obgyn Flashcards
BP readings for diagnosis of gestational HTN?
BP ≥ 140/90
-2 occasions
-4 hours apart
-20+ weeks gestation
-previously normal BP
Severe BP readings of gestational HTN?
BP ≥ 160/110
Severe features (that can aid in the diagnosis of preeclampsia in the absence of proteinuria)?
7
- thrombocytopenia
- impaired liver fxn
- RUQ / epigastric pain
- renal insufficiency
- pulmonary edema
- new onset HA
- visual disturbances
Diagnosis of preeclampsia most common after how many weeks gestation?
20 (and frequently near term)
High risk factors for preeclampsia?
6
- prior hx
- multifetal gestation
- chronic HTN
- pregestational / gestational DM
- kidney disease
- autoimmune disease
Treatment if high risk factors for preeclampsia?
start low dose ASA between 12-16 weeks gestation
Moderate risk factors for preeclampsia?
5
- nulliparity
- pre-pregnancy BMI > 30
- family hx
- sociodemographic characteristics
- maternal age > 35
Treatment if moderate risk factors (1+) for preeclampsia?
consider starting low dose ASA between 12-16 weeks gestation
HELLP syndrome LDH levels?
≥ 600
HELLP syndrome AST / ALT elevation?
> 2 x ULN
HELLP syndrome platelet levels?
< 100
Main presenting symptoms of HELLP?
RUQ pain, generalized malaise, N/V
Convulsive manifestation of the hypertensive disorders of pregnancy?
eclampsia
Eclampsia often preceded by what symptoms?
severe / persistent HA’s, visual disturbances, AMS
Fetal consequences of HTN pregnancy disorders?
5
- fetal growth restriction
- oligohydraminos
- placental abruption
- nonreassuring fetal status
- preterm delivery
Maternal consequences of HTN pregnancy disorders?
7
- pulmonary edema
- MI
- stroke
- ARDS
- coagulopathy
- renal failure
- retinal injury
Recommendation if gestational HTN/ or preeclampsia with severe features at 34+ weeks?
Delivery
(after maternal stabilization, with labor / PROM)
Loading dose of magnesium if eclampsia or gestational HTN / preeclampsia with severe features?
4-6 g IV over 20-30 min
Maintenance dose of magnesium if eclampsia or gestational HTN / preeclampsia with severe features?
1-2 g IV / hour
Timing of magnesium admin if c-section?
Begin before, continue during + 24 hours following delivery
Correction for elevated magnesium levels and risk of impending respiratory depression?
calcium gluconate 10% solution, 10 mL IV over 3 min + IV lasix
Acute BP management (initiate within 30-60 min) with labetalol?
10-20 mg IV then 20-80 mg q 10-30 min to max cumulative dose of 300 mg
OR
constant infusion of 1-2 mg / min
Acute BP management (initiate within 30-60 min) with hydralazine?
5 mg IV or IM then 5-10 mg IV q 20-40 min to max dose of 20 mg
OR
constant infusion of 0.5-10 mg / hr
Acute BP management (initiate within 30-60 min) with nifedipine?
10-20 mg orally, repeat in 20 min if needed, then 10-20 mg q 2-6 hours, max daily dose of 180 mg
Expectant BP management (initiate within 30-60 min) with labetalol?
200 mg q 12 hours, increase to 800 mg q 8-12 hours as needed
(max 2400 mg daily)
(+ short acting nifedipine added gradually if needed)
Contraindications for labetalol admin?
5
- asthma
- preexisting myocardial disease
- decompensated cardiac function
- heart block
- bradycardia
Consequences of eclamptic seizures?
3
prolonged fetal HR decels, fetal bradycardia, increase in uterine contractility / baseline tone
Weeks of gestation considered preterm birth?
20 0/7 - 36 6/7
plus contractions and cervical dilation / effacement
Upper limit for the use of tocolytic agents?
34 weeks
Contraindications to tocolysis?
8
- intrauterine fetal demise
- lethal fetal anomaly
- nonreassuring fetal status
- severe preeclampsia or eclampsia
- maternal bleeding with hemodynamic instability
- chorioamnionitis
- PPROM
- maternal contraindications to tocolysis
Corticosteroids used in the antenatal period for fetal organ maturation?
betamethasone & dexamethasone
Preterm labor at risk of delivery within 7 days +/- ruptured membranes or multiple gestations should be given?
single course of corticosteroids between 24-34 weeks gestation
Dose of corticosteroids in the antenatal period?
12 mg IM q 24 hours x 2 doses
OR
6 mg IM q 12 hours x 4 doses
Common tocolytic agents?
