Pregnancy Flashcards
Rx to avoid
Stop retinoids / Vitamin A >10,000 units/day (risk of malformations in T1)
Stop ACE-i/ARB (risk of fetal kidney disease in T2/T3)
Change to methyldopa, labetalol, calcium channel blocker (Nifedipine XL)
Stop oral anti-hyperglycemic
Consider metformin or glyburide
Stop warfarin (risk of malformations in T1)
Consider heparin/LMWH
Avoid lithium (very low risk of Ebstein anomaly and malformations in T1)
Avoid valproic acid/anticonvulsants (risk of malformations in T1)
Avoid Sulpha drugs and Trimethoprim (anti-folate risk in T1, and kernicterus in T3)
Avoid tetracycline (bone development, teeth staining)
Avoid NSAIDs (cardiac defects after 20w, spontaneous abortion - reduced PGs during implantation; before 20w unclear but avoid)
Risks of untreated depression often outweigh risks of antidepressants
Low risk of teratogenicity (some data suggests paroxetine may have small increase in congenital heart defects, other studies have not found this association)
May be associated with a small reduction in gestational age at birth that is not clinically significant
ASA wks to start and until how many weeks
Prevent Pre-eclampsia
ideally after 12 weeks and before 16 weeks
can start before 28 wks
ad delivery vs 36 wks vs 10 d prior delivery (diminish risks of bleeding)
When to start ASA
either 1 high risk factor or 2 moderate risk factors:
- 1 high risk factor: history of preeclampsia, multifetal gestation, chronic hypertension, DM1 or DM2, renal disease, autoimmune disease (SLE, antiphospholipid)
- 2 moderate risk factors: Nulliparity, Obesity (BMI≥30), family history of preeclampsia, age 35 years and older, sociodemographic risk factors (low socioeconomic status, etc), or personal history factors (fetus is small for gestational age, previous adverse pregnancy outcomes, etc)
What to do if Rh - woman
Rh Ig (WinRho) 300mcg IM at 28w
Ultra sound during pregnancy (4)
- T1 dating ultrasound
- Serum Integrated Prenatal Screen SIPS + Nuchal Translucency ultrasound (11-13.6w, best at 12-13.3w)
- 20w morphology
- T3:
GDb: Serial ultrasound to monitor growth
LOW amniotic fluid index (AFI), less than 5 cm, the pregnant woman has oligohydramnios
Second Trimester (13-28w) what do you do and when
Each visit: weight, BP, FHR (by handheld Doppler starting T2)
20w - Routine ultrasound
Symphysis Fundal Height
Fetal movement should be felt
26-28w - Labs
50g OGT
CBC, ferritin
Repeat Type and Screen if Rh neg
28w - Rh Ig (WinRho) 300mcg IM
Consider repeat HIV, Gono/Chlam, Syphilis if high risk
Third Trimester (29-40w) what do you do and when
Visits q2w
Fetal movement counts if decreased movements (NST/BPP if <6 distinct movements in 2h)
Vaccin coqueluche (26-32 sem)
35-36w - GBS vaginal and rectal swab (results valid for 5w)
HSV prophylaxis PRN (eg. Valtrex 500mg PO BID)
Give copy of prenatal sheets
Visits weekly
38w - Consider cervical examination and membrane stripping
40w - Consider induction of labour for postdates (at 41.1-41.5) vs. expectant management (fetal monitoring with NST/AFI twice weekly)
Bactérieurie tx (sx ou asx)
Amoxicillin 500mg PO TID x7d
Nitrofurantoin 100mg PO BID x 7d (avoid at labour because of hemolytic anemia)
TMP-SMX 1 DS tab BID x 3d (avoid in first trimester and near term)
Amoxicillin-clavulanate 500mg PO BID x7d
Consider repeat culture 1-2w after treatment
PROm vs PPROM;
RPPM RPM RSM and mngmt
Premature rupture of membranes (PROM) is a rupture (breaking open) of the membranes (amniotic sac) before labor begins.
If PROM occurs before 37 weeks of pregnancy, it is called preterm premature rupture of membranes (PPROM).
