysmaturity
transient HTN
nonsustained +140/80
follow up with ambulatory BP log
chronic HTN
sustained +140/80
onset before 20 weeks
no U/A findings, no symptoms
tx: a-methyldopa, may also use labetelol, hydralazine
f/u: close monitoring for pre-E (U/A, U/S)
gestational HTN
sustained +140/90 AFTER 20 weeks
no U/A changes or symptoms
tx and f/u: same as chronic HTN
may progress to pre-E
mild pre-eclampsia (PEC: pre-E without severe features)
sustained +140/90 after 20 weeks
+300mg/dL proteinuria on 24hr (1+ or 2+ on dipstick)
NO symptoms, some edema (hands, feet, face)
tx: deliver if 37+ wks
f/u: frequent screening and visits
severe pre-eclampsia (SPEC: pre-E with severe features)
sustained + 160/110 after 20 weeks
+5g/mL proteinuria 24-hr (3+ dipstick), WITH symptoms (AMS, vision, liver), generalized edema
tx: Mg+ and deliver via induction
eclampsia
SPEC with seizures
tx: Mg+ and deliver (C-section)
HELLP syndrome
Hemolysis, Elevated Liver enzymes, Low platelets
tx: same was as eclampsia: Mg+ and deliver
if giving Mg+ check for ?
decreased DTRs, may lead to decrease RR and resp. failure
tx: Ca2+ as antidote
severe features of eclampsia
RUQ pain, low plts, ^LFTs, hemolysis, ^Cr (+1.1 or doubling), pulmonary edema, HA, vision changes, BP +160/110
if twins are different genders
dizygotic gestation
dichorionic, diamniotic
2 fertilizations
risks: preterm delivery (4 wks for each visit), malpresenation (^risk C-section), postpartum hemorrhage
if twins are same gender and 2 placentas are present
may be monozygotic gestation
dichorionic, diamniotic
(“identical twins”)
split in 0-3 days (tubal phase)
if same placenta but 2 sacs
monozygotic
monochrorionic, diamniotic
split in 4-8 days (blastocyst phase)
risk: same blood supply so twin-twin transfusion (donating twin will do better than receiving twin)
if same placenta and 1 sac
monozygotic, monochorionic, monoamniotic
split 9-12 days
risk: conjoined twins (if split +12 days), cord entanglement (also twin-twin transfusion)
post partum hemorrhage
+500 cc in vaginal delivery
+1000 cc in C-section
pregnant females can tolerate more blood loss
PPH and uterus is absent?
uterine inversion
contracting so hard it “births” itself, due oxytocin of ^traction
tx: try to put back manually, may need tocolytics and uterine tonics
PPH and boggy uterus?
uterine atony
due to prolonged labor, oxytocin removed, given tocolytics
tx: massage, oxytocin, PGE, methergine, hemabate, may need sx
PPH and firm uterus?
retained placenta
placenta burrows deeply, has accessory lobe, causes placental tear
tx: D+C, TAH
f/u: B-hCG, ensure no chorioamnionitis
PPH and normal uterus?
vaginal laceration
due to precipitous delivery, macrosomia, episiotomy
tx: pressure, suture, look for DIC
if can’t find cause of PPH and/or it is refractory to treatment
2 large bore IVs (18 gauge+), IVF, type/cross, call surgeon
may try IV estrogen but likely to be unsuccessful
surgical treatments for refractory/unexplained PPH
uterine artery ligation (OB)
uterine artery embolization (IR)
TAH (OB)
placenta probs
accreta: deeper into endometrium
percreta: into myometrium
increta: all the way throw myometrium, may progress to outside organs
may result in retained placenta, may see blood vessels go all the way to edge of removed part of placenta
DIC
low platelets (give platelets), low Hgb (give pRBCs), less fibrinogen (give cryoprecipitate), ^INR (give FFP), schistocytes
normal fibrinogen after delivery is ABNORMAL (should be elevated)
why no ACE-I and ARBs
cause fetal malformations
high-risk pregnancy or decreased fetal movement algorithm
1st do NST
if non reassuring, repeat NST after vibroacoustic stimulation
if still not good BPP (0-10)
if BPP is 0-2 fetal demise imminent (deliver- C/S)
if BPP less than 8 and +37 wks: deliver vaginally
if BPP less than 8 and less than 37 wga: contraction stress test (CST)
if bradycardia or late decels: delivery imminent (C/S)
what you want on NST
appropriate variability (no flat lining or too much)
accelerations: 15/15 (acceleration rises 15 bpm and last for 15 seconds), 2 in 20 min (10/10 if less than 32 wga)
no decelerations
BPP
like “APGAR score” use if fail NST + VAS
look at NST, AFI, breathing, movement, tone
0-2 pts for each
AFI
divide uterus into 4 quadrants sum of all 4, normal is +5 reassuring: 8-25 oligo: less than 5 (kidney problem) poly: +25 (GI problem)
CST
+ contractions
look for LATE decelerations and bradycardia
used in labor or if failed BPP
want 3ctx/10 minutes (200 mV units)
Late decelerations
look like they start when contractions peak
utero-placental insufficiency
immediate C/S
painless vs painful 3rd trimester bleeding
painless: placental problem, baby’s blood (previa, occurs with dilation)
painful: uterus problem, mom’s blood
placenta previa dx and tx
baby is in transverse line on U/S, NST or CST will show fetal distress
VASA previa will only show fetal distress on NST/CST
tx: urgent (not emergent) C/S
Rh Antibodies
“D” antibodies matter (Rh D IgG is antidote)
titers + if greater than 1:8
(bigger number after colon, higher titer)
if mom has + Rh Ab titers (+1:8) and TCD shows ^flow, what to do next?
