UWise - Objectives 12-19 Flashcards
What are some physical features associated with Down Syndrome?
Flattened nasal bridge, small size, small rotated, cup-shaped ears, sandal gap toes, hypotonia, protruding tongue, short broad hands, simian creases, epicanthic folds, oblique palpebral fissures
Wide-spaced nipples and lymphedema in a newborn are associated with ___ syndrome.
Turner
What are the most likely findings in a baby born to a mother with pre-existing diabetes?
IUGR (although macrosomia may occur) and hypoglycemia
How does a septic infant typically appear?
Pale, lethargic, high temperature
Fetal tachycardia coupled with minimal variability is a warning sign that the infant may be ___.
Septic
What is a common complication for the plethoric twin in TTTs? For the donor twin?
Polycythemia; anemia
Discuss the risks of infants born to mothers with diabetes.
Hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia, respiratory distress, polyhydramnios, congenital malformations (CV, neural tube, caudal regression), preterm birth, hypertensive complications
Any history of substance abuse in a mother may be a relative contraindication to the use of naloxone in an infant with respiratory distress - why?
If the mother used narcotics during the pregnancy, giving naloxone to the infant can cause life-threatening withdrawal
In an infant who is unresponsive and has no respiratory effort, what should be done?
Give positive pressure ventilation and prepare to intubate
What should be done to manage an infant born to a mother who is HIV+ and had an undetectable viral load throughout the second and third trimester?
AZT immediately after delivery; HIV testing at 24 hours; discourage breastfeeding
What is the correct position for application of positive pressure ventilation in a newborn infant? What is the recommended rate of oxygen flow?
Sniffing position (neonate’s head back and lifting the chin); 10 L/min
What are the 5 components of APGAR?
- Heart rate
- Respiratory rate
- Reflex
- Activity
- Color
Following delivery for a vigorous infant, what should happen immediately?
Initiate skin to skin contact with the mother
After skin to skin contact, what should happen next?
- Clear the airway by suctioning the mouth and nose IF NEEDED
- Dry off the newborn with a towel
- 30-60 seconds after birth, clamp and cut the umbilical cord
What happens in Sheehan’s syndrome?
In the setting of significant blood loss, the anterior pituitary may become hypoperfused, leading to ischemic necrosis and loss of gonadotropin, TSH, and ACTH production.
Signs and symptoms of Sheehan’s syndrome?
Slow mental function, weight gain, fatigue, difficulty staying warm, no milk production, hypotension, and amenorrhea
How is Sheehan’s syndrome treated?
Replacement and supplementation of hormones
Endometritis in the postpartum period is most closely related to what?
The mode of delivery (<3% of vaginal births, 5-10x higher incidence after Cesarean deliveries)
List 6 factors related to increased rates of infection with a vaginal birth.
- Prolonged labor
- Prolonged rupture of membranes
- Multiple vaginal exams
- Internal fetal monitoring
- Manual removal of the placenta
- Low SES
What is the most common cause of postpartum fever?
Endometritis
DDx - postpartum fever
- UTI
- Lower genital tract infection
- Wound infections
- Pulmonary infections
- Thrombophlebitis
- Mastitis
What sign is commonly observed in patients with endometritis?
Uterine fundal tenderness
Bacterial isolates related to postpartum endometritis are usually ___. Why?
Polymicrobial, reulting form a mix of aerobes and anaerobes in the genital tract; most common causative agents are S. aureus and Strep
Postpartum depression often begins within ___ after deliery.
2 weeks to 6 months
What is a useful symptom in distinguishing between postpartum depression and postpartum blues/normal changes that occur after delivery?
Ambivalence toward the newborn
What is the safest method to suppress lactation?
Breast binding, ice packs, and analgesics (hormonal interventions predispose to thromboembolic events and risk of rebound engorgement, bromocriptine is associated with HTN/stroke/seizures)
Breastfeeding is associated with a decreased incidence of ___ cancer.
Ovarian (some studies also show a decreased incidence of breast cancer)
What is the optimal nutrition for all infants?
Human milk
What is the AAP recommendation regarding breastfeeding?
Exclusive breastfeeding for the first 6 months after birth
Breast milk is a major source of Ig__.
A (associated with a decrease in newborn’s GI infections)
Why are progesterone-only or non-hormonal contraceptive methods more ideal than estrogen-containing methods of contraception?
