OB Patients

Question 1

Barker hypothesis

Answer 1

Poor placental development has been linked to preeclampsia, preterm birth, and intrauterine growth restriction (IUGR), all of which are associated with low birth weight (<2500 grams), and may play a role in fetal programming of chronic diseases later in life. This is known as the Barker hypothesis

Question 2

Importance of preconception care

Answer 2

By the time most pregnant women have their first prenatal visit, it is too late to address the risk of low birth weight and obesity, and to reduce the risk of some birth defects.

Question 3

Elements of prenatal care

Answer 3

the three basic components of prenatal care are (1) early and continuing risk assessment, (2) health promotion, and (3) medical and psychosocial interventions and follow-up

prenatal diagnostic testing with amniocentesis or chorionic villus sampling (CVS) be offered to all pregnant women regardless of their age

Question 4

Confirmation of pregnancy and viability

Answer 4

It is important to differentiate a normal pregnancy from a nonviable or ectopic gestation. In the first 30 days of a normal gestation, the level of hCG doubles every 2.2 days. In patients whose pregnancies are destined to abort, the level of hCG rises more slowly, plateaus, or declines.

It is important to differentiate a normal pregnancy from a nonviable or ectopic gestation. In the first 30 days of a normal gestation, the level of hCG doubles every 2.2 days. In patients whose pregnancies are destined to abort, the level of hCG rises more slowly, plateaus, or declines

If a live, appropriately growing fetus is present at 8 weeks’ gestation, the fetal loss rate over the next 20 weeks (up to 28 weeks) is in the order of 3%.

Question 5

Incidence of early pregnancy loss

Answer 5

spontaneous abortion occurs in 10-15% of clinically recognizable pregnancies. The term biochemical pregnancy refers to the presence of hCG in the blood of a woman 7 to 10 days after ovulation but in whom menstruation occurs when expected.

Question 6

Threatened abortion

Answer 6

Threatened abortion - vaginal bleeding before 20th week. Pain, such as dull ache, may occur. 25-50% of threatened abortions result in loss.

Question 7

Inevitable abortion

Answer 7

a clinical pregnancy is complicated by both vaginal bleeding and cramp-like lower abdominal pain. The cervix is frequently partially dilated, contributing to the inevitability of the process.

Question 8

Incomplete abortion

Answer 8

There is passage of some products of conception

Question 9

Complete Abortion

Answer 9

Passage of all the products of conception and the bleeding and uterine contractions abate.

Question 10

Missed Abortion

Answer 10

Fetus has died but is retained in the uterus for more than 6 weeks. Coagulation problems can occur, surgical intervention is needed.

Question 11

Recurrent abortion

Answer 11

Three successive spontaneous abortions usually occur before a patient is considered to be a recurrent aborter. Referral to genetic counseling is needed.

Question 12

Etiologies of early pregnancy loss

Answer 12

Infection (Toxoplasma, Listeria, Mycoplasma)
Smoking and alcohol
Psychosocial stress
Medical disorders (DM, HTN, Lupus, Hypothyroid)
Maternal age (10% risk at age 40)
Uterine abnormalaities
Fetal genetic abnormality (most common cause)
Placental factors

Question 13

Cervical Incompetence

Answer 13

The diagnosis of cervical incompetence is usually made when a mid-trimester pregnancy is lost with a clinical picture of sudden unexpected rupture of the membranes, followed by painless expulsion of the products of conception.

Question 14

Management of each type of early pregnancy loss

Answer 14

Threatened - if a live fetus is on ultrasound, reassurance and genetic testing of fetus for abnormalities
Incomplete - Pain management and stabilization, then refer to surgery
Missed - Confirm with ultrasound

Always send pathology samples and Rh study

Question 15

Calculate gestational age / EDC

Answer 15

determined by adding 9 months and 7 days to the first day of the last menstrual period

Question 16

Folic Acid

Answer 16

vitamins plus folic acid daily before conception. Because neural tube closure is complete by 28 days post-conception, initiating folic acid after the first 28 days has no prophylactic value.

