Quick & Dirty MUST KNOWS Flashcards
Antidote to Mag Toxicity?
STOP INFUSION
Calcium gluconate 1 g (10 cc) over 3 minutes
***Can give more if not responding
Put on caridac monitor
Monitor UOP
Repeat labs
Management of Eclamptic Seizure
- Call for HELP
- Lateral Decubitus position
- Vitals, give O2
- 2 g Mag IV over 5 mins (prevents next seizure)
Self limiting
If “recurrent” = still seizing 20 mins after bolus or > 2 episodes, give additional agent
Diazepam 5-10 mg IV every 5 mins (MAX DOSE 30 mg)
NOT indication for CS, FHT will normalize after maternal stabilization (recurrent decels, bradycardia during)
After seizure will likely see minimal variability
Consider GA, Cervix - needs to be delivered expeditiously
Management of Thyroid Storm in Pregnancy
Admit to ICU, 1% of pregnancies, usually Graves Disease
- Inhibit release of T3/T4
- PO PTU
- 1000 mg loading dose PO, then 200 mg Q6h - Stabilize Thyroid Gland
- Add back Iodine 1-2 hours after PTU
- Lugol’s iodide 10 drops PO q8h - Block peripheral conversion of T4 to T3
- DEXAMETHASONE
- 2 mg IV q6h - Symptom management/ Can control tachycardia w/ b blocker (however this may precipitate heart failure)
Define shoulder dystocia
Turtle sign! Head retracts into perineum
Gentle traction fails to deliver the shoulder
The fetal head has beed delivered for 60 seconds and the anterior shoulder is stuck under the pubic bone and is unable to be delivered with gentle downward traction
Shoulder dystocia management
- Identify
- Call for help, additional nurse
- Instruct patient to NOT push
- McRobert’s: moves symphysis anteriorly to create large AP diameter of the pelvis
- Suprapubic pressure: causes shoulder to internally rotate
- Posterior arm: flex posterior elbow by applying pressure at the ante-cubital fossa, grab the forearm and hand and pull it out of the vagina
- Rubin: Apply pressure on the anterior scapula
- Woods: Apply pressure on the posterior shoulder (clavicle)
- Gaskin: knees + chest (butt in air), downward traction first, delivery posterior shoulder first
- Axillary traction/shoulder shrug
- Break clavicle (pull anterior clavicle outward)
Try all maneuvers again - Zavanelli: I would only do this in extreme situations and no other alternatives. Reversal of the cardinal movements of labor.
- Abdominal rescue: apply pressure on anterior shoulder through incision on abdomen
- Symphisotomy: catheter in urethra, move to the side, place scalpel in midline and cut upwards
Why may we use Cryoprecipitate over fresh frozen plasma in MTP?
FFP is more likely to cause TRALI (Transfusion-related acute lung injury)
What must you give for every 4 units of pRBC?
1 g calcium gluconate to bind citrate buffer (preservative in pRVCs)
Citrate increases acidemia, acidemia inhibits coagulation!
Define delayed/secondary postpartum hemorrhage
Most likely causes?
24 hours after delivery up to 12 weeks postpartum
Sub-involution of placental site
Retained products of conception
Infection
Inherited coagulation defects
Why should you limit early crystalloid use in the setting of a hemhorrage?
May worsen bleeding!
- Dilution of clotting factors +platelets (coagulopathy often exists prior to hemo-dilution)
- Hypothermia + acidosis which inhibit coagulation cascade
- Increases hydrostatic pressure and dislodges vessel wall thrombi
Why is “permissive hypotension” helpful in a PPH?
- Limits ongoing blood loss
- Up regulates coagulation cascade
When the acuity increases, what 5 things can you do to get YOUR DUCKS IN A ROW?
- Identify EMERGENCY
- Call for HELP
- Labs
- Blood Bank
- Patient counseling/informed consent
How do you handle breech at the introitus?
- Open OR, attempt to move towards cesarean section if at all possible
- Allow breech to deliver to the knees with maternal forces. DO NOT PULL.
