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Ideal criteria for MTX therapy in ectopic pregnancy.
Hemodynamically stable
Able and willing to comply with posttreatment monitoring
Pretreatment serum hCG concentration less than 5000 mIU/mL
Tubal size of less than 3 to 4 cm and no fetal cardiac activity
No renal, hepatic, or hematologic disorders
Single dose protocol of MTX for ectopic pregnancy.
Day 1: hCG, 50 mg/m2 IM
Day 4: hCG
Day 7: hCG. If < 15% decrease in hCG from day 4, or < 25% decrease from day 1, give another dose.
Day 14: hCG. If < 15% decrease from day 7, give another dose.
Day 21 and 28: hCG. If 3 doses have been given, and < 15% decrease from day 21 and 28, then laparoscopic surgery.
When should GBS prophylaxis be given?
If positive, and in active labor or ROM

If no swab was done, then treat if:
- preterm labour
- PROM > 18 hours
- maternal fever > 38
- documented GBS + in past pregnancy
- prior newborn with GBS sepsis
What is given for GBS prophylaxis?

What if allergic to the first agent?
Pen G 5 million U IV x 1, then
Pen G 2.5 million U IV q4h until delivery

If Pen allergy, use Ancef 2g IV, then 1g IV q8h
If Pen allergy and risk of anaphylaxis, then clindamycin 900mg IV q8h or erythromycin 500 mg IV q6h
4 types of maternal pelvis
Gynecoid
Android
Platypelloid
Anthropoid
Criteria for dystocia.
> 4 hours active labour with <0.5 cm/hr dilation
> 1 hr with no descent during active pushing
Empiric treatment for urethritis/cervicitis.
Cefixime 400 mg PO x 1 dose or Ceftriaxone 125 mg IM x 1

and

Azithromycin 1 g PO x 1 or Doxycycline 100 mg PO bid x 7 days
Empiric treatment for acute PID, both inpatient and outpatient.
Inpatient tx:
Cefotetan 2 g IV q12h or Cefoxitin 2 g IV q6h
AND
Doxycycline 100 mg PO/IV q12h
Switch to oral meds if improving after 24 hours - Doxycycline 100 mg PO bid for total of 14 days

Outpatient treatment:
Ceftriaxone 250 mg IM x 1 dose
AND
Doxycycline 100 mg PO bid x 14 days
Consider adding Metronidazole 500 mg PO bid x 14 days
F/U within 72 hours to ensure clinical improvement occurring
Criteria for hospitalization in acute PID.
Surgical emergencies cannot be excluded (e.g. appendicitis)
Not responding to oral abx
Unable to follow or tolerate outpatient oral regimen
Severe illness, N/V, high fever
Tubo-ovarian abscess
Risk factors for developing PID.
Age < 25
Young age at first intercourse
Multiple sex partners
Lack of contraception
Prior history of PID
IUD insertion (first 3 weeks after)
What is the blood supply to the external genitalia?
Internal pudendal artery.
Branches of the pudendal nerve.
Dorsal nerve of clitoris
Perineal nerve
Inferior rectal nerve
What are the branches of the anterior division of internal iliac artery?
1. Umbilical artery
- Superior vesical artery
2. Uterine artery
3. Obturator artery
4. Inferior vesical artery (aka vaginal artery)
5. Middle rectal artery
6. Internal pudendal artery
7. Inferior gluteal artery
What is the blood supply to the cervix?
Cervical branch of uterine artery
Approach to abnormal uterine bleeding.
Pregnant
-1st trimester
--normal pregnancy: implantation bleed, SA
--abnormal pregnancy: intrauterine molar pregnancy, extrauterine ectopic

Not pregnant
-adolescent
-reproductive
-perimenopausal
-postmenopausal
What is metrorrhagia?
Bleeding at irregular intervals particularly between expected menstrual periods
What is DUB?
Abnormal bleeding not attributable to organic (anatomic/systemic) disease. DUB is a diagnosis of exclusion.

