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Med School > Pregnancy: Newborn and Delivery > Flashcards

Pregnancy: Newborn and Delivery Flashcards

1
Q

Who is offered GDM screening and when? What tests are done?

A
  • offered to everyone at 24-28w, also 12-16w if high risk

One Step Screen
- 75g glucose
- 3 measurements: fasting, 1h, 2h (5.1,10,8.5)
- if anything is above a cutoff, Dx
- single visit, but high false (+) rate

Two Step Screen
- 50g glucose
- 1 measurement: 1h (under 7.8, 7.8-11, over 11)
- if between 7.8-11 then 75g test done (5.3,10.6,9)
- lower false (+) rate, no fast unless second test

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2
Q

How much more calories does a pregnant person need?
Iron?
Folic acid?
Omega FAs?
Vitamin A?

Why are all these needed?

A
  • 350-450kcal/day, 1-3 extra servings/day from all 4 food groups
  • 16-20mg/day iron in supplement (needed for hematopoiesis of both mom/fetus and fetal neurocognitive development)
  • 0.4mg/day supplement folic acid (needed for maternal hematopoiesis and fetal NT development)
  • 150g fish/week or 2 servings (also walnuts, flax seed, canola oil), needed for fetal neuro and retinal development
  • vitamin A can be teratogenic so no more than 10,000 IU/day

*calcium and vitamin D are the same as pre-pregnancy
*vitamin B12 only a concern if vegan/celiac/ IBD
*zinc only a concern if low resource community
*choline important for cell membrane synthesis, neurotransmission, and brain development but not yet recommended

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3
Q

Things to avoid in pregnancy - why?

A
  • listeria (unpasteurized milk/cheese, sushi, meat, raw sprouts)
  • toxoplasmosis (meat, uncured meat if not frozen)
  • salmonella (raw eggs)
  • smoking (LBW, miscarriage, stillbirth, premature delivery, abruption, SIDS)
  • weed (still birth, neuro development)
  • alcohol (FASD/ARND, liver, kidney, eyes)
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4
Q

Exercise Recommendations in Pregnancy

A
  • continue as before (do not exceed)
  • walking 15m 2-3x/week
  • avoid shear forces, stop/start/ trauma risks
  • start pelvic floor exercises in intermediate postpartum (decreases urinary incontinence)
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5
Q

Vitamin D/B12/Calories/Iron/Vitamin A/C/ choline requirements while breastfeeding?

A

Vitamin D - prevents Ricketts/ RA/ osteoporosis/ etc.
- 400/day if exclusively bf in 1st year
- 800/day if northern indigenous in winter

Vitamin B12 - deficiency rare, concern of vegan/ pernicious anemia in mom

Calories - more than pregnancy (400-600cal/day) - will be hungrier!

Iron - less iron needed (only 9mg/day)
- stores depleted around 6 months, can delay CNS

  • more vitamin A/C/ choline than pregnancy
  • hydrate and rest, continue prenatal vitamin
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6
Q

Sensitivity
Specificity
False (+) Rate (equation)
PPV

A

Sensitivity - true (+) rate, ability to rule something out by correctly identifying who has it
= true (+)/ (true(+) + false (-))

Specificity - true (-) rate, ability to rule something in by correctly identifying who doesn’t have it
= true (-)/ (true (-) + false (+))

False (+) Rate = 1 - specificity
PPV - true (+)/ all (+) (proportion of + results that are actually truly diseased)

  • a false positive does NOT indicate an ongoing risk
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7
Q

How does disease frequency affect test performance?

A
  • even with the same Sn/Sp, there is a higher PPV if the prevalence is higher
  • for population screening of a rare disease, need test with very high specificity
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8
Q

Differences between diagnostic and screening testing?

A

Diagnostic - symptomatic population, reference intervals (percentiles), increased precision and accuracy, lower throughput and higher cost

Screening - asymptomatic population, screening cutoffs, must have high sensitivity and specificity, higher throughput and lower cost

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9
Q

What is the Dobrow Criteria for Screening?

