MFM

SOGC what GA may Rhesus be unnecessary?

may be unnecessary before 10 weeks

sogc pneumatic compression devices

may be useful if on for up to 5 days, not much in 1 Can consider in women who can't receive heparin - active bleeding - thrombocytpoenia - heparin allergy or HIT

benefits of cannabis

may improve bone density may reduce pain, but no strong evidence

steroids in HELLP (when to deliver right away vs delay)

may temporarily improve lab values (especially platelets).... but does NOT improve maternal outcomes ... does not lower risk of fetal death deliver immediately: eclampsia Stroke abruption non reassuring FHR pulmonary edema DIC uncontrollable BP Can wait - renal dysfunction - liver dysfunction - low platelets - oligohydramnios - reversed EDF

prosthetic valves pregnancy

Biprosthetic valves usually do well, but lifespan is short, about 20% fail in 10-15 years Mechanical valces have high risk for valve thrombosis (around 5%)...

epilepsy and fetal risk

Seizures are associated with fetal hypoxia !! might be risk of abruption Increased risk of PTB, IUGR, preeclampsia, developmental delay

Pseudosinusoidal Pattern

Sinusoidal-appearing, undulating FHR pattern of short duration that is both preceded and followed by an FHR with normal characteristics. Usually transient, resolves spontaneously. There may be an occasional acceleration and some degree of variability with a somewhat jagged saw-tooth appearance Associated with: - fetal thumb sucking - hiccups - rhythmic breathing - maternal morphine

Positive antibody screen at term type and screen vs type and crossmatch

Type and screen identifies the ABO group, Rh type, and any major antibodies Crossmatch checks the same, but also checks patient serum is checked against donor RBC's to ensure compatibility. Not a bad idea to crossmatch patients who have a positive antibody screen once they are in labor or before CS, in case there is a PPH.

acute pancreatitis pregnancy

U/S not useful increased lipase, amylase

GBS complications in mom

UTI endometritis Chorio Wound infection can cause PPROM and PTB

# fetal circulation

UV brings oxygen/nutrient rich blood from placenta to fetus UV gives rise to branches: left inferior portal vein left superior portal vein right portal vein DV UV terminal branch is the PORTALVEIN

CMV ultrasound findings

Ultrasound detects fetal abnormalities in only 8.5% of women with primary CMV infection and in 15% of congenitally CMV-infected fetuses. These findings are growth restriction ventriculomegaly, oligohydramnios, echogenic bowel choroid plexus cyst (unilateral), pleural effusion brain and liver calcification, and hydrops fetalis [24]. Microcephaly, hydrocephaly, and intracranial calcifications are signs of high risk for neonatal sequelae

treat ICP

maybe urso Mechanism of action: Ursodiol is a hydrophilic bile acid that inhibits intestinal absorption of other bile acids, enhances excretory hepatocyte function and choleretic activity, stabilizes hepatocyte cell membranes and dilutes toxic bile acids in the enterohepatic circulation [13]. Ursodiol may also allow for transport of bile acids out of the fetal compartment . Dose: 10 to 25 mg/kg orally divided into two doses daily. The standard starting dose is 300 mg to 500 mg orally twice a day

manage face presentation

mentum anterior is okay, will usually deliver Mentum posterior- cesarean (rotation is contraindicated)

electrolyte abnormalities from massive blood transfusion

metabolic acidosis hypothermia coagulopathy hypocalcemia (citrate) Hyperkalemia

risks of progesterone

nonsignificant increase in composite maternal complications (gestational hypertension, preeclampsia, gestational diabetes, maternal infection including chorioamnionitis) with progesterone supplementation....., mostly as a result of increased gestational hypertension and maternal infection events;

normal IA vs abnormal IA

normal contractions (no tachy) FHR 110-160 no decels accels not required Abnormal is therefore: tachysystole FHR < 110 or > 160 changing baseline Arrhythmia decels

protein S deficiency pregnancy

normally is reduced during pregnancy < 30 % antigen level is abnormal during pregnancy A value <55% should be followed by assessing free protein S levels. If testing was done during pregnancy, free protein S <30% and <24% in the second and third trimesters, respectively, may be used to diagnose protein S deficiency.

SFH in obesity

not recommended over estimates macrosomia underestimates FGR

chronic hypertension

persistent high blood pressure, over 140 systolic OR 90 mm Hg... either - under 20 weeks - beyond 12 weeks post partum The American College of Cardiology and American Heart Association recently changed the diagnostic criteria for hypertension in adults. Stage 1 hypertension is now diagnosed with a systolic BP of 130-139 mmHg or diastolic BP of 80-89 mmHg. Stage 2 hypertension is > 140 or 90

chromosomal abnormalities in miscarriage

present in 50-60% of all miscarriages of those most common individual is Turners (around 20%) trisomies are around 50%

risk factors for GBS sepsis

preterm prolonged ROM chorio IUGR heavy growth

pregnancy risks with spinal lesions

preterm birth Preterm labor PPROM those with physical disabilities were more likely to have hypertension, mood disorders, and a history of abuse than those without physical disabilities. 16 Women with SB and SCI have an increased risk of urinary tract infection and pyelonephritis in pregnancy; these may increase the risk of preterm labour and birth.

risks for CP

preterm birth low birth weight multipls chorio

when to treat ITP in pregnancy?

-symptomatic bleeding regardless of platelets (ie, epistaxis, easy bruising) - any platelets under 30,000 - to bring to thresdhold (25, 50, 80 for vaginal, cesarean and epidural)

precautions to reduce aspiration

-use of nonparticulate oral antacids prior to induction of anesthesia - rapid-sequence induction methods - use of a cuffed endotracheal tube

iron deficiency anemia pregnancy

. Blood volume increases by about 50%, while red blood cells increase by only about 25%, resulting in an anemia of dilution. Iron requirements increase in order to support the increase in red blood cell mass, Iron is required for placenta and fetal function Hemolysis or bleeding

mechansm of obesity inhibiting contractions How to overcome ?

. Leptin and apelin—adipocytokines that are secreted from adipose tissue—are elevated in obesity, and both inhibit myometrial activity Early an liberal use of oxytocin

comprehensive diabetic management pregn

1 Use a multidisciplinary preconceptional care team, which may include an obstetrician, endocrinologist, family physician, diabetic educator, and dietitian. 2 Perform a full medical and obstetric evaluation in the preconceptional period to assess risks. 3 Evaluate and treat diabetic complications before pregnancy, including • Retinopathy: diagnostic examination for all women with pregestational diabetes • Nephropathy: diagnostic examination for all women with pregestational diabetes • Neuropathy: diagnostic examination for symptomatic women • Cardiovascular disease: diagnostic examination for symptomatic women • Hypertension: diagnostic examination for hypertensive women (>130 mm Hg systolic or >80 mm Hg diastolic) 4 Measure and optimize thyroid hormone levels in women with type 1 diabetes. 5 Review all current medications, and modify or discontinue agents that have evidence of fetal risk: • Angiotensin-converting enzyme inhibitors • Angiotensin II receptor blockers • Statins • Diuretics • β-Blockers 6 Assess level of metabolic control. Measure Hb A 1c monthly until control is achieved. Hb A 1c should remain below 7%, and lower if possible. 7 Manage blood glucose levels: • Work to achieve optimal pregnancy glycemic goals preconceptionally: preprandial, bedtime, and overnight glucose levels, 60-99 mg/dL; 1-h or 2-h postprandial glucose levels, 100-129 mg/dL. • Higher glucose targets may be used in patients with hypoglycemia unawareness or the inability to cope with intensified management. • Maintain glucose levels without hypoglycemia. Counsel about hypoglycemia awareness and management. • Insulin is the safest and most effective medication to achieve target blood glucose levels. 8 Begin folic acid supplementation, 1-4 mg orally daily from before conception until at least 12 weeks' gestation, to minimize congenital anomalies. 9 Provide counseling: • Inform about risks of miscarriage, congenital malformation, and perinatal mortality with poor metabolic control and unplanned pregnancy. Inform about how DM affects pregnancy and how pregnancy affects DM. • Encourage smoking cessation and reduction in alcohol intake. • Encourage regular exercise and management of weight to achieve a BMI <27. • Encourage a diet with complex carbohydrates, soluble fiber, and reduced levels of saturated fats. 10 Use effective contraception until target blood glucose control is achieved before conception. 11 Contraindications to pregnancy: • Hb A 1c >10% • Impaired renal function with creatinine >0.2 mmol/L (increased risk of progression to dialysis during pregnancy) Glycemic control should be assessed directly from glucose logs or meter downloads and by glycosylated hemoglobin levels. • For patients who have had diabetes for 10 years or longer, an electrocardiogram, an echocardiogram, and assessment of microalbuminuria and serum creatinine should be considered. • Because retinopathy can progress during pregnancy, all patients with preexisting diabetes should establish a relationship with a qualified ophthalmologist. A baseline retinal evaluation should be completed within the year before conception, with laser photocoagulation performed if needed. Previous laser or anti-vascular endothelial growth factor treatment is not a contraindication to pregnancy and may preclude significant hemorrhage during pregnancy. • Thyroid function (i.e., thyroid-stimulating hormone and free thyroxine levels) should be evaluated and corrected as necessary in all patients with T1DM because of the frequent coincidence of autoimmune thyroid disease and diabetes. • Prenatal supplementation of folic acid (1-4 mg daily) should be prescribed for a minimum of 3 months before conception, because folate or folic acid supplementation significantly reduces the risk of congenital neural tube defects. 172 Glycemic control should be assessed directly from glucose logs or meter downloads and by glycosylated hemoglobin levels. • For patients who have had diabetes for 10 years or longer, an electrocardiogram, an echocardiogram, and assessment of microalbuminuria and serum creatinine should be considered. • Because retinopathy can progress during pregnancy, all patients with preexisting diabetes should establish a relationship with a qualified ophthalmologist. A baseline retinal evaluation should be completed within the year before conception, with laser photocoagulation performed if needed. Previous laser or anti-vascular endothelial growth factor treatment is not a contraindication to pregnancy and may preclude significant hemorrhage during pregnancy. • Thyroid function (i.e., thyroid-stimulating hormone and free thyroxine levels) should be evaluated and corrected as necessary in all patients with T1DM because of the frequent coincidence of autoimmune thyroid disease and diabetes. • Prenatal supplementation of folic acid (1-4 mg daily) should be prescribed for a minimum of 3 months before conception, because folate or folic acid supplementation significantly reduces the risk of congenital neural tube defects. 172

Normal FHR SOGC

110-160 bpm normal contractions (no tachysystole) variability 6-25 - <5 BPM for 40 mins - accels are not required decels - none - early decels - non repetitive uncomplicated variables Non-repetitive: 1 or maximally 2 in a row (repetitive = 3+)

HR targets with exercise in obese

100-120 Begin second trimester 11,000 steps a day Best indicator is rate of perceived exertion

recommended amount of exercise during pregnancy

150 mins moderate activity accumulated over 3 days a week should be able to talk, reduce activity if not possible Target HR of around 120-140

how much does blood volume increase in pregnancy?

1500 - 2000 ml

acog when is transfusion recommended?

1500 ml of blood loss, with ongoing bleeding these patients are at high risk for DIC

short interpregnancy interval

18 months from one delivery to the next is CDC definition. Other places consider <24 months from 1 delivery to next.

fetal size aga lga sga

1Infants whose weights were lower than the 10th percentile were called small for gestational age (SGA) . 2 Infants whose birth weights were between the 10th and 90th percentiles were labeled as appropriate for gestational age (AGA) . 3 Infants larger than the 90th percentile were called large for gestational age (LGA) .

SOGC calcium supplmentation

1g recmmended 2g if low calcium

pelvic abscess

Pelvic abscesses typically are located in the anterior or posterior cul-de-sac or within the leaves of the broad ligament Suspect if no resolution of fever with Abx for suspected endometritis Get a CT or MRI

outcomes from laser fetoscopy (refine)

Residual AV connections risk of fetal death PTB PPROM neurologic injury small chance of TAPS

workup for polyhydramnios

detailed U/S for anomalies Lab testing - CBC, antibody screen - GDM - amnio for karyotype/microarray (more if severe) Patients found to have associated sonographic findings (e.g. hydrops, growth restriction, hepatosplenomegaly, cerebral ventriculomegaly, intracranial, and intraabdominal calcifications, echogenic fetal bowel, and/or ascites) should have the following evaluation considered also: o Fetal infection (rubella, toxoplasmosis, parvovirus, CMV, syphilis)

opioid stopping pregnancy

detoxification is not recommended, but if so, it is unlikely to cause harm in second/third trimesters. MMT (methadone maintenance treatment) is associated with longer adherence to treatment and lower risk of relapse. Thus, substitution is recommended over detox.

deliver twins

di-di : 37-38 weeks mono-di : 35-36 mono-mono: 32-35 Yet, these current data confirm that, if indicated, planned vaginal delivery for twins is safe at 32 weeks gestation or later when the first twin is presenting cephalic, regardless of the presentation of the second twin Consequently, for a second twin with a non-cephalic presentation and EFW >1500 g, vaginal delivery should be offered if the health care provider is skilled in IPV and breech delivery. In twins with growth discordance >25%, when the smaller twin is presenting, a cesarean delivery should be considered, given the high likelihood of breech delivery of the second twin. Epidural analgesia is recommended !

twins

di/di: arly division, within the first 3 days after fertilization (70% of monozygotic twins), usually results in dichorionic placentation. mono/di (3-9) Division in the blastocyst stage, after formation of the chorion but before formation of the amnion (3 to 9 days after fertilization; 25%) mono-mono (8-12) Late division (8 to 12 days after fertilization; 2%) whereas even later zygotic splitting (13 to 16 days after fertilization; 1 : 100,000) results in conjoined monoamniotic-monochorionic twinning.

umbilical vein varix

focal dilatation of the intra-abdominal portion of the umbilical vein May have an association with - chromosomal anomalies - congenital anomalies (cardiovascular) -

SOGC low risk folic acid dose

follow a diet containing folate-rich foods from 2 to 3 months prior to conception into the first trimester and to take a daily oral multivitamin supplement containing folic acid (0.4 mg), vitamin B12 (2.6 μg) as well as an iron supplement of 16-20 mg from 2 to 3 months prior to conception until 4-6 weeks postpartum, or as long as breastfeeding continues.

presentation of ICP

itching, occasioanlly dark urine, pale stools, fatigue, loss of appetite, and, rarely, jaundice ALT is better than AST Bili and others not that helpful

suppressive therapy

keflex

diabetes baseline workup (pregestational GDM)

kidney function, liver function ECG retinal exam- recommended before pregnancy AND in first trimester .... follow up depends on extent of disease

types of diabetes in pregnancy

T1DM T2DM GDM other causes (MODY, glucocorticoids) A1GDM refers to those whose are euglycemic with diet and lifestyle modifications alone A2GDM refers to those who require medication for blood glucose optimization. NOTE: ACOG no longer recommends A1/A2 GDM, it recommends 1. T1 DM- beta cell destruction a) without vascular compromise b) with vascular compromise (specify which) 2. T2DM a) without vascular compromise b) with vascular compromise (specify which)

HIV transmission untreated HIV

blood, semen, vaginal fluid, breast milk 20% vertical transmission before 36w 50% near delivery 30% intrapartun breast feeding risk can be 20% If treated for 6+ weeks, very low risk, < 1%

late life risks of preeclampsia

chronic HTN diabetes dyslipedemia coronary artery disease heart failure stroke peripheral arterial disease

cerclage suture material

Usually - monofilament (prolene) - multifilament (braided)... including uncoated polyester/mersilene

thyroid requirements for mom and fetus

maternal requirements increase ~50% fetus takes some of mom's iodine in first trimester, fetus depends entirely on maternal thyroid at 20 weeks, fetal HPA axis takes over.

