Pregnancy *** Flashcards
What to cover in Preconception Counselling
Review previous pregnancies
Mental health
Family + genetic hx
Optimise chronic medical conditions + meds
CI in pregnancy: ACEi, valproic acid, lithium, topiramate, methotrexate, warfarin
Better anticonvulsants: carbamazepine or lamotrigine
Immunizations
Screen for STIs
Lifestyle: smoking cessation, stop alcohol and substance use
Supplementation: folic acid, calcium, omega 3s, vit D, vit B12
Nutrition: Avoid undercooked or raw meat + fish, unpasteurized milk, fish high in mercury (tuna steak, swordfish, shellfish)
Recommended dose of folic acid
0.4 to 1mg daily
5mg for people with RF
Sx associated with pre-eclampsia
RUQ Pain
Visual Changes (blurring/scotoma)
Headaches
Edema
Nausea
Vomiting
Somnolence
Irritability
Hyperreflexia
Indications for Rhogam
In negative women
Routinely at 28 weeks gestational age
Within 72 hours of birth of a Rh positive infant
Miscarriage
Antepartum Hemorrhage
Ectopic Pregnancy
Invasive Procedures During Pregnancy
Positive Kleinhauer-Betke Test
Tests performed in maternal serum screen
Alpha-Feto Protein
B-hCG
Estriol (unconjugated estrogen)
First visit content to cover
Is pregnancy desirable?
Assess risk factors (teens, substance use, DV victims, single moms, HIV, diabetes, epilepsy)
Establish dates
Advise pt about ongoing care (include SW as needed)
Bloods:
bHCG
Blood type + Rh status
CBC (Hb + MCV)
TSH
HIV, rubella, varicella, HBsAg, Syphilis, Hep C (if RFs)
Urine: midstream C+S
Swabs: GC + CT, pap if out of date
What to cover at 10-14 weeks
Dating US
SIPS1
IPS (SIPS1 + NT) for women 35-39
What to cover at 12 weeks
GDM screen if high risk
SFH
What to cover at 15-21 weeks
SIPS2 or Quad screen
What to cover at 18-20 wks
Anatomy, gender + placenta US
What to cover at 24-26 wks
Repeat blood type + Rh status in Rh negative pts
GDM screening: 1 hour 50g OGTT screen, 75g 2 hour test for confirmation
What to cover at 28 wks
Rh Ig to Rh negative
Edinburgh PDS
Repeat CBC, consider iron
Tdap
What to cover at 34 wks
Assess presentation, ECV if necessary
What to cover at 35-37
GBS screen
Suppression therapy for current HSV
Recommended vax + CI in pregnancy
Flu shot if during flu season
Tdap between 21-32w for every pregnancy
Hep A, B, meningococcal and pneumococcal if high risk
Contraindicated: live influenza, herpes, MMR, polio, rubella, varicalla
What is the 1st stage of labour?
regular contractions causing cervical dilatation and effacement
Latent: complete when nulliparous >4cm, parous 4-5cm
Active: starts at >4cm NP and 4-5cm MP
What is the 2nd stage of labour?
full dilatation to delivery of baby
Passive = no pushing
Active = pushing
What is the 3rd + 4th stage of labour?
immediately after delivery of baby to delivery of placenta
4th: immediately after delivery of placenta to 1hr postpartum
Indications for continuous FM
Decels, single umbilical artery, velamentous cord insertion, >3 nuchal loops of cord, spinal-epidural anesthesia, labour dystocia, FHR arrhythmia, BMI >35
Pain relief options
Non-pharmacologic (self-hypnosis, acupuncture, water immersion
Systemic: nitrous oxide, opioids
Regional: pudendal nerve block (inferior to sacrospinal ligament + medial to ischial spine bilaterally), epidural
3rd stage management
Prophylactic uterotonic (oxytocin)
Early cord clamping
Controlled cord traction
Bishops score characteristics
C-PEDS
Consistency
Position
Effacement
Dilatation
Station
What is the definition of decreased cervical length + what is the Rx
<25mm @ 16-24w GA
Rx: vaginal progesterone from 16-36w
What is normal and decreased fetal movements, and rx for decreased?
Normal = >26w = 6 movements / 2 hrs
<6 = NST, normal = daily movement counting, abnormal = biophysical
When would HTN be considered gestational?
> 20wks
RF for GHTN
<18 or >35, 1st pregnancy new partner, primip, >1 fetus
Maternal and fetal complications of GHTN
Maternal: sz, retinal detachment, stroke, TIA, HELLP
Fetal: placental abruption, IUGR, oligohydramino
Screening for HTN
UA + BP each visit
Ix if UA + for protein
CBC, INR, PTT, fibrinogen, BUN, Cr, lytes, glucose, AST, ALT, LDH, bili, albumin (low)
24hr urine
fetal movement count/ NST, US for growth, middle cerebral artery doppler
Prevention of GHTN
Calcium supplementation
No EtOH
Smoking cessation
High risk women: LMWH if prev placental complications
When to deliver in GHTN/ pre-eclampsia
Severe = immediate
Hemolysis + raised LFTs - deliver >35w
Non severe = >37w
Rx for GHTN
Labetalol or methyldopa 1st line, clonidine 2nd line
Nifedipine if severe
MgSO4 4g IV to prevent eclampsia
Corticosteroids for fetus if <34+6
HELLP management: consider blood or platelet transfusion
RF for GDM
prev GDM, fam hx, macrosomia, >25y/o, obese, PCOS, steroids, hispanic/ asian/ african
Complications of GDM
cephalo-pelvic disproportion, LGA, shoulder dystocia, VSD, NTD, neonatal hypoglycemia, Erb palsy, pyloric stenosis, premature
Ix + results for GDM
screen at 24-28w w/ 75g OGTT, GDM if FBG >5.1, >10 @ 1hr or >8.5 @ 2hrs
Rx of GDM
Nutritional counselling
Monitor fetal growth q4w from 24w
Weekly NST from 36w
Induce at 38w
Monitor newborn for hypoglycemia
Repeat 75g OGTT between 6w-6mo PP
Rx for hyperemesis
pyridoxine 10mg QID or diclectin 10mg QID
+ gravol 50mg Q4H
+ metoclopramide 5-10mg Q8H PO/ IM/ IV
+ ondansetron 8mg Q12H IV