Obs Flashcards
How to assess GESTATIONAL AGE via US?
1st trimester—-> Gestational sac diameter
1st and 2nd—-> Crown rump length
2nd and 3rd—-> Biparietal diameter / head circumference/ femur length
Important point of gestational age assessment
If USG during 2nd and 3rd trimester shows discrepancy between EGA (calculated from 1st trimester crown rump length) and fetal measurements, growth problems should be considered (e.g. fetal macrosomia, fetal growth restriction)
Define Anemia in pregnancy
Anemia in pregnancy defined as: Hb <11 g/dl in 1st and 3rd trimester and <10.5 g/dl in 2nd trimester
What are the risk factors for HYPEREMESIS GRAVIDARUM?
Past hx of HYPEREMESIS GRAVIDARUM
Multiple gestation
Gestational trophoblastic disease
How to manage GESTATIONAL TROPHOBLASTIC DISEASE (GTD)?
D and C
F/u with Contraception and regular monitoring of B-HCG
Name the vaccine given in WOMEN OF CHILDBEARING POTENTIAL
Tdap
Inactivated influenza vaccine
Name the vaccine contraindicated during pregnancy
HPV
MMR
Varicella
Small pox
Intra nasal influenza vaccine
Name the general test done in first prenatal visit
Cervical cytology
Rh type and antibody screen
Cbc
Genetic testing for down syndrome and Cystic fibrosis
Name the the general infectious test done in first prenatal visit
Rubella and Varicella
Urine culture
Syphilis testing and HBV antigen
Chlamydia and HIV testing
Influenza
Consequences of syphilis in pregnancy
Pregnancy effects—–>preterm labor / Intrauterine fetal demise
Fetal effects—->Hepatomegaly and jaundice
H.anemia with low.PLTs
Long bones abnormalities
when to sample and how to t/m Group B.Strep?
Rectovaginal culture at 35-37 weeks gestation
Give Pencillin as a t/m
What are the indications of GBS treatment?
GBS bacteriauria OR UTI during pregnancy
GBS positive within 5 weeks of labor
Prior birth to an infant affected with early onset GBS disease
What are the indications of GBS treatment?part 2
Unknown GBS status status with;;
- less than 37 wk of gestation
- Intra partum fever
- Rupture of aminotic membrane for more than 24 hours
How to manage unvaccinated pregnant women with confirmed rubella exposure?
termination of pregnancy—->if pt do not wish termination—–> treat with IV immuno globulin—benefits unknown
Name the non invasive PRENATAL TESTING FOR FETAL ANEUPLOIDY?
First and 2nd trimester markers(9-13)///(15-20) both are non invasive and non dx
2nd trimester US and Cell free fetal DNA (18-20)///(>10wks)
Name the invasive test PRENATAL TESTING FOR FETAL ANEUPLOIDY
CVS and aminocentesis (10-30)(15-20wks)
Both test dx karo typic abnormalities
What are the indications for cell free fetal DNA testing?
Maternal age more than 35
Abnormal maternal serum screening test
Fetal ANEUPLOIDY on US and past hx
Parental based robertsonian translocation
What are the uses of Cell free fetal DNA TESTING?
Detection of ANEUPLOIDY
Fetal sex determination
Important point of Cell free Fetal DNA testing
Abnormal test: confirmed by chorionic villus sampling in 1st trimester and amniocentesis in 2nd trimester
Pts who do not meet high-risk criteria for cffDNA: can undergo 1st trimester combined test or 2nd trimester quadruple screen
When to Do OGTT test in pregnancy?
All pregnant women should have OGTT at 24-28 wks—high risk pts (e.g. marked obesity, FH od DM) may receive earlier
Risk Factors of CHORIOAMNIONITIS/INTRAAMNIOTIC INFECTION
Prolong labor
Prolong rupture of membrane
Presence of Genital tract pathogen
Internal fetal Or uterine monitoring devices
Triad of CHORIOAMNIONITIS/INTRAAMNIOTIC INFECTION
High grade maternal fever with maternal tachycardia
Malodorous / Purulent AMNIOTIC fluid Or vaginal discharge
Fetal tachycardia with increased WBC count
Maternal::
Uterine atony
Endometritis
PPH
-Neonate
Premature birth
Cerebral palsy
Infection encephalopathy
Name the tests for ANTEPARTUM FETAL SURVEILLANCE
Non stress test
BPP
Contractions stress test
Doppler US of the umbilical artery
When to call Non stress test “REACTIVE”?
