OBS Flashcards
What is the risk of placenta accreta in the presence of a previa and 0, 1, 2, 3, 4 CS
Previa and:
- 0 prior CS: 3 %
- 1 prior CS: 25 %
- 2 prior CS: 40 %
- 3 prior CS: 61 %
- 4 prior CS: 67 %
What is the risk of placenta accreta in the absence of placenta previa
Accreta without previa
- 1 prior CS: 6.6 %
- 2 prior CS: 17%
- > 3 prior CS: 55%
What is the risk of accreta with 1 prior CS and with and without previa
One previous CS
- No previa: 6.6%
- Previa: 25%
What is the risk of accreta with 2 prior CS and with and without previa
Two (2) previous CS
- No previa: 17%
- Previa: 40%
What is the risk of accreta with 3 prior CS and with and without previa
- No previa: 55%
- Previa: 61%
Name the indications for aspirin in pregnancy (10)
- AMA (Age > 40)
- ART
- BMI > 30
- History of IUGR
- History of PET
- Chronic HTN or previous GHTN
- Multiple pregnancy
- DM 1 or DM2
- History of placental abruption
- History of placental infarct
When should ASA be started
12- 16 weeks
What is the mechanism of action of labetolol
Mixed alpha + beta adrenergic ANTAGONIST
What is the mechanism of action of metyldopa
Alpha-2 adrenergic AGONIST
What is the mechanism of action of hydralazine
Vascular smooth muscle relaxant
Name the sources of progesterone in pregnancy (2)
- Corpus luteum cyst (until 6-7 weeks)
- Placenta
What are the most common congenital anomalies in patient with T1 or T2 DM
Neural tube defect (4.2 fold increase)
Congenital heart disease (3.4 fold increase)
What does BV in pregnancy predispose to?
PPROM
PTL
PTB
Post partum endometritis
When are depression symptoms worse in adolescent pregnancy?
Between T2 and T3
1/2 have symptoms in early post partum period
What adverse outcomes are adolescent pregnancy linked to?
PTB
PPROM
LBW/ IUGR
NICU admissions
Stillbirth
Congenital anomalies
What congenital anomalies are linked to adolescent pregnancies?
CNS
(anencephaly, spina bifida, hydrocephaly, microcephaly)
GI
(Gastroschesis, omphalocele)
MSK
(clift lip, cleft palate, polydactyliy, syndactaly)
What is the most common lower genital tract disorder in women of reproductive age?
Bacterial vaginosis
What are some risk factors for BV (4?)
Black race
Smoking
Sexual activity
Use of vaginal douches
What are the two ways to establish a diagnosis of BV?
Amsel criteria
Nugent score (Gram stain, score > 7)
Amsel criteria:
Adherent and homogenous vaginal discharge
Vaginal pH > 4.5
Detection of clue cells
Positive wiff test
What is the treatment + f/u of BV in pregnancy ?
Metronidazole (Flagyl) 500 mg PO BID x 7 days
Clinda 300 mg PO daily x 7 days
Repeat culture 1 month after treatment - high recurrence
Topical agents have similar cure rates but
- Not effective to prevent PTL in high risk population
Name the adverse pregnancy outcomes with BV (5)
Spontaneous abortion
PTL and PTB
PPROM
Chorioamionitis
PP infections (Endometritis + CS wound infection)
When should you screen for BV in pregnancy?
NO routine screening
Screen if bothersome and persistent discharge
Screen at 12-16 weeks in high risk women
What is oral fluconazole in pregnancy associated to?
Tetralogy of Fallot
Safety in 2nd and 3rd trimester not investigated
What is boric acid associated to in pregnancy?
2 fold increase in birth defects (during first 4 months)
Define shock index
HR / sBP
< 0.7 → normal
> 0.7 → transfuse
Absolute contraindications to neuraxial anesthesia
Maternal coagulopathy
Thrombocytopenia
LMWH within 12h
Sepsis
Skin infection at site of needle placement
Refractory maternal hypotension
Increased intracranial pressure caused by mass lesion
3 coags / 2 infection / 2 BP
Describe the following signs:
Goodell
Chadwick
Hegar
Goodell : Softening of LUS
Chadwick : Cyanosis / bluish discoloration
Hegar: Softening of cervix
(Hegar = cx dilator)
What test should you order to r/o GDM in patient who underwent gastric bypass surgery?
