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100 Cards in this Set
- Front
- Back
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What percentage of population is Group B strep positive |
20 %
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PPROM and Group B Strep
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treat based on cultures
if no culture, take culture and begin treatment, IF no ensuing labor, discontinue antibiotics after 48 hours and recommence when in labor if additional cultures are indicated and are positive |
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Treat based on Risk Factors for GBS
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preterm labor
PPROM ROM > 18 hrs History of previous pregnancy infant born with GBS (but not maternal carriage in a previous pregnancy) Intrapartum fever >38 degrees C Positive GBS culture or GBS bacteriuria |
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How long after ruptured should you treat for GBS
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18 hours if not delivered
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Transmission of Toxoplasmosis
1st trimester 2nd trimester 3rd trimester |
1st trimester 15%, severe
2nd trimester 30% intermediate 3rd trimester 60% mild |
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What types of anomalies do you see with toxoplasmosis in the baby
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Intracranial calcifications
Chorioretinitis Hepatosplenomegaly Hearing Loss Mental Retardation all head problems except for hepatosplenomegaly |
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With serology in Toxoplasmosis
what does IGM mean and IGG mean |
IGM- acute infection
IGG- Immunity |
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How does CMV infection present in newborn
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Chorioretinitis
Hepatosplenomegaly IUGR Fetal Hydrops |
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What is the prevalence and transmission of CMV in pregnancy
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Prevalence 3%
vertical transmission in 30% of this 3% of infected neonates 30% will have disease of neonates with disease 30% will die |
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What is the recurrent risk of neonatal infection with CMV
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Negligible
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Vertical transmission in CMV is more common when
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in later trimesters
but more severe in first trimester |
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Can you nurse with hepatitis
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yes, If hep B, okay but if active disease baby needs vaccine
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How is Hep A transferred
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Fecal oral route,
associated with travelers diarrhea no effect in pregnancy |
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What does HBeAg mena
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means active replication, associated with cirrohsis and liver cancer
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What does HBcAg
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Core antigen
found in hepatocyte postive with natural but not vaccine based immunity |
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What is transmission rate if HbsAg pos
HbsAG +HbcAg pos |
HbsAg pos 20% vertical transmission rate
HbsAg + HbcAg pos-90% vertical transmission rate mostly during 3rd trimester |
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When does transmission of HepB usually occur
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90% occurs at delivery
10% occurs through placenta and breast feeding |
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What is Hepatitis B treatment
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ifnat of sero pos mother shoudl receive hyper immune globulin at birth and vaccine
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Hepatitis B transmission
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vertical trasmission rate
most common cause of world wide infeciton 15% if HbsAg pos 90% if HbsAg + HbeAg pos Not affected by mode of delivery invasive prenatal testing not proven to be harmful if mother sero positive infant of seropos mother should receive hyper immune globulin at birth at 24 hours and vaccine at 0, 1 and 6 onths |
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Is nursing okay in HbSag mothers
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yes
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Prenatal screening will detect what percentage of Hep B carriers
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60%
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anemia
heart failure hydrops in fetus |
Parvo Virus B19
replicates in bonemarrow presents similar to isoimmunization |
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What percentage of population is immun to parvo
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50% are IgG positive
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What is the vertical transmission of parvovirus
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30%
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How does Mom present with parvo virus
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rash
arthritis flu like illness |
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Infection with Parvo virus in first trimester causes
late 2nd and 3 rd trimester |
1st trimester- SAB
Late 2nd and 3rd- hydrops and FDIU |
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How do you diagnose Parvovirus
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Elisa and Confirm with a Western Blot both IgG and IgM
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what is treatment and survival rate with Parvovivurs
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Treatment-Pubs look for anemia and possible transfusion.
