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Royal College > Obstetrics Guidelines > Flashcards

Obstetrics Guidelines Flashcards

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1
Q

Benefits of delayed cord clamping in the preterm infant

A

decreased rates of blood transfusion
decreased IVH
decreased sepsis

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2
Q

Benefits of T1 U/S

A 
confirm viability
accurate dating
identification of multiples
determination of twin chorionicity
early detection of major structural anomalies
aneuploidy screening (NT)
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3
Q

Risks associated with large NT

A 
aneuploidy
congenital heart disease
fetal akinesia
structural malformations
single gene d/o (ie. noonan's)
poor pregnancy outcome (ie. IUFD)
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4
Q

What minimum fetal fraction do you need to accurately perform NIPS?

A

> 10%

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5
Q

Factors affecting fetal fraction rates

A

GA
Maternal obesity (inversely related to ff)
Chromosome aneuploidy in placenta or mother

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6
Q

What are LR for each of these soft markers:

  • inc. nuchal fold
  • EICF
  • CPC
  • echogenic bowel
  • mild ventriculomegaly
A 
inc nuchal fold: 17
EICF: 2
CPC: 7 (only T18)
echogenic bowel: 6
mild ventriculomegaly: 9
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7
Q

Increased risks associated with echogenic bowel other than aneuploidy

A
  • CF
  • fetal infection
  • GI malformations
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8
Q

Presence of isolated increased nuchal fold on T2 U/S should not be used to adjust a priori risk for T21 (T/F)

A

False! Only NF would cause to adjust risk, isolated findings of any other soft markers would NOT

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9
Q

Which three Chromosomal abnormalities can you recommend screening for in Ashkanazi jewish pop?

A

Tay Sachs
Canavan Disease
Familial dysautonimia

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10
Q

Disorders associated with low uE3

A 
X-linked ichthyosis
Smith-Lemli-Opitz syndrome
CAH
multiple sulfatase def
Antley-Bixler syndrome
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11
Q

Increased risks in its with GDM

A 
Shoulders
CS
Prematurity
LGA
Preeclampsia
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12
Q

Risk factors for GDM

A 
hx GDM or glucose intolerance
family hx of diabetes
previous macrocosmic baby
px unexplained SB
previous neonatal hypoglycaemia, hypocalcemia, hyperbilirubinemia
AMA
Obesity
Polyhydramnios
Suspected macrosomia
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13
Q

At what GA should you recommend IOL in GDM on insulin? GDM diet controlled?

A

39 weeks

40 weeks

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14
Q

What percentage of patients with GDM are diagnosed with T2DM at their PP GCT?

A

1/3

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15
Q

What volume of fetal blood is covered by a 300mcg dose of WinRho?

A

30mL (15mL fetal RBCs)

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16
Q

List 7 procedures after which you should give Rh prophylaxis

A
  1. SA/TA
  2. Ectopic pregnancy
  3. Molar pregnancy (may be partial)
  4. Amniocentesis
  5. CVS
  6. Cordocentesis
  7. ECV
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17
Q

Incidence of maternal alloimmunization in Canada

A

0.4 per 1000

~1-2% of D-neg women

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18
Q

Anti-D does not cross the placenta (T/F)

A

False. Crosses placenta and binds to fetal RBCs without causing hemolysis, anemia or jaundice

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19
Q

At what GA is D antigen detectable on embryonic RBCs?

A

7+3w GA

?do not need to give WinRho if SA <7weeks

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20
Q

After which GA does the dose of WinRho need to be increased from 120 to 300mcg?

A

12-13 weeks

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21
Q

5 absolute C/I to OVD

A
  1. non-vertex or brow
  2. unengaged head
  3. incomplete cervical dilation
  4. clinical evidence of CPD
  5. fetal coagulopathy
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22
Q

Which of the following is a contraindication to a TOLAC?

a) multiples
b) GDM
c) suspected fetal macrosomia
d) previous myomectomy
e) A+D

A

D only

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23
Q

Contraindications to VBAC

A
  1. px classical, T scar
  2. previous full thickness hysterotomy/myomectomy
  3. previous uterine rupture
  4. C/I to labour
  5. woman requests ERCS
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24
Q

Most common infectious cause of stillbirth

A

Parvovirus B19

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25
Q

Most common etiology of IUFD

A

Placental abruption

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26
Q

two ways to induce contractions during a contraction stress test?