A

Disease - should be understood, clear target population, significant health concern
The Test - efficacious, affordable, allows for risk stratification
The intervention - effective, available, improves outcomes, burden of screening understood and accepted
The System - adequate infrastructure, coordinated, cost-effective, ongoing support

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10
Q

How does new born screening work?

A
  • must be informed, it is an opt-out program
  • must repeat testing if the infant is over 1500g or transfused prior to collection
  • prenatal genetic screen –> trisomy 18/21, open NTDs, need confirmation from amnio or CVS

NIPS - detection of fetal cell-free DNA in maternal circulation, better performing but self-pay

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11
Q

Changes that occur to the BLOOD in pregnancy

A
  • 40-45% increase in blood volume (plasma) - helps maintain perfusion to the placenta, protect against partition related blood loss (this is even more if it’s a twin pregnancy!)
  • thrombocytopenia due to hemodilution, only a concern if platelets are under 150x10^9, can get as low as 100
  • leukocytosis, WBC may go up to 25x10^9 in labour
  • Hgb lowers - there is an increase in erythrocyte production but this is outweighed by increase in plasma volume (if under 105-110 consider iron supplement)
  • iron demands increase in 2nd/3rd trimester, 27mg/day recommended

*screened for anemia at 28 weeks

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12
Q

Mass effect changes that occur during pregnancy?

A
  • appendix may move
  • worsens urinary frequency
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13
Q

Changes that occur in the KIDNEYS during pregnancy?

A
  • hydronephrosis - uterus compresses ureters against the pelvic brim (more so on the right side as sigmoid colon cushions L), most renal colic in pregnancy is on the right side
  • renal plasma flow increases (GFR increases by 50% by 2nd trimester)
  • hypervolemia
  • creatine decreases
  • urinary frequency common
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14
Q

What changes occur with respect to RA in pregnancy?

A
  • most autoimmune disease improve in pregnancy and flare postpartum
  • RA flares increase risk of preterm delivery/ placental dysfunction
  • change in meds - NSAIDs can cause oligohydramnios/ premature closure of ductus arteriosus, methotrexate is teratogenic so switch to hydroxychloroquine and sulfasalazine
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15
Q

What changes occur with RESPIRATION in pregnancy?

A
  • diaphragm rises 4cm and thoracic circumference increases by 6cm
  • total lung volume is mostly unchanged (small decrease)
  • minute ventilation increases but respiratory rate is unchanged
  • tidal volume and inspiratory capacity increase, FRC decreases, progesterone increases respiratory. drive
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16
Q

What changes occur in the HEART with pregnancy?
- what are some red flags?

A
  • heart displaces due to the rising diaphragm - LAD on ECG and increased silhouette on CXR
  • 90% will have systolic ejection murmur
  • splitting of S1
  • 3rd heart sound ventricular gallop (increased blood volume hitting a compliant LV)
  • CO increases by 30-50%
  • HR increases about 10bpm, palpitations common
  • supine hypotension syndrome (SV lowers when supine and increases when lateral)
  • LV mass increases by 30-35%, function is normal - this occurs due to decreased SVR

*red flags for palpitations are PROLONGED, syncope, chest pain, SOB
* failure to establish a low resistance high flow shunt often lead to hypertension in pregnancy, failure of trophoblasts to invade spiral arteries can lead to abnormal implantation

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17
Q

Definition of:
- Gestational HTN
- Pre-existing HTN
- Pre-eclampsia

A

Gestational - over 140 SBP or 90 DBP (at least 2 measurements 15m apart)
- develops around 20 weeks and resolves around 12 weeks postpartum

Pre-Existing - high BP prior to 20 weeks, persistent after 12 weeks postpartum
- risk of superimposed gestation HTN/pre-eclampsia

Pre-Eclampsia - gestation HTN with new proteinuria or presence of adverse features
- 20% of pre-eclamptic seizures occur without proteinuria

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18
Q

Risk factors for HTN Disorders in Pregnancy (HDP)?
Prevention of HDP?

A
  • prior pre-eclampsia, pre-exisitng HTN, obesity, DM/CKD/SLE, age 35+, nulliparity, multiple pregnancies
  • calcium 1g/day (anti-inflamm and decreases endothelial cell activation)
  • low dose aspirin before 16w (prevents inflammation and thrombosis)
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19
Q

What is the etiology of HDP?