Progestin-only methods have not been shown to impact milk production or volume, and have not been shown to have adverse effects for the infants. Estrogen-progesterone containing contraceptives, especially in the first 30 days postpartum, may diminish lactation and cause issues with breastfeeding.
Although the side lying position is a good one for breastfeeding, it is important for mother and baby to be ___ in order for the infant to be in a good position to latch on appropriately, taking a large part of the areola into its mouth.
Belly-to-belly
What are 2 hospital policies that promote breastfeeding?
Getting the baby on the breast within a half hour of delivery and rooming-in for the baby to ensure frequent breastfeeding on demand
Discuss the mechanisms leading to slight delay in breast milk coming in.
With delivery, there is a rapid and profound decrease in the levels of progesterone and estrogen, which removes the inhibitory influence of progesterone on the production of alpha-lactalbumin by the rough ER. The increased alpha-lactalbumin serves to stimulate lactose synthase and ultimately to increase milk lactose. Progesterone withdrawal allows prolactin to act unopposed in its stimulation of alpha-lactalbumin production. This may take up to two days.
What is the classic presentation for candidiasis of the nipple?
Severe discomfort and nipple pain (classic mastitis does not usually cause intense nipple pain)
How is candidiasis of the nipple treated for both mom and baby?
Localized candida of the nipple - antifungal, topical medication such as clotrimazole or miconazole
Topical antibiotic ointment is an option, because nipple fissures can concurrently present with candida of the nipples, and S. aureus is significantly associated with nipple fissures
Topical steroid cream can be used to facilitate healing for cases in which the nipples are very red and inflamed
Baby - oral nystatin (first line), oral fluconazole is also an option
What are 4 signs that a baby is getting sufficient milk?
3-4 stools in 24 hours
6 wet diapers in 24 hours
Weight gain
Sounds of swallowing
What are some strategies to address breast engorgement when milk comes in?
Frequent nursing
Taking a warm shower or warm compresses to enhance milk flow
Massaging the breast and hand expressing some milk to soften the breast
Wearing a good support bra
Using an analgesic 20 minutes before breastfeeding
What hormone is responsible for milk production? For milk ejection?
Production - prolactin
Ejection - oxytocin
What stimulates production of oxytocin?
Suckling (this works better than a breast pump for stimulating the ejection of milk)
There is a ___x increased risk for ectopic pregnancy in women with a prior history of ectopic pregnancy. What other risk factors exist?
10
Age between 35 and 44 y/o (3x)
Prior abdominal surgery and history of STIs, sterilization failures, endometriosis, congenital uterine malformations
Up to ___% of all normal pregnancies experience first trimester spotting/bleeding.
30
How is ectopic pregnancy diagnosed?
- Fetal pole visualized outside the uterus on U/S
- Beta-hCG over the discriminatory zone (usually 2,000) + no intrauterine pregnancy
- Inappropriately rising beta-hCG (less than 50% increase in 48 hours) + levels that do not fall following diagnostic D&C
What conditions must be met prior to starting MTX treatment for ectopic pregnancy?
- Hemodynamic stability
- Non-ruptured ectopic pregnancy
- Size of ectopic mass <4cm without a fetal HR or <3.5 cm with a fetal HR
- Normal liver enzymes and renal funciton
- Normal white cell count
- Ability of the patient to follow up rapidly
Presentation of a ruptured ectopic pregnancy?
Signs of hypovolemia (tachycardia, hypotension) with peritoneal signs (rebound, guarding, and severe abdominal tenderness), positive pregnancy test
What is the standard of care for surgical management in the setting of ruptured ectopic pregnancy?
Removal of the ectopic pregnancy and ruptured tube (salpingectomy)
What accounts for the majority of first trimester spontaneous abortions?
Genetic abnormalities involving the conceptus (50-60% contain some form of chromosomal abnormalities)
What is the most common abnormal karyotype encountered in spontaneous abortuses (40-50%)?
Autosomal trisomy
Triploidy - 15%, Tetraploidy - 5%, Monosomy X - 15-25%
What systemic diseases are associated with early pregnancy loss?
DM, chronic renal disease, and lupus
In a pregnant patient who is actively bleeding, hemodynamically unstable, and anemic, what is indicated?