90% are due to anovulation.
10% are due to dysfunction of corpus luteum and inadequate progesterone production, or an atrophic endometrium (due to OCP)
Mechanism of tranexamic acid.
"Cyklokapron" works by inhibiting fibrinolysis.
Treatment of dysmenorrhea
NSAIDs
OCP to suppress ovulation and reduce menstrual flow
Absolute contraindications to combined E+P OCP
Known/suspected pregnancy
Undiagnosed abnormal vaginal bleeding

Hypercoagulable states
-Pregnancy (and 6 weeks postpartum)
-History of thromboembolism
-Hereditary thrombophilia
-Smoker > 35
-Uncontrolled hypertension, ischemic heart disease, CVA
-Migraines with focal neurological deficit
-Complicated valvular heart disease
-Diabetes with retinopathy/nephropathy/neuropathy

Liver disease
Breast cancer (current)
Adverse effect of Yasmin
Hyperkalemia. Contraindicated in renal and adrenal insufficiency.
Treatment of DUB
Medical:
- Combined OCP (decreases blood flow, regulates cycles)
- Mirena IUD (many achieve amenorrhea)
- NSAIDs
- Tranexamic acid

Surgical:
- Endometrial ablation
- Hysterectomy
Compare/contrast vaginal discharge from BV and Trichomoniasis.
BV: grey, thin, fishy odour

Trichomoniasis: yellow-green, malodorous
Treatment of bacterial vaginosis
Only treat if pregnant, symptomatic, or undergoing pelvic surgery.

Metronidazole 500 mg PO bid x 7 days
OR
Clindamycin 2% 5 g cream intravaginally qhs x 7 days
Treatment of Trichomoniasis
Treat even if asymptomatic, unless pregnant. Can treat symptomatic pregnant women.

Metronidazole 2 g PO x single dose
Diagnosis of PID.
Must have:
1. lower abdo pain
2. CMT
3. adnexal tenderness

PLUS 1 or more of:
1. Oral temperature >38.3 C
2. Abnormal cervical or vaginal mucopurulent discharge
3. Abundant numbers of white blood cells (WBCs) on saline microscopy of vaginal secretions
4. Elevated ESR
5. Elevated CRP
What are the complications of PID?
I FACE PID

Infertility
Fitz-Hugh-Curtis syndrome
Abscesses
Chronic pelvic pain
Ectopic pregnancy
Peritonitis
Intestinal obstruction
Disseminated infection (sepsis, endocarditis, arthritis, meningitis)
Absolute contraindications to HRT.
A: Acute liver disease
B: undiagnosed vaginal Bleeding
C: Cancer (breast/uterine)
D: DVT (thromboembolic disease)
Classification of uterine prolapse.
0 = no descent
1 = descent between normal position and ischial spines
2 = descent between ischial spines and hymen
Procidentia: failure of genital supports and complete protrusion of uterus through the vagina
3 = descent within hymen
4 = descent through hymen
What tests are permitted for FIGO clinical staging of cervical cancer.
Physical exam
LFT
Cervical biopsy
Proctoscopy/cystoscopy
IVP
US liver/kidneys
CXR
What is cystocele?
Protrusion of bladder into anterior vaginal wall
Difference between miscarriage and stillbirth.
Miscarriage, sometimes called spontaneous abortion, occurs when a fetus dies before the 20th week of the pregnancy. Stillbirth is the death of a baby after the 20th week—it usually is detected while the baby is still in the mother’s uterus but, occasionally, not until labor is underway.
Risk factors for ovarian cancer
Age is the most important factor
Family hx of ovarian cancer
Infertility
Nulligravity
Definition of pre-existing hypertension in pregnancy.
• DBP ≥ 90. If SBP ≥ 140, follow closely for diastolic hypertension
• Onset < 20 weeks GA (except in GTN), or persists longer than 12 weeks postpartum.
Criteria for diagnosing preeclampsia in pre-existing htn or gestational htn.
Pre-existing:
-Resistant HTN
-Proteinuria ≥ 2+ (or 0.3 g/day in 24 hour urine collection)
-Adverse conditions