A
  • decimal immune cell - EVT interactions –> inadeuquate placentation (early onset)
  • normal placentation (macrosomia, multiple pregnancies) (late onset)
  • endothelial cell activation
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20
Q

Pre-Existing HTN effects on pregnancy?
- med changes?

A
  • decreases perfusion which can lead to IUGR, oligohydramnios, HDP
  • BP (in normal pregnancy) should lower in 2nd trimester and then increase again at end of pregnancy
  • avoid ACEi/ARBs, switch to labetalol and nifedipine
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21
Q

What are some adverse consequences of HDP?

A
  • headache, eclampsia, GCS <13, stroke/TIA
  • chest pain, dyspnea, pulmonary edema, MI
  • increased WBC and INR, DIC, low platelets
  • increased Cr and Uric Acid, AKI, dialysis
  • N/V, RUQ or epigastric pain, increased AST/ALT/bilirubin, hepatic dysfunction or rupture
  • placental abruption
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22
Q

Monitoring and treatment for HDP?

A
  • monitor kick counts, should be 6 or more in 2h
  • non-stress test
  • U/S (growth, fluid, umbilical arteries)
  • treat with labetalol/nifedipine/methyldopa to prevent hemorrhagic stroke
  • treat with MgSO4 to prevent seizure
  • DELIVER AS SOON AS BABY IS 37 WEEKS, if under 35 weeks weigh pros and cons, corticosteroids and MgSO4 to prevent cerebral palsy if under 32 weeks
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23
Q

What is primary vs secondary vs tertiary prevention?

A

Primary - reproductive carrier screening
Secondary - newborn screening and early treatment
Tertiary - treatment of symptomatic patients

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24
Q

Where is high definition vision?

A
  • Macula (even better in the fovea, which is only cones)
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25
Q

Afferent vs Efferent visual pathways

A

Afferent - ganglion cells of retina project through optic nerve to the ipsilateral pretectal nucleus

Efferent - pupillary motor output from pretectal nucleus to the ciliary sphincter muscle of iris (dinger Westphal)

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26
Q

Myopia vs Hyperopia

A

Myopia - can’t see far, image is formed before the retina, long eyeball

Hyperopia - can’t see close-up, image formed behind the retina, short eyeball (more common in children)

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27
Q

Growth and development of newborn eyes

A
  • newborn eye is 15-16mm, adult size by age 14
  • newborn eyes has axial hyperopia which is neutralized by an increase in axial length
  • vision in a newborn is 20/1200 (can fix a face within 1 meter), 20/600 at 1 month, and 20/200 at 4 months
  • do not get to 20/20 until age 5
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28
Q

Important developmental milestones from 0-adulthood

A
  • 0-3months - macula thins, brain learns to see
  • 6 weeks - definite fixation and following reflexes
  • first 3-4 months - time when issues should be resolved to prevent permanent problems
  • 3-5 years - developing visual acuity
  • few months to 7/8 years - when deprivation causes amblyopia
  • time of deprivation to adult - period when amblyopia can be fixed
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29
Q

What are considered normal optic findings after normal delivery?

A
  • retinal or subconjunctival hemorrhages that are limited to the sclera (pressure of delivery)
  • eyelid edema or eversion
  • dysconjugate movement up to 2 months (unless fixed)
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30
Q

Torticollis
Asymmetric Blink
Ptosis

  • treatments?
  • when to refer?
A

Torticollis - head turn that can make eyes appear straight, often a 6th nerve palsy

Asymmetric Blink - 7th nerve palsy, unable to move lips on affected side and nasolabial fold flattening
- most resolve within days, treat with cornea lubrication and investigate with electro testing if not
- could also be absence/ hypoplasia of depressor angle iris

Ptosis - drooping of levator palpebrae, 3rd nerve palsy (eye also down and out)
- often compensate with chin up and eyebrow raise
- Marcus gunn jaw winking - when jaw opens, eye opens
- refer if young or older and signs of palsy/abnormality
- treat with a frontal sling or elevator resection

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31
Q

Common lumps around the eye
- when to refer?