serial ulatrasounds for fetal well being and hydrops survival-80% with treatment 20% without treatment |
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what is the definition of AID
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HIV positive with CD4 less than 200
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When do you use Rapd HIV test
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for patients in labor with unknown HIV status
takes hours for result a negative test is not definative a positive test is not definative requires confirmatory test eg. western blot. |
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What do you need to do if you get a positive rapid HIV test
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inform patient she may have HIV and infant may be at risk
perform a confirmatory test teatment without waiting for confirmatory test CD if labor not yet commenced and no ROM (value of CD in presence of labor or ROM is unknown) postpone breastfeeding till confirmatory test rules out HIV |
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What is Sensitivity
Specificity Pos predictive value of Rapid HIV test |
sensitivity 100%
specificity 90% Positive predictive value 90% |
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Vertical Transmission of HIV
without AZT with AZT with AZT and CD No Rx and Viral load <1000 |
without AZT 24%
with AZT 8% with AZT and CD 2% No rx, viral load <100 2% thus CD optional but not critical |
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What are screening tests for HIV
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ELISA- Enzyme Linked Immuno-Sorbent Assay
Confirmatory test-Western Blot |
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What is the sensitivity and specificity of ELISA with a confirmatory Western Blot
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99%
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If both ELISA and Western Blot are positive what should you follow up with
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CD4 and Viral Load,
Hep C ab, CBC and LFTs |
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What is the Opt in option for HIV
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testing done only if pt opts in
not included in routine testing results in lower screening rate Neither CDC or ACOG recommends this. |
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What is the opt out option for HIV testing
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testing done, not done only if pt opts out
inlculded in routine prenatal screening higher amount get tested Both CDC and ACOG recommend this |
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Who should be tested in 3rd trimester for HIV
and when should it be done |
high risk groups
high prevalence areas patients who decline conventional testing earlier in pregnancy preferably done before 36 weeks |
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What is the treatment of HIV
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Zidovudine AZT
100 mg 5 times a dy from 14 weeks till labor recent literature recommends 200 mg TID HAART (highly active anti retroviral therarpy) |
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What is treatment of HIV in Labor
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AZT load with 2 mg/kg then 1 mg/kg/hr
Perform CD at 38 wks prior to onset of labor Prior to ROM Viral load > 1000 copies/ml |
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If someone HIV +, not on AZT, how should you treat
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if presents for CD, start IV AZT > 3 hrs prior to surgery
If already in labor or ROM, individualize pros and cons of CD If viral load <1000 can offer but not essential to perform CD |
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If not pregnant when should start meds
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When CD4 down to 500, previously had been 200
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HSV II
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typcially genital
accounts for most recurrences 25% of population are seropositive Majority of these are subclinical |
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How do you diagnose HSV infection
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culture
clinical assessment (very often wrong sensitivity (40%) serology with PCR is test of choice |
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Clasification of HSV
Primary Infection Non primary infection 1st episode recurrent infection |
Primary infection Ab neg
Non primary infection, 1st episode- Abpos, ab and clinical type dont match e.g. Type I Ab positive with genital lesion recurrent infection- Ab pos, Ab and clinical type do mathc |
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HSV in pregnancy transmission
primary infection? non primary first episode recurrent infection |
primary infection- 50% vertical transmission treat
non primary first episode-33% vertical transmission recurrent infection- 3% vertical transmission, If >36 wks gestation |
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Acyclovir for primary infection
or non primary first episode recurrent infection supression |
Primary- 200 mg 5 times a day for 10 days
Recurrent- 400 mg TID x 5 days Supression 400 mg BID |
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What is mechanism of action of
Acyclovir Famciclovir Valacyclovir |
Acyclovir-inhibits thymidine kinase
Famciclovir-converted to acyclovir in liver (with greater bioviability) Valacylovir- no data on use in pregnancy |
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Mode of delivery if HSV
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CD is active lesion
Not indicated in presence on non genital lesions indicated if ROM (regardless of duration) If PPROM: CD only if active lesions at time of delivery, add medical Rx if prolonged duration |
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What are Varicella maternal effects
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Chicken Pox
Varicella Pneumonia (3rd trimester) mortality 15%, as highas 35%-treat wih antivirals (acyclovir IV) ICU admission Enephalitis-rare |
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Fetal side effects of Varicella
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Sponaneous abortion