Question 17

Antidepressant of choice in pregnancy

Answer 17

Fluoxetine

Question 18

Normal lab values in pregnancy

Answer 18

Slight decrease in albumin
Gradual 10% decrease in calcium
Slight dip (2-4) in sodium
Gradual 10% decrease in glucose
Decrease in BUN 1st trimester
Amylase increases by 50-100%
Hgb/HCT decreases
WBC slight increase
Cortisol can double
Prolactin gradually increases by 100% or more
T4/T3 slight early increase

Question 19

CV changes in pregnancy

Answer 19

Body water increases by 6-8 L
Blood volume increases by 40% (anemia of pregnancy results)
Systolic BP drops by week 24, then rises to normal
MAP slight decrease
Heart rate increases slightly
Stroke volume increases by 10-30%
Cardiac Output increases by 33-45%
Oxygen consumption is higher

Question 20

Respiratory changes in pregnancy

Answer 20

Slow increase in tidal volume
Expiratory reserve decreases
Residual volume and capacity falls significantly
Vital capacity normal
Minute ventilation increases by 40%
Respiratory alkalosis is common
Dyspnea is common

Question 21

Renal changes in pregnancy

Answer 21

Renal blood flow increases by 30%
GFR increases by 40-50%
Lower levels of creatinine and BUN
Enhanced renal elimination of bicarb due to the respiratory alkalosis

Question 22

Homeostasis in pregnancy

Answer 22

insulin response to glucose stimulation is augmented. After early pregnancy, insulin resistance emerges, so glucose tolerance is impaired. The fall in serum glucose for a given dose of insulin is reduced compared with the response in earlier pregnancy.

Increased risk of ketoacidosis

Question 23

Endocrine changes in pregnancy

Answer 23

the thyroid gland undergoes moderate enlargement during pregnancy as a result of placenta-derived hCG

Adrenocorticotropic hormone (ACTH) and plasma cortisol levels are both elevated from 3 months’ gestation to delivery

Question 24

Weight changes in pregnancy

Answer 24

Should be 25-28 pounds.

Question 25

Mechanisms of transfer from mother to fetus across placenta

Answer 25

The placenta receives 60% of the combined ventricular output

Question 26

Process of fetal oxygenation and fetal circulation

Answer 26

The fetal circulation is a parallel circuit characterized by channels (ductus venosus, foramen ovale, and ductus arteriosus) and preferential streaming, which function to maximize the delivery of more highly oxygenated blood to the upper body and brain, less highly oxygenated blood to the lower body, and very low blood flow to the nonfunctional lungs.

Question 27

Innate and adaptive immunity in pregnancy

Question 28

Development of fetal immunity

Answer 28

Immature granulocytes can be found in the fetal spleen and liver by 8 weeks. NK cells are detected in the liver by 8 to 13 weeks and complements 2 and 4 by 8 weeks

Maternal IgG crosses the placenta as early as the late first trimester, but the efficiency of the transport is poor until 30 weeks. Significant passive immunity can be transferred to the fetus in this manner and for this reason premature infants are not as well protected by maternal antibodies. IgM, because of its larger molecular size, is unable to cross the placenta.

Question 29

Immunological responses during pregnancy

Answer 29

he nonspecific (innate) mechanisms of the immunologic system (including phagocytosis and the inflammatory response) are not affected by pregnancy. The specific (adaptive) mechanisms of the immune response (humoral and cellular) are also not significantly affected

Pregnant women are at higher risk of severe infection and death from certain pathogens such as viruses (hepatitis, influenza, varicella, cytomegalovirus, polio), bacteria (listeria, streptococcus, gonorrhea, salmonella, leprosy), and parasites (malaria, coccidioidomycosis) compared with nonpregnant women. Vitamin D supplementation during pregnancy, therefore, may be important not only to reduce the risk of immunologic fetal rejection, but also to help prevent infection.

