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Obs Flashcards

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
Q

N/V Mx

A

Weigh
Hydration evaluation
Urine ketones

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26
Q

Ginger max

A

1000 mg/d

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27
Q

Medication for N/V

A 
Diclectin (doxylamine succinate + B6)
No response, dimenhydrinate
Hydroxyzine
Pyridoxine
Phenothiazine
Metoclopeamide
B6 lollipop
\+/- fluid replacement
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28
Q

Hyperemesis gravidarum

A

CBC, lytes, BUN, Cr, LFT, U/A, U/S

R/O other causes: TFT, beta

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29
Q

Mx of hyperemesis gravidarum

A 
Thiamine
Diclectin
Dimenhydrinate
Hydroxyzine
Pyridoxine
Phenothiazine
Metoclopramide
Ondansetron
Methylprednisolone
Admission, NPO, then small frequent meals, correct fluid/lytes/ketosis, TPN
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30
Q

Encephalopathy due to hyperemesis gravidarum

A

Wernicke

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31
Q

Prenatal visits

A

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

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32
Q

Doppler for FHR

A

10-12 wk

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33
Q

Leopold time

A

After 30-32 wk

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34
Q

Legal aspect of prenatal screening

A

Requires informed concent

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35
Q

1st dating U/S

A

8-12 wk

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37
Q

Prenatal screening

8-12 wk

A 
Dating U/S
Pap
Chlamydia/Gono
Urine C&amp;S
HIV
VDRL
HBsAg
CBC, blood group, screen
Parvovirus IgM/G if contact with small children
Varicella if no Hx of disease/immunization
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38
Q

NIPT

Cell-free fetal DNA

A

> 10 wk

Requires dating U/S

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39
Q

CVS

A

10-12 wk

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40
Q

Enhanced FTS

A

11-14 wk

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41
Q

Screening

11-14 wk

A

Enhanced FTS
IPS part1

(NT, beta, PAPP-A, PIGF, AFP)

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42
Q

NT

A

11-14 wk

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43
Q

Amniocentesis

A

15-16 wk to term

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44
Q

IPS part2

A

15-20 wk

MSAFP, beta, unconj-est, inhibin A

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45
Q

MSS

A 
15-20 wk
MSAFP
Beta
Unconj-est
Inhibin A
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46
Q

Fetal movement quickening

A

18-20 wk to term

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47
Q

Routine dating U/S (2nd)

A

18-20 wk

Dates, growth, anatomy

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48
Q

GDM screening

A

24-28 wk

50 g OGCT

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49
Q

Repeat CBC, BG, Rh, Rhogam

A

28 wk

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50
Q

GBS screen

A

35-37 wk

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51
Q

6 wk postpartum

A 
Contraception
Mense
Breastfeeding
Depression
Mental health
Support
Breast exam
Pelvic exam (pap if due)
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52
Q

Most accurate dating method

A

U/S 8-12 wk

CRL (+/- 5d margin of error)

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53
Q

U/Ss in pregnancy

A

8-12 wk dating
11-14 wk NT
18-20 wk growth/anomaly/ dating (error: +/- 10 d)

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54
Q

What does NIPT search for?

A

Down
Trisomy 18,13, some X/Y disorders, some microdeletions
Ready in 7-10 d

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55
Q

Increased NT

A

Down
Turner
Cardiac anomalies
Trisomy 18

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56
Q

Disadvantages of NIPT

A

Doesn’t test for NTD

Needs confirmation with invasive tests

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57
Q

Down in FTS

A

Increased NT
Increased Beta
Decreased PAPP-A

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58
Q

Trisomy 18 in FTS

A

Increased NT
Decreased PAPP-A
Decreased Beta

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59
Q

Disadvantages of FTS

A

Doesn’t check NTD (needs combination with MSAFP at 15-20 wk)