Gestational htn:
-Proteinuria ≥ 2+
-Adverse conditions
Criteria for severe preeclampsia
• Onset before 34 weeks
• Heavy proteinuria 3-5 g/day
• One or more adverse features
What are the "adverse conditions" preeclampsia diagnosis?
Maternal symptoms
- Persistent or new/unusual headache
- Visual disturbances
- Persistent abdominal or RUQ pain
- Severe N/V
- Chest pain
- Dyspnea
- Signs of end-organ dysfunction
□ Eclampsia
□ Severe hypertension
□ Pulmonary edema
□ Suspected placental abruption

- Abnormal lab tests
□ High creatinine
□ AST
□ ALT
□ LDH
□ Platelets < 100
□ Serum albumin < 20 g/L

Fetal morbidity
- Oligohydramnios
- IUGR
- Absent or reversed end-diastolic flow in umbilical artery by Doppler velocimetry
- IU fetal death
Risk factors for preeclampsia.
Preexisting disease:
□ HTN
□ Renal disease
□ DM
PMHx of FHx of gestational HTN
Hereditary thrombophilia
Onset of gestational HTN prior to 34 weeks GA
Elevated uric acid
Multiple gestation, or ART
Cocaine/methamphetamines
Maternal age ≥ 40
Obese BMI ≥ 35
Primigravida
First conception with new partner
Interdelivery interval of > 10 or <2 years
Antiphospholipid antibody syndrome
Abnormal triple screen, uterine dopplers
Infection during pregnancy
Lab investigations in hypertensive disease of pregnancy.
Urine dip
CBC, creatinine
Liver enzymes
Albumin
LDH
Uric acid
PTT, INR, fibrinogen
Fetal investigations when suspect hypertensive disorder of pregnancy.
Non-stress test
Ultrasound
□ Growth
□ Fluid volume
Umbilical cord doppler
Biophysical profile
When should a hypertensive disorder of pregnancy be admitted as inpatient?
Admit for inpatient tx
- Severe preeclampsia
- Severe hypertension

Could treat as outpatient with close follow-up, based on judgment
- Non severe preeclampsia
- Non severe hypertension
Treatment goals, and meds for non-severe hypertension ± preeclampsia.
Target BP
No comorbidities:
SBP 130-155
DBP 80-105
Comorbidities:
SBP 130-139
DBP 80-90

Methyldopa
250-500 mg PO bid-qid (max 2 g/day)

Labetalol
100-400 mg PO bid-tid (max 1200 mg/day)

Nifedipine
PA tablets 10-20 mg PO bid-tid (max 180 mg/day) or
XL preparation 20-60 mg PO daily (max 120 mg/day)
Treatment goals, and meds for severe hypertension ± preeclampsia.
Target SBP < 160, DBP < 110

Labetatol
Start 20 mg IV, repeat 20-80 mg IV q30min or 1-2 mg/min, max IV at 300 mg then switch to oral

Nifedipine
5-10 mg capsule bitten and swallowed, or just swallowed every 30 mins
Or 10 mg PA tablet q45 min to max of 80 mg/day

Hydralazine
Start 5 mg IV, repeat 5-10 mg IV q30min, or 0.5-10 mg/hr IV, max of 20 mg IV
Recommendations on timing of delivery for women with preeclampsia.
< 34 weeks → expectant management

34-36 weeks and mild preeclampsia → expectant? Insufficient evidence to make recommendation

34-36 weeks and severe preeclampsia → immediate delivery

≥ 37+0 weeks → immediate delivery
Management of eclampsia.
MgSO4 4 g IV bolus, then 1g/hr infusion

Recurrent seizure → 2nd bolus of 2-4 g
Signs of MgSO4 toxicity.
Depressed DTRs
Respiratory depression
Anuric
Hypotonic
CNS or cardiac depression

Give calcium gluconate 1 g IV bolus
Screening for GDM. When? What are the thresholds?
Test between 24-28 weeks, or in first trimester if "high risk"
75 g oral GTT. GDM if any one of:

