Mom
Recommended first-line pharmacologic therapy for gestational diabetes
Insulin
Vessels of umbilical cord. Vessel(s) that carry oxygenated blood.
1 umbilical vein, 2 umbilical arteries
Umbilical vein carries oxygenated blood
Definition of PPROM
Preterm prelabor rupture of membranes. Rupture of membranes without labor before 37 weeks.
Maternal infection that can lead to non-immune fetal anemia
Parvovirus B19
Definition of labor and three phases of labor
Regular contractions leading to cervical change.
1st - cervical dilation (0-10 cm)
2nd - descent (10 cm to delivered)
3rd - placenta (delivery to placental delivery)
Severe features of preeclampsia
SBP at least 160 mmHg or DBP at least 110 mmHg at least 4 hours apart or shorter if treated with anti-hypertensives
Plts <100,000 x 10^9/L
Cr >1.1 mg/dL or doubling of Cr in absence of other renal disease
LFTs 2x upper limit of normal
Pulmonary edema
HA, vision changes, RUQ pain unchanged by analgesia and not explained by alternate dx
10/10 APGARs
Appearance - 2+ pink
Pulse - 2+ >100 bpm
Grimace (reflex irritability) - 2+ cry/cough/sneeze/pull away in response to stimulation
Activity (tone) - 2+ Active, good tone (strong flexion of extremities)
Respirations - 2+ Vigorous cry
Two most likely causes of uterine bleeding between 24-34 weeks and how to differentiate between them
Placental abruption has abdominal pain, fetal intolerance, prompt mentions trauma or drug use. Placenta previa is painless, can be identified on TVUS.
Note: for patients with vaginal bleeding, spec then US. Do not do a manual exam!
Indications for intrapartum antibiotic prophylaxis for group B strep
+GBS swab
+GBS in urine
Previous child with early onset GBS disease
Unknown GBS + temp>100.4 F, >18 hrs ruptured, GA <37 weeks, or +NAAT. May offer for people with prior hx GBS+.
Cardinal movements of labor
Engagement, descent, flexion, internal rotation, extension, external rotation and expulsion
Management of maternal cardiac arrest
Call a code
Chest compressions w/ backboard
Manual leftward displacement of uterus
Ventilate (mask or intubation)
Place defibrillator, analyze rhythm
If shockable rhythm (V.tach, V.fib, SVT), defibrillate
If non-shockable rhythm (PEA, asystole), epi 1 mg IV/IO every 3 min
If no ROSC in 4 minutes (and uterine size >20 weeks), perform resuscitative hysterotomy
DO NOT PLACE FETAL MONITOR
Tests included in a sequential integrated prenatal screen
Serum PAPP-A, hCG at 10-13 weeks
NT scan 11-14 weeks
Quad screening: AFP, hCG, estriol, inhibin A at 15-20 weeks
Management of PPROM at 24-34 weeks, 34-37 weeks, 37-39 weeks, and >39 weeks
24-34 weeks: 1st course BMZ (rescue doses are debated), latency antibiotics (resident bonus: ampicillin 2g q6hr x48 hrs -> amoxicillin 500 mg TID x5 d + azithromycin 1,000 mg PO x1), expectant management
34-37 weeks: consider r/b 1st course BMZ (no rescue doses), proceed to delivery without delay for BMZ
>37 weeks: proceed to delivery
Ultrasound findings of congenital toxoplasmosis. Definitive diagnosis.
Ventriculomegaly, intracranial calcifications, microcephaly, ascites, hepatosplenomegaly, & IUGR.
