Pregnancy

Question 1

Fertilized egg journey

Answer 1

Fertilized egg moves through fallopian tube over 2 days
At day 3 it reaches the uterus
Cell division cont for another 2-3 days before implantation
At day 6 the cell mass is called blastocyst and implantation begins
By day 10 post fertilization: blastocyst is implanted under the endometrial surface and receive nutrition from maternal blood
— 3weeks after fertilization it’s called an embryo
* hcg is detected 8-9 days after ovulation in maternal urine
**embryonic stage is from week 2 until week 8 post fertilization
*** after week 8 it’s called a Fetus until delivery ~40weeks
Most body structures are formed during embryonic stage and cont to mature and grow in the fetal period

Week2-8 embryonic stage; forming of body structures
Week 8-40 fetal period; maturation and growth of structures

Question 2

Gravidity, parity

Answer 2

Gravidity: number of times that woman has been pregnant
Parity; number of pregnancies exceeding 20 weeks of gestation a) term b) preterm c) abortion d) number of living children

Question 3

How to calculate delivery date?

Answer 3

Add 7 days to the first day of last menstrual period
And subtract 3 months
For ex if the first day of last menstrual period was 7/5
We add 7 then 14/5 and subtract 3 months, thus due date is 14/2

Question 4

Gestational age

Answer 4

Is the age of embryo/ fetus since the first day of last menstrual period ( 2 weeks before fertilization)

Question 5

Early symptoms of pregnancy

Answer 5

Is fatigue and increase frequency of urination
Followed by nausea and vomiting after first- second missed menstrual period
N& v resolve at 14-16 weeks of gestation

Question 6

Fetal movement can be felt at?

Answer 6

Week 14-20 (3.5 to 5 months)

Question 7

Pharmacokinetic changes during pregnancy

Answer 7

Maternal plasma volume, cardiac output, GFR all increase by 30-50% , thus lowering the conc of renally excreted drugs , altering the vd
Albumin conc is decreased ( due to dilution and edema) thus increase vd of albumin bound drugs
At the same time the kidneys and liver are highly active in pregnancy thus eliminate the unbound drugs; thus the net change in conc is minimal
Hepatic perfusion is increased; more extraction of drugs
Activity of metabolic enzymes; vary: some increase (cyp450,3A4, 2C9) and some decrease (1A2)
** N&V and delayed gastric emptying affect the absorption of drugs
—HCL secretion Varies, But gastric is increased thus more acidic media which may affect absorption of drugs

Question 8

Drugs that Transfer through placenta properties;

Answer 8

1.molecular weight < 500 dalton readily cross the placenta
While 600-1000 da cross more slowly
>1000 dalton don’t cross like insulin & heparin
2. Lipophilic drugs (opioids, antibiotic) cross the placenta more than hydrophilic
3. Protein binding; we should avoid highly protein bound drugs because the conc of maternal albumin is decreased while the fetus albumin increases; thus highly pb drugs may transfer to the fetus
4.fetal ph is slightly more acidic than maternal ph; so weak basic tend to pass the placenta and be ionized in fetal circulation and will be trapped there ; so we should avoid basic drugs (basic antibiotics for ex)

So Avoid low mwt, highly Lipophilic, highly protein bound, basic drugs in pregnancy

Question 9

Teratogenicity & fetus age

Answer 9

In the first 2 weeks the Teratogen result in all or none Phenomenon; we either loss the embryo or no effect happens
The embryonic stage (week2-8) in which organogenesis occur: exposure to a teratogen result in structural anomalies
After week 8 in fetal stage; exposure to a teratogen result in growth retardation, CNS abnormalities or death

Question 10

Example of Teratogenic meds during organogenesis stage

Answer 10

Chemotherapy (methotrexate, cyclophosphamide, sex hormones (androgens, progestational drugs , lithium , retinoids, thalidomide, some anti epileptic drugs & coumarin derivatives

Ex phenobarbital cause teratogenicity in 1st trimester & bleeding in third trimester
Danasol androgenic medication that cause male like characteristics in female fetus
Sulfonamides cause hemolysis in fetus