□ FPG ≥ 5.1
□ 1 hr ≥ 10.0
□ 2 hr ≥ 8.5

Overt diabetes if
□ A1C ≥ 6.5%
□ FPG ≥ 7.0
□ Random glucose ≥ 11.1 and reconfirmed by FPG or A1C
Complications of GDM.
Fetal risks
- Spontaneous abortion
- Congenital malformations (heart, GU, limbs, neural tube)
- IUGR
- Fetal macrosomia
- Preterm birth
- Stillbirth
- Shoulder dystocia
- Neonatal complications (hypoglycemia, RDS, hyperbilirubinemia)

Maternal complications
- Retinopathy
- Nephropathy
- Hypertension
- Preeclampsia
- DKA
What maneuver is used if there is shoulder dystocia?
McRobert's maneuvre
What is symmetric vs. asymmetric IUGR caused by?
Symmetric:
-congenital anomalies
-TORCHES
-drugs, smoking, EtOH
-genetic syndromes

Asymmetric:
-placental insufficiency
Diagnostic criteria for IUGR
Use ultrasound to estimate:
Fetal weight < 10th percentile, or
Fetal abdominal circumference < 10th percentile, or
Postnatal birth weight < 10th percentile
Impact of IUGR during perinatal, infantile, childhood and adult periods.
Perinatal death
• Asphyxia (hypoxia causing apparent harm)
• Meconium aspiration
• Hypoglycemia, decreased glycogen reserves
• Hypocalcemia, secondary to hypoparathyroidism
• Hypothermia, decreased subcutaneous tissue
• Polycythemia
• Hypercoagulability
• Hyperbilirubinemia, secondary to polycythemia
• Thrombocytopenia

Infant death
• 30% of infants who die of SIDS were IUGR

Childhood
• Neurodevelopmental abnormalities
• Learning disorders
• ADHD

Adulthood
• CAD
• Hypertension
• COPD
• Babies with IUGR
5 parameters of biophysical profiling.
Breathing
Amniotic fluid volume
Tone
Movement
NST
If antenatal screening tests are abnormal, what additional tests should be performed?
• Fetal movement counting
• Non-stress test
• Ultrasound (growth and AFI)
• Fetal Doppler (umbilical artery ± other vessels)

Consider BPP and contraction stress test.
Causes of postterm pregnancy
Dating error
Brain: anencephaly
Adrenal: fetal adrenal hypoplasia
Placental: deficiency of enzyme placental sulfatase
Membrane/decidua: high level of prostaglandin catabolizing enzyme
Extrauterine pregnancy
Management of postterm pregnancy
1. Sweeping of membranes, offer at 38-41 weeks
2. If risk factors (HTN, diabetes, IUGR, hydramnios, multiple gestation), strongly consider delivery by 40 weeks, or serial fetal surveillance
3. At BCW, labor induction offer at 41+3 weeks
4. If opt for expectant management, then monitor 2x/week with NST and AFV
Before IOL, what is the scoring system to assess cervical favorability?
Bishop score.
If ≤ 5, then cervix unfavorable, and need cervical ripening prior to IOL. Prepidil or Cervidil.
Management of excessive uterine activity.
Stop prostaglandin/oxytocin
Supportive measures
-Left lateral position
-O2
Tocolytic - nitroglycerin
What age should pap smears be started?
3 years after 1st sexual intercourse, or at age 21 whichever earlier.
What are the office tests that can be done if woman complaining about vaginal discharge? How do you interpret them?
2 swabs
-PCR swab for Chlamydia and GC
-"Everything else" swab for bacterial vaginosis, Trichomonas, yeast

pH test
-If > 4.5, then either BV or Trichomonas. If inflammation and erythema then Trichomonas. No erythemia then BV.