A
  • hemangioma
  • mucocele
  • dermolipoma
  • refer if mucocele not resolving by 2w/ infected
  • hemangioma that affects eyelid/orbit
  • stye not resolving by 2 months
  • orbital mermaids
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32
Q

Cause of nasolacrimal duct obstruction
- risk factors
- sx
- dx
- tx

A
  • membranous obstruction of valve of Hasner
  • Down’s, craniosynostosis
  • signs: mucous discharge, tearing, reflux with massage
  • dx: fluorescin dye
  • tx: massage, tear duct probing, surgery if longer than 12m

OR

  • dacryocele
  • tx: lacrimal probing no later than 1m after birth
  • if progression to dacrocystitis, ABX and surgical decompression
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33
Q

Opthalmia Neonatorum (broad category)
- causes

A
  • pink eye
  • chlamydia, gonococcal, HSV, chemical irritant
  • emergency! can cause blindness within 48h
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34
Q

Chlamydia Conjunctivitis
- timeline
- sx
- dx
- tx

A
  • most common infectious cause
  • 5-14 days postpartum
  • discharge, pseudomembranes

Dx: culture of conjunctiva, spot tests (ELISA) and PCR
Tx: systemic erythromycin

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35
Q

Gonococcal Conjunctivitis
- timeline
- sx
- dx
- tx

A
  • secondary to prohlyaxis
  • 2-5 days postpartum
  • profuse purulent discharge, eyelid edema
  • dangerous! cornea can ulcerate/ perforate

Dx: culture and gram stain of conjunctiva
Tx: IM ceftriaxone, topical penicillin G

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36
Q

HSV Conjunctivitis
- risks for baby
- type? sx
- tx

A
  • 50% risk if mom has primary disease, 30% if first episode, 1-3% if recurrent
  • often type 2 in neonates, type 1 in children
  • type 1 - bilateral conjunctivitis, vesicles, dendritic ulcer on corneal epithelium
  • tx: acyclovir, head CT/MRI at end of therapy
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37
Q

Glaucoma
- why does it happen?
- sx
- tx

A
  • big or cloudy eyes
  • fluid is made by the ciliary body and flows into the trabecular meshwork. glaucoma occurs when fluid inflow is more than outflow
  • i.e. absence of angle recess with iris directly in the trabceulum (congenital disorder)
  • corneal edema, lacrimation, photophobia, optic disc cupping, buphthalmos, breaks in the descemet membrane

tx - goniotomy - needle placed into meshwork

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38
Q

Important aspects of infant vision assessment

A

-reaction to light (newborn)

  • stimulus run to a face (6 weeks)
  • red reflex - should be symmetric, no opacities/white/dark spots, strabismus (RR is more intense from deviated eye), leukocoria - white/yellow reflex, can indicate cataract or retinoblastoma (REFER)

Strabismus - estropea (in), exotropia (out), hypotropia (one eye out), hypertrophic (one eye up)

39
Q

When should you refer a child with eye concerns?

A
  • constant, intermittent but persists for 3 months
  • nystagmus
  • abnormal red reflex
  • poor vision
  • not tracking by 2 months
  • not tracking at any age with nystagmus or abnormal pupil reactions
40
Q

How is glucose managed from fetus to neonate?

A
  • fetus gets ALL glucose from mom
  • after cord clamping, glucose rapidly decreases and then increases over 2-3 hours

1st hour - resp quotient decreases to 0.8, suggesting a shift from glucose to significant fat contribution

day 1 - 50% endogenous glucose comes from glycogenolysis, 35% from gluconeogenesis

41
Q

BF effect on glucose

A
  • breast fed babies have less glucose but more ketones
  • tolerate a decrease in glucose without clinical manifestations
42
Q

How is glucose regulated?

