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OB GYN > Antepartum Care > Flashcards

Antepartum Care Flashcards

1
Q

preconception counselling issues

A
  • folic acid - 0.4mg x3 mo, decrease risk 70% of NTD
  • age - SA, chronomosal issue, infertility
  • BMI
  • immunization - rubella + varicella
  • genetic risk: ethnicity and fam hx
  • medical conditions - optimize
  • meds: no ACEi, no wafrarin, anti-epileptics
  • Ob Hx - 3 SA or any mid-trimester, work-up
  • ASA:
  • sochx - DV, drugs, alc, smoking, exercise
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2
Q

when to work-up for preg loss + what to do

A
  • 3 consecutive SA or 1 midtrimester:
  • thrombophilia testing
  • sonohyst
  • genetics/karyotype
  • ASA if inidcated
  • clerclage at 13-14 weeks if insufficiency
  • progesterone supplementationt
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3
Q

indications for ASA

A
  • start 12-28 wks, ideally before 16 wks, continue until delivery
  • high risk for pre-eclampsia:
    • hx
    • multiples
    • chronic HTN
    • t1 or t2 DM
    • renal disease
    • SLE or APA syndrome
  • if 2+ mod RFs can consider:
    • nullip
    • obese
    • mom or sis pre-eclamp
    • african america or low SES
    • 35+
    • personal Hx (10 year interval, SGA, prev adverse outcome)
  • hx of placental abruption or thrombosis
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4
Q

GI changes in preg

A

progesterone = smooth muscle relaxant

  • GI - constipation, reflux, cholestasis
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5
Q

skin changes in preg

A

hyperpigment, spider nevi, palmar erythema, moles, skin tags

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6
Q

cardiovascular changes in preg

A
  • HIGH: CO, HR, BV

- LOW: BP, venous return

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7
Q

renal changes in preg

A

renal: low BUN + creatinine, increase GFR + renal plasma flow, dilated ureters + renal pelvis –> glycosuria (less resorption, don’t use to dx D)

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8
Q

hematologic changes in preg

A

HIGHER: plasma, RBC mass, coag proteins, transport proteins

LOW: hg, tot prot, albumin (dilution)

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9
Q

resp changes in preg

A
  • resp: increased CO2 sensitivity, VC same,
    • HIGH: minute vent
    • LOW: TLC, FRC, RV
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10
Q

endocrine changes in preg

A

higher: thyroid size, basal MR, tot thyroid (more binding glob), tot + free cortisol
- lower: tot Ca (less albumin), PTH (increased bone resportion, increased gut absortion)
- free T4 and TSH same, free Ca same
- more bone turnover but no loss in density b/c estrogen

higher cortisol –> insulin resistance

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11
Q

presumptive signs of preg

A
  • amenorrhea
  • chadwicks
  • breast tenderness, areola darkening
  • fatigue
  • urinary freq
  • GI issues
  • quickening: 20 weeks
  • chloasma
  • striae
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12
Q

probably signs of pregnancy

A

abdo enlargement
uterus enlargement
hegar’s sign: cervix soft

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13
Q

positive signs of preg

A
  • fetal heart
  • FM by examiner
  • TVUS: sac at 5 wks, pole at 6 wks, HR at 7-8 wks
  • positive BhCG (serum 9 days post conception + doubles in 48 until 8-10 wks), urine (28 days GA)
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14
Q

GA assessment

A
  • LMP + 280 days
  • LMP - 3 mo + 7 days, adjust according to cycle length

US: +/- 5 days = 1st trim, 1-2 weeks for 2nd, 2-3wks for third

Fundus:

  • symphysis - 12 wks,
  • mid 16 wks
  • umbilicus 20 wks
  • xyphoid term

SFH in cm = wks (from 20-36)

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15
Q

first prenatal visit

A
  • hx of pregnancy (LMP, EDD, OCP, bleed)
  • OBHx
  • med hx, surgeries
  • fam hx (consanguinity, genetic)
  • meds, allergies
  • soc hx: substances
  • ROS
  • physical:
  • VS, weight
  • thyroid
  • cardiovasc (murmurs)
  • breast changes
  • abdo (uterus)
  • pelvic: external, spec, cultures, PAP if due - NO INTRACERVICAL BRUSH, bimanual exam (uterus/cervix/adnexa)
  • periph edema/varicosities
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16
Q

follow-up antenatal visit schedule

A

first visit - 8-12 wks
every 4 wks until 28
every 2 wks until 36
every week 36 - deliv

