Pregnancy Flashcards
1
Q
How is ectopic pregnancy diagnosed?
A
Transvaginal ultrasound - visualization of extrauterine gestational sac/fetal pole
Positive hCG (>2000, the discriminatory zone where gestational sac is reliable observed on US) and no conception products on uterine aspiration with subsequent rising (<35-50% over 48h) or plateauing hCG levels, or levels that do not fall following diagnostic dilation and curettage
Visualization at surgery wit histologic confirmation following resection
2
Q
What is expected level of progesterone in normal pregnancy?
A
> 20 ng/mL
3
Q
What is expected bhCG increase during pregnancy?
A
During first 42 days (6 weeks), should rise by 50% every 48h
4
Q
What surgery should be done for a ruptured or unruptured tubal ectopic pregnancy?
A
Ruptured: Salpingectomy (do not try to repair)
Unruptured: Salpingostomy
5
Q
When can pregnancy be diagnosed by bhCG
A
8-9 days - serum bhCG
6
Q
When can fetal heart tones be heard in pregnancy?
A
10 wga
7
Q
When would gestational sac be detected by ultrasound?
A
5-6 wga
8
Q
What is the % risk of isoimmunization?
A
<20% total (1-2% antepartum, 10% after full term, 7% with subsequent pregnancy)
9
Q
What is the best noninvasive test for fetal anemia?
A
Doppler US - middle cerebral artery peak systolic velocity
10
Q
What does Rh isoimmunization cause?
A
Fetal anemia and hydrops (severe swelling/edema)
11
Q
How is fetal hydrops diagnosed on US?
A
Decreased hepatic protein production –> ascites, pericardial/pleural edema, scalp edema
Placental edema, polyhydramnios
If extramedullary hematopoiesis is extensive: hepatosplenomegaly
12
Q
How to determine how much anti-D IgG to provide after fetomaternal hemorrhage?
A
Kleihauer-Betke test/flow cytometry - quantify volume of fetal blood
Anti-D IgG: 10 mcg/mL fetal blood (1 mL fetal blood = 0.5 mL fetal RBCs)
13
Q
Which antibodies should be feared/not feared?
A
Lewis Lives, Duffy Dies and Kell Kills
14
Q
Amniotic fluid contains what in severely isoimmunized pregnancy?
A
Bilirubin - due to severe hemolysis
Not ferritin, an acute-phase reactant associated with spontaneous preterm delivery
15
Q
What to do for fetus with severe hemolytic disease at 30 wga?
A
Immediate fetal transfusion (umbilical vein preferred, intraperitoneal second, maternal plasmapheresis third)
16
Q
What to test if Kell alloimmunization is detected in patient?
A
Determine paternal erythrocyte Ag status (-/- means fetus is Ag-, +/+ means fetus is Ag+)
Determine fetal Ag type only if paternal is heterozygous or unknown
17
Q
When is chorionic villus sampling done vs amniocentesis?
A
CVS: 11-14 wga
Amniocentesis: 15 wga or later; tests for neural tube defects
18
Q
What is best method for determining gestational age in 1st trimester (up to 12 wks)?
A
US for crown-rump length
19
Q
Indications for cesarian in terms of fetal size
A
Fetal head BPD >12 cm
EFW >5,000 g in patient without diabetes
Uterine fibroids in lower uterine segment that would obstruct labor
20
Q
Risks of vacuum extractors for fetal delivery
A
Lacerations at edges of vacuum cup
Cephalohematoma if torsion is applied –> jaundice + hyperbilirubinemia
Transient neonatal lateral rectus paralysis (usually resolves spontaneously)
21
Q
Risks of forceps delivery
A
Maternal laceration
Pelvic organ prolapse
22
Q
How does fetal anemia affect tracing?
A
Sinusoidal pattern of regular smooth sine waves with regular amplitude and frequency
23
Q
What are the complications of surgical tubal sterilization?
A
Unplanned pregnancy: 1% (1/3 ectopic)
Reduced lifetime risk of epithelial ovarian cancers
24
Q
What is cervical insufficiency?
