OB emergencies
What is the definition of HELLP ?
Hemolysis
Elevated LFTs
Low platelets
What are the components of the Bishop score and what does it mean?
Dilation, effacement, station, consistency, position
8 or more is favorable, chance of SVD with induction similar to spontaneous labor
What is the normal HCG trend in early pregnancy? (depends on initial HCG)
<1,500: 50%
1,500 - 3,000: 40%
>3,000: 33%
List the 4T's, how it's diagnosed and treatment for each
Tone - bimanual = uterotonics
Trauma - vaginal, cervical, uteirine lacs = surgical repair
Tissue - US = D&C
Thrombin - coags = resuscitation with products
What is the treatment for chorioamnionitis (UCSF and ACOG)?
Cefoxitin (UCSF)
Amp/Gent (ACOG)
Describe the maneuvers used in a shoulder dystocia
Stop pushing
McRoberts and suprapubic pressure
Wood's Screw
Rubin
Posterior arm
Gaskin
Clavicular fracture
Zavanelli
What conditions are contraindications to ECV?
absolute - contraindication to SVD (i.e. previa, breech, prior classical)
relative: oligo, labor, uterine anomalies, preterm <34 weeks, fetal anomalies, FGR, multiple gestation, NRFHT, abruption, SROM,
What is criteria used to diagnose early pregnancy loss?
Absent FP with CM 11 days after GS with YS
Absent FP with CM 14 days after GS without YS
CRL 7mm or more without CM
MSD 25mm or more without FP
List the uterotonics used to treat atony in a postpartum hemorrhage and contraindications
Hemabate - severe asthma
Methergine - HTN, caution with macrolides, protease inhibitors (HIV meds, paxlovid), azole antifungals)
Misoprostol
TXA - DIC, h/o VTE, coagulopathy
What are the indications for GBS prophylaxis? GBS unknown?
GBS+
GBS bacteruria
h/o infant with GBS sepsis
GBS unknown - preterm, prolonged rupture > 18h, h/o GBS in prior pregnancy
What is the risk of eclampsia with and without magnesium in severe pre-eclampsia?
What is the risk of uterine rupture with prior LTCS? 2 prior LTCS? classical? T-incision? myomectomy? prior uterine rupture?
LTCS x 1: 0.5%
LTCS x 2: 1-2%
classical, T-incision, myomectomy: 6-10%
prior rupture: 6% (LUS) -30% (contractile)
What is initial evaluation and management of preterm labor?
IVF
Mg (<32 weeks)
Cervical length: 2-3cm -> FFN
FFN: 23+0 to 34+6
Tocolytics -- only for BMS up to 48 hours
Contraindications: severe pre-eclampsia/eclampsia, IAI/chorio
1) Indocin: < 32 weeks
Side effects: oligo, premature closure of ductus arteriosus
Contraindications: maternal platelet dysfunction or bleeding disorder, hepatic dysfunction, PUD, renal dysfunction, sensitivity to aspirin
2) Nifedipine
Contraindictions: preload dependent cardiac lesions, caution with heart failure, Mg
3) Terb
Side effects: maternal and fetal tachycardia, hypotension, palpitations, tremor, CP/SOB, pulm edema, hypokalemia, hyperglycemia, MI
Contraindications: tachycardia sensitive cardiac disease, poorly controlled hyperthyroidism or DM
DDx and workup of 2nd and 3rd trimester bleeding?
US, SSE, wet mount, GCCT, cervical exam, abruption labs if suspicion
Previa
Abruption
Cervicitis/vaginitis
Labor
Polyp/ectropion
What antibiotics are used for GBS prophylaxis if PCN allergy?
Mild allergy - Ancef
Severe - Clinda (if sensitive) or Vanc (if resistant or sensitivities unknown)
What magnesium level is therapeutic? What levels are toxic and what are the symptoms? What is the treatment for magnesium toxicity?
Therapeutic: 4.8 - 8.4
>9: loss DTR
>12: respiratory paralysis
>30: cardiac arrest
Treatment: 1g calcium gluconate
Which patients are not candidates for late preterm steroids (ALPS exclusion criteria)?
prior BMS administration or stress does steroids this pregnancy
pregestational diabetes
twins
chorio
NRFHT
Delivery expected within 12 hours of administration (PPROM in labor: 3cm or more or >6 ctx/hr; PTL: 8cm or more)
What are the contraindications to MTX treatment for ectopic (list 6)?
Absolute - IUP, immunodeficiency, moderate to severe anemia, leukopenia, or thrombocytopenia, MTX sensitivity, active lung disease, active PUD, clinically important hepatic or renal dysfunction, breastfeeding, ruptured ectopic, hemodynamically unstable patient, inability to follow-up
Relative - +CM, HCG > 5000, ectopic > 4cm, refusal to accept blood transfusion
Definition and etiology of delayed postpartum hemorrhage?
Definition: 24hrs to 6 weeks PP
- Subinvolution of the placental site
- Retained POCs
- Infection
- Inherited coagulation defects (eg, vWF deficiency)
- AVM
What is the differential diagnosis for postpartum fever?
Atelectasis
Mastitis
Endometritis
UTI/pyelo
DVT/PE
Wound infection
Septic thrombophlebitis
Wonder drugs
What are contraindications to magnesium and what are the alternatives?
Contraindication: myasthenia gravis
Anternatives: Versed, Ativan, Valium, Phenytoin
What are the requirements for vaginal twin breech delivery?
<20% discordance
Twin A cephalic
GA > 32w
EFW > 1500 of second twin
What is the definition of hyperemesis gravidarum?
Persistent vomiting not related to other etiology, ketonuria, 5% prepregnancy weight loss
Steps of management of uterine inversion?
Call anesthesia
Give uterine relaxant - halothane, nitroglycerine, Terb
Replace and given uterotonics
What is the treatment for syphilis (depends on stage)?
Primary, secondary, latent < 1 year: Bicillin 2.4m units x 2
Latent > 1 year, tertiary or unknown: Bicillin 2.4m units weekly x 3
PCN allergic - needs desensitization