HR 110-160 with moderate variability
More than 2 acceleration
When to call Non stress.test “Non Reactive “?
Less than 2 acceleration
Recurrent variable Or late deaccleration
What are the causes of Non Reactive stress test?
Fetal sleep cycle
Fetal hypoxia due to placental insufficiency fetal cardiac or neurologic abnormalities
Important point
FHR accelerations are the product of the fetal sympathetic nervous system, which matures at 26-28 weeks—extremely premature don’t demonstrate accelerations
Name the causes of Antepartum bleeding
Normal labour
Placental abruption / Previa / vasa
Uterine rupture
How to approach antepartum bleeding?
Start with speculum examination followed by TV.US
Triad of Normal labour
Intermittent pain
Contractions
Small amount of bloody tinged mucus (“bloody show”)
What are the risk factors of placental abruption?
Past hx
maternal HTN or Pre eclampsia / eclampsia
Abdominal trauma
Cocaine and tobacco use
How to dx placental abruption?
Clinically
Or
US to rule out P.Previa; would show retroplacental hematoma
What are the risk factors for Placental Previa?
Past hx
Past hx of C-sec Or any uterine surgery
Advance maternal age with multiparity
Smoking
How to manage Placental Previa?
TA.US followed by TV US
Plus
NO intercourse OR Digital vaginal Ex
Require C-Sec as a t/m
Important point
Fetal heart tracing usually unaffected as bleeding is maternal in origin
What are the risk factors of uterine rupture?
Past hx of Uterine surgery
Protracted Or Induced labour
Congenital uterine anomalies
Fetal macrosomia
Triad of Uterine rupture
Per vaginal bleeding with painful abdominal contraction
Loss of fetal station with palpation of fetal parts on abdominal Examination
Cessation of uterine contraction
Important point of Uterine rupture and P.abruption
No uterine contraction in U.RUPTURE
Tachysystole in placental abruption
How to prevent fetal and maternal exsanguination due to U.Rupture?
Prevention of fetal and maternal exsanguination: emergency laparotomy to confirm diagnosis and expedite delivery
Name type of UTERINE surgery in which trial of labour (vaginal delivery) is not contraindicate
Low transverse (Horizontal) C-section
Name type of UTERINE surgery in which trial of labour (vaginal delivery) is contraindicate
Classical C sec(vertical)
Abdominal myomectomy with uterine Cavity entry
Abdominal myomectomy without uterine Cavity entry
How to manage patient with hx of classical cesarean delivery or extensive myomectomy or myomectomy with uterine cavity entry?
Elective C section
If present in labor—>perform urgent laparotomy followed by hysterotomy (for fetus delivery if unruptured) or uterine repair (if rupture occurred)
Triad of Vasa Previa
Painless per vaginal bleeding with rupture of membrane
FHR shows bradycardia Or sinusoidal tracing
Bleeding causing fetal distress
How to dx and manage Vasa Previa?
Gold standard test is antenatal abdominal and transvaginal Doppler USG
Management is C section
What are the risk factors of PLACENTA ACCRETA?
Hx of C-Sec
Myomectomy
h/o dilatation and curettage, maternal age >35
US findings of Placental accreta
Antenatal ultrasound: an irregular or absent myometrial-placental interface and intraplacental villous lakes—typically diagnosed antenatally
Define Stage 1 ARRESTED of labor?
when dilation is >/=6 cm with ruptured membranes and 1 of the following
-No cervical change for >/=4 hours despite adequate contractions
OR
-No cervical change for >/= 6 hours with inadequate contractions
Define ADEQUATE CONTRACTIONS
Contractions summing to >/=200 Montevideo units for >/=2 hours
Define Latent Labor
Painful contractions causing cervical size change
Regular and Increase intensity/ frequency of contractions
Define false labor
No Or mild painful contractions without causing cervical size change
Irregular and weak intensity of contractions
How to manage false labor?
reassure and discharge with routine prenatal care
Define Precipitous labor
fetal delivery that occurs within 3 hours of the initiation of the contractions.
What causing Precipitous labor
risk factor for precipitous labor is multiparity.
It is spontaneous and not caused by oxytoci infusion
What are the S.E of oxytocin?