RPPM: rupture préterme prématurée des membranes = rupture + travail <37 sem
* RPM: rupture prématurée des membranes = rupture sans travail
o Si >= 36 sem et col favorable –> induction si pas de CU à 6-12h post RPM
o Si >= 36 sem et col NON favorable sans infection –> induction à 24h
* RSM: rupture spontanée des membranes = rupture + travail entre 37-40 sem
visits
Visits:
* Q 1 mois ad 32 sem
* Q 2 sem ad 36 sem
* Q 1 sem ad accouchement
Pre-éclampsie Risk Factos
ATCD prééclampsie ou HTA gestationnelle personnelle ou familiale
o 1ère grossesse ou nouveau partenaire
o Multiples gestations, grossesse aN (molaire)
o Mère <18ans ou >35 ans
o HTA, DB II, obésité (IMC >30)
o Maladies rénales ou lupus (ex. néphrite lupique)
Pre-éclampsie diagnistique
- Hypertension (TA systolique ≥ 140mmHg ou diastolique ≥90mmHg 2x à 4h d’intervalle) chez
une femme avec TA N auparavant - Protéinurie (≥0,3 g (300 mg/d) de protéines en 24 heures ou protéine/créatinine ≥0,03 (30
mg/mmol)) et/ou évidence de dysfonction d’autres organes
Pre-éclampsie investigations
Labos:
* FSC, INR/PTT, fibrinogène (si suspicion de DPPNI)
* Fonction hépatique: ALT, LDH, albumine
* Fonction rénale: Créat, DFG, A/U, protéinurie 24h OU spot prot/créat urinaire
Pre-éclampsie prevention tx
ASA 81 аt ≥12 weeks of gestation, and ideally prior to 16 weeks
some advocate discontinuation аt 36 weeks of gestation or 5 to 10 days before expected delivery to diminish the risk of bleeding during delivery
Pre-éclampsie tx
1 Adalat XL 30 mg PO BID max 120 mg/j (Nifédipine)
▪ Action brève: si grave, action intermédiaire: si modérée, action longue (XL): si
non grave
#2 Hydralazine 5 mg IV (Rx d’URGENCE) –> répéter 5-10 mg IV toutes les 30 min, ou de 0,5-
10 mg/h IV, max: 20 mg IV (ou 30 mg IM)
▪ Pourrait accroître risque d’hypoTA maternelle
min, ou de 1-2 mg/min, max. : 300 mg (puis passer PO)
▪ Éviter l’utilisation chez les femmes avec asthme ou IC
▪ Risque de brady fœtale lors de travail
HELLP syndrome definition
HELLP (Hémolyse, Elevated Liver enzymes, Low Platelets) syndrome
Eclampsia definition
convulsions + signes et sx pré - éclampsie
avant pendant ou après accouchement
HTA chronique vs pré-éclampsie
- existance avant grossesse
- dév avant 20e sem
- persistance 12 sem après accouchement
dx surjaouté à la pré-éclampsie
- protéinurie après 20e sem; trombocytopnie, ALT augmenté
- augmentation soudaine TA
- résistance à 3 anti-TA
HTA gestationnelle definition
HTA sans protéinurie ou autres signes de dysfonction des organes apparait pour la première fois
après 20 semaines de gestation ou dans les 48 à 72 heures suivant l’accouchement et se résout
12 semaines après l’accouchement.
GDM maternal complications
Hypertension
* Polyhydramnios
* Retinopathy
* Hypoglycemia
* Pyelonephritis/UTI
GDM fetal complications
Macrosomia
* IUGR
* Hypoglycemia
* Polycythemia
* Fetal lung immaturity
GD risk factors
Obesity
o Previous pregnancy with GDM or IGT
o Family history of DM
GD diagnosis
Screen at 24-28w with 50g OGTT, consider early HbA1c or fasting glucose if higher risk
* 1h 50g OGTT
* <7.8 mmol/L = normal
* 7.8-11.0 -> Indication for 2h 75g OGTT
- 2h 75g OGTT
- FPG ≥ 5.3 mmol/L
254 - 1h ≥ 10.6 mmol/L
- 2h ≥ 9.0 mmol/L
- ≥ 11.1 GDM
GD pharmacoltherapy
insulin, metformin, glyburide (diabeta aka sulfo mais pas diamicron)
GD mngmt towards the end; during labour and pp
Serial ultrasound to monitor growth
o Induce by 40w gestation
* Blood sugars hourly during labour
o Follow-up with repeat 75g OGTT between 6 weeks and 6 months postpartum (risk of DM2)
PRURITUS during pregnancy, look for
intrahepatic cholestasis
- pruritis hands and soles worse at night, no lesions
- elevated transaminases
intrahepatic cholestasis during pregnancy tx and mngm