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17
Q

follow up antenatal visits

A
  • general issues
  • fetal movement
  • weight
  • BP
  • measure SFH
  • doppler after 15 wks
  • leopolds after 30 wks (present, lie, engagement)
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18
Q

prenatal labs at 1st visit

A
  • Hep B surface antigen
  • VDRL
  • HIV - consent
  • Rubella
  • Gonorrhea + Chlamydia (urine or swab)
  • CBC
  • blood group + screen
  • urinalysis + microscopy, culture (MSU)
  • pap if due
  • sickle-cell / Hg electrophoresis if at risk

others:

  • TSH - ? value of routine
  • Hep C if RFs (low vert transmission)
  • varicella zoster titre if not immune on hx
  • toxoplasmosis - cats, gardeners
  • hemoglobin A1C if DM
  • TB - RFs
  • urinalysis by dip if high BP
  • hx of HSV - give oral antiviral from 36 weeks until delivery
  • low dose ASA if needed
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19
Q

genetic screening

A
  • NIPT: 10+wks
  • 13, 18, 21, X +Y, microarray
  • eFTS: 11-14wks
  • NT, PAPPA, BHCG, P1GF/AFP
  • downs + trisomy 18
  • Quad (MSS): 15-20wks
  • CVS: 11-14 wks
  • karyotype + microarray
  • loss = 1-2%
  • amniocentesis: 15-20wks
  • loss 1/200
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20
Q

GDM testing

A
  • 25-28 weeks (earlier if lots RF, repeat if needed)

Glucose Challenge Test

  • no fasting
  • 50 g glucose
  • 1 hrs test
  • 7.8 - 11 –> more testing
  • over 11 = GDM

Glucose Tolerance Test

  • FBS
  • then 75g glucose
  • 1 hr glucose
  • 2 hr glucose
  • if any abnormal = GDM
  • FBS >= 5.3
  • 1hr >= 10.6
  • 2hr >= 9
21
Q

GDM management

A
  • diet, metformin or insulin if needed (usually insulin)
  • counsel re risks
  • multidisciplinary
  • blood sugar checking
  • repeat GTT at 6wks - 6months PP
22
Q

Rhogam administration

A
  • Rh neg and not sensitized
  • 28 weeks
  • any bleeding (SA, termination, ectopic, CVS/amnio, bleed, PP)
  • protection lasts 12 weeks
  • Rhogam = IgG antibody
  • dose: 300 mcg IM (protects against 25mls fetal blood)
  • larger bleed: Betke-Kleihauer to adjust dose
23
Q

management of other antibody positive

A
  • test father
  • refer to high risk clinic
  • fetal status testing?
  • serial antibody titres/US for fetal anemia/hydrops
  • risk depends which antibody
24
Q

GBS testing

A
  • swab at 35 - 37 wks
  • earlier if TPTL or multiples
  • 1 swab into vag + rectum
  • if positive give prophylaxis in labour
  • if GBS bacturia in preg = positive, no swab needed
25
Q

BPP uses

A
  • if post dates: twice weekly in 41st week until delivery

- or if issue

26
Q

assessments of fetal well being

A
  • growth (SFH, US)
  • kick count (after 30wks)
  • NST
  • US
  • BPP
  • AFI
  • Dopplers
27
Q

NST antenatal NORMAL

A

Baseline - 110-160

Variability - mod (6-25bpm), less for <40min

Decels - none or occasional variable <30s

Accels - 2+ 15x15 in <40min

Accels <32 wks - 2+ 10x10 in <40min

Action: no further assessment needed

28
Q

NST antenatal ATYPICAL

A

Baseline: 100-110, or >160 for <30min

Variability: absent/min for 40-80min

Decels: variable decels 30-60s

Accels: 2 or less 15x15 in 40-80mins

Accels <32: same but 10x10

Action: FURTHER ASSESSMENT

29
Q

NST antenatal ABNORMAL

A

Baseline: >160 for >30min, or <100, or erratic

Variability: mod or min for >80min, sinusodal, >25bpm >10min

Decels: variables >60s, lates

Accels: 2 or less accels in >80 min

Accels <32: same but 10x10

ACTION: urgent! assess situation /w US or BPP, maybe deliver

30
Q

when can you do NST

A

mid second trimester + up (around 24 wks)