Question 30

4 stages of parturition

Answer 30

Parturition means childbirth

Phase 0 - Quiescence - progesterone plays a role in maintaining

Phase 1 - Activation. Uterine stretch seems to trigger. ACTH expression and secretion of SP-A to start labor

Phase 2 - Stimulation. Cascade of events, increasing estrogen overrides progesterone, prostaglandins trigger cervical ripening.

Phase 3 - Involution. Maternal oxytocin and uterine contractions with eventual explusion

Question 31

Elements of the fetoplacental unit and their role in endocrinology

Answer 31

The hormonal and nonhormonal changes that occur during pregnancy and parturition are regulated through a physiological mechanism referred to as the fetoplacental unit. A series of hormones and transmitters are produced by each of the components of this unit, and they have multiple effects within and between the fetus, the placenta and the mother.

Question 32

Function of endocrine hormones during pregnancy

Answer 32

Oxytocin causes uterine contractions, but impairment of oxytocin production, as in diabetes insipidus, does not interfere with normal labor.

Relaxin is associated with the softening of the cervix, which is one of the anatomical signs of pregnancy. Its primary function appears to be in promoting implantation of the embryo by facilitating angiogenesis.

Question 33

What patients should be referred for genetic counseling? When?

Answer 33

Ideally before they decide to conceive, should be offered to all couples regardless of age.

Especially if family history of defects, previous child with defect, multiple fetal losses, teratogenic exposure, know carrier of genetic disorder

Question 34

Types of chromosomal disorders

Answer 34

Fragile X - 2nd most common cause of developmental delay
Trisomy (Down syndrome)
Klinefelter syndrome
Sickle Cell
Cystic Fibrosis
Tay-Sachs disease
Thalassemia
Neural Tube Defects (multifactorial)

Question 35

Multiple screening approaches for fetal aneuploidy in each trimester

Answer 35

1st - B-Hcg and plasma protein-A, ultrasound to visualize fetal facial nasal bone absence
2nd - MSAFP testing, if elevated then ultrasound or amniocentesis
Combined / Integrated - most cost effective and sensitive

Question 36

Concept of teratology and teratogens that affect fetus

Answer 36

teratogens may be assigned to three broad categories: (1) drugs and chemical agents, (2) infectious agents, and (3) radiation.

The most vulnerable stage is between day 17 to day 56 postconception or from approximately 4 weeks to 10 weeks by gestational age

Question 37

Common disorders of pregnancy

Answer 37

Heartburn - elevate head of bed at night, avoid supine after eating, calcium carbonate
Constipation - Increase fiber and water, stool softeners
Hemorrhoids - rest and leg elevation, avoid constipation
Leg Cramps - Massage and stretching, Increase vitamin D
Backaches - exercise, proper shoes, rest, heat, tylenol

Question 38

N/V and Hyperemesis

Answer 38

protein snacks at night, saltine crackers at the bedside, and room-temperature sodas are nonpharmacologic approaches that may provide some relief. Where medication is deemed necessary, antihistamines appear to be the drug of choice, though no single product has been satisfactorily tested for efficacy and safety. Vitamin B6 (pyridoxine) and accupressure (“sea sickness arm bands”) may be effective.

Question 39

Recommended weight gain for pregnancy

Answer 39

25-28 pounds

Question 40

Interval of follow up during pregnancy

Answer 40

About 4-week intervals until 28 weeks
2-week intervals from 28 to 36 weeks
Weekly thereafter until delivery

Question 41

What assessments are performed at each pregnancy visit?

Answer 41

Screening for disorders
Taking measures to reduce fetal and maternal risks
Counseling

Question 42

Differentiate the types of assessment of fetal well being

Answer 42

fetal movement counts (kick count), the non-stress test, biophysical profile, modified biophysical profile, contraction stress test, and Doppler ultrasound exam of the umbilical artery.

Question 43

Define Rh alloimmunization

Answer 43

hesus (Rh) alloimmunization is an immunologic disorder that occurs in a pregnant, Rh-negative woman who is carrying an Rh-positive fetus. The immunologic system in the mother is stimulated by fetal cells that cross the placental barrier into the maternal circulation to produce antibodies to the Rh antigen, which then cross the placenta into the fetal circulation and opsonize fetal Rh-positive red cells, resulting in their destruction in the spleen.