Ursodeoxycholic acid (ursodiol) 15mg/kg/day = 300mg PO TID
* Sx tx: anti-histaminique ou crème hydratante (ex. Atarax)
* Early delivery at 36w
* Follow LFTs up to 6-8w post-partum
RPM (PROM) complications
Infection (fetal/maternal), umbilical cord prolapes/compression
Labor dystocia definition stade 1 actif
prolongation or arrest of labor less than 0.5cm in 4h
or no dilation in 2h
dystocia causes (4P) and general mgmt (one word)
*Puissance des contractions - oxy
* Passage - empty bladder
* Passager : Position, taille (macrosomie, disproportion céphalo-pelvienne), attitude, aN - reposition
* Psyché : Dlr + Anxiété - réassurance
type de dystocie spécifique and possible consequences
shoulder dystocia
cause - macrosomie + souvent
Impaction of anterior shoulder on symphysis pubis (AP diameter)
risk:
hypoxia, fractures, brachial plexus pasly
shoulder dystocia what to do (5)
ALARM
- ask for help and tell pt to stop pushing
- lift legs up: mcroberts position
- apply pressure on symphysis
- roll on all 4s
- manual remove - try getting post arm
4 T PP hemorrhage
uterine atony [Tone]; laceration, hematoma, inversion, rupture [Trauma]; retained tissue or invasive placenta [Tissue]; and coagulopathy [Thrombin]
HPP definition
HPP définition: > 500 ml au moment de l’accouchement ou >1000 ml après une césarienne
mgnmt HPP
- massage
- oxy 10 units IM, then 20-40 units/1L NS infusion 200-500mL/h titrated to uterine tone
- empty bladder
- Tranexamic acid 1g IV over 10 mins, repeat after 30 mins if needed
Consider other uterotonics
5. Carboprost (Hemabate) 0.25mg IM q15mins (max 2mg)
6. Avoid in asthma
o Misoprostol 800mcg sublingual or rectal
Prelabour Rupture of Membranes (PROM) mngmt and when to indice
1) admit
2) daily biophysical profile + WBC
3) term PROM = induce >37wk
confirmation de PROM (7)
- hx of gush
- post fornix poooling
- fern test ou fougère au microscope
- nitrazine bleu = positif
- amnisure test / actim
- écho pour voir liquide amniotique
- culture pour STIs (r/o)
PPROM management according to weeks
Glucocorticoids (betamethasone x2) + antibio <34w
Magnesium sulphate for neuroprotection <32w
3 ways to induce labour (pharma)
IV Oxytocin
Vaginal Prostaglandin (higher chorio rates if PROM)
PO Misoprostol
high risk patients social (5)
teens,
domestic violence victims, single parents,
drug abusers,
impoverished women
change valproic acid (valproic / depakene) and phenytoin (dilantin) for which epileptic drugs
Lamotrigine (lamictal)
levetiracetam (keppra)
definition Chronic (preexisting) hypertension 2
prior to pregnancy or onset <20w gestation
sBP ≥140 or dBP ≥90 on two measurements at least four hours apart
Definition Gestational Hypertension 4
(onset >20w gestation)
sBP ≥140 or dBP ≥90 on two measurements at least four hours apart
No proteinuria
No severe features of preeclampsia
Definition Preeclampsia
sBP ≥140 or dBP ≥90 on two measurements at least four hours apart, or sBP ≥160 or dBP ≥110 confirmed within shorter interval (within minutes)
AND one of the sx:
Proteinuria (eg. Urine PCR ≥0.3, or ≥0.3g protein in 24h urine )
OR
Severe features of preeclampsia
Definition de protéunirie pour le dx de pré-éclampsie (3 possibilités)
protein/creatinine ratio ≥0.3 (30 mg/mmol) in a random urine specimen
Proteinuria ≥0.3 g in a 24-hour urine specimen
or dipstick ≥2+ if a quantitative measurement is unavailable
definition Preeclampsia on chronic hypertension
Sudden increase in blood pressure,
with new onset proteinuria
OR
Severe features of preeclampsia
definition Eclampsia
Generalized seizures due to preeclampsia
HELLP syndrome definition
Hemolysis, Elevated Liver enzymes, Low Platelets
May have hypertension
Severe features of Preeclampsia
1) Symptoms of CNS dysfunction
