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99 Cards in this Set
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4 high-risk cardiac disorders for which pregnancy should NOT be advised due to risk of sudden death.
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1. Pulmon HTN
2. Eisenmenger synd. 3. Severe valvular disorders 4. Prior postpartum cardiomyopathy |
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When are cardiovascular changes in pregnancy the maximal?
(from week ? till week ?) |
28-34 weeks. Underlying cardiac conditions may be unmasked or worsen.
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Heart failure with NO identifiable cause, developing between last month of preg to 5 mos postpartum
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Peripartum cardiomyopathy
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Risk factors for peripartum cardiomyopathy (4)
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1. Multiparity
2. Age =>30 3. Multiple gestations 4. Preeclampsia |
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5-year mortality rate of peripartum cardiomyopathy
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50%
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Which 2 classes of heart failure are associated with risk of maternal or fetal death?
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III and IV
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Never use which 2 drugs for heart failure during pregnancy
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ACE inhibitor
Aldosterone |
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3 meds that can be continued for heart failure during pregnancy
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1. Loop diuretics
2. Nitrates 3. Beta-blockers |
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1 med that may be used during pregnancy to improve symptoms of heart failure, but with no improvement of outcome
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Digoxin
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How to manage arrhythmias during pregnancy (2)
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1. Continue RATE control as with nonpregnant pts
2. Do NOT give AMIODARONE of WARFARIN |
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Are the indications for endocarditis prophylaxis DIFFERENT during pregnancy?
What are the indications? 4 cardiac defects 3 procedures |
Same as for non-pregnant
A. Only these cardiac defects 1. Prosthetic valves 2. Unrepaired cyanotic heart disease 3. Previous endocarditis 4. Transplant recipients who develop valve disease B. Only these procedures 1. Dental procedures that cause bleeding (Amoxicillin or for Pen-Allergic Clindamycin) 2. Respiratory tract surgery 3. Surgery of infected skin |
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How often should prophylaxis be given to pts with rheumatic heart disease?
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Daily
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When not to give prophylactic Abxs in pregnant pts with valvular disease or prosthetic valves (2)
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1. Uncomplicated vaginal delivery
2. Uncomplicated cesarean delivery |
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Which type of valvular diseases are well tolerated and do not require tx during pregnancy?
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Regurgitant lesions
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Which type of valvular lesions have an increased risk of maternal/fetal morbidity and mortality
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Stenotic lesions
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What does a pregnant women with Mitral Stenosis have an increased risk of? (2)
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1. Pulmonary edema
2. Atrial fibrillation |
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What is the leading cause of maternal death in the US?
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Pulmonary Embolism
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What % of pregnant women that develop thromboemboli have an UNDERLYING thromboembolic disorder?
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50%
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When is anticoagulation during pregnancy the answer? (5)
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1. DVT or PE
2. Afib WITH underlying heart disease 3. Antiphospholipid syndrome 4. SEVERE heart failure (EF<30%) 5. Eisenmenger syndrome |
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Why is LMW Heparin the anticoagulant of choice? (2)
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1. Does not cross the placenta (Warfarin does and causes fetal abnormalities, even death)
2. Not associated with osteopenia (as is unfractionated heparin) |
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What is the management of pregnant pts with PREVIOUS Hx of
1. DVT / PE or 2. underlying thrombophilic condition (3) |
1. Prophylactic LMWH throughout pregnancy
2. Unfractionated heparin during L&D 3. Warfarin x 6wks postpartum |
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When are thrombolytics used in PE during pregnancy?
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Same indications as in non-pregnant, when pts are hemodynamically unstable, namely HYPOtensive.
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What 2 outcomes are associated with HYPERthyroidism in pregnancy?
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1. Fetal growth restriction
2. Stillbirth |
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What 2 outcomes are associated with HYPOthyroidism in pregnancy?
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1. Intellectual defects
2. Miscarriage |
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Does pregnancy change the Sxs of hypo- or hyper- thyroidism?
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No change of Sxs
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What are the normal values and ranges of free T4 and TSH during pregnancy?
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Same values and ranges as for non-pregnant.
T4 free: 0.8 - 2.3 ng/dL TSH: < 10 microU/mL ; >60yrs, M 2-7.3, F 2-16.8 |
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How to manage pts with HYPOthyroidism on hormone replacement during pregnancy
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Continue hormone replacement
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The drug of choice for SYMPTOMATIC HYPERthyroidism during pregnancy?
Never give WHAT during pregnancy |
Beta-blockers
Never give radioactive iodine |
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The drug of choice for Graves' Disease during pregnancy, also 2nd line drug.