Question 11

Example of teratogenic drugs during 2nd and 3rd trimester

Answer 11

NSAIDS, tetracycline derivatives

NSAIDs cause premature closure in the ductus arterioles

Question 12

Neural tube defects

Answer 12

Are caused by use of certain anti epileptic drugs, & by obesity and other factors
Folic acid 0,4-.8 mg supplements in woman at reproductive age reduce NTD
*alcohol is associated with birth defects

Question 13

Constipation in pregnancy

Answer 13

Start with dietary fiber intake,fluids.sits of baths , moderate physical activity
2. Laxatives, supplemental fibers, stool softeners can be used
A) Bulk forming laxatives (psyllium , polymethylcellulose, polycarbophil) are safe as they aren’t absorbed
B) osmotic laxatives (polyethylene glycol, laculose, sorbitol) are safe with PEG preferred agent
C) stimulant senna and bisacodyl are also used (bisacodyl for short term only)

D) Castor oil and mineral oil are contraindicated because they stimulate contractions and impair absorption of fat soluble vitamins.
E) magnesium and sodium should be avoided due to electrolyte imbalance effect.

Question 14

Hemorrhoids in pregnancy

Answer 14

Topical anesthetic, skin protectants, astringents ( ex witch hazel ) can be used for anal irritation and pain
Hydrocortisone may be reduce inflammation and pruritis.

Question 15

Gastroesophageal reflux disease GERD in pregnancy

Answer 15

Lifestyle and dietary modifications; small frequent meals, avoid alcohol and tobacco, avoid eating before bedtime, elevation of head of the bed

2. Antacids ( mg, Al, Ca, preparations or sucralfate are acceptable however; sodium bicarbonate, mg trisilicate, large AL doses should be avoided; electrolyte imbalance
3. H2 blockers ; ranitidine and cimetidine in women unresponsive to lifestyle changes and antacids
4. Ppi; omeprazole is reserved for women unresponsive to h2 blockers bcz more clinical data is available for h2 blockers

Question 16

Nausea and vomiting in pregnancy

Answer 16

Begin between 4-6 weeks and resolve within 16-20
Ifestyle; eat small frequent, bland meals, avoid fatty and spicy meals
Pressure at acupressupoint p6 on the volatile aspect of the wrist
Ginger is effective
Medications may be used; pyridoxine vitb6 alone or in combination with doxylamine
Or antihistamine-1 agents+ phenothiazines can also be sued as first line but cause sedation
2nd line is metoclopramide (due to extra pyramidal effects dystopia and sedation
Ondansetron : conflicted data

Question 17

Hyperemesis gravidarum

Answer 17

Unrelenting vomiting causing weight loss >5% of pre-pregnancy weight , dehydration and electrolyte imbalance and ketonuria
May be treated with corticosteroids but after first trimester due to risk of oral clefts

Question 18

Overt diabetes readings

Answer 18

If A1C > 6.5
Or fasting bg >126
Or 2 hrs after giving OGTT > 200
Or random > 200 in pt with hyperglycemic crisis or classic hyperglycemia symptoms

Question 19

In which trimester GDM occur?When we should screen for gestational dm?

Answer 19

It mainly develops in the second and third trimester
And overt dm should be excluded in the first prenatal visit, to be sure if in 2nd trimester dm developed its gestational dm not overt
— screening for GDM should occur at week 24-28 using one step 75 g OCTT or 2 steps 50 g 1 hr glucose challenge test followed by 100 g, 3 hr OGTT

Question 20

Diagnosis for GDM

Answer 20

in one step test we give 75 g OGTT if one of the following readings was found, then it’s GDM
Fasting bg >92<
1 hr bg > 180
2 hrs > 153

Or in two step test
 we give 50 g OGTT if the reading after 1 hr was > 130 we proceed to step 2
And give 100 g OGTT 
IF two or more of the following readings was met, the. It’s GDM 
FATSONG > 95
1 hr > 180
2 hrs > 155
3 hrs > 140

Question 21

Treatment of GDM

Answer 21

Lifestyle modification, exercise, bg monitoring 4 times daily
If didn’t work; initiate drug therapy
Drug therapy insulin > metformin > glyburide
Both metformin and glyburide cross the placenta
Screen with 2 hr OGTT 6 weeks postpartum is recommended for all women with GDM