Low sodium
Low BP
Excessive Uterine contractions (tachysystole)
What are the S.E of EPIDRUAL ANESTHESIA?
Low BP
Depression of cervical spinal cord and brainstem activity
CSF leakage
Triad of CSF leakage due to Epidural ANESTHESIA
Due to dura is inadvertently punctured during epidural
postural headaches that are worse with sitting up
improved with lying down after delivery
Define Preterm labor
regular contractions at <37 wks of gestation that cause cervical dilatation and/or effacement
What are the risk factor of Preterm labor?
Past Hx
Multiple gestation
Short cervical length
Surgery of cervical
Cigarette use
How to Prevent Preterm labor with negative past Hx?
If No Past Hx—>check Cervical length on TVUS—>if normal—>routine pregnancy
If short length—>Vaginal progesterone and Check length till 24 weeks
How to prevent preterm labor with positive past Hx?
Give Progesterone injections and Do check Cervical length on TVUS
If short length—>Cerclage and serial US till 24 weeks
If normal cervix—->check length till 24 weeks
@What are the predictors of Preterm labor?
Short cervix
Positive fetal fibronectin test on 24-33 wk
Important point
Fetal fibronectin (FFN) in vaginal secretions is usually low from 22-33 weeks gestation
an elevated FFN concentration during this period is associated with an increased risk of preterm delivery.
Before and after 22-33 weeks gestation, FFN is normally high and therefore not a useful test
How to manage Preterm labor?
If before 32wk—>steroid / tocolytics
MgSO4 and Abx for GBS
If after 32 but before 33 wk—->same as above except MgSO4
If after 33 wks but before 37 wks—->only ABx for GBS and with OR without steroids
What are the indications of CESAREAN DELIVERY?
Fetal distress indicated by deceleration
Loss of FHR variability (occurs in fetal academia)
Breech presentation
Multiple prior cesarean deliveries
What are the risk factors of Breech presentation?
.
Risk factors:
prematurity
multiparity
multiple gestation
uterine anomalies
fetal anomalies
and abnormal placentation
Important point of ECV
It can be performed between 37 weeks gestation and the onset of labor and has been shown to reduce the rate of cesarean deliveries.
Before doing ECV, make sure no contraindications of VAGINAL delivery
What are the contraindications of ECV?
Indication of C-sec regardless of fetal lie
-placental abnormalities
- Rupture membrane
- Hyperextended neck
- Fetal Or uterine anomaly
- multiple gestation
D/F B/W ECV AND ICV
ECV done in singleton
ICV always in twin baby
How to manage PRETERM BREECH PRESENTATION?
Before 37 but after 34 weeks
Perform C section only.
No use of uterotonic agents
What are the risk factors ofTRANSVERSE LIE
prematurity,
uterine anomalies,
placenta previa
multiple gestations
How to manage TRANSVERSE LIE?
Give Trial of Labor if baby converts into Vertical position
Remain in traverse lie or converts to breech—> ECV (if not CI)—>successful—> trial of labor
unsuccessful ECV or ECV CI—> C.sec
Define SPONTANEOUS ABORTION (SAB)
fetal loss before the 20th week of gestation
How to approach spontaneous abortion?
US of abdomen OR TVUS
Serial B-HCG monitoring
Name the types of miscarriage in which cervix is open
Inevitable
Incomplete
Septic
Name the type of miscarriage in which cervix is closed
Threatened
Complete
Triad of Threatened miscarriage
Per vaginal bleeding with closed cervical Os
No issue in fetal cardiac activity
Expectant management if fetus is alive and repeat US
Triad of missed miscarriage
No vaginal bleeding
closed cervix
No fetal cardiac activity Or Empty sac
Triad of Inevitable miscarriage
Per vaginal bleeding
Open cervix
POC seen or felt at Or above cervical Os
Triad of Incomplete abortion
Vaginal bleeding
Open cervix
POC 50% seen in reproductive tract
Triad of complete abortion
No vaginal bleeding Or very minimal
Closed cervix
No POC left
How to manage Incomplete/ Inevitable and missed miscarriage?
If hemodynamic stable with minimal bleeding—–>Expectant management/ Prostaglandins Or surgical Evacuation
If unstable with heavy bleeding—-> D and C
Important point
Hospitalization and bed rest—not indicated in 1st trimester abortion spontaneous or threatened abortio
Oxytocin infusion—not used in 1st trimester (used in late 2nd or 3rd trimester)
How septic abortion occur?