A
  • main energy source for the brain
  • regulated by [plasma] and GLUT1 in the brain and GLUT3 in the cerebellum
  • a drop in glucose activates alternate fuels such as pyruvate, lactate, ketones
43
Q

Neurogenic vs. Neuroglycopenic symptoms of hypoglycaemia

A

Neurogenic
- adrenergic - tremors, irritable, tachypnea, pallor, anxiety and palpitations in adults
- cholinergic - sweating, hunger and parenthesis in adults

Neuroglycopenic
- poor suck, poor feeding, weak and high pitched cry, decreased LOC, seizures, hypotonia

*other (not specific) - apnea, bradycardia, cyanosis, hypothermia

44
Q

Risks for neonatal hypoglycaemia

A
  • low reserve - preterm, SGA, IUGR, low glycogen stores
  • increased demand - hyperthermia, sepsis, polycythemic
  • abnormal regulation - GDM (hyperinsulinemia results in less gluconeogenesis), hypercortisolemia, GH deficiency
45
Q

How is screening for neonatal hypoglycaemia done?

A
  • routine screening in term/healthy infants is not recommended
  • if asymptomatic but at risk, screen every 3-6 hours starting at 2 hours
  • if SGA/ preterm, screening is continued for 24 hours after birth
  • if GDM/LGA, screening is continued for 12 hours after birth
  • in general, screening continues until the vulnerable period has passed or [glucose] remains over 2.6 in first 72 hours and over 3.3. over 72 hours
46
Q

When do we treat neonatal hypoglycaemia?

A
  • if symptomatic, treated for glucose under 2.6mmol/L
  • enteral supplement is given in asymptomatic babies if between 1.8-2.5
47
Q

Why do we treat neonatal hypoglycaemia?

A
  • longer time spent with NH results in impaired psychomotor and mental development
  • assx with learning disabilities, seizure disorders, visual impairment (affects portico-visual pathways on MRI), neurodevelopment delay if severe (under 1mmol/L) or persistent (over 2/3 hours)
48
Q

What cause of hypoglycaemia would you suspect if:

  • acidemia, increased lactate
  • acidemia, increased ketones
  • non-acidemic, low ketones and high FFAs
  • non-acidemic, low ketones and low FFAs
A
  • acidemia, increased lactate - gluconeogenic enzyme deficiencies
  • acidemia, increased ketones - GH or cortisol deficiency
  • non-acidemic, low ketones and high FFAs - fatty acid oxidation effect
  • non-acidemic, low ketones and low FFAs - hyperinsulinism
49
Q

How do we treat neonatal hypoglycaemia? How do you calculate glucose infusion rate (GIR)?

A
  • feeding, dextrose gel, IV dextrose, glucagon, dizoxide (prevents insulin release), glucose polymers

GIR = (IV rate (mL/h) x [dextrose] (g/100mL) x 1000mg/g)/ 60(min/h) x weight (kg)

i.e. D10W at 3mL/h, 1.5kg = 3 x 10 x 1000/ 60x 1.5 = 333.33 or 3.33mg/kg/min

50
Q

Hyperbilirubinemia in Neonates
- risk factors

A
  • results in jaundice once bilirubin is more than 85mmol/L (head), over 340mmol/L (feet)
  • risk factors: visible jaundice <24h or before discharge, under 38 weeks gestation, previous sibling, male, mom over 25, asian or European, dehydration, exclusive or partial breast feeding
51
Q

Physiological vs. Pathological Hyperbilirubinemia

A

Physiological - 2-3 days postpartum, decrease RBC lifespan, increased RBC mass, immature liver enzymes

Pathological - under 24 hours or over 2 weeks
- conjugated, excessive rate of increase (over 85 per 24 hours)

52
Q

Causes of Unconjugated vs. Conjugates bilirubinemia in neonates

A

Unconjugated - bleeding (cephalohematoma, hemorrhage, delayed cord clamping, twin to twin or mom to fetus transfusion)
- Rh/ABO incompatibility, PKD, thalassemia
- dehydration, breast feeding day 10-14
- Gilbert’s
- HYPOthyroidism
- bowel obstruction (more enterohepatic circulation)

Conjugated - biliary atresia (PALE WHITE STOOLS), choledochal cyst
- hepatitis (CMV, HBV, sepsis)
- inborn errors of metabolism (CF, hypothyroidism, a.a disorders)