Immediate surgical treatment consisting of D&C
In the setting of an incompetent cervix, what is indicated?
Cervical cerclage at 14 weeks
Define recurrent abortion.
3 successive first trimester losses
It is important to rule out systemic disease in a patient with recurrent abortion - what testing should be done?
Lupus anticoagulant, anticardiolipin antibodies, DM, and thyroid disease
Maternal and paternal karyotypes
Consider infectious causes
Uterine imaging with hysteroscopy or hysterography to exclude septum or another anomaly
Medical management of miscarriage with misoprostol has what benefit?
Shortens the time to expulsion of the pregnancy
The use of ACEIs beyond the first trimester of pregnancy has been associated with what fetal complications?
Oligohydramnios, fetal growth restriction and neonatal renal failure, hypotension, pulmonary hypoplasia, joint contractures, death
___ is used in pregnancy to treat migraine headaches.
Amitriptyline
How should HIV-infected pregnan women be managed?
Antiretroviral therapy (treat mom + reduce the risk of perinatal transmission regardless of CD4+ count or HIV RNA level)
The baseline transmission rate of HIV to newborns can be reduced from 25% to 2% - how?
HAART protocol antepartum and continuing through delivery with IV zidovudine in labor and zidovudine treatment for the neonate
Cesarean delivery prior to labor can reduce the rate of transmission in women who have viral loads >1,000 copies/mL
What is the most common cause of sepsis in pregnancy?
Acute pyelonephritis
What is one of the indications for moving to the next line of treatment of asthma in pregnancy? What is the next line?
The need to use beta agonists more than 2x/week; inhaled corticosteroids or cromolyn sodium
How should syphilis be treated in pregnancy in a woman with a penicillin allergy?
Confirm the allergy with a skin test, then perform penicillin desensitization and give IM benzathine penicillin G treatment
Why is doxycycline contraindicated in pregnancy?
It can complicate tooth formation and can cause permanent discoloration of teeth
When should universal screening for underlying DM2 or gestational diabetes be performed?
Between 24 and 28 weeks in women who do not have risk factors
At the first visit in women with risk factors for underlying DM2 or glucose intolerance (BMI >30, history of gestational diabetes in a prior pregnancy, known impaired glucose metabolism)
How is BV treated in pregnancy?
Oral metronidazole or oral clindamycin
Among women with cardiac disease, patients with ___ are among the highest risk for mortality during pregnancy, with a 25-50% risk for death. When are these women at greatest risk?
Pulmonary HTN; when there is diminished venous return and right ventricular filling
(Similar rates are seen in aortic coarctation with valve involvement and Marfan syndrome with aortic involvement)
For women who are symptomatic due to a mitral valve prolapse in pregnancy, what should be given?
Beta-blockers, to decrease sympathetic tone, relieve chest chest pain and palpitations, and reduce the risk of life-threatening arrhythmias
What are the characteristics of alpha thalassemia trait?
Mild anemia, macrocytic and hypochromic anemia, normal Hgb electrophoresis
What are the risks associated with maternal obesity?
Chronic HTN, gestational DM, preeclampsia, fetal macrosomia, higher rates of C-section and postpartum complications
What are the two most common causes of anemia in pregnancy and the puerperium?
Iron deficiency and acute blood loss
Classical morphological evidence of iron-deficiency anemia?
Erythrocyte hypochromia and microcytosis
Which SSRI is a category D drug due to the risks to the fetus? What are the risks?
Paroxetine (Paxil); fetal cardiac malformations, persistent pulmonary HTN
___ is one of the most common indications for surgical abdominal exploration during pregnancy.
Suspected appendicitis
How is the diagnosis of appendicitis made in pregnancy?
Clinical findings + graded compression ultrasonography that is sensitive and specific especially before 35 weeks gestation
Where might abdominal pain be shifted in appendicitis in pregnancy?
Upward and outward toward the flank, out of the RLQ
True or false - peritonitis and appendiceal rupture are more common during pregnancy.
True
True or false - varicella infection in the first trimester does not impact mode of delivery.
True
When is the risk of congenital anomalies lowest in the setting of maternal varicella infection?
First trimester
How should pregnant women with uncomplicated varicella be treated?
Oral acyclovir therapy 800 mg 5x/day for 7 days
In a patient with respiratory depression secondary to magnesium toxicity, what should be done?
