Obgyn 8

Front 1

General tx of preeclampsia at term?

Back 1

MgSo4 and delivery

Front 2

best anticonvulsant to prevent seizures in preeclampsia?

Back 2

MgSo4

Front 3

1st sign of mag toxicity?

Back 3

loss of DTRs

Front 4

**Major Causes of Maternal Death (non-abortive, excluding ectopic pregnancies)

Back 4

1. Pulmonary embolism
2. Hypertensive disorders of pregnancy
3. Uterine hemorrhage
4. Sepsis

Front 5

*Risk Factors for Maternal Mortality:

Back 5

1. Advanced age
2. General anesthesia (unable to tube, aspiration)
3. Race (black 3x risk)
4. Hypertensive dz (HTN, preeclamp, eclamp)
5. C/S (anesthesia, infection, thrombus) (6x vaginal risk)
6. Cyanotic heart dz (pulmonary HTN)

Front 6

Is low socioeconomic status something that impacts pregnancy?

Back 6

Low socioeconomic status is related to an increased risk of perinatal morbidity and mortality.

Front 7

Tobacco Use → increased risk of:

Back 7

Abruptio placentae
Placenta previa
Bleeding during pregnancy
Premature rupture of membranes (PROM)
Prematurity
Spontaneous abortion
Sudden infant death syndrome (SIDS)
Fetal death
Low birthweight
Reduced breast milk supply
Respiratory illness

Front 8

Drugs→ effect depends on the drug

Back 8

Tolerance
Withdrawal
IUGR
Congenital anomalies
Infections assoc with unsterile injections (HIV, hep)
Malnutrition
Premature delivery

Front 9

ETOH:
exact level/quantity of alcohol consumption during pregnancy that causes adverse fetal effects?

Back 9

Because the effects of occasional use of alcohol (or the quantity of alcohol) on the fetus are unknown, most recommend abstinence of alcohol during pregnancy

Front 10

**Fetal Alcohol Syndrome (FAS)

Back 10

Constellation of abnormalities in the infants born to women who abuse alcohol during pregnancy.
Spectrum of severity
*Includes: growth retardation, CNS effects, abnormal facies.
Affects every organ system; many cardiac abnormalities

Front 11

Most significant consequence of alcohol abuse during pregnancy.

Back 11

Fetal Alcohol Syndrome (FAS)

Front 12

Obstetric History:
If have had macrosomic infant, think about:

Back 12

glucose intolerance
shoulder dystocia
C-section for CPD
neonatal hypoglycemia

Front 13

Macrosomic

Back 13

>4000g

Front 14

Obstetric History:
Ectopic pregnancy

Back 14

must be evaluated at 5 or 6 weeks gestation by pelvic exam or vaginal US to determine site of pregnancy

Front 15

*Contraindications to VBAC:

Back 15

Active herpes infection at term
CPD
Vertical uterine incision
Myomectomy with penetration into the endometrium

Front 16

Obstetric History:
Preeclampsia and eclampsia

Back 16

Familial tendency.
Likely to develop essential hypertension in future.

Front 17

PMHx: Chronic Hypertension:
Incr risk of:

Back 17

preeclampsia
abruptio placentae
perinatal loss
maternal mortality
MI
uteroplacental insufficiency
CVA

Front 18

PMHx: Cardiac disease:
Especially dangerous are:

Back 18

primary pulmonary hypertension
Marfan's syndrome
significant mitral stenosis

Front 19

Risk to offspring of parents with cardiac disease

Back 19

*Offspring of parents with cardiac disease have an increased risk of developing cardiac disease in their lifetimes.
*Meds used to control cardiac disease have potential fetal complications.

Front 20

Effect of pregnancy on Collagen Vascular Disease (rheumatic disease):

Back 20

Effect of pregnancy is unpredictable; precipitation, aggravation, remission

Front 21

High Risk genetics/factors?

Back 21

Consider consanguinity, ethnicity and parental age.

Consider genetic counseling, carrier testing, chorionic villi sampling, amniocentesis

Front 22

PMHx: Pituitary Disorders (prolactinoma)

Back 22

Pituitary abnormalities responsible for problems with conception.

Front 23

PMHx: Adrenal Disorders (acute adrenal insufficiency):

Back 23

Inadequate adrenal function may be life-threatening.