Question 22

Glycemic control goal during pregnancy

Answer 22

Fasting <95
1 hr postprandial <140
2 hr postprandial <120

Question 23

Htn disorders of pregnancy

Answer 23

Chronic HTN ( developed before 20 weeks of gestation , or preexisting htn )
Preeclampsia ( htn + proteinuria)
Htn superimposed by preeclampsia
Gestational HTN ( htn without proteinuria developed after 20 weeks of gestation

Question 24

Bp reading to diagnose HTN and proteinuria readings

Answer 24

> 140/90 is mild non severe HTN
160/110 is severe HTN
we start treatment in >= 160/105
If no end organ damage and bp is less than 160 and d bp is less than 105 tx is not suggested
Goal of tx is to maintain bp between 120-160 mmHg and d bp between 80 and 105

Question 25

Preeclampsia definition, complications, diagnosis

Answer 25

Multisystem syndrome that complicate pregnancy; renal failure, maternal morbidity/mortality, preterm delivery, intrauterine growth restriction
High bp and proteinuria >300 mg /24 hrs
Or protein / cr >300
If no proteinuria, severe preeclampsia may include thrombocytopenia, srCr >1.1 or double the baseline, elevated Liver transaminases at least twice the upper limit or cerebral or visual symptoms

Question 26

High and moderate risk factors for preeclampsia and prophylaxis for these pts

Answer 26

History of preeclampsia in prior pregnancy, dm , chronic HTN, renal disease, anti phospholipid antibodies, underlying medical condition

Other moderate risks; null parity,multiple gestation, obesity b,I >35 , family history, maternal age > 40 , black ethnicity

low dose aspirin 60-81 beginning between 12-28 weeks in women with one high risk factor or 2 moderate factors reduce the incidence of severe preeclampsia and fetal growth restriction

Supplementation with vitamin D and calcium is recommended to decrease the risk of preeclampsia

Question 27

The only cure for preeclampsia is ?

Answer 27

The delivery of placenta

Question 28

Eclampsia

Answer 28

Occurrence of tonic clinic seizures superimposed on preeclampsia, it’s a medical emergency that can occur antepartum, intrapartum , postpartum
Usually prceeded by headache and visual changes
Treatment is delivery Magnesium sulfate may decrease risk of progression to eclampsia by 50% and it’s recommended to treat eclampsia seizures 4-6 g iv over 15-20 min followed by 2g/hr cont infusion
During labor and 12-24 hrs postpartum

Question 29

Gestational transient thyrotoxicosis

Answer 29

Is often associated with hyperemesis gravidum
GTT usually resolved by week 20 of gestation,bcz production of hCG declines an no need for anti thyroid

No need for antithyroid in GTT
postpartum thyroiditis , we can treat symptoms only by bb propranolol 10-20 mg daily prn

Question 30

Most common cause for maternal death is:

Answer 30

Thromboembolism

Risk of VTE in pregnancy is increased by fivefold to tenfold and 15-35 fold 6weeks postpartum

Question 31

Treatment of thromboembolism

Answer 31

LMWH IS recommended throughly pregnancy and 6 weeks after delivery
The minimum total duration shouldn’t be less than 3 months

Question 32

If severe heparin induced thrombocytopenia happened, what agents should we give?

Answer 32

Fonaparinux, injectable direct thrombin inhibitors (lepirudin and bivalirudin )

Question 33

Women with mechanical heart valve and warfarin

Answer 33

Warfarin is ci in pregnancy due to its teratogenic effect( nasal hyperplasia, stippled epiphyses, Abscene of corpus callosum, eye abnormalities, microcephalic, fetal bleeding, and demise) except in women with mechanical heart Valves
1. Women who are controlled at doses <5 mg can cont to take warfarin even in first trimester
If dose of warfarin is >5 mg, switch to LMWH OR UFH every 12 hrs and adjust dose based on anti factors a at 4 hrs of .08-1.2 u/ml
2. In the second trimester w can either go back to warfarin or cont on LMWH
3. Near delivery at week 36 warfarin should be dc and therapy with heparin should be initiated until delivery.