IUFD Varicella Embryopathy in exposure after 20 weeks limb hypoplasia, muscle atrophy, digital malformations, microcephaly, cortical atrophy, cataracts, chorioretinitis, microphthalmia ultrasound findings of varicella embryopathy include-hydramnios, hydrops, echogenic foci of liver/bowel/spleen |
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How do you diagnose Varicella
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Varicella IgM
PCR Varicella DNA analysis best within 4 days of exposure |
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Treatmen of maternal exposure of varicela
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VZIG 1 vial/10kg weight to maximum 5 vials (60-80% preventive)
Acyclovir prophylaxis 800 mg po 5 x a day for 7 days (>80% effective |
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If maternal varicella infection occurs at 5 days predelivery to 2 days post delivery how do you treat
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treat mom but also give VZIG to neonate upon delviery
delay delivery 5-7 days after onset maternal varicella to prevent neonatal varicella (20-30% mortality |
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Can you give the varicella vaccine in pregnancy
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No
live attenuated vaccine contra indicated in pregnancy defer pregnancy 3 months after vaccination |
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What is antibiotic prophylaxis for Ceserean Delivery
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Ancef 1 gram IV over Ampicillin
Ancef 2 grams IV if BMI over 30, or weight >100 kg Single dose prophylaxis only, up to 69 mins prior to incison If PCN allergy: Clindomycin with an aminoglycoside |
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What do yo give if PPROM <37 wks to prolong latency to 48 hrs
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IV ampicillin to 48 hrs
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Antibiotics not recommended
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Intact preterm labor
Term PROM <24 hrs Cerclage placment 3-4th degree lacration repair Manual extraction of placenta |
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What is the definition of recurrent aboriton
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3 or more spontaneous pregnancy losses
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What percentage of diagnosed pregnancy losses end in pregnancy loss
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20%
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What are the causes of pregnancy losses
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40% are genetics
Luteal phase deficieny (controversial) uterine abnormalities (septate and bicornuate carry worst prognosis) acquired fiborids Infection torch parvovirus B19 ureaplasma syphllis Genetics (balanced tranloscation) Immune disorders antiphospholipid syndrome allo-immun (eg hydrops) |
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What is acronym to remember causes of fetal loss
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UGLII (ugly)
uterine anomalies genetic lueal phase defect immune disorders infection |
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what is the workup for fetal loss
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indicated after only 2 losses because the risk of further loss is equivalent to that after 3 losses
history- family pedigree, maternal medical hisotry exposures examination- inspect placenta, autopsy of fetus CBC Urine tox screen TORCH Titers RPR anticardiolipin ab and lupus anticoagulent Kelihauer Betke (if isoimminuization is a consideration) thyroid function tests random glucose genetic karyotype HSG Endometrial culture for ureaplasma urealyticum endometrial biopsy for luteal phase defect |
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If Ab screen for Rh is 1:16 or greater then what do you do
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Doppler US middle cerebral artery to assess level of anemia and thus fetal compromise
this replaces amnio to measure OD 450 Liley Curve PUBS to measre HCT directly |
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Iso-immunizaiton work
blood type of mother If maternal RH is negative? IF paternal RH is positive? |
If maternal Rh is negative do blood screen on father
If paternal Rh is positive- do Ab screen (done routinely in calses of Rh neg mother and in fact all prenancies) |
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When do you give mini dose of Rhogam
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50 microgram dose
give in any first trimester pregnancy loss |
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When do you give the regular dose of rhogam
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Regular dose 300 mcg, covers up to 15 cc of fetal blood cell transfusions
efective for 10-12 weeks (T1/2 = 24 days) |
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Can rhogam help if patient has had already a positive ab screen
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no
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What is the Du variant in iso-immunization
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patient is actually Rh positve , but this varian is not picked up by all tests and may be erroneously claimed as RH negative
despite these patients actually being Rh positive they can rarely produce iso-immunization (not what you would expect) and thus Rhogam should be given |
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Minor antigens
Kelly Duffy Lewis |
Kelly ab K kills (IgG)
Duffy ab Dies (IgG) Lewis L= Lives (IgM) |
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How much rhogam to cover fetal blood
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300 cc Rhogam/30 cc whole blood
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What are causes of microcytic anemia
What is the MCV |
Fe deficienty anemia, Thalassemias
MCV < 80 |
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What are caues of Normocytic anemia
What is the MCV |
Sickle Cell Disease
MCV 80-100 |
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What are causes of macrocytic anemia
What is the MCV |
B12 and Folate
Macrocytic > 100 |
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Describe Hgb structure
