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RC ObGYN 2021 > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

What is most distressing immediate complication of perineal injury?

A

Perineal pain

SOGC 330

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2
Q

What are the reported rates of anal incontinencefollowing primary repair of OASIS range?

A

Between 15-61%. Mean 39%

SOGC 330

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3
Q

Which degree of OASIS does the patient have if her external sphincter is more than 50% torn?

A

3b

SOGC 330

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4
Q

Which of the following will have the highest risk of anal sphincter injury?

  1. Occiput posterior and vacuum delivery
  2. Forceps and mediolateral episiotomy
  3. Large gestational age and vacuum delivery
  4. Midline episiotomy and forceps
A
  1. Midline episiotomy and forceps

SOGC 330

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5
Q

By how much (%) does head control at the time of delivery decrease the risk of anal sphincter injury?

A

50-70%

SOGC 330

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6
Q

What is the NNT of a Cesarean section to prevent one patient with a previous OASIS?

A

2.3
To prevent 1 case of anal incontinence in a women with a previous OASIS, 2.3 elective CS need to be done.

SOGC 330

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7
Q

Is it the internal or external anal sphincter that is most responsible for maintaining anal sphincter tone at rest?

A

Internal anal sphincter
○ 70-80% of resting anal pressure
○ 40% of anal pressure in response to sudden distention
○ 65% of anal pressure in response to constant rectal distention

SOGC 330

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8
Q

Does pregnancy increase or decrease or not affect the levels of the following factors?

  1. Factor VIII
  2. von Willebrand Factor
  3. Factor IX
  4. Factor XI
A
  1. Increase, reaches its maximal peak at 29-35 weeks
  2. Increase, reaches its maximal peak at 29-35 weeks
  3. Unchanged
  4. Unchanged

Returns to normal about 7-10 days after delivery

SOGC 163

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9
Q

What is average yearly number of births to adolescent mothers worldwide?

A

14 million

10% of births worldwide
23% of maternal morbidity and mortality

SOGC 327

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10
Q

Name 9 risk factors for the development of GDM and Type 2 diabetes postpartum.

A
  • Maternal age >35
  • Obesity BMI >30
  • Ethnicity (Aboriginal, African, Asian, Hispanic, south Asian)
  • Family hx of diabetes
  • PCOS
  • Acanthosis nigricans
  • Corticosteroid use
  • Previous pregnancy complicated by GDM
  • Previous macrosomic infant

SOGC 393

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11
Q

According to the SOGC, at how many weeks should screening for GDM be offered?

A

24 to 28 weeks

SOGC 393

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12
Q

What are the abnormal values of the OGTT at fasting for the 2-step approach? 1-hour? and 2-hour?

A

Fasting >=5.3
1-hour >=10.6
2-hour>=9.0

For alternative 1-step approach, values are a bit different:
Fasting >= 5.1
1-hour >= 10.0
2-hour >=8.5

SOGC 393

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13
Q

What are the targets for maternal glycemic control?

A

Fasting <5.3
1-hour 7.8 OR 2-hour 6.7

SOGC 393

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14
Q

In pregnant women who have not yet received screening or diagnostic testing for GDM, how many days after a betamethasone injection can we perform the test?

A

After 7 days

** Note that recommended to do a 1-step 75g OGTT

SOGC 393

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15
Q

Name the contraindications to VBAC. (5)

A
  1. Previous classical incision
  2. Previous inverted T incision or low vertical incision
  3. Previous full-thickness surgery (e.g. myomectomy)
  4. Previous uterine rupture
  5. Patient refusal to TOLAC

SOGC 382

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16
Q

What are some factors that increase the likelihood of VBAC?

A 
Maternal
		○ Age <=30 years old
		○ BMI <30
		○ Caucasian 
	Obstetric
		○ Previous vaginal birth *** Best odds ratio
		○ Previous CS indication not dystocia
		○ Spontaneous labor
		○ Bishop Score >=6 on admission
	Fetal
		○ Birth weight <4000g

SOGC 382

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17
Q

What is the most important predictor for a successful VBAC?

A

Previous vaginal delivery

86.7% instead of 60.9% if they never delivered vaginally

* 63.3% after 0 VBAC
* 87.6% after 1 VBACs
* 90.9% after 2 VBACs
* 90.6% after 3 VBACs
* 91.6% after 4 or more VBACs

SOGC 382

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18
Q

What is the most common finding in women who experience a uterine rupture?

A

Fetal tracing abnormality

SOGC 382

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19
Q

What is the percentage of uterine rupture in a patient who has had
A) 1 previous LTCS?
B) a classical CS?
C) an inter delivery interval of less than 12 months?

A

A) 0.4%
B) 4-9%
C) 4.8%

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20
Q

What is the percent of uterine rupture in a woman who has had 1 previous CS and undergoes
A) induction of labour with oxytocin for a favourable cervix?
B) IOL with PGE2?
C) IOL with misoprostol?

A

A) 1.1%
B) 2%
C) 6%

SOGC 382

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21
Q

What is the incidence of vasa previa in patients with villamentous cord insertions?

A

1 in 50

SOGC 231

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22
Q

Name 4 risk factors for vasa previa.

A

Risk factors for vasa previa
• IVF (1 in 202 instead of 1 in 2200 for non-IVF)
• Second trimester placenta previa
• Bilobed and succenturiate-lobed placentas
• Fetal anomalies (renal tract anomalies, spina bifida, single umbilical artery, exomphalos)

Must be a villamentous cord insertion!

One of these risk factors is present in 89% of vasa previa cases

SOGC 231

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23
Q

What is the recommended delivery management for a pregnancy known for placenta previa?

A

Planned elective CS at 35-36 weeks
Betamethasone at 28-32 weeks of gestation

Antenatal admission is debated

SOGC 231

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24
Q

What is the recommendation for exercise in pregnancy?

A

150 minutes of moderate intensity exercise per week if the patient has no contraindications

SOGC 367

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25
Q

What are the contraindications to exercise in pregnancy?