Question 34

Uti common pathogens + secreening

Answer 34

Klebseilla, enterobacter, E. coli, gabs
May be symptomatic (cystitis and pyelonephritis)or asymptomatic (bacteruria)
Both should be treated in pregnancy
Screening should occur early in pregnancy up to 16 week gestation by:: urine culture (not dipstick )

Duration of treatment for bacteruria and cystitis is 3-7 days
While for pyelonephritis is 7-14 days
Agents to be used: 1.nitrofurantoin first line but can’t be used in pts with G6pd deficiency after week 37
2. B lactams can be used but resistance is a concern
3.TMP-smx is ci in first trimester due to cardiovascular anomalies
4.FQs are ci due to impaired cartilage development and tetracyclines are ci due to teeth discoloration if given after 5 months of gestation

***In pyelonephritis woman should be hospitalized and given 2nd -3rd gen cephalosporins parenteral: cefuroxime and ceftriaxone, ampicillin plus gentamicin, or ampicillin/sulbactam
If afebrile for 48 hrs=> switch to oral

^^ in pyelonephritis; nitrofurantoin shouldn’t t be given because it can’t reach adequate conc outside the urine

Question 35

Sexually transmitted infections screening

Answer 35

In first prenatal visit; HIV, hepatitis B and syphilis should be screened

Question 36

Migraine and pregnancy

Answer 36

More than 50% of pregnant women experience symptoms improvement during pregnancy because migraines are usually associated with estrogens fluctuations and in pregnancy estrogen level is maintained

Question 37

Treatment of migraine and tension headache in pregnancy

Answer 37

Tension headaches: Acetaminophen is safe
Ibuprofen should be avoided in first trimester due to risk of spontaneous abortion and third trimester due to risk of premature closure of ductus arteriosus
Aspirin not recommended
Opioids rarely used in tension headaches
**in migraine;
Acetaminophen and ibuprofen
Opioid but contribute to migraine associated nausea and can cause neonatal withdrawal if used near end of pregnancy
For unresponsive migraines; Tristan’s may be used (sumatriptan is the Tristan of choice for migraines in pregnancy)

Ergotamine and dihydroergotamine are CONTRAINDICATED bcz they affect uterine tone

Question 38

For migraine associated nausea we use?

Answer 38

Promethazine, porchlorperazine, and metoclopramide

Question 39

Migraine prophylaxis

Answer 39

Dietary supp; riboflavin, coenzyme Q10, pyridoxine

Medications; propranolol lowest effective dose agent of choice
Alternatives; TCA; amitriptyline and nortriptyline preferred over ssri and Snri

Question 40

Asthma and pregnancy

Answer 40

Step1 Saba (albuterol)
Step2 albuterol + ICS or a labs
budesonide is the preferred ICS
alternatives; cromolyn, and leukotirene receptor antagonist and theophylline (more toxic)
Systemic CS recommended in severe disease only

Question 41

Allergic rhinitis and pregnancy

Answer 41

Due to nasal congestion can be caused by pregnancy bcz of vascular engorgement in the nasal passages and hormonal effects on mucus secretions
As in non pregnancy avoid allergens, use immunotherapy, or pharmacotherapy

Oral antihistamines (chlorphenamine,diphenhydramine, hydroxyzine) and leukotriene receptor antagonists as well as intra nasal antihistamines decongestants 
Intra nasal Cromones and ICS (budesonide, beclo ethasone) can be used 

If unresponsive; use oral CS or inhaled ipratropium

Question 42

Epilepsy and pregnancy

Answer 42

• seizure frequency doesn’t change for most pregnant women with epilepsy (if she was stable most probably will remain stable)
• seizure relapse is most common in the first few days postpartum

changes in maternal hormones , sleep deprivation and medication adherence problems due to perceived teratogenic risks are main factors that may lead to increased seizure frequency
Also change in Pharmacokinetics in maternal blood may affect the conc of the anti epileptic medications (vd increase, hypoalbuminemia, increase hepatic metabolism and renal clearance ): so dose adjustment may be Needed in pregnancy.

