Obs Flashcards
Name: Infectious disease testing (6)
- HIV
- rubella IgG
- varicella
- syphilis testing
- hepatitis B
- gonorrhoea/chlamydia
Name: Nutrition supplementation (3)
- 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
When to do US in routine antenatal assessments according to GA?
-
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)
When to do screen for gestational diabetes in routine antenatal assessments according to GA?
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
What’s normal maternal BP?
normal < 140/90 mm Hg
What’s normal FHR?
110 - 160 bpm
How to estimate date of confinement?
Naegele’s rule = (LMP+ 7d) − 3mo (for 28-d menstrual cycle)
Visible gestational sac visible at which week? (2)
- 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)
Name: Types of Prenatal Screening Tests (3)
- 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
What are the findings in prenatal screening tests for: Neural Tube Defect?
↑ Maternal Serum AFP (MSAFP) approximately 80% to 90% sensitivity
What are the findings in prenatal screening tests for: Trisomy 21 vs Trisomy 18?
- Trisomy 21 → ↓ MSAFP, ↑ b-hCG, ↓ unconjugated E3, ↑ inhibin
- Trisomy 18 → ↓ MSAFP, ↓ b-hCG, ↓ unconjugated E3, ↓ inhibin
Smoking is associated with ↑ risk of what? (6)
- Spontaneous abortion (1.2–1.8×)
- Abruptio placentae
- Placenta previa
- Preterm birth
- Low birth weight infant
- Sudden Infant Death Syndrome
Describe management of no/vo (4)
- 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
Describe management of UTI (5)
- 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
Describe management of constipation (3)
- Drink ≥6–8 glasses fluid/d
- ↑ High fiber foods intake
- Exercise
Describe management: Postdates (5)
- 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
Name safe (5) and contraindicated (5) vaccines in pregnancy
Name indications NST (4)
- 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
Analyse results of BPP (3)
- 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
Name components of BPP (4)
Differentiate chronic vs gestational DB
Divided into chronic (Dx preceding pregnancy or diagnosed at GA < 20 wk) or gestational (Dx at GA ≥ 20 wk)
Define HTN and severe HTN
- 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
Describe the management of HTN in pregnancy (2)
- 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
Describe timing of delivery for HTN (3)
- IOL at ≥ 37 wk for pts with preeclampsia or GHTN
- Requires OB consult
- Pts with severe preeclampsia may require earlier delivery—requires OB consult
Describe: Classification of Diabetes in Pregnancy (2)
- 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.)
Describe screening GDM
Describe management glycemic control and surveillance: GDM (5)
-
(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
Describe delivery: GDM (2)
- Recommend delivery by 41 weeks to all GDM, and by 39 weeks to IDGDM
- If EFW >4.5 kg → C/S recommended
Describe management postpartum: GDM (1)
- 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)
Differentiate PROM, prolonged PROM, preterm ROM and Preterm PROM (PPROM)
- 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
How to confirmation of rupture of membranes? (3)
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
Describe the management of PROM (figure)
Describe the approach to PTL (figure)
Name tocolysis options (2)
- CCB (nifedipine) - First line
- PG synthesis inhibitors (Indomethacin - limit use to < 32 weeks GA)
Name common etiologies for Antepartum Hemorrhage (4)
- 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)
Describe investigations: Abruption (2)
- Lab: CBC, liver and renal function, coagulation studies including fibrinogen, type and crossmatch
- Speculum exam if previa ruled out
Describe management: Abruption (4)
- 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)
Describe investigations: Placenta previa (2)
- U/S to confirm previa
- CBC, type and crossmatch
Describe management: Placenta previa (4)
- 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
Describe investigations: Vasa previa (3)
- CBC, type and crossmatch
- Speculum exam and Apt test
- U/S with color Doppler if vasa previa suspected (before bleed)
Describe management: Vasa previa (4)
- 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)
Name painless abnormal bleeding (2)
- Placenta previa
- Vasa previa
Describe investigation: Cervical pathology (4)
- Speculum exam
- Pap smear
- Swab for CandG
- ± U/S for cervical length if cervix appears short or associated with cramping/contractions
Describe management: Cervical pathology (2)
- Dependent on etiology
- Treat cervicitis
- Do not remove cervical polyp—refer to colpos- copy if AbN appearing/AbN pap smear
RhD isoimmunization leads to what? (2)
- 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).
Describe prophylaxis of RhD isoimmunization for Rh- Women (5)
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
Name stages of labor with average duration (table)
Describe: Normal tracing (3)
- Baseline: 110 - 160 bpm
- Variability: 6 - 25 bpm, < 5 bpm for < 40 min
- Decelerations: none or occasional uncomplicated variables or early decelerations
Describe: Atypical tracing (3)
- 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
Describe: Abnormal tracing (3)
- 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)
Describe: Early Decelerations (4)
- 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
Describe: Variable Decelerations (3)
- 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
Variable Decelerations are due to what? (2)
- Due to cord compression
- or, in second stage, forceful pushing with contractions
Describe: Complicated Variable Decelerations (6)
- 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
Describe: Late Decelerations (4)
- Uniform shape
- Gradual ↓
- Late onset (starts at end of contraction)
- Can be associated with change in baseline or ↓ variability
Late Decelerations are due to what? (4)
-
Uteroplacental deficiency due to
- (a) maternal hypotension
- (b) uterine hyperstimulation
- (c) placental dysfunction
- Result = hypoxia ± acidosis of fetus
Describe: Management of an Atypical or Abnormal FHR Tracing (11)
- 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
Screening for Group B Strepto should be done when?
36 wk GA
Indications for Antibiotic Prophylaxis for GBS (5)
- 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
Name ATB used for GBS prophylaxis (4)
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)
Name rx for pain relief in labor (3)
- 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
Name RIs for epidural or spinal considerations (6)
- Pt refusal
- Untreated coagulopathy
- Skin infection of lumbararea
- Refractory hypotension/hypovolemia
- Active neurologic disease
- Septicemia
Compare median (midline) episiotomies and mediolateral (4)
- 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
Describe: Management of Shoulder Dystocia (7)
- 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
Describe active management of third stage of labor (2)
- Oxytocin
- Controlled cord traction
Name methods of induction of labor (2)
- Artificial ROM (amniotomy)—stimulates PG synthesis and secretion
- Oxytocin (Pitocin)
Describe: Augmentation of labor
- Promotes adequate uterine contractions when spontaneous labor fails to progress
- IV infusion of oxytocin
Name: Common postpartum complications (4)
- Postpartum hemorrhage
- Postpartum fever
- Postpartum blues
- Postpartum depression
Describe initial management of postpartum hemorrhage (8)
- 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
Describe timeline of postpartum blues
Usually begins between postpartum day 3 and 10 days
Describe: Postpartum depression (2)
- Depression occurring in a woman within 1 y of childbirth
- Antidepressants, Psychotherapy, Supportive care
Describe tx: Endometritis (2)
clindamycin + gentamicin