Question 44

Pathophysiology and incidence / risks, management, prevention of Rh alloimmunization

Answer 44

Most immunizations occur at the time of delivery, and antibodies appear either during the postpartum period or following exposure to the antigen in the next pregnancy.

Because RhD immunization occurs in response to exposure of an RhD-negative mother to the RhD antigen, the mainstay for prevention is the avoidance of maternal exposure to the antigen. Rh immune globulin diminishes the availability of the RhD antigen to the maternal immune system

Question 45

HTN criteria in pregnancy

Answer 45

140 systolic or more, and/or diastolic of 90 or more

Question 46

Preeclampsia / eclampsia

Answer 46

new-onset hypertension in the latter half of gestation, accompanied by new-onset proteinuria and/or other evidence of organ dysfunction.

Eclampsia is the presence of new-onset grand mal seizures in a woman with preeclampsia that cannot be attributed to other causes.

Question 47

Chronic hypertension

Answer 47

The diagnosis of chronic hypertension requires at least one of the following: known hypertension before pregnancy or the development of hypertension before 20 weeks’ gestation.

Question 48

Chronic hypertension with superimposed preeclampsia

Answer 48

women with chronic hypertension who develop new-onset proteinuria (≥0.3g in a 24-hour collection) after the 20th week of gestation. In pregnant women with preexisting hypertension and proteinuria, the diagnosis of superimposed preeclampsia should be considered if they experience sudden significant increases in blood pressure or proteinuria or the new onset of any of the other signs and symptoms of severe preeclampsia

Question 49

Gestational hypertension

Answer 49

The diagnosis of gestational hypertension is made if hypertension without proteinuria or other signs of organ dysfunction first appears after 20 weeks’ gestation or within 48 to 72 hours of delivery and resolves by 12 weeks postpartum. It is extremely difficult to differentiate this condition from the early stages of preeclampsia. These women must be followed closely because a significant percentage go on to develop proteinuria and the full preeclamptic syndrome at a later stage in pregnancy. Others will have previously unrecognized chronic hypertension. The diagnosis of gestational hypertension can only be made in retrospect

Question 50

Managing Gestational HTN

Answer 50

The ACOG Task Force recommends starting antihypertensive therapy if the systolic blood pressure is ≥160mmHg or the diastolic blood pressure is ≥105mmHg. There is little evidence that lowering blood pressure below the 140/90mmHg range benefits the pregnancy.

Methyldopa is considered to be the safest antihypertensive medication in pregnancy, but calcium channel blockers and labetalol are also considered to be safe.

ACE-I / ARBs must be avoided!

Question 51

Incidence and definition of gestational diabetes

Answer 51

glucose intolerance with onset or first recognition during pregnancy. 80-90% of diabetes in pregnant women is gestational, and about 10% is pregestational

Screen at first prenatal visit, repeat at 24-28 weeks. OGCT >130 is positive, follow with a 3 hour OGTT after overnight fast - two or more abnormal values during the 3 hour tests is confirmation. If the OGCT is >200, the 3 hour test is not needed that is confirmatory.

Question 52

Complications of gestational diabetes

Answer 52

lucose crosses the placenta easily by facilitated diffusion, causing fetal hyperglycemia that stimulates pancreatic β-cells, and results in fetal hyperinsulinism. Fetal hyperglycemia during the period of embryogenesis is teratogenic. Results in IUGR, prematurity

Goal is fasting level 95, postprandial <140.

Dose insulin to maintain 80-120 BGL

Question 53

Thyroid disorders during pregnancy

Answer 53

Increased GFR can result in iodine excretion deficiency and goiter, consider supplementation

TSH may slightly rise during 1st and 2nd trimester

Question 54

Maternal hyperthyroidism

Answer 54

An elevated serum free T4 level and a suppressed TSH level establish the diagnosis of hyperthyroidism. Other symptoms may be hard to differentiate from OB changes.