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1st: Propylthiouracil (PTU)
2nd: Methimazole |
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In the tx of Graves' Disease, PTU crosses the placenta and may cause what in the fetus? (3)
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1. Goiter
2. HYPOthyroidism 3. Congenital Graves' Disease may be masked for 7-10 days after birth. |
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In Graves' Disease, maternal thyroid-stimulating Igs and thyroid-blocking Igs cross the placenta and cause what? (3)
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1. Fetal tachycardia
2. Growth restriction 3. Goiter |
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Target values for
1. Fasting Blood Sugar (FBS) 2. 1-hour postprandial sugar during pregnancy |
1. <90 mg/dL
2. <120 mg/dL |
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How to manage Gestational DM ? (2)
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By DIET alone.
Glyburide, though controversial, has been used by some. |
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How to manage DM during pregnancy?
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Insulin
1. increase throughout course of pregnancy 2. decrease asa PLACENTA is delivered |
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Why should oral hypoglycemics be avoided during breastfeeding? (1)
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They can cause hypoglycemia in neonates.
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Routine monitoring of Diabetic pts during pregnancy. (5)
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1. HbA1C (each trimester)
2. Triple marker screen (16-18wks) 3. Sonogram (monthly) 4. BPP (monthly) 5. NST & AFI (weekly, starting @26wks or 32wks) |
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In a diabetic pt, HbA1C is found to be elevated in the FIRST trimester. What should be done and when? (2)
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1. @18-20wks: targeted US for structural abnormalities
2. @22-24wks: fetal ECHO for congenital heart disease |
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In a diabetic mother, WEEKLY NSTs and AFIs should start when and for what conditions? (2+4)
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@26 wks if
1. small vessel disease 2. poor glycemic control @32 wks if 1. taking insulin 2. macrosomia 3. previous stillbirth 4. HTN |
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For GDM pts, what test should be ordered postpartum and when?
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2-hour 75g OGTT
@ 6-12 wks postpartum to determine of DM has resolved. 35% of GDM develops to DM within 5-10 yrs. |
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What UNcommon congenital abnormality is associated with overt DM during pregnancy?
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Caudal regression syndrome
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In DM mothers, congenital malformations (especially NTDs) are stronly associated with what?
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HbA1C > 8.5 in FIRST trimester
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Why is GDM not associated with congenital abnomalies?
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Hyperglycemia in GDM is NOT present in the FIRST 1/2 of pregnancy.
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When should delivery be scheduled in DIABETIC mothers, and why?
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@40 wks because of delayed fetal maturity
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When and under which conditions should labor be induced in diabetic mothers? (2)
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1. @39-40 wks if < 4.5 kg
2. Earlier if poor glycemic control |
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If labor is induced before 40 wks in a diabetic mother, what should be checked and why?
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1. lecithin/sphingomyelin (L/S) ratio 2.5
2. presence of phosphatidyl glycerol Ensures lung maturity |
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If fetus is > 4.5 kg in diabetic mother, how should L&D be conducted?
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Schedule cesarean section d/t risk of shoulder dystocia
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During labor of a diabetic mother, what level should blood glucose be at, and how should it be maintained?
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80-100 mg/dL
using both 1. 5% dextrose in H2O 2. insulin drip |
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How to use insulin after delivery. (2)
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1. Stop insulin infusion, because insulin resistance decreases with rapidly falling levels of hPL p delivery of placenta
2. Maintain blood glucose with sliding scale |
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Neonatal HYPOglycemia is caused by
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Maternal HYPERinsulinemia
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Neonatal HYPOcalcemia is caused by
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PTH synthesis failure
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Neonatal polycythemia is caused by
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Hypoxia
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Neonatal HYPERbilirubinemia is caused by
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Excessive neonatal RBC breakdown
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Neonatal RDS is caused by
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Delayed surfactant production
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Woman of European descent c/ twins (multiple gestation) c/o intractable nocturnal pruritis on palms and soles
PE: no skin findings |
Intrahepatic cholestasis of pregnancy
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How to Dx intrahepatic cholestasis of pregnancy.
How to Tx. (2) |
10 - 100 x increase of bile acids
1. Ursodeoxycholic acid 2. Symptomatic relief c/ antihistamines and cholestyramine |
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29yo primigravida @33wks becomes confused, nausea, vomiting, anorexia x3d.
