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1
Q

Term

A

> 37wk

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2
Q

Premature

A

20-36+6 wk

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3
Q

Abortion

A

<20wk
Or
<500 g

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4
Q

Goodell’s sign

A

Softening of cervix

4-6 wk

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5
Q

Chadwick’s sign

A

Bluish discoloration of cervix and vagina

6wk

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6
Q

Hegat

A

Softening of the cervical isthmus

6-8wk

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7
Q

Time of beta detection in pregnancy

A

9d post conception in serum

28d after LMP in urine

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8
Q

Beta doubling time

A

q 1.4-2 d

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9
Q

Peak of beta in pregnancy

A

8-10 wk

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10
Q

Visible pregnancy on TVS

A

5wk: gestational sac
6wk: fetal pole
7wk: FHR

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11
Q

Visible pregnancy on transabdominal U/S

A

6-8wk

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12
Q

Beta rule of 10

A

Missed mense:10
Wk 10: 100,000
Term:10,000

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13
Q

No of WBC in preg

A

Increased

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14
Q

Plt in preg

A

> 70,000
Asymptomatic
Returns to nl 2-12 wk following delivery

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15
Q

Normal glycosuria in pregnancy

A

T3

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16
Q

Folic acid supplementation

A

8-12 wk preconception until end of T1
All women: 0.4-1 mg/d
Previous NTD/AED/DM/BMI>35 :5mg/d

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17
Q

Supplements before pregnancy

A

Folic acid
Iron
Prenatal vitamins

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18
Q

Preconception genetic testing indications

A

Known carriers
Recurrent loss/stillbirth
Family member with developmental delay/birth anomaly/genetic disease
Consanguinity

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19
Q

Prenatal infection screening

A 
Rubella
HBsAg
VDRL
HIV
Pap smear
Gonorrhea
Chlamydia
TB (Hx of travel, health care worker)
Varicella (Hx, vaccination)
Parvovirus (exposure to children)
CMV (health care workers)
Toxo (exposure to cats, gardening)
Pertussis (vaccine)
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20
Q

Initial prenatal visit

A

Within 8-12 wk of LMP

Earlier if <20, >35

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21
Q

Naegle’s rule for EDC

A

1st day of LMP + 1y -3mo +7d +number of cycle days more than 28

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22
Q

If unreliable LMP

A

Dating U/S

Change EDC if T1 U/S is greater than 5 days in difference from LMP due date

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23
Q

Initial prenatal investigations

A

CBC, Blood group, Rh, antibody screen, infection screen
Urine R&M, midstream urine C&S
Pelvic exam: Pap smear, cervical/urine PCR for gono/chlamy