Retained POC after elective abortion with non sterile technique
Triad of Septic abortion
Prodromal Sxs
Dilated cervix with Purulent Or bloody discharge
Boggy and tender uterus
Pelvic US finding of septic abortion
Retained POC
Increase vascularity
Echogenic material in the cavity
Thick endometrial stripe
How to manage septic abortion?
ABx and IV fluids
Suction curettage
Removal of uterus if no response to ABX OR develop abscess Or signs of clostridial infection
Important point
Misoprostol is a syntheticprostaglandin approved for use with mifepristone to terminate pregnancies of <49 days gestation
Triad of INTRAUTERINE FETAL DEMISE (IUFD)
Death of afetus in utero after 20 wks of gestation
absence of fetal movement and fetal cardiac activity On US
Cause is Unknown in 50% cases
Approach to Coagulopathy INTRAUTERINE FETAL DEMISE (IUFD)
Monitoring the coagulation profile: done after USG confirm IUFD
suspected coagulation derangement—> delivery without delay
coagulation parameters normal: expectant management Or induction of labor (patient preference)
What are the t/m options of Still birth delivery in 2nd trimester?
D and C upto 24 weeks
Induction of labor
Spontaneous vaginal delivery
What are the t/m options of Still birth delivery in 3rd trimester?
Do C-sec if past hx of it
Spontaneous vaginal delivery
Induction of labor with Or without cervical ripening
What are the LATE TERM AND POSTTERM PREGNANCY COMPLICATIONS in fetus?
C-SOM Convulsion Stillbirth Oligohydramnios Meconium aspiration /macrosomia
What are the LATE TERM AND POSTTERM PREGNANCY COMPLICATIONS in mother?
PPH
Perineal trauma
Infection
C section
Important point
Induction of labor ASAP in late and post term pregnancy as utero placental insufficiency would occur which causes Oligohydramnios
What are the causes of Symmetrical fetal growth restriction?
Due to fetal factors Viz Genetic disorder CHD TORCHss
What are the causes of Asymmetric fetal growth restriction?
Due to maternal factors
Viz
Vascular dis like HTN related and DM
APLA
Autoimmune dis like SLE
Cyanotic cardiac disease
Drug abuse
Important point of Macrosomia
No change in prognosis whether PPx C-sec or Vaginal delivery
What are the risk factors for fetal macrosomia?
Maternal:::
Advance age with DM
Excessive Wt gain during pregnancy
Multiparty
Fetal:::
Post term pregnancy
Male sex
African American Or Hispanic
What are the complications of Shoulder DYSTOCIA?
Fractured clavicle and humerus
Erb Duchene palsy and klumpke palsy
Perinatal asphyxia
Important point of complications of shoulder DYSTOCIA
In both clavicle and humerus fracture, Moro reflex absent
And
Grasp reflex present and intact biceps
What are the risk factors for the neonatal displaced clavicular fracture?
Fetal macrosomia
Instrumental delivery
Shoulder dystocia
How to t/m Clavicular fracture?
Reassurance and Gentle handling
Analgesics
Place affected arm in a long sleeve garment and pin sleeve to chest with elbow flexed at 90*degree
How to manage ERB-DUCHENNE PALSY?
Fortunately, up to 80% of patients have spontaneous recovery within 3 months
No improvement by 3-6 month surgical intervention can be considered but not necessarily curative
Complications of 1st trimester Maternal hyperglycaemia
CHD
Neural tube defects
Small left colon syndrome
Spontaneous abortion
Complications of 2nd and 3rd trimester of maternal hyperglycaemia
All due to fetal hyperglycaemic which results increase insulin
- Polycythemia
- Organomegaly
- Macrosomia
- Neonatal hypoglycaemia
How Uterine Inversion occur?
Excessive Fundal pressure
Excessive umbilical cord traction
Triad of Uterine Inversion
PPH with lower abdominal pain
Round mass protrude via cervix
Uterine fundus not palpable trans abdominal
What are the risk factors for Uterine Inversion?
nulliparity
fetal macrosomia
placenta accreta
rapid labor and delivery
What are the risk factor for the uterine atony?
Uterine fatigue from prolong or induce labor
Chorioamionitis
Over distend uterus
Retained placenta
What are the contraindications of medicine use in uterine atony?