- NEED SACRUM ANTERIOR
- PINARD maneuver. Press on popiliteal fossa which causes the knee to flex, and leg to externally rotate
- Support infant at horizontal/blue towel
- Maternal forces continue, until scapula are are past the introitus
- LOVESET maneuver. Press parallel to the anterior humerus to sweep the infants arm across the thorax. Rotate 180 degrees and repeat.
- Forearm underneath the infant
- Mauriceau-Smellie-Veit. Supporting the fetus with forearm, place middle and index fingers on the maxillae and using the other hand apply pressure to the fetal occiput to flex the head
How do you manage head entrapment?
Piper Forceps:
- Position underneath the fetus
- Apply right hand blade first (infant left)
- Then apply left hand blade (infant right)
- Articulate the forceps underneath the infant
- Continue maternal efforts and pulling forces along the curve of the pelvis
Duhrssen’s Incisions:
- Incisions on the cervix at 10, 2 and 6 o’clock
Symphysiotomy : I could describe how to do it hypothetically, but I would likely not perform it
**Abdominal rescue: **
- General anesthesia
- VML incision
- Push on lower uterine segment to facilitate flexion
- Perhaps hysterotomy
Risks of breech vaginal delivery
- headentrapement/asphyxia
- cord prolapse
- spinal cord injury
- brachial pelxus injury
Dosing of uterotonics
Oxytocin 10-40 units/L LR (IV or IM)
Methergine 0.2 mg Q2hrs (in practice most MD’s w/ give Q15 mins)
Hemabate (PGF2alpha) 0.25 mg Q15 mins x 8 doses
Misprostol PGE1 1000 mcg (PO, SL, Rectal)
MOA and dosing of TXA?
Antifibrinolytic
1 g IV given within 3 hours after birth
Does not appear to increase risk of thrombosis
When do you initiate a blood transfusion for PPH?
Ongoing bleeding + EBL > 1,500 OR tachycardia/hypotension
What is given during a massive transfusion protocol?
pRBC : PLT : FFP
1:1:1 ratio
What is the volume of 1 u pRBC and how much would you expect Hgb or Hct to rise?
Volume is 300 ml
Should see Hgb rise by 1 gm
Hct should rise by 3%
When should platelets be transfused?
Either part of MTP
PLT < 50 K and pt is needing surgery
If surgery is not expectated can wait until PLT < 30 k
What is the volume of a unit of platelets? How much would expect platelets to rise?
1 unit = 50 ml
PLT rise 5K/unit
Usually released in a “pack” of 6 units
Management of maternal cardiac arrest?
- Prioritize bag mask ventilation w/ 100% and EARLY intubation w/ small ET tube (6-7 mm)
- Aortocaval compression by uterus larger than 20 wks. Manual left uterine displacement early in resuscitation
- Chest compression 100 bpm (30 compressions: 2 breaths)
- Consider defibrillation
- Epinephrine is the vasopressor of choice and should be administered by IV and IO access above the diaphragm
- Start C/S at 4 minutes, delivery by 5
- Consider cardiopulmonary bypass or ECMO
Presentation & management of AFE?
- Sudden onset cardiorespiratory arrest OR hypotension w/ evidence of respiratory compromise + DIC
- Occurs during labor or within 30 minutes of delivery
- NO FEVER
Mangement:
- Begin CPR (100 bpm 30 compression: 2 breaths)
- Give hemodynamic support (IVF, pressors)
- Manage hemhorrhage and DIC = MTP and TXA
- Devliery of fetus within 5 minutes to help resusitative efforts
- Get labs
- Other interventions = A-OK Protocol
- 0.2 mg Atropine, Odansetron 8 mg, Ketoralac 15 mg IV
- 50/50/100 Protocol: Diphenhydramine 50 mg, famotidine 50 mg, 100 mg hydrocortisone
Cesarean Under Local….
Dosing + Side effects
Max dose of lidocaine is 7 mg/kg
(which is 490 mg in a 70 kg person)
1% lidocaine has 10 mg lidocaine/cc
Max lidocaine dose is 500 mg = 50 cc
Mix w/ 50 cc sterile injectable saline
(or could just use 100 cc of 0.5% lidocaine w/ EPI)
SE/Signs of Lido Toxicity:
- Metalic taste
- Perioral numbness
- Tinnitus
- Slurred speech/blurred vision
- LOC/Seziures
- Arrhthymias
- Cardiac Arrest
Considerations while doing CS under local
Cardiac monitor + pulse ox continuously
Do VML (quicker/less bleeding)
Inject skin, perietal and visceral periotneum
Do not manipulate bowel
Do not pack gutters
Do not exteriorize uterus
Cardiac contraindications in pregnancy?