Complications of chorio

maternal sepsis PPH Hysterctomy miscarriage Cerebral palsy neonatal sepsis

acog post partum visit weeks

maximum within 3 weeks comprehensive visit no later than 12 weeks

valproate NTD risks

neural tube oral clefts urogenital

smoking risks

nicotine is a vasoconstrictor, increases uterine resistance and decreases flow Risks: Miscarriage stillbirth FGR Previa Abruption PTB

do heparins cross the placenta?

no do not cause teratogenicity or bleeding

how frequent to measure cervical length

no closer than once a week. decreases max of 8mm a week. Stop surveillence around 28-32 weeks

Hep A exposure pregnancy, treatment

no risk to baby (doesn't transmit) receive hep A immunoglobulin

switch from IA to EFM

no tachysystole (CTX of max 5 over 10 mins) FHR is normal (110-160, no decels, accels not required) switch if tachysystole FHR out of range changing baseline decels Arrhythmia If normal for 20 mins, can switch back to IA (if no risks)

do COCP's cause yeast infections

no, not low dose

highest risk associated with blood clotting

non "O" blood group (A, B, AB) Has higher levels of von willebrand activity Also sickle cell - anticoagula

what else should be evaluated if there is a prolactin pituitary macroadenoma?

other pituitary adenomas - GH secreting (screen with IGF-1 as a surrogate marker) - TSH (rare) - ACTH (rare) - gonadotropin (FSH/ LH... these are rare)

fetal alcohol syndrome

physical and cognitive abnormalities in children caused by a pregnant woman's heavy drinking FAS (thin vermillion border (upper lip), smooth philrum, small/wide set eyes, upturned nose ..... look up ears) cardiac defects microcephaly short stature cognitive defects (devt delay, low iQ)

contraindications to internal monitoring

placenta previa face presentation Maternal infections (HIV, active herpes, maternal hep B/C)

ARDS (acute respiratory distress syndrome)

respiratory insufficiency marked by progressive hypoxia , CXR with bilateral pulmonary infiltrates. ARDS is a common complication of sepsis and is usually manifested by : - dyspnea - stridor - cough - tachypnea - bilateral rales - wheezing

menchanism of bleeding in previa

separation of placenta from the underlying lower uterine segment and tearing of myometrial vessels, resulting in maternal hemorrhage uterus unable to contract and compress

GBS complications

sepsis, pneumonia, or meningitis typically presenting within the first 12-48 hours after birth, and carrying a high risk of morbidity, mortality, and/or long‐term sequelae.

what maternal condition is pyelo associated with?

sepsis, septic shock AKI ARDS (CXR is important !!!) All septic patients should have a CXR.

rescue course of steroids

under 34 weeks, and more than 1-2 weeks out of previous steroid course

covid anticoagulation

unfractionated heparin prophylactic dose

questions for third trimester bleeding

when did it happen, how much, any clots, bright red vs dark, etc. pain ? contractions? trauma? intercourse? smoking/drugs ? ultrasounds ?

what patients are likely to suffer serious harm from sepsis?

≥1 chronic comorbid conditions, such as chronic renal disease, chronic liver disease, or congestive heart failure

contraindication to pregnancy SLE

●o Severe renal failure o Nephrotic syndrome o Severe HTN o Pulmonary HTN

leading known cause of preventable developmental disability in Canada

fetal alcohol spectrum disorder (FASD)

complications of ECV

fetal bradycardia rhesus sensitization abruption PPROM preterm labor AFE

# anemia in pregnancy value

< 11 g/dL (110) in first and third trimester < 10.5 in second trimester < 110 again in third Ferritin under 10-15 is iron deficiency anemia .... but some people consider it under 30... or even under 50.

Fetus papyraceus

fetal death that occurs after the fetus has reached a certain growth that is too large to resorb into the uterus

SOGC manage a pregnancy with preeclampsia

insufficient evidence for angiogenic Fetal scan at least q2 weeks (consider BPP weekly) twice weekly PIH labs Consider NST 2x weekly (not SOGC)

Nitabuch's layer

interface between placenta and endometrium, barrier to stop penetration of trophoblasts

peptic ulcer disease in pregnancy

Pregnancy improves symptoms, probably from -estrogen decreasing gastric acid - progesterone protecting GI mucosa

TTP pregnancy

Pregnancy is an important precipitant of acute TTP, accounting for approximately 5-10% of all cases of TTP inwomen pregnancy (increased vWF, estrogen) lowers ADAMTS13

treat CMV in pregnancy (fix)

SOGC : Uncertain evidence Valtrex may work at large dose (8g a day) (some studies show this) CMV -HIG is not recommended

test for PE in pregnancy (American Thoracic society)

SOGC advocates for VQ Normal CXR = VQ scan Abnormal CXR = CTA (gold standard) When the CTA is inconclusive or inadequate, serial whole leg ultrasound examination or repeat testing with a VQ scan is recommended

SOGC cerclage

SOGC recommends that cerclage be considered in women with singleton gestations with a history of spontaneous preterm birth or possible cervical insufficiency if the cervical length is <25 mm before 24 weeks gestation Consider if <10mm (ultrasound indicated)- also ACOG recommendation, even in singletons.

can you induce a breech ?

SOGC says Induction of labour has not been well studied; however, several case series suggest safety for the well-selected woman and breech fetus

physiology of cardiac ischemia

acute reduction in blood volume leads to -sympathetic compensation - peripheral vasoconstriction, tachycardia, and increased myocardial contractility, which in turn increases the myocardial demand for oxygen, to a level that cannot be maintained

what to consider if you find an accreta intra-op ?

intraoperative consultation including image transfer; so long as the uterus has not been incised the abdomen may be closed and the patient transferred to a designated regional centre

conception after bariatric surgery

wait 2 years less may be associated with SGA or NICU admission Baseline: CBC, CMP (liver function, kidney function, lytes/ext lytes) Vit D, B12, folate, ferritin May need to supplement with Ca and B12

indications for IUPC

maternal obesity labor dystocia oxytocin dose >30 mu/min TOLAC

what to assess in a PPROM patient

maternal vitals cardinal 4 Labs (? ) (? urine culture) Fetal assesment consider cervical length do GBS

relative contraindications to DCC

(in term infants) risk factors for significant hyperbilirubinemia (e.g., polycythemia, severe IUGR, pre-gestational diabetes), cases where maternal antibody titres are high when the first infant in a pair of monochorionic twins is delivered.

# normal hemoglobin

"Fetal- (alpha 2, gamma 2) Hemoglobin A- (alpha 2, beta 2) Hemoglobin A2 (alpha 2, delta 2).... So, think that alpha is most important chain."

Thrombocytopenia by trimester

"Other" indicates miscellaneous disorders, including infection, DIC type IIB von Willebrand disease immune and nonimmune drug-induced thrombocytopenia paroxysmal nocturnal hemoglobinuria bone marrow failure syndromes (aplastic anemia, myelodysplasia, myeloproliferative disorders, leukemia/lymphoma, and marrow infiltrative disorders), among others. HUS, hemolytic uremic syndrome PEC, preeclampsia/HELLP; TTP, thrombotic thrombocytopenic purpura.

SOGC ovarian vein thrombosis

"Septic pelvic thrombophlebitis (SPT) is a well-recognized but rare puerperal complication that has two types: 1) ovarian vein thrombophlebitis (OVT) 2) deep septic pelvic thrombophlebitis (DSPT). " treat via broad spectrum antibiotics for at leadst 48 hours after fever. Longer if septic. Therapeutic anticoagulation for 1-3 months

prophylactic lmwh doses RCOG by weight

"We tend to favor enoxaparin 1 mg/kg once-daily,"

trisomy 13 findings

# trisomy 13 findingsadd later

indications for 4mg folate

- prior NTD - multiple gestation - anti epileptics

diagnose BV

Amsel criteria or nugent score

risks of PPROM before viability

Chorio endometritis abrupiton RPOC

4th stage

Immediately after delivery of the placenta to 1 hour postpartum.

impacted fetal head risks

Macrosomia / CPD Prolonged Second Stage Fetal Malposition Failed Assisted Vaginal Birth

best pessary in pregnancy

Ring

consequences of monochorionic twins

TTTS TAPS Selective fetal growth restriction TRAP

treat cholecystitis

Treat via 24 hours ABX (piptazo 3.375g IV q6h) ...... and then laparoscopic cholecystectomy

what measure of biometry has the most variation?

abdo circumfernce

renal disease in pregnancy creatinine

mild ( (Cr) 0.9 -1.3 mg/dL) moderate (Cr 1.4 -2.5) severe (Cr >2.5) In the setting of preterm labor, indomethacin should not be used, since it is renally excreted.

breastfeeding benefits How long to breastfeed?

recommend for 6 months exclusively (ideally) Then introduce some formula, but recommend to continue to breast feed until a year. (maybe longer, if mom wants)

risk of birth defects and teratogens

risk is about 2-4% baseline.... teratogen must increase this

chignon

temporary swelling

Risks of opioids to mom-

tolerance (need to increase doses), dependence (withdrawl if stopped)- OD

Terburaline

B2 agonist Used for tocolysis and asthma Adult — tachycardia, anxiety, nervousness, tremors, headache, hyperglycemia, hypokalemia, hypertension and, rarely, pulmonary edema. Fetal — tachycardia and hypoglycemia.

pharmacology for fat loss

BMI > 30 or BMI > 27 with comorbisity Canada, there are 2 main drug therapies: orlistat (lipase inhibitor) - 30% of fat not abdorbed liraglutide 3.0 mg. (GLP-1) - reduced hunger, slows gastric emptying

SOGC BPD vs HC

BPD is less reliable in determining gestational age when there are variations in skull shape, such as dolichocephaly or brachycephaly; hence some authors feel that BPD is less reliable than head circumference. BPD is NOT reliable on Hadlock. As a single parameter, head circumference correlates better to gestational age than the other 3 standard parameters in the second trimester, and as with all others, it becomes less accurate with increasing gestational age

BV pregnancy overvie

Bacterial vaginosis shift from lacrobacilli to anaerobes G. vaginalis is present in 95% of cases but also is present in 30% of baseline a decreased concentration of lactobacilli and an increase in pathogenic bacteria. There is no single organism whose presence confirms the diagnosis of bacterial vaginosis, but rather many different bacteria may be present, including Gardnerella vaginalis, Mobiluncus species, Bacteroides and Prevotella species, and Mycoplasma species Clinically, the principal manifestation of BV is a malodorous, thin, gray discharge

remove cerclage with pprom

Based on the available limited data and our own clinical experience, we remove the cerclage in women with PPROM if (1) there is any evidence of chorioamnionitis or (2) the pregnancy is at least 32 weeks of gestation. Before 32 weeks, in the absence of clinically apparent infection, we leave the cerclage in place as we are more concerned about the possible increased risk of preterm delivery with cerclage removal than the possible increased risk of ascending infection with the cerclage left in place.

treat DKA in pregnancy

Baseline ABG Serum glucose, creatinine, ketones, electrolytes Keep checking q 1-2 hourly 1) 1L of NS in first hour 500ml NS for hour 2, 3, 4 250 ml NS for hour 4-16 125 ml NS for hour 16-24 2) Insulin- mix 50u normal insulin in 500ml NS - infusion should be started at a fixed rate of 0.1 unit/kg/h.... if do not reach enough, increase by 1u per hour 3) critical to maintain potassium at 4-5 - hold briefly if > 5.5 - if level is normal, give infusion of 40 meq per hour If potassium is low, replace this before insulin. 4) Once glucose is less than 250 (14), add 10% dextrose to the existing saline at 125 ml/hr... until DKA is resolved 5) Consider 1 amp of bicarb if pH < 7.1 Check for causes, treat it. Metabolic targets (per hour): -reduce ketones by ~0.5 mmol/L - decrease capillary glucose by 3 mmol/L (54 mg/dL) - increase HCO3- by 3 mmol/L (3 mEq/L) Resolution pH > 7.3 anion gap < 12 bicarb > 15 blood ketones < 0.6 mmol/L

what can IA assess? What can IA not assess?

Baseline FHR including determination of MHR -Rhythm (regular or irregular, NOT associated with Uterine Activity) -Accels -Decels It cannot assess - variability - type of decel

what pregnancy condition is associated with hep C

cholestasis (20x risk)

Fetal Thrombotic Vasculopathy

vascular thrombotic condition causing obstruction of arteries and veins in the fetal circulation of the placenta, resulting in ischemic changes in the villi peripheral to the obstruction. When sufficiently extensive, FTV may cause 1) reduction in functional placental reserve - which leads to FGR/stillbirth 2) may be associated with additional thrombotic or thromboembolic events in the somatic vessels of the fetus itself. ....this may result in infarcts of various fetal structures, such as the brain, kidney, or, rarely, an extremity, such as an arm or leg The most significant predisposing abnormalities are problems resulting in vascular stasis. These include: - cord prolapse - hypercoiling - velamentous insertion Low risk of recurrence

neonatal gonorrhea

vertical transmission to the infant occurs in ~40% cases if cervical infection is present at the time of delivery Bacterial infection of the eye that may cause blindness in newborn if the mother has Gonorrhea (STI). Treat via silver nitrate (erythro for chlamydia)

HPV pregnancy considerations

very rate (~1/1000) Respiratory papillomatosis (laryngeal papilloma) is a rare disease in the neonate that is caused by HPV-6 and HPV-11. Laryngeal papillomas can be particularly troublesome because they may produce respiratory distress secondary to obstruction and because recurrence after treatment is common. Transplacental and intrapartum transmission of HPV can occur, as well as infection via contact during the neonatal period.

Shingles

viral disease that affects the peripheral nerves and causes blisters on the skin that follow the course of the affected nerves PAINFUL.

weak D

weak form of the D antigen that requires the indirect antiglobulin test for its detection In women who initially test as Rhesus neg, they are probably rhesus positive and very low risk of producing anti-D antibodies

Weak D

weak form of the D antigen that requires the indirect antiglobulin test for its detection . At BIDMC, we perform RHD genotyping on women of childbearing age with D typing discrepancies or a history of a serologic weak D phenotype. Types 1-3 can be managed like they are RH+ (they will not form antibodies), and can receive Rh positive blood. There is a discrepancy between molecular weak D or partial D allele .... this can be determined by RHD genotyping. If testingconfirms a weak D genotype that is not associated withanti-D formation (1, 2, 3) , the patient will receive D+ RBCs units and is not considered a candidate for RhIG. If testing indicates a partial D genotype, the patient is treated as D- and receives D- RBCs and is considered a candidate for RhIG

what options to give if corpus luteal removal?

weekly 17 hydroxy progesteronr Oral micronized progesterone 200-300 mg 8% vaginal progeserone gel PLUS 100-200 oral progesterone Do this until 10 weeks

reassuring factors for SLE

well controlled disease no anti-phospholipid antibodies no renal disase, or other organ sequalae well controlled BP Disease controlled on meds that are not teratogenic (hydroxychloroquine, tacrolimis...

risks for having twins

fertility treatments (IVF, ovulation induction) family hx Increasing age

pregnancy modivations for epilepsy

fetal echo 4mg folic pre-conceptual monitor AED levels

evaluate Non-immune hydrops

fetal ultrasound for anomalies, other causes (twins, hydrothorax, arrhythmia) MCA doppler (for anemia) fetal echo blood type and antibody screen (indirect coombs) CBC, MCV - iron studies (serum iron, transferrin saturation, TIBC) - hemoglobinopathy screening - Kleihauer - ToRCH/B19/syphilis serology Amnio -karyotype - microarray - exon sequencing - amniotic fluid PCR for Toxo, CMV, Parvo, Diagnostic Approach to the Fetus With Hydrops The workup of a patient with a diagnosis of fetal hydrops should be directed at possible causes. Because the diagnosis is confirmed with ultrasonography, this is frequently the first test performed. During a careful ultrasound examination, the known causes of NIH should be kept in mind. Many of the fetal conditions, congenital anomalies, and malformation sequences that are known causes of hydrops are found or eliminated on the initial ultrasound examination. Twins, cardiac arrhythmias, and hydrothorax are all examples of ultrasonography-derived diagnoses. The Doppler study of the blood flow velocity of the middle cerebral artery should be assessed to screen for fetal anemia, as should other Doppler studies, including flow in the ductus venosus. A fetal echocardiogram should be performed. If the examination is unsatisfactory, it should be repeated later to delineate fetal anatomy as well as possible. Although the underlying diagnosis is far more predictive of outcome than are any specific ultrasonographic features, the initial examination can be used to assess the severity of the hydrops and to initiate antenatal testing, if appropriate, depending on gestational age.Assessing the severity of the hydrops is particularly important if the fetus is observed for some length of time or if fetal therapy is attempted. Ultrasound features can be followed longitudinally to attempt to predict further fetal decompensation or fetal response to in utero therapy. A history should be taken, with particular attention to ethnic background and any family history of genetic diseases or congenital anomaly, consanguinity, recent maternal infections or exposures, and maternal medications. Once again, careful scrutiny of the listed causes of hydrops gives direction to the types of questions that

diabetes in late pregnancy risks

fetal: -LGA- - shoulder dystocia, injury (brachial plexus) - increased operative delvery operative delivery - polyhydramnios - PTB - Inpaired pulmonary maturity, RDS - polycythemia... causing hyperbil and jaundice - hypoglycemia - hypocalcemia (due to hypomagnesemia in the mother and the infant due to increased maternal urinary excretion of magnesium during pregnancy. Hypomagnesemia causes functional hypoparathyroidism in the infant) - fetal cardiomyopathy (usually resolves) - death - increases the risk of c/s - preeclampsia

absolute contraindications to DCC

few but have included the following: - fetal hydrops, _ certain fetal anomalies (e.g., diaphragmatic hernia at term), - need for immediate resuscitation of mother or infant (except in centres with appropriate experience and equipment to perform resuscitation with an intact cord), - disruption of the placental circulation (e.g., bleeding vasa previa or placenta previa, placental transection or abruption) - known TTTS or TAPS

repair a perineal laceration dehiscence

first or second, maybe expectant management 3rd or 4th, antibiotics (if infected) and immediate repair