-risk of tonic clinic seizures are more than the risk associated with the anti epileptics

Question 43

Anti epileptics during pregnancy, which are ci and which can be used

Answer 43

Valporic acid should be avoided due to dose related malformations as neural tube defects, facial c,efts,cognitive teratogenicity
- phenobarbital should be avoided if possible due to cardiac malformation and cleft palates

• topiramate and zonisamide; low birth weight and length
• ** ALL women taking anti epileptics should be on folic acid 4-5 mg daily before pregnancy and continue through first trimester and preferably through entire pregnancy

Safest to use; 
Levetiracetam (used in Jordan)
Carbamazepine 
Lamotrigine
Phenytoin ( but may cause cleft palates)

Lower risk than valporic acid
Gabapentin, oxacarbazepine,zonisamide

Great risk; phenobarbital,topiramate, valporic acid .

Question 44

Chronic HTN In pregnancy

Answer 44

Physiologic decrease in bp occurs in the first trimester and reach the lowest in week 16-18
Treatment when bp is >160/105
Tx includes ; parenteral labetalol (preferred) land hydralazine
Others; oral nifedipine
***If proteinuria; magnesium sulfate
Refractory htn: nitroprusside, diazoxide, nitroglycerin

Question 45

Hypothyroidism cause and treatment

Answer 45

caused by hashimoto, iodine deficiency, thyroidectomy
If untreated cause; preeclampsia, premature birth, growth restriction, miscarriage, impaired neurological fx
Starting dose; Give levothyroxine 0.1 mg to get TSH 0.1-2.5 in first trimester,,, 0.2-3 in second trimester,,, and 0.3-3 in third trimester

Women already on levothyroxine before pregnancy may need to increase the dose.

Measure TSH every 4-6 weeks to titrate dose

Question 46

Hyperthyroidism in pregnancy cause , complications and tx

Answer 46

Is due to Graves’ disease mainly 
Cause fetal death, growth restriction, low birth weight, preeclampsia 
Tx (thiomides) 
In the first trimester us PTU 
In second and third use Methimazole 

***PTU has hepatotoxicity effect
Methimazole has embryopathy effect

Question 47

Depression in pregnancy tx

Answer 47

Paroxetine: possible cardiac malformation try to avoid
Ssri/ snri ; not major teratogens but may be associated with persistent pulmonary htn in newborn and neonatal adaptation syndrome ( cardiac, respiratory, neuron GI, metabolic complications in neonate due to withdrawal of drug after delivery or due to drug toxicity but still not confirmed

TCA ; not major teratogen ,but also neonatal withdrawal syndrome when used late in pregnancy

Diazepam; oral cleft not confirmed in meta analysis

Benzodiazepines; in third trimester cause sedation and withdrawal symptoms in neonates; floppy baby syndrome ( hypothermia, poor muscle toon, feeding difficulties, poor temp adaptation

Question 48

Bipolar in pregnancy

Answer 48

Lithium ; no longer considered a major teratogen but monitoring on serum conc, renal and thyroid FX is a must .
Side effects; lethargy, cyanosis, hypothermia, hypotonia, ECG changes

Others; carbamazepine and Lamotrigine

Question 49

Schizophrenia in pregnancy tx

Answer 49

Typical Or atypical antipsychotics; not adequate studies but typical has minimum toxic or teratogenic potential
Clorpromazne, haloperidol and perphenazine have long history of use without teratogenic effects

Atypical has lower side effects

Question 50

Pre term labor; time, risk factors, indicators, can it be predicted, prevented?

Answer 50

Occur in week 20-37 of gestation; when changes in cervical dilation+- effacement happen with regular uterine contractions or contractions + dilation > 2cm
Risk factor; smoking, illicit drugs, age <18 or > 35
, history, infection, multiple pregnancy, poverty

No adequate test available for monitoring, or prevention

Indicator; presence of fetal fibronectin in cervicovaginal secretions indicate a high risk for preterm birth
And cervix shortening is also another indicator
But both can’t help in preventing the preterm labor

Bed rest and hydrated is not recommended and don’t decrease risk of preterm labor; in contrast they increase risk of VTE, bone demineralization, deconditioning so not recommended

Question 51

Tocolytic therapy; definition, purposes, when to use / not use

Answer 51

To delay the labor maixmum one week to prepare the mother and the fetus for delivery
For ex to give corticosteroids for lung maturation in preterm fetus
Or to transfer the mother to a facility equipped to deal with high risk deliveries
Or prolongation of pregnancy when there is self limiting condition that caused labor as pyelonephritis or surgery