CCB’s, NSAID’s, beta-adrenergic receptor agonists
(use for up to 48 hours for steroid admin)
definition of PPH
cumulative blood loss ≥ 1000 mL
+/- signs / sxs hypovolemia within 24 hours after birth process
primary PPH is what time frame
within first 24 hours of birth
secondary PPH is what time frame
from 24 hours after delivery and up to 12 weeks PP
4 T’s of PPH
tone, trauma, tissue, thrombin
what should be suspected as first etiology of PPH
uterine atony
first line treatment for PPH due to uterine atony
uterotonic agents
oxytocin, methylergonovine, 15-methyl prostaglandin, misoprostol
most common causes of secondary PPH
4
- subinvolution of placental site
- retained POC
- infection
- inherited coagulation defects
medium risk factors for PPH
7
- prior c-section / uterine surgery
- > 4 previous deliveries
- multiple gestaion
- large uterine fibroids
- chorioamnionitis
- magnesium sulfate use
- prolonged use of oxytocin / prolonged labor
high risk factors for PPH
6
- previa / accreta / increta / precreta
- HCT < 30
- bleeding at admission
- known coagulation defect
- history of PPH
- abnormal vital signs
placenta covers cervical opening
previa
placenta invasion into uterine wall and fails to separate during 3rd stage of labor
accreta / increta
most severe form of accreta, invasion through entirety of myometrium +/- extrauterine tissue
precreta
active management of third stage of labor
oxytocin admin, uterine massage, umbilical cord traction
dose of oxytocin during third stage of labor
bolus dose of 10 units IV vs IM
US finding highly suspicious for retained placental tissue
echogenic mass
classic contraction pattern for placental abruption
high frequency, low amplitude
triad for amniotic fluid embolism
hemodynamic compromise
respiratory compromise
DIC
dose of oxytocin for uterine atony
10-40 units per 500-1000 mL as continuous infusion ot 10 units IM
dose of methylergonovine for uterine atony
0.2 mg IM q 2-4 hours
dose of 15-methyl PGF for uterine atony
0.25 mg IM or intramyometrial 0.25 mg q 15-90 min (max 8 doses)
dose of misoprostol for uterine atony
600-1000 micrograms oral, sublingual, or rectal (once)
when the uterine corpus descends to, and sometimes completely through, the uterine cervix
uterine inversion
treatment of anemia found on routine PP labs
transfusion of PRBCs, oral iron, IV iron
early pregnancy loss definition
nonviable, IU pregnancy w/ either an empty GS or GS + embryo / fetus without fetal heart rate activity
time frame of early pregnancy loss
within the first 12 6/7 weeks
~50% of all early pregnancy losses are due to?
fetal chromosomal abnormalities
most significant risk factors for early pregnancy loss
advanced maternal age, prior early pregnancy loss
common sxs of early pregnancy loss
vaginal bleeding, uterine cramping
findings diagnostic of pregnancy failure
CRL of __ mm + __
CRL of ≥ 7mm + no heartbeat
findings diagnostic of pregnancy failure
Mean sac diameter of __ mm + __
Mean sac diameter of ≥ 25 mm + no embryo
findings diagnostic of pregnancy failure
Absence of __ ≥ __ after a scan that showed a gestational sac without a yolk sac
Absence of embryo with heartbeat ≥ 2 weeks after a scan that showed a gestational sac without a yolk sac
findings diagnostic of pregnancy failure
Absence of __ ≥ __ after a scan that showed a gestational sac with a yolk sac
Absence of embryo with heartbeat ≥ 11 days after a scan that showed a gestational sac with a yolk sac
common criteria for complete expulsion of pregnancy tissue (on US)
absence of GS and endometrial thickness < 30 mm
when can medical management for early pregnancy loss be considered
without infection, hemorrhage, severe anemia, or bleeding disorders
medical management for early pregnancy loss (dosing)
Misoprostol 800 micrograms, intravaginally + mifepristone 200 mg orally 24 hours prior
with repeat dose as needed
(no earlier than 3 hours after first dose and typically within 7 days if there is no response to the first dose)
Administration of Rh(D)-immune globulin should be considered, especially if ?
later in the first trimester & Rh(D) negative and unsensitized
(prophylaxis if surgical management)
dose of Rh(D)-immune globulin
50 micrograms
timing of Rh(D)-immune globulin if medical management
within 72 hours of the first misoprostol administration
“too much bleeding” with early pregnancy loss
soaking of 2 maxi pads per hour for 2 consecutive hours
surgical uterine evacuation if ?
retained tissue, hemorrhage, hemodynamic instability, signs of infection
dose of abx with surgical intervention of early pregnancy loss
single dose of doxycycline 200 mg 1 hour prior
most common site of ectopic pregnancy
fallopian tube
heterotopic pregnancy
co-occurence of ectopic pregnancy with IU pregnancy
risk factors for ectopic pregnancy
5
- prior ectopic pregnancy
- previous damage to fallopian tubes
- ascending pelvic infection
- prior pelvic / fallopian tube surgery
- assisted reproductive technology
US findings of ectopic pregnancy?
mass +/- hypoechoic area separate from ovary
collection of fluid or blood in the uterine cavity, sometimes visualized with ectopic pregnancy
pseudogestational sac
an IU gestational sac with yolk sac should be visible when ?
between 5-6 weeks gestation
chorionic villi found on uterine aspiration confirms what?
failed IU pregnancy
absolute contraindications to methotrexate in ectopic pregnancy
8
- IU pregnancy
- immunodeficiency
- anemia / leukopenia / thrombocytopenia
- pulmonary disease
- PUD
- hepatic dysfunction
- renal dysfunction
- breastfeeding
single dose regimen of methotrexate for ectopic pregnancy
-day 1: 50 mg/m2 IM
-day 4 & 7: measure hCG
-if decrease > 15%, measure until non-pregnant level
-if decrease < 15%, re-administer methotrexate 50 mg/m2 IM
two dose regimen of methotrexate for ectopic pregnancy
- day 1 & day 4: 50 mg/m2 IM
-day 4 & &: measure hCG
-if decrease > 15%, measure until non-pregnant level
-if decrease < 15%, re-administer methotrexate 50 mg/m2 IM on day 7
-day 11: re-check hCG
-can repeat again on day 14 if needed
most common adverse effects of multiple doses of methotrexate
GI problems
what to avoid on methotrexate
folic acid supplements, foods that contain folic acid, NSAIDs
(all decrease efficacy)
avoid pregnancy during treatment and for how long after methotrexate therapy
one ovulatory cycle
surgical options for ectopic pregnancy
laparoscopic salpingostomy vs laparoscopic salpingectomy
-removal of the ectopic pregnancy while leaving the affected fallopian tube in situ
-removal of part or all of the affected fallopian tube