deliver if +32 weeks (earlier than other diseases)
if less than 32 weeks: do PUBS (determine baby Hgb and can transfuse)
tests no longer used in Rh alloimmunization
amniocentesis, Liley Graph
GBS screening
urine culture wk 10
rescreen wk 35
if no screening, baby will be toxic day 1 after birth
tx: ampicillin
next line (based on allergies): cefazolin, clindamycin, vancomycin
risk factors for GBS
previous GBS+, prolonged ROM, intrapartum fever
Hep B prophylaxis for baby if mom is Hep B+
passed through blood, do C-section, give Hep B IVIG, Hep B vaccine to baby day 1
(vaccinate mom before she gets pregnant)
if HIV+ at 10 wk screen
tx: 2 NRT-i + 1 NNRT-i or Protease-i + ritonavir
NRT-i’s: Tenofovir +Emtricitabine (class B)
older/cheaper: Zidovudine + Lamivudine (class C)
NNRT-i: Nevirapine
PI: Atazanavir
NO Enfavirenze
what to do when HIV+ mom presents in labor
viral load less than 1000 and on HAART can deliver vaginally!
otherwise: C-section
if do not know status and presents in labor: give AZT
do not need ampicillin if mom is GBS+ when?
planned C/S with NO ROM with onset of labor
brain calcifications, ventriculomegaly, seizure, what to ask and what should have done?
did mom have a “mono-like” illness? think Toxo
should have gotten Toxo-Ab screen: if + no worries, if - at risk of contracting during pregnancy, avoid cat litter
syphilis stages and dx
1: painless chancre (Darkfield microscopy)
2: targetoid lesions (palms and soles) (RPR, FT-Abs)
latent: + but no symptoms (2)
3: neuro symptoms (CSF: VDRL or RPR*)
syphilis tx
all stages get PCN 1, 2, EL: IMx1 LL: IM qwk for 3 wks 3: IV q4hrs for 7-10 ds (even if PCN-allergic)
congenital syphilis
1st trim: dead baby
3rd trim: snuffles, saber shines, saddle nose, hutchinson’s teeth
congenital rubella
if mom has primary viremia
blueberry muffin rash
cataracts, congenital heart disease, deafness
(IUGR/abortion if 1st trim)
give MMRV 3 months prior to getting pregnant!
congenital HSV
primary viremia in mom with painful, burning prodrome, then vesicles IUGR, preterm delivery, blindness dx: HSV PCR from scraping of rash tx: val or acyclovir C-section if active lesions
urgent vs emergent C-section
urgent: prolonged labor, arrest of labor, ecclampsia?
emergent: hemodynamic instability, fetal distress
vaginal birth after C-section?
low risk: 2 or less C/S with low transverse cuts (attempt to VBAC, if fail called TOLAC)
high risk: greater than 2 C/S with any that were not low transverse cuts (planned C/S)
when to use vacuum/forceps
fetal distress and prolonged or arrest of labor
need full effacement, +2 station
risk: denuding vagina with vacuum, cephalohematoma or Bell’s palsy with forceps
episiotomy types
medial: most common, easy to re-suture, more painful and risk of grade 4
mediolateral: hurts less, harder to repair, no risk grade 4
laceration grades
1: only vagina
2: involves perineal body
3: into anal sphincter but not mucosa
4: invades into anal mucosa, may form rectovaginal fistula
cerclage
used to prevent incompetent cervix (repeat STIs, dilations, PID, D/C), see 2nd trimester losses
put in week 14 (risk of ROM)
take out week 36 (may cause rupture if leave in)
anesthesia
general: opiates, avoid in latent phase stage 1, may prolong and may need to give baby naloxone upon delivery
epidural: requires tocometer and coach (risk: hypotension and death if lidocaine into subdural)
injected anesthetics
paracervical: stage 1: prevents pain of dilations (fetal HR may drop)
pudendal: stage 3: helps pain of delivery
long acting reversible contraception (LARC)
non-IUD (under skin): Explanon, Implanon, last 3 yrs
IUD:
hormonal: 5 yrs (E+P so may ^DVT risk, decrease bleeding overall)
copper: 10 yrs (may ^bleeding)
both ^risk PID (get genital cx prior to placement)
“Ingestion” contraception in decreasing order of efficacy
injections: Depo-provera (last 3 mos)
patches: ortho-Evra (1 mo) (highest risk of DVT/PE)
rings: Nuva-ring (1 mo)
OCPs: (E+P) good for dysf. bleeding, chorio, GTD, molar
mini pill: progesterone only (less DVT risk) requires higher compliance down to hr
DVT risk
estrogen contraception
smoking
age (+35)
Plan B
Levonogestrel
used within 72 hrs
not abortifactant
