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Revision LMCC > Obs > Flashcards

Obs Flashcards

1
Q

Name: Infectious disease testing (6)

A
  • HIV
  • rubella IgG
  • varicella
  • syphilis testing
  • hepatitis B
  • gonorrhoea/chlamydia
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2
Q

Name: Nutrition supplementation (3)

A
  • Folic acid—0.4–1 mg OD starting at least 2–3 mo preconception until end of T1 or 5 mg OD if have FHx of NTD, current Hx IDDM, obesity, epilepsy, or Hx poor compliance
  • Fe – recommended 27 mg/d for maintenance, 150–200 mg /d to treat anemia
  • Prenatal multivitamins
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3
Q

When to do US in routine antenatal assessments according to GA?

A
  • 8 - 12 wk : Dating U/S
    • measure of crown-rump length; margin of error± 5d
  • 18 - 22 wk :
    • (a) anatomy and growth of fetus; margin of error ± 7 d;
    • (b) placental position;
    • (c) Amniotic Fluid Volume (Note: In obese women, U/S should be delayed until 21–22 wk GA)
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4
Q

When to do screen for gestational diabetes in routine antenatal assessments according to GA?

A

24 - 28wk

  • Screen for gestational diabetes (GDM)—50 g oral glucose tolerance test (OGTT)
    • Plasma glucose < 7.8 mmol/L → normal
    • Plasma glucose > 7.8 to < 10.3 mmol/L (50g OGTT)→ do 2h 75g OGTT
    • Plasma glucose > 10.3 (50 g OGTT) → GDM
  • Dx of Impaired Glucose Tolerance and/or GDM
    • 1–2h 75 g OGTT: 1AbN = IGT and 2+ AbN = GDM
    • Fasting plasma glucose > 5.3 mmol/L
    • 1 h plasma glucose (75 g OGTT) > 10.6 mmol/L
    • 2 h plasma glucose (75 g OGTT) > 8.9 mmol/L
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5
Q

What’s normal maternal BP?

A

normal < 140/90 mm Hg

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6
Q

What’s normal FHR?

A

110 - 160 bpm

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7
Q

How to estimate date of confinement?

A

Naegele’s rule = (LMP+ 7d) − 3mo (for 28-d menstrual cycle)

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8
Q

Visible gestational sac visible at which week? (2)

A
  • Transvaginal US: Visible gestational sac at 5 wk (b-hCG > 1,500–3,000 IU), fetal pole at 6 wk, and fetal heart beat by 6 to 7 wk
  • Transabdominal U/S: 6 to 8 wk (hCG > 6,500 IU)
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9
Q

Name: Types of Prenatal Screening Tests (3)

A
  • First Trimester Screening (FTS) = measures Nuchal Translucency US (NTUS) + Pregnancy-Associated Plasma Protein A (PAPP-A) + b-hCG
  • QUAD = measures Maternal Serum AFP (MSAFP) + b-hCG+ unconjugated E+ inhibin A
  • IPS= combines QUAD screenmarkers + NTUS + PAPP-A
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10
Q

What are the findings in prenatal screening tests for: Neural Tube Defect?

A

↑ Maternal Serum AFP (MSAFP) approximately 80% to 90% sensitivity

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11
Q

What are the findings in prenatal screening tests for: Trisomy 21 vs Trisomy 18?

A
  • Trisomy 21 → ↓ MSAFP, ↑ b-hCG, ↓ unconjugated E3, ↑ inhibin
  • Trisomy 18 → ↓ MSAFP, ↓ b-hCG, ↓ unconjugated E3, ↓ inhibin
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12
Q

Smoking is associated with ↑ risk of what? (6)

A
  1. Spontaneous abortion (1.2–1.8×)
  2. Abruptio placentae
  3. Placenta previa
  4. Preterm birth
  5. Low birth weight infant
  6. Sudden Infant Death Syndrome
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13
Q

Describe management of no/vo (4)