If positive, confirm with CVS/amniocentesis/NIPT

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60
Q

Down in MSS

A

Decreased MSAFP
Increased Beta
Decreased est

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61
Q

Trisomy 18 in MSS

A

Decreased beta
Decreased MSAFP
Decreased est
Decreased inhibin

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62
Q

ONTD in MSS

A

Increased MSAFP

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63
Q

Disadvantages of MSS

A

Late
Only offered if missed IPS/ FTS
If positive needs U/S, amniocentesis OR NIPT

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64
Q

IPS

A

NT+ FTS + MSS

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65
Q

Disadvantage of IPS

A

If positive, needs U/S, amniocentesis, NIPT

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66
Q

Fundus at pubic symphysis

A

12 wk

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67
Q

Fundus at umbilicus

A

20 wktwd

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68
Q

Mature fetal lung in AC

A

L:S ratio: 2

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69
Q

Indication of diagnostic tests (AC, CVS)

A

Age>35
Abnl screen (FTS, MSS,IPS, NIPT)
PHx/FHx of: chromosomal anomaly, genetic disease, carrier parent, consanguinity, >3 spontaneous abortions

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70
Q

Time of results for AC and CVS

A

AC: 14-28d (FISH/PCR: 48 h)
CVS: 48 h

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71
Q

Which one is more accurate? AC or CVS?

A

AC

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72
Q

Vitamin insufficiency implicated in NTD

A

Folate

Zn

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73
Q

Risk of isoimmunization (Rh neg mom, Rh pos fetus)

A

16 %

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74
Q

Inv for isoimmunization (if Rh neg mother)

A 
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)
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75
Q

Rh titer indicating increased risk of fetal hemolytic anemia

A

1:16

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76
Q

Rhogam in nl pregnancy (coombs negative mom)

A

28 wk

Within 72 h of delivery

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77
Q

Amount of fetomaternal bleeding covered by 1 Rhogam

A

30 ml

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78
Q

If Rh neg, coombs positive mother

A

Monthly ab titer,
+ U/S
+/- serial AC

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79
Q

Milk product in pregnancy

A

3-4 servings/d

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80
Q

Daily caloric increase

A

T1: 100
T2:300
T3:300
Lact:450

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81
Q

Multivitamins

A

In inadequate intake in T2

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82
Q

Folate

A

0.4/d

5 if high risk

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83
Q

Ca

A

1200-1500

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84
Q

Vit D

A

1000

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85
Q

Iron

A

T1: 0.8
T2: 4-5
T3: >6
Suppl: 30 mg/d

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86
Q

Caffein

A

Less than 300

1- cup

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87
Q

Mercury in fish

A

0.5

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88
Q

Exercise

A

Talk test

No supine after 20 wk

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89
Q

Contra to exercise if Hb

A

10 or less

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90
Q

Exercise with twin pregnancy

A

Not after 28 wk

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91
Q

Air travel

A

Not after 36-38 wk

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92
Q

Intercourse

A

May continue except:

Risk of abortion, preterm labour, placenta previa

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93
Q

Medication with risk of kernicterus

A

Sulpha in T3

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94
Q

Grey baby syndrome

A

Chloramphenicol

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95
Q

Oral typhoid vaccine in preg

A

Not allowed

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96
Q

Vaccines for all during preg

A

Influenza

Tdap at 26 wk

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97
Q

Postpartum vaccines

A

Rubella if none immune

HBV to infant within 12 h (if mother positive or unknown), then at 1 and 6 mo

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98
Q

If mother has received an adult booster of MMR and is still non immune against rubella

A

Should NOT be revaccinated

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99
Q

Radioactive iodine during pregnancy

A

Contraindicated

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100
Q

1st notice of fetal movement

A

Primigravida:18-20 wk
Multigravida:1-2 wk earlier
Anterior placenta:1-2 wk later

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101
Q

FM count if:

A

High risk woman
Concerned woman
Usually after 26 wk

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102
Q

If subjective decrease in FM

A 
Drink juice
Eat
Change position
Move to a quiet room
Count for 2 h
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103
Q