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24
Q

NT

A

12 wk

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25
N/V Mx
Weigh Hydration evaluation Urine ketones
26
Ginger max
1000 mg/d
27
Medication for N/V
``` Diclectin (doxylamine succinate + B6) No response, dimenhydrinate Hydroxyzine Pyridoxine Phenothiazine Metoclopeamide B6 lollipop +/- fluid replacement ```
28
Hyperemesis gravidarum
CBC, lytes, BUN, Cr, LFT, U/A, U/S | R/O other causes: TFT, beta
29
Mx of hyperemesis gravidarum
``` Thiamine Diclectin Dimenhydrinate Hydroxyzine Pyridoxine Phenothiazine Metoclopramide Ondansetron Methylprednisolone Admission, NPO, then small frequent meals, correct fluid/lytes/ketosis, TPN ```
30
Encephalopathy due to hyperemesis gravidarum
Wernicke
31
Prenatal visits
1st: 8-12 wk from LMP Then q 4-6 wk until 30 wk Q 2-3 wk from 30 wk q 1-2 wk from 36 wk
32
Doppler for FHR
10-12 wk
33
Leopold time
After 30-32 wk
34
Legal aspect of prenatal screening
Requires informed concent
35
1st dating U/S
8-12 wk
37
Prenatal screening | 8-12 wk
``` Dating U/S Pap Chlamydia/Gono Urine C&S HIV VDRL HBsAg CBC, blood group, screen Parvovirus IgM/G if contact with small children Varicella if no Hx of disease/immunization ```
38
NIPT | Cell-free fetal DNA
>10 wk | Requires dating U/S
39
CVS
10-12 wk
40
Enhanced FTS
11-14 wk
41
Screening | 11-14 wk
Enhanced FTS IPS part1 (NT, beta, PAPP-A, PIGF, AFP)
42
NT
11-14 wk
43
Amniocentesis
15-16 wk to term
44
IPS part2
15-20 wk | MSAFP, beta, unconj-est, inhibin A
45
MSS
``` 15-20 wk MSAFP Beta Unconj-est Inhibin A ```
46
Fetal movement quickening
18-20 wk to term
47
Routine dating U/S (2nd)
18-20 wk | Dates, growth, anatomy
48
GDM screening
24-28 wk | 50 g OGCT
49
Repeat CBC, BG, Rh, Rhogam
28 wk
50
GBS screen
35-37 wk
51
6 wk postpartum
``` Contraception Mense Breastfeeding Depression Mental health Support Breast exam Pelvic exam (pap if due) ```
52
Most accurate dating method
U/S 8-12 wk | CRL (+/- 5d margin of error)
53
U/Ss in pregnancy
8-12 wk dating 11-14 wk NT 18-20 wk growth/anomaly/ dating (error: +/- 10 d)
54
What does NIPT search for?
Down Trisomy 18,13, some X/Y disorders, some microdeletions Ready in 7-10 d
55
Increased NT
Down Turner Cardiac anomalies Trisomy 18
56
Disadvantages of NIPT
Doesn’t test for NTD | Needs confirmation with invasive tests
57
Down in FTS
Increased NT Increased Beta Decreased PAPP-A
58
Trisomy 18 in FTS
Increased NT Decreased PAPP-A Decreased Beta
59
Disadvantages of FTS
Doesn’t check NTD (needs combination with MSAFP at 15-20 wk) If positive, confirm with CVS/amniocentesis/NIPT
60
Down in MSS
Decreased MSAFP Increased Beta Decreased est
61
Trisomy 18 in MSS
Decreased beta Decreased MSAFP Decreased est Decreased inhibin
62
ONTD in MSS
Increased MSAFP
63
Disadvantages of MSS
Late Only offered if missed IPS/ FTS If positive needs U/S, amniocentesis OR NIPT
64
IPS
NT+ FTS + MSS
65
Disadvantage of IPS
If positive, needs U/S, amniocentesis, NIPT
66
Fundus at pubic symphysis
12 wk
67
Fundus at umbilicus
20 wktwd
68
Mature fetal lung in AC
L:S ratio: 2
69
Indication of diagnostic tests (AC, CVS)
Age>35 Abnl screen (FTS, MSS,IPS, NIPT) PHx/FHx of: chromosomal anomaly, genetic disease, carrier parent, consanguinity, >3 spontaneous abortions
70
Time of results for AC and CVS
AC: 14-28d (FISH/PCR: 48 h) CVS: 48 h
71
Which one is more accurate? AC or CVS?
AC
72
Vitamin insufficiency implicated in NTD
Folate | Zn
73
Risk of isoimmunization (Rh neg mom, Rh pos fetus)
16 %
74
Inv for isoimmunization (if Rh neg mother)
``` Indirect coombs at first prenatal visit KB test U/S (hydrops) MCA doppler (fetal anemia) Serial AC ( bil, if MCA doppler not available, to assess degree of hemolysis) Cordocentrsis (fetal Hb, not 1st line) ```
75
Rh titer indicating increased risk of fetal hemolytic anemia
1:16
76
Rhogam in nl pregnancy (coombs negative mom)
28 wk | Within 72 h of delivery
77
Amount of fetomaternal bleeding covered by 1 Rhogam
30 ml
78
If Rh neg, coombs positive mother
Monthly ab titer, + U/S +/- serial AC
79
Milk product in pregnancy
3-4 servings/d
80
Daily caloric increase
T1: 100 T2:300 T3:300 Lact:450
81