A
  • Non pharmacologic: avoid spicy/greasy foods. Eat dry crackers, small frequent meals
  • Pharmacologic: if causing dehydration, weight loss, and metabolic abnormalities (hyperemesis gravidarum)
    • IV/P.O. hydration,
    • antiemetic therapy (i.e., diclectin)
    • ± nutrient supplementation
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14
Q

Describe management of UTI (5)

A
  • Treat asx bacturia and uncomplicated UTI based on culture results
  • Common antibiotics include: amoxicillin, Nitrofurantoin.
  • Avoid TMP-SMX, especially in T1, due to antifolate effect.
  • Complicated UTI or pyelonephritis: hospitalization and IV antibiotics
  • ** Follow with post treatment urine culture and monthly cultures for remainder of pregnancy
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15
Q

Describe management of constipation (3)

A
  • Drink ≥6–8 glasses fluid/d
  • ↑ High fiber foods intake
  • Exercise
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16
Q

Describe management: Postdates (5)

A
  • Offer membrane stripping from 38 to 41 wk
  • Expectant management until 41 + 0
  • Daily fetal kick counts from 40 + 0
  • Increase surveillance (Min NST, fluid assessment 2× /wk) at 41 wk
  • Induction of labor between 41 and 42 GA
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17
Q

Name safe (5) and contraindicated (5) vaccines in pregnancy

A
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18
Q

Name indications NST (4)

A
  • Indication: decreased FM
    • Normal NST and risk factors or suspected oligo-IUGR = BPP within 24h
    • Atypical or abnormal NST = urgent assessment with U/S
  • Indication: pregnancies at high risk
    • If stable, a normal NST generally indicates favourable outcome for 1 wek
    • In IDDM or GDM, or postdate pregnancy, frequency of NST is recommended 2x/wk
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19
Q

Analyse results of BPP (3)

A
  • 8/10 to 10/10 with normal fluid, 8/8 with no NST= intervention for obstetric/maternal factors
  • 6/10 or 8/10 with low fluid = consult OB
  • 0/10 to 4/10= immediate delivery required—consult OB
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20
Q

Name components of BPP (4)

A
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21
Q

Differentiate chronic vs gestational DB

A

Divided into chronic (Dx preceding pregnancy or diagnosed at GA < 20 wk) or gestational (Dx at GA ≥ 20 wk)

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22
Q

Define HTN and severe HTN

A
  • HTN: systolic pressure > 140 mmHg or diastolic pressure > 90 mmHg on two occasions
  • Severe HTN: systolic pressure ≥ 160 mm Hg ± diastolic pressure ≥ 110 mm Hg
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23
Q

Describe the management of HTN in pregnancy (2)

A
  • Antihypertensives: target BP 130/80 to 155/105 mm Hg if no comorbidities
    • Methyldopa, b-Blockers (Labetalol)
    • IV for emergencies: Nifedipine XL, hydralazine
  • Hospit: For BP > 160/110, or any adverse features
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24
Q

Describe timing of delivery for HTN (3)

A
  • IOL at ≥ 37 wk for pts with preeclampsia or GHTN
  • Requires OB consult
  • Pts with severe preeclampsia may require earlier delivery—requires OB consult
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25
Q

Describe: Classification of Diabetes in Pregnancy (2)

A
  • Preexisting diabetes (type 1 or 2)
  • GDM (onset of DM during pregnancy)
    • GDM is usually diagnosed in the late gestation (i.e., T2 pregnancy).
    • If diagnosed before 24 wk, GA is likely undiagnosed type 2 DM. (Consider ordering an HbA1c; if elevated, more likely undiagnosed type 2 DM.)
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26
Q

Describe screening GDM

A
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27
Q

Describe management glycemic control and surveillance: GDM (5)

A
  • (A) Strict glycemic control:
    • Diet control, exercise
    • Insulin therapy → initiate if blood glucose not well controlled on lifestyle modification alone
  • (B) Fetal surveillance:
    • FM counts (6 movements in 2 hours)
    • U/S to asses fetal growth/size at 36–39 wk
    • If on insulin → twice weekly NST and BPP from 32 wk until delivery
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28
Q

Describe delivery: GDM (2)