53
Q

Kernicterus
- what is it
- sx
- risks
- prognosis

A
  • deposition of unconjugated bilirubin into the brain
  • early sx: lethargy, poor feed, respiratory distress, less reflexes, no moro reflex
  • late sx: opisthotonus, bulging fontanelle, twitching, high pitched cry
  • increased risk if premature, infection, hyperosmolic, asphyxia
  • can lead to hearing loss, lowered IQ, rigidity, movement disorders, death
54
Q

Treatment for Jaundice

A
  • if high risk, phototherapy (look at bilirubin graphs for severity)
  • blue/green light (460-490nm) most effective
  • causes configurational and structural isomers that get excreted in bile, photooxidation products excreted in urine
  • exchange transfusion if severe
55
Q

Growth in the first year of life

A
  • at birth - lose up to 010% BW, but regain by 7-10 days
  • 0-6m - grow 1.5-2.5cm/month, HC grows 2cm/month, 20-30g/day, x2 BW by 5m
  • 6m - 1y - grow 1cm/month, HC grows 0.5cm/month, 12-20g/day, x3 BW by 1 year

*highest calorie requirements EVER are as a fetus

56
Q

Barker Hypothesis

A
  • prenatal and childhood nutrition and health can lead to adverse health outcomes (CVD, T2DM, obesity)
57
Q

Benefits of breast feeding

A
  • protects against bacteremia, meningitis, diarrhea, UTIs, T2DM, leukaemia, obesity, SIDS
  • each month reduces risk of hospital due to infxn
  • helps with neurocognition and IQ
  • source of LCPUFAs which develop brain and retina

for mom - improve bonding, decrease post partum bleeds, earlier return to pre-pregnancy weight, decreased risk of breast and ovarian cancers, decreased fertility for birth spacing

58
Q

What are recommendations for breast feeding? What are contraindications?

A
  • exclusive bf for first 6m, can continue up to 2 years+
  • galactosemia, PKU, HIV, TB, HSV on breast, some meds
59
Q

Why no alcohol when breast feeding?

A
  • impaired motor development/ sleep, hypoglycaemia, less milk intake and flow
  • elimination is 0 order kinetics so you cannot speed up expulsion
60
Q

Milk Banks

A
  • donors are screened for HBV/HCV/HIV
  • milk is frozen and pasteurized
  • never been a case of disease transmission
61
Q

What is colostrum?

A
  • first milk produced around delivery
  • contains lymphocytes, IgA/G/M, lots of protein and less fat
  • mild laxative effective which helps passing of bilirubin and meconium
62
Q

When to transition to solid foods? What to avoid?

A
  • 6 months (waiting too long can lead to Fe deficiency and allergies!)
  • give if hungrier, can sit up without support, holds food in mouth, shows interest in food, can decline food
  • homogenized cows milk at 9-12m, nothing else until 2 years
  • avoid added salt/sugar, choking hazards, honey under 1 year (botulism)
63
Q

Tier 1/2/3 of Birth Control

A

Tier 1 - implant, IUD, sterilization
Tier 2 - pill, patch, ring, shot
Tier 3 - withdrawal, condom, planning

64
Q

Common abortion MYTHS (debunked)

A
  • risk of dying is actually higher from birth than abortion
  • abortion rates are declining due to better methods of contraception
  • 1st term abortion poses NO risk of infertility, ectopic pregnancy, miscarriage, birth defects, preterm, LBW delivery, breast cancer, mental health
65
Q

Surgical vs. Medical Abortion
- pros and cons of each

A

Surgical
- suction evacuation (1st trimester) - dilation and curettage, under 10 minutes
- dilation anf evacuation (2nd trimester) - prep cervix with osmotic dilators/ misoprostol (fetal demise if over 18 weeks)

Medical
- medical abortion (1st trimester, up to 70 days)
- termination induction of labour (2nd trimester) - mifepristone if outpatient, misoprostol if inpatient, fetal demise first

*surgery is quick, free, less bleeds and cramping, and 99% successful
- but it involves instruments, anesthesia, need a facility, rare complications

  • medical can be done anywhere, no anesthesia or instruments
  • but it can lead to cramps/ heavy bleeding, higher failure rate, may need multiple visits
66
Q

Mifepristone/ Misoprostol

A
  • approved in Canada 2015
  • can use up to 63 days after LMP
  • oral is less effective, best route is buccal/vaginal (less GI sx)
  • 90% will abort in 24 hours
67
Q

What are the common DDx for hemorrhage before 20 weeks and after 20 weeks?