Mother BP 150/95, blood glucose 52mg/dL, Plt 75k, PTT prolonged, Cr 2.1mg/dL, Uric acid 11.9mg/dL LDH 1063 U/I, ALT 220 U/I, AST 350 U/I, Tot bilirubin 8.4mg/dL, Serum ammonia elevated, Urine dipstick 3+ protein. FHR 145/min, nonreactive NST. |
Acute fatty liver
Rare disorder of fetal metabolism of fatty acids. Can mimic preeclampsia c/ HTN, proteinuria, edema. |
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How to Dx acute fatty liver in pregnant women. (5)
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1. Elevated liver enzymes (ALT, AST, GGT)
2. HYPERbilirubinemia 3. DIC 4. HYPOglycemia (unique) 5. Serum ammonia elevated (unique) |
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How to Tx acute fatty liver in pregnant women. (3)
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1. Admit ti ICU
2. Aggressive IV fluid tx 3. Prompt delivery |
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1. Urine culture +
2. No urgency, freq, burning 3. No fever What is it, and how to Tx? (3) |
Asymptomatic bacteriuria
Outpatient PO Abx 1. Nitrofurantoin (drug of choice) 2. Cephalexin (alternative) 3. Amoxicillin (alternative) |
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1. Urine culture +
2. Urgency, freq, burning 3. No fever What is it, and how to Tx? (3) |
Acute cystitis
Outpatient PO Abx 1. Nitrofurantoin (drug oc) 2. Cephalexin (altern.) 3. Amoxicillin (altern.) |
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What complication can occur if Asymptomatic bacteriuria or Acute cystitis is untx'ed.
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30% develop Acute pyelonephritis
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1. Urine Cx +
2. Urg, freq, burning 3. Fever 4. CVA tenderness What is it, and how to Tx? (4) |
Pyelonephritis
1. Admit to hospital 2. IV hydration 3. IV cephalosporins or gentamicin 4. Tocolysis |
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What complication can occur after Pyelonephritis during pregnancy? (4)
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1. Preterm L&D
and in severe cases 2. Sepsis 3. Anemia 4. Pulmon dysfxn |
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How is abortion induced in 1st trim? (2 methods)
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1. D&C (most common, <13wks)
a. Prophylactic Abx b. Conscious sedation c. Paravertebral block local anesthetic 2. PO Mifepristone + PO Misoprostol (=<63d p/ amenorrhea) |
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What are the complications and their txs of D&C during 1st trim? (2)
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1. Endometritis (o/p Abx)
2. Retained products of conception (repeat curettage) |
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What are the possible sequelae of medically induced abortion in 1st trim? (2)
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1. Incomplete abortion 2% (requires D&C)
2. Clostridium sordellii SEPSIS rarely |
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How is abortion induced in 2nd trim? (2 methods)
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1. D&E (most common)
2. Intact D&E ("partial birth") a. wide cervial dilation b. assisted breech delivery c/ US guidance |
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What are the early and delayed complications of induced abortion in 2nd trim? (6+2)
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Early
1. Retained placenta (most common) 2. Uterine perforation 3. Retained tissue 4. Hemorrhage 5. Infection 6. DIC (rarely) Delayed 1. Cervical trauma 2. Cervical insuff. |
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Etiologies of Symmetric IUGR (3)
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Fetal causes
1. Aneupleidy 2. Infection (TORCH) 3. Structural anomlies a. congenital heart dis. b. NTD c. ventral wall defects |
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Etiologies for Asymmetric IUGR (4+4)
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Maternal causes
1. HTN 2. Small vessel disease (e.g. SLE) 3. Malnutrition 4. Tobacco, Alcohol. Street drugs Placental causes 1. Infarction 2. Abruption 3. Twin-twin transfusion 4. Velamentous cord insertion |
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Work-up for symmetrical IUGR (3)
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1. Detailed sonogram
2. Karyotype 3. Screen for fetal infections |
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Work-up for asymmetrical IUGR (5)
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Monitor with serial
1. Sonograms 2. NST 3. AFI (often decreased c/ severe uteroplacental insuff.) 4. BPP 5. Umbilical artery dopplers |
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What is the 1st step in dx'ing IUGR?
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Make sure pregnancy dating is accurate.
If not, EARLY sonogram (<20wks) is next step. NEVER change gest. age based on late sonogram. |
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What are the RFs for Macrosomia? (6)
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1. GDM
2. DM 3. Prolonged gestation 4. Obesity 5. Excessive weight gain during pregnancy 6. Male fetus |
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What are the complications for Macrosomia?
Maternal (3) Fetus (3) Neonate (2) |
Maternal
1. Injury during birth 2. Hemorrhage 3. Emergency C-section Fetus 1. Shoulder dystocia 2. Birth injury 3. Asphyxia Neonate 1. Hypoglycemia 2. Erb palsy |
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What is the management for Macrosomia? (1)
Diabetic vs. Non-diabetic mother |
Elective C-section
Diabetic: EFW > 4.5 kg Non-diabetic: EFW > 5.0 kg |
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What is BPP?