A
Cervical dilation before 24 wga with expulsion of pregnancy in 2nd trimester, in absence of labor or clear pathology like infection or ruptured membranes)
25
What lab value suggests multiple gestation?
2x expected maternal serum AFP
DDx:
Neural tube defects
Pilonidal cysts
Sacrococcygeal teratoma
Fetal abdominal wall defects
Cystic hygroma
Fetal death
26
In twins, already at greater risk of preterm birth, what is greatest predictor of preterm birth?
Cervical length <= 25 mm
27
What birth defects are more likely in twins?
Congenital anomalies, particularly monozygotic twins
28
What kinds of twins have twin-twin transfusion syndrome?
Monochorionic twins - intrauterine transfusion occurs, with polyhydramnios around one and oligohydramnios around the other
29
Should all women with multifetal gestations be offered routine aneuploidy screening?
Yes
30
What are the risks of breech delivery?
Head entrapment
Umbilical cord prolapse
31
What is the optimal mode of delivery if one twin is breech?
C-section
32
Describe the timeframe that different twins emerge
Division by:
Day 3 - dichorionic diamniotic
Day 4-8 - monochorionic diamniotic
Day 9-12 - monochorionic monoamniotic
Day >12 - conjoined twins
33
Who is at most risk for postpartum depression?
Hx of psychiatric illness and/or depression
34
What are common side effects of fluoxetine?
Insomnia
Sexual dysfunction (decreased libido and delayed/absent orgasm)
35
What fetal effect is 3rd trimester use of SSRIs associated with?
Poor neonatal adaptation (hours to days):
Agitation
Abnormal muscle tone (up or down)
Tremor
Temperature instability
Insomnia or somnolence
Difficulty feeding
36
How is the Edinburgh Postnatal Depression Scale specific for postpartum depression?
Excludes questions about somatic symptoms (e.g. sleep, appetite disturbances), which are common in postpartum women
37
What score of the EPDS indicates postpartum depression?
>=11/30
38
When is GDM screened?
50g glucose challenge test at 24-28 weeks gestation, followed by confirmatory 100g 3h GTT if positive
39
When is GBS screened? When should antibiotics be given?
36 to 37.6 wga for those who do not already have an indication for intrapartum antibiotic prophylaxis (e.g. already diagnosed during this pregnancy or previously given birth to neonate with early-onset group B streptococcal disease)
Antibiotics given in labor
40
What are the criteria for retained placenta?
>30 min elapsed with active management of third-stage (e.g. early cord clamping, controlled cord traction during placental delivery, and immediate administration of prophylactic uterotonics)
41
What are the risks of retaining a dead fetus to wait for spontaneous abortion?
Developing coagulation abnormalities
42
What should be done with umbilical cord prolapse?
Elevate fetal head with hand in vagina (to avoid cord compression) and call for urgent C-section
43
How are Montevideo units calculated?
Add amplitudes of contractions over 10-minute window of time; >=200 is considered adequate for normal labor progression
44
What is normal amniotic fluid volume in terms of single deepest pocket?
>=2 and <8 cm
45
What opioid substitution should be provided for opioid-dependent pregnant patients?
Methadone (long-acting agonist) - prevents withdrawal symptoms
Buprenorphine
46
How does polymorphic eruption of pregnancy appear?
Pruritic, erythematous papules starting within abdominal striae in 3rd trimester
No palms or soles
47
When is Doppler of umbilical artery indicated?
Evaluation in fetal growth restriction - looking at high-velocity vs decreased, absent, or reversed end-diastolic flow
48
When is a contraction stress test indicated?
When BPP results are equivocal (6/10) to assess fetal well-being
49
What are the degrees of perineal laceration?
1st: Vaginal mucosa + perineal skin
2nd: Bulbocavernosus muscle + perineal body
3rd: External + internal anal sphincters
4th: Rectal mucosa
50
How does TSH, total T4, free T4 change during pregnancy?
TSH decreases, total T4 increases, free T4 unchanged or mildly increased
bhCG stimulates T4 production in 1st trimester, and TSH secretion is then suppressed
Estrogen also stimulates TBG; increased T4 needed to maintain steady free T4 level
51
Patients at risk of preterm birth often have what abnormal anatomical measurement?
