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RCE > OB Medicine > Flashcards

OB Medicine Flashcards

1
Q

Definition gestational HTN

A

HTN >=140/90 in office or >=135/85 at home developing >= 20 weeks GA

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2
Q

Definition pre-eclampsia

A

HTN (Pre-existing or gestational) + 1 of:

1) new/worsening proteinuria (2+ dipstick, uPCR >30, 24h >300mg)
2) 1+ adverse condition or severe complications

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3
Q

Definition severe hypertension in pregnancy

A

BP >=160/110

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4
Q

BP Target in pregnancy

A

sBP 130-140, dBP <85

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5
Q

Treatment of HTN in pregnancy

A

1st line: Labetalol, Nifedipine XL (not IR), Methyldopa

2nd line: Hydralazine, Clonidine, thiazides, other BB (except atenolol)

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6
Q

Treatment of severe HTN (>160/110) in pregnancy

A

Labetalol 10-20mg IV
Hydralazine 5-10 mg IV
Nifedipine IR PO chew 5-10 mg

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7
Q

Risk Factors for pre-eclampsia

A

Pt factors:

  • Extremes of age (<20 >35)
  • HTN, DM, CKD, Obesity
  • SLE, APLA
  • Personal/Fam Hx of pre-eclampsia

Pregnancy factors:

  • 1st preg, molar preg, IVF preg
  • New partner,
  • multiple gestation
  • hydrops fetalis
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8
Q

Adverse conditions in pre-eclampsia

A

CNS: Headache, visual changes, hyperreflexia, clonus
CVS: Chest pain
Resp: SOB, SpO2 <97% but not requiring O2
GI: N/V, RUQ/epigastric Pain, Mild elevation in LE/Bili, low alb
GU: High uric acid, Elevated Cr but <150
Haem: High INR/PTT, Plts <100
Fetal: Abn FHR, IUGR, Oligohydramnios, Absent or reverse end diastolic flow on doppler

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9
Q

Severe Complications in pre-eclampsia (warranting MgSO4 and urgent delivery)

A

VS: Uncontrolled HTN despite 3 agents
CNS: Seizure, PRES, Cortical blindness, Stroke/TIA, GCS <13
CV: Troponin elevation, ECG changes, Pulmonary edema
Resp: SpO2 <90% or requiring FiO2>=50% or intubation
GI: hepatic hematoma/rupture, INR >2 or synthetic dysfxn
GU: Renal failure with Cr >=150 or requiring IHD
Haem: DIC, Plts <50
Fetal: No FHR, Placental abruption, reverse ductus venous A wave, fetal distress, IUGR

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10
Q

Treatment of Pre-eclampsia

A

Tx HTN
If severe complications or HELLP: MgSO4 4g load then 1-2g/hr + urgent delivery
If non-severe: Tx BP, Delivery if >=36 wks, antenatal steroids if <35 wks GA

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11
Q

Mg Toxicity and how to treat

A

LOW everything:

  • BP, HR, RR, LOC
  • Hyporeflexia
  • Decreased U/O

Treat:

  • Stop Mg
  • Ca gluc
  • HD
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12
Q

Long-term risks pre-eclampsia

A

Similar to RF of preeclampsia: HTN, DM, CKD, heart dz, stroke, VTE,

Recurrent pre-eclampsia

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13
Q

Pre-eclampsia prevention: Indications

A

1+ Major RFs or >=2 Minor RFs

Major:

  • Prior pre-eclampsia
  • Chronic HTN, DM, or CKD
  • SLE/APLA
  • Multiple gestation

Minor:

  • First pregnancy or new partner
  • Obese (BMI>30)
  • IVF
  • FHX preeclampsia
  • Age >35
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14
Q

Pre-eclampsia prevention

A

ASA 81-162 OD starting at 12-16 weeks until 36 wks
Ca 1000 mg if low oral intake
Exercise: 150min/week (not in placenta previa)

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15
Q

Indications for APLA testing and primary prevention

A
  1. Lab criteria: 2 positive results >12 wks apart (<5y prior to clinical manifestations: LAC (affected by heparin, FP if DOAC, warfarin ok), ACL (IgM and IgG), B2GP
  2. Clinical criteria:
    -1+ venous, arterial, small vessel thrombosis OR
    OB indications:
    -1 loss after 10 wks gestation
    - 3+ unexplained consecutive miscarriage <10 wk GA
    - 1 premature delivery before 34 wks GA due to pre-eclampsia or placental insuffic

*if positive: ASA + prophylactic LMWH + placental US and biomarker testing (PLGF)