=>8 is reassuring |
1. AFI
2. Fetal tone 3. Fetal activity 4. Fetal breathing movements 5. NST |
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Define a reactive NST
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=>2 accelerations in 20 mins,
that are =>15 beats above baseline, and last =>15 secs. |
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What is OCT or CST?
Oxytocin Challenge Test Contraction Stress Test |
Induce =>3 contractions in 10 mins and analyze FHR as in NST.
Late decelerations in =>half of contractions is + and worrisome. |
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Define spontaneous abortion. (2)
It's presentation. (2) |
Expulsion of embryo/fetus
1. < 500 g or 2. < 20 wks 1. Uterine pain 2. Vaginal bleeding |
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Define fetal demise.
It's most common Sx |
In utero death => 20 wks
Loss of fetal movements |
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27yo @7wks p/w vaginal bleeding and pelvic pain. Dx?
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Threatened abortion (chances are 50/50)
1st step in management? |
Speculum exam for any vaginal bleeding in EARLY pregnancy
If pregnancy is advanced enough, US or Doppler for fetal cardiac activity |
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Early pregnancy p/w painful cramps, continued bleeding, and dilated cervix per speculum. Dx?
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Inevitable abortion
Tx? |
Emergency suction D&C
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Early pregnancy p/w
1. loss of early pregnancy Sxs (eg. nausea, breast tenderness) 2. loss of fetal cardiac activity Dx? |
Missed abortion
How to confirm Dx? |
US shows nonviable fetus
Cervix is usually closed |
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1. Vaginal bleeding
2. Uterine cramping 3. Cervical dilation 4. Expulsion of products of conception What is the next step? |
US to check retained POC.
If incomplete, Emergency D&C is needed. If complete, follow-up? |
Serial beta-hCG titers WEEKLY until negative, to r/o ectopic pregnancy
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Most common cause of spontaneous abortion?
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Chromosomal abnormalities
RFs? (3) |
1. Advanced maternal age
2. Previous spont. abortion 3. Smoking |
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Most common cause of fetal demise?
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Idiopathic
RFs? (5) |
1. Antiphopholipid syndrome
2. overt DM 3. Trauma 4. Severe maternal isoimmunization 5. Fetal infection |
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When should exam per speculum NEVER be made in case of vaginal bleeding during pregnancy?
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Late trimester bleeding
Why? |
Risk of bleeding in case of low lying placenta
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The most serious complication of prolonged fetal demise (> 2 wks)?
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DIC resulting from release of tissue thromboplastin from fetal organs.
How to r/o DIC? (5) What to do if positive? |
1. Platelet count
2. D-dimer 3. Fibrinogen 4. PT 5. PTT If positive, IMMEDIATE delivery! |
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1. Amenorrhea
2. Vaginal bleeding 3. Unilateral pelvic-abdominal pain Dx? |
Ectopic pregnancy
When to suspect rupture? (3) |
1. Abdominal guarding / rigidity
2. hypotension 3. tachycardia |
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RFs for Ectopic pregnancy (5)
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1. PID (most common)
2. Tubal scarring d/t IUD 3. Hx of tubal surgery (ligation) 4. Diethylstilbestrol(DES) exposure in utero 5. Previous Hx of ectopic pregnancy |
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How to Dx ectopic pregnancy? (2)
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1. Beta-hCG > 1500 mIU
2. Vaginal US shows NO intrauterine pregnancy Note: absence of adnexal mass does NOT r/o |
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When can an intrauterine pregnancy be seen by US? (2)
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Vaginally @5 wks, beta-hCG > 1500mIU
Abdominally @6 wks, beta-hCG > 6500mlIU |
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Indications for methotrexate (4)
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1. Pregnancy mas < 3.5 cm
2. NO fetal heart motion 3. Beta-hCG < 6000 mIU 4. NO Hx of folic supplement ? |
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How to manage ruptured ectopic preg?
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Immediate laparotomy / salpingectomy
Note: RhoGAM for Rh neg mothers What if unruptured? (2) |
1. Methotrexate or
2. Laparoscopy (salpingostomy) |
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Follow-up after management of ectopic pregnancy?
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Follow beta-hCG
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First step in the case of cervical dilation s/ labor or abruption.
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R/o Chorioamnionitis
If it is ruled out? |
Emergency cerclage (vaginally or abdominally)
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RFs for cervical insuff. (4)
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Hx's of
1. 2nd trim abortion 2. Cervical laceration during delivery 3. Deep cervical conization 4. Diethylstilbestrol (DES) exposure |
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Indication for management of cervical insuff.
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=>3 UNEXPLAINED MID-trimester pregnancy losses
What is the management? (2+1) |
1. Elective cerclage @ 13-16 wks
2. Removal at 36-37 wks URGENT cerclage ONLY after r/o labor and chorioamnionitis |