PTU should be used to treat overt hyperthyroidism in the first trimester, and methimazole should be used in the second and third trimesters. Importantly, antithyroid drugs should be reduced to the lowest dose that results in free T4 levels within the upper range of normal

Question 55

Thyroid storm

Answer 55

Human chorionic gonadotropin (hCG) levels peak in the first trimester and can cause transient, subclinical hyperthyroidism. In the setting of a molar pregnancy, the extremely high hCG levels can result in thyrotoxicosis.

It is not uncommon to mistakenly attribute the signs and symptoms of severe hyperthyroidism to preeclampsia. Lack of proteinuria may be an indicator of thyroid storm. Treat with propranolol and PTU

Question 56

Neonatal thyrotoxicosis

Answer 56

bout 5% of pregnant women with a history of Graves disease give birth to children with thyrotoxicosis due to transplacental transfer of TSH receptor antibodies. It is transient and lasts less than 2 to 3 months, but if clinically significant and untreated, it is associated with neonatal morbidity and mortality. Fetal thyrotoxicosis can be suspected if the baseline fetal heart rate consistently exceeds 160 beats per minute.

Question 57

Hypothyroidism

Answer 57

The most important laboratory finding of hypothyroidism is an elevated TSH level. If the TSH level is elevated, the diagnosis of overt vs. subclinical hypothyroidism can be made based on whether free T4 levels are supressed.

levothyroxine should be started, and serum TSH levels should be measured monthly with appropriate adjustments in levothyroxine dosage.

untreated maternal hypothyroidism has been associated with an increased risk of spontaneous abortion, preeclampsia, abruption, low-birth-weight or stillborn infants, and lower cognitive function in offspring.

Question 58

Congenital hypothyroidism

Answer 58

Thyroid hormone defi­ciency during the fetal and early neonatal periods leads to generalized cognitive impairment. This should be identified in routine neonatal screening.

Question 59

Impact of cardiac disease during pregnancy

Answer 59

important cause of maternal mortality. The cardiovascular adaptations to pregnancy, delivery, and the early puerperium can trigger acute cardiovascular decompensation in women with high-risk lesions

Question 60

Rhuematic heart disease

Answer 60

Mitral stenosis is common in Rheumatic heart disease. Asymptomatic patients may develop symptoms of cardiac decompensation or pulmonary edema as pregnancy progresses. Atrial fibrillation is more common in patients with severe mitral stenosis, and nearly all women who develop atrial fibrillation during pregnancy experience congestive heart failure

Question 61

Congenital heart disease

Answer 61

patients with primary pulmonary hypertension or cyanotic heart disease with residual pulmonary hypertension are in danger of experiencing decompensation during pregnancy

In general, significant pulmonary hypertension with Eisenmenger syndrome is a contraindication to pregnancy due to the high maternal mortality that accompanies this condition.

Question 62

Cardiac arrhythmias

Answer 62

Atrial premature beats are common, but usually benign and do not require therapy

A-Fib and A-Flutter are more concerning for underlying issue.

Question 63

Ischemic heart disease

Answer 63

Most concerning issues are the medications used for treatment such as ACE-I/ARBs and fetal toxicity

Question 64

Peripartum cardiomyopathy

Answer 64

Pregnant women particularly at risk of developing cardiomyopathy are those with a history of preeclampsia or hypertension and those who are poorly nourished. It appears to be a dilatational cardiomyopathy with a decreased left ventricular ejection fraction (LVEF < 45%).

Question 65

Immune thrombocytopenia

Answer 65

In the absence of bleeding, therapy for ITP is usually not initiated unless platelet counts are less than 50,000/µL. Oral prednisone at a dose of 1mg/kg per day is given initially, and once platelet counts improve, it is tapered off over several weeks. Severe cases may need platelet transfusion.