Methylergonovine in HTN
Carboprost in Asthma
What are the normal findings in Postpartum period?
Transient rigors and chills
Peripheral Edema
Lochia rubra
Uterine contraction and involution
Breast engorgement
What routine care to do in postpartum period?
Rooming in /Lactation support serial examination for uterine atony // bleeding
Perinatal care
voiding trail
Pain management
Name the Lochia Occur first few days after delivery
lochia rubra
which is a red or reddish-brown vaginal
Name the Lochia Occur after 3-4 days delivery
(lochia serosa)
discharge becomes thin and pink or brown colored
Name the Lochia Occur after 2-3 weeks delivery
lochia alba::
After 2-3 weeks,the discharge becomes white or yellow
Define Postpartum urine retention
inability to void by 6hours after vaginal delivery or 6 hours after removal of indwelling catheter after C. sec.
Name the test which confirm the dx of postpartum urine retention
Bladder catheterization more accurate than bladder USG >/=150 mL of urine confirms diagnosis
How Postpartum urine retention occur?
Regional anesthesia—->↓ motor and sensory impulses of sacral spinal cord——>suppression of micturition reflex and/or ↓ in bladder tone (↓ detrusor tone), pudendal nerve palsy from injury, or periurethral swelling
Triad of POSTPARTUM ENDOMETRITIS
High grade fever outside the first 24 hours postpartum (less than 24 postpartum fever is normal)
Uterine tenderness with foul smelling lochia
Leukocytosis
How to manage postpartum endometritis?
Causes are polymicrobial so IV clindamycin + IV aminoglycoside such as gentamicin
What are the risk factor for Endometritis?
Risk factors for endometritis include,
Prolonged rupture of membranes (>24 hours)
Prolonged labor (>12 hours)
C. section
Use of intrauterine pressure catheters or fetal scalp electrodes
Define Chronic HTN with superimposed Pre eclampsia
PRE EXISTING HTN with new onset proteinuria Or worsening of existing Proteinuria
Occur after or at 20wks
What risk occur to mother due to HTN?
Remember sequence
GDM ——>placental abruption ——>C delivery ——>PPH
Superimposed pre eclampsia
What risk occur to fetus due to HTN ?
FGR
Perinatal mortality
Preterm delivery
Oligohydraminos
What are the risk factors of pre eclampsia?
maternal age <18 or >40
multiple gestation
nulliparity
preexisting DM
chronic kidney disease
and prior preeclampsia
What features suggest SEVERE PRE ECLAMPSIA?
BP MORE THAN 160/110
Low PLTs with elevated LFT and creatinine
Pulmonary Edema
New onset visual Or cerebral SXS
Important point of medication given in Pre eclampsia
Labetalol can’t be given in low pulse——>Give Hydralazine
Oral Nifedipine can’t be given in EMESIS
Loop diuretics if pulmonary Edema
Name the 2nd line agent given in Eclampsia
diazepam more phenytoin would be indicated as 2nd line
How to manage PULMONARY EDEMA IN PRE-ECLAMPSIA OR ECLAMPSIA?
supplemental oxygen
fluid restriction
diuresis in severe cases.
Fluid restriction and diuresis must be used with caution as plasma-volume is effectively ↓ed through third-spacing and placental perfusion can be compromised
What are the causes of CAUSES OF HYPERANDROGENISM IN PREGNANCY ?
LUTEOMA
KRUKENBERG TUMOR
Theca luteum cyst (low Risk of fetal virilization)
Triad of KRUKENBERG TUMOR
Mets from GIT cancer
US shows B/L ovarian mass
High risk of fetal virilization
Triad of LUTEOMA
Yellow Or yellow brown masses of large lutein cells
B/L solid ovarian mass on US
High risk of fetal virilization
Triad of Theca lutein cyst
B/L ovarian cyst on US
Associated with molar pregnancy And multiple gestation
Low risk of virilization
How to manage ovarian mass causing hyperandrogenism?