Expected movements

A

6 or more during 2 hr

If less, pt presented to labour and delivery tiage

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104
Q

NST normal baseline

A

110-160

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105
Q

Nl variability

A

6-25

If 5 or less, <40 min

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106
Q

Normal deceleration

A

None/occasional variable, <30 sec

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107
Q

Nl acceleration in term

A

2, 15 or more bpm, 15 s in <40 min

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108
Q

Nl acceleration in preterm

A

> 2, >10 bpm, 10 s, in <40 min

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109
Q

Abn baseline NST

A

<100: bradycardia
>160 for >30 min: tachy
Erratic baseline

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110
Q

Abn variability

A

5 or less for for 80 min
Sinusoidal
25 bpm for >10 min

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111
Q

Abn deceleration

A

Variable deceleration > 60 s

Late deceleration

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112
Q

Abn acceleration in term

A

<2 accelerations wirh acme of 15 or more, lasting 15s in > 80 min

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113
Q

Abn acceleration in pre-term

A

<2 accelerations with acke of >10 bpm, 10s, in >80 min

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114
Q

Atypical NST baseline

A

100-110

>160 for <30 min

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115
Q

Atypical variability

A

5 for 40-80 min

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116
Q

Atypical deceleration

A

Variable 30-60 sec

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117
Q

Atypical acceleration

A

2, 15 or more bpm, 15 s in 40-80 min

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118
Q

Atypical acceleration in preterm

A

<2, >10 bpm, 10 s in 40-80 min

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119
Q

Atypical NST Mx

A

Requires further assessment

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120
Q

Abn NST Mx

A

Requires urgent action

U/S, BPP, delivery

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121
Q

If no acceleration in 1st 20 min of NST

A

Stimulate the fetus, continur monitoring for another 30 min

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122
Q

BPP parameters

A

Flexion/extension x1
Movement x3
Breathing x 30s
AFV, one 2x2 pocket

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123
Q

Marker of chronic hypoxia in BPP

A

AFV

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124
Q

Interpretation of BPP

A

8: nl
6: repeat BPP in 24 h
0-4: consider delivery

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125
Q

Mean onset of bleeding in previa

A

30 wk

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126
Q

Pelvic exam in T3 bleeding

A

DO NOT PERFORM UNTILL PREVIA RULED OUT BY U/S

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127
Q

Amount of overlap in T3 that predicts C/S

A

> 20 mm

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128
Q

Amount if overlap after 35 wk that predicts C/S

A

Any amount

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129
Q

Previa investigation

A

TVS

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130
Q

Indication of repeating TVS in T3 in previa

A

Placenta lies between 20 mm of overlap and 20 mm away from os

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131
Q

Mx of previa

A 
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
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132
Q

Delivery time in previa

A

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

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133
Q

The most common cause of DIC in pregnancy

A

Abruptio placenta

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134
Q

The most common cause of pathological bleeding in T3

A

Abruptio placenta

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135
Q

Dx of abruptio

A

Clinical

No role for U/S

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136
Q

Mx of abruptio

A

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

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137
Q

Delivery in abruptio

A

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

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138
Q

inv for vasa previa

A 
Apt test (blood+NaOH)
Wright stain on blood (nucleated RBCs)
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139
Q

Vasa previa Mx

A

Emergency C/S

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140
Q

The most important RF for preterm labour

A

Hx of preterm labour

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141
Q

Cervical length and PTL

A

If > 30 mm in 34 wk, high NPV

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142
Q

Bacterial RFs for PTL

A

BV, ureaplasma urealyticum

But screening only indicated for high risk women

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143
Q

The most common cause of neonatal mortality

144
Q

Predicting PTL in symptomatic women

A

Cervicovaginal fluid fibronectin
+
U/S of cervical length

145
Q

PTL Dx

A

Regular contractions: 2/10 min, >6/h
Cervix> 1cm dilated
Cervix> 80% effaced
Length< 2.5 cm