A

Absolute contraindications to exercise:
• Ruptured membranes
• Premature labour
• Unexplained persistent vaginal bleeding
• Placenta previa after 28 weeks gestation
• Pre-eclampsia
• Incompetent cervix
• Intrauterine growth restriction
• High-order multiple pregnancy (triplets)
• Uncontrolled type 1 diabetes
• Uncontrolled hypertension
• Uncontrolled thyroid disease
• Other serious cardiovascular, respiratory or systemic disorder

Relative contraindications to exercise
	• Recurrent pregnancy loss
	• Gestational hypertension
	• Hx of spontaneous preterm birth
	• Mild/mod cardiovascular or respiratory disease
	• Symptomatic anemia
	• Malnutrition
	• Eating disorder
	• Twin pregnancy after 28th week
  • Other significant medical conditions

SOGC 367

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26
Q

True or false.
Prenatal physical activity is associated with a reduction in odds of GDM, pre-eclampsia, gHTN, prenatal depression and macrosomia WITHOUT increasing odds of adverse outcomes including preterm birth, low birth weight, miscarriage and perinatal mortality

A

True

SOGC 367

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27
Q

Should pelvic floor muscle therapy be recommended in pregnancy to decrease risks of urinary incontinence?

A

Yes it should.

Prenatal PFMT is associated with 50% reduction in prenatal and 35% reduction in postnatal urinary incontinence

SOGC 367

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28
Q

What is the definition of a surgical site infection and what percentage occurs after hospital discharge?

A

SSI is infection of the incision up to 30 days after the surgery.
84% of SSI occurs after discharge from the hospital

SOGC 247

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29
Q

In what 2 situations should another dose of prophylactic antibiotic be administered?

A
  1. Surgery duration > 3 hours
  2. Estimated blood loss > 1.5L

SOGC 247

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30
Q

What is the most important risk factor for postpartum maternal infection?

A

Cesarean section

SOGC 247

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31
Q

What is the recommended antibiotic regiment for 3rd or 4th degree perineal tears?

A

Cefoxitin 1g IV x1 or Cefotetan 1g IV x1

SOGC 247

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32
Q

Penicillin allergy is reported in what percentage of patients? How many of those are actually pen-allergic?

A

10% report an allergy
10% of those are allergic to penicillin

SOGC 247

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32
Q

Penicillin allergy is reported in what percentage of patients? How many of those are actually pen-allergic?

A

10% report an allergy
10% of those are allergic to penicillin

SOGC 247

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33
Q

What is the incidence of maternal alloimmunization?

A

0.4 per 1000 births
1-2% of Rh negative women

SOGC 133

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34
Q

What is the incidence of maternal alloinmunization if Rh negative women did not receive:

1) Postpartum prophylaxis?
2) Antenatal prophylaxis?

A

1) 12-16% of women would become sensitized during the next pregnancy
2) 1.6-1.9% of women would become sensitized

SOGC 133

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35
Q

What is the incidence of maternal alloinmunization if Rh negative women did not receive:

1) Postpartum prophylaxis?
2) Antenatal prophylaxis?

A

1) 12-16% of women would become sensitized during the next pregnancy
2) 1.6-1.9% of women would become sensitized

SOGC 133

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36
Q

How much fetal blood does WinRho 30ug IM x 1 cover?

A

30mL of fetal blood
(Same as 15mL of fetal red blood cells)

SOGC 133

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37
Q

In what scenario does the patient not require a dose of WinRho 300ug?

  1. Rh- mother with Rh+ fetus who received WinRho 2 weeks prior to delivery; KB test 35mL
  2. Rh- mother with ruptured ectopic pregnancy
  3. Rh- mother undergoing amniocentesis
  4. Rh- mother undergoing therapeutic abortion at 8 weeks
A
  1. Rh- mother undergoing therapeutic abortion at 8 weeks

Only WinRho 120ug required as total fetal blood is less than 3mL

SOGC 133

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38
Q

What is the percentage risk of placenta accreta in a patient with a placenta previa, who has had:

1) 1 cesarean section?
2) 2 cesarean sections?
3) 3 cesarean sections?
4) more than 4 cesarean sections?

A

1) 11%
2) 40%
3) 61%
4) 67%

SOGC 361

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39
Q

To prevent risks of neonatal respiratory distress, an elective cesarean section should only be done after what gestational age?

A

39+0 weeks

SOGC 361

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40
Q

What is the most common indication for cesarean section?

A

30% of all CS are for previous cesarean sections

SOGC 382

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41
Q

Name 5 contraindications for TOLAC.

A

Contraindications for TOLAC
• Previous or suspected classical CS
• Previous inverted T or low vertical uterine incision
• Previous uterine rupture
• Previous major uterine reconstruction (e.g full-thickness repair for myomectomy or repair of mullerian anomaly/corneal resection)
• Woman requests elective repeat CS (ERCS) rather than TOLAC

SOGC 382

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42
Q

Name a few factors that increase the chances of a successful VBAC and a few factors that decrease the chances of a successful VBAC. (5 of each)

A 
Factors that improve likelihood of VBAC
	Maternal
		○ Age <=30 years old
		○ BMI <30
		○ Caucasian 
	Obstetric
		○ Previous vaginal birth *** Best odds ratio
		○ Previous CS indication not dystocia
		○ Spontaneous labor
		○ Bishop Score >=6 on admission
	Fetal
		○ Birth weight <4000g
Factors that decrease likelihood of VBAC
	Maternal
		○ Age >= 35 years old
		○ BMI > 30
		○ Preeclampsia
	Obstetrics
		○ Previous CS indication is dystocia
		○ Need for induction of labour requiring cervical ripening
		○ Need for augmentation of labour
	Fetal
		○ Birth weight >4000g
Gestational age >40 weeks

SOGC 382

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43
Q

What is the most independent predictor for succesful VBAC?

A

Previous vaginal delivery
(86.7% vs 60.9%)

VBAC rates increase with increasing number of prior VBACs
	• 63.3% after 0 VBAC
	• 87.6% after 1 VBACs
	• 90.9% after 2 VBACs
	• 90.6% after 3 VBACs
  • 91.6% after 4 or more VBACs

SOGC 382

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44
Q

What is the rate of uterine rupture in patients who have had a previous CS?

A

0.3%

In TOLAC, 4.7 per 1000 or 0.47% vs elective repeat 0.26 per 1000 = 0.026%

SOGC 382

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45
Q

What is the risk of uterine rupture in a patient who has had:

1) a previous classical CS
2) Interdelivery interval <18 months
3) induction of labor
4) use of PGE2
5) use of misoprostol?