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4 globin chains each with a Fe molecule
several different kinds of globin chains, (alpha, beta, gamma and others) audlt Hgb comprises of 2 alpha chains plus either 2 beta chains (Hgb A) or 2 gamma chains (Hgb F: small fraction) Hgb F predominates in the fetus at 12-24 wks or 2 Delta chiains (Hgb A2) |
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What is work up iwht patient with anemia
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CBC
all at dirsk groups should get Hgb electrophoresis if at risk for Thalassemias do MCV If confirmed to have Thalassemia do serum ferritin |
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Sickle Cell
how is trasnmitted what is the incidence |
Autosomal Recessive
Sicle Cell Trait heterozygous Hb AS Sickle Cell Disease Homozygous Hb SS incidence of gene in African Americans 1:12 also common among greeks and italians |
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What is the pathophsyiology of SS Diesease
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decreased P02 causes RBC sickling leading to micro vessel obsturciotn
decreased perfusion and organ damage (autosplenecotmy leading to increased infection risk) Most significant is acute chest syndrome which comprises 1. Pulmonary infiltrate (vaso-occlusive disease) 2. Fever 3. Hypoxemia 4. Acidoses |
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How do you diagnose SS disease
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by Hgb electrophoresis
SS disease- all Hgb is HbS with minimal Hb A2 and HbF AS disease-highr percentge of HbA and asyptomatic |
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What are risks of Sickle Cell disease in pregancy
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PTL
PROM Increased atepartum admission post partum infection |
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Name 3 things that can precipitate pain crisis in SS Disease
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cold environment
physcial stress dehydration |
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What are the fetal risks with SS disease
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IUGR Low Birth Weight
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How do you manage a SS patient in pregnancy
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Increase Folate need to be on 4 mg a day
Transfusion want your Hb S fraction <40% wnat Total Hgb >10 increased fetal testing U/S and FH monitoring |
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How do you manage a SS pain crisis in pregancy
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Pain control
02 if 02 sat are less than 95% treat any specific organ damage |
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Thalassemia
cause microcytic anemia MCV <80 what groups do you see this in |
South east asia
mediterranean W. Indies Hispanics |
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What is defective in the thalassemias
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nomenclature relates to globin chain which is defective
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alpha chain is coded by 4 genes
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1 gene gone clinically asymptomatic
2 genes absent- alpha thalassemia mnior carier trait with mild anemia 3 genes absent Hb H disease moderate hemolytic anemia If all 4 genes absent Bart's disease, (a thalassemia major) hydrops |
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Alpha Thalassemia Minor
missing 2 genes which one more likely to have offspring with Hgb H |
if 2 absent genes on smae chromosome _ _/aa (cis) form
common among Southeast asia. more likely to have offspring with Hgb H on opposing chromosome _a/_a (trans) form less likely to have Hgb H |
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Alpha Thalassemia describe 4 types
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missing 1- aymptomatic
missing 2-a thallasemia minor missing 3-Hb H disease missing 4- Barts disese, alpha thallasemia major |
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Hgb A
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2 alpha chains and 2 beta chains
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How do you treat a thalassemia in pregnancy
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similar to normal pregnancy
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Descirbe Beta thalassemia
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reduced ability to make B chains thus adult Hgb (HbA) production is compromised
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Describe B thalassemia minor
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heterozygote
management in pregnancy is low risk aysmptomatic mild anemia is the biggest problem micorcytic anemia |
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Homozygous for Beta thalassemia is
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B thalassemia major or cooleys anemia
severe anemia death usually within 10 years |
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management of B thalassemia major in pregnancy
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pregnancy is extremely rare
patients need extensive monitoring |
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What is the differential diagnosis for fetal hydrops
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Immune- Rh disease
Non immune- infectious-parvo congenital congeintal heart defects supra-ventricular tachycardia Placental AV malformaiton (chorioangioma) |
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Name 4 antibiotics contraindicated in pregnancy
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Tetracycline- teeth discoloration
Cholamphenicol- grey baby syndrome Quinalones- affects cartilage Erythromycin estolate- erythromycin stearate is acceptable |
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Name 3 nonantibiotic meds that are contraindicated in pregnancy
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retinoic acid
warfarin oral hypoglycemic agents |
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What is the fetal blood volume
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80 cc/kg
important if you have an abruption and need to do a kleihauer bethke test |