The fetus / neonate must be monitored for thrombocytopenia

Question 66

Lupus

Answer 66

SLE can flare up during any trimester or in the postpartum period. There is good evidence that the best pregnancy outcomes occur if the disease has been quiescent or under good control for at least 6 months before conception and there is no evidence of active lupus nephritis. A lupus flare, if it occurs, can be life-threatening, but it is often difficult to differentiate from superimposed preeclampsia, and both may coexist

Flares and active disease are generally managed with steroids and hydroxychloroquine, drugs that have less fetal toxicity than other immunosuppressive agents

Question 67

Antiphospholipid syndrome

Answer 67

The antiphospholipid syndrome is defined as the presence of at least one of these antibodies in association with arterial or venous thrombosis and/or one or more obstetric complications. These complications include an unexplained fetal demise after 10 weeks’ gestation, a history of preterm delivery before 34 weeks’ gestation due to severe preeclampsia or placental insufficiency, or three or more unexplained miscarriages before 10 weeks’ gestation

LMW Heparin and aspirin are treatments.

Question 68

GI disorders during pregnancy

Answer 68

about 50-80% of pregnant women complain of nausea and vomiting during the first trimester.

Question 69

Hyperemesis gravidarum

Answer 69

Persistent N/V associated with ketosis and 5% weight loss. Symptomatic treatment and IV fluid, B6, antihistamines are used. Promethazine or Metoclopramide may be used, but stop them at once if signs of tardive dyskinesia appear

Question 70

GERD

Answer 70

patients are instructed to eliminate dietary triggers; refrain from eating large and late meals; avoid the recumbent position, especially after meals; and use an extra pillow to elevate the head when sleeping. Antacids can be helpful, H2 or PPI may be considered.

Question 71

PUD

Answer 71

Pregnancy conveys relative protection against the development of peptic ulceration and may ameliorate an already-present ulcer. Treatment may be needed (H2/PPI)

Question 72

Mendelson syndrome

Answer 72

Acid Aspiration Syndrome
delayed gastric emptying and increased intrabdominal pressure increases the risk and can result in ARDS. Risk increases when sedatives or analgesia is used (why women in labor need to be NPO)

Question 73

Chronic IBD

Answer 73

he best pregnancy outcomes occur in those patients who are in remission at the time of conception and whose disease activity can be controlled with medication that has minimal fetal toxicity. Major teratogens such as methotrexate must be discontinued before conception.

Sulfasalazine does not appear to be associated with fetal toxicity. Prednisone is metabolized by placental enzymes and relatively little crosses the placenta. However, first trimester use has been associated with cleft lip and palate, and high doses can inhibit fetal growth

Question 74

Hepatic disorders of pregnancy

Answer 74

lthough the pathogenesis of intrahepatic cholestasis of pregnancy (ICP) is not known, some distinctive features are (1) cholestasis and pruritus in the second half of pregnancy without other major liver dysfunction, (2) a tendency for recurrence with each pregnancy, (3) an association with oral contraceptives and multiple gestations, (4) a benign course in that there are usually no maternal hepatic sequelae, and (5) an increased rate of meconium-stained amniotic fluid and fetal demise

Question 75

Intrahepatic cholestasis of pregnancy

Answer 75

The main symptom of ICP is itching (most intense on the palms and soles), without abdominal pain or a rash, which may occur as early as 20 weeks’ gestation. Jaundice is rarely observed. Laboratory tests show elevated levels of serum bile acids.

Symptomatic treatment with cold baths, emollients, and antihistamines such as hydroxyzine may be of some help. The best results have been obtained with ursodeoxycholic acid. It significantly ameliorates the pruritus and reduces serum levels of bile acids, aminotransferases, and bilirubin

Question 76

Acute fatty liver disease of pregnancy

Answer 76

Acute fatty liver of pregnancy is a rare but extremely serious complication that can occur in the third trimester of pregnancy. It is associated with diffuse microvesicular fatty infiltration of the liver, resulting in hepatic failure.

Hypertension and proteinuria are present in approximately 50% of patients, raising the issue of coexisting preeclampsia. Patients can develop coagulopathy with intraabdominal hemorrhage, hepatic coma, and renal failure.