Front 24

Parathyroid Disorders:
Calcium requirements

Back 24

Calcium requirements increase during pregnancy and are usually maintained by a normal diet.

Front 25

Liver Disease:

Back 25

May become aggravated or difficult to follow in pregnancy. Can be dangerous to fetus (viral hepatitis)

Front 26

Neurologic Disorders:

Back 26

Must evaluate risk of medical treatments (drugs) with effects on fetus vs. risk of uncontrolled disease to mother and fetus

Front 27

Venous Thromboembolic Disorders:

Back 27

Pregnancy and immediate postpartum period can predispose women to venous thrombosis.

Front 28

**TORCH
can all be teratogenic, cause abnormalities

Back 28

toxoplasmosis, other (parvovirus), rubella, CMV, HSV

Front 29

Cytomegalovirus (CMV):

Back 29

Risk of congenital anomalies (CNS); neonatal death from disseminated disease may
occur.

Front 30

Herpes Simplex Virus (HSV):
Transmission

Back 30

Vertical transmission with passage through infected birth canal or ascending spread of virus from cervix after membranes rupture.
C-section if virus active at term.

Front 31

Herpes Simplex Virus (HSV):
Effect on infant

Back 31

Increased risk of prematurity.

May cause fatal disseminated disease in newborn. Ophthalmologic and neurologic sequelae in newborn.

Front 32

Hepatitis B (HBV):
Transmission

Back 32

Infection in 1st trimester NOT assoc with fetal disease.
Transmission risk in acute 3rd trimester disease and chronic hepatitis B (especially if E positive as well)

Front 33

Increased risk of vertical transmission from mothers with chronic hepatitis B when____?

Back 33

especially if E positive as well

Front 34

Hepatitis B (HBV):
Effect on infant

Back 34

increased risk of prematurity
Infant can be asymptomatic, develop fulminant disease, cirrhosis or hepatocellular carcinoma, or become chronic carriers.

Front 35

Hepatitis B (HBV):
*Prevention

Back 35

Pregnant women exposed to HBV should receive both hepatitis vaccine and hepatitis B immune globulin

Repeat HBIG in 1 month.
Repeat vaccine in 1 and 6 months.

Front 36

If mother is a chronic carrier or has acute third-trimester disease, treatment to infant at birth includes:

Back 36

NG aspiration to remove secretions
Hyperimmune serum globulin (HBIG)
Hepatitis B vaccine as prophylaxis

Front 37

Hepatitis B (HBV):
*Screening

Back 37

*Screen in first-trimester to identify seropositive women.

Front 38

*Groups at high risk for Hep B

Back 38

IVDU, HIV positive women, and Southeast Asian women.

Front 39

Hepatitis B vaccine general recommendations?

Back 39

*Universal immunization of ALL neonates, even those of HBsAg negative mothers
Immunizations given THREE times: Birth, 1 m, 6 m

Front 40

Toxoplasmosis:

Back 40

Parasitic infection that can infect fetus in utero.
Cats serve as reservoir for toxo. Have patients avoid kitty liter box. Use serologic test if suspect toxo.

Front 41

Toxoplasmosis: Risks to fetus

Back 41

Increased risk of abortion, stillbirth, severe congenital infections in fetus

Front 42

"Fifth Disease"
is what infection?

Back 42

Parvovirus
"Erythema Infectiosum"

Front 43

Parvovirus Infection/Erythema Infectiosum

Back 43

macular rash which usually occurs in school-age
children and is preceded by fever, myalgias, and respiratory or GI symptoms.

Front 44

Parvovirus Infection in adults

Back 44

Adults also exhibit arthritis or arthralgias and women may have aplastic crises with hemolytic
anemia.

Front 45

Parvovirus Infection:
*Effects on fetus

Back 45

asymptomatic infection, congenital anomalies-eye (very rare), miscarriage, fetal death, Hydrops Fetalis (due to severe nonimmune hemolytic anemia)

Front 46

HIV in women of childbearing age.
Main exposure risk?