A

Before - abortion, molar pregnancy, implantation bleed, ECTOPIC

After - placenta prevue, placental abruption, vasa previa
- cramping over 20 weeks is a threatened abortion (preterm labour)

68
Q

Symptoms suggesting:
- Placenta Previa
- Placental Abruption
- Preterm Labour
- Vasa Previa (velamentous cord insertion with low lying placenta or bilobed/ succenturiate placenta)

A
  • Placenta Previa - bright red bleed, no pain, no membrane rupture, fetal movements
  • Placental Abruption - dark clots, painful (pain persists in-between contractions), no membrane rupture, maybe fetal movements
  • Preterm Labour - mucous show, painful, ruptured membranes, fetal movements
  • Vasa Previa - small bleed, no pain, no membrane rupture, no fetal movements
69
Q

Risk factors for:
- Placental Abruption
- Placenta Previa
- Preterm Labour

A
  • Placental Abruption - HTN in pregnancy, trauma, previous abruption
  • Placenta Previa - no prenatal care or U/S, previous C-section/ previa, multiple pregnancies, old mom
  • Preterm Labour - prior preterm birth, cervical surgery, infection, polyhydramnios, multiple babies

*smoking and cocaine are risks for all of these

70
Q

Tests for antenatal hemorrhage

A
  • vaginal exam is contraindicated if placental location is unknown
  • U/S cannot rule in/out abruption
  • CBC, group/screen, coagulation profile, Kleihauer Betke (determine if fetal blood is in the maternal circulation)
71
Q

Management for antenatal hemorrhage

A
  • stabilize (IV fluids, RBCs)
  • prepare for delivery (corticosteroids if before 35 weeks, MgSO4 if before 32 weeks)
  • C-section

*if mom Rh(-) give RhoGAM

72
Q

Types of shock

A
  • Hypovolemic - hemorrhage/ dehydration
  • Distributive - sepsis, decreased vascular tone, anaphylaxis
  • Cardiogenic - cardiomyopathy, arrythmia, hypoxia-ischemia
  • Obstructive - cardiac tamponade, coarctation, PE, tension pneumothorax
73
Q

What is cervical insufficiency?

A
  • premature cervical dilation without any signs of labour
74
Q

When is depression in pregnancy most common? Diagnosis?
When is suicide most common?

A
  • 2nd and 3rd trimester
  • 1 in 8 people will be depressed during pregnancy

*must have at least one of depressed mood or loss of interest/ pleasure for at least a 2 week period (5 sx total)

  • Most suicides occur between 9-12 months postpartum, more common in rural and remote regions
75
Q

Risk of not treating depression/ anxiety during pregnancy?

A

Depression - poor prenatal care, pre-eclampsia, SUD, impaired bonding, PPD worsening
- preterm, LBW, fussy, long term emotional and cognitive defects

Anxiety - ADHD, externalizing behaviours, child anxiety

76
Q

Post Partum Blues

A
  • transient, non-pathologic, 50-80% of new moms
  • tearful, distressed
  • usually 3-5 days postpartum and usually self-limiting by 2 weeks
  • only 13% will progress to PPD
77
Q

PPD

A
  • during pregnancy or within 4 weeks of delivery or within 12 months of birth
  • lack of enjoyment in baby, difficulty sleeping when baby asleep, worthlessness/guilt associated with parenting, intrusive thoughts of harming baby, suicidal as baby would be better off
78
Q

Risk factors for perinatal mood disorders and perinatal major depression.

A

Mood - less sleep, immune dysregulation, genes, HPA axis, est/progest dysregulation

Major Depression - prior hx in self or family, discontinuing meds, medical/obgyn problems, bf difficulties, lack of support, ACEs, multiple births, low SES, abuse, infant illness

79
Q

When do we screen for perinatal depression? With what?

A
  • 28-32 weeks gestation
  • 6-16 weeks postpartum
  • screening is done with the Edinburgh Postnatal Depression Scale
  • of they score any positive points on thoughts of harming themselves, discuss suicidality and hospitalize if yes
80
Q

Non-Pharm Treatment for PPD - when to switch to meds?