146
Q

Initial Mx of PTL

A 
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
Q

1st line tocolytic <30 wk

A

Indomethacin

148
Q

1st line tocolytic in polyhydramnios

A

Indomethacin

149
Q

Contraindication to beta/dexa

A

Maternal active TB

150
Q

Inv in PROM

A 
sterile speculum
Nitrazine turns blue
Cascade sign/fluid pooling in posterior fornix
Ferning
U/S, BPP
Decreased AFV
151
Q

PROM Mx

A 
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
Q

Delivery in PROM

A 
<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
Q

AB use in PROM not in labour

A

<32wk, administer

>32wk, if lung maturity cannot be proven/delivery not planned

154
Q

AB associated with NEC

A

Amoxi/clavu

155
Q

Postdate definition

156
Q

Postdate delivery

A

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
Q

MSAFP in fetal demise

158
Q

Fetal demise on doppler

A

Not diagnostic

159
Q

Dx of fetal demise

A

Absent cardiac activity and FM on U/S

160
Q

Mx

A

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
Q

Fetal demise Tx

A

<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
Q

Risk of DIC with fetal demise

163
Q

IUGR definition

A

Wt<10th percentile
Or
<2500 g at term

164
Q

Most important RF for IUGR

A

Previous IUGR

165
Q

Inv for IUGR

A

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
Q

IUGR prevention

A

Risk modification before preg

167
Q

IUGR Mx

A

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
Q

Mode of delivery in IUGR

169
Q

Macrosomia definition

A

> 90th percentile

>4000 g

170
Q

Macrosomia inv

A

Serial FSH

If high risk mother/ SFH > 2cm ahead of GA, further inv

171
Q

Macrosomia Mx

A

If EFW> 5000 in non-diabetic, C/S

If EFW> 4500 in diabetics, C/S

172
Q

Polyhydramnios definition

A

AFI>25
Or
Single deepest picket>8cm

173
Q

Poly Mx

A

Screen for mother disease/infection

Complete fetal U/S evaluation

174
Q

Poly Tx

A

Mild-mod, nothing

Severe, hospitalize, therapeutic AC

175
Q

Olygohydramnios definition

A

AFI<5

Deepest pocket <2 cm

176
Q

Oligo manage

A 
Admit
R/O ROM
NST/BPP
U/S Doppler of umbilical cord/uterine artery
Hydration
Fluid injection
Delivery if term.
177
Q

Time of U/S chorionicity determination

178
Q

Mx of multiple gestation

A

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
Q

Mode of delivery in twins

A

May attempt NVD if twin A vertex

Otherwise C/S

180
Q

If separation in 72h

A

Diamniotic-dichorionic

181
Q

If 4-8d

182
Q

Mono-mono

183
Q

Concern in twin-twin transfusion syndrome

A

> 30 % discordance in wt

184
Q

The twin with kernicterus risk

185
Q

Twin-twin transfusion investigation

A

U/S screening

Doppler flow analysis

186
Q

Mx of twin-twin transfusion

A

Serial AC of recipient
Intrauterine blood transfusion to donor
Laparoscopic occlusion of placental vessels
Fetoscopic laser ablation of vascular anastomoses

187
Q

Most common breech

188
Q

Most common breech to be delivered vaginally

189
Q

ECV criteria

A 
>36 wk
Singleton
Unengaged
Reactive NST
Not in labour
190
Q

Contra to ECV

A 
T3 bleed
Prior classical C/S
Previous myomectomy
Oligo
PROM
Previa
Abn U/S
Suspected IUGR
HTN
Uteroplacental insufficiency
Nuchal cord
191
Q

ECV method

A 
Tocometry
Rhogam
U/S guide
Constant fetal heart monitoring
Pre/early labour U/S (if not available, C/S)
192
Q

Criteria for vaginal breech delivery

A 
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
Q

C/S recommended in breech if:

A

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
Q

Contra to NVD in breech

A

Cord presentation
Inadequate pelvis
Fetal factors (macrosomia, IUGR, hydrocephalus)