A
  • ​Recommend delivery by 41 weeks to all GDM, and by 39 weeks to IDGDM
  • If EFW >4.5 kg → C/S recommended
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29
Q

Describe management postpartum: GDM (1)

A
  • Postpartum (R/O persistent DM):
    • Follow up fasting plasma glucose + 2 h 75 g oral glucose tolerance test at 6–12 wk postpartum (for mothers with postdelivery fasting glucose > 7 mmol)
30
Q

Differentiate PROM, prolonged PROM, preterm ROM and Preterm PROM (PPROM)

A
  • PROM: ROM before labor at any GA
  • Prolonged PROM: > 24 h between ROM and labor onset
  • Preterm ROM: ROM before 37 wk GA
  • Preterm PROM (PPROM): ROM before 37 wk GA and before onset of labor
31
Q

How to confirmation of rupture of membranes? (3)

A

Sterile speculum exam

  • Observe for pooling of amniotic fluid in posterior fornix, and fluid leaking from cervix during cough/valsalva
  • Nitrazine test (amniotic fluid turns nitrazine paper blue)
  • Note: do not do a cervical exam to avoid introduction of infection unless signs of labor
32
Q

Describe the management of PROM (figure)

A
33
Q

Describe the approach to PTL (figure)

A
34
Q

Name tocolysis options (2)

A
  • CCB (nifedipine) - First line
  • PG synthesis inhibitors (Indomethacin - limit use to < 32 weeks GA)
35
Q

Name common etiologies for Antepartum Hemorrhage (4)

A
  • Abruption: separation of placenta from uterus before delivery of fetus (after 20 wk GA)
  • Placenta previa: placenta covers or is close to (< 2 cm) cervical os
  • Vasa previa: velamentous insertion of umbilical cord vessels into placenta, so vessels traverse the cervical os before entering the placenta
  • Cervical pathology: (cervical polyp, ectro- pion, cervical dilation, infection)
36
Q

Describe investigations: Abruption (2)

A
  • Lab: CBC, liver and renal function, coagulation studies including fibrinogen, type and crossmatch
  • Speculum exam if previa ruled out
37
Q

Describe management: Abruption (4)

A
  • Maternal stabilization (large-bore IVs, IV fluids ± blood transfusion)
  • If mother Rh–, give Rh immunoglobulin
  • Delivery if fetal distress or term infant
  • Expectant management if mother and premature infant stable (steroids if < 34 wk, no Tocolysis, consider transfer to higher level facility)
38
Q

Describe investigations: Placenta previa (2)

A
  • U/S to confirm previa
  • CBC, type and crossmatch
39
Q

Describe management: Placenta previa (4)

A
  • Maternal stabilization
  • If mother Rh–, give Rh immunoglobulin
  • Expectant management if GA 24–36 wk and mother/fetus stable
  • Delivery via C/S at 36–37 wk
40
Q

Describe investigations: Vasa previa (3)

A
  • CBC, type and crossmatch
  • Speculum exam and Apt test
  • U/S with color Doppler if vasa previa suspected (before bleed)
41
Q

Describe management: Vasa previa (4)

A
  • Steroids at 28–30 wk GA
  • Manage as inpt from 30–32 wk GA
  • Elective delivery at 34–36 wk GA
  • Emergent delivery if bleeding (50% fetal mortality)
42
Q

Name painless abnormal bleeding (2)

A
  • Placenta previa
  • Vasa previa
43
Q

Describe investigation: Cervical pathology (4)

A
  • Speculum exam
  • Pap smear
  • Swab for CandG
  • ± U/S for cervical length if cervix appears short or associated with cramping/contractions
44
Q

Describe management: Cervical pathology (2)

A
  • Dependent on etiology
  • Treat cervicitis
  • Do not remove cervical polyp—refer to colpos- copy if AbN appearing/AbN pap smear
45
Q

RhD isoimmunization leads to what? (2)

A
  • a. Fetal/neonatal hemolytic anemia ± hyperbilirubinemia 25% to 30% and/or
  • b. Hydrops fetalis 25%

The amount of RhD+ blood required to cause isoimmunization is small (< 0.1 mL).