TB testing

first step is Mantoux skin test (can still do in people with bCG, just gives false positives). If this is positive, do a CXR for active disease.... or even better, sputum if possible. Intereron Gamma is not affected by bCG vaccine.

risk of hep B vertical transmission

first trimester 10%, third trimester 80% to 90%, ..... of which 90% occurs because of intra-partum exposure to blood and secretions. the risk of transmission from mother to child without prophylaxis is as high as 90% in mothers with HBeAg positivity even in HBeAg‐negative/anti‐HBe‐positive mothers without prophylaxis the rate of antenatal infection of the newborn is 12% within 12 hours of birth, Infants born of HBsAg‐positive mothers should receive both : - passive (hepatitis B immune globulin (HBIG) - and active immunoprophylaxis (HBV vaccine) Unfortunately, 10-20% still get itif the e-antigen is present

Testing for GDM What

high risk women should be screened early, once pregnancy confirmed. then 24-28 weeks

BMI and trisomy 21

higher risk due to lower prenatal DX NIPT is messed up with age

ITP pregnancy

highly suspect platelets under 50

mastitis

inflammation of the breast; most commonly occurs in women _who are breastfeeding Usually staph aures (most common) or strep affected women initially experience malaise, followed by a relatively high fever (≥39°C) and chills. Thereafter an erythematous, tender area appears in the affected breast. In addition, patients also may experience pain and tenderness in the ipsilateral axilla, and the milk from the infected breast may be discolored. Treat with - Dicloxacillin is first line - Clindamycin or erythromycin could be second - use Septra if MRSA

EFM and foley time

30 mins before 30 mins after

EFM and misoprostol time

30 mins before 60 mins after

in what 2 conditions may FMH be falsely positive? false positive kleihauer

"The most commonly used quantitative test for fetal red cells in the maternal circulation is the acid elution or Kleihauer-Betke (KB) test (Kleihauer, 1 957) . Fetal erythrocytes contain hemoglobin F, which is more resistant to acid elution than hemoglobin A. After exposure to acid, only fetal hemoglobin remains, such that after staining, the fetal erythrocytes appear red and adult erythrocytes appear as "ghosts" (Fig. 1 5-3) . The fetal cells are then counted and expressed as a percentage of adult cells. The KB test is labor intensive. Importantly, there are two scenarios in which it may not be accurate: ( 1 ) maternal hemoglobinopathies such as beta-thalassemia in which the fetal hemoglobin (HbF) level is elevated and (2) pregnancies at or near term, when the fetus has already started to produce hemoglobin A." Of note, you can more accurately quantify fetal-maternal hemorrhage using flow cytometry but this is practically only performed for research purposes

early decels

"fetal head compression"... causes vagal response Often with moderate variability Gradual drop and return to baseline

eclampsia neuro imagine ( ie, pres)

(#1) PRES (posterior reversible encephalopathy syndrome) is the most common finding. Bilateral edema that is most often located in the parito-occipital regions. Edema may be seen as: - hypodense on CT scanning - MRI reveals vasogenic edema as bright on T2/FLARE sequences. (#2) More severe cases may reveal diffusion restriction, which implies the presence of cytotoxic edema that may be irreversible. This may reflect the presence of superimposed vasospasm (e.g., overlap between Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome ) (#3) In very severe cases, there may be subarachnoid hemorrhage and small cortical hemorrhages (especially in the parietooccipital and occipital regions)

Placental investigations stillbirth

(1) cord: thrombosis and true knot; (2) placenta: infarcts, calcifications, thrombosis, hematoma, abruption (clot), and vascular malformation; and (3) signs of subclinical infection: funisitis, amnionitis. Histology of the placenta is warranted A bacterial culture of the chorion is recommended. Bacterial cultures of the fetal surface of the placenta, including group B Streptococcus, Listeria, and Escherichia coli, must be performed. Other cultures may be considered if clinically indicated. Even where gross clinical findings are not evident, histologic lesions such as - fetal and/or maternal vascular malperfusion - chronic histiocytic intervillositi - perivillous fibrin deposition may suggest a placental cause and will therefore affect the risk of recurrence.

what tissues for karyotype?

(1) skin or fetal cartilage (from the patella or costochondral junction), if consent for autopsy is granted; (2) Achilles tendon and/or intracardiac fetal blood (when available) if the baby is macerated; (3) a piece of umbilical cord; and (4) fetal body fluid: ascites, hygroma, and pleural effusion.

Autonomic Dysreflexia

(potentially life threatening emergency!) riggered by labour, delivery, bladder distension, blocked catheters, catheterization, urinary tract infection, constipation, vaginal examinations, contact with hard or sharp objects, deep vein thrombosis, or surgery. Happens in people with spinal damage T6 or above. a potentially life-threatening condition that presents with critically elevated blood pressure caused by an unopposed sympathetic response that triggers the release of norepinephrine, dopamine-beta-hydroxylase, and dopamine However, autonomic dysreflexia tends to have an acute onset, whereas preeclampsia can have a variable onset. Preeclampsia can also be associated with abnormal liver enzymes, low platelets, and elevated uric acid and lactate dehydrogenase, whereas autonomic dysreflexia is not. They would have: Hypertension pounding heacache blurred vision Skin flushing profuse sweating Piloerection ABOVE the level of the lesion (cold and pale BELOW)

gonorrhea discharge

*Purulent when present, but many women produce no symptoms* coinfection with bacterial vaginosis, trichomonas, or C. trachomatis is common and often causes abnormal vaginal discharge.

Target glucose levels in pregnancy

*if these are present after diet and exercise modifications for 1-2 weeks, start insulin*

treat pyelo in pregnancy

, pregnant patients with acute uncomplicated pyelonephritis may be stratified into two groups: 1) those with severe disease, who require hospitalization and parenteral antibiotics According to Infectious Diseases Society of America guidelines - mild disease is characterized by low-grade fever, normal or slightly elevated white blood cell count, and absence of nausea and vomiting. 2) those with mild to moderate disease, who can be treated on an outpatient basis with oral agents. Patients requiring hospitalization are those with high fever, high white blood cell count, vomiting, dehydration, evidence of sepsis, or no response during an initial period of observation. the duration of therapy has been reduced from 6 to 2 weeks Vital signs, including respiratory rate, and urine output should be closely monitored. Tachypnea, hypotension, and oliguria are signs of impending sepsis or septic shock. At and beyond 24 weeks' gestation, uterine activity and fetal heart rate should be monitored closely.

HSV testing (if partner has it)

- A pregnant woman without a clinical history of HSV (but who has had a partner with genital HSV) should have type-specific serology testing to determine risk of acquiring genital HSV in pregnancy before pregnancy or as early in pregnancy as possible. Testing should be repeated at 32 to 34 weeks' gestation. By extrapolating the data, antiviral suppression could be offered to the partner with genital HSV (in conjunction with condom use) in order to decrease the risk of transmission to the pregnant partner

RCSE jaundice in pregnancy

- Characterized by pruritis, icterus or both - Usually develops late in pregnancy - RF - Multifetal pregnancies - Genetics - Pathogenesis: bile acids cleared incompletely and accumulate in plasma due to changes in sex steroid levels and gene mutations - Biochemical: - Hyperbilirubinemia - Elevated ALP (more than normal in pregnancy) - LFTs (normal to moderately elevated, seldom >250) - Management = antihistamines, topical emollients, cholestyramine (but Vit K dec'y → fetal coagulopathy), ursodeoxycholic acid, early IOL to decrease stillbirth Acute fatty liver of pregnancy (AFLP) - Most common cause of acute liver failure in pregnancy - Almost always manifests late in pregnancy - Characterized by accumulation of microvesicular fat that 'crowds out' normal hepatocytic function - RF - Nulliparous - Male fetus - Multifetal gestation - Symptoms = N/V, malaise, anorexia, epigastric pain, progressive jaundice - 50% have signs of pre-eclampsia syndrome (HTN, proteinuria) - Characteristic = hypoglycemia common, profound hypofibrinogenemia - Management = supportive measures, delivery is cure Acute viral hepatitis - Most asymptomatic - Symptoms = N/V, HA, malaise, jaundice, low grade fever (if Hep A) - LFTs range 400-4000, elevated bilirubin Cholelithiasis/Cholecystitis - Occurs when cystic duct is obstructed - Bacterial infection in 50-85% of cases - Symptoms = N/V, RUQ pain, low-grade fever, mild leukocytosis - 30% of pregnant women have biliary sludge; regreses post-partum - Management = laparoscopic cholecystectomy HELLP/Pre-eclampsia - See chart below - Jaundice uncommon

Chronic Histiocytic Intervillositis

- Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. Normal uterine artery doppler - It can also lead to intrauterine growth restriction (IUGR) and intrauterine death. - The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes. - It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.

nuchal translucency

- Gestation 11-13 weeks (ACOG, 10-14 weeks)... and crown-rump length 45-84 mm - fetal head, neck, thorax should occupy >50% of screen - fetus in midsagittal plane - fetal neck in neutral position (not flexed/extended) - fetus should be away from the amnion - calipers should be on the inner border - measurement perpendicular long access take 3 measurements, use the maximum acceptable one. It can identify chromosomal and genetic disorders, including: - trisomy 21 - Noonan syndrome - congenital anomalies (including cardiac malformations) - risk of spontaneous abortion. Fetal NT measurement alone can identify more than 75% of fetuses with trisomy 21 and other major chromosomal defects, with a false-positive rate of 5% .... NT measurement in the 95th centile is equivalent to 3 mm and does not change on the basis of CRL.

types of sickle cell disease

- Hemoglobin SS ( HbSS aka sickle cell disease) : most severe. Homozygous for hemoglobin S - Hemoglobin SC disease (HbSC - one copy of S and one copy of hemoglobin C - not quite as severe as SS - Hemoglobin SB+ (beta) thalassemia minor - one copy of S, and one copy of B+ thalassemia (produces LESS beta) Hemoglobin SB- (beta thalassemia major) - one copy of S, and one copy of B- (produces no beta chain) - Sickle cell trait (HbAS)

HSV treatment if PPROM or TPTL

- If TPTL: If preterm delivery is predicted in a woman with recurrent genital herpes, then use of suppressive antivirals may be considered at an earlier gestational age than 36w - If PPROM: where prolongation of pregnancy is preferable, then use of suppressive antiviral is recommended until delivery. If PRIMARY HSV... then the risks are very high. Probably best to do a cesarean immediately. The literature suggests that if antiviral therapy has started within 6 days of lesion onset, then shedding duration is reduced from 9 days to 2 days.

risks for uterine inverstion

-fundal placenta - uterine atony -excessive traction on the umbilical cord before placental separation -abnormally adherent placenta.

bishop score

-greater than 8 (9+) = favorable for spontaneous and induced labor -cervical dilation -cervical effacement -station -cervical consistency -cervical position

Breastfeeding contraindications

- Infant is diagnosed with classic galactosemia - a rare genetic metabolic disorder1 - Mother is diagnosed with the human immunodeficiency virus (HIV)1 (Note: recommendations about breastfeeding and HIV may be different in other countries) - Mother is infected with human T-cell lymphotropic virus type I or type II - Mother is using an illicit street drug, such as PCP (phencyclidine) or cocaine1 (Exception: Narcotic-dependent mothers who are enrolled in a supervised methadone program and have a negative screening for HIV infection and other illicit drugs can breastfeed) -Mother has suspected or confirmed Ebola virus disease Should temporarily NOT breastfeed/feed infants expressed breastmilk: ​​Mother is infected with untreated brucellosis1 Mother is taking certain medications The mother is undergoing diagnostic imaging with radiopharmaceuticals (**Though the ACR Manual on Contrast Media 2022 disputes this) Mother has an active herpes simplex virus (HSV) infection with lesions present on the breast (Note: Mothers can breastfeed directly from the unaffected breast if lesions on the affected breast are covered completely to avoid transmission) Mothers should NOT breastfeed but CAN feed expressed breastmilk: Active Varicella infection that developed within the 5 days prior to delivery to the 2 days following delivery Mother has untreated, active tuberculosis1(Note: The mother may resume breastfeeding once she has been treated appropriately for 2 weeks and is documented to be no longer contagious)

sickle cell pain crisis

- Maternal vital signs. • Supplemental oxygen to maintain saturations >95%. • Aggressive fluid resuscitation. • Initial laboratory testing: type and screen, CBC, reticulocyte count, LDH, haptoglobin, urinalysis, urine culture. • Investigation of precipitating cause (infection, dehydration, severe anemia, etc.). • If oxygen desaturations or chest pain are present, then obtain chest x‐ray to evaluate for acute chest syndrome. Provide adequate analgesia; opiates are often mainstay of therapy and continuous infusion/patient‐controlled anesthesia may be necessary. • VTE prophylaxis while in crisis. • Fetal assessment with fetal heart tones if previable or nonstress test if viable. • Antenatal steroids for evidence in the setting of nonreassuring fetal testing. • Empiric antibiotics if infection or acute chest syndrome is suspected. • Multidisciplinary care approach with hematology consultation. Consider exchange transfusion

most common malignant ovarian mass in pregnancy

- Most common ovarian MALIGNANCY in pregnancy = dysgerminoma - Malignancy in pregnancy: germ cell and sex cord-stromal tumors > low-malignant-potential tumors > epithelial tumors

admit pregnant covid patients

- O2 less than 94 - comorbidities (uncontrolled diabetes, HTN) - fever > 39 - RR > 30 - lung infiltrates >50%

HSV delivery

- Primary infection in T3 = CS - Ask if experiencing prodromal symptoms (vulvar burning, itching) - Carefully examine the vulva, vagina and cervix SOGC 208: Caesarean section is recommended if an HSV lesion or prodrome is present at the time of delivery. This is the case even if the lesions are remote from the vulvar area, such as on the buttocks or thighs, as there is still a risk for concurrent cervical or vaginal shedding of virus.

# fetal tacycardia

- Re-entrant atrial tachycardia - Atrial fultter - Ventricular tachycardia

# fetal bradycardia evaluation (<10)

- Regular or irregular? - blopcked atrial bigeminy-

high risk for HIV

- Sharing needles or any other components during intravenous drug use •Unprotected sex with multiple partners •Unprotected sex with a known HIV-positive individual •Unprotected sex with a partner who is from an HIV-endemic area •Unprotected sex with a partner participating in known high-risk behaviour test these women every trimester Rapid testing in labor (with treatment in labor and after birth) drops risk from like 50% to 15%) If they stroll up in labor, and have high risks, offer: - empiric treatment in labor - empiric neonatal prophylaxis

# mood stabilizer teratogens

- Valproate - carbemazapine - Lithium

# causes of fetal anemia (overview)

- allo-immunizatrion - rhesus disease- - parvovirus

# trisomy 18 ultrasound findings

- cystic hygroma (rare ) - cardiac defects (double outlet RV, ASD, VSD) agenesis of corpus callosium - meningomyocele - ompalocele - esopageal atresia (not duodenal) Overlapping fingers short long bones echogenic bowel Choroid plexus cysts growth restriction

goal of fetal monitoring

- detect potential fetal decomposation - allow timely intervention to prevent perinatal/neonatal morbidity/mortality

monochorionic complications

- higher perinatal mortality - higher incidence of preterm birth - low birth weight - NICU - structural malformations - chromosomal anomalies The overall perinatal mortality is approximately 12% in monochorionic twins compared with 2% to 5% in dichorionic twins, and mortality is even higher in monoamniotic twins. monochorionic twin pregnancies are susceptible to a specific set of complications including.... TTTS, TAPS, TRAP sequence, discordant growth restriction, and malformations.