Multivitamins
In inadequate intake in T2
82
Folate
0.4/d | 5 if high risk
83
Ca
1200-1500
84
Vit D
1000
85
Iron
T1: 0.8 T2: 4-5 T3: >6 Suppl: 30 mg/d
86
Caffein
Less than 300 | 1- cup
87
Mercury in fish
0.5
88
Exercise
Talk test | No supine after 20 wk
89
Contra to exercise if Hb
10 or less
90
Exercise with twin pregnancy
Not after 28 wk
91
Air travel
Not after 36-38 wk
92
Intercourse
May continue except: | Risk of abortion, preterm labour, placenta previa
93
Medication with risk of kernicterus
Sulpha in T3
94
Grey baby syndrome
Chloramphenicol
95
Oral typhoid vaccine in preg
Not allowed
96
Vaccines for all during preg
Influenza | Tdap at 26 wk
97
Postpartum vaccines
Rubella if none immune | HBV to infant within 12 h (if mother positive or unknown), then at 1 and 6 mo
98
If mother has received an adult booster of MMR and is still non immune against rubella
Should NOT be revaccinated
99
Radioactive iodine during pregnancy
Contraindicated
100
1st notice of fetal movement
Primigravida:18-20 wk Multigravida:1-2 wk earlier Anterior placenta:1-2 wk later
101
FM count if:
High risk woman Concerned woman Usually after 26 wk
102
If subjective decrease in FM
``` Drink juice Eat Change position Move to a quiet room Count for 2 h ```
103
Expected movements
6 or more during 2 hr | If less, pt presented to labour and delivery tiage
104
NST normal baseline
110-160
105
Nl variability
6-25 | If 5 or less, <40 min
106
Normal deceleration
None/occasional variable, <30 sec
107
Nl acceleration in term
2, 15 or more bpm, 15 s in <40 min
108
Nl acceleration in preterm
>2, >10 bpm, 10 s, in <40 min
109
Abn baseline NST
<100: bradycardia >160 for >30 min: tachy Erratic baseline
110
Abn variability
5 or less for for 80 min Sinusoidal 25 bpm for >10 min
111
Abn deceleration
Variable deceleration > 60 s | Late deceleration
112
Abn acceleration in term
<2 accelerations wirh acme of 15 or more, lasting 15s in > 80 min
113
Abn acceleration in pre-term
<2 accelerations with acke of >10 bpm, 10s, in >80 min
114
Atypical NST baseline
100-110 | >160 for <30 min
115
Atypical variability
5 for 40-80 min
116
Atypical deceleration
Variable 30-60 sec
117
Atypical acceleration
2, 15 or more bpm, 15 s in 40-80 min
118
Atypical acceleration in preterm
<2, >10 bpm, 10 s in 40-80 min
119
Atypical NST Mx
Requires further assessment
120
Abn NST Mx
Requires urgent action | U/S, BPP, delivery
121
If no acceleration in 1st 20 min of NST
Stimulate the fetus, continur monitoring for another 30 min
122
BPP parameters
Flexion/extension x1 Movement x3 Breathing x 30s AFV, one 2x2 pocket
123
Marker of chronic hypoxia in BPP
AFV
124
Interpretation of BPP
8: nl 6: repeat BPP in 24 h 0-4: consider delivery
125
Mean onset of bleeding in previa
30 wk
126
Pelvic exam in T3 bleeding
DO NOT PERFORM UNTILL PREVIA RULED OUT BY U/S
127
Amount of overlap in T3 that predicts C/S
>20 mm
128
Amount if overlap after 35 wk that predicts C/S
Any amount
129
Previa investigation
TVS
130
Indication of repeating TVS in T3 in previa
Placenta lies between 20 mm of overlap and 20 mm away from os
131
Mx of previa
``` Large bore IV, fluid, O2 V/S, U/O, blood loss, Hct, CBC, plt, PTT, INR, fibrinogen, FDP, type and cross match EFM U/S when stable Rhogam, KB ```
132
Delivery time in previa
If: GA 37wk or more, profuse bleeding, L/S:2, delivery by C/S If <37 wk and minimal bleeding, admit, limit (activity, douche, intercourse, enema), Steroid, delivery if any of the above conditiins
133
The most common cause of DIC in pregnancy
Abruptio placenta
134
The most common cause of pathological bleeding in T3
Abruptio placenta
135
Dx of abruptio
Clinical | No role for U/S
136
Mx of abruptio
Large bore IV, fluid, O2 V/S, U/O, blood loss Hct, CBC, plt, PTT, INR, fibrinogen, FDP, blood type and cross match EFM Blood products on hand (red cell, plt, CP) Rhogam, KB test
137
Delivery in abruptio
If mod-sev: Hydrate, restore blood loss, correct coagulation, the NVD NVD C/S if: live fetus and fetal/maternal distress, labour fails to progress, containdicated NVD If mild: If 37 wk or higher or mature fetus or profuse hemorrhage, deliver Otherwise serial Hct
138
inv for vasa previa
