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Swabs: GC + CT, pap if out of date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
IUGR definition
<10th % on US d/t pathological process
Causes of IUGR
smoking, drugs, TORCH, genetic abnormalities
Screening for IUGR
in trisomy 21, uterine dopplers @ 19-23w
Rx for IUGR
Previable - monitor
Viable (>500g + >24w) - EFW, AFV, umbilical doppler, weekly BPP in 3rd trimester
If growth plateaus <34w = corticosteroids, consider hospitalisation, increased surveillance
If >34w + abnormal (AFV <5cm or DVP <2cm) BPP + doppler, consider delivering
Polyhydraminos causes
GDM, fetal hydrops, genetics, GI problem
Oligohydraminos causes
renal problem, placenta hypoxia, PROM
TOLAC
Success rate
Rupture rate
Who is at increased risk
Who is likely to have reduced success
Success rate = 75%
Rupture rate = 1%
Increased risk: >2 CS, <18mo since CS, induction of labour
Reduced success: increasing age, BMI, GA >40w, BW >4000g, hx dystocia
Rx for previa
Management: US at 32 + 26
No vaginal or anal sex, no insertion of FB into vagina
What dose of Rhogam to give?
If Rh neg, repeat at 28w
Give RhoGAM:
<12w = 120mcg
>12w = 300mcg
Amniocentesis = 300mcg ;
How do you test for parvovirus in pregnancy?
Parvovirus B19 IgG (positive indicates past infection and immunity)
Parvovirus B19 IgM (positive indicates recent infection)
Rx for Group B strep
Rx w/ IV penicillin
Reasons + risks of inducing
Reasons: spontaneous ROM, IUGR, reduced fetal movement, postdates, pre-eclampsia, maternal conditions
Risks: increased risk of operative delivery, abnormal FHR, uterine rupture, cord prolapse
Pre-requisites + CI to induction
CI: prev uterine rupture, fetal transverse lie, placenta previa, invasive cervical cancer, active genital herpes
Pre-requisites: Bishop >6
How to ripen cervix
vaginal prostaglandin (Prepidil 0.5mg q12H x 3 doses), foley catheter
Oxytocin risks
fetal compromise, uterine rupture, hypotension
When can you perform ARM
active labour + head engaged
Definition of dystocia in 1st + 2nd stage
Active first stage >4hrs w/ <0.5cm/hr dilatation
2nd stage >1hr w/ no descent
Causes + rx of dystocia
Causes:
Power
Passenger
Passage
Psyche
Management:
Oxytocin augmentation
RF for placental abruption
previous abruption, HTN, vascular dz, smoking, alcohol use, multiparity, increasing maternal age, PPROM
Sx of placental abruption
painful vaginal bleeding, sudden onset, constant, lower back + uterus, fetal distress
Complications of placental abruption
prematurity, hypoxia, DIC, anemia, shock, amniotic fluid embolism
RF for uterine rupture
prev uterine scar, oxytocin, grand multip, previous uterine manipulation
Sx of uterine rupture
acute onset abdo pain, abnormal FHR, vaginal bleeding
Complications of uterine rupture
hemorrhage, shock, DIC, amniotic fluid embolism, fetal distress
Premature rupture of membranes management
sterile spec, r/o cord prolapse, looking for 1) pooling, 2) nitrazine blue 3) ferning. Determine GBS status.