MSS second trimester

- human chorionic gonadotropin (hCG) - a hormone made by the placenta during pregnancy -alpha-fetoprotein (AFP) - a protein produced by the baby's liver - inhibin-A - a protein produced by the baby and the placenta - unconjugated estriol (uE3) - a form of estrogen that increases during pregnancy

#treat opioid addictions, what meds?

- methodone (full agonist) - Buprenorphine (partial agonist) - naltrexone (angtagonist) Methodone (full opioid agonist) is from a provider (can cause OD)- - requires a treatment center, usually Buprenorpine (partial agonist) , so it can cause withdrawal..... though less withdrawal in newborns. - doesn't need a dispensary SOGC: Offer symptomatic therapy including dimenhydrinate (Gravol) for nausea and vomiting, acetaminophen/non-steroidal anti-inflammatory for myalgias •Consider methadone or buprenorphine initiation •Can use morphine 5-10 mg po q4-6 h prn if methadone or buprenorphine is not available

admit to ICU covid

-inability to keep O2 >94 with supplemental oxygen - hypotension (MAP <65) - altered mental status, renal/liber issues if cannot maintain O2 > 94, then intubate

contraindications to ecv

-major Uterine anomalies -3rd trimester bleeding -Multiple gestation -oligohydramnios - ruptured membranes -Evidence of uteroplacental insufficiency -Nuchal cord -Previous c-section

Mom risks with SLE

- often correlate with disease activity, especially at baseline - 1/3 worsen, 1/3 improve, 1/3 are stable Most flares during pregnancy are mild, typically consisting of arthritis and cutaneous manifestations, and easily treatable. Fifteen percent to 30% of flares are severe, and some can be life-threatening. Flares may occur during any trimester and in the postpartum period. Risk factors for a flare occurring during pregnancy include: - active disease within the 6 months before pregnancy -severe underlying disease -active nephritis - discontinuation of hydroxychloroquine Risk of flares (risk of VTE (especially with anti phospholipid antibodies) thrombocytopenia - can have bleeding worsening kidney function HTN preeclampsia (with it's risks, liver function, kidney function, stroke) Severe risks ● Lupus nephritis (DPGN - diffuse prolierative glomerularnephritis) ● Lupus cerebritis (10-35%) ● Pericarditis ● Pulmonary HTN ● Severe HTN ● Stroke ● Thrombocytopenia ● Death

wound infection

- take culture - ABX If frank pus or significant serosanguineous effusion is present in the incision, the wound must be opened and drained completely. Once the wound has been opened, it should be irrigated and repacked with moistened gauze two to three times daily. A clean dressing should be applied, and the wound should initially be allowed to heal by secondary intention. In morbidly obese patients, application of a suction device to the wound may enhance healing. After all signs of infection have resolved and healthy granulation tissue is apparent, a secondary closure may be considered. Antibiotics should be continued until the base of the wound is clean and all signs of cellulitis have resolved. Patients usually can be treated on an outpatient basis once the acute signs of infection have subsided.

# carrier screening

- testing of individuals to test if they carry one allele for a condition where they do not have the phenotype

pregnant heart failure workuo

-12 lead ECG - exercise testing - TTE TTE determines type and severity of valvular lesions, concomitant ventricular dysfunction, and the presence of pulmonary hypertension or other associated cardiac defects Should see: Cardiology MFM anesthesia NICU

what are indications for classic CS

-Placenta accreta spectrum - especially if previa with anterior attachment -Prior radical trachalectomy for cervical cancer - Active cervical cancer -Poorly developed lower segment (eg generally under 28w GA or with SGA fetus in breech presentation) - Lower segment unsafe to access - eg. dense bladder adhesions, lower segment fibroid, extreme maternal obesity Fetal: Transverse lie of a large fetus Back down transverse lie Small and breech Multiple fetuses

Types of Cerebral Palsy

-Spastic (80%....., increased tone) -Dyskinetic (dystonia, choreoathethoid movements) -Ataxic (balance issues) -Mixed (usually spastic/diskinetic) can be further classified by number of limbs: quadriplegia diplegia (often lower limbs only) hemiplegia (one side) monoplegia (one limb). ONLY types associated with birth injury are spastic quadriplegia dyskinetic

Types of Conjoined Twins?

-Thoracopagus - chest, common sternum, diaphragm, upper abdominal wall, liver, pericardium, and gastrointestinal tract.... common hearts -Craniopagus - Head -Pyopagus - the twins share a common sacrum and face away from each other. -Omphalopagus - Abdomen -Ischiopagus - Ischium bone

Eisenmenger syndrome

-Uncorrected left-to-right shunt (VSD, ASD, PDA) causes remodeling of vasculature pulmonary arterial hypertension. RVH occurs to compensate shunt becomes right to left. -Causes late cyanosis, clubbing, and polycythemia. -Age of onset varies pregnant women with Eisenmenger syndrome tolerate hypotension poorly, and death usually is caused by right ventricular failure with cardiogenic shock. In a review of 73 pregnancies, Weiss and associates (1998) cited a 36-percent maternal death rate. Given such poor outcomes for both mother and fetus, Eisenmenger syndrome is considered to be an absolute contraindication to pregnancy

11 to 14 week scan benefits

-confirm viability - establish gestational age - determine the number of fetuses - assess the adnexa/ovaries, - in multiple pregnancy, assess chorionicity and amnionicity. - detect fetal abnormalities (~50% of them) - NT thickness for anomaly scan - preeclampsia prediction

# what conditions can be offered screening for in general (ACOG)

-cystic fibrosis - spinal muscular atrophy - hemoglobinopathies (divided into sickle cell disorders or thalassemias)

Manage turners

. Renal anomalies, when present, rarely cause significant health problems; if congenital heart disease is part of the phenotype, surgery is usually effective. The congenital lymphedema usually disappears during infancy. If webbing of the neck poses a cosmetic problem, it can be corrected by plastic surgery. Short stature, however, is a persistent problem. If a diagnosis is made early, height increase and external sexual development may be managed with the collaboration of a knowledgeable endocrinologist. In particular, growth hormone therapy is standard and results in a significant increase in adult height. Affected patients are almost always sterile. The emotional adjustment to this issue should be part of any medical management of gonadal dysgenesis Hypothyroidism ▫ 10% of patients with Turner's Syndrome ▫ Recommend yearly screening of T4/TSH and antibodies

How much should cals change in pregnancy

0-100 kcal in first half of pregnancy 300 beyond 20 weeks 450 in third trimester . For mos twomen with obesity, a baseline caloric intake of 2100 kcalis sufficient in thefirst half of pregnancy, increasing to2400 kcal daily after 20 weeks. 40-50% carbs 25-30% fat 20-25% protein (minimum 60g)

SOGC delay GDM screening after steroids

1 week

YEARS criteria

1) Are there clinical signs of DVT? 2) Does the patient have hemoptysis? 3) is PE the most likely diagnosis. If the answer to all 3 questions is no, the D-dimer threshold is set at 1000 if the answer is "yes" to any of the 3 questions, the D-dimer threshold is set at 500 ng/mL

Approach one a maternal antibody screen is positive

1) Determine paternal erythrocyte antigen status, provided that paternity is certain: - if the father is negative for the red cell antigen to which the mother is sensitized, the pregnancy is not at risk. - If the father is a homozygote for the antigen, then the baby is definitely at risk - If the father is heterozygous—or if paternity is not known—, the baby MIGHT be at risk.... so the woman should be offered assessment of fetal genotype - The one exception to this is the RhD antigen where the lack of a "d" antigen is secondary to the nonexpression of the RHD gene. In this situation, testing for paternal zygosity should be undertaken through DNA methods at a reference laboratory. 2) Fetal genotype testing A) - Amniocentesis and PCR testing of uncultured amniocytes is almost 100% accurate Fetal testing for other antigens—such as E/e, C/c, Duy, Kell, Kidd, also available with this method. CVS not recommended due to risk of fetal maternal hemorrhage. b) NIPT for fetal D genotyping has been performed using cell-free DNA (cDNA) from maternal plasma (not available for other antigens) 3) If determined the baby is at risk, follow maternal tiers, until reach the critical titer (usually considered 1:16 or 1:32) Titers are tested: - monthly until 24 weeks - q2 weeks after Note: If the titer undergoes a 4 fold increase, it should be considered significant regardless of if the critical value has been reached. Also note: Critical tiers do not apply for Kell....once identified baby is at risk, go right to MCA to monitor for anemia. 4) Once critical titer is reached, perform MCA PSV for severe anemia (if above 20 weeks, since it is so difficult to transfuse <20 weeks) - Scan weekly if MCA PSV < 1.5 MoM... as long as it stays normal, deliver at 37 weeks - Once > 1.5 MoM, then perform cordocentesis to determine hematocrit. ....HCT < 30% requires intrauterine transfusion (note, this is different than B19 where you increase scanning to q 2-3x weekly until hydrops) If MCA > 1.5 MoM but HCT is >30%, then keep checking HCT again in 1 week. If MCA > 1.5, or baby received transfusion, deliver at 34 weeks. Remember, if the mom has a previous pregnancy affected by alloimmunization, then just go ri

pharmacologic treatment of nausea and vomiting

1) Diclectin 2tabs QHS.... up to 2 tabs BID 2) Gravol (anti histamine) 3) Then dopamine antagonist Prochloperazine (aka compozine/stemetil)..... 3) then Maxeran or Zofran 4) consider methylprednisone

reasons for primary cesarean

1) Failure to progress 2) Nonreassuring FHR 3) malpresentation

GT vs ITP (6 things)

1) GT does not respond to IV immune globulin (IVIG) or corticosteroids, which has been tried when thrombocytopenia is so severe as to compromise epidural anesthesia or delivery 2) thrombocytopenia does not resolve within 1 to 2 months of delivery, the diagnosis of ITP or HT may become evident only in hindsight. 3) Level - GT is rarely below 100, almost never below 70 4) Timing- GT happens later in pregnancy (mid second trimester or later) 5) Baby may have ITP 6) ITP- may have hx of bleeding

diagnose cervical insufficiency

1) Obstetric history-based diagnosis — history of 1+ second-trimester pregnancy losses or extremely preterm births associated with no or minimal mild symptoms...... The presence of risk factors for structural cervical weakness supports the diagnosis. Most of these cases are pregnancy losses before 24 weeks. 2) Ultrasound-based diagnosis — In asymptomatic patients with a past history of 1+ extremely preterm birth associated with no or minimal mild symptoms .....we perform serial TVU examinations and make a diagnosis of cervical insufficiency when CL is ≤25 mm before 24 weeks (typically 12-24) Unknown if cerclage is of benefit in short cervix <25mm without hx of PTB 3) Physical examination-based diagnosis — We make a diagnosis of physical examination-based cervical insufficiency in patients at 14 to 28 weeks of gestation with a dilated and effaced cervix on physical examination and no contractions or weak irregular contractions that appear inadequate to explain the cervical dilation and effacement. The membranes may be prolapsed or ruptured. Labor, infection, and bleeding related to placental abruption or placenta previa should be excluded.

diagnose maternal rubella

1) Serology is most common. Serological studies are best performed within 7 to 10 days after the onset of the rash and should be repeated 2 to 3 weeks later (i.e., acute and convalescent). (similar to CMV) IgM becomes positive shortly after the onset of rash and remains positive for about four weeks 2) NAAT and PCR are useful to confirm rubella infection when IgM test results are equivocal and for surveillance of circulating genotypes. Nasopharyngeal and throat specimens are the ideal samples if collected in the first 5 days after the rash onset...... In addition, viral cultures drawn from nasal, blood, throat, urine, or cerebrospinal fluid may be positive from 1 week before to 2 weeks after the onset of the rash Recent rubella infection is defined as •A 4-fold rise in rubella IgG antibody titres between acute and convalescent serum specimens •Rubella-specific IgG seroconversion OR •A positive serological test result for rubella-specific IgM antibody and low-avidity IgG OR •A positive rubella culture or viral detection via reverse-transcription PCR Even though a positive rubella-IgM result in the right clinical context was traditionally confirmatory of acute infection, positive rubella-IgM antibodies in pregnancy should be interpreted with caution, as false positives occur and occasionally rubella-specific IgM antibodies may persist for months or years after infection or vaccination. Since false-positive results are becoming relatively more frequent as rubella incidence declines, it is important that a positive rubella-IgM result in a pregnant woman is thoroughly investigated using other confirmatory tests such as paired IgG (acute and convalescent), IgG avidity, or rubella virus isolation by culture or NAAT, to avoid unnecessary terminations of pregnancy.

most common fetal anomalies diabetes

1) cardiac is common, specifically complete AV septal defect (ASD and VSD) others = coarc, tetralogy of fallot 2) neural tube defects hydrocephaly - most common anencephaly 3) renal cleft palate renal anomalies Highest odds (not most frequent) are The caudal regression syndrome.... which is - sacral agenesis (total absence of coccyx and total or distal absence of sacrum) AND associated with spinal cord anomalies, e.g. syringomyelia.

manage cervical insufficiency (indications for cerclage)

1) history indicated Cerclage - We suggest cerclage placement (called a history-indicated cerclage) at 12 to 14 weeks of gestation in patients with 1+ second trimester losses for *cervical insufficiency..... Start progesterone - At 16 weeks of gestation, the author also begins progesterone supplementation with vaginal progesterone daily and continues progesterone until 36+6 weeks of gestation. No good evidence for progesterone with it. 2) Ultrasound-based cervical insufficiency Cerclage: We suggest cerclage placement (called ultrasound-indicated cerclage) in patients with 1+ spontaneous preterm birth AND TVU CL ≤25 mm before 24 weeks in the current pregnancy. Supplemental progesterone - For patients with a prior spontaneous preterm birth, the author prescribes vaginal progesterone beginning at 16 (optimal) to 20 weeks of gestation (which may be before or after cerclage placement) and continues it through 36+6 weeks. note: combination method MAY reduce preterm birth in <24 of 28 weeks. 3) Physical examination-based cervical insufficiency -- (1-4 cm dilated <24 weeks) Cerclage - For patients with physical examination-based cervical insufficiency before 24 weeks of gestation, we consider cerclage placement a reasonable option (called physical examination-indicated cerclage). This is a stronger recommendation ●Progesterone supplementation - The author's practice is to continue progesterone supplementation post-cerclage in patients who had been on the drug pre-cerclage because of a previous preterm birth. For patients with no history of previous preterm birth, the author begins vaginal progesterone post-cerclage.

what to exclude with cervical insufficiency

1) labor 2) bleeding from placental abruption or placenta previa......... should be excluded by history and physical and ultrasound examination as these disorders could account for biochemically mediated cervical ripening leading to second-trimester pregnancy loss or preterm delivery independent of structural cervical weakness 3) infection (urinalysis/culture, IAI) In patients with an ultrasound-based diagnosis, amniocentesis is not routinely performed as most patients do not have significant cervical dilation, prolapsed membranes, or abnormal-appearing amniotic fluid. In patients with a physical examination-based diagnosis, amniocentesis is often indicated since many patients have significant cervical dilation, prolapsed membranes, or abnormal-appearing amniotic fluid.

benefits of treating diabetes in pregnancy (SOGC)

1) normalizes fetal growth (less macrosomia) 2) less C/S and instrumental delivery 3) less risk of shoulder dystocia (brachial plexus injury, bone fracture, death) and other neonatal complications (hypoglycemia, jaundice) 4) reduced preeclampsia or GHTN 5) reduced anomalies + stillbirth Diet and exercise recommended. also less maternal morbidity - less retinopathy (microvascular)

prolactinoma and infertility

1)high prolactin decreases GnRH pulsatility 2) Also less LH frequency 3) Directly decreases estrogen 4) Decreases ovulation 5) Causes luteal phase defect in up to 2/3... this causes a poorly developed endometrium and poor embryo implantation