Mostly regress after pregnancy
In case of pressure SXS do surgery
INDICATIONS FOR PROPHYLACTIC ANTI-D IMMUNE GLOBULIN ADMINISTRATION FOR AN UNSENSITIZED Rh-NEGATIVE PREGNANT PATIENT
At 28 to 32 wk of gestation
With 72hrs of RH positive fetus delivery
Ectopic pregnancy/ Hydatidform Mole pregnancy / Abortion
2nd Or 3rd trimester bleeding
Abdominal Trauma
CVS sampling / amnioncentesis
ECV
Consequences of Anorexic mother in fetus
1.Premature
- Small for gestational age (due to IUGR) or both
- Miscarriage
- Hyperemesis gravidarum
- C. sec
- Postpartum depression (not postpartum psychosis)
Classified Genital Ulcer on the basis of Pain
If painless—> syphilis / chlamydia / klebsiella
If painful—>HSV / H.Ducreyi
How the ulcer of HSV presents?
Multiple grouped ulcer
Shallow with erythematous base
How the ulcer of h.ducreyi Present?
Single OR Multiple group ulcer With irregular boarder
Gray Or yellow exudate
Matted lymph nodes (suppurate / rupture)
Important point of Chancroid
Organisms clump in long parallel strand (school.of fish)
How the ulcer of klebsiella present?
Ulcerative lesion without LAD
Beefy appearing lesion with bleeding
Base has granulation like tissue
How lymphogranuloma venerum Present?
Small shallow ulcer
Large painful inguinal LAD
Large painful fluctuant buboes
Sinus tract
How the ulcer of syphilis presents?
Single painless ulcer which is indurated
Clean base
Triad Bacterial vaginosis presents?
Thin white discharge with fishy odor
pH more than 4.5 with clue cells
metronidazole 500mg twice a day for 7 days
Triad of TRICHOMONAS VAGINALIS
Thin frothy yellow green malodorous discharge
pH more than 4.5
metronidazole and tinidazole
Triad of Candida vaginitis
Thick cottage cheese discharge Normal PH (3.8-4.5) Fluconazole as a t/m
Traid of PHYSIOLOGIC LEUKORRHEA
Copious white or yellow discharge non-malodorous
squamous cells and polymorphous leukocytes on microscope
No treatment needed
How to manage PELVIC INFLAMMATORY DISEASE (PID)?
If no response Or unable to oral ABx /fever and pregnancy—–>cefoxitin or cefotetan/doxycycline and clindamycin/gentamicin
How to manage non hospitalise PID?
non-hospitalized patients: IM cefoxitin + oral probenecid and oral doxycycline
or
IM ceftriaxone and oral doxycycline.
What are the potential Complications of HEPATITIS -C IN PREGNANCY?
Gestational DM
Preterm pregnancy
Cholestasis of pregnancy
How to manage mother if HEPATITIS C IN PREGNANCY?
No ribvairin
Vaccine against HBV AND HAV
How to prevent vertical transmission of HCV?
Avoid C-section and scalp electrodes
No contraindications of breastfeeding unless blood present in nipples
Antepartum management of HIV
If viral load less than 1k—->ART and vaginal delivery
If viral load more than 1k—->ART / zidovudine and C section
Important point of HIV management in intrapartum
Avoid rupture of membrane
Avoid operative vaginal delivery
Avoid fe tal scalp electrode
How to manage mother and baby postpartum?
Continue ART in mother
If viral load >1k give multi drug ART
IF viral load <1k zidovudine
What are the risk factors of AMNIOTIC FLUID EMBOLISM?
REMEMBER C— GAP
C c section or Instrument delivery
G gravida more than 5
A advance mother age
P placenta previa / abruption / Pre eclampsia
How to manage AMNIOTIC FLUID EMBOLISM?
Respiratory Or Hemodynamic support
With Or without transfusion
Name the liver disorder in Pregnancy
INTRAHEPATIC CHOLESTASIS OF PREGNANCY
ACUTE FATTY LIVER OF PREGNANCY (AFLP)
HELLP
Traid of INTRAHEPATIC CHOLESTASIS OF PREGNANCY
Intense generalised itching esp at night
Direct jaundice pattern in LFT
T/m as direct jaundice
Triad of ACUTE FATTY LIVER OF PREGNANCY (AFLP)
RUQ pain with N/V
Low glucose with deranged LFT
Increase bilirubin
Traid of PRURITIC URTICARIAL PAPULES AND PLAQUES OF PREGNANCY
Skin manifestation occur in 3rd trimester
red papules within striae with sparing around the umbilicus
No abnormalities in labs
How to approach ACUTE APPENDICITIS IN PREGNANCY?
US»»MRI»»MRI not available»>only then CT can be performed»>diagnostic laparoscopy with last option (lower midline vertical laparotomy)
How to dx RENAL STONES in pregnancy?