Back 46

Heterosexual contact exposure has surpassed that of IV drug use

Over half of all pregnant women infected with HIV do not belong to a "high risk" group

Front 47

*Women with HIV should also be evaluated for:

Back 47

• Gonorrhea and syphilis
• Chlamydia
• HBV
• TB
• CMV
• Toxoplasmosis

Front 48

*Pregnant women with HIV infection at increased risk for:

Back 48

PROM
Low-birthweight infants
HIV infected infants

Front 49

HIV screening

Back 49

*All pregnant women should have HIV counseling/testing-Elisa, Western blot.
Monitor HIV positive pregnant women with CD-4 counts, T-lymphocytes counts, HIV-1 RNA

Front 50

When can HIV transmit to infant?

Back 50

in utero, during delivery, and after birth from contaminated breast milk.

Front 51

Types of HIV Testing in Pregnancy:

Back 51

• Opt-out - Most routine testing in US
• Opt-in
• Mandatory – CT, NY, NJ
• Rapid HIV testing during labor if mom’s HIV status unknown

Front 52

65% of vertical transmission of HIV occurs when?

Back 52

during labor

Front 53

Risk factors for Vertical Transmission of HIV

Back 53

Labor
Poor nutrition
Chronic disease
Low CD4 counts
High viral load
Placental abnormalities
PROM
Preterm delivery

Front 54

Treatment of HIV in Pregnancy:

Back 54

*HIV pos pregnant pts should receive mono or combo therapy.
Monitor frequently with CBC, LFTs, kidney function tests.

Capacity of HIV virus to mutate has lead to the use of combo therapy.
• 2 nucleoside reverse transcriptase inhibitors & 1 protease inhibitor
• Use AZT/ZDV at delivery

Front 55

** ACTG 076 study (landmark study)
administration of AZT

Back 55

Give AZT during the antepartum (start at week 14 of gestation through delivery) and intrapartum periods and to the infant for 6 weeks postpartum → decrease in rate of transmission

Front 56

AZT in HIV positive women who have not been previously treated?

Back 56

Abbreviated course given intrapartum and to newborn within 48 hours

Front 57

Mode of Delivery in HIV?
Indication for vaginal vs C/S

Back 57

Vaginal delivery if viral load undetectable.
C/S for PROM, prolonged labor, chorioamnionitis, fetal distress
Elective C-section (at 38 wks) likely to reduce risk of transmission if HIV RNA level higher than 1,000.

*Discuss contraceptive options post delivery.

Front 58

AZT in C/S

Back 58

Administer continuous AZT/ZDV 3 hours before and during surgery.

Front 59

Postnatal Care of the Neonate of HIV Infected Mom:

Back 59

Serial HIV testing at 6 weeks, 3 months and 6 months
2 consecutive positive tests = HIV positive.

Start therapy 8-12 hours after delivery with AZT (ZDV)
Defer pediatric immunization schedule until HIV status known.

Front 60

Interventions to decrease rate of vertical transmission of HIV

Back 60

Zidovudine therapy (AZT)
Highly active antiretroviral therapy
Suppress maternal viral load to undetectable levels
Elective C-section at 38 weeks if HIV RNA > 1,000
Prevention of opportunistic infections
Prevention of preterm delivery
Reduce time between ROM and delivery to < 4 hours
Minimize fetal exposure to maternal blood

Front 61

Elective C/S in HIV?

Back 61

at 38 weeks if HIV RNA > 1,000

Front 62

To reduce risk of vertical transmission of HIV, want what time btw ROM and delivery?

Back 62

< 4 hrs

Front 63

Group B Streptococcus (GBS)
Causative agent?

Back 63

Streptococcus agalactiae

Bacteria commonly found in vagina and rectum of pregnant women (1 in 4)

Front 64

Group B Streptococcus
colonization v infection rate?

Back 64

**High colonization rate and relatively low infection rate in pregnancy
Usually asymptomatic
*Clinical illness in pregnancy variable.
Maternal-fetal transmission rates of GBS range from 35% to 70%.

Front 65

Group B Streptococcus
Must differentiate what in the fetus?

Back 65

*Important to differentiate fetal colonization from fetal infection.
**Leading cause of perinatal infectious morbidity and mortality.