A

1) 4 to 9%
2) up to 5%
3) 1.4%
4) 2%
5) 6%

SOGC 382

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46
Q

True or False.

External cephalic version is contraindicated in a women who had a previous CS birth

A

False.
ECV is not contraindicated

SOGC 382

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47
Q

What is the risk of placenta previa after previous cesarean sections?

A

Risk of placenta previa
• 1 prior CS = 1%
• 2 prior CS = 2.6%
• 3 or more prior CS = 3.0%

If patient has 3 or more prior CS AND placenta previa, risk of placenta accreta is 50-67%

SOGC 382

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48
Q

What is the earliest sign of uterine rupture?

A

Abnormal fetal heart tracing
Will typically appear 30 mins prior to rupture

SOGC 382

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49
Q

The risk of congenital anomalies related to long-term diabetic control is:

1) for HgB A1C <7%
2) for HgB A1C 7-9%
3) for HgB A1C 9-11%
4) for HgB A1C >11%

A

1) no increased risk (baseline risk is 2-3 %)
2) 15%
3) 23%
4) 25%

Berghella Obs p. 7

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50
Q

What is the recommended weight gain in the following BMI?

1) <18.5
2) 18.5-24.9
3) 25.0-29.9
4) >= 30

A

1) 12.5-18kg (27-40lbs)
2) 11.5-16kg (25-35lbs)
3) 7.0-11.5kg (15-25lbs)
4) 5-9kg (11-20lbs)

Berghella Obs p. 20

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51
Q

What is the most common birth defect?

A

Structural cardiac anomalies
8/1000 births

If mother has a cardiac anomaly, risk to have a child with anomaly is 5-6%
If father, risk is 2-3%

Second most common birth defects are neural tube defects

Williams Obs p.275

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52
Q

Name 5 risk factors for fetal aneuploidy based on maternal history.

A
  1. Maternal age
  2. Previous pregnancy affected by aneuploidy
  3. Maternal or paternal chromosome rearrangements with increased risk for chromosomal imbalance
  4. Hx of congenital anomalies
  5. Recurrent spontaneous abortions NYD

SOGC 348

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53
Q

What is the cut-off for abnormal nuchal translucency at 11+3 to 13+6 weeks?

A

3.5mm

If higher than 3.5mm, it should be considered a major marker for fetal chromosomal and structural anomalies

SOGC 348

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54
Q

Name two factors that affect the fetal fraction in NIPT screening.

A
  1. Gestational age
    Between 11 and 14 weeks, fetal fraction 10%
    Not recommended before 10-11 weeks
  2. Maternal obesity
    For women >110kg, failure rate of cfDNA >10%
    Possibly due to dilutional effect

SOGC 348

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55
Q

What is the false positive rate of NIPT? Name 5 possible reasons for this.

A 
False positive rate 1%
Reasons:
1. Confined placental mosaicism (CPM) 
2. Maternal aneuploidy 
3. Maternal CNVs (copy number variant) 
4. Maternal malignancy 
5. Co-twin demise

SOGC 348

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56
Q

At how many weeks of gestation can chorionic villus sampling and amniocentesis be performed?

A

CVS 10-13 weeks
Amniocentesis 14-20+ weeks

SOGC 348

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57
Q

Name soft markers that can be seen during second trimester ultrasound suggestive of T21. (5)

A
  1. Thickened nuchal fold
  2. Intracardiac echogenic focus
  3. Echogenic bowel
  4. Ventriculomegaly
  5. Hypoplastic/absent nasal bone

SOGC 348

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58
Q

What is the most common non-obstetrics infection during pregnancy?

A

Pneumonia

Also the third most common cause of indirect obstetric death
Maternal mortality is 10%

SOGC 225

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59
Q

What are the most common fetal complications that arise from maternal pneumonia during pregnancy?

A
  1. Prematurity (most common!)
  2. Preterm labour
  3. IUGR
  4. Neonatal demise
  5. IUFD

SOGC 225

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60
Q

Optimizing glycemic control in GDM has been shown to decrease which outcomes?

A

PET
LGA
shoulder dystocia
C-section rate

SOGC 393

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61
Q

How should GDM screening be performed in a patient with prior bariatric surgery?

A

standard 2-step at 24-28weeks in addition to HbA1c

SOGC 393

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62
Q

When should screening for GDM occur in a patient with risk factors?

A

2-step approach in the 1st half of the pregnancy with repeat 2-step approach at 24-28weeks if initial testing normal.

RFs:

  • age ≥35
  • obesity
  • ethnicity: AA, Asian, Hispanic
  • previous macrocosmic or GDM
  • fam hx of DM
  • PCOS, acanthosis nigricans
  • Corticosteroid use

SOGC 393

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63
Q

When should ultrasound assessment be initiated for patient with GDM?

A

28 weeks, then q3-4 weeks

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64
Q

Fetal surveillance for GDM should begin at 36 weeks and be performed weekly. What tests should be done?

A

NST
NST + AFI
BPP
all correct

SOGC 393

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65
Q

What is the timing for IOL for GDM?

A

38-40 weeks

SOGC 393

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66
Q

What test should be done for postpartum diabetes testing in patient with a history of GDM?

A

75g. (not 50g)

6weeks-6 months postpartum

SOGC 393

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67
Q

What is the incidence of abnormal diabetes testing postpartum for patients with history of GDM?

A

1 in 3

SOGC 393

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68
Q

What is the incidence of diabetes later in life for patients with history of GDM?

A

15-50%

SOGC 393

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69
Q

What are the effects of breastfeeding for 6months in a patient with a history of GDM?

A
  • decrease risk of neonatal hypoglycaemia
    • decrease risk of childhood obesity
    • decrease risk of maternal DM
    • reduce maternal hyperglycaemia

SOGC 393

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70
Q

Patient with GDMA2 received Beta. How should insulin be adjusted?

A
  • Day 1: increase night insulin by 25%
  • Day 2 & 3: increase all insulin by 40%
  • Day4: increase all insulin by 20%
  • Day 5: increase all insulin by 10-20%
  • Day 6-7: taper insulin to pre-beta doses

SOGC 393

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71
Q

Does GDM testing meet criteria of a screening test?

A

No

SOGC 393

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72
Q

Which method of testing for GDM is preferred?