Question 77

VTE in pregnancy

Answer 77

Pregnancy is a hypercoaguable state and lack of mobility or reduced activity increases risk.

Houman sign (pain in calf with foot dorsiflexion) and dull ache when walking along with a size difference in calf may be indicative of DVT. Most DVT in pregnancy are in left leg.

Heparin to treat, stop it 24 hours before delivery.

Question 78

Asthma in pregnancy

Answer 78

During pregnancy, condition improves in about one-third of patients and deteriorates in about one-third, and about one-third have no significant change. Most exacerbations occur before the third trimester

Labor and delivery are usually not triggers of acute asthma attacks.

Question 79

Seizure disorder in pregnancy

Answer 79

In patients who have had no seizure activity for at least 2 years, AED therapy can be discontinued before conception. All AEDs are teratogens but valproic acid may be the most dangerous. If taking an AED, increase folic acid supplements before conception.

regnant patients with epilepsy have a twofold increase in maternal complications such as preeclampsia, abruption, hyperemesis, and premature labor. Fetal hypoxia is a potential consequence of maternal seizures, and there is a high incidence of intrauterine fetal demise

Question 80

General guidelines for surgery in pregnancy

Answer 80

Elective surgery should be avoided in pregnancy. When surgery must be done, but not emergently (e.g., an ovarian neoplasm), the second trimester is the safest time. During this period, the risks of teratogenesis and miscarriage are much lower than in the first trimester, and the risk of preterm labor is lower than in the third trimester. Regional analgesia is preferred because it is associated with lower mortality and morbidity than general anesthesia

Question 81

Anemia

Answer 81

Iron deficiency anemia (IDA) is very common in pregnancy

iron replacement therapy with 60 to 120 mg of elemental iron daily is indicated if hemo­globin is less than 11 g/dL, along with an increase in iron-rich food intake.

Question 82

UTI in pregnancy

Answer 82

Do a urine culture at 12-16 weeks to look for asymptomatic UTI

Nitrofurantoin and sulfonamides are the first line agents for treatment and prevention of UTI in the second and third trimesters while Amoxicillin/Augmentin is preferred in first.

Do a test-of-cure after treatment and repeat culture every 6-12 weeks

Question 83

Group B Strep

Answer 83

GBS may not be significant to the woman but there is a chance of passing it to the baby during birth. Universal screening for GBS should occur at 35-37 weeks with treatment during labor if positive.

Question 84

Zika exposure

Answer 84

Mother-fetus spread
Avoid travel to outbreak / prone areas
Test
Ultrasounds if exposed to find fetal anatomy problems

Question 85

Vaginitis

Answer 85

the most appropriate first-line treatment for vaginal yeast infections in pregnancy is a 7-day topical vaginal azole cream

BV/Trich has higher risks of complications and should be treated with metrondiazole

Question 86

Bleeding in pregnancy

Answer 86

Twenty percent to 25% of women will experience bleeding during the first trimester

Rule out threatened abortion, ectopic, infection, molar, hormonal imbalance, substance use, trauma, implant bleeding

Monitor hCG

Question 87

Preterm labor

Answer 87

reterm labor, defined as spontaneous rupture of membranes and/or uterine contractions that cause cervical change and dilation before 37 weeks of gestation, is a serious pregnancy complication that often (45% of the time) leads to premature delivery. Approximately 70% of neonatal deaths are related to prematurity

Tocolytics can buy 48 hours for corticosteroids for the fetal lung and antibiotics for GBS

Question 88

Post Partum Bleeding Stages

Answer 88

0 - all women in labor. Oxytocin, fundal massage, assess

1 - >500 (vaginal) ot >1000 (C-section) - Type and crossmatch 2 units, increase oxytocin, give methergine and fundal massage

2 - Total loss 1000-1500 - Rapid Response Team, give carboprost, transfuse 2 units, place intrauterine balloon or embolization procedure

3 - Total loss >1500 - Coag studies, more blood transfuion, surgical ligation or hysterectomy

Question 89

Accreta

Answer 89

Placenta accreta implies an abnormal attachment of the placenta through the uterine myometrium as a result of defective decidual formation

Question 90

Ectopic pregnancy

Answer 90

Most in the fallopian tube

hCG levels that are slow to rise along with Ultrasound is diagnostic (no presence in uterus). Common to have significant abdominal pain.

classic triad of symptoms is (1) missed menses, (2) vaginal bleeding (usually spotting), and (3) lower abdominal pain.