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16
Q

Indications for high dose folic acid prenatally

A 
Everyone - 0.4 mg OD (in PNV)
Moderate risk (FHX NTD, DM, Epilepsy on AEDs, GI malabsorption dz): 1 mg OD
High risk (NTD in prior preg, self/spouse with NTD): 4 mg OD
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17
Q

Work-up of suspected DVT in pregnancy

A

1) Doppler US entire proximal venous system including external iliac
2) If neg:
- If suspicion for isolated iliac V DVT: MRI without constrast
- Otherwise: Repeat Doppler within 7 days
3) If still neg: Close follow-up (no empiric Anticoag if 2 neg dopplers)

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18
Q

Work-up of suspected PE in pregnancy

A
  • Empirically anti-coagulate if high suspicion
    1) Bilateral full leg dopplers - If + = treat
    2) If neg, VQ Scan (perfusion only)
  • If high probability: PE diagnosed
  • Low probability: PE R/O, close follow-up
  • Intermediate probability or non-diagnostic: –> CT PE if high susp, serial doppl if low
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19
Q

Acceptable radiation limit in pregnancy

A

<5 rads (CXR = 0.005, CTPA 0.5)

10 rads for miscarriage/teratogenicity

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20
Q

Treatment option and duration VTE in Pregnancy

A

LMWH (or UFH) for minimum 3 months and must include 6 weeks post-partum

  • Can change to warfarin or continue LMWH post-partum while lactating (or DOAC if not lactating)
  • *Consider IVC filter if VTE dx within 2-4 weeks of delivery
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21
Q

Treatment of HIT or Tx VTE if Hx HIT in Pregnancy

A

1st line - Danaparoid

2nd line - Fondaparinux (Crosses placenta in T1 and not good for breastfeeding)

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22
Q

Delivery while on anticoagulation

A

If on therapeutic:

  • Schedule delivery
  • stop LMWH 24 hrs pre-epidural
  • Can resume 6-8 hrs post C/S, 4 hrs post vaginal, 4 hrs post epidural cath removal

If on ppx: Withhold 12 hrs pre-epidural

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23
Q

Indications for VTE Prophylaxis in Pregnancy

A

Antepartum + 6 weeks postpartum if:

  • Past unprovoked
  • Estrogen related (OCP/Preg)
  • Low risk thrombophilia
  • ATIII def or homozyg PT2021A if family history
  • APLA and hx of recurrent preg loss (add ASA to AC)

6 weeks Postpartum ONLY:

  • Past provoked, not estrogen related, reversible/temporary RF
  • Prot C/S if + family history
24
Q

Indications for Primary VTE Prophylaxis in pregnancy (ie. no past VTE)

A

1) Homozyg FVL, combined, Obstetric APS: PPX AC antepartum + 6 wks PP, obs APS also gets ASA
2) Homozygous PT2021A: If + FHX –> PPX AC antepartum + PP; -FHX –> PP AC only
3) ATIII deficiency: If + FHX VTE –> PPX AC antepartum + PP, - FHX –> No AC
4) Protein C/S deficiency: If + FHX –> AC PP only, If - FHX –> No AC
5) PP ppx if 2+ of: Obese, Pre-eclampsia, Past C/S, Age >35, immobility, smoking, IUGR

25
Q

Management of APLA in pregnancy

A

1) APLA with no APS: ASA only
2) APLA with Obstetric APS: ASA + Prophylactic AC antepartum + 6 wks PP
3) APLA with thrombotic APS: ASA + Therapeutic AC antepartum + PP

26
Q

Anticoagulation of mechanical valves in pregnancy

A

Continue warfarin up until conception
If warfarin dose <=5mg/day, can:
a) Continue warfarin throughout pregnancy (risk fetal embryopathy low at <5mg) or
b) Dose adjusted LMWH T1, then back to warfarin for T2/3

If warfarin dose >5mg/day, can:

a) Dose-adjusted LMWH T1, then warfarin T2/3 OR
b) Dose-adjusted LMWH T1-3

*LMWH for mech valve: BID dosing, need to target dose to anti-Xa of 0.8-1.2 u/ml 4-6h post dose

27
Q

Delivery of patient with mechanical valve on warfarin

A
  1. Stop warfarin 1 week pre-scheduled delivery and switch to dose-adjusted BID LMWH or IV UFH
  2. Stop LMWH 36 hrs pre-delivery and change to therapeutic UFH
  3. Stop UFH 6 hrs prior to delivery

