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Oral boards > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What are maternal and neonatal risks associated with GDM?

A

Maternal:

  1. Preeclampsia
  2. Cesarean section
  3. T2DM or impaired glucose tolerance later in life

Neonatal:

  1. Macrosomia
  2. Birth trauma
  3. Polyhydramnios
  4. Hypoglycemia
  5. Hyperbilirubinemia
  6. Stillbirth
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2
Q

How do you screen and diagnose patients with GDM?

A
  1. I screen ALL my pregnant patients for GDM at 24-28 weeks gestation unless early screening is indicated by risk factors
  2. I perform screening by a 2-step approach. The 1st step consists of a 50-g 1-hr GTT, for which values 140 mg/dL or greater are considered positive. If a patient has a positive 1-hour GTT, I perform a 100-g 3-hr GTT. If a patient has two or more values that meet or exceed 95 mg/dL, 180 mg/dL, 155 mg/dL or 140 mg/dL at fasting, 1-hr, 2-hr and 3-hr time points, they meet the criteria for GDM.
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3
Q

How do you initially counsel patients who have a new diagnosis of GDM?

A
  1. BLOOD GLUCOSE MONITORING: I recommend that patients check their blood glucose 4x/day: once after fasting when they wake up in the morning, and 1 hr after breakfast/lunch/dinner. Fasting values should be < 95 mg/dL and 1 hr post-prandial values should be < 140 mg/dL (or < 120 mg/dL if 2 hrs post-prandial).
  2. NUTRITION: I refer them for nutrition counseling. I recommend that their caloric intake be distributed as 40% carbohydrates, 20% protein and 40% fat. Intake should be divided into 3 meals and 2-3 snacks. (see additional flash card for details)
  3. EXERCISE: I recommend patients engage in 30 minutes of moderate intensity aerobic exercise at least 5 days a week or a minimum of 150 minutes per week.
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4
Q

What nutrition counseling do you provide your patients with GDM?

A

I counsel my patients about caloric allotment, caloric composition and caloric distribution.

  1. CALORIC ALOTTMENT: 1800-2500 kcal/day
    Normal weight: 30 kcal/kg/day
    >120% IBW: 24 kcal/kg/day
    Morbidly obese: 14 kcal/kg/day
  2. CALORIC COMPOSITION: Patients should divide their calories into 40% CHO, 20% protein and 40% fat
  3. CALORIC DISTRIBUTION: 10-20% breakfast, 20-30% lunch, 30-40% dinner, up to 30% for snacks

I recommend that they consume 3 meals per day with 2-3 snacks between meals and at bedtime

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5
Q

When do you start patients with GDM on pharmacotherapy and what do you use?

A
  1. I start patients on pharmacotherapy when 30% of values on their blood glucose logs are > 95 mg/dL fasting or > 140 mg/dL 1-hr after meals.
  2. I use insulin as my first choice for pharmacotherapy and use a typical starting dose of 0.7-1 unit/kg daily depending on gestation.
  3. There are several regimens for insulin administration. My preference is to use a combination of long-acting agents (Lantus, Levemir) and rapid-acting agents (Lispro, Aspart). Half of the total insulin requirement is administered as a long acting agent QHS, and the other half of the insulin requirement is administered as a rapid acting agent (1/3 with each of the 3 meals).
  4. I will continue to monitor blood glucose testing and adjust insulin regimens as necessary.
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6
Q

How do you assess the fetus in patients with GDM?

A
  1. Antenatal testing is not required in patients with well-controlled GDMA1.
  2. In patients with GDMA2 or poorly-controlled GDM, I recommend antenatal testing starting at 32 weeks gestation with twice-weekly NSTs.
  3. I perform a growth scan at 36 weeks to evaluate for macrosomia and consider fetal growth surveillance every 4 weeks in the 3rd trimester for patients with poorly controlled blood glucose.
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7
Q

How do you counsel patients with GDM about timing of delivery?

A
  1. For patients with well-controlled GDMA1, I perform expectant management up to 40 6/7 weeks.
  2. For patients with well-controlled GDMA2, I recommend delivery between 39 0/7 weeks and 39 6/7 weeks of gestation.
  3. For patients with poorly controlled GDM, I perform delivery between 37 and 38 6/7 weeks gestation.
  4. I discuss a scheduled cesarean delivery for patients with an EFW of 4500 g or greater.
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8
Q

How are patients with GDM managed post-partum?

A
  1. I counsel patients that they are at risk for developing glucose intolerance of T2DM post-partum.
  2. I screen all patients with GDM at 4-12 weeks post-partum with a fasting blood glucose and a 75 g 2-hr GTT. A fasting value > 125 mg/dL or 2-hr value > 199 indicates diabetes mellitus. A fasting value > 100 mg/dL or a 2-hr value > 140 mg/dL indicates impaired glucose tolerance. A fasting value < 100 mg/dL or 2-hr value < 140 gm/dL is normal and it is recommended to rescreen every 1-3 years.
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9
Q

What are indications for early GDM screening?