A

1-step or 2-step both acceptable
The Centre need to pick one and be consistent
No method is superior, no RCT done to compare

SOGC 393

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73
Q

What maternal comorbidities are associated with obesity?

A

cardiac, OSA, CKD, DM, DLP, NAFLD, Depression, VTE

SOGC 393

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74
Q

What antenatal complications are associated with obesity?

A 
SAB
RPL
>1 visit for anatomy scan
decreased detection of cfDNA
increase in fetal anomalies
GDM
gHTN, PET

SOGC 391

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75
Q

What neonatal complications are associated with obesity?

A

hypoglycemia, MAS, NICU admission, jaundice, mortality

SOGC 391

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76
Q

What childhood complications are associated with obesity?

A

obesity
cardiovascular
DM

SOGC 391

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77
Q

What fetal anomalies are associated with maternal obesity?

A

NTD, cardiac, omphalocele, anencephaly, cleft palate, anal atresia

SOGC 391

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78
Q

What obstetrical complications are associated with maternal obesity?

A 
increased CS(plan and ER), IOL, failed induction, failed VBAC, shoulder dystocia, failed cfDNA, PTB
increased scans for anatomy (75% BMI 35, 40% BMI 40+), failed cFHRM / need scalp electrode

SOGC 391

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79
Q

What fetal complications are associated with maternal obesity?

A

anomalies*, macrosomia, LGA, IUFD, fetal distress

*= NTD, cardiac, omphalocele, anencephaly, cleft palate, anal atresia

SOGC 391

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80
Q

What investigations should be planned during a prenatal visit of an obese patient?

A 
CBC, ferritin, B12
Creat, LFT, TSH
HbA1c
EKG
Cardiac echo (if HTN ≥5yr)
OSA Screening Questionnaire (Berlin)

SOGC 391

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81
Q

What interval between bariatric surgery and pregnancy should you recommend?

A

24 months

- need to wait 24months after bariatric surgery (<2yr= increased NICU, PTB, SGA)
- patients are at risk of nutritional deficiencies, GI bleed, anemia
- patients are at risk of volvulus, internal herniation, obstruction
- bariatric surgery decreasing PET risk by 50%, HTN by 75%

SOGC 391

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82
Q

At what BMI should you recommend medical treatment of obesity?

A

≥30. or ≥27 with comorbidities.

Orlistat = blocks lipase= prevents dietary fat breakdown
Liraglutide = GLP1 R stimulator = suppresses appetite, reduces gastric emptying

SOGC 391

83
Q

What is the estimated incidence of OSA in the obese pregnant population?

A

15%

SOGC 391

84
Q

What supplements are recommended for the obese pregnant patient?

A
  • screen HB, MCV, ferritin, B12
  • folic acid 400mg (enough in Materna)
  • Calcium carbonate 2500mg (need 1-2g supplement)
  • vit D 400 IU (enough in Materna)
  • ASA if BMI >30 and nulliparous
  • omega3, fish oil, probiotics, mayo-inositol = insufficient evidence

SOGC 391

85
Q

In what circumstances would an obese pregnant patient require ASA supplementation?

A

BMI ≥30 AND one of the following:

  • nulliparous
  • interpregnancy interval ≥10yr
  • socioeconomic factors (AA, low SES)
  • age ≥35
  • previous SGA
  • Fam hx of PET

SOGC 391

86
Q

What are the indications for ASA supplementation?

A

≥1 RF:

  • hx of PET
  • chHTN
  • autoimmune (SLE, APLS)
  • renal disease
  • multifetal gestation
  • DM 1 or 2

≥2 RFs:

  • BMI ≥30
  • nulliparous
  • interpregnancy interval ≥10yr
  • socioeconomic factors (AA, low SES)
  • age ≥35
  • previous SGA
  • Fam hx of PET

SOGC 391

87
Q

What is the nutritional advice for a pregnant obese woman?

A
  • good sleep hygiene
  • ideally nutritionist consultation
  • T1 = 100cal extra (2100), >20wk = 300 cal extra (2400)
    - carbs 40-55% (High quality, min processed)
    - fat 25-30% (monounsaturated ideally); saturated should be 10%
    - protein 60g/day = 20-25% of daily caloric intake
    - Fiber 20-35g/day

SOGC 391

88
Q

What is the weight loss % associated with improved maternal and fetal complication in an obese patient planning pregnancy?

A

5-10%

SOGC 391

89
Q

What are the consequences of excessive weight gain in pregnancy?

A
  • LGA, macrosomia
  • gHTN, PET, DM
  • operative delivery
  • PP weight retention

SOGC 391

90
Q

What is the counselling regarding exercise that you can provide for your obese pregnant patient?

A
  1. Rule out contraindication for exercice/ PARmed-X questionnaire. http://www.csep.ca/cmfiles/publications/parq/parmed-xpreg.pdf
  2. Advice:
    • structured walking
    • start T2 early, 3x/week, 25min, increase 2min per session until 40min per session
    • need to do 11000 steps daily
    • age 20-29: aim HR=100-125; age 30-39: aim HR 100-120
    • avoid vigorous activity, risk of falling, balance loss, abdo trauma

SOGC 391

91
Q

What is the percentage of patients with BMI >40 who complete their anatomy US in 1 sitting?

A

40% for BMI ≥40
75% for BMI ≥35
Most difficult to visualize: face, genitalia, extremities

SOGC 391

92
Q

What are some strategies to improve anatomy US for obese patients?

A
  • vaginal US
  • ask the patient to sit and scan from above umbilicus
  • ask the patient to sit sideways and scan from flank or groin
  • ensure full bladder
  • increase signal-to-noise ratio
  • use the umbilicus as an acoustic window

SOGC 391

93
Q

what is the timing of IOL for BMI ≥40?

A

39 weeks

  • Unfavourable cervix and IOL are more common with obesity
  • Cervidil (PGE2) less likely to achieve Bishop 6, more likely to require multiple doses
  • balloon doesn’t seen to increase risk of failed IOL
  • increased incidence of failed induction (BMI dependant)

SOGC 391

94
Q

What are some theories regarding underlying mechanisms for IUFD in the obese population?

A

underlying HTN
increased risk of anomalies or genetic defects
increased predisposition to infection
supine position (more weight on uterus and IVC)
underlying OSA

SOGC 391

95
Q

What is the recommended pregnancy weight gain for a patient with BMI 37?