*IF goes into spontaneous labour while on VKA: Give PCC + Vit K to reverse and do C/S

28
Q

Differentiating gestational thrombocytopenia from ITP

A

Gestational:

  • Mild (usually >70-100)
  • Develops in T3, resolves 6w PP w/o tx
  • No pre-existing thrombocytopenia pre-pregnancy
29
Q

Indications to treat ITP in pregnancy

A
  • Plts <30 and vaginal delivery
  • Clinically bleeding
  • Plts <50 and C-section
  • Plts <50 if >=36 wks GA (if very close to term use IVIG>Pred; avoid Dex - crosses placenta)
  • Plt <80 and neuraxial anesthesia
30
Q

Indications to transfuse HELLP/preeclampsia

A

1) Plts <20
2) Going for C-section and plts <50
3) Bleeding with Plts >50

31
Q

Risks of hyperglycemia in pregnancy

A

Maternal: Pre-eclampsia, pre-term labour, DKA, pelvic injury, increased C/S rate, GU infection
Fetal: cardiac malformation, spinal cord defect, cleft lip/palate, stillbirth/miscarriage, macrosomia/shoulder dystocia
Neonatal: hypoglycemia, hypocalcemia, hyperbilirubinemia

32
Q

Oral anti-glycemics safe in pregnancy/breastfeeding

A

Metformin
Glyburide

*If on other OAH prepreg- switch to insulin

33
Q

Timeline if liver dz in pregnancy

A

T1: Hyperemesis gravidarum
T2-3: Intra-hepatic cholestasis, HELLP (>=20 wks)
T3: Acute fatty liver of pregnancy
Post-Partum: Budd Chiari

34
Q

Clinical manifestation of Intrahepatic cholestasis of pregnancy

A

Develops in T2-3
Pruritis (NO RASH) starting at palms/ soles, worse @ night
AST and ALT in 100-1000 range, bili N/mildly elevated
Fasting Bile Acid >10 = diagnostic; >40 = meconium aspiration + preterm birth; >100 = STILLBIRTH
**RULE OUT HEP C

35
Q

Treatment Intrahepatic cholestasis of pregnancy

A

Ursodeoxycholic acid
Hydroxizine for pruritis
+/- Rifampin

36
Q

Presentation of Acute Fatty Liver of Pregnancy

A
  • N/V, abdo pain, ascites,
  • Encephalopathy (high ammonia),
  • Jaundice (Bili +++ (conjugated))
  • AST and ALT <500,
  • Coagulopathy (low fibrinogen, prolonged INR/PTT)
  • Hypoglycemia
  • POLYURIA, POLYDIPSIA
  • Renal Failure
37
Q

Treatment options nausea and vomiting in pregnancy

A

Nonpham: Stop iron, take folic acid only, small frequent meals, cold/clear/carbonated fluids, ginger QID, acupressure, mindfulness

1st: Pyridoxine/Diclectin (VitB6)
2nd: Gravol
Then: Maxeran, Chlorpromazine, Zofran

38
Q

Physiologic Cardiac Symptoms and Signs in pregnancy

A 
Symptoms: Dyspnea, orthopnea, peripheral edema, palpitations, dizziness
Signs: 
- High JVP
- Sinus Tachy
- Low BP
- Displaced apex (bc diaphragm)
- + S3, +/- S4
- Flow murmur
39
Q

Causes of heart failure in pregnancy

A 
Peripartum Cardiomyopathy (EF<40% from last mo of preg until 5mo PP without another cause)
Pre-eclampsia
Ischemia, arrhythmia, new valvular dz 
PE or amniotic fluid embolus
Sepsis
40
Q

Treatment peripartum cardiomyopathy

A

Similar to HF:

  • Beta blocker (metoprolol preferred; NO atenolol)
  • Lasix if pulm edema (caution bc vol contract + placental perfusion)
  • Afterload reduction: Nitroglycerine (No nitroprusside - fetal cyanide toxicity), hydralazine
  • Dig for refractory HF
41
Q

Safe Antibiotics in pregnancy

A

B-lactams
Macrolides (Azithro)
Fosfomycin
Carbapenems

unsafe: tetracycline (teeth staining, bone growht suppression), sulfa (relative C/I bc kernicterus, ensure high dose folate), FQs (?cartilage/malformation)

42
Q

Indication for C-section in infection

A

HIV: Viral load at time of deliver >=1000
HSV: active lesions (consider acyclovir 36w+ to suppress outbreak)