46
Q

Describe prophylaxis of RhD isoimmunization for Rh- Women (5)

A

Administration of one prophylactic dose (300 mg) of RhoGAM

  • At 28 wk unless the father of the baby is known to be Rh−
  • Within 72 h of delivery of an Rh+ infant, even if she had received her antepartum dose.
  • Following T1 miscarriage, threatened miscarriage, induced abortion, ectopic pregnancy, or molar pregnancy
  • Post invasive procedures (i.e.,CVS, amniocentesis,fetal blood sampling)
  • Any T2/T3 bleeding, external cephalic version, blunt abdo trauma
47
Q

Name stages of labor with average duration (table)

A
48
Q

Describe: Normal tracing (3)

A
  • Baseline: 110 - 160 bpm
  • Variability: 6 - 25 bpm, < 5 bpm for < 40 min
  • Decelerations: none or occasional uncomplicated variables or early decelerations
49
Q

Describe: Atypical tracing (3)

A
  • Baseline
    • Bradycardia 100–110 bpm
    • Tachycardia > 160 bpm for < 30 min
  • Rising baseline
    • Variability: ≤ 5 bpm for 40–80 min
  • Decelerations:
    • Repetitive (≥ 3) uncomplicated variable decelerations
    • Occasional late decelerations
    • Single prolonged deceleration
50
Q

Describe: Abnormal tracing (3)

A
  • Baseline:
    • Bradycardia < 100 bpm
    • Tachycardia > 160 bpm for < 30 min
    • Erratic baseline
  • Variability
    • > 80 min
    • ≥ 25 bpm for > 10 min
    • Sinusoidal
  • Decelerations:
    • Repetitive (≥ 3) complicated variables
    • Single prolonged deceleration (> 2 min but < 10 min)
51
Q

Describe: Early Decelerations (4)

A
  • Uniform shape with onset early in contraction, returns to baseline by end of contraction, mirrors contraction (nadir occurs at peak of contraction)
  • Gradual deceleration and return to baseline
  • Often repetitive; no effect on baseline FHR or variability
  • Benign, due to vagal response to head compression
52
Q

Describe: Variable Decelerations (3)

A
  • Variable in shape, onset, and duration
  • Most common type of periodicity seen during 160 labour
  • Often with abrupt drop in FHR >15 bpm below baseline (>15 s, <2 min); usually no effect on baseline FHR or variability
53
Q

Variable Decelerations are due to what? (2)

A
  • Due to cord compression
  • or, in second stage, forceful pushing with contractions
54
Q

Describe: Complicated Variable Decelerations (6)

A
  • FHR drop <70 bpm for >60 s
  • Loss of variability or decrease in baseline after deceleration
  • Biphasic deceleration
  • Slow return to baseline
  • Baseline tachycardia or bradycardia
  • May be associated with fetal acidemia
55
Q

Describe: Late Decelerations (4)

A
  • Uniform shape
  • Gradual ↓
  • Late onset (starts at end of contraction)
  • Can be associated with change in baseline or ↓ variability
56
Q

Late Decelerations are due to what? (4)

A
  • Uteroplacental deficiency due to
    • (a) maternal hypotension
    • (b) uterine hyperstimulation
    • (c) placental dysfunction
    • Result = hypoxia ± acidosis of fetus
57
Q

Describe: Management of an Atypical or Abnormal FHR Tracing (11)

A
  • Recheck the tracing
  • Backup
  • Change maternal position to Left lateral decubitus position—relieves compression of IVC by the gravid uterus
  • Provide fetus O2 by 100% O2 mask to mother
  • Stop augmentation of labor—↓ hyperstimulation
  • Fetal scalp stimulation
  • R/O causes of utero placental deficiency (i.e.,correct any maternal hypotension—IVFs, ephedrine)
  • Amniotomy
  • Fetal scalp electrode if unable to obtain adequate tracing with external monitoring
  • Measurement of fetal scalp blood pH—(pH≥ 7.25= normal, pH ≤ 7.20= fetal acidosis)
  • ± Amnioinfusion—protects cord from compression
58
Q

Screening for Group B Strepto should be done when?