- Pulmonary Hypertension
- Heart Failure w/ EF < 30%
- Marfan Syndrome w/ aortic dilation > 45 mm
- Aortic stenosis/bicuspid aortic valve w/ aortic diameter > 50 mm
Management of uterine inversion
- Discontinue uterotonics
- Call for assistance
- Establish adequate IV access/fluid + blood resuscitation
- DO NOT REMOVE PLACENTA
- Attempt to manually repalce the inverted uterus into normal position (Johnson maneuver)
- Prompt intervention is critical. since the lower uterine segment and cervix will contract over time and create a constriction ring making manual repalcement more difficult
- Give nitroglycerin 50 mcg IV (max 200 mcg)
- (Could also do terb or inhalational anesthetic)
- Take to OR for laparotomy
- Huntington procedure = place allis on each round ligament entering the cup about 2 cm deep, gently pull the clamps upward. Repeatdly clamp in 2 cm increments along the ligament and exert traction until the inversion is corrected (like pulling up an anchor)
- Haultain procedure = make an incision 1.5 cm on the posterior surface of the uterus to transect the contrction ring. Surgical release of the constriction ring should allow manual reduction of the uterine inversion. Then repairn incision.
Once returned to normal location, hold uterus in place
Administer uterotonic drugs
Theraputic Mag levels?
Toxicity levels?
4.8-8.4 mg/dL is theraputic
9 mg/dL Loss of reflexes
12 mg/dL Respiratory arrest
30 mg/dL Cardiac arrest
Dosing of diazepman for recurrent seizures?
10 mg IV Q10 mins (max dose 30 mg)
*be prepared to intubate
Contraindications to Magnesium?
Myasthenia Gravis
Complete heart block
Severe renal impairment
Hypocalcemia
Contraindications to VAVD?
GA < 34 w
Fetal osteogenesis imperfecta
Fetal thrombocytopenia/bleeding disorders
Unknown fetal position
Risks of VAVD? Both maternal and fetal?
Maternal: Increased risk of lacerations (especially 3rd/4th degree)
Fetal:
* Scalp lacerations
* Cephalohematoma (swelling beneath the scalp)
* Subgaleal hemhorrage
* Subdural hematoma
* Intracranial bleeding
* Retinal hemhorrhage
How do you perform a VAVD?
- Counsel/Consent the patient
- Bladder drained
- Optimal maternal position
- Adequate anesthesia
- Ensure complete cervical dilation, and 2+ fetal station
- Find flexion point (2 cm from posterior fontanel over the mid sagittal suture line)
Antibiotics for PPROM?
Oral Azithromycin 1 g
IV Ampicillin 2 g Q6 hours for 48h
Oral amoxicillin 875 mg BID for 5 additional days
Maternal cardiac arrest management
No pulse, no respirations
Call for help
Start compressions on back board
Manual left uterine displacement
Bag mask ventiliation/intubation
Remove fetal monitor, put on defibrillator pads
Analyze rythm, if shockable rythm then defibrillate
If non shockable rythmn then give Epinephrine 1 mg IV/IO Q3-5 mins
If no resusication after 4 mins start perimortem cesarean
How much fluid do you put in a Bakri?
Max 500 cc saline
Dosing of Methergine?
0.2 mg IM
Repeat in 2 hours (max 3 doses)
Most OBs will repeat in 15 mins (max 6 doses)
Contraindication in HTN or if HIV on protease inhibitor?*
Dosing of Hemabate?
PGF2alpha
0.25 mg IM
Repeat in 15 mins
Max dose is 8
How do you make a diagnosis of DIC?
Fibrinogen </= 200 mg/dL
Prolonged INR + PTT
Low platelets
Lab goals of MTP?