43
Q

Indications to treat STIs in pregnancy

A

-Always: HIV, Syphilis, GC, Chlamydia

  • HBV if DNA >200 000 at T3 (Tenofovir ok with breastfeeding)
  • HSV if recurrent disease >=36wks (C/S if active lesions)

-HCV - never, only treat PP (no breastfeeding on antiviral)

44
Q

PFT Changes in pregnancy

A
  • Decreased: FRC and ERV (bc uterus compresses diaphragm)
  • Increased: Tidal volume
  • Same: TLC unchanged (ERV decreases, thoracic space increases - “balances out”)
45
Q

Anti-HTN to avoid

A
  • Atenolol: IUGR, fetal bradycardia in breastfeeding
  • ACE/ARB: fetal renal agenesis, oligohydramnios, pulmonary aplasia, especially in T2/T3.
  • Prazosin
  • Spironolactone - avoid in preg; ok for breast feeding
  • Stop statin in preconception

*enalapil, captopril, quinapril ok in breastfeeding

46
Q

D-dimer threshold to rule out PE

A

3 negative factors + D dimer <1000 or 1 negative factor+ D dimer <500

Factors:

1) S/S of DVT
2) Hemoptysis
3) PE most likely dx

If fails, do CTPA

47
Q

Indications for “considering” postpartum thrombophrophylaxis

A

2+ of following

  • Preeclampsia
  • Smoker, obesity, age>35
  • Bedrest >7d antepartum,
  • major surgery (C/S, postpartum hemorrhage),
  • FVL hetero w/ obesity or C/S
  • Placenta previa, IUGR
48
Q

Blood Glucose Targets in Pregnancy

A

A1C <6.5%
Intrapartum BG between 4-7

Fasting <5.3
1h Postprandial <7.8
2h Postprandial <6.7

49
Q

Gestational Diabetes Screening and Diagnosis

A

Screen @ 24-28 weeks

50g 1h OGCT: GDM if >11.1, Borderline 7.8-11.1 (do 75g OGTT), Normal if <7.8

75g 2h OGTT:

  • As 2nd step: FPG >5.3, 1h >10.6, 2h>9.0
  • As 1st step (not recommended): FPG>5.1, 1h>10.0 2h>8.5

COVID alternative: A1C>5.7 or random plasma >11.1

50
Q

Gestational Diabetes Tx

A
  • Diet/Exercise
  • 1st line: insulin NPH (target FPB) +/- rapid acting to target post-prandial
  • Metformin (as alternate to insulin but may still need insulin) +/- Glyburide (if refuse insulin) *not gliclazide
51
Q

Postpartum Diabetes Mx

A

Preexisting DM: Decrease insulin to pre-preg dose,

  • Screen for postpartum thyroiditis in T1DM,
  • Resume ACEi

Gestational: Stop insulin/metformin/glyburide

  • 75g OGTT at 6weeks-6mo postpartum to r/o T2DM
  • Breastfeeding immed to prevent neonatal hypoglycemia
52
Q

Obesity in pregnancy Mx

A

Intrapartum:

  • Weight gain target 5-10kg if BMI>30,
  • Exercise >150min/week,
  • ASA for preeclampsia,
  • Folic acid >1mg/d, Vit D>400IU/d

Postpartum:

  • Screen depression/anxiety,
  • Thrombophylaxis if C-section
53
Q

Hyperemesis Gravidarum

Pt, Ix, Tx

A

Pt: N/V, dehydration, 5% wt loss
Ix: Ketosis/ketonuria, AST/ALT 100s, NORMAL bili
Tx: PPI acutely, Gravol/Maxeran, IVF/lytes

54
Q

IBD in pregnancy

  • Pre-preg
  • Maintenance
  • Flare
  • Fistula
  • Vaccinations
A
  • Pre-preg: Steroid free remission + stop MTX 3mo before conception
  • Maintenance: Continue 5ASA, azathioprine, and TNFi, consider VTE pp
  • Flare: pred, 5ASA, antiTNF + stress dose at delivery
  • Fistula: C/S
  • Vaccinations: no live vaccines for baby x6mo if exposed to TNFi
55
Q

Vaccines in preganancy

A

Avoid live: varicella, MMR, rabies, yellow fever, nasal influenza

YES: inactivated influenza,
-Tdap in EVERY preg at T3 (27-32wks)

56
Q

Postpartum Hemorrhage (4T’s) + Tx

A

– Tone (uterine atony)
– Trauma (lacerations in birth canal etc)
– Tissue (retained placenta)
– Thrombin aka coagulopathy=least common cause of PPH

Tx: TXA (mortality benefit)

RCE (18 decks)

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