KOH tests
-Whiff test: smells fishy ("amine odour") = BV
-KOH slide microscopy: if hyphae seen, then yeast infection

Wet mount prep
-Flagelles = Trichomonas
-Clue cells = BV
-Spores = Candida

Gram stain
- look for same as wet mount
What properties of the fetus are you trying to assess with each step of the Leopold's maneuver?
1st - presentation
2nd - lie and also which side the back faces
3rd - engagement
4th - attitude
What is an absolute contraindication to vaginal exam during labour?
Placenta previa, which is diagnosed on US
What should be assessed during initial evaluation of labour?
Contractions
SFH
Leopold's maneuvers
FHR
Vaginal exam
Causes of postpartum hemorrhage.
• Tone
• Tissue
• Trauma/tears
• Thrombosis (coagulopathy)
Risk factors for postpartum hemorrhage.
Too stretched
-Macrosomia
-Multiple gestation
-Polyhydramnios
-Grand multiparity (means having parity ≥ 5)

Too tired
-Long labor
-Fast labor
-Augmentation with oxytocin

Too damaged
-Episiotomy
-Forceps
-Clamps
-Chorioamnionitis
-Preeclampsia
-Fibroids
-Anesthesia
Pharmacologic treatment of postpartum hemorrhage.
Oxytocin 20-40 U IV in 1 L NS, bolus
Misoprostol rectal tabs 800-1000 mcg x 1
Methylergonovine (Methergine) 0.2 mg IM x 1
Hemabate (PGF2α)
Dinoprostone or Prostin (PGE2)
Physical signs of pregnancy.
CHUG
Chadwick, 6 weeks - blue cervix and vagina
Hegar, 6-8 weeks - softening of cervical isthmus
Uterine enlargement
Goodell, 4-6 weeks - softening of cervix
When is beta HCG detectable in serum?
9 days post-conception
Differential for HCG levels lower than expected by dates.
Ectopic
Abortion
Inaccurate dates
Differential for HCG levels higher than expected by dates.
Multiple gestation
Molar pregnancy
Trisomy 21
Inaccurate dates
What is the expected weight gain during pregnancy in T1 vs T2/T3?
1.5-3 lb during T1, then
0.8 lb/week in T2/3
Frequency of prenatal visits.
First prenatal visit before 12 weeks.
q4-6 weeks until 28 weeks
q2 weeks 28-36 weeks
q1 week from 36-delivery
What should be done on history, physical exam, and investigations for EVERY prenatal visit?
History of present pregnancy: fetal movements, uterine bleeding, leaking, cramping.

Physical: BP, weight, SFH, Leopold's maneuvers (T3)

Investigations: U/A for glucosuria, ketones, proteinuria. FHR starting at 12 weeks with Doppler US.
DDx of decreased fetal movements
DASH

Death of fetus
Amniotic fluid decreased
Sleep cycle of fetus
Hunger/thirst
What is the threshold for number of fetal movements per unit of time when consulting an MD is appropriate?
< 6 movements in 2 hours.
At what week should Rhogam be given to Rh -ve women?
28 weeks GA
What is L:S ratio?
Lecithin:Sphingomyelin ratio, measures lung maturity.
Measured from amniocentesis. If L:S > 2:1, then RDS is less likely to occur.
What tests should be ordered at first prenatal visit?
Bloodwork:
-CBC
-Blood group, Rh status, indirect Coombs.
-Infection screening (rubella, HBsAg, VDRL, HIV, toxoplasmosis, CMV, TB, varicella)

Urine R&M, C&S

Pelvic exam
-Pap smear unless done in last 6-12 months
-Swab for Chalmydia and GC
-Swab for BV
What is the Kleihauer Betke test?
Tests extent of fetomaternal hemorrhage. Used to determine the dose of Rhogam to give to an Rh -ve mother.
Pharmacologic treatment of hyperemesis gravidarum.
Diclectin (10 mg tabs) 2 tabs qhs + 1 tab qam, 1 tab qpm (afternoon) - can be increased to 8 tabs per day.