195
Q

Routine mode of delivery in breech

A

Present ECV and elective C/S as options

Obtain informed concent

196
Q

Pre-existing HTN definition

A

> 140/90
Prior to 20 wk
Persisting >7 wk postpartum

197
Q

Gestational HTN

A

sBP> 140, dBP>90
Developing after 20 wk
No proteinuria

198
Q

Fetus evaluation in gestational HTN

A 
FM
NST
U/S for growth
BPP
Doppler
199
Q

Inv for gestational HTN

A 
CBC
PTT,INR, fibrinogen (if abn LFT or bleeding)
AST, ALT
Creatinine, uric acid
24h urine collection (pro, ACR)
200
Q

Tx of pre-existent/gestational HTN

A

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
Q

Delivery in HTN

A

If no deterioration, follow until 37 wk, then IOL

202
Q

Preeclampsia definition

A

HTN (pre-existing/gestational)

+ new onset proteinuria/ adverse conditions

203
Q

Mx of preeclampsia

A
  • 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
Q

Greatest risk of seizure in preeclamsia

A

First 24 h postpartum

205
Q

Postpartum Mx of preeclampsia

A

Continue MgSO4 12-24 h

Vitals q 1h

206
Q

Return to normotensive

A

Within 2 wk

207
Q

Eclampsia

A

Generalized convulsion/coma in setting of preeclampsia

208
Q

Dx evaluation in eclampsia

A

Not needed if typical.

Indications: focal deficits, prolonged coma

209
Q

Eclampsia Mx

A 
ABC
LLDP
O2
If BP: 160/105 or more, aggressive hydralazine/labetalol
MgSO4
Delivery
210
Q

Mode of delivery in eclapsia

A

Depends on fetal-maternal condition

211
Q

Prevention of preeclampsia in high risk women

A

Aspirin 75-100 until delivery

212
Q

Eclampsia prior to 20 wk

A

Underlying molar pregnancy

APLS

213
Q

Tx of IDA

A

30-120 mg/d

214
Q

325 mg ferrous…

A

Fumarate: 106 mg elemental iron
Sulfate: 65
Gluconate:36
Polysaccharide-iron complex: 150

215
Q

Iron needed per fetus

216
Q

Diabetes 1/2 in preconception period

A

Refer to high risk clinic
Optimize glycemic control
Counsel pt
Evaluate: retinopathy, neuropathy, CAD

217
Q

DM 1/2 in pregnancy

A

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
Q

Fetal surveillance in DM1/2

A

Increased
BPP
NST
Echo

219
Q

Indication of fetal echo in DM 1/2

A

High HbA1c during T1/ prior to pregnancy

220
Q

Delivery in DM1/2

A

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
Q

Mode of delivery in DM1/2

A

Elective C/S if > 4500 g

222
Q

Postpartum in DM1/2

A

No need for insulin for 48-72 h
Monitor BS q 6 h
When BS> 8 restart insulin (2/3 of prepregnancy dosage)

223
Q

Controversial OHA during preg

A

Merformin

Glyburide

224
Q

GDM screening

A

24-28 for all

At any GA for high risk

225
Q

Screening options for GDM

A
  • 1 step screening with 75g

* 2 step screening with 50g random non-fasting OGTT, then 75g fasting OGTT

226
Q

BS aims in DM1/2 during pregnancy

A

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
Q

The glucose level most effective at determining adverse outcomes

A

Post prandial

228
Q

Mx of GDM

1st line

A

Diet modification
Increased physical activity
Continue for 2 wk

229
Q

If LSM not useful after 2 wk

A

Initiate insulin

OHA off-label

230
Q

Postpartum GFM

A 
Stop insulin
Stop diabetic diet
75g OGTT by 3 mo 
Glucose challenge test q 3 y
LSM
231
Q

End-organ involvements/deterioration

A

In type 1/2 DM (NOT GDM)
Retinopathy
Nephropathy

232
Q

Congenital anomalies in DM

A

Occurs with DM1/2 (NOT GDM)