Preterm labour Ix + Rx
Ix: fetal fibronectin, US for cervical length
Management:
- betamethasone 12mg IM q24 x2,
- transfer to NICU place
- nifedipine
- magnesium sulphate 4g IV
RF for shoulder dystocia
obesity, DM, multiparity, macrosomia, longer gestation, long 2nd stage, advanced maternal age, male newborn, induction
Sx of shoulder dystocia
Turtle sign (head retracting after delivery)
Complications of shoulder dystocia
PPH, uterine rupture, newborn brachial plexus injury/ clavicle fracture, hypoxia
Rx for shoulder dystocia
ALARMER: apply suprapubic pressure, legs in full flexion, anterior shoulder disimpaction, release posterior shoulder, manual corkscrew, episiotomy, roll over onto hands and knees
Rx of Non-reassuring FHR
Management: ensure fetal tracing, call for help, LLD position, 100% O2, stop oxy, give fluids, r/o cord prolapse
Postpartum history
Brain: depression, psychosis, sleep, suicide, substances, support, sex
Breasts: feeding, concerns
BP
Bladder/ bowels: incontinence, UTI
Bleeding: colour, smell, clots
Baby: bonding, feeding, concerns
Contraception options postpartum (lactating vs not)
Non lactating: OCP from 3wks
Lactating: micronor 6wks PP + change to OCP at 3mo or sooner if formula fed
IUD from 6w PP
What to counsel parents on after birth
Transition to parenthood
Family violence + safety
Nutrition + healthy living
Contraception
Pelvic floor exercises
Community resources
Future pregnancies
Preconception planning
C/S: discuss VBAC + pregnancy spacing
FU for pts w/ HTN, DM, preterm, IUGR, placental abruption after delivery
If HTN, DM, preterm, IUGR, placental abruption:
6mo: BMI, BP, lipids, glucose, UA
12mo: BMI + BP
FU for GDM after delivery
75g OGTT 6w PP + a1c q1yr
Definition of PPH
Blood loss >500ml for SVD or >1000ml for CS, up til 6wks
Causes of PPH
uterine atony, retained placenta, laceration of cervix/ vagina/ uterus, coagulopathy, DIC, ITP, TTP
Management of PPH
Cross match 4 units
Oxytocin infusion
Ergotamine 0.25mg IM q5 mins
Hemabate 0.25mg IM
Manual compression/ uterine massage
D+C, lap w/ ligation of uterine arteries
Causes of postpartum fever
Wind (atelectasis, PNA), water (UTI), wound, walking (DVT), womb (endometritis)
Ix for postpartum fever
Ix: blood + genital cultures if suspecting endometritis
Definition + causes of retained placenta
Undelivered placenta >30 mins from delivery of baby
Causes: accreta, incret, percreta
RF + Rx of retained placenta
RF: placenta previa, prior CS, curettage, uterine infection
Management: explore uterus, firm traction, oxytocin into umbilical vein, manual removal, D+C
How to manage existing hypothyroidism
May need to decrease thyroxine dose in known hypothyroid pts
Rx for endometritis
Management: clindamycin + gentamicin
Blues vs depression
Blues: onset day 3-10, lasts <2wks
Depression: within 4wks - 6mo from delivery
RF for depression
personal or fam hx, prenatal depression or anxiety, stressful life situation, poor support, unwanted pregnancy, sick infant
How to offer abortion
confirm gestational age, exclude ectopic, assess for CI (uncontrolled asthma, chronic adrenal failure, chronic steroid use, hematological dz, remove IUD), advise on how to take meds, expect pain, FU - mifepristone/ misoprostil
How to diagnose gestational HTN?
> 140/90 x2 >20 wks
How to diagnose preterm labour?
Fetal fibronectin + serial vaginal exam
RF for PPH
prior hx, rapid delivery, shoulder dystocia, instrumentation
Causes of postpartum infection
endometritis, septic pelvic thrombophlebitis
What supplements reduce sz occurrence in pregnant pts?
Calcium, folic acid
Bipolar med advice in pregnancy
lowest effective dose, monotherapy, avoid valproate, psychosocial preferred over meds in 1st trimester
Recommended wt gain per week in pregnancy
Underweight = 0.5kg/wk
Healthy = 0.4kg/wk
Overweight = 0.3kg/wk
Obese = 0.2kg/wk
Recommended wt gain in pregnancy for obese women
5-9kg
Bugs causing mastitis
staph aureus, beta hemolytic strep, e coli