``` Apt test (blood+NaOH) Wright stain on blood (nucleated RBCs) ```
139
Vasa previa Mx
Emergency C/S
140
The most important RF for preterm labour
Hx of preterm labour
141
Cervical length and PTL
If > 30 mm in 34 wk, high NPV
142
Bacterial RFs for PTL
BV, ureaplasma urealyticum But screening only indicated for high risk women
143
The most common cause of neonatal mortality
PTL
144
Predicting PTL in symptomatic women
Cervicovaginal fluid fibronectin + U/S of cervical length
145
PTL Dx
Regular contractions: 2/10 min, >6/h Cervix> 1cm dilated Cervix> 80% effaced Length< 2.5 cm
146
Initial Mx of PTL
``` Hydration LLDP Morphine Avoid repeated pelvic exam U/S, BPP of fetus Erythro if PPROM Tocolytic •CCB, nifedipine •indonethacin MgS, if delivery between 24-31+6 wk or prevention of eclampsia Beta/Dexa ```
147
1st line tocolytic <30 wk
Indomethacin
148
1st line tocolytic in polyhydramnios
Indomethacin
149
Contraindication to beta/dexa
Maternal active TB
150
Inv in PROM
``` sterile speculum Nitrazine turns blue Cascade sign/fluid pooling in posterior fornix Ferning U/S, BPP Decreased AFV ```
151
PROM Mx
``` Admit Expectant management V/S q4h WBC/d BPP/d Beta if <34 wk (up to 36+6 wk if no infection) +/- tocolytic, if labour Screen for UTI, STI, GBS Tx GBS at the time of labour Penicillin/macrolide if not in labour Urgent delivery if: fetal distress, choriamnionitis ```
152
Delivery in PROM
``` <24wk: termination 24-25 wk: counseling of parents 26-34 wk: expectant management 34-36 wk: either expectant Mx or delivery 37 or more: induction of labour ```
153
AB use in PROM not in labour
<32wk, administer | >32wk, if lung maturity cannot be proven/delivery not planned
154
AB associated with NEC
Amoxi/clavu
155
Postdate definition
>42 wk
156
Postdate delivery
If mother>40, IOL in GA>39 wk GA 40-41 wk: expectant management GA>41 wk: offer IOL (last nl week) If GA>41 and expectant management chosen, serial fetal surveillance (FM count, BPP q 3-4 d) If AFI decreased, should induce labour
157
MSAFP in fetal demise
Increased
158
Fetal demise on doppler
Not diagnostic
159
Dx of fetal demise
Absent cardiac activity and FM on U/S
160
Mx
U/S HbA1c, fasting glucose, TSH, KB test, VDRL, ANA, CBC, anticardiolipins, Ab screens, INR/PTT, serum/urine toxicology, cervical/vaginal cultures, TORCH screen Fetal: karyotype, cord blood, genetic evaluation, autopsy, AF culture for CMV/parvo B19/ HSV Placenta: pathology, bacterial cultures
161
Fetal demise Tx
<12wk: dilation and curettage 13-20 wk: dilation and evacuation, maybe IOL >20 wk: IOL Monitor for coagulopathy Psychological care/bereavement support Discussion about results of investigations within 3 mo Help plan future pregnancies
162
Risk of DIC with fetal demise
10%
163
IUGR definition
Wt<10th percentile Or <2500 g at term
164
Most important RF for IUGR
Previous IUGR
165
Inv for IUGR
SFH If high risk mother/SFH lagging> 2cm behind GA: U/S(BPD, HC,AC,FL,Wt,AFV,rate of growth) +/- BPP Doppler of umbilical cord
166
IUGR prevention
Risk modification before preg
167
IUGR Mx
Modify controllable factors: smoking, alcohol, nutrition, illnesses Bed rest in LLDP Serial BPP Delivery if: abn function tests, absence of growth, severe oligo, especially if >34 wk
168
Mode of delivery in IUGR
C/S
169
Macrosomia definition
>90th percentile | >4000 g
170
Macrosomia inv
Serial FSH | If high risk mother/ SFH > 2cm ahead of GA, further inv
171
Macrosomia Mx
If EFW> 5000 in non-diabetic, C/S | If EFW> 4500 in diabetics, C/S
172
Polyhydramnios definition
AFI>25 Or Single deepest picket>8cm
173
Poly Mx
Screen for mother disease/infection | Complete fetal U/S evaluation
174
Poly Tx
Mild-mod, nothing | Severe, hospitalize, therapeutic AC
175
Olygohydramnios definition
AFI<5 | Deepest pocket <2 cm
176
Oligo manage
``` Admit R/O ROM NST/BPP U/S Doppler of umbilical cord/uterine artery Hydration Fluid injection Delivery if term. ```
177
Time of U/S chorionicity determination
8-12 wk
178
Mx of multiple gestation
Serial U/S q 2-3 wk from 24 wk More U/S if mono-di or mono-mono Doppler weekly if discordant fetal growth BPP as needed
179
Mode of delivery in twins