A

7kg

Suggested weight gain:

  • underweight (BMI <18.5): 12-18kg
  • normal weight (BMI 18.5-25): 11-16 kg.
  • overweight (BMI 25-30): 7-11 kg
  • obese (BMI ≥30): 7kg

SOGC 2018 obesity guideline

96
Q

What is the WHO classification of obesity?

A 
Based on BMI
class 1: 30-35
class 2: 35-40
class 3: 40+

SOGC 2018 obesity guideline

97
Q

What are some particularities about labour in the obese population?

A
  • longer 1st stage, increased CS 1st stage, dysfunctional labour pattern
  • VE more difficult
  • CFHRM if BMI >35
  • intrauterine pressure catheters are no recommended, but considered
  • decision-to-delivery and decision-to-incision increased by 5 min, still within 30min
  • more augmentation required
  • dystocia: increased
  • failed VBAC increased

SOGC 392

98
Q

What are some considerations about C-section intra-operative and postoperative management in the obese patients?

A

Incision: consider supra umbilical transverse
Increased wound infection, dehiscence; ancef 3g
2 layer closure
No evidence for JP, PICO dressings, prolonged abx
Patients to inspect, keep dry
DVT prophylaxis

SOGC 392

99
Q

Are obese patients candidates for intermittent auscultation in the absence of other risk factors?

A

CFHRM recommended for BMI ≥35

SOGC 392

100
Q

What is the risk of regional anesthetic failure in a patient with BMI >35?

A

Anesthesia

  • greater risk of regional anesthestetic failure (about 10% if BMI >35)
  • more likely to experience hypotension with decels post epidural
  • higher risk of aspiration; more restriction on PO intake

SOGC 392

101
Q

What are some of the aetiologies for decreased breastfeeding in the obese population?

A
  • less likely to initiate BF, initiate BF later, less exclusive BF, shorter duration
    • less latching
    • decreased lactogenesis
    • more CS
    • more separation (bb in NICU)
    • larger breasts

SOGC 392

102
Q

What are the preferred postpartum contraceptive methods in the obese population?

A

45% use contraception at 12mo PP

IUD (hormonal, copper) - acceptable, effective; more challenging insertion
DMPA- safe; less preferred by pt due to weight gain, menstrual irregularities
E2 contraception:
-not given PP due to VTE risk
-need to review other VTE risk factors
-might have less serum drug level
-aim for 20-30ug ethinyl estradiol
Transdermal patch- same as E2
-may have reduced efficiency; can consider if don’t mind failing
Ring - same as normal BMI
HSC tubal occlusion- good; not in Canada
Implants- good, no wait gain; not in Canada

SOGC 392

103
Q

Why is T1 CRL better than LMP at determining GA?

A
  • irregular cycles
  • ovulation time assumed in middle of cycle
  • fertilization time assumed in middle cycle
  • correct recall of LMP
  • off OCP x several months- periods not regular
  • ovulation-to-implantation duration can vary by as much as 11 days, affecting size and growth
  • LMP underestimates EDC by 2-3 days

SOGC 388

104
Q

What is the greatest advantage of GA determined by T1 US rather than LMP?

A

Decreased incidence of IOL for PD.

SOGC 388

105
Q

T1 US dating is chosen rather than LMP when the difference in number of days is greater than ___

A

Tricky question.
0 days.
T1 US dating should always prevail over LMP.

SOGC 388

106
Q

What dating is more accurate than T1 dating?

A

IVF implantation date

SOGC 388

107
Q

What is the earliest T1 US that can be used for dating?

A

7 weeks or CRL ≥10mm.
If two T1 US done, use the earliest.

GS can be used, less reliable when embryo can be identified
CRL has less inter observer variability than GS
YS should not be used for dating; max size 6mm by 10wk

SOGC 388

108
Q

What is the best measure to estimate GA between 12-14 weeks?

A

CRL or BPD

SOGC 388

109
Q

What is the best measure for estimating GA when CRL ≥84mm?

A

BPD

SOGC 388

110
Q

What measurements can be used to estimate GA at the anatomy US?

A

need combination of BPD, HC, FL, AC; no added benefit with extras

- most accurate: HC
- least accurate: AC (breathing, position)
- FL = ethnic variations

SOGC 388

111
Q

What elements should be visualized in order to obtain an accurate estimation of the BPD?

A

plane including CSP, 3rd ventricle, thalami, falx cerebrum, tectorial hiatus

measure outer to inner
SOGC 388

112
Q

What elements should be visualized in order to obtain an accurate estimation of the FL?

A

visualize femoral head, trochanter, condyle;
no epiphysis;

SOGC 388

113
Q

8 week US- if GA better estimated by TA or TV US?

A

TA vs TV = previously increase accuracy with TVUS, now evidence that they are similar if CRL >6wk

SOGC 388

115
Q

What are some advantages of T1 US in addition to dating?

A
  • confirm IUP, multiple gestation;
    - early detection of major anomalies
    - opportunity of NT
    - decreased IOL for PD
    - improved sensitivity for screening
    - better peri-viability dating

SOGC 388

116
Q

What were the findings of the Term Breech Trial?

A

2000, RCT
◦ Low-PNM countries: no difference in PNM; but short term neonatal morbidity 0.4 vs 5% (CS vs breech SVD)
◦ 2yr follow-up: no difference in neurological status;
Limitations: multiple countries including countries with high PNM, context not applicable to Canada; IUGR and macrosomia included- lack of routine US (7/16 perinatal deaths were in IUGR babies); protocol allowed for slow labour progress (0.5cm/hr 1st stage, 3.5h second stage)

SOGC 384

117
Q

Comment on the risk of perinatal mortality, CP, and neurological outcomes in vaginal breech and planned CS

A

CP outcomes same between breech SVD and CS
prenatal mortality low in both, slightly higher with breech SVD (0.8-1.7 vs 0-0.8 per 1000)
long-term neurological outcomes are similar
short-term neurological morbidity worse with breech

SOGC 384

118
Q

What is the role of US for a term planned vaginal breech delivery?

A

◦ type of breech
◦ flexion of head
◦ fetal growth- if no recent US

SOGC 384

119
Q

What are the contraindications to vaginal breech delivery?