Types of breech presentation

1. *Frank breech*: fetus's hips are flexed with extended knees B/L 2. *Complete breech*: fetus's hips and knees are flexed B/L 3. *Footling breech*: fetus's feet are first: one leg (single footling) or both legs (double footling)

HIV testing

1. 4th gen HIV-1 and HIV-2 Ag/Ab combo immunoassay is initial screening if negative, no infection If positive, needs a confirmatory test 2. To confirm, do multispot test (for HIV-1 and HIV-2 antibody differentiation if multispot detects HIV antibodies, HIV is confirmed 3. If multispot test is negative, do a HIV1 Nucleic acid test (NAT) for RNA viral load

2 step GDM screen

1. 50g of glucose .... - no fasting - measure 1 hour later - if it is >140 (7.8) , then do the 3 hour test 2. If positive, a 100-g, 3-hour OGTT is performed.... must be FASTED. -Fasting- 5.3, - 1 hour - 10 - 2 hour- 8.6 - 3 hour - 7.8 2+ values count for diagnosis Criticism- : (1) the inability to identify women with isolated elevated FPG (2) limited reproducibility; (3) incomplete uptake of the diagnostic test in those that screen positive (they don't come back (4) delay in diagnosis of GDM (5) Sensitivity of the test is only 76.6% (less sensitive than 1 step)

Sepsis workup

1. CBC with differential 2. CMP 3. CXR 4. ?CT abdo? 5. Blood cultures 6. urine cultures (use catheter, and monitor urine output!) 7. LP ? ?sputum? 8. Procalcitonin 9. Lactate 10. CRP 11. VBG/ABG 12 DIC workup - Pt/INR, PTT - fibrinogen

pharmacologic causes of high prolactin

1. Dopamine receptor antagonists (phenothiazine, risperidone, metoclopramide, domperidone) 2. Dopamine-depleting agents (alpha methyldopa, reserpine) 3. Antidepressants (tricyclic antidepressants, SSRI) 4. Opiates 5. Verapamil (CCB) 6. Histamine H2-receptor antagonist (cimetidine)

benefits of early dating scan

1. Increases the early detection of multiple pregnancies. 2. Increases the detection of major fetal anomalies. 3. Reduces the incidence of late-term and post-term pregnancies and rates of induction of labor for late-term pregnancy by allowing a more precise estimation of gestational age. 4. No significant differences are detected for clinical outcomes such as perinatal mortality. The effect of ultrasound on perinatal mortality is dependent on the detection rate of fetal malformations and on the uptake of pregnancy termination for anomalies in the population at study. . First-trimester ultrasound also allows earlier detec- tion of multiple pregnancies, nonviable pregnancies, certain fetal anomalies, and screening for Down syndrome and other aneuploidy with nuchal translucency (NT)

pathologic causes of high prolactin

1. Pituitary disease a. Prolactinomas (micro< 10mm; macro > 10mm) b. Intersellar lesions causing stalk compression (meningiomas, gliomas, adenomas, metastases cause low dopamine transmission --> less inhibitory effect -- --> more prolactin) c. Rathke's cleft cyst (remnants of Rathke's pouch) d. Other adenomas (non-functioning or hormone-secreting) i. Hormone-secreting pituitary adenomas often co-secrete prolactin ii. Serum IGF-1 to test for growth hormone excess (acromegaly) 2. Hypothalamic and pituitary stalk disease (Tumors: harmartoma, glioma, craniopharyngioma, meningioma, metastases; Granulomatous disease: sarcoidosis, tuberculosis; Cranial irradiation; Pituitary stalk transection; CNS trauma; Empty sella syndrome; Vascular: AV malformation, aneurysm) 3. Primary hypothyroidism (PRL will normalize with Tx of thyroid disease; due to TRH acting as prolactin-stimulating factor) 4. Chronic renal disease (hemodialysis pts due to decreased clearance, and dysfunction of pituitary prolactin production) 5. Cirrhosis 6. Chest wall trauma (herpes zoster, burns, surgery) 7. Seizures 8. PCOS 9. Ectopic secretion of prolactin

neonatal withdrawal

96% of neonates show withdrawal symptoms.

neonatal HSV what are 3 levels ?

1. Skin/eye/mouth- rarely fatal, but still a risk of neurologic (encephalitis) 2) central nervous system disease (manifested as encephalitis with or without skin, eye, and mouth infection) 3. disseminated disease (the most serious form of infection, which has a 90% mortality rate if untreated) The risk for neonatal infection seems to be greatest when maternal primary infection occurs in the third trimester. In this situation, the mother acquires infection but is unable to complete seroconversion to IgG prior to delivery, and the infant is delivered in the absence of protective passive IgG from the mother. In this case, there is a 30% to 50% risk ofneonatal herpes infection Neonatal HSV causes disseminated or CNS disease (seizures, lethargy, irritability, tremors, poor feeding, temperature instability, and bulging fontanelles) in approximately 55% of cases. Up to 30% of infants will die and more than 50% can have neurologic damage despite antiviral therapy. The classic triad is skin lesions, chorioretinitis, and CNS abnormalities. In all cases of suspected neonatal or congenital HSV infection, an early consultation with a pediatrician or pediatric infectious diseases expert is highly recommended. Intravenous antiviral therapy (acyclovir) should be initiated as soon as possible as per standard dosing guidelines. There is evidence of significant reduction in mortality(from 58% to 16%) and neurologic sequelae with its use Studies had suggested that primary infection occurring in the first or second trimester caused an increase in spontaneous abortion and/or prematurity and fetal growth restriction.....However, more recent series have not confirmed these findings. in rare cases, there is trans-placental transmission resulting in congenital (in utero)infection. This is typically very severe. The fetal manifestations include microcephaly, hepatosplenomegaly, IUGR, and IUFD

strong factors for adverse fetal outcome with growth

< 3% oligo high UA

CRL acuracy MSD accurae

3 to 8 days 4 to 11 days BPD 3-8 days in T1 7-12 days in T2

Amsel Criteria for BV

3+ of 1. Thin gray homogenous vaginal discharge. 2. Positive whiff test with KOH. 3. Clue Cells 4. Elevated Vaginal pH. > 4.5

hep B serology

1.) HBsAG is KEY MARKER for infection. First marker that arises during infection. If it stays for longer than 6 months, then you're chronic., 2.) IgM vs core in the beginning. Transition to IgG when you level up. If you WIN then HBsAG goes away. If you don't it stays, 3.) IgG vs HBsAB means VICTORY.(or immunization) 4.) HBeAG indicates infectivity. "need an envelope to mail to friend, etc."

glargine (lantus) dosing in pregnancy

1/2 Lantus QHS 1/2 lispro (humalog) OR aspart (Novolog/novorapid) 1/3 of this with each meal

influenza pregnancy what types of vaccines and symptoms?

2 types of vaccines: 1) Live, attenuated nasal vaccine (not meant for pregnant women) 2) inactivated, trivalent vaccine by IM injection with a sudden onset of fever and rigors -diffuse myalgias - malaise - headache - nonproductive cough - Sore throat, rhinitis, abdominal pain, nausea and vomiting may also be present. Tachycardia and tachypnea are common, especially in pregnant women. Though most symptoms resolve within a few days, the cough and malaise may persist for greater than two weeks. Viremia is infrequent and vertical transmission is rare.

risk of recurrent fetal demise

2-10x higher Also, there is an increased rate of obstetric complications such as preeclampsia, fetal growth impairment, and preterm birth in sub-sequent pregnancies

NPH dosing in pregnancy

2/3 of total insulin in AM 1/3 of total insulin in PM of the 2/3 AM: 2/3 NPH and 1/3 Lispro or Aspart of the 1/3 PM : 1/2 NPH and 1/2 lispro or aspart

Reactive NST

20 mins duration - normal FHR baseline - moderate variability - two accelerations 15 beats per minute for at least 15 seconds (>32 weeks) or 10x 10 (28-32 weeks) - early decels are okay.... no variable or late decels If all of these are not there, it is considered non-reactive Note: this is different than Cat 1/2/3 in labor

sogc lowest age for steroids

24 universal reomendation Women between 22 + 0 weeks and 23 + 6 weeks gestation at high risk of preterm birth within the next 7 days should be provided with a multidisciplinary consultation regarding the high likelihood for severe perinatal morbidity and mortality and associated maternal morbidity. Antenatal corticosteroid therapy may be considered if early intensive care is requested and planned (Conditional, Low).

in a patient on synthroid already, how much to increase on diagnosis of pregnancy ?

25% Check TSH q 4-6 weeks

monitor diabetic ultrasounds and surveillence

28 weeks- ultrasound then q4 weeks ultrasound If Poorly controlled, may begin weekly surveillance at 32 weeks. Might not need it in well controlled. SOGC says weekly surveillence at 36 weeks (NST, BPP) If obesity, poor gycemic control, LGA, HTN, or SGA... can test earlier and more frequently than 36weeks.

SOGC growth scans obesity

28, 32, 36 weeks Weekly assesment after 37 weeks

Zidovudine (AZT) dose labor

2mg / kg bolus over an hour... then 1mg per kg per hour infusiuon

criticism of term breech

30% did not have imaging to see if head was extended 30% of the infants with death or serious morbidity were delivered by OB's without adequate expertise, or OB's in training. Unlikely able to perform 16 deaths: 2 occured way after delivery (SIDS/gastroenteritis) 2 died during delivery, either stillbirth or early second stage 4 cases of neonatal death occurred after what was described as difficult vaginal delivery. - 1 weighed 2400 grams - 1 had significant anomalies birth weights above 4kg almost twice as much in SVD

calculate vials of winrho, how many vials (300 mcg) does a mom need if the Kb is 1.8% fetal cells, maternal blood volume of 5,000 mL, and

300 mcg covers 30ml fetal blood, or 15mL fetal RBC's 5,000 mL x 0.018 = 90 mL fetal blood 3 vials

Kleihauer covers

300 mcg covers 30ml fetal whole blood, 15ml fetal RBCs

Deliver PAS

34-36 weeks

deliver vasa previa

34-36 weeks

Diabetic diet

35 -40 kcal/kg - underweight 30-35- kcal/kg- nor normal weight 25 kcal/kg- for obese or above

when can you do IA? (SOGC)

37-41 + 3 absence of risk factors consider at 41-42 if normal NST and amniotic fluid

NT measurement and chances of normal fetus when is further workup warranted ?

3mm (95th percentile) 3.5mm is 99th percentile

When is it most important for growth to control sugars? (for fetal weight)

3rd trimester, about 75% of growth occurs then.

how long to monitor in maternal trauma?

4 hours minimum recommend 24 hours if blunt abdo trauma and there are - uterine activity on toco - maternal contractions

# fetal BPP (know this)

4 short term - tone, movement, Breathing, NST 1 long term - fluid Short term reflects impaired CNS 8-10- normal 6= repeat in 24 hours 4 or less, consider delivery fetal tone- normal is 1+ extension/flexion movements (limb, trunk, hand) over 30 mins fetal movement- normal is 3+ discrete limb movements over 30 mins fetal breathing - 30+ seconds

recurrent vulvovaginal candidiasis What is treatment ?

4+ episodes a year

Stillbirth and obesity

4-8x higher Mechanisms include placnetal disease HTN genetic or structural anomalies Infections

Kleinfelter's Syndrome

47,XXY karyotype. Major physical features of Klinefelter syndrome are as follows: 1. Relatively tall and slim body type, with relatively long limbs (especially the legs) is seen beginning in childhood. 2. Hypogonadism is seen at puberty, with small, soft testes and usually a small penis. Infertility is the rule. Gynecomastia is frequent, and cryptorchidism or hypospadias may be seen. Lack of virilization at puberty is common; indeed, it is often the reason for the patient to seek medical attention. 3. There is a tendency toward lower verbal comprehension and poorer performance on intelligence quotient tests, with learning disabilities a common feature. There is a higher incidence of behavioral and social problems, often requiring professional help

SOGC active phase

4cm in nulliparous 4-5 cm in a multip dystocia is: - <0.5cm per hour over 4 hours - NO change over 2 hours Note: ACOG definition is - no cervical change in active labor (6 cm) and adequate contractions for: - 4 hours on oxytocin - 6 hours without oxytocin

Enalapril postpartum

5 mg once daily for 1 week then 10 mg for 2 weeks then 20 mg maintenance dose beneficial for cardiac function All ACE inhibitors and ARBs provide "kidney protection"

how much longer does it take to get ready for a CS in obese to start?

5 mins

ITP thresholds for delivery

50 for C/S 25 for vaginal 80 for epidural

threshold of radiation for teratogen from imaging in pregnancy

50 mGY CTA is 20-35 mGY VQ scan is 0.28 mGY

Nitroglycerin for tachysystole

50 ug of nitro every 3 mins.... Max of 4 doses 1ml nitro + 9cc saline....2.5ml

heart changes pregnancy

50% increase in blood volume AND cardiac output..... bigger increase in plasma than RBC mass Faster heart rate ~20 BPM 20% decrease in resistance patients are at risk of heart failure and pulmonary edema

GBS treatment time

50% with delivery within 1 hour 25% within 2 hours 2% with 4 hours

2 step "preferred" GDM - diabetes canada- endorsed by SOGC

50g glucose - if 1 hour glucose is > 7.8-11 , then do 75g (2 hour) (GDM if > 11.1) 2. 75g Fasting > 5.3 1 hour - 10.6 2 hour- 9.0 ANY of these count for GDM

treat candida (yeast)

7 days of vaginal "azole" Clotrimazole (canesten) 100mg tab, 1 tab vavginally a day x 7 Avoid fluconazole oral in first trimester (?congenital heart defects)

what GA can the D antigen be detected

7.5 weeks GA (38 days from conception)

TOLAC success

70-80% of women with CS will have a repeat CS about 70% successful less if for dystocia (higher if breech, or maternal reason) More likely for - tall women - previous SVD - normal size - spontaneous labor (as opposted to IOL) Less likely if they need -cervical ripening -augmentation -post dates - macrosomia (>4kg)

Normal PaO2 levels and refractory hypoxia in Covid

75-100

1 step 75gg GDM screen (based on HAPO study)- SOGC "alternate"

75-g glucose overload with 2 hours duration: measures plasma glucose concentration - fasting state (92).... or 5.1 - 1 hour (180) ...... or 10 - 2 hours (153) .... or 8.5 - ANY of these count 1 step detects more GDM

what is the test for postpartum GDM testing?

75g OGTT 2 hours

preeclampsia fluid intake hourly

80 ml / hr

SOGC breech time of second stage

90 mins passive second stage delivery imminent in 60 secs

HIV viral load threshold delivery

<1,000- SVD, > 1,000- cesarean (risk is about 25% of vertical transmission!!) Do a cesarean if we do not know viral load Test around 34 weeks.... if above 1,000, do C/S at 38w (less likely to go into labor) Gize zidovudine (AZT) before a C/S for 3 hours before surgery (2 mg/kg for 1 hour, then 1 mg/kg/hour until delivery) When indicated, the goal is to complete at least 3 hours of ZDV prior to delivery, including scheduled cesarean deliveries.

acog gestational hypertension

>140/90, 4 hours apart, within 1 weeek of each other. GHTN with severe ranges, should be classified as PEC with severe features

what else should be checked in b19 infection w/hydrops?

A platelet count should also be determined with platelets available for immediate transfusion if necessary.!!!

prevent maternal rubella

A 2015 Cochrane collaboration systematic review supports postexposure prophylaxis with intramuscular or intravenous infusion of rubella-specific immunoglobulin for the prevention of rubella infection among exposed pregnant women up to 5 days after exposure, with a number needed to treat of 4; however, there is insufficient evidence to know whether this strategy prevents CRS.

metformin dose

A biguanide, inhibits hepatic gluconeogenesis and glucose absorption, while increases tissue sensitivity causing increased peripheral uptake. 500 mg BID to start Up to 2g a day it crosses placenta (insulin doesn't) Avoid in patients with renal dysfunction

congenital diaphragmatic hernia

A diaphragmatic hernia is a protrusion of the abdominal contents into the thoracic cavity through a defect in the diaphragm. The defect occurs on the left 85% of the time but can occur on the right (10-15%) or even near the middle of the diaphragm (<2%) The diaphragm is formed by 8 weeks gestational age. Movement of abdominal contents into the thorax may not occur until later in gestation (maybe even the third trimester), when breathing movements create negative intrathoracic pressure. This movement of abdominal contents into the thorax commonly shifts the location of the thoracic structures and compresses the developing lung tissue, potentially resulting in pulmonary hypoplasia, the leading cause of death in infants with this congenital anomaly.