Shortened cervical lengths (<=2.5 cm)
52
What the cardiac and pulmonary changes of pregnancy?
Cardiac:
Cardiac output increase (SV in early pregnancy, HR in late)
SVR and BP decrease
Pulmonary:
Progesterone increases minute ventilation via tidal volume (not RR)
Enlarged uterus elevates diaphragm, decreasing FRC
53
What consideration is needed with drug dosing in pregnancy?
Renally excreted drug dosage needs to be increased to compensate for higher GFR
54
Lab definition of anemia in pregnancy
<11 in 1st and 3rd trimesters
<10.5 in 2nd trimester
55
What meds should be avoided for restless legs syndrome in pregnancy?
Gabapentin, pregabalin (alpha-2-delta calcium channel ligands)
Provide iron if ferritin is low-normal (<75 ng/mL)
56
Risk factors for placental abruption?
Tobacco or cocaine
Hypertension
Abdominal trauma
57
Where is preeclampsia headache more common?
Bilateral frontal or occipital
58
Intrahepatic cholestasis of pregnancy requires what management?
Regular NST
Delivery at 37 wga
59
What is polymorphic eruption of pregnancy?
Pruritus and urticaria papules and plaques spreading centrifugally but sparing palms and soles
60
Are spider angiomas normal in pregnancy?
Yes - increased estrogen can cause increased blood vessel vascularity
61
Early GDM screening (GCT at initial prenatal visit) is indicated in whom?
Obesity and >=1 of:
Prior GDM
Prior macrosomic infant
FHx of T2DM
PCOS
Maternal age >=40
62
When is Tdap vaccine given?
27-36 weeks to maximize transplacental Ab transfer
63
Differentiate between metoclopramide, prochlorperazine, promethazine, and doxylamine
Metoclopramide: Anti-emetic and gut motility improver; dopamine antagonist
Prochlorperazine: Anti-emetic; antipsychotic that mainly blocks D2 dopamine receptors in brain
Promethazine: Anti-emetic; anti-dopaminergic, -histamine, and -cholinergic properties
Doxylamine: Anti-emetic; antihistamine
64
How is a mo/mo twin gestation handled?
Inpatient monitoring with NST and steroids at 28 wga
Planned C/S at 32-34 wga
65
Risk factors for preeclampsia
Chronic HTN
T1DM
Systemic lupus
Multiple gestation
66
When is progesterone given at beginning of a pregnancy?
Hx of prior preterm delivery
67
Acute fatty liver of pregnancy - signs
Fulminant liver failure:
Thrombocytopenia (<100,000)
Profound hypoglycemia
RUQ pain, jaundice, elevated transaminases
68
What are 2nd-trimester signs of placenta accreta?
Low-lying placenta
Myometrial thinning
Numerous placental lacunae (vascular spaces filled with maternal blood)
69
Hyperemesis gravidarum requires hospitalization for antiemetics, rehydration, and electrolyte repletion if what signs are present?
Ketonuria - due to prolonged hypoglycemia from inadequate oral intake
70
What does progesterone do to respiratory center in late pregnancy?
Stimulates it, leading to hyperventilation, hypocapnia, and chronic respiratory alkalosis
71
What is pseudocyesis?
When someone has symptoms of pregnancy but negative pregnancy test
72
Short (<6-18 months) interpregnancy interval risks what?
Maternal anemia
Low birth weight
PPROM
Preterm delivery
73
After what gestational age are tocolytics no longer used?
>=34 weeks
Indomethacin may close PDA, cause oligohydramnios
Nifedipine may cause maternal hypotension and tachycardia
74
Magnesium is used for fetal neuroprotection prior to what gestational age?
32 wga
75
Emergency cervical cerclage is used up to what gestational age?
<24 wga
76
Active phase of labor - protraction vs arrest
Should be >=1 cm dilation every 2 hours
Protraction: cervical change slower than expected +/- inadequate contractions -> give oxytocin
Arrest: no cervical change >=4 hours with adequate contractions OR >=6 hours with inadequate contractions -> cesarean
77
What is preferred method of assessing PE in pregnancy?
