1
Q
Name: Infectious disease testing (6)
A
- HIV
- rubella IgG
- varicella
- syphilis testing
- hepatitis B
- gonorrhoea/chlamydia
2
Q
Name: Nutrition supplementation (3)
A
- Folic acid—0.4–1 mg OD starting at least 2–3 mo preconception until end of T1 or 5 mg OD if have FHx of NTD, current Hx IDDM, obesity, epilepsy, or Hx poor compliance
- Fe – recommended 27 mg/d for maintenance, 150–200 mg /d to treat anemia
- Prenatal multivitamins
3
Q
When to do US in routine antenatal assessments according to GA?
A
- 8 - 12 wk : Dating U/S
- measure of crown-rump length; margin of error± 5d
- 18 - 22 wk :
- (a) anatomy and growth of fetus; margin of error ± 7 d;
- (b) placental position;
- (c) Amniotic Fluid Volume (Note: In obese women, U/S should be delayed until 21–22 wk GA)
4
Q
When to do screen for gestational diabetes in routine antenatal assessments according to GA?
A
24 - 28wk
- Screen for gestational diabetes (GDM)—50 g oral glucose tolerance test (OGTT)
- Plasma glucose < 7.8 mmol/L → normal
- Plasma glucose > 7.8 to < 10.3 mmol/L (50g OGTT)→ do 2h 75g OGTT
- Plasma glucose > 10.3 (50 g OGTT) → GDM
- Dx of Impaired Glucose Tolerance and/or GDM
- 1–2h 75 g OGTT: 1AbN = IGT and 2+ AbN = GDM
- Fasting plasma glucose > 5.3 mmol/L
- 1 h plasma glucose (75 g OGTT) > 10.6 mmol/L
- 2 h plasma glucose (75 g OGTT) > 8.9 mmol/L
5
Q
What’s normal maternal BP?
A
normal < 140/90 mm Hg
6
Q
What’s normal FHR?
A
110 - 160 bpm
7
Q
How to estimate date of confinement?
A
Naegele’s rule = (LMP+ 7d) − 3mo (for 28-d menstrual cycle)
8
Q
Visible gestational sac visible at which week? (2)
A
- Transvaginal US: Visible gestational sac at 5 wk (b-hCG > 1,500–3,000 IU), fetal pole at 6 wk, and fetal heart beat by 6 to 7 wk
- Transabdominal U/S: 6 to 8 wk (hCG > 6,500 IU)
9
Q
Name: Types of Prenatal Screening Tests (3)
A
- First Trimester Screening (FTS) = measures Nuchal Translucency US (NTUS) + Pregnancy-Associated Plasma Protein A (PAPP-A) + b-hCG
- QUAD = measures Maternal Serum AFP (MSAFP) + b-hCG+ unconjugated E+ inhibin A
- IPS= combines QUAD screenmarkers + NTUS + PAPP-A
10
Q
What are the findings in prenatal screening tests for: Neural Tube Defect?
A
↑ Maternal Serum AFP (MSAFP) approximately 80% to 90% sensitivity
11
Q
What are the findings in prenatal screening tests for: Trisomy 21 vs Trisomy 18?
A
- Trisomy 21 → ↓ MSAFP, ↑ b-hCG, ↓ unconjugated E3, ↑ inhibin
- Trisomy 18 → ↓ MSAFP, ↓ b-hCG, ↓ unconjugated E3, ↓ inhibin
12
Q
Smoking is associated with ↑ risk of what? (6)
A
- Spontaneous abortion (1.2–1.8×)
- Abruptio placentae
- Placenta previa
- Preterm birth
- Low birth weight infant
- Sudden Infant Death Syndrome
13
Q
Describe management of no/vo (4)
A
- Non pharmacologic: avoid spicy/greasy foods. Eat dry crackers, small frequent meals
- Pharmacologic: if causing dehydration, weight loss, and metabolic abnormalities (hyperemesis gravidarum)
- IV/P.O. hydration,
- antiemetic therapy (i.e., diclectin)
- ± nutrient supplementation
14
Q
Describe management of UTI (5)
A
- Treat asx bacturia and uncomplicated UTI based on culture results
- Common antibiotics include: amoxicillin, Nitrofurantoin.
- Avoid TMP-SMX, especially in T1, due to antifolate effect.