A

Women who are overweight or obese and have one of the additional following risk factors:

  1. Physical inactivity
  2. 1st degree relative with DM
  3. High risk ethnicity (basically everyone except caucasian)
  4. Prior infant > 4000 g
  5. HTN, HLD, HTG, CVD
  6. Known impaired glucose tolerance, Hgb A1C > 5.6%
  7. Hx GDM
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10
Q

How is pregestational DM diagnosed?

A

Diagnosis of DM in the 1st or early 2nd TM with the following criteria:

  1. Hgb A1C of 6.5% or greater, OR
  2. Fasting glucose > 125 mg/dL, OR
  3. 75-g 2-hr GTT > 200 mg/dL
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11
Q

What are maternal risks associated with pre-gestational DM?

A
  1. Worsening nephropathy –> hypertensive disorders, placental insufficienty, preterm birth
  2. Worsening retinopathy
  3. PEC (especially with co-existing chronic HTN)
  4. Acute MI
  5. DKA (check urine ketones when glucose > 200 mg/dL)
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12
Q

What are fetal risks associated with pre-gestational DM?

A
  1. Congenital anomalies (10%) - cardiac, CNS, skeletal
  2. SAB
  3. Spontaneous preterm labor
  4. Other general risks associated with diabetes in pregnancy

CNS: anencephaly, spina bifida
Skeletal: sacral agenesis

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13
Q

How do you initially evaluate pregnant patients with pre-gestational DM?

A
  1. I evaluate for underlying vasculopathy and retinopathy. This includes performing a retinal exam by an ophthalmologist, EKG, lipid panel, 24-hr urine protein and creatinine clearance, Hgb A1C.
  2. I check TFTs for co-existing thyroid dysfunction.
  3. I initiate folic acid supplementation (400 mcg to 1 gm daily) as early as possible and low-dose aspirin (81 mg daily) before 16 weeks gestation. Both are continued until delivery.
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14
Q

What are delivery considerations for patients with pre-gestational DM?

A
  1. Well-controlled PGDM can be managed until 39-39 6/7 weeks if antenatal testing remains reassuring and no other comorbities.
  2. In patients with vasculopathy, nephropathy, poor glucose control, or prior still birth, I would consider early delivery between 36-39 weeks.
  3. In patients with an EFW > 4500 g, I discuss a scheduled cesarean delivery.
  4. I am aware of and prepared for the increased risk of shoulder dystocia.
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15
Q

How is blood glucose managed during labor and delivery?

A
  1. I advise patients to take their usual dose of intermediate or long-acting insulin at bedtime, and to hold their morning dose of insulin.
  2. Once admitted, I start an infusion of normal saline.
  3. If glucose levels are < 70 mg/dL or active labor begins, I change the infusion from saline to 5% dextrose and deliver at 2.5 mg/kg/min. I check hourly glucose levels with a goal of 100 mg/dL.
  4. If glucose levels exceed 100 mg/dL, I start regular insulin at a rate of 1.25 units/h.
  5. Insulin and glucose infusion rates are adjusted hourly.
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16
Q

What are the strongest predictors of preterm birth?
What are modifiable risk factors of preterm birth?

A
  1. Prior preterm birth
  2. Prior PPROM
  3. Multiple gestations (60% of all twins, 98% of all triplets)
  4. Short cervix (< 25 mm on endovaginal US between 16 and 24 weeks)
  5. Low maternal pre-pregnancy weight
  6. Smoking and substance abuse
  7. Short interpregnancy interval < 18 months
17
Q

For a patient with a singleton pregnancy and NO prior preterm birth, what are the screening and interventions for prevention of preterm birth?

A
  1. Cervical length assessment at time of anatomy sono 18-23 weeks.
  2. If cervical length is < 25 mm, I recommend vaginal progesterone.
  3. There is no indication for 17-OHP.
  4. There is insufficient data to recommend an ultrasound-indicated cerclage, although a cerclage may have benefit if length is < 10 mm.
  5. If the cervix is dilated on exam between 16 and 24 weeks, I consider cerclage placement.
18
Q

For a patient with a singleton pregnancy and a prior spontaneous preterm birth, what are the screening and interventions for prevention of preterm birth?

A
  1. I perform serial cervical length measurements by endovaginal ultrasound beginning at 16 weeks and repeated every 1-4 weeks until 24 weeks gestation.
  2. I offer progesterone supplementation either with 17-OHP or vaginal progesterone.
  3. If the cervical length is < 25 mm and the patient is not on vaginal progesterone, I offer vaginal progesterone vs cerclage. If the patient is already on vaginal progesterone, I offer a cerclage.
  4. If the cervix is dilated on exam between 16 and 24 weeks, I offer cerclage placement.
19
Q

How is prelabor ROM managed at 37+ weeks gestation?

A

I avoid digital cervical exams if possible given the increased risk of infection and use speculum exams instead.