31
Q

US in pregnancy

A
  • dating: first trimester, include NT if 11-14 wks
  • anatomy scan - 18-20 wks, also placenta location, NTD
  • growth - EFW, AC, BPD, FL, not more than every 2 wks
  • third trimester: around 32 wks, no real evidence, indicated if DFM, growth, position, previa, other issue
32
Q

BPP components

A
  • must be in 30 mins
  • gross movements: 3 body or limb
  • fetal tone: 1x extension + flexion
  • breathing: 1 30s episode
  • AF: 2x2 pocket
33
Q

normal AFI

A

5-25cm

34
Q

doppler flow studies

A
  • UA: PI (high = bad), absent EDF = admission ?deliver, reverse EDF = deliver
  • MCA: PI for IUGR (shows low PI, EDF increased in brain sparing = bad sign), PSV for anemia (high)
  • Uterine Artery: abnormal at 20-22 wks –> risk for placental insufficiency (IUGR) and pre-eclampsia
35
Q

NVP management

A
  • severe: r/o twins, molar preg, other causes
  • check electrolytes, ketonuria, hydration status, weights
  • tx: small meals, sleep, stop iron, ginger
  • drugs: diclectin 2-4 tabs/day up to 8
  • dimenhydrinate or promethazine, then metoclopramide, then odansatron (ADD at each step)
  • severe: home care for IV drugs/fluids
36
Q

dietary advice in preg

A
  • 3-4 milk per day
  • 100kCal, then 300kCal more/day
  • folate, Ca, vitD, Fe, fatty acids important
37
Q

optimal weight gain in pregnancy

A
  • 2-8lbs in first trimester
  • then 1 lb per week

BMI<20: 12.5-18kg tot
BMI 20-27: 11.5-16kg
BMI>27: 7-11.5 kg

38
Q

smoking associated /w risk of

A

prematurity, IUGR, in home: SIDS

39
Q

cocaine associated /w risk of

A

IUGR, abruption, demise, anomalies, /w drawal

= vasoactive

40
Q

contraindications to exercise in preg

A

absolute:
- ROM
- PTL
- HTN
- incompetent cervix
- IUGR
- triplets or more
- previa after 28wks
- persistent 2nd or 3rd trim bleeding
- uncontrolled T1DM, thyroid, cardiac, resp, other

relative:

  • prev SA
  • prev preterm
  • mild/mod CVD/resp issue
  • anemia <100 Hb
  • malnutricion
  • twins after 28wks
  • other sig med issue
41
Q

vaccinations in preg

A
  • NO: MMR, varicella, BCG (give after)
  • YES: flu, Tdap (21-23wks), others not up to date

no live vaccines

42
Q

SSRI in pregnancy risks + CI

A
  • rare increased risk of PPHN + /w drawal

- paroxetine C/I, switch

43
Q

common C/I medications

A

ACEi: renal, IUGR, oligohydraminos

Tetracycline: teeth + bone

retinoids (accutane): major malformations

DES: historical risk, clear cell carcinoma + mullerian abnormalities

Others may consider:
anticonvulsants: NTD, hydantoin syndrom, cardiac, limbs, skeletal

lithium: ebsteins anomaly (heart)
warfrin: SA, embryopathy

Prostaglandin inhib/NSAIDs: indomethacins + ibuprofen after 32 wks –> premature closure of DA

44
Q

Contraindications to breastfeeding

A
  • HIV

- HepB and HepC ok (HepB babies vaccinated)

45
Q

tx of common BF issues

A
  • nipple: lanolin cream, topical steroid
  • candida - topical clotrimazole (no ketoconazole)
  • engorgement: cool, expression
  • mastitis: cloxacillin
  • inadequate: fnugreek, domperidone (not used often)
46
Q

vaginitis in preg

A

yeast:
- tx /w topical (monistat/canesten), use finger instead of applicator, repeat if needed

  • if fails use fluconazol PO

BV:

  • controversial to tx, tx if RF of PTL
  • do treat if asymptomatic
  • oral or vaginal metronidazole
47
Q

common complaints general approach

A
  • r/o serious cause (hx + px)

- treat with non medical, reassurance, only meds as needed

48
Q

when to go to hospital for ROM

A
  • green fluid
  • GBS positive
  • bloody fluid
  • baby not vertex

Or if Term PROM, for induction (after x hours?)

OB GYN (22 decks)

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