- Severe headache (ie, incapacitating, “the worst headache I’ve ever had”) or headache that persists and progresses despite analgesic therapy
- Altered mental status
2) VISUAL sx Photopsia, scotomata, cortical blindness, retinal vasospasm
3) Pulmonary edema
HELLP (2/3 labs)
4) Hepatic abnormality
- Severe RUQ or epigastric pain unresponsive to medication and no alternative diagnosis
- Serum transaminase ≥2 x ULN
5) Thrombocytopenia
Platelets <100,000 platelets/microL
6) Renal failure
Creat >97.2 micrmol/L or doubling of concentration (in absence of other renal disease)
Prevention of preeclampsia low risk vs high risk (2 molecules)
low risk
- ASA low dose = not helpful
- Calcium supplement >1g/d or increase dietary calcium
High risk
- Low-dose aspirin (75-160mg daily) small decrease in risk (~10%)
Earlier = better (<16w)
- High dose calcium 1-2g calcium
Note: If already established preeclampsia, no difference if given aspirin/Calcium
Investigations preeclampsia (labs + baby) 7+2
1) Vitals (including Oxygen saturation)
2) UA (≥1+ proteinuria without RBC or casts)
3) Urine protein:creatinine ratio ≥0.3 (may consider confirming ≥0.3g protein in a 24-hour urine specimen)
4) CBC (decreased Hb/plat)
5) INR/aPTT, fibrinogen (increased INR/aPTT, decreased fibrinogen)
6) Serum creat, uric acid, glucose, AST/ALT, LDH, Bili, Alb
7) Blood type and crossmatch (if suspect will need transfusion)
8) Fetal status (NST, BPP)
9) Consider ultrasound for amniotic fluid volume and fetal weight (risk of oligohydramnios and fetal growth restriction)
mgmt pre-eclmapsia acute
refer to obs
acute lower BP <160/110 for strokes
maintenance: Target BP <140/90
mngt Antihypertensive drugs - acute (3)
First line:
- Nifedipine 5-10mg PO q30 mins for response or = adalat
- Labetalol 20-40mg IV q30mins (max 220mg/day)
Second line:
Hydralazine 5mg IV q30mins (max 20mg/day)
mngt Antihypertensive drugs - chronic HTA (3)
First line
oral labetalol,
oral methyldopa,
Nifedipine PA or XL
seizure prophylaxis - eclampsie
MgSO4 4g IV over 30 min
during labour and first 24h
+ sx of Mg toxicity
if Mg toxicity what to give
10mL of 10% calcium gluconate IV
Preeclampsia with severe features when to deliver
deliver regardless of age
1st trimester bleeding ddx (5)
Implantation bleed
Abnormal pregnant (Ectopic/molar)
Abortion (threatened, inevitable, incomplete, complete, missed, septic)
subchorionic hematoma (hématome sous-chorionique)
Non-Obstetrical (Uterine, Cervical Vaginal Pathology)
2nd and 3rd trimester bleeding ddx (5) not painful (3) and painful (2)
NOT PAINFUL
1) Bloody show - 72h prior labor PPROM
2) Placenta previa (20%), placenta covering OS
3) Vasa previa (rare) vessels covering OS
PAINFUL
4) placental abruption (30%) =
décollement placentaire
* contractions
5) Uterine rupture (rare)
investigations pregnancy bleeding (4-5)
CBC
Blood type
Serial b-hCG
Abdominal Ultrasound
Transvaginal Ultrasound
Chorioamnionitis how to diagnose (2 of 4)
Presumptive diagnosis
1) Fever (T (≥39°C or ≥38°C on two occasions 30mins apart)
2) One of
- Baseline FHR >160/min for ≥10 mins (excluding periods of variability)
- Maternal WBC >15 in absence of corticosteroids (ideally showing left shift)
- Purulent fluid from cervical os visualized by speculum
Chorioamnionitis treatment
1) antibio
- Broad-spectrum antibiotics, eg. Ampicillin 2g IV 6h and Gentamicin 5mg/kg once daily
- Consider Clindamycin or Metronidazole to cover aneaerobes if undergoing surgery
2) Prompt induction or augmentation of labor (cesarean only for standard obstetrical indications)
Normal Fetal HR baseline - monitoring
110-160, at least 2 accelerations (≥15bpm lasting ≥15s) in 40mins strip
Heart rate - when to worry tachy and brady
Abnormal >160 for 10 mins or <110 for 10 mins,