Front 66

Screening for GBS

Back 66

**Screen all pregnant women for GBS between 35 and 37 weeks; antibiotics during labor to those with positive test.

Front 67

Fetal Effects of GBS:

Back 67

• Respiratory distress
• Neonatal sepsis
• Pneumonia
• Meningitis
• Shock
• Death

Front 68

GBS and Neonatal sepsis

Back 68

leading cause of neonatal sepsis-within 7 days of life

Front 69

Maternal Effects of GBS:

Back 69

• Chorioamnionitis
• Endometritis
• Cystitis
• Pyelonephritis
• UTI
• Osteomyelitis
• Endocarditis

Front 70

Risk Factors for Neonatal GBS Infection:

Back 70

Colonization with GBS
Preterm labor (< 37 weeks)
PROM (< 37 weeks)
Prolonged rupture of membranes (> 18 hours)
Previously affected pregnancy
Diabetes
Maternal fever during labor (100.40F)
African-American race
Mother < 20 y.o.

Front 71

Diagnosis of GBS:

Back 71

Culture (lower vagina and rectum)
Latex agglutination
ELISA

Front 72

GBS Prophylaxis:

Back 72

*Intrapartum antibiotics decr transmission
Use: Women with risk factors, positive cultures (35-37 weeks), previous history of infant with invasive GBS
Abx: IV Penicillin, Ampicillin, Clindamycin and Erythromycin for PCN allergic patients

Vax currently in trials

Front 73

Syphilis:
Infection in pregnancy can lead to

Back 73

stillbirth, prematurity, congenital syphilis (deafness, neurologic disorders, bone deformities).

Front 74

Syphilis:
screening

Back 74

**Screen all patients (VDRL or RPR) at first prenatal visit; repeat at weeks 28-32 if at high risk.
Confirmatory tests- FTA-ABS or MHA-TP

Front 75

Treatment of Syphilis:

Back 75

Parenteral penicillin G preferred therapy for all stages of syphilis
Treatment of choice for infants is Pencillin G
Repeat maternal testing at 6, 12, 24 months after treatment

Front 76

Parenteral penicillin G for Syphilis
watch for what?

(SPELLING)

Back 76

**Jarisch-Herxheimer reaction→headache, myalgias, fever, hypotension, tachycardia, skin lesions.
?from releases of treponemal toxic products

Front 77

Short stature or underweight mothers at risk for:

Back 77

perinatal morbidity and mortality,
low-birthweight infants, preterm delivery

Front 78

Obese mothers at increased risk of:

Back 78

HTN, DM, aspiration of gastric contents during anesthesia, wound complications, thromboembolism

Front 79

On exam, smaller than estimated gestational age, think:

Back 79

IUGR, infection, chromosomal abnormalities, congenital anomalies

Front 80

On exam, larger than estimated gestational age, think:

Back 80

improper dates, uterine anomalies, polyhydramnios, multiple gestation, hydatidiform mole

Front 81

Impact of Fibroids on pregnancy

Back 81

depends on location and size of myoma. Increased risk of abortion, postpartum hemorrhage, obstruction of labor, unstable fetal lie, dysfunctional labor

Front 82

Incompetent cervix, concern of:

Back 82

second trimester miscarriages with minimal labor contractions

Front 83

*Exposure to DES-observe closely because of increased risk of:

Back 83

Abortion or ectopic pregnancy (1st trimester)
Incompetent cervix (2nd trimester)
Premature labor, PROM, premature delivery (3rd trimester)

Front 84

Blood Type and Antibody Screen:

Back 84

hemolytic disease caused by
ABO, Rh sensitization
Kidd, Kell, Duffy blood group antigens

Front 85

VDRL (Venereal Disease Research Laboratory)

Back 85

Syphilis (late abortion, stillbirth, congenital infection)

Front 86

Gonorrhea Culture, because can cause:

Back 86

IUGR, prematurity, PROM, chorioamnionitis, sepsis in neonate, maternal arthritis, rash or peripartum fever.

Front 87

Rubella Titer, concern of:

Back 87

first trimester abortion, congenital anomalies

Front 88

Rubella infection in what trimester is most concerning?

Back 88

*Maternal infection in first trimester carries greatest risk to fetus

Front 89

What Rubella titer is inadequate, what do you do?

Back 89

*Maternal rubella titer of less than 1:8 should be immunized POSTPARTUM.

Front 90

All pregnant women with a family history of DM should have at least what test?

Back 90

one-hour glucose screen at 24-28 weeks gestation.