233
Q

ROM duration for GBS

234
Q

GBS screening

235
Q

Intrapartum GBS prophylaxis indications

A 
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
Q

GBS inv

A

Vaginal/anorectal swab for culture
All women
35-37 wk

237
Q

GBS prophylaxis

A 
Penicillin G
If allergy to penicillin:
• if risk of anaphylaxis: vanco
• if no risk: cefazolin
IV
Until delivery

If fever: broad spectrum

238
Q

UTI infection inv

A

U/A
Urine C&S

If recurrent: cystoscopy, renal function tests

239
Q

1st line for uncomplicated UTI during preg

A

Amoxicillin 250-500 tid x7d

240
Q

Alternatives for uncomplicated UTI

A

Nitrofurantoin 100 bid

241
Q

F/U for UTI in preg

A

Monthly urine culture

242
Q

Pyelonephritis Tx in preg

A

Hospitalize, IV AB

243
Q

Greatest transmission risk of varicella

A

13-30 wk

5d pre- to 2d post-delivery

244
Q

Mx of mother exposure to varicella

245
Q

Greatest transmission risk of CMV

246
Q

Greatest transmission of erythema infectiosum (parvo)

247
Q

Mx of parvo

A 
Serology
PCR
MSAFP
If IgM present: fetus U/S for hydrops
If hydrops: fetal transfusion
248
Q

Greatest transmission of HBV

249
Q

Risk of transmission of HBV

A

If only HBsAg +, 10%

If both HBsAg and HBeAg +, 90%

250
Q

Mx of HBV in pregnancy

A

HBIG to neonate

+ vaccine (birth, 1, 6)

251
Q

Greatest transmission of HSV

A

Delivery

Less commonly in utero

252
Q

Mx of HSV in preg

A

Acyclovir if mother symptomatic
Suppressive Tx at 36 wk: controversial
If active genital lesions, even remote from vulva: C/S

253
Q

Greatest transmission of HIV

A

1/3 in utero
1/3 at delivery
1/3 breastfeeding

254
Q

Mx of HIV in preg

A 
Triple ART
C/S if:
• no ART
• only monotherapy
• viral load unknown
• viral load > 500
• unknown prenatal care
• pt request
255
Q

Greatest transmission of syphilis

256
Q

Tx of syphilis during preg

A

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
Q

F/U of syphilis Tx

A

VDRL monthly

258
Q

Rubella greatest transmission

259
Q

Toxo greatest transmission time

A

T3
But most severe if T1
Concern only with primary infection during pregnancy

260
Q

Toxo Dx

A

Serology

AF PCR

261
Q

Toxo Tx

A

Spiramycin: decreases fetal morbidity but not fetal transmission

262
Q

Transmissible via breast milk

263
Q

Highest risk of DVT

A

T3, postpartum

264
Q

Highest risk of PE

A

Postpartum

265
Q

DVT inv

A

Duplex venous Doppler sono
CXR & V/Q scan
Spiral CT

266
Q

Mx of DVT/PE

A 
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
Q

VTE prophylaxis

A

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
Q

False labour (Braxton-Hicks)

A 
Irregular
Unchanged intensity
Long intervals
Throughout pregnancy
No cervical dilation
No effacement
No descent relieved by rest or sedation
269
Q

Delivery mode in brow presentation

270
Q

Delivery mode in face presentation

A

Mentum posterior: C/S

Mentum anterior: can deliver vaginally

271
Q

Rate of cervical dilatation in active phase

A

Nuliparous: 1 cm/h or more
Multiparous: 1.2 cm/h or more

272
Q

Third stage duration before intervention

273
Q

Best time for oxytocin

A

After delivery of anterior shoulder
Or
After delivery of placenta

To reduce PPH

274
Q

Stages of labour most dangerous to mother (hemorrhage)

A

3rd and 4th

275
Q

Fetal monitoring during labour

A

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
Q

Normal variability indicates:

