Obstetrics Flashcards
What should you advise women with high-risk conditions such as pulmonary hypertension, Eisenmenger syndrome, severe valvular disorders, and prior postpartum cardiomyopathy?
Advise them not to get pregnant due to high risk of death
At what point during pregnancy are cardiac complications at the maximum rate?
28-34 weeks; when CO rises most
What cardiac complication can arise in the first 5 months postpartum with no identifiable cause?
Postpartum cardiomyopathy
Should you prescribe ACEi or ARB in pregnancy?
No
What anti-arrhythmic and anti-coagulant are contraindicated in pregnancy?
Amiodarone
Warfarin
In general, are regurgitant or stenotic valvular lesions worse during pregnancy?
Stenotic
What type of anticoagulation is used during pregnancy?
Low molecular weight heparin (LMWH)
*Warfarin crosses placenta and effects fetus; UFH causes osteopenia
A pregnant patient presents to you and upon reviewing history you realize her previous pregnancy was complicated by DVT. What therapy do you recommend and over what time course?
LMWH throughout pregnancy
UFH during labor and delivery
Warfarin for 6 weeks postpartum
What effects does hyperthyroidism during pregnancy have on the fetus?
Fetal growth restriction and stillbirth
What effects does hypothyroidism during pregnancy have on the fetus?
Intellectual deficits and miscarriage
How should dose on levothyroxine be adjusted when hypothyroid patients become pregnant?
Increased by 25-30%
For pregnant patients with symptomatic hyperthyroidism what is the drug of choice? What is never given?
Give beta blockers
Never give radioactive iodine
What is the drug of choice for Graves disease during pregnancy? What effect will it have on the fetus and when will this effect be seen?
Propylthiouracil (PTU) during the 1st trimester (Methimazole during 2nd and 3rd trimester); PTU may cause goiter and hypothyroidism in fetus which appears 7-10 days after birth when drugs effects wear off
What is the initial mgmt of gestational DM?
Diet and light exercise
What is the medication of choice for managing gestational diabetes?
Insulin
*Insulin requirements increase over course of pregnancy but drop once placenta is delivered
If A1C is elevated during the first trimester then what should you do to evaluate the fetus?
US at 18-24 weeks looking for structural anomalies
Fetal Echo at 22-24 weeks to look for cardiac anomalies
Monthly sonograms in diabetic pregnant patients help evaluate what cause of diabetes on the fetus?
Macrosomia or IUGR
In patients on insulin, with previous stillbirths hypertension, or macrosomia what should you do to monitor the fetus every week starting at 32 weeks?
Weekly nonstress test and amniotic fluid index
*Can start NST at 26 weeks if small vessel disease present or poor glycemic control
Caudal regression syndrome is associated with …
Overt DM during pregnancy
Is gestational DM associated with congenitla defects in pregnancy?
No because hyperglycemia is not present during the first trimester when they would have an effect on structural development
A diabetic patient comes in at 39 weeks gestation and you estimate the fetus’ weight as 4000g. What do you do?
Induce labor.
If
A diabetic patient comes in at 40 weeks gestation and you realize her estimated fetal weight is 5000g. What do you do?
Schedule C-section since weight >4500 grams places a considerable risk of shoulder dystocia
In your diabetic pregnant patient in labor how should you monitor blood sugars?
Keep between 80-100mg/dL and give a 5% dextrose in water and insulin drip
After delivery of the placenta what should you do for the diabetic patient?
Turn off insulin drips and monitor with sliding scale insulin since insulin requirements drastically fall with lowering levels of hPL after placenta delivery
How does intrahepatic cholestasis of pregnancy present?
Intractable noctural pruritis on palms and soles of feet without skin findings. 10-100 fold increase in serum bile acids
How is intrahepatic cholestasis of pregnancy treated?
Ursodeoxycholic acid
How are asymptomatic bacteruria and acute cystitis treated during pregnancy?