Front 91

Alpha-Fetoprotein Screening
when, for what?

Back 91

(16-18 weeks).
Elevated→neural tube defects;
Low→ Downs Syndrome.

Front 92

Laboratory

Back 92

Type and Screen
VDRL
Gonorrhea Culture
Rubella Titer
CBC (anemia)
Urinalysis
PAP smear
Blood Sugars
AFP

Front 93

Rh Isoimmunization
Definition:

Back 93

*Rh isoimmunization caused by maternal antibody production in response to exposure to fetal red blood cell antigens of Rh group.

Front 94

Immunology of Rh Isoimmunization:
Initial exposure to foreign antigen leads to production of?
Subsequent exposures produce?

Back 94

*Over 90% Rh isoimmunization due to D antigen.
Initial exposure --> maternal IgM
subsequent (amnestic response) --> IgG

Front 95

What Ig can affect the fetus?

Back 95

*Only IgG is capable of placental transfer to fetus (small size of Ig)

Front 96

Effect of Rh isoimmunization on fetus

Back 96

The antibody response may potentially destroy fetal red blood cells, causing anemia and may result in erythroblastosis fetalis.
Mild hemolysis --> incr erythropoiesis rate
Severe hemolysis --> anemia --> hydrops fetalis, death

Front 97

What antigen makes up the Rh complex?

Back 97

A number of antigens make up the Rh complex: C, D, E, c, e, Du and other variants.
*Over 90% Rh isoimmunization due to D antigen.

Front 98

Fetal circulation occurs at when?

Back 98

At approximately 4 weeks gestation
(D antigen can be detected as early as 38 days after conception)
Therefore, Rh isoimmunization can occur at any time during pregnancy.

Front 99

Mechanisms of Rh Sensitization:

Back 99

fetal to maternal hemorrhage

“Grandmother” Theory: Rh-negative woman may be sensitized from birth by exposure to enough Rh positive cells from her mother during her own delivery to produce an antibody response.

Front 100

Multiple exposures in Rh Sensitization:

Back 100

*Two exposures to Rh antigen required to produce any significant sensitization, unless first exposure is massive.

First exposure --> primary sensitization (IgM)
Second exposure (IgG) causes amnestic response → rapid production of immunoglobulins (can → transfusion reaction or hemolytic disease of the fetus).

Front 101

*Degree of Rh Sensitization Depends on:

Back 101

1. Rates of occurrence-varies btw people
2. Difference in immunogenicity of offending antigen
3. Low rate of transfer of antigen from fetus to mother
4. Low rate of transfer of antibody from mother to fetus
5. Variability of maternal response rate to different degree of incompatibility and other interfering antibodies-ex: ABO incompatibility
6. Differences in binding of maternal antibody to fetal red cell antigens

Front 102

ABO effect in Rh Sensitization

Back 102

*ABO incompatibility has protective effect for an Rh-negative mother with Rh-positive fetus
A and B antigens capable of mounting a strong immunogenic response.
Fetal RBCs entering the mom are usually rapidly destroyed before they can elicit an antigenic response. Most isoantibodies to blood group “A” and “B” antigens are IgM and do NOT cross the placenta. And, fetal RBCs have a diminished number of A and B antigenic sites compared to adult life.

Front 103

Risk Factors for Rh Isoimmunization:

Back 103

Amniocentesis
Ectopic
Spontaneous/threatened/elective abortion
Vag bleed
Placental abruption/previa
Previous transfusion of Rh positive blood
Sensitization in utero. (Grandmother Theory) - rare
ABO effects (ABO compatible)
Abdominal trauma
Delivery
**Inadequate Rhogam dosage

Front 104

Rh Sensitization
Identification of High Risk Patients:

Back 104

*Obtain ABO, Rh and Antibody screen on first pre-natal visit.
Obtain father's status, if Rh pos obtain Rh genotype

*At delivery, cord blood must be sent for determination of fetal blood group, Rh type and direct Coombs’ test.

Front 105

Rh negative women (with Rh positive partner) who have negative initial antibody screen should have anti-D antibody titers checked when?

Back 105

at 28-30 weeks and again at 34-36 weeks.