A

◦ contraindications to SVD
◦ IUGR
◦ Macrosomia >4000g
◦ Inadequate pelvis (no pelvimetry, but good labour progress= good pelvis)
◦ Hyperextended head
◦ Non-frank/complete breech (footling, cord first)

SOGC 384

120
Q

Comment on the role of synto for breech deliveries for IOL and augmentation.

A

1) IOL not contraindicated, but evidence is limited
2) augmentation with synto is acceptable, but one should have a low threshold for CS if FTP is suspected
3) consider after delivery of the body to assist with head delivery since contractions might slow after body is delivered

SOGC 384

121
Q

What is the maximum duration to go from 5 to 10cm in a vaginal birth delivery?

A

7 hours

in the Term Breech Trial, only 1.4% of patients needed more than 7hours to go from 5 to 10cm. if slower than 5cm, suspect CPD and a difficult breech –> CS

SOGC 384

122
Q

What is the maximum duration of passive 2nd stage of labour for a breech vaginal delivery?

A

90min

SOGC 384

123
Q

What is the maximum duration of active 2nd stage of labour for a breech vaginal delivery?

A

60min

SOGC 384

124
Q

What is the Loveset Manoeuver?

A

assist with deliveries of the arm

SOGC 384

125
Q

What forceps are used for assisting with an entrapped head during a vaginal breech delivery?

A

Piper forceps

SOGC 384

126
Q

What is the Mauriceau-Smellie-Veit manoeuver?

A

Delivery of the fetal head by applying suprapubic pressure and fingers on the baby’s mandible.

SOGC 384

127
Q

What are the maneuvers for a trapped head?

A

Piper forceps
Nitro, salbutamol, GA
Duhnssen’s cervical incision: 2,6, 10 o’clock
symphisiotomy or Zavanelli

SOGC 384

128
Q

What is the biggest risk factors for placenta accreta?

A
  • Previa (OR 292)
  • AMA >35. (OR 4.6)
  • IVF (OR 3.1)
  • CS: 1 prior OR 6.6, 2 prior OR 17.4, 3 prior OR 56
  • minor uterine sx such as HSC, D&C. OR 3.4
  • case reports: myomectomy, UAE, asherman’s

SOGC 383

129
Q

What is the sensitivity and specificity of ultrasound to diagnose placenta accreta?

A

US: SEN 90.7%, SPEC 96.9%
MRI: SEN 94%, SPEC 84%

SOGC 383

130
Q

At what GA should placenta accreta be delivered?

A

34-46wk
Plan for corticosteroids

SOGC 383

131
Q

What multidisciplinary teams should be involved in the prenatal care of placenta accreta?

A 
OB anesthesia
MFM
Designed team (gyn, onc, specific staff) for accreta
Radiology
NICU

SOGC 383

132
Q

In addition to Ancef, what other medication should be given at time of surgical timeout for placenta accreta?

A

TXA
Ancef to be repeated after EBL >1.5L

SOGC 383

133
Q

What incision is preferred for management of placenta accreta?

A

midline
classical uterine incision

SOGC 383

134
Q

What urological arrangements should be made in the context of placenta accreta?

A

3-way catheter
methylene blue available
consider intermittent filling of the bladder

no routine use of cystoscopy, consider having in OR
no routine use of ureteric stents

SOGC 383

135
Q

Which techniques can assist with significantly decreasing blood loss during a caesarean hysterectomy for placenta accreta?

A 
TXA at OR timeout
IIA balloons- evidence is mixed
1 layer uterine closure
do not attempt to remove the placenta 
use of cell salvage
avoid GA

SOGC 383

136
Q

What percentage of patients with placenta accreta spectrum in which conservative management was chosen with placenta left in situ will subsequently require emergency hysterectomy?

A

40%

SOGC 383

137
Q

What is the estimated percentage of recurrence in patients treated conservatively for placenta accreta?

A

15-27%

SOGC 383

138
Q

Which medications are required during the first 24h postpartum after C-hyst for placenta accreta?

A

LMWH

No evidence for routine antibiotics, TXA

SOGC 383

139
Q

How do you manage placenta accreta treated conservatively with placenta left in situ?

A
  • clamp, short cord with absorbable suture, IV abx
  • NPO x12-24h, as possible need for OR
  • devascularization, f-u q week x 4-6wk
  • 40% need hyst, 40% major complications
  • acceptable method of delivery bt is associated with protracted course of recovery and persistent need for hysterectomy

SOGC 383

140
Q

Which document should a patient with placenta percreta carry with her?

A

a patient letter in case of emergency

SOGC 383

141
Q

What is the definition of microcephaly?

A

HC 3 SD below mean

SOGC 380

142
Q

What are the infections causing microcephaly and which one is the most common?

A 
CMV **
Syphillis
Toxoplasmosis
Rubella
Herpes 
HIV
Zika

SOGC 380

143
Q

What are the aetiologies for microcephaly?

A

genetic
infectious (TORCH, HIV, Zika, Syphillis)
exposure (smoking, radiation, alcohol, arsenic, mercury)

SOGC 380

144
Q

Which toxic exposures have been linked to microcephaly?

A 
arsenic
mercury
EtOH
smoking
radiation

SOGC 380

145
Q

What is the required work-up for microcephaly?

A 
TORCH
detailed brain US (3ry care)
fetal MRI
3 generation family tree
parental HC
detailed history: exposure, substance use, comorbidities
genetic consultations
serial US

SOGC 380

146
Q

What percentage of US women who deliver at home consume their placenta

A

1 in 3!

SOGC 378

147
Q

What are the nutritional components of the placenta?

A
  • no heavy metals
  • iron (less than goose liver; more than ground beef)
  • minerals: only trace
  • hormones (estradiol, progesterone)- likely low levels post dehydration

SOGC 378

148
Q

Rats placenta express POEF (placenta opioid enhancing factors). this is associated with which benefits for rats?

A

pain relief
adaptive maternal behaviour

SOGC 378

149
Q

What are potential harms of placentophagy?

A

Lack of standardization of placental processing
Case reports of GBS sepsis / risk of blood born organisms infections
Lack of sterilization

SOGC 378

150
Q

What percentage of the Canadian population is rural according to SOGC?

A

20%

SOGC 379

151
Q

What are the conditions to be met by a community maternity centre?

A

availability of:

  • informed consent decisions
  • obstetrician consult over phone
  • ER OB meds: beta, Mg, adalat, uterotonics
  • access to transport

SOGC 379

152
Q

What is the difference between Emergency and Urgent C-section?