Wont be beneficial if given after 34 weeks
Not given in; previability (viable~20 weeks)
Intrauterine Fetal death,distress
Intrauterine infection, severe preeclampsia

Question 52

Tocolytics examples, duration of action

Answer 52

B agonist (terbutaline, ritodrine ) , magnesium ccbs, prostaglandins inhibitors (NSAIDs)
NSAIDs and ccbs are preferred
Delay labor for 48 hrs to 1 week

• b agonist has more maternal side effects ( arrhythmia, hyperkalemia, hyperglycemia,hypotension, pulmonary edema )
• mg sulfate unsupported by evidence but used mainly for neuroprotection ( cerebral palsy)
• ccbs: nifedipine fewer side effects than b agonist and mg sulfate, on,y concern is hypotension and change in uteroplacental blood flow
  -NSAIDs mainly indomethacin oral or rectally
  Benefit; can be used in concomitant with mg sulfate when both neuroprotection and tocolysis is needed because using mg sulfate with ccbs or b agonist increase risk of hypotension; this doesn’t happen with NSAIDs

Question 53

Drugs should be given in preterm labor: antibiotics ?

Answer 53

infection is a potential cause for preterm labor
BUT antibiotics administration is not recommended however if the pt experienced preterm premature rupture of membranes before 34 weeks od gestation;
Prophylactic antibiotics should be given
—7 day course of broad spectrum antibiotics should be used
Regimen; ampicillin 2g iv q6 hrs plus erythromycin 250 mg iv q 6hrs for 48 hrs
followed by amoxicillin 250 mg po q hrs and then erythromycin 333 mg po q 8 hrs

Question 54

Drugs should be given in preterm labor: progesterone ?

Answer 54

Used to prevent recurrent spontaneous preterm delivery in sing,Eaton pregnancies

Role? ; Diminish cervical ripening ( softening of the cerivx is necessary for cervical dilation before birth) , reduce uterine wall contractility, modulate inflammation
Regimen: IM alpha hydroxyprogesterone weekly 250 mg starting from weeks 16-24 cont through week 36 in women with a previous spontaneous preterm birth

Question 55

Drugs should be given in preterm labor: corticosteroids?

Answer 55

Antenatal cs for fetal lung maturation to prevent respiratory distress, necrotizing enterocolitis ,intraventricular hemorrhage, deaths in infants
Regimen; betamethasone 12 mg IM every 24 hrs for 2 doses
Or dexamethasone 6 mg IM every 12 hrs for four doses to pregnant woman between 24-34 weeks of gestation who are at risk for preterm delivery in next 7 days

Question 56

Group b streptococcus infection ; complications, screening, tx

Answer 56

Maternal infection is associated with invasive disease in the newborn
Gas is colonized in many pregnant women
The consequences of infant infection is ; bacteremia, meningitis,pneumonia, and fatality
-all women who previously gave birth to a an infant with invasive gbs should receive antibiotics
- universal screening is recommended at 35-37 weeks of gestation by vaginal or rectal culture ,if negative ; don’t give AB
-women present at labor with no screening information;antibiotics are given if there is fever 38 c or membrane ruptured at least 18 hrs prior or gestation under 37 weeks
Regimen: penicillin G 5 million units iv followed by 2.5 million units every 4 hrs until delivery is recommended
Or ampicillin 2g iv followed by 1 g every 4 hrs
Pen all; give cefazolin 2 g followed by 1 g every 6 hrs
If ig mediated : clindamycin 900 mg iv every 8 hrs if resistant give vancomycin 1 g every 12 hrs until delivery

Question 57

Labor induction indications, contraindications , possible complications , scoring system

Answer 57

1. Post term pregnancy >42 weeks
2. Pregnancy induced HTN/ or maternal HTN
3. Fetal growth restriction
4. Premature rupture for membranes

Contraindications: placenta previa, transverse lie, Pelvic structure abnormalities, prolapsed umbilical cord, active herpes
Concern is about ineffective labor and Side effects ; uterine hyperstimulation