Hgb > 8
PLT > 50 k
Fibrinogen > 200 mg/dL
INR < 2
Lactate < 4
pH > 7.3
Define MTP
If > 10 units pRBC in 24 hours
If > 4 units pRBC in 1 hour + ongoing bleeding
Replacement of entire blood volume
**Don’t forget DVT PPx after giving MTP!
Difference between B lynch and Hayman compression suture?
Use #1 Chromic!
B-lynch: need hysterotomy, on continuous suture
Hayman: 2-4 primary vertical compression sutures. Right and left sides are placed separetly without the need to open up the uterus. Knots are tied over the fundus
Acrreta risk(%)
US findings
Management
Delivery timing
Risk w/ previa 3%, 11%, 25%, 60% (1st, 2nd, 3rd, 4th)
Loss of hypoechoic placental/myometrial boundary zone
Thinning or loss of uterine serosa/bladder interface
Placenta lakes
Multiple lacunae w/ turbulent flow
Address pre-exisiting anemia
Counsel patient on risks
Antepartum surviellence
Betamethasone
Send to tertiary care center for delivery at 34 weeks
Uterine incision above placental attachment site
Leave placenta in situ
Perform cesarean hysterectomy
When should you evacuate vaginal hemotomas?
Most will be self limited - serial exams/labs/pain management/foley
< 4 cm
Evacuate clot, close in layers
Pack vagina
If rapidly decreasing Hgb not correlating with hematoma, consider extension into pararectal and retroperitoneal space
Begin blood replacement + obtain imaging
Consult IR/transfer
How do you perform an O’Leary suture?
Suture is placed using a large needle just below the level of the hysterotomy.
Needle is passed through the uterine muscle approximately 1-2 cm medial to the lateral margin of the uterus traveling anterior to posterior.
It is then brought through an avascular portion of the broad ligament and tied
Could also place an additional “high” stitch just below the junction of the utero-ovarian ligament and the uterus
Should address broad ligament hematoma!!!
If expanding retroperitoneally/not responding to O’leary. STOP! Apply pressure, start transfusing, and get help. DO NOT OPEN AREA, massive bleeding in location with complex anatomy. CAN BE DANGEROUS.
Delivery of vasa previa?
Admit pt at 32 wks for surveillance
Steriods
CD at 34 wks
Delivery of suspected PAS?
34 wks
Uterine dehiscence at time of scheduled cesarean?
Incorporate dehiscence into current hysterotomy
Excise to health tissue margins
TWO LAYER uterine closure
ECV contraindications/risks/procedure
Only perform AFTER 37 wks
Contraindications: not a candidate for vaginal delivery, multiple gestation, oligohydrmanios, uterine anomalies, fetal anomalies, FGR, active labor, placental aburption, hyperextended fetal head
Risks: Fetal intolerance, ROM, placenta abruption, Uterine dehiscense if prior CS
Sign infromed consent
NST, confirm breech presentation
IV access
Available OR/in OR
+/- spinal
Give 0.25 mg IM terbutaline
Perform version
Repeat US + NST
GIVE RHOGAM IF RH NEGATIVE
Give return precautions
Risk of recurrent OASIS injury in next pregnancy?
3%
Offer C/S if:
Had breakdown or infection
Had stool incontinence at any time
Pschologically traumatized
What is considered a normal BP by AHA?
< 120/80
Treatment for TCP/ITP in pregnancy?
Thresholds for treatment?
Symptomatic bleeding
PLT < 30k
PLT < 50 + needs surgery
PLT < 70 + needs epidural
Prednisone 20 mg/daily (reheck in 2 wks)
IVIG 1 g/kg one time (can repeat if needed). Recheck in 72h
Ab pain, N/V, Anion gap acidosis, Serum ketones
DKA in pregnancy management
ICU
Aggressive fluid hydration (1-2 L in the first hour)
Use NS, use D5NS if glucose < 200
IV Insulin gtt
Restore K (will be rapid decrease in plasma levels, as insulin pushes it back into cells)
Most common Rheuatic Heart Lesion?
Mitral Stenosis
General Principles for Cardiac Disease in pregnancy?