Renal and pelvic USG is the diagnostic study of choice
Important point of Renal stones management in pregnancy
Shockwave lithotripsy—not done in pregnancy.
If a pregnant patient fails to improve with conservative measures, ureteroscopy or nephrostomy may be considered.
D/F categories of URINARY TRACT INFECTION (UTI) IN PREGNANCY
Asymptomatic bacteriuria
Acute cystitis
Acute pyelonephritis
Profile of thyroid hormone in pregnancy
Total T4 and Free T4 increase
TSH decrease
At what week screening of GDM is conducted?
24-28 weeks
How to screen for GDM?
Give 1hour 50g glucose and check after 1 hour—->if less than 140 No GDM
If more than 140—–>give 100g glucose and take 4 readings
What is the target level of blood glucose in GDM?
Fasting should be less than 95
1 hours post meal should be less than 140
2 hours post meal should be less than 120
Important Point of GDM
Usually screen test is done in 3rd trimester but if patient has risk factors for GDM, do screening test in first Trimester or First prenatal visit
lmportant point
Small left colon syndrome—–>transient inability to pass meconium and resolves spontaneously.
Not related to intussusception
Triad of Post Partum blues
Occur after 2-3 of pregnancy and resolve within 10 days
Mild depression with tearfulness
Reassurance and monitoring
Triad of Post Partum depression
Occur within 4weeks after pregnancy
Sxs like Major depression disorders
Antidepressants and pyschotherapy
Triad of Post Partum psychosis
Occur day to weeks after pregnancy
Sxs of pyschosis
Start anti psychotic and anti depressants without leaving infant with mother
What are the complications of INAPPROPRIATE WT GAIN?
EXCESSIVE WT GAIN–> GDM / C-SEC / Fetal macrosomia
low wt gain–>FGR / Preterm delivery
What are the consequences of mono placenta mono amniotic membrane?
Twin twin transfusion
umbilical cord enlargement
IU fetal demise
*stat preterm c-sec
-Important point
single placenta with two amnion—> T-SIGN
two placenta with two amnion—>lamda sign
What are the components of BPP?
Non stress test
Fetal movement
Fetal breathing movement
Fetal tone
Amniotic fluid volume
What exactly BPP is assessing?
BPP is performed to assess fetal oxygenation which low in placental insufficiency
What is the normal amniotic fluid volume?
Single fluid pocket more than 2*1cm
Or
Amniotic fluid index more than 5
Name the conditions in which BPP is normal?
BPP is normal in: fetal malpresentation (causes fetal growth restriction or chronic fetal hypoxia but not abnormal BPP)
anterior placental location
When to consider Contractions stress test normal?
No Late Or recurrent variable deceleration
@ When to consider Contractions stress test abnormal?
Late deceleration even with more than 50 percent contractions
What are the cause of fetal Tachycardia?
FHR >160 beats/min.
Common causes:
chorioamnionitis
maternal fever
maternal hyperthyroidism medication use (e.g. terbutaline)
abruptio placenta
Name the causes of Early fetal deceleration
Fetal head compression
But sometime this type of tracing considered normal
How to manage early fetal deceleration due to head compression?
No treatment needed if normal baseline rate, moderate variability, no late or variable decelerations present as does not indicate fetal hypoxemia
Triad of Post dural puncture headache
Occur after epidural anaesthesia
Headache increase increase with upright and decrease on supine
N/V and neck stiffness
Triad of Congenital Zika virus
Fits with hypertonicity
Microcephaly with craniofacial disproportion
Ocular abnormalities
Neuroimage finding of Zika virus
Calcification
Ventriculomegaly
Cortical thinning
Name the Abx given for GBS if patient has allergy to penicillin
Cefazolin
What are the warning signs of shoulder dystocia?
Prolonged labor
Turtle sign—–> Retraction of fetal head into perineum after delivery
What are the cause of Fetal hydrops?
Immune—> Rh negative
Non immune---> Parvo virus Fetal aneuploidy CVS abnormalities Thalassemia
What breech position in which vaginal delivery possible and impossible?
Possible in —->Frank and complete
Impossible—->incomplete and footling
What is the MCC cause 2nd stage arrest?
Fetal malposition (non occpitant
How round ligament pain occur?