Gravol
List the different types of spontaneous abortion.
1. Threatened abortion: bleeding without loss of fluid or tissue. Cervix closed. US confirmation of fetal heart activity.
2. Inevitable abortion: cervical dilation or rupture of membrane.
3. Complete abortion: spontaneous passage of all products of conception. Cervix may be opened or closed. Usually < 12 weeks GA.
4. Incomplete abortion: partial expulsion of pregnancy tissues. Cervix open. Gestational tissue may be visible in the cervix. Usually > 12 weeks GA
5. Missed abortion: in utero death of fetus, with prolonged retention. Cervix closed.
Most common causes of vaginal bleeding in 1st trimester, vs 2nd/3rd trimester
1st trimester:
-threatened abortion
-vaginal, cervical or uterine pathology (including postcoital bleed)
-ectopic pregnancy
-implantation bleed

2nd/3rd trimester
-placenta previa
-abruptio placenta
-bloody show
-uterine rupture
-vasa previa
Clinical features of placental abruption.
Pain: sudden onset, constant, localized to lower back and uterus.
Vaginal bleeding.
Uterine tenderness and contractions.

± Fetal distress, fetal demise, bloody amniotic fluid.
Causes of intrapartum fetal tachycardia.
Maternal factors: fever, hyperthyroidism, anemia.

Fetal factors: arrythmia, anemia.

Uteroplacental factors: early hypoxia (abruption, HTN), chorioamnionitis.
Indications for induction of labor.
Maternal factors: antepartum hemorrhage, preeclampsia, maternal medical problems.

Maternal-fetal factors: isoimmunization, PROM, chorioamnionitis, post-term pregnancy.

Fetal factors: suspected fetal jeopardy from monitoring, fetal demise, severe IUGR.
Classification of perineal lacerations.
1st degree: vaginal mucosa and skin
2nd: muscles of perineal body, but not anal sphincter
3rd: anal sphincter involvement
4th: rectal mucosa
Which antibiotics are contraindicated in pregnancy?
Erythromycin: maternal liver damage.
Tetracyclines: stain infant teeth, affect long bone development
Sulfa drugs: anti folate properties, risk of kernicterus in T3
Metronidazole: anti-metabolite
Chloramphenicol: grey baby syndrome
Fluoroquinolones: risk of cartilage damage
What sort of pregnancy complications do fibroids impose?
1st trimester bleeding
Abruption
Breech
C/S
Dysfunctional labor
Preterm labour and birth
Fetal growth restriction
When do pregnant women usually start to perceive fetal movement?
20 weeks for primigravida
18 weeks for multiparous
What is the "discriminatory zone" for diagnosis of ectopic pregnancy?
Refers to the fact that when hCG reaches 1500 mIU/ml, then a gestational sac should be visible in the uterus on TVUS. If a gestational sac is NOT seen, then ectopic pregnancy is likely.
How early should Doptone be able to detect fetal heart tone?
10 weeks GA.
If not detectable, an US should be performed.
When is the first part of the SIPS done? second part?
First part: 11 - 13 weeks
Consists of PAPP-A and free βhCG

Second part: 16-18 weeks
AFP, total βhCG, uE3, inhibin A
Management of PPROM
If < 34 weeks:
-Betamethasone 12 mg IM q24h x 2
-Antibiotics to prolong latency:
Ampicillin 2g IV q6h x 48h, then amoxicillin 500 mg PO q8h x 5 days and
Erythromycin 250 mg IV q6h x 48h, then 333 mg PO q8h x 5 days

If > 34 weeks, evidence says to offer induction of labour
Management of chorioamnionitis.
Induction of labour

Ampicillin 2g IV x 1 dose, then 1g q6h, and Gentamicin 2 mg/kg x 1 dose, then 1.5 mg/kg q8h OR