Discontinue the mag sulfate + give a dose of calcium gluconate to restore her respiratory funciton
What are the classic signs of mag toxicity?
Muscle weakness, loss of DTRs, nausea, respiratory depression, cardiac arrest
How is mild preeclampsia diagnosed?
24-hour urine protein >300 mg/dL + elevated BP
How is severe preeclampsia diagnosed?
24-hour urine protein >5000mg (5g)
What is the only definitive therapy for preeclampsia?
Delivery of the baby and placenta
Treatment of choice for eclampsia (prevents seizures)?
Mag sulfate
At a mag level of 11 mEq/L, what is likely to occur?
Respiratory depression
What is a therapeutic mag level?
4-7 mEq/L
___ occurs at 7-10 mEq/L of mag.
Loss of DTRs
Cardiac arrest occurs at ___mEq/L of mag.
15
List contraindications to expectant management of severe preeclampsia remote from term (<32 weeks).
- Thrombocytopenia <100,000
- Inability to control BP with max doses of 2 antihypertensives
- Non-reassuring fetal surveillance
- LFT more than 2x normal
- Eclampsia
- Persistent CNS symptoms
- Oliguria
___ is a disease process in the spectrum of preeclampsia with severe features.
HELLP syndrome
What can happen in the setting of HELLP?
Swelling of the liver capsule and possible liver rupture
What indicates hemolysis?
Elevated bilirubin and anemia
In many women, ___ in late pregnancy is the major symptom of HELLP.
Persistent vomiting
When is treatment with an antihypertensive indicated in pregnancy?
BP > 160/105
What are some first-line treatments for hypertension in pregnancy?
- Hydralazine (direct vasodilator) 5 mg IV, followed by 5-10 mg doses IV at 20-minute intervals (max dose = 40 mg)
- Labetalol (combined alpha and beta antagonist) 10-20 mg IV followed by 20 mg, then 40 mg, then 80 mg IV every 10 minutes (max dose = 220 mg)
What is the goal diastolic blood pressure in the setting of preeclampsia?
90-100 mmHg to prevent maternal stroke or abruption without compromising uterine perfusion
List risk factors for developing preeclapmsia
- Nulliparity (3:1)
- Family history (5:1)
- Obesity (3:1)
- Chronic HTN (10:1)
- Chronic renal disease (20:1)
- Age >40 (3:1)
What is the risk of isoimmunization in pregnancy?
Antepartum - 2%
After full term delivery - 7%
With subsequent pregnancy - 7%
Total - <20%
Noninvasive diagnosis of fetal anemia can be performed with ___.
Middle cerebral artery peak systolic velocity measured with Doppler
What is fetal hydrops?
Collection of fluid in 2+ body cavities, such as ascites, pericardia and/or pleural fluid, scalp edema
How is fetal hydrops diagnosed and why does it develop?
U/S; decreased hepatic protein production
___ mL of fetal blood is neutralized by the 300 mcg dose of RhoGAM.
30
Why should a patient be reassured in the presence of Lewis antibodies?
They are IgM antibodies and do not cross the placenta
Discuss the risk of various atypical antibodies.
Lewis Lives
Duffy Dies
Kell Kills
Measurement of ___ in the amniotic fluid is best indicative of the severity of Rh hemolytic disease. Why?
Bilirubin
Quantified by spectrophotometric measurements of the optical density between 420 and 460 nm, the wavelength absorbed by bilirubin
What indicates the presence of severe hemolytic disease?
Values in Zone 3 of the Liley curve
In the presence of severe hemolytic disease, how soon will hydrops and fetal death occur?
7-10 days
In the setting of severe hemolytic disease at 30 weeks, what should be done?
Intravascular transfusion into the umbilical vein; if this is impossible, then intraperitoneal transfusion; maternal plasmapheresis in severe disease when transfusions are not possible
True or false - on rare occasion, an Rh-negative woman will subsequently be sensitized, despite prophylaxis.
True
The protection afforded by a standard RhoGAM administration is ___.
Dose-dependent - one dose will suppress the immune response to up to 30 cc of whole fetal blood
What is the Kleihauer-Betke test used for?
To quantitate the volume of fetomaternal hemorrhage and administered the appropriate amount of anti-D IgG