AVOID fluid overload, Tele in labor, Strict I/Os
NSVD preferred (with exception of Marfans syndrome with dilated aortic root, they should have cesarean)
Avoid valsalva, allow patient to labor down (let uterus do the work)
Shorten second stage (operative vaginal delivery)
Reverse trendelenberg, avoid raising legs over heart
Third stage most risky with fluid shifts!
In what conditions is pregnancy contraindicated?
Pulmonary Hypertension
Severe Cardiomyopathy, EF < 30%
Severe aortic stenosis, bicuspid aortic valve with dilation
Marfan’s syndrome with dilated aortic root (> 4.5 cm)
NYHA Class 4 cardiac disease
Work up for cardiac symptoms in pregnancy?
BNP > 100 suggests diagnosis of HF, ECHO
Troponin + EKG to rule out ACS
CXR to evaluate for pulmonary etiology
Holter monitor for arrhytmias
CT if concern for PE or aortic dissection
*Consider exercise stress test w/ pre-conception counseling
Define peripartum cardiomyopathy?
Pregnant or 5 months PP
EF < 45%
Treatment of STEMI?
Oxygen
Nirates
ASA
IV unfractionated heparin
B blocker
Treatment of peripartum cardiomyopathy?
Diuresis
BBlocker (metroprolol)
ACE/ARB POSTPARTUM
Anticoagulation
Treat arrythmias
Risk of vertical transmission of HIV?
W/out ZDV = 24%
W/ ZDV = 8%
W/ ZDV + CS = 2%
Viral load < 1000k, on HAART, NSVD < 2%
HIV Testing
Screening test = ELISA
Confirmatory testing = Westernblot
If unknown status in labor
Get RAPID HIV TEST
Treat for HIV w/out waiting for confirmatory result
Neg result is definitive
Pos result is NOT definitive (confirm w/ westerblot)
Route of delivery for HIV
VL > 1,000 = C/S at 38w (ZVD for 3 hours prior)
If VL < 1,000 = NSVD + ZVD 2 mg/kg IV load, then 1 mg/kg/hr until delivery
What should FEV1 be for a pregnant patient w/ asthma exacerbation to be managed outpatient?
FEV1 >/= 70% of predicted
Treatment of asthma exacerbation?
Continuous O2 monitoring (> 95%)
Continuous fetal monitoring
FEV1 testing
Albuterol nebulizer
If inadequate response > ipratropium
Consider oral or IV steroid
If FEV1 < 50% = impending respiratory arrest = ICU/intubation
Treatment for influenza in pregnancy?
Tamiflu/Oseltamivir 75 mg BID for 5 days
Risks/Treatment for COVID-19 in pregnancy?
Risks: IUC admit, mechanical ventialtion, death, severe illness, PTL, PTD
Treat: Paxlovid +/- dexamethasone
Risks of antidepressant use in pregnancy?
Persistent pulmonary hypertension of the newborn
- Rare ( 1 in 1000), but 20% mortality risk
- SSRI exposure can cause vasoconstriction and smooth muscle cell proliferation in fetal lung
- Inreased risk if > 20 wks during use
**Sertraline least likely to cause this
Transient neonatal adaption syndrome (risk 10-30%)
- Irritability, restlessness, tremores, sleep disturbance, poor feeding
- Resolves on its own within 2 weeks
Risks for postpartum psychosis? how/when does it present?
Usually within 2 weeks of birth
Hallucinations, delusions, mania, restlessness, loss of inhibition, paranoia, confused
Risk Factors:
PP Psychosis in previous pregnancy
Bipolar disorder
Hx of bipolar or fm hx of biopolar
ADMIT TO HOSPITAL
High risk thrombophilias?
Factor V homozygous
Prothrombin mutation homozygous
Antithrombin III Deficiency
Double hetero for Factor V + prothrombin mutation
Always gets PPx lovenox in pregnancy
Personal hx of DVT = always gets PPx lovenox too!
If thrombophilia with personal hx of DVT = theraputic dosing
Low risk thrombophilias?
Factor V Hetero
Prothrombin mutation hetero
Protein C deficiency
Protein S deficiency
If low risk thrombophilia w/ Hx of DVT = PPx lovenox
MOA Heparin? PPx and theraputic dosing? Lab goals?
What about active PE?