Surgical emergency but some may be treated with methotrexate

Question 91

Placenta previa

Answer 91

Painless bleeding later in pregnancy, placenta covers part (or all) the cervical opening

Question 92

Abruptio placenta

Answer 92

Placenta detaches, abdominal pain with bleeding (but may be hidden), uterine hyperactivity

Question 93

Medications to stop during pregnancy

Answer 93

ACE-I/ARBs, Warfarin, known teratogens, most antideprassants except fluoxetine (prozac)

Question 94

Mastitis

Answer 94

Usually manifests with fever, generalized malaise, influenza-like symptoms, local erythema, and breast warmth and tenderness

Treatment of mastitis includes the application of warm packs to the breast and frequent breastfeeding or pumping.

Antibiotics such as amoxicillin-clavulanate, dicloxacillin, or a broad-spectrum cephalosporin to cover a probable staphylococcal or streptococcal infection.

Question 95

Jaundice

Answer 95

Most newborns become mildly jaundiced during the third to fifth days of life. Breastfed babies commonly appear jaundiced into the third or fourth week of life and less commonly for 8 to 12 weeks

Question 96

Poor latching

Answer 96

If the baby is having difficulty latching on, positioning strategies can improve comfort for the mother and milk transfer for the baby. Mothers should be taught how to bring the baby to the breast to prevent the infant from sucking on the nipple tip. Shallow latch causes pain and poor let-down

Question 97

Engorgement

Answer 97

Breast engorgement may occur on the third or fourth postpartum day in first-time mothers and sooner in women who have had previous births. It can usually be minimized by feeding the infant 8 to 12 times each day in the days leading up to the milk coming in.

Deep asymmetric latch-on and sustained suckling will resolve most engorgement. If engorgement persists, ice packs may be applied to the breasts

Question 98

Delayed let down

Answer 98

Stress, pain, and alcohol inhibit let-down. The let-down response is enhanced through thoughts about the infant, breast massage, and relaxation

Question 99

Low milk production

Answer 99

Low milk production usually results from inadequate suckling and breast emptying, low prolactin levels, inadequate mammary glandular tissue, delayed or inadequate lactogenesis, or undetermined causes. Uniformly low prolactin levels suggest an endocrine basis for low milk supply. Inadequate mammary glandular tissue can result in low milk production despite normal prolactin levels

Try double pumping and consult with lactation specialist

Question 100

Low infant weight gain

Answer 100

to assess an infant with low weight gain, providers must observe a breastfeeding session. Strategies to increase success include breast pumping to increase the milk supply and increased feeding frequency

Supplemental nutrition / formula may be needed

Question 101

Cracked nipples

Answer 101

Cracked nipples are usually caused by attachment or latch-on problems. The nipple becomes abraded when the infant latches only to the tip of the nipple, instead of to the underside of the breast followed by the nipple. Mothers should be taught the asymmetric latch-on technique. Treatment of cracked nipples includes correcting the attachment and supporting milk extraction.

Use of medical lanolin, nipple shields, avoid over-drying of nipples, warm/moist compresses after feeding.

Question 102

Postpartum depression

Answer 102

Normal depressed mood for first 10-14 days after delivery due to stress, lack of sleep, feeding schedule.

PPD persists beyond that and requires intervention

Question 103

Inevitable abortion

Answer 103

a clinical pregnancy is complicated by both vaginal bleeding and cramp-like lower abdominal pain. The cervix is frequently partially dilated, contributing to the inevitability of the process.