Treat with oral nitrofurantoin
Alternatives are cephalexin or amoxicillin
What are methods of first trimester abortion and their acceptable time limits?
Most commonly D&C in first 13 weeks;
Medically: oral mifepristone and oral misoprostol in first 63 days of amenorrhea
What is MOA of mifepristone?
Misoprostol?
Mifepristone: progesterone antagonist
Misoprostol: prostaglandin E1
What is the main difference between spontaneous abortion and fetal demise?
Spontaneous abortion: 20wks often p/w loss of fetal movements
What type of abortion?
US: no POC, cervix closed
Complete
What type of abortion?
US: some POC, cervix closed
Incomplete
What type of abortion?
US: POC present, intrauterine bleeding, dilated cervix
Inevitable
What type of abortion?
US: POC present , intrauterine bleeding, no dilation of cervix
Threatened
What type of abortion?
Fetus dead but remain in uterus
Missed
What type of abortion?
Infection of uterus
Septic
Mgmt complete abortion
F/U with B-hCG
Mgmt incomplete abortion
D&C
Mgmt inevitable abortion
Medical induction or D&C
Mgmt threatened abortion
Bed rest
Mgmt missed abortion
Medical induction or D&C
Mgmt septic abortion
D&C and levofloxacin and metronidazole
What is most common cause of spontaneous abortion?
Chromosomal abnormalities of fetus/embryo
In cases of prolonged fetal demise (>2 wks) what is a complication you should fear? What is it due to?
DIC due to release of tissue thromboplastin from dying fetal organs
Most common risk factor of ectopic pregnancy?
PID
When is intrauterine pregnancy normally seen on vaginal US? Abdominal US?
Vaginal US: 5 weeks (B-hCG >1500)
Abdominal US: 6 weeks (B-hCG >6500)
Can you make a complete diagnosis of ectopic pregnancy with US if B-hCG is
No, bc you cannot rule out an intrauterine pregnancy
Repeat B-hCG to see if >1500 and then vaginal US
Mgmt ruptured ectopic pregnancy
Immediate laparotomy and salpingectomy
Mgmt unruptured ectopic pregnancy
Methotrexate or laparoscopy (salpingostomy –> to open fallopian tube)
What should you keep in mind for future potential pregnancies when a women presents with an ectopic?
Give RhoGam if Rh negative
Before vaginal or abdominal cerclage in a pregnant women presenting with cervical insufficiency what should you rule out?
Chorioamnionitis
What are risk factors for cervical insufficiency?
2nd trimester abortion
Cervical laceration during previous delivery
DES exposure
Deep cervical colonization
When can a cerclage be removed in a pregnant patient that had cervical insufficiency?
36-37 weeks after fetal lung maturity
Quantitative cutoffs for IUGR
What are causes of symmetric IUGR?
Aneuploidy
Infection (e.g. TORCH)
Structural anomalies occurring early in development
Decreased placental perfusion often causes what type of IUGR?
Asymmetric
T/F
Asymmetric IUGR normally has decreased abdominal measurements and normal head measurements
True
Quantitative cutoffs for macrosomia
> 4500g
>90-95% for gestational age
What are risk factors for macorsomia?
Gestational DM, overt diabetes, obesity, male fetus, increased weight gain during pregnancy, multiparity
An elective C-section should be scheduled if fetus weight is above what threshold in diabetic and non-diabetic mothers?
> 4500g in diabetic mothers
>5000g in nondiabetic mothers
What can be used to estimate gestational age at 10-13 wks?
Crown-rump length measurements
When are chorionic villous sampling and amniocentesis normally done during pregnancy?
CVS at 12-14 weeks
Amniocentesis past 15 weeks
What is the most common risk factor for premature rupture of membranes?
Ascending infection from lower genital tract
When testing fluid obtained from vaginal speculum exam what labs confirms a premature rupture of membranes?
Nitrazine positive and ferning positive
US will show oligohydramnios
Maternal fever, uterine tenderness, and PROM is how what presents?