- Complicated UTI or pyelonephritis: hospitalization and IV antibiotics
- ** Follow with post treatment urine culture and monthly cultures for remainder of pregnancy
15
Q
Describe management of constipation (3)
A
- Drink ≥6–8 glasses fluid/d
- ↑ High fiber foods intake
- Exercise
16
Q
Describe management: Postdates (5)
A
- Offer membrane stripping from 38 to 41 wk
- Expectant management until 41 + 0
- Daily fetal kick counts from 40 + 0
- Increase surveillance (Min NST, fluid assessment 2× /wk) at 41 wk
- Induction of labor between 41 and 42 GA
17
Q
Name safe (5) and contraindicated (5) vaccines in pregnancy
A
18
Q
Name indications NST (4)
A
- Indication: decreased FM
- Normal NST and risk factors or suspected oligo-IUGR = BPP within 24h
- Atypical or abnormal NST = urgent assessment with U/S
- Indication: pregnancies at high risk
- If stable, a normal NST generally indicates favourable outcome for 1 wek
- In IDDM or GDM, or postdate pregnancy, frequency of NST is recommended 2x/wk
19
Q
Analyse results of BPP (3)
A
- 8/10 to 10/10 with normal fluid, 8/8 with no NST= intervention for obstetric/maternal factors
- 6/10 or 8/10 with low fluid = consult OB
- 0/10 to 4/10= immediate delivery required—consult OB
20
Q
Name components of BPP (4)
A
21
Q
Differentiate chronic vs gestational DB
A
Divided into chronic (Dx preceding pregnancy or diagnosed at GA < 20 wk) or gestational (Dx at GA ≥ 20 wk)
22
Q
Define HTN and severe HTN
A
- HTN: systolic pressure > 140 mmHg or diastolic pressure > 90 mmHg on two occasions
- Severe HTN: systolic pressure ≥ 160 mm Hg ± diastolic pressure ≥ 110 mm Hg
23
Q
Describe the management of HTN in pregnancy (2)
A
- Antihypertensives: target BP 130/80 to 155/105 mm Hg if no comorbidities
- Methyldopa, b-Blockers (Labetalol)
- IV for emergencies: Nifedipine XL, hydralazine
- Hospit: For BP > 160/110, or any adverse features
24
Q
Describe timing of delivery for HTN (3)
A
- IOL at ≥ 37 wk for pts with preeclampsia or GHTN
- Requires OB consult
- Pts with severe preeclampsia may require earlier delivery—requires OB consult
25
Describe: Classification of Diabetes in Pregnancy (2)
* Preexisting diabetes (type 1 or 2)
* GDM (onset of DM during pregnancy)
* GDM is usually diagnosed in the late gestation (i.e., T2 pregnancy).
* If diagnosed before 24 wk, GA is likely undiagnosed type 2 DM. (Consider ordering an HbA1c; if elevated, more likely undiagnosed type 2 DM.)
26
Describe screening GDM
27
Describe management glycemic control and surveillance: GDM (5)
* **(A) Strict glycemic control:**
* Diet control, exercise
* **Insulin** therapy → initiate **if blood glucose not well controlled on lifestyle modification alone**
* (B) Fetal surveillance:
* FM counts (6 movements in 2 hours)
* U/S to asses fetal growth/size at **36–39 wk**
* **If on insulin → twice weekly NST and BPP from 32 wk until delivery**
28
Describe delivery: GDM (2)
* Recommend delivery by **41 weeks** to all GDM, and by **39** weeks to IDGDM
* **If EFW \>4.5 kg → C/S recommended**
29
Describe management postpartum: GDM (1)
* Postpartum (R/O persistent DM):
* Follow up fasting plasma glucose + 2 h 75 g oral glucose tolerance test at **6–12 wk postpartum** (for mothers with postdelivery fasting glucose \> 7 mmol)
30
Differentiate PROM, prolonged PROM, preterm ROM and Preterm PROM (PPROM)
* **PROM:** ROM before labor at any GA
* **Prolonged PROM**: \> 24 h between ROM and labor onset
* **Preterm ROM**: ROM before 37 wk GA
* **Preterm PROM (PPROM)**: ROM before 37 wk GA and before onset of labor
31
How to confirmation of rupture of membranes? (3)
Sterile speculum exam
* Observe for pooling of amniotic fluid in posterior fornix, and fluid leaking from cervix during cough/valsalva
* **Nitrazine** test (amniotic fluid turns nitrazine paper blue)
* Note: do not do a cervical exam to avoid introduction of infection unless signs of labor
32
Describe the management of PROM (figure)
33
Describe the approach to PTL (figure)
34
Name tocolysis options (2)
* CCB (**nifedipine**) - First line
* PG synthesis inhibitors (**Indomethacin** - limit use to \< 32 weeks GA)
35
Name common etiologies for Antepartum Hemorrhage (4)
* **Abruption**: separation of placenta from uterus before delivery of fetus (after 20 wk GA)
* **Placenta** **previa**: placenta covers or is close to (\< 2 cm) cervical os
* **Vasa previa**: velamentous insertion of umbilical cord vessels into placenta, so vessels traverse the cervical os before entering the placenta
* **Cervical pathology**: (cervical polyp, ectro- pion, cervical dilation, infection)
36
Describe investigations: Abruption (2)
* Lab: CBC, liver and renal function, coagulation studies including fibrinogen, type and crossmatch
* Speculum exam if previa ruled out
37
Describe management: Abruption (4)
* Maternal **stabilization** (large-bore IVs, IV fluids ± blood transfusion)
* **If mother Rh–, give Rh immunoglobulin**
* **Delivery** if fetal distress or term infant