Cofactor for anti-thrombin
Increases inhibition of thrombin and Factor XA
PPX = 5K units SQ daily
Theraputic = 10k units SQ daily
Theraputic goal is PTT 1.5-2.5 x normal
Check 6 hours after administrating
Active PE = Load with 150u/kg > 20 u/kg/h for 5 days
MOA of LMWH? PPx and theraputic dosing? Lab goals?
LMWH = Direct Factor Xa inhibitor
PPx dosing = 40 mg Subq daily
Theraputic dosing = 1 mg/kg BID
Lab: Check anti Factor Xa 4 hours after dosing
Theraputic goal 0.6-1 u/mL
Normal caloric intake in pregnancy
Normal weight gain in non-obese pt
Normal calls = 2,200 cal/day
Wt gain is 25-35 lbs
Generalized pruritus WITHOUT rash
Especially on palms and soles
Worse at night
Management?
Intrahepatic cholestasis of pregnancy
Bile Acids > 10
Start ursodiol for itching (does not decrease risk of IUFD)
Check bile acids weekly
Counseling regarding seizure disorder in pregnancy?
Increased risk of stillbirth + FGR
Neural tube defects, Cardiac defects, cleft palates
Increase is seizure incidence
Avoid polypharmacy
Keppra or Lamictal preferred
Monitor levels during pregnancy
1 mg Folic Acid + vitamin D
Detailed anatomy, Growth US
Pregnancy risk if low fetal fraction on NIPT?
Associated with aneuploidy, elevated BMI and gestational age
Increases risk of GDM/Pre E in pregnancy
Why use NIPT for genetic screening?
Most sensitive and specific test
Only test that can identify fetal sex, and sex chromosome abnormalities
Obtain after 10 wks gestation
Very low false positive rate, BUT still need diagnostic testing if abnormal
What are the options of diagnostic genetic screening in pregnancy?
CVS at 10-12 wks (cannot detect NTD)
Amnio after 15 wks (can detect NTD)
When can you draw AFP?
What is considered elevated?
Elevated AFP is associated with what?
15 weeks (same as amnio!)
Elevated if > 2.5 MoM
Associated with: Open NTD, anencephaly, abdominal wall defects
Can be elevated in multiple gestation
With normal karyotyping > still associated with adverse outcomes
Pregnancy loss, FGR, PTL, Pre E
Plus increased risk of SIDs until 6 months of age
Best time to get a NT?
What is considered thickened?
What is thickened NT associated with?
13 wks
NT >/= 3 mm
Associated with: 50% risk of aneuploidy, CHD, abdmonal wall defects, and diaphragmatic hernies
Polyhdramnios definition, causes, management
Polyhydramnios → 1) Idiopathic 2) Maternal Diabetes 3) Congenital anomalies (GI obstruction, kidney dysfunction, high output cardiac failure)
AFI < 25 = normal
AFI 25-30 = mild (DVP 8-12)
AFI 30-35 = moderate (DVP 12-16)
AFI > 35 = Severe (DVP > 16)
Risks: PPROM, PTL, Macrosomia, Malpresentation, Cord prolapse, Abruption, Stillbirth, Atony/PPH. If severe + symptomatic (maternal respiratory distress) consider amnioreduction.
Treatment for pyleonephritis in pregnancy?
IV Ceftriaxone 1 g Q24, continue until 24-48h afebrile
Then PO abs for 7 days (Amoxicillin 875 mg BID)
Then suppressive therapy (pyleo recurs in 6-8% of preg women)
Macrobid 100 mg nightly
Keflex 500 mg nightly
Risks: PTL, Anemia, renal abscess, ARDS, bacteremia, recurrent pyelo
When would you treat a term pregnancy w/ unknown GBS status?
Fever in labor
ROM > 18h
Positive in prior preg
APS Testing
Lupus Anticoagulant
Anticardiolipin Ab
Anti B2 Glycoprotein
When do you treat for Hep B in pregnancy? with what?
Can you treat Hep C?
Treat if VL > 200k in pregnany to decrease risk of vertical transmission
Treat with Tenofovir
Infant will need Hep B Vax + HepBIG
**No treatment for Hep C in pregnancy, treat postpartum