Listeriosis

A disease of the nervous system of humans that can cause fever, meningitis, miscarriage, or premature birth and is spread by eating food contaminated with listeria Of concern to the obstetrician is the association between maternal listerial infection and stillbirth, preterm labor, and fetal infection most common route of infection is hematogenous dissemination of the organism through the placenta, which leads to placental abscesses and ultimately to fetal septicemia.

uterine inversion

A first-degree inversion is an inversion in which the corpus extends into the uterine cavity but not beyond the cervical ring. A second-degree inversion is a protrusion through the cervical ring that does not extend to the perineum. A third-degree inversion is an inversion in which the inverted fundus extends to the perineum. A fourth-degree inversion exists when the entire uterus prolapses through the cervix and the fundus is visible outside the vaginal introitus. With a prolapsed inverted uterus, the entire uterus prolapses through the cervix and the fundus is visible outside of the vaginal introitus. Timing of uterine inversion is defined as - acute (24 or fewer hours after delivery) - subacute (more than 24 hours postpartum) - chronic (more than 1 month postpartum).

limitations of CVS

A limitation of CVS is that chromosomal mosaicism is identified in up to 2 percent of specimens In most cases, the mosaicism reflects confined placental mosaicism rather than a true second cell line within the fetus.... in this case, amnio is necessary. Creasy: The major sources of these errors included 1) maternal cell contamination 2) misinterpretation of mosaicism confined to the placenta. Today, genetic evaluation of chorionic villi provides a high degree of success and accuracy, particularly in regard to the diagnosis of common trisomies. The U.S. Collaborative Study revealed a 99.7% rate of successful cytogenetic diagnosis, with only 1.1% of the patients requiring a second diagnostic test such as amniocentesis or fetal blood analysis to further interpret the results..... In most cases, the additional testing was required to delineate the clinical significance of mosaic or other ambiguous results (76%), whereas laboratory failure (21%) and maternal cell contamination (3%) also required follow-up testing Maternal Cell Contamination Chorionic villus samples typically contain a mixture of placental villi and maternally derived decidua. Although specimens are thoroughly washed and inspected under a microscope after collection, some maternal cells may remain and grow in the culture. As a result, two cell lines, one fetal and the other maternal, may be identified. In other cases, the maternal cell line may completely overgrow the culture, thereby leading to diagnostic errors, including incorrect sex determination, and potentially to false- negative diagnoses, although there are no published reports of the latter. Confined Placental Mosaicism Mosaicism can then occur through two possible mechanisms. 1) An initial meiotic error in one of the gametes can lead to a trisomic conceptus that would normally spontaneously abort. However, if during subsequent mitotic divisions, one or more of the early aneuploid cells loses one of the trisogmic chromosomes through anaphase lag, the embryo can be "rescued" by reduction of a portion of its cells to disomy. This results in a mosaic morula with the percentage of normal cells dependent on the cell division at which rescue occurred. More abnormal cells are present when correction is delayed to the second or a subsequent cell division. Because most cells in the morula proceed to the trophoblast cell lineage (processed by the direct preparation), it is highly probable that that lineage will continue to contain a significant number of trisomic cells. On the other hand, because only a small proportion of cells are incorporated into the inner cell mass, involvement of the fetus depends on the random distribution of the aneuploid progeni- tor cells. Involvement of the mesenchymal core of the villus, which also evolves from the inner cell mass, is similarly depen- dent on this random cell distribution. Noninvolvement of the fetal cell lineage produces confined placental mosaicism, in which the trophoblast and perhaps the extraembryonic mesoderm will have aneuploid cells but the fetus will be euploid. In the second mechanism, mitotic postzygotic errors produce mosaicism with the distribution and percentage of aneuploid cells in the morula or blastocyst dependent on the timing of nondisjunction. If mitotic errors occur early in the develop- ment of the morula, they may segregate to the inner cell mass and have the same potential to produce an affected fetus as do meiotic errors. Mitotic errors occurring after primary cell dif- ferentiation and compartmentalization have been completed lead to cytogenetic abnormalities in only one lineage.

ESRD, types of dialysis, and vascular volume

A major practical problem with achieving a successful pregnancy outcome while on hemodialysis is proper maintenance of maternal vascular volume. Dialysis teams are accustomed to removing significant vascular volume at each session. However, during a normal pregnancy, there is a progressive expansion in vascular volume of at least 20% to 30% above nonpregnant values from 8 to 30 weeks' gestation. This volume augmentation is required to maintain uteroplacental perfusion and fetal growth. Pregnancies in which vascular volume does not increase appropriately have high incidences of IUGR and stillbirth. The poor prognosis associated with hemodialysis combined with other considerations has prompted increased interest in continuous ambulatory peritoneal dialysis. Although fluid and chemical balance is constant and heparinization is not necessary, intrauterine deaths, abruption, prematurity, hypertension, and fetal distress still occur. The best strategy for most diabetic women on dialysis who desire pregnancy is to undergo a prepregnancy kidney transplant.

measure cervical length

A minimum of 3 measurements are taken over several minutes, and the shortest image should be used to determine the cervical length. The cervical length should be noted along with the presence or absence of funnelling. If funnel-ling is present, the length of the cervix is the remaining closed cervix (from the tip of the funnel to the external os) Next, suprapubic or fundal pressure may be applied forabout 15 seconds to watch for cervical change, includingfunnelling (a (with or without funelling) shaped indenta-tion of the internal cervical os).

when to do microarray ? (SOGC)

A piece of umbilical cord constitutes an adequate sample for DNA microarray. should be considered if there is evidence of any of the following: (1) congenital malformation, (2) intrauterine growth restriction, (3) hydrops, (4) ambiguous genitalia, or (5) dysmorphic features.

quantitative PCR and CMV

A quantitative PCR count of ≥10^3 genome equivalents/mL of AF is a certain sign of congenital infection and ≥10^5 genome equivalents/mL can predict symptomatic infection

diagnose diabetes (in general)

A1c > 6.5 fasting (8 hrs) > 125 (7) 75g gtt 2 hour > 200 (11) random > 200 Note: OU does an A1C in all patients at initial screen. If A1C >6.5, then Dx as T2DM.

rubella vaccination How well does it work ?

A single dose of this vaccine will result in measurable antibody in almost 95% of susceptible persons; primary failure of the rubella vaccine occurs in less than 5% of immunizations. Antibody levels can be detected for at least 18 years in more than 90% of the vaccine recipients ; however, up to 20% of vaccinated individuals will have rubella titres below the protective level after 2 decades from immunization Although rubella infection may occur in immunized pregnant women, these reinfections result in only 8% risk of CRS in the first trimester of pregnancy compared with a risk of 65% to 85% among patients without any immunity.

single UA and growth What anomalies? (MCQ)

A single umbilical artery, in the absence of aneuploidy or structural malformations, is usually not associated with FGR. But, it MAY be associated with aneuploidy, or anomalies (cardiac, genito-urinary) SMFM Consider weekly surveillence at 36w or third trimester growth scans OU A single umbilical artery is associated with an increased likelihood of associated structural anomalies, with cardiac and genitourinary malformations being the most common. A specialized ultrasound evaluation, as well as a fetal echocardiogram, is recommended for all cases of SUA. Several studies have documented an increased risk of fetal growth restriction with isolated SUA. As such, serial growth ultrasounds every four weeks should be initiated starting at 28 weeks.

sinusoidal pattern of FHR:

A sinusoidal FHR pattern is a smooth, repetitive sine wave-like pattern of FHR that: - persists for ≥20 minutes - amplitude of 5 to 15 bpm - frequency of 3 to 5 cycles per minute. In a pathological sinusoidal FHR tracing, the FHR does not respond to uterine contractions, fetal movement, or fetal stimulation. The physiological cause of this difference is not clear but can often be related to fetal anemia and/or hypoxia. The tracing is considered abnormal after ≥20 minutes. However, if the clinical picture suggests potential fetal anemia, do not wait 20 minutes but initiate clinical response immediately.

HIV classification

A) Asymptomatic B) AIDS-defining condition C1) CD4 > 500 C2) CD4 200-500 C3) CD4 < 200 OR AIDS defining illness

SOGC stillbirth checklist

A. Family history (i)Review of family conditions □Recurrent spontaneous abortions1 □Venous thromboembolism (VTE) or pulmonary embolism (PE) □Congenital anomaly or abnormal karyotype □Hereditary condition or syndrome □A child with dysmorphic features □Consanguinity B. Maternal history (i)Review of maternal medical history □VTE or PE □Diabetes □Chronic hypertension □Antiphospholipid syndrome □Lupus □Autoimmune disease □Severe anemia □Consanguinity □Maternal heart disease □Other medical condition such as chronic renal disease (ii) Review of maternal obstetric history □Recurrent miscarriages □Baby with anomaly or hereditary condition □Growth restriction □Preeclampsia with adverse conditions □Massive placental abruption □Previous stillbirth C Current pregnancy history □Maternal age □Gestational age at fetal death □Hypertension □Pre-existing or gestational diabetes □Smoking, alcohol, or substance abuse □Pre-pregnancy weight □Abdominal trauma □Cholestasis □Placental abruption □Maternal-fetal hemorrhage (i) Specific fetal conditions □Alloimmunization □Non-immune hydrops □Growth restriction □Infection □Congenital anomalies □Chromosomal abnormalities □Complications of multiple gestations or higher order multiples (e.g., twin-twin transfusion syndrome, stuck twin, placental insufficiency, polyhydramnios-oligohydramnios sequence)56 (ii) Placental or cord complications detected by ultra- sound or macroscopic examination □Large or small placenta □Hematoma □Edema □Large infarcts □Abnormalities of structure, length, or insertion of the umbilical cord □Cord prolapse □Cord knots □Placental tumours

polyhydramnios

AFI > 24 or MVP > 8 (singletons) In twins, it is only MVP >8 Severe is much more likely to be anomalies Note: AFI may be more beneficial in singletons, while MVP may be more beneficial in twins Recognition of polyhydramnios is clinically important as perinatal mortality is increased 2-5‐fold compared to pregnancies with normal amniotic fluid volume. Polyhydramnios is also associated with increased frequency of: - preterm birth - placental abruption, - etal anomalies - maternal morbidity, including postpartum hemorrhage. Even when adjusting for the etiology of polyhydramnios such as congenital anomalies or maternal disease such as diabetes, the risk of perinatal death is increased.

Oligohydramnios

AFI under 5... or MVP pocket under 2 (singleton) Twins= AFI <2 MVP is easier to reproduce, it reduces intervention, no change in outcomes Early on, more so dx with congenital anomalies... Late, more so PPROM and FGR

Diabetes A!C and average

AIC of 8 = average value of 80 A1C of 6 = average of 120 Each point = 30

OU AMA advanced maternal age

AMA has also been associated with an increased risk of ectopic pregnancy, spontaneous abortion, fetal chromosomal abnormalities, congenital anomalies, stillbirth, multiple gestation, placenta previa, gestational diabetes, preeclampsia, fetal growth restriction and cesarean delivery. These complications may lead to a higher rate of iatrogenic preterm birth. delivery at age 35 recommendations - ASA - growth q4 weeks at 28 weeks - weekly BPP at 36 weeks - delivery by 39 weeks

anticoagulation for APS in pregnancy

ASA !!! plus either: - (if prior VTE) therapeutic doses of unfractionated or low molecular weight heparin (e.g., enoxaparin 1 mg/kg subcutaneously every 12 hours, adjusted to achieve anti‐factor Xa level at 0.6-1 U/mL 4 h after an injection) . ... check this weekly until therapeutic, then monthly. If on unfractionated heparin, target an Xa of 0.3-0.7 U/mL, 6 hours after the injection. It is noteworthy that activated partial thromboplastin time (aPTT) is unreliable for assessment of anticoagulation in women with LA • (if no prior VTE) prophylactic doses of unfractionated or low molecular weight heparin (e.g., enoxaparin 30-40 mg subcutaneously every 12 hours).

contraindications to assisted vaginal delivery

Absolute •Non-vertex presentation (unless forceps are used for face presentation or the after-coming head in vaginal breech delivery.) •Unengaged head, with more than one-fifth of the fetal head palpable abdominally above the pubic brim. •Incomplete cervical dilation. •Uncertainty of the fetal head position. •Suspected CPD. •Fetal coagulopathy, thrombocytopenia, or brittle skeletal dysplasia. •Inability to progress to timely Caesarean delivery should the AVB be unsuccessful. Relative •Vacuum delivery for fetal prematurity, particularly <34+0 weeks gestation.

SOGC absolute contraindications to exercise

Absolute contraindications to exercise are the following: •Ruptured membranes •Premature labour •Unexplained persistent vaginal bleeding •Placenta previa after 28 weeks' gestation •Preeclampsia •Incompetent cervix •Intrauterine growth restriction •High-order multiple pregnancy (e.g., triplets) •Uncontrolled type 1 diabetes •Uncontrolled hypertension •Uncontrolled thyroid disease •Other serious cardiovascular, respiratory, or systemic disorder

Cholecystitis

Acute cholecystitis occurs when the cystic duct is obstructed either by a gallstone or by inflammation. This leads to gallbladder wall inflammation and ischemia, with bacterial translocation eventually causing sepsis

acute hypoxia in pregnancy

Acute hypoxia may be associated with - complete placenta abruption - maternal collapse - uterine rupture - complete cord compression or prolapse

Acute pyelonephritis

Acute pyelonephritis is characterized by high fever (>38.5°C), chills, flank pain, dysuria, urgency, and frequency. Nausea and vomiting may also be present. On physical examination, patients typically have distinct costovertebral angle tenderness. Laboratory abnormalities include pyuria and bacteriuria. White blood cell casts are highly predictive of acute pyelonephritis. The diagnosis is ultimately confirmed by a positive urine culture WBC > 5 cells/hpf Order CBC CRP/ESR Urinalysis Urine culture (cath)

early pregnancy congenital varicella

Acute varicella infection during pregnancy has been associated with - spontaneous abortion -intrauterine fetal death - congenital anomalies. However, these complications are rare. (<2% in first half of pregnancy) test with Ultrasound....Possible findings include - microcephaly /hydrocephalus - chorioretinitis - limb hypoplasia - skin scaring - growth restriction Outcomes include ●Neurological abnormalities (eg, mental retardation, seizures, Horner's syndrome) ●Ocular abnormalities (eg, optic nerve atrophy, cataracts, chorioretinitis, microphthalmos, nystagmus) ●Limb abnormalities (hypoplasia, atrophy, paresis) ●Gastrointestinal abnormalities (gastroesophageal reflux, atretic or stenotic bowel) ●Low birth weight

sides of dopamine agonists

Administration of bromocriptine may cause -nasal stuffiness - nausea - headache - drowsiness - orthostatic hypotension. Cabergoline is associated with the same side effects but the symptoms are usually less severe and of shorter duration.

how is rubella transmitted

Adults: Respiratory droplet, then hematogeneous dissemination through the body Vertical crosses placenta by hematogenous spread

varicella exposure trimester

After maternal infection, the risk of congenital varicella syndrome can be estimated using: - PCR testing of amniotic fluid for VZV DNA - ultrasound for the detection of fetal anomalies. PCR testing for VZV DNA is a sensitive test, which is usually obtained between 17 and 21 weeks of gestation.... if they are negative, then offer reassurance. - if PCR is positive but ultrasound is negative, still follow with ultrasound q 4-6 weeks When possible, delivery should be delayed until five days after the onset of maternal illness to allow for passive transfer of maternal IgG across the placenta to the fetus.

fetal acid base after the breech crowns

After the breech crowns, fetal expulsion is invariably accompanied by cord compression and fetal bradycardia. A normally grown fetus enters this phase well-oxygenated without acidemia. It can tolerate several minutes of delay while developing primarily a respiratory acidosis, easily reversed once ventilation is established. However, a growth-restricted fetus has a high likelihood of metabolic acidemia in labour due to placental insufficiency. This reduces fetal tolerance to cord compression during expulsion: an early metabolic acidosis can rapidly worsen and cause fetal damage. Significant cord compression beyond several minutes will eventually lead to severe metabolic acidosis even in a normal fetus, and prevention and treatment of expulsive delay are critical components of delivery technique.

high risk for GDM testing

Age > 35 Obesity before pregnant - high risk ethnicity (african, aboriginal, asian, hispanic) - family hx diabetes (first degree) - Insulin resistanct (PCOS or acanthosis, -previous GDM In these cases, you can do the 1 hr 50g Note: if you suspect diabetes, you can test at any time, even late pregnancy

SOGC factors tied to T2DM after GDM

Age >35 Obesity family hx diabetes previous pregnancy with diabetes PCOS acanthosis nigricans macrosomic infant

what infections are tested in blood products ?