* Expectant management if mother and premature infant stable (steroids if \< 34 wk, **no Tocolysis**, consider transfer to higher level facility)
38
Describe investigations: Placenta previa (2)
* U/S to confirm previa
* CBC, type and crossmatch
39
Describe management: Placenta previa (4)
* Maternal **stabilization**
* **If mother Rh–, give Rh immunoglobulin**
* Expectant management if GA 24–36 wk and mother/fetus stable
* **Delivery via C/S at 36–37 wk**
40
Describe investigations: Vasa previa (3)
* CBC, type and crossmatch
* Speculum exam and Apt test
* **U/S with color Doppler** if vasa previa suspected (before bleed)
41
Describe management: Vasa previa (4)
* Steroids at 28–30 wk GA
* Manage as inpt from 30–32 wk GA
* Elective delivery at 34–36 wk GA
* Emergent delivery if bleeding (50% fetal mortality)
42
Name painless abnormal bleeding (2)
* Placenta previa
* Vasa previa
43
Describe investigation: Cervical pathology (4)
* Speculum exam
* Pap smear
* Swab for CandG
* ± U/S for cervical length if cervix appears short or associated with cramping/contractions
44
Describe management: Cervical pathology (2)
* Dependent on etiology
* Treat cervicitis
* Do not remove cervical polyp—refer to colpos- copy if AbN appearing/AbN pap smear
45
RhD isoimmunization leads to what? (2)
* a. Fetal/neonatal hemolytic anemia ± hyperbilirubinemia 25% to 30% and/or
* b. Hydrops fetalis 25%
The amount of RhD+ blood required to cause isoimmunization is small (\< 0.1 mL).
46
Describe prophylaxis of RhD isoimmunization for Rh- Women (5)
Administration of one prophylactic dose (300 mg) of RhoGAM
* At 28 wk unless the father of the baby is known to be Rh−
* Within 72 h of delivery of an Rh+ infant, even if she had received her antepartum dose.
* Following T1 miscarriage, threatened miscarriage, induced abortion, ectopic pregnancy, or molar pregnancy
* Post invasive procedures (i.e.,CVS, amniocentesis,fetal blood sampling)
* Any T2/T3 bleeding, external cephalic version, blunt abdo trauma
47
Name stages of labor with average duration (table)
48
Describe: Normal tracing (3)
* Baseline: 110 - 160 bpm
* Variability: 6 - 25 bpm, _\<_ 5 bpm for \< 40 min
* Decelerations: none or occasional uncomplicated variables or early decelerations
49
Describe: Atypical tracing (3)
* Baseline
* Bradycardia 100–110 bpm
* Tachycardia \> 160 bpm for \< 30 min
* Rising baseline
* Variability: ≤ 5 bpm for 40–80 min
* Decelerations:
* Repetitive (≥ 3) uncomplicated variable decelerations
* Occasional late decelerations
* Single prolonged deceleration
50
Describe: Abnormal tracing (3)
* Baseline:
* Bradycardia \< 100 bpm
* Tachycardia \> 160 bpm for \< 30 min
* Erratic baseline
* Variability
* \> 80 min
* ≥ 25 bpm for \> 10 min
* Sinusoidal
* Decelerations:
* Repetitive (≥ 3) complicated variables
* Single prolonged deceleration (\> 2 min but \< 10 min)
51
Describe: Early Decelerations (4)
* Uniform shape with onset early in contraction, returns to baseline by end of contraction, mirrors contraction (nadir occurs at peak of contraction)
* Gradual deceleration and return to baseline
* Often repetitive; no effect on baseline FHR or variability
* **Benign, due to vagal response to head compression**
52
Describe: Variable Decelerations (3)
* Variable in shape, onset, and duration
* Most common type of periodicity seen during 160 labour
* Often with abrupt **drop in FHR \>15 bpm below baseline (\>15 s, \<2 min);** usually no effect on baseline FHR or variability
53
Variable Decelerations are due to what? (2)
* Due to cord compression
* or, in second stage, forceful pushing with contractions
54
Describe: Complicated Variable Decelerations (6)
* **FHR drop \<70 bpm for \>60 s**
* Loss of variability or decrease in baseline after deceleration
* Biphasic deceleration
* Slow return to baseline
* Baseline tachycardia or bradycardia
* **May be associated with fetal acidemia**
55
Describe: Late Decelerations (4)
* Uniform shape
* Gradual ↓
* Late onset (starts at end of contraction)
* Can be associated with change in baseline or ↓ variability
56
Late Decelerations are due to what? (4)
* **Uteroplacental deficiency** due to
* (a) maternal hypotension
* (b) uterine hyperstimulation
* (c) placental dysfunction
* Result = **hypoxia** ± **acidosis** of fetus
57
Describe: Management of an Atypical or Abnormal FHR Tracing (11)
* Recheck the tracing
* Backup
* Change maternal position to Left lateral decubitus position—relieves compression of IVC by the gravid uterus
* Provide fetus O2 by 100% O2 mask to mother
* **Stop augmentation of labor**—↓ hyperstimulation
* **Fetal scalp stimulation**
* R/O causes of utero placental deficiency (i.e.,correct any maternal hypotension—IVFs, ephedrine)
* Amniotomy
* Fetal scalp electrode if unable to obtain adequate tracing with external monitoring
* Measurement of fetal scalp blood pH—**(pH≥ 7.25= normal, pH ≤ 7.20= fetal acidosis)**
* ± Amnioinfusion—protects cord from compression
58
Screening for Group B Strepto should be done when?