A
  • psychoeducation, CBT, IBT, MBCT, couples therapy
  • Nutrition, Exercise, Sleep, Time alone, Supports (NESTS)
  • IBT good if role disputes/transitions
  • Switch to meds if cannot do ADLs, insomnia, panic attacks, thoughts of harm, psychotic symptoms
81
Q

Pharmacological Treatments for PPD

A
  • SSRIs are first line - sertraline (Zoloft), citalopram (Celexa), escitalopram (Cipralex), fluoxetine (Prozac)
  • not contraindicated if benefits outweigh risks, take smallest dose and least amount of meds possible
  • do NOT stop or lower before delivery
  • no connection to ASD, may have transient risk with respiratory. distress/ temperature/ jitters
82
Q

Postpartum Psychosis
- course
- sx

A
  • technically a bipolar spectrum illness
  • more common in 1st time moms
  • rapid onset, lasts about 40 days
  • occurs within 2 weeks of delivery
  • insomnia, mood swings, OCD, mania, depression , delusions, hallucinations, disorganized behaviour, confusion
  • EMERGENCY need to hospitalized, can lead to infanticide in 3%
83
Q

Definition of maternal death, late maternal death, maternal morbidity ratio (MMR)

A
  • while pregnant or under 42 days postpartum
  • over 42 days but under 1 year postpartum

MMR = maternal deaths per 100,000 live births

84
Q

Goals for ending MMR

A
  • attend 4 or more antenatal visits
  • skilled health personnel
  • access postnatal care within 2 days of delivery
  • access to ER care within 2 hours of travel time
  • education
85
Q

Postpartum Hemorrhage Defintion

A
  • over 500mL if vaginal
  • over 1L if C-section

*estimated blood loss os often only 50% of actual

86
Q

Compensated vs. Mild vs. Moderate Shock

A

Compensated - under 1L, HR under 100

Mild - 1-1.5L, HR over 100, orthostatic changes in BP

Moderate - 1.5-2L, HR over 120, marked fall in BP

87
Q

What are some possible etiologies of postpartum hemorrhage?

A

Tone - over distended, uterine muscle exhaustion, intra-amniotic infection, bladder distension preventing uterine contraction

Trauma - uterin rupture or inversion, excessive cord traction, operation, laceration

Tissue - retained placenta/ blood clots, incomplete placenta at delivery

Thrombin - DIC, gestational hypertension, coagulopathies

88
Q

What are 4 signs of placental separation?

A
  1. Gush of blood
  2. Umbilical cord lengthens
  3. Uterus rises
  4. Uterus becomes globular
89
Q

What is involved in active management of the 3rd stage of labour?

A
  • utertonics - aid with contraction, speeds placental separation
  • oxytocin 10 units IM after delivery, carbetocin 100mcg IV after C-section
  • controlled cord traction to help speed up
  • risks of uterine inversion or cord avulsion
90
Q

Initial management steps for postpartum hemorrhage

A
  • evaluate vital signs every 5 minutes
  • 2 large bore IV accesses
  • resuscitation with crystalloid (33% IV 77% interstitial), colloids, blood products (need to G/S, crossmatch)
  • bimanual massage, utertonics to help with tone

*hypotension is a LATE sign

91
Q

Drugs used to reduce postpartum bleeds

A
  • Oxytocin (IM and IV)
  • Carboprost (IM)
  • Ergonovine (IM)
  • Misoprostol (Buccal/ rectal)
92
Q

Refractory Atony Tx

A
  • balloon tamponade, uterine compression sutures, radiolgic uterine artery embolization, hysterectomy
93
Q

Random Facts idk

A
  • Resp rate over 20 and temp under 36 or over 38 are the same in pregnancy for criteria of Systemic Inflammatory Response Syndrome
  • pregnancy makes SIRS/ sepsis criteria more sensitive and less specific
  • it takes 30 minutes to infuse 1L of normal saline through a 22g IV
  • 3L of normal saline is needed to replace 1L of blood loss (as only 1/3 actually enters the ECF)

Med School (21 decks)

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