May attempt NVD if twin A vertex | Otherwise C/S
180
If separation in 72h
Diamniotic-dichorionic
181
If 4-8d
Di-Mono
182
Mono-mono
9-12d
183
Concern in twin-twin transfusion syndrome
>30 % discordance in wt
184
The twin with kernicterus risk
Recipient
185
Twin-twin transfusion investigation
U/S screening | Doppler flow analysis
186
Mx of twin-twin transfusion
Serial AC of recipient Intrauterine blood transfusion to donor Laparoscopic occlusion of placental vessels Fetoscopic laser ablation of vascular anastomoses
187
Most common breech
Frank
188
Most common breech to be delivered vaginally
Frank
189
ECV criteria
``` >36 wk Singleton Unengaged Reactive NST Not in labour ```
190
Contra to ECV
``` T3 bleed Prior classical C/S Previous myomectomy Oligo PROM Previa Abn U/S Suspected IUGR HTN Uteroplacental insufficiency Nuchal cord ```
191
ECV method
``` Tocometry Rhogam U/S guide Constant fetal heart monitoring Pre/early labour U/S (if not available, C/S) ```
192
Criteria for vaginal breech delivery
``` Frank/complete GA> 36 wk EFW 2500-3800 Head flexed Continuous monitoring 2 experienced obstetricians, assistant, anesthetist Ability to perform C/S within 30 min No IOL recommended Informed consent ```
193
C/S recommended in breech if:
Breech not descended to perineum in 2nd stage after 2 h Absence of active pushing Vaginal delivery not imminent after 1 hour of active pushing
194
Contra to NVD in breech
Cord presentation Inadequate pelvis Fetal factors (macrosomia, IUGR, hydrocephalus)
195
Routine mode of delivery in breech
Present ECV and elective C/S as options | Obtain informed concent
196
Pre-existing HTN definition
>140/90 Prior to 20 wk Persisting >7 wk postpartum
197
Gestational HTN
sBP> 140, dBP>90 Developing after 20 wk No proteinuria
198
Fetus evaluation in gestational HTN
``` FM NST U/S for growth BPP Doppler ```
199
Inv for gestational HTN
``` CBC PTT,INR, fibrinogen (if abn LFT or bleeding) AST, ALT Creatinine, uric acid 24h urine collection (pro, ACR) ```
200
Tx of pre-existent/gestational HTN
Non-severe (140-159/90-110?): If comorbidity, target: <140/90 If without comorbidity, target: <155/105 , >130/80 • labetalol, nifedipine, a-methyldopa Severe (>160/110): •labetalol (IV), nifedipine, hydralazine (IV) • Ca 1g/d
201
Delivery in HTN
If no deterioration, follow until 37 wk, then IOL
202
Preeclampsia definition
HTN (pre-existing/gestational) | + new onset proteinuria/ adverse conditions
203
Mx of preeclampsia
* if stable/no adverse factors, admit, follow, delivery in 34-36 wk * if severe, stabilize and deliver (maternal monitoring: hourly input/output, urine dip q 12 h, hourly neurological vitals, fetal monitoring: continuous) * antihypertensive therapy: labetalol, nifedipine, hydralazine * seizure prevention in severe preec: MgSO4 * umbilical Doppler * steroids for all < 34wk * Ca at least 1g/d
204
Greatest risk of seizure in preeclamsia
First 24 h postpartum
205
Postpartum Mx of preeclampsia
Continue MgSO4 12-24 h | Vitals q 1h
206
Return to normotensive
Within 2 wk
207
Eclampsia
Generalized convulsion/coma in setting of preeclampsia
208
Dx evaluation in eclampsia
Not needed if typical. | Indications: focal deficits, prolonged coma
209
Eclampsia Mx
``` ABC LLDP O2 If BP: 160/105 or more, aggressive hydralazine/labetalol MgSO4 Delivery ```
210
Mode of delivery in eclapsia
Depends on fetal-maternal condition
211
Prevention of preeclampsia in high risk women
Aspirin 75-100 until delivery
212
Eclampsia prior to 20 wk
Underlying molar pregnancy | APLS
213
Tx of IDA
30-120 mg/d
214
325 mg ferrous...
Fumarate: 106 mg elemental iron Sulfate: 65 Gluconate:36 Polysaccharide-iron complex: 150
215
Iron needed per fetus
1 g
216
Diabetes 1/2 in preconception period
Refer to high risk clinic Optimize glycemic control Counsel pt Evaluate: retinopathy, neuropathy, CAD
217
DM 1/2 in pregnancy
Switch to insulin Tight glycemic control Adjust dose in T2 In addition to nl pregnancy monitoring: initial 24 h urine protein, CrCl, retinal exam, HbA1c
218
Fetal surveillance in DM1/2
Increased BPP NST Echo
219
Indication of fetal echo in DM 1/2
High HbA1c during T1/ prior to pregnancy