  1. I proceed with delivery via induction of labor with oxytocin or cesarean delivery, as indicated.
  2. I administer GBS prophylaxis as indicated.
  3. I treat intraamniotic infection if present.
  4. If the patient strongly desires, a period of 12-24 hours is reasonable to wait for spontaneous labor prior to initiating induction or proceeding with cesarean delivery.
20
Q

How is prelabor ROM managed at 34-37 weeks?

A

I avoid digital cervical exams if possible given the increased risk of infection and use speculum exams instead.

  1. I assess the patient for intra-amniotic infection and abruption, and if either are present I will move forward with delivery.
  2. If intra-amniotic infection is present, I will treat with antibiotics.
  3. If infection and abruption are not present, I discuss expectant management vs proceeding with delivery as there is no strong evidence either way.
  4. If delivery is expected between 24 hours and 7 days, the patient has not yet received steroids AND THERE IS NO EVIDENCE OF CHORIO, I administer a single course of corticosteroids.
  5. I perform GBS screening and prophylaxis as indicated.

NO LATENCY ANTIBIOTICS (ONLY FOR < 34 WEEKS)

21
Q

How is prelabor ROM managed between 24 and 34 weeks?

A

I avoid digital cervical exams if possible given the increased risk of infection and use speculum exams instead.

  1. I assess for intra-amniotic infection and if present, I treat with antibiotics and proceed with delivery.
  2. If no infection is present, I recommend expectant management.
  3. Given gestational age < 34 weeks, I administer a 7-day course latency antibiotics of IV ampicillin and IV erythromycin followed by oral amoxicillin and erythromycin. This prolongs pregnancy, reduces maternal and neonatal infections, and reduces neonatal morbidity.
  4. I administer a single course of corticosteroids
  5. If < 32 weeks, I administer magnesium sulfate for neuroprotection.
  6. I collect a vaginal-rectal swab for GBS culture and administer GBS prophylaxis as indicated.
22
Q

What is your management of a patient in preterm labor between 24 and 37 weeks?

A
  1. I would rule out any treatable causes including infection, trauma.
  2. I would administer a single course of corticosteroids in patients who are at risk of delivery within the next 7 days. If the patient already received a course of corticosteroids > 14 days prior and is < 34 weeks, I would administer a rescue course of corticosteroids.
  3. I would provide tocolysis only for 48 hours to allow completion of a course of corticosteroids.
  4. I would not use latency antibiotics if membranes are intact.
  5. I would perform GBS testing and administer prophylactic antibiotics as indicated.
  6. If < 32 weeks, I would administer magnesium sulfate for neuroprotection.
23
Q

What are contraindications to tocolysis?

A
  1. IUFD
  2. Lethal fetal anomaly
  3. Non-reassuring fetal status
  4. Severe PEC or eclampsia
  5. Maternal bleeding with hemodynamic instability
  6. Chorioamnionitis
  7. Preterm premature ROM (can consider for transport or steroid administration)
  8. Maternal contraindications to tocolysis
24
Q

What are the low risk thrombophilias and what type of AC do you offer?

A
  1. FVL heterozygote
  2. Prothrombin mutation heterozygote
  3. Protein C
  4. Protein S

No history of VTE: Post-partum prophylaxis only

If history of VTE: Prophylactic AC

25
Q

What are the high risk thrombophilias and what type of AC do you offer?

A
  1. FVL homozygote
  2. Prothrombin mutation heterozygote
  3. Compound FVL/PT heterozygote
  4. Antithrombin III

No history of VTE: Prophylactic AC

History of VTE: Therapeutic AC

26
Q

In pregnancy, who should be screened for thrombophilias?

Who should be tested for Antiphospholipid syndrome?

A

Thrombophilias:

  1. Personal hx of unprovoked VTE
  2. 1st degree relative with: hx of high risk thrombophilia or unprovoked VTE < age 50

Poor fetal outcome is not an indication for thrombophilia screening!

APL syndrome:

  1. History of VTE
  2. Poor pregnancy outcome
27
Q

What are the diagnostic criteria for antiphospholipid syndrome?

A

One laboratory AND one clinical criteria

Laboratory (measured on 2 occasions at least 12 weeks apart):

  1. Lupus anticoagulant: present
  2. Anticardiolipin antibody: high titer > 99%ile
  3. Anti b2-glycoprotein 1 antibody: high titer > 99%ile

Clinical:

History of VTE OR pregnancy morbidity

  1. ≥ 3 unexplained spontaneous consecutive pregnancy losses < 10 weeks
  2. Fetal death > 10 weeks
  3. PEC, severe PEC or uteroplacental insufficiency < 34 weeks
28
Q

How do you treat antepartum patients with APL syndrome?

A
  1. If hx VTE: maintain therapeutic (or start ppx) AC
  2. If no hx of VTE: Start ppx AC + ASA 81 mg
  3. Serial growth ultrasounds
  4. Antenatal testing starting at 32 weeks

Oral boards (3 decks)

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