36 wk GA
59
Indications for Antibiotic Prophylaxis for GBS (5)
* A positive GBS screen
* Unknown GBS status and other RFs for neonatal disease
* (a) Prev.infant with invasive GBS infection
* (b) GA \< 37 wk
* (c) \> 18 h since ROM
* (d) GBS bacteriuria in current pregnancy
60
Name ATB used for GBS prophylaxis (4)
IV
* Penicillin
* Cefazolin (non anaphylactic penicillin allergy)
* Clindamycin (anaphylactic penicillin allergy with documented GBS sensitivity)
* Vancomycin (anaphylactic penicillin allergy with GBS resistance to Clindamycin or sensitivity unknown)
61
Name rx for pain relief in labor (3)
* **Entonox**: A mixture of nitrous oxide gas and O2 administered through a mask
* **Narcotics**: morphine, can cause respiratory depression in the neonate, reverse with Narcan 0.01 mg/kg
* **Regional anesthesia**:
* Loss of pain sensation occurs below T8/T10
* Must hydrate the patient with **dextrose free isotonic IV** before initiation of epidural
62
Name RIs for epidural or spinal considerations (6)
* Pt refusal
* Untreated **coagulopathy**
* Skin infection of **lumbararea**
* **Refractory hypotension/hypovolemia**
* Active **neurologic** **disease**
* **Septicemia**
63
Compare median (midline) episiotomies and mediolateral (4)
* Median (midline)
* Advantage = easy repair and improved healing
* likely to extend into anal musculature/rectal mucosa
* Mediolateral
* Advantage = ↓ likely to extend into anal sphincter and rectum
* Mediolateral → ↑ scar tissue, ↑ blood loss, ↑ pain, ↑ dificult to repair, dyspareunia sequelae
64
Describe: Management of Shoulder Dystocia (7)
* A: Ask for help
* L: Lift/hyperflex both legs (McRobert maneuver)
* A: **Anterior** shoulder disimpaction (suprapubic pressure by assistant or **Rubin** **maneuver** by MD)
* R: Rotation of **posterior** shoulder (**Wood cork screw maneuver**)
* M: Manual removal of posterior arm
* E: Episiotomy
* R: Roll onto all 4s
65
Describe active management of third stage of labor (2)
* Oxytocin
* Controlled cord traction
66
Name methods of induction of labor (2)
* **Artificial ROM** (amniotomy)—stimulates PG synthesis and secretion
* **Oxytocin** (Pitocin)
67
Describe: Augmentation of labor
* Promotes adequate uterine contractions when spontaneous labor fails to progress
* IV infusion of **oxytocin**
68
Name: Common postpartum complications (4)
* Postpartum hemorrhage
* Postpartum fever
* Postpartum blues
* Postpartum depression
69
Describe initial management of postpartum hemorrhage (8)
* Resuscitation:
* large-bore IVs ± IVFs
* O2 using mask
* cross and type 4 units PRBC
* monitor vital signs
* Assess etiology: “4 Ts”
* Tone—assess uterine atony
* Tissue—explore uterus for retained placental tissue or blood clots
* Trauma—explore the lower genital tract for lacerations
* Thrombin—review if patient has Hx of coagulopathy (vWD, ASA use, DIC, ITP, etc.)
* Investigations: CBC, coagulation profile
70
Describe timeline of postpartum blues
Usually begins between postpartum day 3 and 10 days
71
Describe: Postpartum depression (2)
* Depression occurring in a woman within 1 y of childbirth
* Antidepressants, Psychotherapy, Supportive care
72
Describe tx: Endometritis (2)
clindamycin + gentamicin
Revision LMCC
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