220
Delivery in DM1/2
If BS well controlled, BPP normal, wait for spontaneous labour Induce: 38-39 wk Monitor BS q1 h Insulin+ dextrose drip Aim: BS: 3.5-6.5
221
Mode of delivery in DM1/2
Elective C/S if > 4500 g
222
Postpartum in DM1/2
No need for insulin for 48-72 h Monitor BS q 6 h When BS> 8 restart insulin (2/3 of prepregnancy dosage)
223
Controversial OHA during preg
Merformin | Glyburide
224
GDM screening
24-28 for all | At any GA for high risk
225
Screening options for GDM
* 1 step screening with 75g | * 2 step screening with 50g random non-fasting OGTT, then 75g fasting OGTT
226
BS aims in DM1/2 during pregnancy
FPG 5.3 or less (95) 1 h post prandial PG 7.8 or less (140) 2 h post prandial PG 6.7 or less (120) Monthly HbA1c
227
The glucose level most effective at determining adverse outcomes
Post prandial
228
Mx of GDM | 1st line
Diet modification Increased physical activity Continue for 2 wk
229
If LSM not useful after 2 wk
Initiate insulin | OHA off-label
230
Postpartum GFM
``` Stop insulin Stop diabetic diet 75g OGTT by 3 mo Glucose challenge test q 3 y LSM ```
231
End-organ involvements/deterioration
In type 1/2 DM (NOT GDM) Retinopathy Nephropathy
232
Congenital anomalies in DM
Occurs with DM1/2 (NOT GDM)
233
ROM duration for GBS
18h
234
GBS screening
35-37wk
235
Intrapartum GBS prophylaxis indications
``` Previous infant with GBS infection GBS bacteriuria during any trimester Positive vaginal/rectal screening culture Unknown GBS status at the onset of labour if: •<37wk •rupture18 h or more •intrapartum T 38 or more •intrapartum NAAT positive for GBS ```
236
GBS inv
Vaginal/anorectal swab for culture All women 35-37 wk
237
GBS prophylaxis
``` Penicillin G If allergy to penicillin: • if risk of anaphylaxis: vanco • if no risk: cefazolin IV Until delivery ``` If fever: broad spectrum
238
UTI infection inv
U/A Urine C&S If recurrent: cystoscopy, renal function tests
239
1st line for uncomplicated UTI during preg
Amoxicillin 250-500 tid x7d
240
Alternatives for uncomplicated UTI
Nitrofurantoin 100 bid
241
F/U for UTI in preg
Monthly urine culture
242
Pyelonephritis Tx in preg
Hospitalize, IV AB
243
Greatest transmission risk of varicella
13-30 wk | 5d pre- to 2d post-delivery
244
Mx of mother exposure to varicella
VZIG
245
Greatest transmission risk of CMV
T1-T3
246
Greatest transmission of erythema infectiosum (parvo)
10-20 wk
247
Mx of parvo
``` Serology PCR MSAFP If IgM present: fetus U/S for hydrops If hydrops: fetal transfusion ```
248
Greatest transmission of HBV
T3
249
Risk of transmission of HBV
If only HBsAg +, 10% | If both HBsAg and HBeAg +, 90%
250
Mx of HBV in pregnancy
HBIG to neonate | + vaccine (birth, 1, 6)
251
Greatest transmission of HSV
Delivery | Less commonly in utero
252
Mx of HSV in preg
Acyclovir if mother symptomatic Suppressive Tx at 36 wk: controversial If active genital lesions, even remote from vulva: C/S
253
Greatest transmission of HIV
1/3 in utero 1/3 at delivery 1/3 breastfeeding
254
Mx of HIV in preg
``` Triple ART C/S if: • no ART • only monotherapy • viral load unknown • viral load > 500 • unknown prenatal care • pt request ```
255
Greatest transmission of syphilis
T1-T3
256
Tx of syphilis during preg
Penicillin G 2.4 m x1 IM if early Penicillin G 2.4 m x3 IM if late If allergy: clindamycin 900 IV tid
257
F/U of syphilis Tx
VDRL monthly
258
Rubella greatest transmission
T1
259
Toxo greatest transmission time
T3 But most severe if T1 Concern only with primary infection during pregnancy
260
Toxo Dx
Serology | AF PCR
261
Toxo Tx
Spiramycin: decreases fetal morbidity but not fetal transmission
262
Transmissible via breast milk
HIV HBV CMV
263
Highest risk of DVT
T3, postpartum
264
Highest risk of PE
Postpartum
265
DVT inv
Duplex venous Doppler sono CXR & V/Q scan Spiral CT
266
Mx of DVT/PE
``` Baseline CBC, plt, PTT UFH Bolus 5000 then 30000/24h aPTT after 6h Maintain aPTT at 1.5-2 x normal Once therapeutic, repeat aPTT q 24h ``` Can also use LMWH Compression stockings
267
VTE prophylaxis
Women on long-term anticoag: full therapeutic throughout pregnancy and 6-12 wk postpartum Women with non-active PMHx of VTE: UFH suggested Women with acquired thrombophilia: ASA+ heparin