Front 106

Rh Sensitization
*At delivery, cord blood must be sent for

Back 106

determination of fetal blood group, Rh type and direct Coombs’ test (test for presence of antigen)

Front 107

Erythroblastosis Fetalis:

Back 107

Rh-positive fetal red blood cells hemolyzed by maternal Rh antibody.

Hemolytic Disease of the Fetus and Newborn

Front 108

Erythroblastosis Fetalis:
hemolysis produces what?

Back 108

Hemolysis produces high levels of bilirubin
Fetal anemia stimulates erythropoietin production.
BM can't keep up → extramedullary hematopoiesis

Front 109

Fetal extramedullary hematopoiesis: Locations?

Back 109

fetal liver, spleen, adrenal gland, kidneys, placenta and intestinal mucosa

Front 110

Complications of Extramedullary Hematopoiesis:

Back 110

Portal and umbilical vein obstruction→ portal HTN
Decreased protein synthesis
Hypoalbuminemia
Edema
Fetal anemia

Front 111

Hemolytic disease - Coomb's test results?

Back 111

*All infants with hemolytic disease have a positive direct Coomb's test of their umbilical cord blood.

Front 112

Cord hemoglobin level where considered severely anemic?

Back 112

less than 7-12 g/dl

Front 113

Hemolytic Disease of the Fetus and Newborn:

Back 113

positive direct Coomb's test
anemia
Hydrops Fetalis
Treatment ranges from close observation to transfusion during pregnancy.

Front 114

Hydrops Fetalis

Back 114

*Total body edema (anasarca)
Occurs if fetus is not transfused.
Occurs when hgb falls by more than 7 g/dl below normal level (12-18 g/dl).

Front 115

*Signs of Hydrops Fetalis:

Back 115

Generalized edema (effusions and ascites)
Hepatosplenomegaly, hepatocellular damage, portal HTN
CHF
Extramedullary hematopoiesis
Enlarged, edematous placental villi→ poor placental perfusion

Front 116

*If Rh negative mother has Rh positive partner and a positive antibody screen, must determine antibody:
IgM vs IgG

Back 116

IgM-doesn't place pregnancy at risk for erythroblastosis fetalis

IgG-may cause erythroblastosis fetalis-must titer antibody level

Front 117

Severity of Hemolytic Disease:

Back 117

*Rh disease either remains at same level of severity from infant to infant or becomes more severe with each successive pregnancy.

Front 118

Rh sensitization: *Important to get information about previously affected fetuses with respect to what?

Back 118

previously affected fetuses: type of delivery, severity of hemolytic disease, therapy used to treat anemia, previous Ig titer levels.

Front 119

Rh sensitization: *Very important to test what?

Back 119

*Very important to test cord blood:
Hgb
Hct
Direct Coomb's test
Reticulocyte count
Bilirubin level

Front 120

What helps predict severity of erythroblastosis fetalis in current pregnancy

Back 120

*Maternal Antibody Titers and Obstetric History (62%)
Using US and amniocentesis, predictability is 89%

Front 121

Rh Isoimmunization
*Maternal Antibody Titers: Usefulness?

Back 121

Anti-D antibody titers provide limited info on severity of disease
Used to help guide use of invasive testing
Higher titers require amnio
Antibody titer greater than 1:16 = 10% risk fetal death
Indirect Coombs' titer greater than 1:32 is significant

Front 122

*High Maternal Antibody Titers --> what testing do you do now?

Back 122

amniocentesis- determine severity of fetal anemia
amniotic fluid spectrophotometry- amount of bili in fluid correlates with fetal hct at 27 weeks gestation

Repeat antibody titers monthly

Front 123

Amniotic fluid in fetus with hemolytic anemia has what?

Back 123

elevated levels of bilirubin

Front 124

Amniotic fluid bilirubin reflects

Back 124

degree of hemolysis.

Front 125

Rh Isoimmunization:
Usually start serial amniocentesis at

Back 125

18-20 weeks (intrauterine transfusions usually unsuccessful prior to that time).
Repeat at 1-4 week intervals

Front 126

Cordocentesis

Back 126

Percutaneous Umbilical Blood Sampling
*Sampling blood from umbilical cord using US directed needle aspiration.

Front 127

Use of PUBS?

