Pregnancy Flashcards
What are risk associated with multi-fetal pregnancies?
Both maternal and fetal risks!! Miscarriage, cervical insufficiency, PPROM, PTL, prematurity, cerebral palsy, growth restriction, GDM, HDP, PPH, need for cesarean
What is difference between multifetal pregnancy reduction vs. selective reduction
Multifetal: reduce fetuses based on technical consideration (i.e location of fetus)
Selective reduction: decision about which fetus is based on health status of the fetus.
What is risk of spontaneous pregnancy loss (entire preg) for twins, triplets, quads?
Risk increases w/ increasing number of fetuses. Twins 8%, triplets 15%, Quads 20%.
How do you measure CRL and how accurate is it?
If up to 8w6d: +/- 5d.
If up to 13w6d, +/- 7d
3 discrete measurements and take the average of the 3: mid-sagittal plane (genital tubercle and fetal spine in view), from crown to rump
How can we limit number of multifetal pregnancies from ART? Implant 1 embryo. For ovulation induction, choosing letrozole over clomid.
What are benefits and any risks to exercise in pregnancy?
Benefits: decr risk GDM, cesarean delivery, operative vaginal delivery, postpartum cesarean recovery. Prevents postpartum depression. Risks of low activity: bone demineralization psychosocial.
Avoid Scuba diving, surfing, gymnastics, Downhill skiing, water skiing. Contact sports: soccer, basketball (maybe avoid).
Contraindications to aerobic exercise during pregnancy? Placenta previa, preterm labor, ruptured membranes, severe anemia. Significant heart and lung disease.
Most common indications for primary cesarean delivery?
- abnormal labor (failed IOL/arrest of descent)
- Non-reassuring fetal heart rate
- malpresentation.
30% CS rate in US.
Mono-di twin pregnancies: How would you counsel on complications?
Start with complications with all twins and then specific to mono-di
Risk of miscarriage, structural anomalies, FGR, HDP, GDM, fetal anomalies, PTL/Prematurity
Counsel on shared placenta and associated risks: TTTS, TAPS, selective FGR.
Refer to MFM
Serial CL, monthly growth US, genetic screening
bASA
Delivery at 36-37wks. Later discuss mode of delivery
What is TTTS?
What are management options?
Unidirectional flow can occur in these AV anastomoses and result in the shunting of blood towards 1 twin and away from the other when the AV anastomoses are unbalanced.
5 stages: oligo/polyhydramnios, absent bladder in donor twin, abnormal dopplers, hydrops, fetal death.
What are pre-requisites: monochorionic diamniotic twin pregnancy
MANAGEMENT:
- SERIAL AMNIOREDUCTION IN POLYHYDRAMNIOS
- AMNIOTIC SEPTOSTOMY
- laser ablation of placental anastomoses most common
- demise of 1 twin in monochorionic circulation=high risk death or neuron-impairment in 2nd twin. need weekly UAD and early delivery 34-36wks in surviving twin.
How should EC be used?
- no office exam or hcg. see if menses >7d late, AUB or pain develops.
WITHIN 3 DAYS
- combined estrogen/progestin pill (100ug estrogen and 0.5mg levonorgestrel) x 2 doses 12hr apart
- Plan B (OTC): Progestin only 1.5mg levonorgestrel single dose. 3% failure rate.
WITHIN 5D
- Copper iUD (99% effective) - good for obese women
- 52mg LNG IUD (97% effective)
- Ulipristal (Ella) 30mg single dose - selective progesterone modulator. inhibits ovulation. 99% elective.
Follow-up: if no period in 3 weeks, do hcg and counsel on contraception.
– general IUD failure rate is 0.5%
What are risk factors for preterm delivery?
prior PTD, infection, placental abruption, pre-eclampsia multiple gestation, short cervix, younger age <18, black race, PPROM, bleeding in pregnancy
What is likelihood of delivery at term for pt in PTL?
50%
What are contraindications to tocolytics?
PTL, vaginal bleeding, evidence of infection, GA>34wks, IUFD, fetus w/ lethal anomaly, non-reassuring fetal status. PEC-SF or eclampsia.
At what Mag level do you have loss of reflexes?
Respiratory paralysis?
Cardiac arrest?
loss of reflexes (>9)
respiratory paralysis (>12)
cardiac arrest (>30).
When is aspirin indicated?
What is mechanism of action of aspirin?
1+ moderate risk factor or 1 high-risk factor
High: hx cHTN, PEC, pre-gestational DM, renal disease, autoimmune (SLE, APLS), multifetal gestation
Low: nullip, fam hx PEC, black race, low income, Ama, IVF
- aspirin works by reducing production of thromboxane by platelets. Thromboxate promotes vasoconstriction.
What are modifiable and non-modifiable RF for PTB?
Modifiable:
- low maternal pre-pre weight
- smoking/substance abuse
- short interpret interval (<18 months)
Non-modifiable
- prior PTB
- UTI and infections (BV)
- vaginal bleeding
- multiple gestation (60% PTB w/ twins)
- short cervix
- race
how do you manage a pregnancy w/ IUD?