V/Q scan - technical challenges with contrast admin in pregnancy
Only normal scan shouldn't be followed with CTA or further analysis
78
Placenta previa - analysis
Transabdominal US, followed by transvaginal US if positive (due to false-positive rate)
79
Tocolytic <32 wks vs 32-34 wks
<32: Indomethacin
32-34: Nifedipine
Terbutaline (beta agonist) for uterine tachysystole during labor
80
Preeclampsia with severe features or HELLP syndrome vs acute sickle cell crisis
Sickle cell crisis has normal platelets and normal AST and ALT (compared to >=2x upper limit of normal)
81
Why is Mg given to premature fetus before 32 weeks?
Neuronal protection, decrease risk of cerebral palsy
82
Ectopic pregnancy - Doppler appearance
Increased flow - "ring of fire" around it
83
Vasa previa - management
Diagnosed at 18-20 weeks, planned cesarean at 34-35 weeks, inpatient management during 3rd trimester in case of emergency
84
Renal complications of pregnancy
Nephrolithiasis in 2nd or 3rd trimester
Due to urinary stasis from progesterone and increased calcium excretion
Can also cause irregular contractions through inflammation and prostaglandin irritating uterus
85
Describe the sequence of amniotic fluid embolism
Proinflammatory mediators cause pulmonary vasoconstriction -> hypoxemic respiratory failure, as well as obstructive shock -> RB and LV failure -> pulmonary edema and cardiovascular collapse
Also DIC
86
Which face presentation has diameter too large to pass, requiring cesarean?
Mentum posterior (mentum = chin) because neck cannot bend further back
87
What is the preferred fetal position for delivery?
Occiput anterior (back of head anterior) with vertex presentation
88
What can cause maternal hypotension during delivery?
Neuraxial anesthesia - due to sympathetic nerve blockade from epidural
Can cause uteroplacental insufficiency
Treat by positioning patient on left side to improve venous return, IV fluid bolus, and vasopressor (e.g. phenylephrine, ephedrine)
89
Concern for bleeding after cesarean but no visible sign at incision and minimal abdominal or back pain
Uterine artery bleeding into retroperitoneum
Requires urgent laparotomy
90
What should be added for multiple gestation pregnancy before 16 wga?
Aspirin - due to 3-fold higher risk of preeclampsia
91
When is it considered preterm labor?
Labor-type contractions causing cervical dilation
92
3 indications for cerclage
1. Current cervical dilation
2. 1 previous preterm delivery and current cervical length <2.5 cm
3. 2 previous consecutive, painless 2nd trimester losses
93
After when does risk for DIC increase in pregnancy?
15 wga
94
E coli UTI in pregnancy - treatment
Risk of pyelonephritis
Treat with fosfomycin and beta-lactams (e.g. cefpodoxime, Augmentin)
Followed by test of cure
95
Rectus abdominis diastasis - treatment
Reassurance - unlike true hernia, no associated fascial defect or risk of complications
96
Bleeding in placenta previa vs vasa previa
Placenta previa - maternal blood loss, heavy, hemorrhagic shock
Vasa previa - fetal blood loss, minimal, absent fetal heart tracing
97
When does placenta take over progesterone production from corpus luteum?
8-10 wga
98
Increased vs decreased maternal serum AFP during pregnancy
Increased: open neural tube defects, abdominal wall defects, multiple gestation, inaccurate dating
Decreased: aneuploidies
99
What test is used to determine dose of anti-D Ig to give after delivery, placental abruption, or procedures?
Kleihauer-Betke test - from maternal blood, adult Hgb lyses when exposed to acidic solution, revealing percentage of fetal Hgb
100
Why is Bactrim avoided in 3rd trimester of pregnancy?
Neonatal kernicterus
101
Why can prolonged oxytocin cause seizure?
Similar structure to ADH (vasopressin) - water retention -> hyponatremia
102
What is the cause of polymorphic eruption of pregnancy? How does it appear?