A

nipple stim

oxytocin infusion

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27
Q

what are the components of a modified BPP?

A

NST + AFI (normal if >5cm)

If abN, perform complete BPP

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28
Q

What is the range of a normal SDVP?

A

2-8cm (<2 oligo, >8 poly)

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29
Q

Indications for Uterine Artery Dopplers at 17-22w

A
  1. Previous early-onset GHTN
  2. Hx Placenta abruption
  3. Hx IUGR
  4. Hx Stillbirth
  5. Pre-existing HTN
  6. GHTN
  7. Pre-existing renal disease
  8. T1DM with vascular complications
  9. Abnormal maternal serum screening (hcg or AFP >2.0 MoM)
  10. Low PAPP-A
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30
Q

Obstetrical comorbidities associated with impaired trophoblastic invasion

A

HDP
IUGR
Abruption
IUFD

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31
Q

Four criteria necessary to consider diagnosis of CP

A
  1. Metabolic acidosis in umbilical cord arterial blood (pH <7, BD >12)
  2. Early onset of mod/severe NE in infants born >34 weeks
  3. CP of the spastic or dyskinetic type
  4. Exclusion of other identifiable etiologies
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32
Q

ACOG Criteria for intrapartum asphyxia (5)`

A
  1. sentinel hypoxic event immediately before or during labour
  2. sudden and sustained fetal brady or absent variability in the presence of persistent, late or variable decals, after sentinel event when pattern px normal
  3. Apgars 0-3 beyond 5 mins
  4. onset of multi system organ involvement w/in 72h
  5. early imaging showing evidence of non-focal cerebral abnormality
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33
Q

Area of the brain most likely to be injured during hypoxic even in term infant? preterm?

A

Term: subcortical white matter, cerebral cortex
Preterm: periventricular white matter

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34
Q

benefits of continuous labour support

A 
reduced intrapartum pain meds
reduced regional anesthesia
reduced OVD
reduced C/S
increased SVD
reduced reports of negative experience
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35
Q

Which patient does not require CEFM?

a) epidural
b) IOL w/ oxytocin
c) Healthy multip, GA 42+1
d) VBAC

A

a) epidural

Recommend CEFM with VBAC, IOL, PD >42w, GA <36w

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36
Q

Risks of post-term pregnancy

A 
SB
fetal distress
Labour dystocia
OVD
Macrosomia
Shoulders
Lower Apgar scores
Meconium aspiration
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37
Q

If woman choses expectant management at 41+0, what should you offer for management?

A

NST and AFV bi-weekly until 42w, then recommend IOL

?daily FMC

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38
Q

5 C/I to VBAC

A
  1. Cord presentation, placenta previa
  2. IUGR/Macrosomia (<2500, >4500)
  3. Presentation other than frank or complete breech with flexed or neutral head
  4. clinically inadequate maternal pelvic
  5. Fetal anomaly incompatible with vaginal delivery
39
Q

What are the components of the APGAR score?

A 
Activity (tone)
Pulse
Grimace
Appearance (colour)
Respirations
40
Q

Options for management of an after coming head during vaginal breech delivery

A
  • Pipers forceps
  • Duhrsens incisions
  • symphisiotomy
  • give Nitro or terbutaline
41
Q

What is the recommended weight gain/loss during pregnancy for women with a BMI >40

A

7kg weight gain

42
Q

Which congenital anomalies are increased in obese women?

A

NTD (2fold)
Cardiac
Ventral wall
Orofacial

43
Q

Four features of children born with FASD

A
  1. prenatal exposure to alcohol
  2. growth restriction
  3. Facial dysmorphology
  4. CNS dysfunction
44
Q

4 main causes of IUGR

A
  1. TORCH infections
  2. Aneuploidy
  3. Placental insufficiency
  4. Congenital anomalies
45
Q

What two options for induction are available for term PROM

A
  1. vaginal PGE2 + ocytocin

2. oxytocin

46
Q

How long must you wait before starting oxytocin after cervical ripening with miso? cervidil? prostin gel?