Chorioamnionitis
Mgmt chorioamnionitis
Get cervical cultures, start antibiotics, and schedule delivery
In PROM with no infection how do you manage the pregnant patient at 26 weeks gestation?
Hospitalize and give IM betamethasone; get cervical cultures and give prophylactic ampicillin/erythromycin for 7 days
What are the two phases of stage 1 of labor?
Latent: regular uterine contractions but little cervical change
Active: regular uterine contractions with acceleration of cervical change >1-1.5cm/hr
Mgmt of hypotonic contractions in the active phase of stage 1 of labor
Oxytocin
Mgmt of hypertonic contractions in stage 1 of labor with active phase
Morphine sedation
What is the start and end of stage 2 of labor?
Begins: 10cm cervical dilation (full)
Ends: delivery of baby
What is the 3rd stage of labor?
From delivery of baby to delivery of placenta
If the fetal head is engaged but stage 2 of labor is prolonged what could you do to help deliver?
Trial of vaginal forceps or obstetric vacuum
Severe variable accelerations on fetal heart monitor may indicate what serious issue?
Umbilical cord prolapse
What is mgmt of umbilical cord prolapse?
Knee to chest position with elevation of presenting part
Give terbutaline to reduce force of contractions
Immediate C-section
MOA of terbutaline
Beta2 adrenergic agonist which causes myometrial relaxation
What is normal baseline FHR?
110-160 bpm
Are accelerations reassuring? What causes them?
Accelerations are always reassuring as they represent increases in FHR of
What type of declerations begin and end in sync with contractions? What do they indicate?
Early decelerations
Fetal head compression
What type of declerations are abrupt and unrelated to contractions? What do they indicate?
Variable decelerations
Fetal acidosis due to umbilical cord compression
What type of decelerations are gradual and slightly delayed relative to contractions? What do they indicate?
Late decelerations
Fetal acidosis due to uteroplacental insufficiency
Medications can have what effect on FHR?
Beta blockers and agonists may be primary insult causing fetal bradycardia or tachycardia, respectively
What steps should you take when you see nonreassuring fetal rhythms on monitor?
1) any nonhypoxic causes, such as meds?
2) intrauterine resuscitation (dc some meds like oxytocin, NS, O2, change position, vaginal exam, fetal head stim)
3) prep for delivery if doesn’t get better
What is normal fetal pH?
pH > 7.20
Should you use forceps or vacuum assisted delivery if the mother has a small pelvis or the cervix is not fully dilated?
No
What type incision during C-section increases the risk for rupture in subsequent pregnancies?
Classic vertical
What are situations which justify a C-section?
Cephalopelvic disproportion Fetal malpresentation Nonreassuring EFM strip Placenta previa Infection (e.g. HIV or active herpes) Uterine scar (e.g. previous classic incission or fibroid)
What is the most common cause of postpartum bleeding? How is it managed?
Uterine atony
Uterine massage and contracting agents (e.g. oxytocin, carboprost, misoprostol)
You fail to palpate the uterus and you see bleeding, beefy-looking mass in the vaginal vault. Dx? Mgmt?
Uterine inversion (inside out) Replace the uterus and give oxytocin
In women who are breastfeeding how long can they stay off contraceptives due to anovulation?
3 months
When can combined OCPs be restarted postpartum and why?
3 weeks after to reduce risk of DVT in the immediate post-partum period
What is the only form of contraception which can be used immediately after delivery and also while breastfeeding?
Progestin contraception
Endometritis causes a post-partum fever how many days after delivery? What is mgmt?
2-3 days
Multiple antibiotic agents
Septic thrombophlebitis causes post-partum fever how many days after delivery. What is mgmt?
5-6 days
IV heparin for 7-10 days
When does infectious mastitis case a fever post-partum? Mgmt?
7-21 days
PO nafcillin; breast feeding can contine
What are contraindications to breast feeding?
HIV, active TB, HTLV-1, herpes simplex if a lesion on breast