A

Emergency <30min:
cord prolapse
abnormal FHR
abruptio

Urgent <75min
FTP
FTD
atypical FHR

SOGC 379

153
Q

What are the pregnancies that can be delivered in a T1A centre?

A 
1A is basic- cannot do CS.
only 36+ with no issues
37wk minor issues
singletons
no VBAC

SOGC 379

154
Q

What are the additional aspects of care for T4 compared to T3 centres?

A

multidisciplinary/specialized neonatal care (although 3b can have neonatal surgical capacities)
conditions that are life-threatening for mother or baby

SOGC 379

155
Q

Which negative outcomes increase with CS for FTD compared to other CS?

A

PPH
extensions

Future pregnancies:
risk of accreta
risk of cervical insufficiency
risk of PTB <30wk

SOGC 381

156
Q

What are some interventions shown to promote SVD and avoid instrumental delivery?

A 
one-to-one labour support
synto
IA rather than CFHRM for low-risk
manual rotation OP/OT to OA
delayed pushing
extended pushing (3h nulliparous, 2h multiparous)

SOGC 381

157
Q

What are the requirements for AVB?

A 
pain control
empty bladder
position known
mid or outlet station
consent obtained
availability of CS (plan B)
operator skilled

SOGC 381

158
Q

What are some maternal indications for AVB?

A 
cardiac disease NYHA III/IV
Severe respiratory disease
Proliferative retinopathy
Neuro disease (Myasthenia Gravis, Autonomic dysreflexia)
Cerebral AVM

SOGC 381

159
Q

What are some fetal indications for AVB?

A

abnormal FHR
no descent

SOGC 381

160
Q

What are some contraindications for AVB?

A 
suspected fetal coagulopathy or brittle bone disease
mid or high station
unknown position
suspect CPD
no access to CS

not mentioned in guideline, but: HIV, HepB

SOGC 381

161
Q

What are the classifications of stations for AVB?

A 
HIGH = above spines
MID= 0 to +2
LOW = +2 or higher
OUTLET = skull visible at intraoitus without separating labia

SOGC 381

162
Q

What are risk factors for failed AVB?

A

EFW > 4000
BMI >30
OP/OT
MID

SOGC 381

163
Q

What are the maternal risks for AVB? (compare to emergency CS)

A 
lower genital tract injury, OACIS
vaginal hematomas
urinary injury, subsequent incontinence
psychological sequelae
perineal pain

SOGC 381

164
Q

What are the increased risks of CS compared to AVB?

A

PPH
increased LOS
increased neonatal admission

SOGC 381

165
Q

What are the fetal risks of AVB?

A 
shoulder dystocia
intracranial bleed rare 1:1000 (same for vacuum=forcep=CS)
retinal hemorrhage (regardless of mode of delivery including CS but potentially more with AVB)

vacuum: cephalophematoma
forceps: facial abrasion, facial nerve palsy <1%, ocular trauma 2%

SOGC 381

166
Q

What are the steps to take after AVB?

A 
DOCUMENT
DEBRIEF with family
examine neonate: face, head
PVRs if voiding dysfunction suspected
antibiotics if OACIS
LMWH only if other RF

SOGC 381

167
Q

How can STI screen be done for a 24yo sexually active woman?

A

urine NAAT (as good as the culture)
self-collected culture
physician-collected culture (not necessary)

pelvic exam not needed (unless symptoms- then its diagnostic not screening exam. detect PID, TOA)

SOGC 385

168
Q

What physical examination steps have to be taken prior to OCP prescription?

A

only BP measure
(and history)

pelvic exam not needed in an asymptomatic woman

SOGC 385

169
Q

What examination needs to be done prior to HRT prescription?

A

pelvic exam and vulvar/perineum/anus inspection

differentiating between normal ageing and pathology might not be obvious for the patient

examination for vulvar cancer always important since it is the gyn malignancy with biggest delay in diagnosis

SOGC 385

170
Q

What gyn exams should be done after 70yo?

A

providing N Pap tests so far (if not normal or none done recently, do Q3yr x2 negative results)

needs to screen for vulvar cancer with
inspection of vulva/anus/perineum
(frequency of visits for specified)

SOGC 385

171
Q

In addition of cervical cancer, screening should be done for which other gyn malignancy?

A

vulvar

  • biggest delay in diagnosis
  • external inspection of vulva/anus/perineum
  • frequency not specified after 70yo; prior to 70yo, during Pap test screening exams.

SOGC 385

172
Q

Why should you do a speculum exam in woman with T1 bleeding if the US already showed incomplete SAB?

A

1) remove RPOC from cervix to decrease:
- pain
- bleeding
- vagal reaction
2) rule out other causes of PVB

SOGC 385

173
Q

A woman mentions new GI symptoms (eg. severe constipation) during gyn visit. Why should you do a pelvic exam and what should it include?

A

inspection, speculum, bimanual, rectovaginal

reasons:

  • deep infiltrating endo
  • POP
  • gyn malignancy

SOGC 385

174
Q

Which gyn patients should have pelvic exams more frequently than q3yr?

A

previous abnormal tests
symptomatic

immunocompromised
DES exposure history
genetic predisposition (they mention this in the guideline but technically controversial)
personal history of gyn malignancy

SOGC 385

175
Q

What is the preventive role of screening of gono/chlam?

A

prevent:
PID
infertility
chronic pain

SOGC 385

176
Q

Which provinces removed restrictions on physicians attending homebirth?

A

ON and BC

SOGC 372

177
Q

What are the requirements for midwifes doing home births?

A

First of all these patient have to be selected
Ongoing risk assessment
Hospital privilege
Emergency equipemtn
Emergency transport system
Assistant at time of birth (qualified provider)

SOGC 372

178
Q

A meta-analysis of 4 studies in BC and ON including 21900 homebirths vs 23500 hospital births showed what fetal outcomes

A 
No difference in :
neonatal death <28d
perinatal death
APGARS <7 at 5min
NICU admission
severe neonatal morbidity

*all these outcomes are rare

SOGC 372

179
Q

A meta-analysis of 4 studies in BC and ON including 21900 homebirths vs 23500 hospital births showed what maternal outcomes

A

More: SVD (91% vs 85%)

Less:

  • CS, IOL, augmentation, AVB
  • OASIS, episiotomy
  • infection
  • pharmacologic pain relief

SOGC 372

180
Q

What is the incidence of cerebral palsy at 23-27wk?