A

36 wk GA

59
Q

Indications for Antibiotic Prophylaxis for GBS (5)

A
  • A positive GBS screen
  • Unknown GBS status and other RFs for neonatal disease
    • (a) Prev.infant with invasive GBS infection
    • (b) GA < 37 wk
    • (c) > 18 h since ROM
    • (d) GBS bacteriuria in current pregnancy
60
Q

Name ATB used for GBS prophylaxis (4)

A

IV

  • Penicillin
  • Cefazolin (non anaphylactic penicillin allergy)
  • Clindamycin (anaphylactic penicillin allergy with documented GBS sensitivity)
  • Vancomycin (anaphylactic penicillin allergy with GBS resistance to Clindamycin or sensitivity unknown)
61
Q

Name rx for pain relief in labor (3)

A
  • Entonox: A mixture of nitrous oxide gas and O2 administered through a mask
  • Narcotics: morphine, can cause respiratory depression in the neonate, reverse with Narcan 0.01 mg/kg
  • Regional anesthesia:
    • Loss of pain sensation occurs below T8/T10
    • Must hydrate the patient with dextrose free isotonic IV before initiation of epidural
62
Q

Name RIs for epidural or spinal considerations (6)

A
  • Pt refusal
  • Untreated coagulopathy
  • Skin infection of lumbararea
  • Refractory hypotension/hypovolemia
  • Active neurologic disease
  • Septicemia
63
Q

Compare median (midline) episiotomies and mediolateral (4)

A
  • Median (midline)
    • Advantage = easy repair and improved healing
    • likely to extend into anal musculature/rectal mucosa
  • Mediolateral
    • Advantage = ↓ likely to extend into anal sphincter and rectum
    • Mediolateral → ↑ scar tissue, ↑ blood loss, ↑ pain, ↑ dificult to repair, dyspareunia sequelae
64
Q

Describe: Management of Shoulder Dystocia (7)

A
  • A: Ask for help
  • L: Lift/hyperflex both legs (McRobert maneuver)
  • A: Anterior shoulder disimpaction (suprapubic pressure by assistant or Rubin maneuver by MD)
  • R: Rotation of posterior shoulder (Wood cork screw maneuver)
  • M: Manual removal of posterior arm
  • E: Episiotomy
  • R: Roll onto all 4s
65
Q

Describe active management of third stage of labor (2)

A
  • Oxytocin
  • Controlled cord traction
66
Q

Name methods of induction of labor (2)

A
  • Artificial ROM (amniotomy)—stimulates PG synthesis and secretion
  • Oxytocin (Pitocin)
67
Q

Describe: Augmentation of labor

A
  • Promotes adequate uterine contractions when spontaneous labor fails to progress
  • IV infusion of oxytocin
68
Q

Name: Common postpartum complications (4)

A
  • Postpartum hemorrhage
  • Postpartum fever
  • Postpartum blues
  • Postpartum depression
69
Q

Describe initial management of postpartum hemorrhage (8)

A
  • Resuscitation:
    • large-bore IVs ± IVFs
    • O2 using mask
    • cross and type 4 units PRBC
    • monitor vital signs
  • Assess etiology: “4 Ts”
    • Tone—assess uterine atony
    • Tissue—explore uterus for retained placental tissue or blood clots
    • Trauma—explore the lower genital tract for lacerations
    • Thrombin—review if patient has Hx of coagulopathy (vWD, ASA use, DIC, ITP, etc.)
  • Investigations: CBC, coagulation profile
70
Q

Describe timeline of postpartum blues

A

Usually begins between postpartum day 3 and 10 days

71
Q

Describe: Postpartum depression (2)

A
  • Depression occurring in a woman within 1 y of childbirth
  • Antidepressants, Psychotherapy, Supportive care
72
Q

Describe tx: Endometritis (2)

A

clindamycin + gentamicin

Revision LMCC (6 decks)

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