268
False labour (Braxton-Hicks)
``` Irregular Unchanged intensity Long intervals Throughout pregnancy No cervical dilation No effacement No descent relieved by rest or sedation ```
269
Delivery mode in brow presentation
C/S
270
Delivery mode in face presentation
Mentum posterior: C/S | Mentum anterior: can deliver vaginally
271
Rate of cervical dilatation in active phase
Nuliparous: 1 cm/h or more Multiparous: 1.2 cm/h or more
272
Third stage duration before intervention
30 min
273
Best time for oxytocin
After delivery of anterior shoulder Or After delivery of placenta To reduce PPH
274
Stages of labour most dangerous to mother (hemorrhage)
3rd and 4th
275
Fetal monitoring during labour
Auscultation with doppler q 15-30 min for 1 min in first stage active phase, following a contraction Auscultation q 5 min during 2nd stage when pushing has begun Continuous FHR monitoring if: abn auscultation, prolonged labour, induced/augmented labour, meconium present, multiple gestation, fetal complication. (NOT ROUTINELY)
276
Normal variability indicates:
Acceptable fetal acid-base status
277
Mx of abn FHR
``` LLDP O2 Fluid Scalp stimulation Scalp electrode Scalp pH Stop oxitocin Notify MD Vaginal exam: cord prolapse Fever? Dehydration? Drug effect? Prematurity? ``` If all failed, C/S
278
Most common type of periodicity during labour
Variable deceleration
279
Reason for early deceleration
Head compression
280
Reason for variable deceleration
Cord pressure | Pushing+ contraction
281
Reason for complicated variable deceleration
Acidemia
282
Complicated variable deceleration:
``` Drop to <70 >60 sec Loss of variability or decrease in baseline after return Biphasic deceleration Slow return Baseline tachy/bradycardia ```
283
Late deceleration reason
Uteroplacental insufficiency | Ominous sign
284
Fetal scalp blood sampling indications
Atypical/abn FHR | Indicated by clinic or FHR pattern
285
Interpretation of scalp samplr
pH 7.25 or higher, lactate 4.2 or lower: Nl pH 7.21-7.24, lactate 4.2-4.8: repeat assessment in 30 min, or, delivery if rapid fall pH 7.20 or lower, lactate > 4.8: fetal acidosis, delivery indicated
286
Contra to scalp sampling
Suspected fetal dyscrasia | Active maternal infection
287
1st most common reason for IOL
Post-dates
288
2nd most common reason for IOL
DM
289
Cervical ripening methods
Intravaginal PGE2 gel Cervidil PGE2: may use if ROM Intravaginal PGE1: misoprostol: T2 termination Foley catheter: mechanical
290
IOL methods
Amniotomy | Oxitocin
291
Abn progression of labour
Active phase: > 4 h of < 0.5 cm/h progression 2nd stage: >1h with no descent during active pushing
292
Dystocia Mx
Confirm labour Search for (pressure/passage/passenger/psych) Search for CPD If CPD ruled out, IV oxytocin, amniotomy
293
Dx of dystocia
Adequate contractions (with IUPC) without descent/dilation for > 2h
294
Turtle sign
Shoulder dystocia
295
Erb/klumpke palsies prognosis
90% resolve within 6 mo
296
FHR in cord prolapse
Variable decelerations | Bradycardia
297
Cord prolapse Mx
``` Emergency C/S O2 Elevate fetal head Keep cord moist Mom onto all fours Trendelenburg or Knee-to-chest Emergent C/S If fetal demise or <22 wk, allow VD ```
298
Most common presentation of uterine rupture
Prolonged fetal bradycardia
299
Tx of uterine rupture
R/O abruption Immediate delivery Maternal stabilization
300
Time of amniotic fluid embolus
Intrapartum, immediate post partum
301
Leading cause of maternal death in induced abortion/miscarriage
AF embolus
302
Amniotic fluid embolus Mx
``` High flow O2 Ventilation Fluid Inotropic Intubation Coagulopathy correction ICU admission ```
303
Chorioamnionitis inv
CBC | AF: WBC, bacteria
304
Chorioamnionitis Tx
IV AB Ampi, genta, clinda Expedient delivery regardless of GA
305
Meconium staining Tx
Call respiratory therapy, pediatrician, neonatology to delivery room FHR monitoring
306
Indications of operative VD
``` Atypical/abn FHR Evidence of fetal compromise Prolonged 2nd stage Need to avoid voluntary expulsive effort Exhaustion Lack of cooperation Excessive analgesia ```
307
Contra to operational VD