A

Acceptable fetal acid-base status

277
Q

Mx of abn FHR

A 
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
Q

Most common type of periodicity during labour

A

Variable deceleration

279
Q

Reason for early deceleration

A

Head compression

280
Q

Reason for variable deceleration

A

Cord pressure

Pushing+ contraction

281
Q

Reason for complicated variable deceleration

282
Q

Complicated variable deceleration:

A 
Drop to <70
>60 sec
Loss of variability or decrease in baseline after return
Biphasic deceleration
Slow return
Baseline tachy/bradycardia
283
Q

Late deceleration reason

A

Uteroplacental insufficiency

Ominous sign

284
Q

Fetal scalp blood sampling indications

A

Atypical/abn FHR

Indicated by clinic or FHR pattern

285
Q

Interpretation of scalp samplr

A

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
Q

Contra to scalp sampling

A

Suspected fetal dyscrasia

Active maternal infection

287
Q

1st most common reason for IOL

A

Post-dates

288
Q

2nd most common reason for IOL

289
Q

Cervical ripening methods

A

Intravaginal PGE2 gel
Cervidil PGE2: may use if ROM
Intravaginal PGE1: misoprostol: T2 termination
Foley catheter: mechanical

290
Q

IOL methods

A

Amniotomy

Oxitocin

291
Q

Abn progression of labour

A

Active phase: > 4 h of < 0.5 cm/h progression

2nd stage: >1h with no descent during active pushing

292
Q

Dystocia Mx

A

Confirm labour
Search for (pressure/passage/passenger/psych)
Search for CPD
If CPD ruled out, IV oxytocin, amniotomy

293
Q

Dx of dystocia

A

Adequate contractions (with IUPC) without descent/dilation for > 2h

294
Q

Turtle sign

A

Shoulder dystocia

295
Q

Erb/klumpke palsies prognosis

A

90% resolve within 6 mo

296
Q

FHR in cord prolapse

A

Variable decelerations

Bradycardia

297
Q

Cord prolapse Mx

A 
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
Q

Most common presentation of uterine rupture

A

Prolonged fetal bradycardia

299
Q

Tx of uterine rupture

A

R/O abruption
Immediate delivery
Maternal stabilization

300
Q

Time of amniotic fluid embolus

A

Intrapartum, immediate post partum

301
Q

Leading cause of maternal death in induced abortion/miscarriage

A

AF embolus

302
Q

Amniotic fluid embolus Mx

A 
High flow O2
Ventilation
Fluid
Inotropic
Intubation
Coagulopathy correction
ICU admission
303
Q

Chorioamnionitis inv

A

CBC

AF: WBC, bacteria

304
Q

Chorioamnionitis Tx

A

IV AB
Ampi, genta, clinda
Expedient delivery regardless of GA

305
Q

Meconium staining Tx

A

Call respiratory therapy, pediatrician, neonatology to delivery room
FHR monitoring

306
Q

Indications of operative VD

A 
Atypical/abn FHR
Evidence of fetal compromise
Prolonged 2nd stage
Need to avoid voluntary expulsive effort
Exhaustion
Lack of cooperation
Excessive analgesia
307
Q

Contra to operational VD

A

Non- vertex
Unengaged
Incomplete cervix dilation

308
Q

Contra to vacuum

A 
<34 wk
<2500 g
Fetal head deflexed
Fetus require rotation
Fetal bleeding disorder
Non vertex
309
Q

Midline episiotomy

A

Advantage: heals better
Disadvantage: increased risk of 3rd/4th tears

310
Q

Mediolateral episiotomy

A

Through bulbocavernosus, superficial transverse perineal muscle, levator ani

Advantage: reduced risk of extensive tear, easier to repair
Disadvantage: more painful

311
Q

Indications for classical C/S

A 
Transverse lie
Preterm breech
Fetal anomaly
>2 fetuses
Lower segment adhesions
Obstructing fibroid
Morbidly obese
312
Q