A

9%

SOGC 376

181
Q

When should you follow Mg levels when Mg is prescribed for neuroprotection?

A

no routine measure unless CKD/AKI
need to measure Creatinine
no need for foley

SOGC 376

182
Q

How does maternal care differ between Mg for PET and Mg for neuroprotection?

A

No routine labs if creatinine is normal
No need for foley
Stop at delivery

SOGC 376

183
Q

What is the mechanism of action of MgSo4?

A
  • cerebral vasodilation
  • reduction in inflammatory cytokines
  • reduction in oxygen free radicals
  • inhibits Ca++ influx into cells

SOGC 376

184
Q

What is the NNT for MgSo4 to prevent one case of Cerebral Palsy at 30wk?

A

50s 28-34wk
30 <28wk

SOGC 376

185
Q

What are the maternal side effects of MgSo4

A 
flushing 70%
pain at IV site
N&amp;V
sweating 25%
hypotension 10%
tachycardia
respiratory depression 2%
pull edema 0.7%

SOGC 376

186
Q

What are the maternal contraindications to MgSO4

A

myasthenia gravis
MgSo4 sensitivity
hepatic coma

SOGC 376

187
Q

What are the effects on immediate NICU care at delivery for babies having received MgSo4?

A

Decreased need for intensive resuscitation

No change for:
need for prolonged ventilation
Apgars <7 at 5min
neonatal hypotonia
need for resuscitation

SOGC 376

188
Q

What is the maternal treatment for suspected MgSo4 toxicity?

A

Calcium gluconate

SOGC 376

189
Q

What are the neurological deficits associated with PTB?

A 
-CP
	◦ motor impairment
	◦ Blindness
	◦ Deafness
	◦ Dev delay
	◦ Cognitive delay
	◦ Poor academic performance
	◦ Behavioural disorder

SOGC 376

190
Q

What is the incidence of PTB <32wk?

A

1.2%

SOGC 376

191
Q

What is the incidence of CP?

A

‣ 2-2.5 per 1000 births

	‣ Umbrella term to describe mov and posture disorders +- epilepsy, cognition, perception, beh problems
	‣ Reliably diagnosed by age 2
	‣ GA-related risk is associated with weight <1500g, white mater injury
	‣ Multiples are at increased risk
	‣ No cure, prevention is key;   Cost+++

SOGC 376

192
Q

What is the benefit of repeating course of MgSo4

A

unclear
no evidence to repeat

SOGC 376

193
Q

What is the benefit of bolus+ maintenance vs only bolus for MgSo4 for neuroprotection?

A

none
suggested to give maintenance in order to maintain same standard as with PET, prevent errors
Also no difference with prolonged use vs only 4h

SOGC 376

194
Q

Why should MgSo4 for neuroprotection and adalat tocolysis given together?

A

as per guidelines:

  • because we should only give MgSo4 if delivery is imminent
  • we cannot give tocolysis if delivery is imminent

can start MgSo4 once adalat stopped
only case reports of neuromuscular blockade
they don’t discuss pulmonary oedema

SOGC 376

195
Q

What is the name of the theory by which progesterone can help reduce risk of spontaneous preterm birth?

A

Csapo theory:
high progesterone levels prevent uterine contractions and low levels facilitate contractions

SOGC 398

196
Q

What are the indications for treatment with progesterone during pregnancy for the prevention of spontaneous preterm birth?

A
  1. History of preterm birth
  2. Short cervix (<= 25mm on TVUS) between 16 and 24 weeks

If women have a hx of cold knife cone, LEEP, uterine anomalies, should not be prophetically treated with progesterone. Only if short cervix on TVUS.

Reduced risk of PTB <34 weeks (OR 0.43, NNT 9)
Reduced risk of PTB <37 weeks (OR 0.51, NNT 7)
Decreased risk of neonatal death (OR 0.41, NNT = 30)

SOGC 398

197
Q

What % of women who have had previous spontaneous preterm birth had short cervix?

A

20%
Alternatively, 30% of women with short cervix have a history of previous preterm birth

SOGC 398

198
Q

What is the dose of progesterone suggested for prevention of preterm birth in singleton pregnancy? In multiple gestation?

A

Progesterone 200mg PV qHS in singletons
Progesterone 200mg PV BID in multiple gestations

SOGC 398

199
Q

TRUE or FALSE.

Vaginal progesterone is as safe and as effective intramuscular progesterone.

A

FALSE.
There is increase risk of adverse neonatal outcomes for IM progesterone

SOGC 398

200
Q

When should progesterone treatment for reduction of spontaneous preterm birth begin? Up to when?

A

Start between 16-24 weeks, up to 34-36 weeks of gestation depending on the case.

SOGC 398

201
Q

Administration of antenatal corticosteroids is recommended in women at high risk of delivery between what gestational age?

A

Between 24 and 34+6 weeks of gestational age, when high risk of delivery within 7 days

SOGC 364

202
Q

In order to reduce risks of neonatal respiratory distress, elective CS should not be performed prior to how many weeks gestation?

A

39+0 weeks of gestation

Alternatively, if booked for CS between 37-38+6 weeks, should not routinely administer corticosteroids

SOGC 364

203
Q

What are the 2 different corticosteroids that have been studied for use in pregnant women and what are their dosages?

A

Dexamethasone 6mg IM q12 hours x 4 doses
Betamethasone 12mg IM q24 hours x 2 doses

SOGC 364 - Table 7

204
Q

TRUE or FALSE.

Once corticosteroid was deemed necessary, the entire first course should always be completed.

A

False.
In cases where the first dose of antenatal corticosteroid therapy has been administered and then reassessment suggests that delivery within the next 7 days unlikely, cancellation of the second dose should be considered

SOGC 364

205
Q

After how long should a rescue course of corticosteroid be considered when patients are at high risk of preterm delivery?

A

After 2 weeks (14 days)

SOGC 364

206
Q

In women who received corticosteroid for lung maturity, screening for gestational diabetes should be delayed by how long?

A

A minimum of 1 week.
Do the 75g OGTT test directly.

SOGC 364

RC ObGYN 2021 (11 decks)

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