A

4h after miso, 30 mins after removal of cervidil, 6h after gel

47
Q

Which Korotkoff phase should be used to determine DBP

A

V

48
Q

How long do you have to wait for neuraxial anesthesia for patient on UFH? prophylactic LMWH? therapeutic LMWH?

A

4h after last dose of UFH if normal PT
10-12h after last dose of prophylactic LMWH
24h after last dose of therapeutic LMWH

49
Q

What is the best test to diagnose PE in pregnancy?

A 
VQ scan
(Ok to do CTPE)
50
Q

In a woman with clinical suspicion of DVT in pregnancy, what is the follow-up recommended if compression US is negative

A

Repeat within 7 days

51
Q

What is the medical management of VTE in pregnancy

A

Therapeutic LMWH x 3 months, then decrease to prophylactic dose until 6 MONTHS PP

52
Q

What is the management of ovarian vein thrombus in pregnancy? How is it diagnosed?

A

Broad spectrum IV Abx x 48h afebrile
Therapeutic anticoagulant x 1-3 months
CT/MRI

53
Q

Indications for prophylactic thromboprophylaxis in pregnancy (8)

A
  1. hx unprovoked DVT
  2. Hx DVT due to OCP
  3. Hx provoked DVT and low risk thrombophilia
  4. Asympt. homozygous Factor V Leiden
  5. Asympt. homozygous Prothrombin gene mutation
  6. Asymptomatic antithrombin deficiency
  7. Non-OB surgery during pregnancy
  8. Strict antepartum bedrest >7d and BMI >25
54
Q

Most common location for DVT in pregnancy

A

Left leg iliac or femoral vein

55
Q

What is the most common location for an ovarian vein thrombus?

A

Right ovarian vein

56
Q

What is the most common location for VTE in patients with OHSS

A

upper extremity

57
Q

How many days post-conception does the neural tube close?

A

26-28d (3-4th week)

58
Q

What is the rate of recurrence of NTD in a woman using preconceptual folate? without?

A

1%, 3.5%

59
Q

Vaccines C/I in pregnancy

A 
HPV
MMR
Varicella
Polio (unless going to endemic area)
Yellow fever (unless going to endemic area)
60
Q

Obstetrical risks in adolescent pregnancy

A
  1. PTL/PTB
  2. PPROM
  3. congenital anomalies
  4. IUGR
  5. PPD
  6. Stillbirth
  7. NICU admission/neonatal death
61
Q

Advantages of umbilical cord blood stem cell transplantation

A
  1. greater flexibility in HLA matching

2. lower risk of GVHD and graft failure

62
Q

Disadvantages of umbilical cord blood stem cell transplantation

A
  1. limited number of stem cells in cord blood specimen
  2. delayed engraftment (increased risk of bleeding/infection in recipient)
  3. high cost
63
Q

Who is usually the legal custodian of banked umbilical cord blood

A

mother of baby

64
Q

Complications of OASIS

A
  1. anal incontinance (flatal/fecal)
  2. rectovaginal fistula
  3. chronic pain
  4. dysparunea
65
Q

Risk of recurrence of OASIS

A

4-8%

66
Q

What are the subtypes of 3rd degree tears?

A

3a: injury to EAS (<50% thickness torn)
3b: injury to EAS (>50% thickness torn)
3c: both EAS and IAS torn

67
Q

Which is NOT a RF for hyperemesis

a) previous HG
b) female fetus
c) obesity
d) hx of depression

A

c) obesity
LOW maternal BMI is RF

Also mole, multiples, maternal fam hx

68
Q

Which antiemetic is NOT an H1 receptor antagonist?

a) doxylamine
b) metoclopramide
c) diphenhydramine
d) dimenhydrinate

A

b) metoclopramide (Dopamine receptor antagonist)

69
Q

What are fetal risks of ondasetron use for NVP? maternal?