(# 393)
Fasting glucose
1h post prandial blood glucose
HbA1c
Who should you screen before 24-28 weeks for GDM ?
(#393)
Maternal age > 35 yo
Pre-pregnancy BMI > 30
PCOS
Acanthosis nigricans
Corticosteroid use
Ethnicity (Aboriginal, African, Asian, Hispanic, South Asian)
Family Hx of DM
Previous pregnancy with GDM
Previous macrosomic infant
What are the benefits of optimal glucose control (5)?
(#393)
↓ PET
↓ Fetal macrosomia
↓ Shoulder dystocia
↓ CS
↓ IUFD
What is the advantage of immediate breat feeding in diabetic mothers (1)?
(#393)
↓ neonatal hypoglycemia
In GDM mothers, BF x 6 months has what advantages (2)?
(#393)
Reduce childhood obesity
Reduce maternal hyperglycemia
What proportion of GDM mothers have DM at PP visit?
(#393)
1/3
What proportion of GDM mothers will have DM later in life?
(#393)
15-50 %
Describe the different levels of foreceps application (4)
(#381)
Outlet : Head visible at introitus without spreading the labias
Low: station > +2 **
Mid: Station between 0 and +2 **
High: Station above 0 (head not engaged)
** 2 subdivisions
- Rotation < 45 ° from OA position
- Rotation > 45 ° from OA position (including OP)
When should you induce GDM patients ?
(#393)
Diet controlled: before 40 weeks
Insulin dependant: 39 weeks
How and when do you test for post partum DM?
(#393)
2h 75g OGTT
Between 6 weeks and 6 mo post partum
When planning another pregnancy
When and how to test for GDM in patients who received betamethasone?
(#393)
> 7 days post last dose of beta
2h 75 OGTT
Describe antenatal testing for GDM
(#393)
US q 3-4 weeks starting at 28 weeks
- EFW
- Amniotic fluid volume
Weekly testing at 36 weeks
- NST
- NST + AFI
- BPP
What dermatomes need to be blocked for vaginal delivery and CS?
Vaginal delivery: T10 - S5
CS: T4 - S1
(Williams OB p 513)
What complication of DM1 in pregnancy leads to the highest number of PTB?
(Williams OB p 1131)
Pre-ecclampsia
How do you follow a DM1 pregnancy ?
(Berghella)
Pre-conception
- Normalization of HbA1c < 7 %
- Eye exam
- 24h urine protein
- EKG
Antenatal
- Viability scan
- Early anatomy scan (14 -16 wks) if HbA1c > 8%
- AFP screening 16-20 wks
- Anatomy scan (18-20 wks)
- Fetal echocardiography (20-22 weeks)
- Serial growth US
- 28 weeks: onset of antenatal testing if glucose poorly controlled
- 32 - 36 weeks: NST and BPP weekly or twice weekly
- 36 weeks to delivery : Twice weekly
Delivery:
- 39 weeks
- If CS, administer evening dose of long acting and hold morning short acting dose
Post partum
- Decrease insulin dose by half and administer with onset of PO intake
What are the neonatal effects of DM1 (5)?
(Berghella + Williams)
Hypoglycemia
Hypocalcemia
Hyperbilirubinemia + polycythemia
Cardiomyopathy
Mortality
What is the impact of pregnancy on typical DM1 complications (7)?
(Berghella + Williams)
Pre-ecclampsia
Retinopathy → can significantly worsen
Nephropathy → if severe, can lead to end stage disease
Neuropathy → no effect, only if gastroparesis (high risk of complication + poor perinatal outcome)
Cardiovascular disease → no change in pregnancy
Ketacidosis → ↑ risk
Infection → ↑ risk of all infections
What is a contraindication of pregnancy in pts with DM1?
(Berghella)
Symptomatic cardiovascular disease
How do you prevent progression of retinopathy in DM1 patients?
Good glycemic control
Photocoagulation
When does the fetal thyroid start functioning ?