Indication for low vertical C/S

A

Very preterm

313
Q

Average blood loss in C/S

314
Q

Decreased risk of uterine rupture with TOLAC

A

Low transverse incision
>18 mo interval
>1 layer closure

315
Q

Contra to TOLAC

A 
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
Q

Most common cause of PPH

317
Q

Etiology of PPH

A

Tone
Tissue
Thrombin
Trauma

318
Q

PPH investigation

A

Assess blood loss/shock
Inspect uterus/lower genital tract
Red-topped tube of blood

319
Q

PPH Mx

A 
ABC, Call for help
Large bore IV x2, crystalloids free
CBC, Coagulation profile, cross &amp; type, pRBC
Underlying
Foley to monitor U/O
Oxytocin
Methylergonovin
Carboprost
Misoprostol
Tranex
Bimanual massage
Uterine packing
Bakri balloon
320
Q

Late PPH etiology

A 
Retained tissue (+/- endometritis)
Sub involution of uterus
321
Q

Intractable PPH

A 
D &amp; C
Artery embolization
Laparotomy with bilateral ligation
Hysterectomy
If post hysterectomy bleeding, angiographic embolization
322
Q

Retained placenta inv

A

Explore uterus

Assess blood loss

323
Q

Retained placenta Mx

A 
2 large bore IVs
Type and screen
Brant maneuver (if failed, manual removal)
Oxytocin
D&amp;C
Ancef if manual or D&amp;C
324
Q

Uterine inversion Mx

A 
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
Q

Endometritis Dx

A

Blood/genital cultures

326
Q

Endometritis Tx

A

Clinda+genta IV

Oral if well

327
Q

Mastitis

A

Cloxacillin/cephalexin

328
Q

Wound infection

A

Sitz bath

Cephalexin

329
Q

Prophylaxis agains C/S wound infection

A

Cephazolin 2 g IV 30 min before incision

330
Q

Mammary duct ectasia

A

Post-menopausal women

Gray-green, thick discharge

331
Q

Lactational mastitis time

A

2-3 wk postpartum

332
Q

Etilogy of lactational mastitis

A

Staph aureus

333
Q

Tx of lactational mastitis

A

Packs(hot/ice)
AB (cloxa/cephalexin/erythro)
Continue nursing

334
Q

Purulent breast discharge

335
Q

Lactational abscess Tx

A

IV AB
I&D
Stop nursing

336
Q

Most common type of non-lactational mastitis

A

Periductal

337
Q

Time of non-lactational mastitis

338
Q

Etiology of non-lactational mastitis

A

Staph aureus
Sterile
Anaerobes
RF:smoking

339
Q

Non-lactational mastitis

A

Broad IV AB
I&D
Total duct excision
If no resolution, FNA, U/S

340
Q

Mastitis with nipple inversion

A

Non-lactational

341
Q

Postpartum pyrexia etiology

A 
B-5W
Breast: mastitis, engorgement
Wind: athelectasia, pneumonia
Water: UTI
WOUND: episiotomy, C/S wound
Walking: DVT, thrombophelebitis
Womb: endometritis
342
Q

Postpartum blues

A

Onset: 3-10d
Resolution: by 2 wk

343
Q

Postpartum depression onset

A

Within 6 mo

344
Q

Postpartum major depression Tx

A

Antidepressant
Psychotherapy
Supportive care
ECT

345
Q

Postpartum psychosis onset

A

Within first month postpartum

Over 48-72h

346
Q

Pap smear after delivery

347
Q

Return of ovulation postpartum

A

Non-lactating: 45 d

Lactating: 3-6 mo

348
Q

Locia

A

Rubra 3-4d
Serosa
Alba 3-6 wk

349
Q

Inadequate milk Tx

A

Domperidone

350
Q

Breast engorgement

A

Cool compress

Manual expression/pumping

351
Q

Nipple pain

A

Clean after breast feeding
Moisture cream
Topical steroid

352
Q

Postpartum bladder dysfunction Mx

A 
Kegel exercise
Pelvic physiotherapy
Vaginal cone or pessaries
Limit fluid/caffeine
Surgical Mx
353
Q

After pain time

A

1st 3 days

354
Q

After pain Tx

Med (25 decks)

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