Sharp pain radiates to vagina
What are the complications of Excessive weight gain and Inappropriate weight gain?
Excessive causes GDM + macrosomia + C sec
Inappropriate weight gain:
Fetal growth restriction + Preterm delivery
Triad of Anembryonic gestation
No embryonic development
No uterine size discrepancy
Important point
Down syndrome associated with VACTERAL
Diaphragmatic hernia associated with Edward syndrome
holoprosencephaly associated with pataue syndrome
what are the causes of oligohydramnios in first Trimester?
Mostly due to fetal causes
what are the causes of oligohydramnios in 2nd and 3rd Trimester?
Utero placental insufficiency
Rupture of membranes
Name the medicine for bipolar disorder in pregnancy
Lamotrigine
What are the consequence of short interpregnancy interval?
LAP
L LBW
A anemia
P PPROM / Preterm delivery
US doppler finding of Ectopic pregnancy
Ring of fire around the ectopic pregnancy
How to manage PPROM after 34 week but before 37 weeks?
Delivery
Abx like penicillin for GBS
±steriods
How to manage uncomplicated PPROM before 34 weeks?
Steroid with ABx for GBS
Expectant management
If before 32 wk give magnesium
What does mean by Complicated PPROM?
Infection
Fetal or maternal compromise
How to managed Complicated PPROM before 34 weeks?
Magnesium if before 32 wk
Delivery
Abx like ampicillin and Gentamicin
Steroid
What are the causes of Oligohydramnios in first trimester?
In first Trimester mostly due to fetal causes—>
Posterior uretheral valve
Renal agenesis
Aneuploidy
What are the causes of Oligohydramnios in 2nd or 3rd trimester?
Utero placental insufficiency
(With FGR)
Maternal dehydration or Rupture of membranes (normal fetal growth)
How thyroid hormone production increase to meet metabolic demand in pregnancy?
Estrogen increase TBG result increase only in bound hormones
B-HCG stimulates TSH receptor increase thryoid hormones
Both these suppress TSH
TFT Pattern in Pregnancy
Increase Total 4
Mild Increase or unchanged free T3
Deceased TSH
How to managed Perineal laceration after pregnancy?
If uncomplicated viz no fever or purulence—> NASIDS / Sitz bath
If fever or purulence or wound breakdown or non intact repair —->Abx / suture removal and surgical debridement
What are the causes of Minimal Variability <5 Or absent Undetectable amplitude?
Prematurity
Fetal hypoxia or Sleep
CNS depressants like alcohol, narcotics and drugs
What changes occur in Pulmonary patterns in Pregnancy?
Resp-alkalosis
Normal VC and FEV1
Increase Minute ventilation due to Tidal volume increase
Decrease RV and FRC
Triad of Degenerating Uterine fibroid
Fundal tenderness with palpable mass
Increase WBCs count
Conservative management
Important point of Cerclage
Patient with past hx of 2nd term pregnancy loss manage with prophylactic Cerclage placement ((doesn’t matter if cervical length is short or normal))
Procedure also done if patient has short cervical length
Triad of Intrahepatic choletasis of pregnancy
RUQ pain
Whole body pruritis but more on hand and feet
Only LFT deranged without rash
How to manage Intrahepatic choletasis of pregnancy?
1) Ursodeoxcholic acid
2) Antihistamine
3) delivery at 37th week of gestation
What are the complications of Intrahepatic choletasis of pregnancy?
M-PIN
M. Meconium stained aminotic fluid
P preterm delivery
I intrauterine fetal demise
N Neonatal RDS
How to Prevent and abort Migraine?
Abortive (TANE)
Preventive ABA
Abortive::
(Triptans, Antiemetic, Acetaminophen, NSAIDs, Ergotamine)
Prevent::
Anticonvulsant like topiramate Or Valproate
B BB (given in pregnancy unlike others )
A antidepressants ( TCA or Venlafaxine)
What are the causes of Late (Secondary) PPH?
1) Placental Endometritis
2) Retained POC which present as boggy or tense uterus with heavy bleeding ± uterine atony
Rx via dilation and curettage
3) Placental site Sub involution which present as present as heavy bleeding with uterine atony
Rx via Uterotonics
What are the CVS condition which are CI to pregnancy?
Symptomatic MS and AS
PAH
Symptomatic HF with LVeF less than 30%
Bicuspid AV with ascending aorta enlargement >50mm