Cefoxitin 2g IV x 1 dose, then 1g IV q8h
What criteria must be met to qualify for fetal fibronectin testing?
Intact fetal membranes
GA 24-34 weeks
No coitus or anything inserted into vagina in last 24 hours
Which liver enzyme goes up during pregnancy?
ALP doubles during pregnancy.
ASK, ALT, GGT and bilirubin levels are slightly lower.
How much iron and calcium is recommended during pregnancy?
30 mg/day iron
1.2 g/day calcium
What is the recommendation for exercise during pregnancy?
Continue exercising.
Pick exercise with low risk of trauma. Water exercises ideal. Avoid prolonged time in supine position in T2 and T3.
What is asphyxia?
Hypoxia with metabolic acidosis
Negative effects of epidural on labour.
Longer duration.
Increase incidence of:
-chorioamnionitis
-forcep procedures
-C/S delivery
-maternal pyrexia
What is puerperium?
Period of time between birth and 6 weeks afterward.
Relative contraindications for combined E+P OCPs
Controlled hypertension
Migraines and age > 35
Hypertriglyceridemia
Mild liver disease
Symptomatic gallbladder disease
History of cholestasis on OCP
Use of meds that interfere with OCP metabolism
What are side effects of combined OCPs, specific to estrogen and specific to progesterone?
Both:
-breast tenderness
-headaches

Estrogen:
-nausea
-edema
-weight gain (rare)
-thromboembolic events
-liver adenoma (rare)
-breakthrough bleeding (low estradiol levels)

Progestin:
-amenorrhea/breakthrough bleeding
-increased appetite
-decreased libido
-mood changes
-hypertension
-acne/oily skin
-hirsuitism
Absolute contraindications for an IUD.
1. Pregnancy
2. Unexplained vaginal bleeding
3. Current PID, STI, BV
4. Cervical or endometrial cancer
5. Malignant GTN
6. Severely distorted uterine cavity (Mullerian anomaly)
Relative contraindications for an IUD.
1. Lifestyle associated with high risk of STI
2. Increased susceptibility to infection (HIV, corticosteroid therapy)
3. Within 4 weeks postpartum
4. Ovarian cancer
Absolute and relative contraindications to Progestin-only OCPs
Absolute contraindications
1. Breast cancer (current)
2. Pregnancy
3. Unexplained vaginal bleeding

Relative contraindications
1. Liver disease (active liver disease with elevated liver enzymes, or liver tumours)
Maternal complications of preeclampsia
Abruption
Stroke
Pneumonia
What is fetal hydrops?
Collection of fluid in two or more body cavities:
-scalp edema
-pleural effusion
-pericardial effusion
-ascites
What can be given for prevention of preterm labour in women with risk factors or previous history of PTL?
17alpha-hydroxyprogesterone IM
Starting at 16-20 weeks
What does a sinusoidal fetal heart rate pattern signify?
Fetal anemia (from any cause)
What are contraindications to Hemabate and methergine?
Hemabate - asthma
Methergine - hypertension
Name the different types of placental attachment disorders
Placenta accreta - placental villi attach directly to myometrium

Increta - villi invade myometrium

Percreta - villi penetrate through the myometrium
A pregnant woman who has never had chicken pox or the vaccine comes into contact with a child who has chicken pox. What should be done?
Measure her VZV antibody titre. If not immune, then give varicella immunoglobulin within 96 hours.
Complications of multiple pregnancy.
Maternal:
-hyperemesis
-HDP
-GDM
-anemia
-intrapartum: malpresentation, dystocia, operative delivery, PPH
-postpartum depression

Fetal:
-spontaneous abortion
-preterm delivery
-IUGR
-congenital anomalies
-aneuploidy risk

Specific risks for monochorionic twins
-TTTS
-TRAP sequence acardiac twinning
Antepartum management of multiple gestation pregnancy.
Referral to obstetrician.
Education.
Limit physical activity.
Stop working at 28-30 weeks.
Optimize diet and supplements.
Prenatal diagnosis - NT good, serum screening less accurate.
More frequent office visits (checking cervical length, BP, GDM, NST weekly by 32 weeks).
Monthly US in T3 to monitor for IUGR.
Deliver at 38 weeks.
Most common finding in congenital rubella syndrome.
Deafness.
Management of PTL.
Tocolytics
-nifedipine 10-20 mg q30min, maintain with nifedipine XL 20 mg po bid
-indomethacin 100 mg PR, then 25 mg PR q6h x 48 h (if < 32 weeks GA)
-nitropatch

Steroids for lung maturity between 24-34 weeks