What are incr risk of pregnancy complications?
Perform TVUS to confirm IUP. If IUD is inferior to gestational sac, could attempt removal at IUD. 20% risk miscarriage w/ IUD removal.
Incr risk miscarriage, PTL, septic AB. bleeding
What are contraindications to breastfeeding?
HIV pos, untreated TB, untreated varicella, herpes on breast, substance abuse
How would you evaluate a patient with positive antibody screen in pregnancy?
See if antibody is associated with hemolytic disease of the newborn. If it does, determine paternal antigen and zygosity status.
If antigen neg, fetus not at risk
If antigen pos and heterozygtote or paternity uncertain, determine fetal antigen status by amnio.
If antigen pos and homozygote, fetus is at risk for HDFN.
Get serial maternal titers q2-4weeks. If titers >16, start MCAD at 24w.
Or if previous alloimmunized pregnancy, start MCAD at 24w.
If MCAD >1.5 mOm do PUBS, determine fetal hct. If > 35 weeks, deliver.
Delivery at 37-38w if MCA normal. MCA not as useful after 35w.
Concern for alloimmunization.
What diagnostic tests would you order?
How would you manage the patient throughout the pregnancy?
Why do some antibodies not cause problems in a pregnancy?
IgG crosses the placenta, IgM do not cross placenta
What is differential for postpartum w/ pulse 160, agitated and sweating?
How would you evaluate?
hemorrhage, substance use, supraventricular tachycardia, other cardiac disease, thyroid storm, infection, sepsis
H&P, EKG, CBC, TSH, assess for drug intoxication
How do you evaluate pt w/ hx epilepsy who desires fertility?
H&P, routine prenatal labs, optimize management of med probs. which meds she’s on,. If weaned from aeds, do 6-12 mo before conceiving. Neuro consult
How would you counsel pt with epilepsy in pregnancy and how would you manage during pregnancy?
At risk for PEC, PTD, PPH, FGR, IUFD, maternal mortality and CS.
AED can lead to NTD. on monotherapy, lowest dose. Lamictal and keppra best. Then phenytoin. valproate=NOT GOOD. Folic acid 1mg daily prior to conception and then 0.4mg daily if on ANY AED.
Monitor AED level. Lamictal and keppra can cause changes in clearance. Epilepsy doesn’t incr risk of aneuploidy. Monitor growth.
Continue AED doses in labor and postpartum. Proper sleep hygiene.
Most common surgical problem in pregnancy?
Differential diagnosis for RLQ pain in pregnancy?
Appendicitis. CBC, T&S, lactate if ill-appearing, abdominal US. sx of n/V, anorexia, guarding, rebound, fever.
The McBurney point is the most common site of maximum tenderness in acute appendicitis. one-third of the distance from the anterior superior iliac spine to the umbilicus
Appendicitis, pyelonephritis, nephrolithiasis, uterine rupture, abruption, degenerating fibroid, ruptured ovarian cyst, PTL, GI (constipation, viral gastroenteritis), MSK/muscle strain
How would you manage appendicitis? Consult gen surg. If surgery, would counsel them on fetal monitoring pre and post procedure, proper positioning (LLDB), mechanical VTE prophylaxis.
What foods are at high risk of listeria?
What are symptoms of listeria?
Soft cheese, deli meats, smoked seafood, unwashed produce
N/V, abdominal upset, myalgias, diarrhea
What are fetal effects of listeria?
How do you diagnose?
How do you manage?
Can cause fetal infection, fetal loss, neonatal sepsis and death
DDx w/ Blood culture. Report to health department.
Just monitor for fever. If exposure and fever, IV ampicillin x 14d. If allergic, bactrim.
What is a contraction stress test?
assess fetal wellbeing. -oxygenation decr during uterine contractions and late decals will occur.
- requires 3 contractions lasting 40 sec over 10 min period (achieve w/ labor, nipple stem or IV pit)
- pt in lateral recumbent position
Neg: no decels
Pos: Late decels w/ 50% or more contractions
Suspicious: intermittent late or significant variables
Equivocal: decals following contractions where contractions are q2min and last >90 sec
Unsatisfactory: fewer than 3 contractions in 10min period
What is a BPP?
Comprises 5 components:
- NST
- Breathing (1 fetal breathing movement at least 30sec)
- Tone: 1 flexion/extension movement (Extremity or hand)
- Movement: 3 or more distinct body movements
- AFI with greatest vertical pocket 2cm or greater
8 or 10=normal
6=equivocal
4=abnormal
What would you expect umbilical cord gases to reveal if BPP was 6/8 with occasional variables?
Pathologic fetal anemia: pH <7.0, base deficit linear relationship w/ lactate acid and correlates w/ neonatal neurologic morbidity. Base excess >12 predicts newborn complications. BE 12-16=incr newborn mortality and encephalopathy.