PCR of amniotic fluid
Definition of Reactive NST, Category 1 FHRT, and Category 3 FHRT
NST: fetal heart rate monitoring not in labor. Reactive requires 20 minutes of baseline FHR 110-160 bpm, moderate variability (6-25 bpm), and 2 accelerations (10 bpm for at least 10 seconds <32 weeks, 15 bpm for at least 15 seconds >32 weeks)
Cat 1: baseline FHR 110-160 bpm, moderate variability (6-25 bpm), absence of variable or late decelerations
Cat 3: absent variability with recurrent variable or late decelerations, terminal bradycardia, sinusoidal pattern (regular, smooth, sine wave with variation of 5-15 bpm around baseline with 2-5 oscillations per minute)
Contraindication to Magnesium sulfate for seizure prophylaxis
Maternal myasthenia gravis
Timing of ovum cleavage and correlation to zygosity, chorionicity, and amnionicity of twins
2 separate eggs - dizygotic
For monozygotic:
day 2-3 di/di
day 4-8 monochorion/diamnion
day 9-12 mono/mono
day 13 or after conjoined
Management of preterm labor 24-34 weeks & 34-37 weeks
24-34 weeks: BMZ (consider rescue dose if at least 7-14 days from prior course and high likelihood of delivering w/in 7 days), tocolysis through steroid window (beta-agonist or Ca channel blocker but caution w/ Mg, NSIADs if <32 weeks, Mg if functioning independently), Mg for prevention of cerebral palsy if <32 weeks, pcn for GBS unknown, expectant management
>34 weeks: consider first dose BMZ (rescue dose not indicated), expectant management
Preconception counseling for VZV vaccine. Management of inadvertent VZV vaccine exposure in non-immune woman. Management of VZV disease exposure in non-immune woman.
VZV vaccine should be offered offered vaccination if no history of chickenpox or prior vaccination is elicited and if VZV IgG is negative. Delay pregnancy at least 1 month after vaccine administration.
Expectant management for inadvertent vaccine exposure, no cases of congenital VZV have been associated with vaccine exposure.
VZIG for non-immune women with disease exposure.
Weight at which a primary cesarean section may be offered for suspected macrosomia
At least 4,500 g for diabetic mother
At least 5,000 g for non-diabetic mother
Women with preexisting heart disease who should be counseled to avoid pregnancy or terminate pregnancy due to maternal preexisting condition
Ejection fraction less than 30% or class III/IV heart failure
Severe valvular stenosis
Marfan syndrome with aortic diameter more than 45 mm
Bicuspid aortic valve with aortic diameter more than 50 mm
Pulmonary arterial hypertension
Quintero staging for twin-twin transfusion syndrome
1: DVP>8 cm in recipient sac, DVP<2 cm in donor sac
2: absence of donor bladder
3. donor doppler abnormalities (A/R EDF of UA, A/R a wave in DV, UV pulsations)
4. recipient hydrops
5. fetal demise
Indications for cerclage placement. Indication for antibiotic and tocolytic therapy at time of cerclage placement.
US indicated: Current singleton pregnancy, prior spontaneous preterm birth <34 weeks, & CL <2.5 cm before 24 weeks
PE indicated (rescue): Painless cervical dilation in the second trimester
Hx indicated: Hx at least 1 second-trimester pregnancy loss 2/2 painless cervical dilation w/o labor or placental abruption OR PE indicated cerclage in prior pregnancy
Neither antibiotics nor prophylactic tocolytics have been shown to improve the efficacy of cerclage, regardless of timing or indication
Pharmacologic treatment of acute maternal toxoplasmosis infection
Spiramycin (macrolide abx)
Reduces transplacental parasitic transfer
Requires assistance from the FDA because the drug is not commercially available in the United States
Maternal treatment does not reduce or prevent fetal infection but may reduce congenital disease severity
Treatment of uterine inversion
Leave placenta attached
Uterine relaxants: nitroglycerine, halogenated anesthetics (isoflurane, desflurane, and sevoflurane), nitrous oxide, turbutaline, magnesium sulfate
Manual repositioning
Laparoscopy vs laparotomy -> Huntington procedure (serial clamping and traction of round ligaments) or Haultain procedure (posterior cervical incision)