What are thryroid hormone sources before and after that time?
10 - 12 weeks
- Starts concentrating iodine
- Start formning TSH
- Small amount of thyroid hormones
18-20 weeks
- Increased fetal secretion
Before 10-12 weeks → amternal T4 = only source
Which Thyroid hormones cross the placenta?
T3
T4
TRH (small amount)
TSH receptor Antibody
Does not cross: TSH
Describe the different periods of the development of a fetus and corresponding dates
(W OB p 128)
Weeks 1-2 : implantation
Weeks 3-8: Embryonic period = organogenesis
Weeks 9-38: fetal period = growth
Inheritance pattern of G6PD disorder ?
What medication/ substance should be avoided ?
X-linked (recessive)
Methylene blue / Nitrofurantoin
+ long list but none are used in gyne
Which stage of labour is affected by obesity?
First stage
What maternal infections are associated with stillbirth?
(#394)
CMV
Parvo B19
Listeria
What is the timeline of PP psychosis?
Within 2 weeks of birth
What is often the first signe of PP psychosis?
(UpToDate)
Severe insomnia (more than to take care of infant)
What is the most common cause of maternal death during the first year PP?
Suicide
(UpToDate: post partum psychosis)
What is the risk of infanticide with PP psychosis?
(UpToDate: PP Psychosis)
4 %
What medical condition is increased in PP psychosis?
(UpToDate PP Psychosis)
Autoimmune thyroid disease
Primary Hypoparathyroidism
What are the RF for GDM ?
(Berghella p 60)
Hx of GDM
Family Hx of DM
Obesity
Age > 35
Non white etchnicity
Prior macrosomic infant
Chronic steroid use
Glycosuria
Know impaired glucose metabolism
Prior infant with congenital anomaly
Prior unexplained stillbirth
What is the mechanism of GDM (2)?
Berghella p 61
Insulin resistance caused by:
- ↑ human placental lactogen (maternal and placental production)
- Progesterone
- Growth hormone
- Cortisol
- Prolactin
- ↑ BMI and caloric intake
↓ function of pancreatic islet cells
What is the % of RhD - in the caucasian population?
15 %
In Basque : 30 %
In Asians : 1%
If and RhD - patient does not get Rhogham, what is her chance of immunization?
(Berghella)
17 %
What is the most common reason for izoimmunization ?
(Berghella)
Fetomaternal hemorrhage at delivery (>90%)
Third trimester (10%)
Other than pregnancy, what are other causes of RBC alloimmunization?
Berghella
Amnio 7- 15 %
CVS: 14 %
Induced abortions : 4-5 %
ECV: 2-6 %
First trimester loss (1-2%)
How long is Rogham effective for?
Berghella
12 weeks
Half life = 16- 24 days
What is the incidence of Kell alloimmunization?
(Berghella)
0.1 - 0.3 %
What is the risk of fetal demise with fetal blood transfusion?
(Berghella)
1-2 %
What is the risk of error following fetal sex determination by US ?
(#192)
3 %
Describe warfarin embryopathy ?
When administered in which trimester does it have the worse impact?
What are the other impacts of warfarin on pregnancy?
(#308)
Nasal and limb hypoplasia
Stippled bone epiphyses (pattern of focal bone calcification)
Worse in First Trimester (between 6-7 wks)
Effect is dose dependant
Pregnancy loss
Antigoagulation at time of delivery
How do you manage an ovarian mass in pregnancy?
- < 5 cm → no surveillance needed
-
5- 10 cm, US surveillance.
- Remove if grows, maliganant features, symptomatic
- Surgery between 14 - 20 wks (most benign cyst will have resolved by then)
- > 10 cm → Remove (↑ risk of malignancy)
- NO EVIDENCE for tumor markers except Ca125
- If 15 wks → delivery, Ca125 between 1000 and 10 000 → ABNORMAL
What nerve roots and muscles are affected with Erb’s palsy ?
C5 - C6
Paralysis of deltoid, infraspinatus, flexor muscles of forearm
Arm is straight (elbow extended), internally rotated, wrist is flexed (fingers flexed or spared)