Bishop scoring system: if score <6 then giv cervical ripening if >8 no need and vaginal delivery is likely to be successful
Parameters are: cervical dilation , effacement, station of baby headm consistency of cervix, position of cervix

Question 58

Cervical ripening agents examples

Answer 58

Non pharmacological methods : castor oil, hot baths, sexually intercourse, nipple stimulation

Pharmacological: prostaglandins E2 analogs dinoprostone (prepdil, cervidil)

Prostaglandins E1 analog
Misoprostol oral
Is contraindicated in women with previous uterine scar
Side effects: meconium stained amniotic fluid, uterine stimulation

—oxytocin 10 mU/mL infusion
Effective in both low (physiologic) and high dose (pharmacologic) regimens

Question 59

Labor analgesia phases

Answer 59

First phase; from first onset of labor to complete cervical dilation
Pain is visceral pain abused by uterine contractions
Second phase ; from complete cervical dilation until delivery pain is somatic pain due to perineal stretching

Question 60

Labor analgesia types are?

Answer 60

Parenteral opioids
Epidural analgesia
Use of nitrous oxide is alternative for pain management

Parenteral opioids are less effective than epidural, have more side effects
Pethidine in the opioid of choice , morphine can be used

Epidural is the most commonly used
A catheter is introduced into epidural space and opioid or anesthetic (fentanyl, bupivacaine) is administered
Side effects ; hypotension , pruritus and inability to void

Epidural analgesia is also with prolongation of the second stage of labor but no other complications
Rare complications; severe headaches due to puncture if subarachnoid space

Nitrous oxide is as 50% mixed with oxygen is a choice for women desire a non medicated labor , less effective than epidural

Question 61

Postpartum hemorrhage

Answer 61

Loss of more than 500 ml blood within 24 hrs with vaginal delivery
Or more than 1000 ml within cesarean section

Attention should be attained to uterine atony which is the most common cause for pph

Oxytocin should be given prior to delivery of placenta ( third stage of delivery ) , if inadequate use other uteritonic agents as methylergonovine, carboprost and , rectal,SL,PO misoprostol can all be used as second line agents

Tranexamic acid antifibrinolytic agent can be used for obstetric hemorrhage

Question 62

Lactation

Answer 62

If milk is inadequate despite appropriate breastfeeding frequency and pumping
We can use metoclopramide to increase prolactin level
Regimen : metoclopramide 10 mg po 3 times daily for 7-14 days

Question 63

Transfer of drugs through breastfeeding to the infant

Answer 63

Drug properties affect the transfer as
Highly bound drugs to the maternal plasma are less likely to transfer to the milk and infant

• Low mwt drugs passively diffuse into breast milk
• Higher lipid solubility of drugs increase likelihood of transfer
• higher the drug in the maternal serum , the more likely to be transferred to the infant
• breast milk is acidic, thus basic drugs that are not ionized in maternal blood transfer to milk and become ionized and trapped in the milk : so we should avoid basic drugs if possible

Ph of breast milk 6.8-7
Ph of maternal circulation is 7.4
Thus when basic drugs move to milk they will ionized and less likely to diffuse back into maternal circulation

Longer half live are more likely to transfer to breast milk

Infant properties: frequency of feeding and the amount of milk ingested
Premature or full term (renal function and liver function)

So choose drugs with shorter half lives, more protein binding in maternal plasma,, lower lipid solubility, lower oral bioavailability,
If the drug is taken once daily; take before the infant longest sleeping period
If taken multiple times/day; take immediately after each breastfeeding

If for short term drug therapy ; pumping and discarding milk may be considered to preserve capability of milk producing if medication is not compatible with breastfeeding

Question 64

Mastitis

Answer 64

Infectious or non infectious
Most common cause is milk stasisb
Infectious mainly ; by pencillin resistant staphylococcus aureus
Others E. coli and streptococcus
Tx; ocacillin or dicloxacillim or cephalosporins cephalexin
&For pain relief and inflammation; NSAIDS
non pharma ; heat application and massage + cont breast feeding or pump the milk

Question 65

Postpartum depression

Answer 65

Postpartum blues or baby blues Is common
Psychotherapy

Antidepressant compatible with breast feeding; nortryptilline , fluoxetine, paroxetine, sertaline