All plasma units undergo quarantine and repeated testing to demonstrate that they are nonreactive to syphilis, hepatitis B surface antigen anti-HCV HIV-1 p 24 antigen, anti-HIV-1, and anti-HIV-2

Hep B and pregnancy what and when to treat?

All pregnant women at first prenatal visit Re-screen women of unknown status or new/continuing risk factors at time of delivery Test: HBsAg ACOG: Additionally, a triple panel screen (HBsAg, anti-HBs, and total anti-HBc) can be offered to pregnant patients aged 18 years and older, if not previously completed. Screening with the three tests (triple panel) is recommended at least one time for all adults to help identify persons who have an active hepatitis B virus infection and could be linked to care, have resolved infection and might be susceptible to reactivation (eg, immunosuppressed persons), are susceptible and need vaccination, or are successfully vaccinated.

Alloimminization What are the most common maternal antibodies

Alloimmunization is defined as the development of antibodies in response to foreign substances such as antigens, i.e. transfusion reaction. besides Rhesus, Lewis and anti-I are most common (but these are benign because they are IgM and do not cross placenta ) Of the ones with consequence: - anti‐E is the next most frequently encountered antibody...... followed by anti‐K, and anti‐c. Maternal IgG crosses the placenta and attaches to fetal erythrocytes that express the paternal red cell antigen. These cells are then sequestered by macrophages in the fetal spleen where they undergo extravascular hemolysis producing fetal anemia. In cases of HDFN related to the Kell (anti‐K1) antibody, an additional mechanism for the fetal anemia - suppression of erythropoiesis.

Gestational thrombocytopenia

Almost never occurs in first trimester.

diagose thalassemia

Alpha‐thalassemia cannot be diagnosed by electrophoresis and instead requires genetic testing!!!

Parvovirus B19

Although parvovirus B19 can cause - erythema infectiosum & arthropathy infection in the immunocompetent host is most commonly asymptomatic or has mild symptoms. In patients with hemoglobinopathies, parvovirus B19 can cause severe transient aplastic crisis of red blood cells and in immunocompromised individuals, pure red blood cell (RBC) aplasia and chronic anemia. The incidence of acute primary parvovirus B19 infection in susceptible women during pregnancy is low. However, with vertical transmission, the virus can cause fetal anemia, leading to hydrops fetalis and fetal death.

HIV and treatment in labor

Although intravenous ZDV is not required for women with HIV receiving cART with HIV RNA 1,000 copies/mL or less in late pregnancy, or near delivery, or both, with no concerns about adherence to or tolerance of their cART regimens, some experts have expressed concern that there are inadequate data to determine whether administration of intrapartum intravenous ZDV to such women provides any additional protection against perinatal transmission. These experts have recommended intrapartum intravenous ZDV administration to women with RNA levels in this range, as the transmission risk is slightly higher (approximately 1-2%) when HIV RNA is in the range of 50-999 copies/mL compared to less than 50 copies/mL (1% or less) However, regardless of viral load, in these circumstances the clinician may elect to use or not use intrapartum intravenous ZDV based on clinical judgment

lactate in sepsis

Although lactate levels >2 mmol/L suggest possible sepsis, intrapartum lactate elevations of >2 mmol/L are typical. Some healthy patients, especially in later stages of labor, have normal values >4 mmol/L; thus, these values should be interpreted cautiously during labor

Mumps Rare Complications

Although mumps usually is a self-limited disease, it can cause aseptic meningitis, pancreatitis, mastitis, thyroiditis, myocarditis, nephritis, and arthritis.

diabetes and kidney disease

Although some clinicians discourage pregnancy in women with diabetic renal disease because of concerns about permanent renal deterioration as a result of the pregnancy, recent data consistently indicate that pregnancy does not measurably alter the time course of diabetic renal disease. Progression of diabetic nephropathy is closely related to the degree of glycemic control

end stage renal disease and pregnancy

Although women receiving dialysis for ESRD are often amenorrheic or anovulatory, pregnancies have become increasingly common during therapy.... However, the prognosis for pregnancy in diabetic women with ESRD managed on dialysis continues to be exceedingly poor, with -fewer than one-half of pregnancies among women with ESRD result in viable children. About 60% of births are premature, often because of uncontrollable hypertension, renal failure, or fetal growth failure. Among the 20% to 25% of pregnancies ending in live births, 40% of babies are growth restricted

Antibiotics to avoid during pregnancy

Aminoglycosides (Ototoxicity) - long term Floroquinolones (cartilage damage) Tetracyclines (ie, doxy) (Discolord Teeth, Bone Growth Inhibition) Avoid septra first trimester (antagoizes folic acid)

physiology of hydrops

An elevated central venous pressure has been reported in these fetuses and may cause a functional blockage of the lymphatic system at the level of the thoracic duct as it empties into the left brachiocephalic vein. Reports of poor absorption of red cells transfused into the peritoneal cavity in cases of hydrops support this theory.

amniotic fluid embolism

An extremely rare, life-threatening condition that occurs when amniotic fluid and fetal cells enter the pregnant woman's pulmonary and circulatory system through the placenta via the umbilical veins, causing an exaggerated allergic response from the woman's body

Herpes protection from one area to another

An infection by one type at one mucosal site does not protect against acquisition at another mucosal site, but the signs and symptoms are then much less severe. Type 1 infection does not confer full protection against type 2 but may lessen the signs and symptoms of acquisition of infection at the new mucosal site.

pudendal nerve

An injection of 10 mL of 1% lidocaine or equivalent is made in 2 locations through or just inferior to the sacrospinal ligament, just medial to the ischial spine on each side. The effect is usually felt within 3 to 4 minutes.

prolonged interval between twin delivery

An interval of ≥30 minutes between vaginal delivery of the first and second twin is considered prolonged. prolonged time to delivery for the second twin increase the risk of an associated adverse neonatal outcome, but it can also increase the risk of a combined twin delivery.

Aneuploidy

Aneuploidy is the presence of an abnormal number of chromosomes in a cell, for example a human cell having 45 or 47 chromosomes instead of the usual 46 abnormal number chromosomes can be autosomal ( TS 21, 18, 13) or sex (47 XXY, 45 XO)Deletions and duplications can also occur

# obtain MCA PSV

Angle DEPENDENT.... angle of insemination less than 30 degrees placed in proximal 1/3 of MCA High is > 1.55 MoM for moderate/severe anemia..... though, after a transfusion, the subsequent threshold should be > 1.3

inpatient vs outpatient preeclampsia vs gestational hypertension management

Antenatal Management The evaluation for gestational hypertension, preeclampsia, or superimposed preeclampsia may be performed in clinic as an outpatient if all of the following criteria are met: • Blood pressures are <160/100 mm Hg • The patient is asymptomatic • The fetus is not growth-restricted and antenatal testing is reassuring • Singleton gestation <36 weeks • Patient has a reliable means of transportation and a working phone number The evaluation for gestational hypertension, preeclampsia, or superimposed preeclampsia should be performed in the inpatient setting if any of the following criteria are met: • Blood pressures in clinic are ≥160/100 mm Hg • Any signs or symptoms of preeclampsia with severe features are present • Antenatal testing is non-reassuring or the fetus is growth-restricted (<10%ile) • Gestational age ≥36 weeks • Multifetal gestation • Known protein/creatinine ratio ≥0.3 mg/dL or ≥300 mg protein on 24 hour urine collection • Major medical comorbidities including insulin-dependent diabetes, connective tissue disorders, sickle cell disease, or maternal heart disease • The patient does not have transportation back to the hospital if outpatient or does not have reliable contact information

how much WinRho to give

Anti-D 300 mcg protects against 30 mL fetal blood (15ml fetal RBC's)..... and 120mcg protects against 12 mL (6ml of fetal RBC's) Stillbirth and cesarean patients may need more . If FMH is in excess of the amount covered by the dose given(6 or 15 mL fetal RBC), 10 mcg additional anti-D shouldhe given for every additional 0.5 mL fetal red bloodcells SOGC regimens: 300mcg to all women at 28 weeks GA OR 120 mcg at both 28 and 34 weeks. Note: the total fetoplacental blood volume at 12-week pregnancy is 3 mL; that is, 1.5 mL fetal red cells. A 120ug dose of anti-D would be protective. For miscarriage or induced abortion beyond 12 weeks' gestation, anti-D 300g is indicated

Anti-D for moles

Anti-D Ig may be omitted when complete mole is diagnosed in nonsensitized Rh-negative mothers. Anti-D may not be omitted for partial mole or uncertain diagnosis.

tests for inherited thrombophilias

Antithrombin deficiency Protein C deficiancy Protein S deficiency Factor V leidem mutation Prothrobin gene mutation .... EXCEPT for DNA testing for - Factor V leiden (the DNA test, not screening with activated Protein C) - Prothrombin 20210a You can test any during pregnancy (except protein S)

valvular heart disease

Any disease process involving the heart valves

lifelong rubella immunity

Any woman with positive IgG for rubella does not require screening for rubella immunity in subsequent pregnancies. Women who have 2 documented vaccine doses or positive IgG serology do not need any serological screening thereafter, not even in subsequent pregnancies. Women with low rubella antibodies levels despite documented prior immunization with 2 doses of a rubella-containing vaccine should not be revaccinated and do not need any serological screening thereafter, as 1 lifetime dose of rubella vaccine after the age of 12 months is considered sufficient for life-long immunity (most women in Canada receive 2 doses of MMR) and, if documented with certainty, no further rubella vaccination is required following delivery even in cases where no rubella IgG is detectable by conventional assays.

who is treated for GBS ?

Anyone with a GBS positive swab between 35-37 weeks who is in labour or with ruptured membranes Anyone with GBS bacteriuria in pregnancy regardless of colony count Anyone with an infant previously affected by GBS disease (sepsis, meningitis or pneumonia) regardless of swab status Anyone in preterm labour with GBS status unknown Anyone in labour over 37 weeks with ruptured membranes for over 18 hours where GBS status is unknown ACOG considers any GBS previous in general

maternal symptoms of listeria... how to manage ?

Approximately one-third of pregnant women with listeriosis are asymptomatic. When overt illness is present, affected patients usually present with a flulike syndrome characterized by fever, chills, malaise, myalgias, back pain, and upper respiratory symptoms No specific clinical manifestations help to distinguish listeriosis from other infections that may occur during pregnancy. Therefore pregnant women presenting with these symptoms in the late second or early third trimester should be evaluated for possible listeriosis with blood cultures and an amniocentesis. Because colonies of L. monocytogenes may be mistaken on Gram staining for diphtheroids and therefore ignored, it is important to inform the microbiologist that listeria infection is a concern. In febrile pregnant women, a Gram stain revealing gram-positive pleomorphic rods with rounded ends is highly suggestive of L. monocytogenes infection. Treat with IV Ampicillin

placental released factors FGR

As noted earlier, angiogenic/angiostatic molecules produced by the placenta as a consequence of normal and abnormal implantation also appear to influence fetal growth. Three in particular have been observed to be of considerable significance: - soluble fms-like tyrosine kinase (soluble Flt 1) - placental growth factor (PGF) - endoglin. Elevated levels of soluble Flt 1 and endoglin and decreased concentrations of PGF have been reported in both preeclampsia and FGR.

types of maternal HSV

Ask if history of previous genital HSV - Primary infection occurs when the individual encounters either HSV-1 or HSV-2 and has no prior exposure (i.e., HSV-1 and HSV-2 antibody negative) to either viral type. - Non-primary first episode is the first clinically recognized episode, but the individual has HSV-1 or HSV-2 antibodies from a prior exposure. - Recurrent infection is clinically evident infection in an individual with antibodies to that virus.

Maternal Toxoplasmosis

Asymptomatic (90%) he clinical presentation in pregnant women is not more severe than in non-pregnant women, and most often occurs as an influenza-like illness (low-grade fever, malaise, lymphadenopathy), In contrast to infection in the immunocompetent host, toxoplasmosis can be a devastating infection in the immunosuppressed patient. In these individuals, dysfunction of the CNS is the most common manifestation of infection. Findings typically include encephalitis, meningoencephalitis, and intracerebral abscess. Pneumonitis, myocarditis, and generalized lymphadenopathy also occur commonly.

treat listeria

Asymptomatic patient: No testing or treatment is indicated. The patient should be counseled to return for evaluation if she develops any symptoms suggestive of listeriosis. • Mildly symptomatic but afebrile patient: Manage expectantly. Alternatively, perform blood culture but withhold treatment until culture is proven to be positive. • Febrile patient with or without other symptoms consistent with listeriosis: Perform blood cultures .... Treat with: - intravenous ampicillin (2 g every 8 hours) for 14 days. If the patient is allergic to ampicillin, administer intravenous TMP-SMX (8 to 10 mg/kg/d in two divided doses) for 14 days.

pregnancies with thrombocytopenia delivery

Be VERY careful with instrumental delivery, risk of fetal thromocytopenia (even GT)

OU APS testing

At OU, we do not test patients with a history of a preterm birth before 34 weeks because of eclampsia, preeclampsia with severe features, or features consistent with placental insufficiency, in agreement with ACOG guidance that "although preterm severe preeclampsia and early onset placental insufficiency are indicated as clinical criteria for the diagnosis of APS by expert consensus, insufficient evidence currently exists to support that screening and treatment of women with these conditions improves subsequent pregnancy outcomes."

immediate postpartum blood shift !!

At delivery, central blood volume may drop due to peripartum blood loss...... but 1) Immediately afterward, sustained uterine contraction results in an acute 500mL autotransfusion into the systemic circulation 2) Smaller uterus REDUCES compression of the aorta/ICV.... and increases venous return) 3) Also, there is increased preipheral resistance (loss of placental progesterone) 4) Extravascular fluid shifts to intravascular All these peripartum changes lead to a high‐output state that may persist for up to four weeks postpartum which may confer additional risk to a pregnant patient with VHD

OU baseline asthma

At their initial visit, asthma patients should be given a prescription for a peak flow meter and directed to bring this with them to follow-up appointments so that a baseline peak expiratory flow rate (PEFR) can be established. Most peak flow meters provide a numerical measurement while others simplify this into 3 colored zones - Green = 80-100% of usual PEFR; - Yellow = 50- 80% of usual PEFR - Red = <50% of usual PEFR). Peak flow meters are available in The Children's Hospital Pharmacy. Patients may use a peak flow tracking sheet (see Appendix A).

vasopressors + steroids

At times, fluid resuscitation proves inadequate in restoring optimal cardiovascular performance. In such cases, the use of vasoactive agents is indicated after restoration of adequate intravascular volume. SSC recommends vasopressor therapy initially to target a MAP ≥65 mmHg, with norepinephrine (NE) as the first‐choice vasopressor. Vasopressin 0.03 units/min can be added with the intent of either raising MAP or decreasing NE dosage. NE has been used to maintain blood pressure under regional anesthesia for cesarean delivery and, at least at low doses, seems to be safe for the fetus. SSC guidelines advocate the use of dopamine as an alternative vasopressor agent to NE, but only in highly selected patients (e.g., patients with low risk of tachyarrhythmias and absolute or relative bradycardia). Phenylephrine is not recommended in the treatment of septic shock, except in circumstances where: (1) NE is associated with serious arrhythmias, (2) CO is known to be high and blood pressure persistently low, or (3) as salvage therapy when combined inotrope/vasopressor drugs and lowdose vasopressin have failed to achieve the MAP target. All patients requiring vasopressors should have an arte- rial catheter placed as soon as practical if resources are available. DOBUTAMINE is added to norepinephrine for patients with myocardial dysfunction who persist in septic shock Steroids: A typical corticosteroid regimen for adults in septic shock is intravenous (IV) hydrocortisone (50 mg every 6 hours or as a continuous infusion) for 7 days. The guidelines suggest that corticosteroids be started in patients with an ongoing requirement for vasopressor therapy. Ongoing requirement is defined as a dose of norepinephrine or epinephrine ≥0.25 μg/kg/min for at least 4 hours after initiation to maintain the target MAP. We suggest using IV corticosteroids in pregnant or postpartum patients with septic shock who continue to require vasopressor therapy (GRADE 2B). VTE Because of an increased risk of VTE in sepsis and septic shock, we recommend the use of pharmacologic VTE prophylaxis in pregnant and postpartum patients in septic shock Insulin We suggest initiating insulin therapy at a glucose level >180 mg/dL in cr

Migraine with aura

Auras are usually visual but can also be sensory, motor or verbal disturbances. Visual auras are most common. focal neurologic symptoms that develop gradually and persist for 60 minutes

nocturnal hypoglycemia

Avoiding Nocturnal Hypoglycemia Unopposed action of intermediate-acting insulin during the hours of sleep frequently results in nocturnal hypoglycemia at 3:00 to 4:00 a.m. in individuals with T1DM. Reducing the insulin dose to avoid this complication typically leads to unacceptably high glucose levels on rising at 6:00 to 8:00 a.m..... whereas adding a bedtime snack helps moderate the effect of bedtime insulin and sustain glucose levels during the night. The snack should contain a minimum of 25 g of complex carbohydrate and enough protein or fat to help prolong release from the gut during the hours of sleep.