Non- vertex Unengaged Incomplete cervix dilation
308
Contra to vacuum
``` <34 wk <2500 g Fetal head deflexed Fetus require rotation Fetal bleeding disorder Non vertex ```
309
Midline episiotomy
Advantage: heals better Disadvantage: increased risk of 3rd/4th tears
310
Mediolateral episiotomy
Through bulbocavernosus, superficial transverse perineal muscle, levator ani Advantage: reduced risk of extensive tear, easier to repair Disadvantage: more painful
311
Indications for classical C/S
``` Transverse lie Preterm breech Fetal anomaly >2 fetuses Lower segment adhesions Obstructing fibroid Morbidly obese ```
312
Indication for low vertical C/S
Very preterm
313
Average blood loss in C/S
1000 cc
314
Decreased risk of uterine rupture with TOLAC
Low transverse incision >18 mo interval >1 layer closure
315
Contra to TOLAC
``` Previous classical/inverted T/ unknown incision Previous complete transection of uterine Previa Non-vertex presentation Inadequate facilities/personnel for C/S Previous uterine rupture Previous uterine surgery Multiple gestation ```
316
Most common cause of PPH
Tone
317
Etiology of PPH
Tone Tissue Thrombin Trauma
318
PPH investigation
Assess blood loss/shock Inspect uterus/lower genital tract Red-topped tube of blood
319
PPH Mx
``` ABC, Call for help Large bore IV x2, crystalloids free CBC, Coagulation profile, cross & type, pRBC Underlying Foley to monitor U/O Oxytocin Methylergonovin Carboprost Misoprostol Tranex Bimanual massage Uterine packing Bakri balloon ```
320
Late PPH etiology
``` Retained tissue (+/- endometritis) Sub involution of uterus ```
321
Intractable PPH
``` D & C Artery embolization Laparotomy with bilateral ligation Hysterectomy If post hysterectomy bleeding, angiographic embolization ```
322
Retained placenta inv
Explore uterus | Assess blood loss
323
Retained placenta Mx
``` 2 large bore IVs Type and screen Brant maneuver (if failed, manual removal) Oxytocin D&C Ancef if manual or D&C ```
324
Uterine inversion Mx
``` ABC, IV crystalloids Tocolytics/ IV NTG Replace uterus Manual removal and slow withdrawal of placenta Oxytocin Re-explore uterus May need laparotomy, general anasthesia ```
325
Endometritis Dx
Blood/genital cultures
326
Endometritis Tx
Clinda+genta IV | Oral if well
327
Mastitis
Cloxacillin/cephalexin
328
Wound infection
Sitz bath | Cephalexin
329
Prophylaxis agains C/S wound infection
Cephazolin 2 g IV 30 min before incision
330
Mammary duct ectasia
Post-menopausal women | Gray-green, thick discharge
331
Lactational mastitis time
2-3 wk postpartum
332
Etilogy of lactational mastitis
Staph aureus
333
Tx of lactational mastitis
Packs(hot/ice) AB (cloxa/cephalexin/erythro) Continue nursing
334
Purulent breast discharge
Abscess
335
Lactational abscess Tx
IV AB I&D Stop nursing
336
Most common type of non-lactational mastitis
Periductal
337
Time of non-lactational mastitis
32 yo
338
Etiology of non-lactational mastitis
Staph aureus Sterile Anaerobes RF:smoking
339
Non-lactational mastitis
Broad IV AB I&D Total duct excision If no resolution, FNA, U/S
340
Mastitis with nipple inversion
Non-lactational
341
Postpartum pyrexia etiology
``` B-5W Breast: mastitis, engorgement Wind: athelectasia, pneumonia Water: UTI WOUND: episiotomy, C/S wound Walking: DVT, thrombophelebitis Womb: endometritis ```
342
Postpartum blues
Onset: 3-10d Resolution: by 2 wk
343
Postpartum depression onset
Within 6 mo
344
Postpartum major depression Tx
Antidepressant Psychotherapy Supportive care ECT
345
Postpartum psychosis onset
Within first month postpartum | Over 48-72h
346
Pap smear after delivery
At 6 wk
347
Return of ovulation postpartum
Non-lactating: 45 d | Lactating: 3-6 mo
348
Locia
Rubra 3-4d Serosa Alba 3-6 wk
349
Inadequate milk Tx
Domperidone
350
Breast engorgement
Cool compress | Manual expression/pumping
351
Nipple pain
Clean after breast feeding Moisture cream Topical steroid
352
Postpartum bladder dysfunction Mx
``` Kegel exercise Pelvic physiotherapy Vaginal cone or pessaries Limit fluid/caffeine Surgical Mx ```
353
After pain time
1st 3 days
354
After pain Tx
Analgesic

Med (25 decks)

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