In 3rd trimester, overstretched skin -> connective tissue damage -> inflammatory response
Periumbilical sparing
Erythematous papules in striae
Limited to abdomen
Treat with antihistamines, topical corticosteroids
103
Intrahepatic cholestasis of pregnancy vs polymorphic eruption of pregnancy
Intrahepatic cholestasis of pregnancy: worst in hands and feet, without associated rash
Treat with ursodeoxycholic acid
104
Is tocolysis administered for PPROM?
No - monitoring for contractions is helpful for early detection and management of complications
105
When is tocolysis generally given?
Spontaneous early preterm labor (<34 weeks gestation without ROM)
106
Solid, bilateral ovarian masses on ultrasound during pregnancy
Luteomas of pregnancy - bhCG stimulates luteoma (large lutein cells) to release androgens
High risk of delivering female fetus with virilization
Compare to theca lutein cysts, which are cystic, bilateral ovarian masses from markedly elevated bHCG (e.g. hydatidiform mole, multiple gestation
Less risk of female fetal virilization
107
Treatment of nausea and vomiting in pregnancy
1. Dietary changes
2. Vitamin B6 (pyridoxine) and H1 antihistamine (i.e. doxylamine succinate)
3. Oral dopamine and serotonin antagonists
4. IV fluids and antiemetics
5. Corticosteroids
6. TPN or tube feeds (refractory)
108
Hyperemesis gravidarum vs nausea and vomiting of pregnancy
Has lab abnormalities: electrolytes, hypoglycemia, elevated aminotransferases, ketonuria
109
Indomethacin predisposes to what (when used appropriately and not related to ductus arteriosus)?
Oligohydramnios - cyclooxygenase inhibition -> decreased prostaglandin production -> fetal vasoconstriction -> decreased renal production -> oligohydramnios
110
Most common cause of pulmonary edema in pregnancy
Preeclampsia - due to increased vascular permeability and hemodynamic dysfunction
111
Why does multiple gestation or hydatidiform mole increase risk of hyperemesis gravidarum?
bhCG causes nausea, progesterone causes vomiting (relaxed smooth muscle tone in lower esophageal sphincter and stomach)
112
What exercises should be avoided in pregnancy?
Trauma or fall risk
Risk of dehydration (e.g. hot yoga)
Jogging good; 20-30 min moderate-intensity exercise on most or all days of week recommended anyway
113
When are flu, Tdap, and anti-RhoD given during pregnancy?
Flu: 20 weeks
Tdap: 27-36 weeks
Anti-RhoD: 28 weeks
114
What kind of shock does amniotic fluid embolism cause?
Cardiogenic shock
115
AFLP vs HELLP
Acute fatty liver of pregnancy has hypoglycemia; other labs may be similar
Intrahepatic process due to microvesicular fatty infiltration of hepatocytes secondary to abnormal maternal-fetal fatty acid metabolism -> acute onset fulminant liver failure with inability to convert glycogen to glucose
116
Where are HSV calcifications?
Umbilical cord
117
Toxoplasma calcifications
Diffuse parenchymal intracranial
118
Disseminated abscesses in fetus
Listeria
119
Vertical transmission of what can cause growth abnormalities (e.g. bone/muscle hypoplasia)?
Varicella/zoster virus
120
What can lupus or Sjogren syndrome cause in fetus?
Anti-Ro/SSA Ab can cause congenital fetal heart block (<110/min)
121
When is epidural blood patch used?
For severe/refractory headache secondary to epidural anesthetic getting past dura
Headache worse with sitting/standing upright
122
Intermittent RUQ pain that radiates to back during pregnancy
Likely symptomatic cholelithiasis
Estrogen causes increased biliary cholesterol excretion
Progesterone causes decreased GB motility
123
Pemphigoid gestationis
Like bullous pemphigoid
Includes umbilicus area, usually not face or mucous membrane
Can cause FGR, prematurity, or manifestation in newborn (due to Ab transfer)
IF staining shows C3 deposits
Treat with high-potency topical steroids or systemic if needed
124
What antibiotics should not be used during pregnancy 1st and 3rd trimesters
1st: avoid nitrofurantoin if possible (Augmentin, cephalexin, fosfomycin ok)
1st and 3rd: avoid fluoroquinolones and Bactrim