A

fetal: cleft palate, cardiac anomalies
maternal: constipation, bowel obstruction

70
Q

How would you diagnose discordance between twins?

A

AC deff >20mm

EFW diff >20%

71
Q

What is the Quintero staging?

A

Quintero 1: poly/oli sequence, donor bladder visible
Q2: poly/oli sequence, donor bladder not visible
Q3: abnormal dopplers in one/both
Q4: hydrops in recipient
Q5: death of one or both fetuses

72
Q

U/S diagnostic features of mono/mono twin pregnancy

A
  • absence of the dividing membrane
  • single placenta
  • both fetuses same gender
  • adequate AF around each twin
  • both fetuses moving freely in the amniotic cavity
73
Q

In a patient with placenta prevue and one previous C/S, what is the risk of accreta?

A

25%

74
Q

What is the dose of progesterone for prevention of preterm birth in a woman with a hx of PTB? short cx @ 22-26w?

A

100mg PV OD “prophylactic”

200mg PV OD “therapeutic”

75
Q

RFs for vasa previa

A

IVF
placenta previa
bilobed/succenturiate lobe
Fetal anomalies

76
Q

Benefits of Buprenorphine over Methadone for opiate abusers in pregnancy?

A

Less sedating
Less risk of OD
Lower incidence of NAS

77
Q

What one chemotherapy drug is not a C/I to breastfeedign

A

Azathioprine

78
Q

What are the three primary mechanisms associated with hydrops?

A

Fetal anemia
Fetal heart failure
Fetal hypoproteinemia

79
Q

Management of pregnancy, G1, incidental finding of 2cm cx at 22w U/S?
G2T0P1A0L1 @ 22w with 2cm cx and hx of px del at 28w?

A

Progesterone 200mg PV OD

Emergency cerclage

80
Q

Risks of cerclage:

A 
Sepsis
PPROM
PRL
Cervical dystocia
Cervical laceration at delivery
Hemorrhage
81
Q

Reasons to remove cerclage prior to 36-38w

A

Preterm labour
Evidence of sepsis
PPROM (after 48h, give steroids first)

82
Q

MgSO4 for fetal neuroprotection, NNT to prevent one case of CP?
mag sulf for eclampsia prevention, NNT?

A

63, 50

83
Q

What does ALARA stand for?

A

As Low As Reasonably Achievable

84
Q

What 8 soft markers are evaluated on the anatomy scan

A
  1. Nuchal fold
  2. EICF
  3. CPC
  4. Pyelectesis
  5. Ventriculomegaly
  6. Echogenic bowel
  7. SUA
  8. Enlarged cisterna magna
85
Q

When dating pregnancy by U/S for twin gestation, which twin should you use to calculate GA?

A

Larger twin to avoid missing IUGR

86
Q

What U/S characteristics can you use in T2 to determine chorionicity/amnionicity

A
  1. Fetal genitalia
  2. placental number
  3. chorionic peak sign
  4. membrane thickness
87
Q

Most common congenital malformations in twin pregnancies?

A

Cardiac, neural tube/brain, facial clefts, GI, anterior wall defects

88
Q

If a woman’s viral load is low and CD4 count is high pre-pregnancy, she does not have to start cART in pregnancy (T/F)

A

False. All pregnant women should be on cART regardless of viral load and CD4 count

89
Q

Is there a risk of neonatal HSV if a woman has a remote history of HSV but no outbreaks in pregnancy and no lesions at the time of delivery?

A

Yes, 1% risk of asymptomatic shedding

90
Q

How would you manage a woman with hx of HSV, no lesions, PPROM but not in labour?

A

Start suppressive therapy until delivery

91
Q

What is the most important risk factor for maternal transmission of Hepatitis B

A

HBV DNA levels

92
Q

What two treatments would you give to a neonate born to a mother with Hep B?

A

Hep B vaccine (first dose), HBIG within 12h

93
Q

When does the neural tube close? Embryonic age and GA

A

3rd/4th week embryonic age (21-29d)

5-6w GA

94
Q

The majority of NTDs are associated with known syndromes/malformations

A

False. 70% of NTDs are isolated

Royal College (8 decks)

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