Obstetrics Flashcards
(44 cards)
Contraindications to TOLAC/VBAC
Prior classical or T-incision, transfundal surgery, prior rupture, history of >2 prior c-sections
*undocumented scar not a contraindication
How do you treat hyperthyroidism in pregnancy? Thyroid storm?
PTU 1st tri, methimazole 2nd/3rd tri
Storm: PTU, iodine, propanolol, steroids
Which conditions are managed w/ prophylactic lovenox during pregnancy?
Factor V homozygous, prothrombin homozygous, ATIII mutation, compound heterozygouse factor V/prothrombin, APLS, hx of prior VTE on OCPs, any prior unexplained VTE
Mneumonic/differential dx for recurrent pregnancy loss
AGE IS IT - anatomic (septate/bicorunate uterus), Genetics (aneuploidy/balanced translocation), Endocrine (hypothyroid, diabetic), Infectious (Toxo, CMV, Listeria), Social hx (smoking/alcohol/caffeine), Immunologic, Thrombophilia (APLS)
AEDs during pregnancy & management considerations
- Pregnancy increases the frequency of seizures by 30-50%
- Increased risk of IUGR, stillbirth, cleft palate, cardiac defects, neural tube defects
- Switch to single agent monotherapy (Keppra)
- Increase folate (4mg) and vitamin D supplementation
What comprises different genetic testing options and what are the sensitivity rates?
- First trimester alone (Nuchal translucency, PAPP-A, HCG) - 80% detection
- Second trimester QUAD screen (HCG, estriol, AFP, inhibin) - 80% detection
- Ultrasound alone (50%)
- Cell free DNA (98%)
- Integrated screen (96%), sequential (>90%)
Compare and contrast omphalocele and gastroschisis
Gastroschisis - R abdominal defect, sporadic inheritance, bowel contents exposed
Omphalocele - midline defect, associated w/ aneuploidy, bowel contents covered w/ sac, associated w/ other abnormalities
Varicella in pregnancy - how do you treat if exposed
When is risk of transmission to baby the highest?
Determine immunity status. If susceptible then - If asymptomatic but positive exposure, can give VZIG as prevention. If symptomatic, high risk of varicella pneumonia and mortality - admit and start IV acyclovir. Greatest risk of transmission to newborn is 5 days before and 2 days after delivery
When do you treat for GBS? How do you treat?
How do you treat if PCN allergic?
- Hx of GBS+ UTI, +GBS culture, Hx of prior infant w/ GBS sepsis or infection
- GBS unknown plus PTL, >18hr ROM, intrapartum fever
- Treat w/ PCN 5mil units, followed by 2.4mil q4hr
- Cefazolin if PCN allergic and mild risk of anaphylaxis
- Clinda if BOTH clinda and erythromycin sensitive
- Vancomycin if clinda or erythro resistant
How do you treat mastitis? What if PCN allergic OR resistant to antibiotics? MRSA positive?
Dicloxacillin 500mg four times daily x 7 days
Erythromycin if PCN allergic
Augmentin if resistant to antibiotics
Bactrim if MRSA positive but then pump and dump
Who meets the criteria for offering cell free DNA?
- Maternal age >=35yo at delivery
- Prior pregnancy with trisomy
- Abnormal maternal serum screening (1st or 2nd tri screening)
- Fetal US findings suggesting of aneuploidy risk
- Maternal or paternal balanced robertsonian translocations involving chromosome 21 or 13
What is the mechanism of action for glyburide and metformin?
Glyburide - increases insulin release from pancreatic beta cells and decreases hepatic glucose production
Metformin - increases peripheral glucose uptake by improving insulin sensitivity, decreases hepatic glucose production
What are the cut offs for the 75g 2-hour glucose tolerance test
Fasting: 100-125 impaired; >126 diabetes
2hr value: 130-199 impaired; >200 diabetes
When do you perform early 1-hr glucose test and when is it performed?
What is an alternative to performing glucose testing if patient cannot handle possible dumping syndrome?
Early testing perform if: prior hx of GDM, impaired glucose tolerance, elevated A1C, hx of prior macrosomic baby, maternal obesity, PCOS, metabolic syndrome, excessive maternal weight gain, 1st deg family hx of diabetes
-Alternative: fasting/post prandial blood sugar levels for 1-2 weeks
Which vitamin/nutrition deficiencies should be screened for in patients with hx of gastric bypass/Roux-en-Y (malabsorptive)
Vitamin D, E, A, K
Folic acid, thiamine, B12*
calcium, iron
What are the weight gain considerations for women who are underweight, normal weight, overweight, obese, and morbidly obese?
Underweight (BMI < 18.5) - 28-40lb Normal (BMI 18.5-24.9) - 25-35lb Overweight (BMI 25-29.9) - 15-25lb Obese (>30) - 11-20lb Morbidly obese (>40) - 15lb
Which fetal anomalies are associated with obesity? (list in order from high to low risk)
NTDs, cardiac defects, cleft defects, anorectal atresia, limb reduction
When should you discontinue and restart anticoagulation before/after a delivery?
Prophylactic dose - discontinue 12hr before scheduled delivery
Therapeutic dose - discontinue 24hr before scheduled delivery
Can restart heparin 4-6hr after vaginal delivery and 6-12hr after c-section
When do you test for APLS? (clinical criteria)
- Fetal death >10wk
- Three or more unexplained consecutive pregnancy losses <10wk
- Early onset severe preeclampsia/IUGR < 34wk
What is rhogam? When do you give it? How is it dosed and how long does it confer protection?
Medication to prevent Rh alloimunization. Shot of 300mcg given routinely at 28wk to Rh negative mothers. Given for other indications such as miscarriage, OB procedures (ECV, CVS, amniocentesis), abdominal trauma, ectopic pregnancy etc. Need to given within 72hr of possible exposure. Effect should last for 12wk
Congenital Toxoplasmosis
First determine if patient is susceptible (IgG/IgM). If US concerns of fetal infection, consider diagnosis by amniotic fluid PCR. Early infection has worse neonatal outcomes, late infection has higher vertical transmission rate. Rx with spiramycin for maternal infection and pyrimethamine/sulfadiazine/folinic acid for fetal infection. US signs show intra-abdominal and intra-cranial calcifications, IUGR and hydrops
Varicella in pregnancy
If mother is exposed - test susceptibility. If susceptible + exposed but asymptomatic = treat with VZIG within 96hr of exposure. If exposed and symptomatic = oral acyclovir. Give IV acyclovir if there is varicella pneummonia.
- Congenital varicella - early pregnancy infection has higher risk of malformations; highest transmission in 2nd trimester
- Neonatal varicella - highest risk of mom develops a rash 5d before or 2d after delivery (treat baby with VZIG and isolate). If baby has symptoms, give acyclovir as well.
How long should a couple wait to conceive after traveling to a Zika endemic area? When do you screen or test for Zika during pregnancy?
Women should wait 2 months, men for 3 months. Screen all women. Test women with positive exposure and symptoms OR positive exposure and concerning US findings (NAAT and IgM). NAAT should be done within a week (7 days of exposure/symptoms), if it has been >1 week then can do IgM (first 12wk of symptoms or exposure)
Which maternal infections is breast feeding acceptable and contraindicated?
Hep B and Hep C - allowed
HIV - contraindicated (up to 15% transmission risk)