Back 127

Test for:
a. Hgb/hct
b. Blood group and Rh type
c. Direct Coombs' titer
d. Bilirubin level
e. Reticulocyte count
f. Serum protein levels

Front 128

Treatment of Erythroblastosis Fetalis

Back 128

Intrauterine Transfusion:
Intraperitoneal or Intravascular

Front 129

Intraperitoneal Transfusion:

Back 129

Guided by US. Needle inserted through the maternal abdomen into the fetal abdomen. Packed RBCs go into fetal peritoneal cavity are absorbed by the lymphatic system and enter fetal blood system

Front 130

Complications of Intraperitoneal Transfusion

Back 130

a. Fetal demise
b. Laceration of fetal organ (liver, bowel, bladder)
c. Premature labor
d. PROM
e. Chorioamnionitis

Front 131

Intravascular Transfusion:

Back 131

Needle put through maternal abdominal wall into umbilical vein

Front 132

Complications of Intravascular Transfusion

Back 132

a. Fetal death
b. Bradycardia
c. Bleeding from puncture site
d. Amnionitis
e. PROM

Front 133

Prevention of Rh Isoimmunization:

Back 133

avoidance of maternal exposure to the antigen.
Rh immune globulin decreases the availability of Rh antigen to maternal immune system
*Rh immune globulin (the antibody) protects against an immunologic reaction when an Rh-negative woman is exposed to Rh-positive (D-positive) fetal cells (the antigen).

Front 134

Rh immune globulin protects against what?

Back 134

Sensitization to D antigen
Will not protect against sensitization from the other Rh-positive alleles (c, C, e, and E).

Front 135

*Indications for Protection with Rh Immune Globulin:

Back 135

1. At 28 wks in Rh negative, non-immunized pt when father is Rh postive.
2. Within 72hrs postpartum if non-immunized pt delivers Rh pos baby
3. After amnio or CVS
4. After molar pregnancy, ectopic, abortion, postpartum tubal ligation
5. After transfer of Rh pos blood to Rh neg woman
6. After a platelet infusion
7. Situation where maternal circulation exposed to fetal blood (Placental abruption, undiagnosed uterine bleeding, trauma)

Front 136

**Standard dose-300 microgram dose of Rh immune globulin covers what???

Back 136

fetomaternal hemorrhage of 30 ml of fetal whole blood or 15 ml of fetal red cells.

Front 137

During a normal pregnancy, 300 microgram dose of Rh immune globulin when?

Back 137

at 28 weeks following testing for sensitization with indirect Coombs’ test.

Front 138

Kleihauer-Betke

Back 138

Acid elution test. Estimates QUANTITY of fetal red blood cells that have entered the maternal circulation.
Do test any time fetomaternal hemorrhage is suspected.

Front 139

Positive Kleihauer-Betke?

Back 139

Rh immune globulin given at dose of 10 microgram/ml of fetal blood that entered maternal circulation.

Front 140

Kleihauer-Betke test - what do you see?

Back 140

Count 1000 cells. Adult Hgb eluted with acid→ “ghost cells”. Fetal Hgb F acid elution resistant (dark pink cells).

Front 141

Kleihauer-Betke test - calculation

Back 141

multiply KB result by 5000cc (maternal blood volume is 5 liters in pregnancy) and that estimates the amount of fetal blood in the maternal circulation.

Front 142

Indirect Coombs' Test:

Back 142

Measures free circulating anti-D (Rh immune globulin).

Front 143

If an appropriate amount of Rh immune globulin has been given, what will you see?

Back 143

Positive Indirect Coombs' (agglutination) from excess free antibody a day after the dose.

Front 144

Direct Coombs’ Test:

Back 144

Detects antigen-antibody complexes of fetal red blood cells. Uses patient’s red cells (with auto-antibody). Look for agglutination as “positive” test.

Front 145

Rosette Test:

Back 145

Detects fetal-maternal bleed > 30 ml whole blood. Accurately used to determine Rhogam dose

Rh-D negative maternal blood mixed with anti-D and Rh-D positive cells and look for rosettes.
Few/no Rh-D positive fetal cells→ no rosettes
Presence of rosettes→ fetomaternal bleed > 30 ml

Front 146

*Failure of Rh Immune Globulin Prophylaxis:
Why?

Back 146

Dose too small
Dose too late (within 72 hrs delivery)
Patient immunized and antibody too low to be detected