Macrocytic anemia

B12 deficiency- very rare, - gastric resection, - pernicious anemia - crohn's Folate deficiency -

death of one monochorionic twin

Because nearly all monochorionic pregnancies have connections between the two choriovascular beds, death of one twin affects the outcome of the surviving co-twin. Consequences for the surviving co-twin include - survival with cerebral impairment - preterm delivery with its sequelae - intrauterine death. - Many organ systems may be affected including: - brain (hypoxic-ischemic brain disruptions with microcephaly, hydrocephalus, or porencephaly/hydranencephaly), - gastrointestinal system (intestinal atresia), - skin (aplasia cutis). Proposed mechanisms to explain injury to the co-twin following twin fetal demise include: - the embolic theory, in which thromboplastin-like material is transferred through open placental vascular anastomoses to the survivor - the ischemic theory, in which blood is shunted into the low-resistance circulation of the dead or dying fetus. In monochorionic twins where there has been a demise of one twin, we recommend continuing to evaluate growth of the surviving co-twin every 3-4 weeks o To assist with counseling, consider neurological imaging (e.g. with MRI) of surviving co-twin 4-6 weeks after demise (MC only)

prophylaxis for influenza pregnancy

Because of the high potential for morbidity and mortality for pregnant and postpartum patients, the CDC advises that postexposure antiviral chemoprophylaxis can be considered for pregnant women and women who are up to 2 weeks postpartum (including after pregnancy loss) who have had close contact with infectious individuals. The chemoprophylaxis recommendation is oseltamivir 75 mg once daily for 7-10 days depending on the source of exposure

determine chorionicity

Best performed early (before 10 weeks) 1. Number of gestational sacs Note: before 6 weeks, possible that 1 gestational sac can still be dichorionic 2 gestational sacs = 2 chorions .... etc 2) A thick band of chorion that separates two gestational sacs signals a dichorionic pregnancy, whereas mono- chorionic twins have a single gestational sac. (this is because), monochorionic pregnancies have a dividing membrane that is so thin (generally <2 mm) that it may not be seen until the second trimester. Early in double digit weeks at 10 to 14 weeks' gestation, sonographic assessment of :chorionicity may be determined using 4 factors: 1) Gender (if different, it's obviously dichorionic... if same, it could be either monochorionic or dichorionic) 2) number of placentas (careful, could be 2 fused... AKA bipartite) 3) presence of an intervening membrane dividing the sacs (lambda sign vs t-sign) 4) thickness of the sacs (and number of layers) Dichorionic- 4 layers (amnion-chorion-chorion-amnion) Thicker- >2 mm =dichorionic PPV ~ 95% Monochorionic - 2 layers- (amnion-amnion) Thinner- ≤2 mm =mono PPV ~90%

CMV testing on fetus

Best to do an amnio for CMV DNA PCR (not a viral culture) , should be 6-8 weeks after infection

side effects of varenicline (champix)

Binds to the nicotinic ACh receptors, and acts as an antagonist and patrial agonist Therefore, it provides relief by partial agonist effect... but inhibits reinforcement of nicotine via ACh antagonism. Sides - constipation nausea, vomiting headache sleep disturbances Caution for depression or mood changes, if so, discontinue it.

Subgaleal hemorrhage

Bleeding between the periosteum of the skull and the galea aponeurosis. Compliucation of VACUUM due to tear of the large emissary veins Can cause neonatal hypoglycemia and shock Not as serious though as intracranial hemorrhage (but much more common)

when are coagulation factors in hemorrhage required and when are coag studies recommended ?

Blood losses greater than 20-25% or cases of documented or suspected coagulopathy may require replacement of coagulation factors; coagulation studies are recommended after transfusion of 5 to 10 units of PRBCs

what to have ready for PAS delivery

Blood products (RBC, platelets, FFP) - cell saver Anesthesia - consider GA - art line

candida (yeast), what are predisposing factors

C. albicans is a saprophytic yeast that exists as part of the endogenous flora of the vagina. causes > 90% of yeast infections.... The organism is present in the vagina of approximately 25% to 30% of sexually active women VVC is a much more common infection and is the second most common cause of vaginitis after bacterial vaginosis (BV). predisposing factors associated with vaginal colonization with C. albicans include: - diabetes mellitus, pregnancy, obesity, recent use of broad-spectrum antibiotics or steroids, sexual activity, and immunosuppression.

Chronic hypertension workup

CBC PIH labs EKG (consider echo) An assessment for secondary causes of hypertension should be performed in women with any of the following: - hypertension requiring three or more medications - hypokalemia (not caused by a diuretic) - creatinine ≥1.1 mg/dL - strong family history of kidney Consider - Aldosterone to renin ratio (especially if hypokalemia) - Renal disease. In general, weekly testing beginning at 32 weeks is recommended for chronic hypertension, although rare indications may exist for earlier or more frequent testing . • Serial ultrasounds (Q4 weeks) for fluid and growth should be initiated at 28 weeks. If growth restriction is diagnosed, follow IUGR guidelines. • Weekly visits should begin at 32 weeks, coinciding with antenatal testing, if not started earlier for other indications.

what are the severe antibodies CDE system ? (MCQ)

CDE system includes C,c D (no little D, thats what she said) E, e D, c, E kell are very severe

SOGC indication for delivery in hypertensive disorders

CNS: Eclampsia, Pres, Stroke, TIA Cardio/resp: uncontrolled HTN (as above), pulmonary edema, MI, O2 < 90 Heme: platelets < 50 Nephro: AKI with creat > 150 Liver: INR >2 , hepatic hematoma/rupture placental: severe abruption, absent/reversed a-wave , fetal demise

Severe features of preeclampsia

CNS: visual changes, severe HA, hyperrflexia, clonus, encephalopathy, coma Lungs: pulmoanry edema cardio: BP >160/110 Liver: nausea, vomtiing, RUQ pain, AST and ALT >2x ULN blood: <100k platelets, Creatinine > 1.1 (100) ... or doubling Note: SOGC no longer recommends (severe features) BP value for severe is despite 3 antihypertensives, and lasts for 12 hours

manage cesarean scar pregnancy

CS scar pregnancy is diagnosed in the first trimester, a number of options exist for safe termination of pregnancy with conservation of the uterus if required. In the early first trimester, up to 8-9 weeks - ultrasound-guided potassium chloride injection into the embryo, followed by intramuscular methotrexate may be followed by a latent period of 2-3 days for devascularization THEN then hysteroscopic resection of the pregnancy from within the lower anterior wall of the uterus. In larger CS scar pregnancies (e.g., discovered at the 11-13-week nuchal translucency examination), the aforementioned medical interventions may need to be directly followed by surgical intervention in centres with this experience. A recent case series from a group in Toronto recommends approaching such cases with - laparoscopic assessment - ligation of the anterior divisions of the IIAs then either: - vaginal tissue extraction - laparoscopic wedge resection of the pregnancy and suture repair of the uterus

Septic pelvic thrombophlebitis: treatment

CT and MRI are the diagnostic tests of greatest value in confirming the diagnosis of pelvic vein thrombophlebitis. These tests are most sensitive in detecting large thrombi in the major pelvic vessels. They are not as useful in identifying thrombi in smaller vessels. In some cases, the diagnosis is one of exclusion and is confirmed by observing the patient's response to an empiric trial of heparin. The mainstays are - anticoagulation with unfractionated heparin - broad-spectrum antibiotics (including coverage for anaerobes and common Enterobacteriaceae). Within 48-72 hours of initiation of heparin therapy, fever should resolve. Treatment usually is empirically continued for 7-10 days, although the optimal duration of therapy is not well defined.

risks for PP endometritis

Caesarean section intrapartum chorioamnionitis (13%) prolonged membrane rupture (5-6%) prolonged labour (5-6%) multiple cervical exams (5-6%) low SES bacterial colonization of lower genital tract with GBS, chlamydia, mycoplasma, ureaplasma garnerella general anesthesia CS for multifetal gestation young maternal age and nulliparity prolonged labour induction obesity meconium-stained amniotic fluid

GDM Timing of Delivery

Can be as early as 37..... 37-39 if poorly controlled (Try for 39 weeks, even if on insulin.) Do earlier (34-37) if you cannot control glycemic in hospital, or if adverse fetal surveillence Reduces: - LGA - intrumental delivery - shoulders - NICU admission - cesarean - stillbirth Offer cesarean if above >4500 (5000 if no GDM)

cannabis and menstrual cycle

Cannabinoids modulate the hypothalamic-pituitary-ovarian axis through their interaction with gonadotropin-releasing hormone (GnRH), decreasing luteinizing hormone and estrogen levels. Acute administration of THC appears to disrupt ovulation by suppressing the secretion of GnRH and thyrotropin-releasing hormone (TRH) One study reported that cannabis use was associated a longer follicular phase.

what heart patients require antibiotic prophylaxis labor ?

Cardiac transplants prosthetic valves hx endocarditis -unrepaired cyanotic heart diease give around 60 mins before delivery High Risk IV Regimen No allergy Ampicillin 2 g IV or Cefazolin or ceftriaxone 1 g IV Allergy to penicillin or ampicillinCefazolin or ceftriaxone 1 g IV orClindamycin 600 mg IV High Risk PO Regimen No allergyAmoxicillin 2 g PO Allergy to penicillin or ampicillinCephalexin 2 g PO orClindamycin 600 mg orAzithromycin 500 mg

cervical length

Cervical length should only be determined from images in which the lowermost edge of the empty maternal bladder and the internal os and external os are visible and when the anterior and posterior lips of the cervix are of approximately equal thickness. If the cervix appears asymmetric (thin anteriorly and thicker posteriorly), this suggests excessive probe pressure. When three measurements have been obtained that satisfy measurement criteria and vary by less than 10 percent, the shortest of these is chosen and recorded as the "shortest best." Choosing the shortest of three excellent images reduces interobserver variation. We do not determine the best measurement by image quality because this introduces an unpredictable variable.

Respiratory changes in pregnancy

Chappel As pregnancy proceeds, the subcostal angle widens, leading to an increased transverse diameter of the chest. This results in an increase in lower chest circumference of 5-7 cm, which compensates for the eventual 4-cm elevation of the diaphragm caused by the enlarging uterus. As a result, total lung capacity decreases only 5% due to a 20% reduction in the residual volume. Vital capacity is not altered. However, the changes in chest configuration produce important changes in static mechanical properties. Lung compliance itself does not change during pregnancy, but compliance of the chest wall decreases approximately 30%, causing a parallel but slightly smaller decrease in total respiratory compliance . Minute ventilation increases by 40% in the first trimester and remains elevated throughout pregnancy. This increase isachieved largely by an increase in tidal volume with little increase in respiratory rate Because minute ventilation increases more than the increased metabolic requirements ofpregnancy, arterial PCO2 falls substantially and the normalgravid individual develops a compensated respiratory alkalosis Pregnancy is associated with a significant increase in ventilatory drive both at rest and during exercise. Minute ventilation increases mostly due to an increase in tidal volume with little or no increase in respiratory rate. Alveolar ventilation increases, along with an increase in arterial partial pressure of oxygen (PaO2) and alveolar partial pressure of oxygen (PAO2) There is a decrease in arterial partial pressure of carbon dioxide (PaCO2), with a compensatory decrease in serum bicarbonate, with an overall mild increase in pH, reflecting a state of compensated respiratory alkalosis Uterine enlargement and abdominal distension result in a 4- to 5-cm cephalad displacement of the diaphragm and a 5- to 7-cm increase in thoracic circumference. This results in a - decrease in expiratory reserve volume - decrease residual volume - decreasefunctional residual capacity ● tidal volume and resting minute ventilation increase significantly ● the functional residual capacity and residual volume are decreased as a consequence of the elevated diaphragm ● RR same ● Increases: tidal volume (volume of respiration), resting minute ventilation, inspiratory capacity ● Decreases: Functional residual capacity (expiratory reserve volume and residual volume), Inspiratory residual volume, residual volume ● unchanged: respiratory rate ● -chest tube would need to go higher

SMFM antibiotic regimens sepsis

Chorio- Ampicillin 2g IV q6h + gent 5mg/kg (max of 500mg) Community-acquired pneumonia Cextriaxone 2g IV q24h + Azithromycin 500 mg PO one dose, then 250 mg PO daily Urinary tract - Piptazo if worried NECROTIZING skin infections Vancomycin plus piperacillin-tazobactam. If group A Streptococcus or Clostridium perfringens are present, use penicillin G plus clindamycin.

Chorionicity vs zygosity

Chorionicity = Number of placentas Zygosity refers to the genetic make-up of a pregnancy. Multiple gestations can be monozygotic, dizygotic, trizygotic, etc.... Amnionicity- number of yolk sacs DCDA twins- can be either monozygotic or dizygotic MCDA or MCMA- always monozygotic

when do determine choroniicity/amnionicity ?

Chorionicity and amnionicity are most accurately determined sonographically in the first trimester after 7 -10 weeks (sensitivity ≥98 percent ), but this may be before first recognition of twin pregnancy. Accuracy is lower but acceptable in the early second trimester (sensitivity ≥90 percent Sonographic assessment of the fetal membranes is more difficult and less accurate in the third trimester, especially in the setting of oligohydramnios. SOGC recommends this at 11-14 weeks

NYHA classification

Class I (mild): no sx, no limitations Class II (mild): no sx @ rest, slight limitation, ordinary activity leads to sx Class III (moderate): no sx @ rest, marked limitation w/ physical activity (ie, brisk walking).... less than ordinary activity results in sx Class IV (severe): sx @ rest, unable to do any physical activity w/o discomfort I and II usually okay III and IV high risk

when to measure fetal aternal hemorrhage blood?

Clinical conditions associated with potential placental trauma or disruption of the fetomaternal interface (e.g., placental abruption, external cephalic version, blunt trauma to the abdomen, placenta previa with bleeding these conditions may be more likely to cause fetomaternal hemorrhage in excess of 30 mL, measurement of FMH volume is prudent

how feisible is early anatomy screening

Complete examination of fetal anatomy was achieved in 48% of cases, although non-cardiac anatomy was completed in 86% of cases. (cardiac anatomy is harder) Using a transvaginal approach in addition to the transabdominal scan increased the success rate from 72% to 86%. Other investigators reported that an early scan was considered complete in 62% of cases by a transabdominal scan and in 82% when using a transvaginal scan. The fetal heart was visualized in 62% of cases by either method

what is the biggest factor for timing of delivey??

Complications See ESPIRIT study the prospective risk for unexpected fetal death in otherwise uncomplicated monochorionic twins at 34 weeks' gestation was only 1.5% in the ESPRIT trial. The risk for a composite measure of perinatal morbidity fell from 41% at 34 weeks' gestation to only 5% at 37 weeks, suggesting that it was reasonable to allow uncomplicated monochorionic gestations followed with close fetal surveillance to continue to planned delivery at 37 weeks' gestation

complications of poly

Complications Uterine overdistension can lead to several obstetrical complications including: • premature labor • preterm PROM • malpresentation due to increased fetal mobility • umbilical cord prolapse • cesarean delivery • placental abruption following PROM • postpartum hemorrhage due to uterine atony • maternal respiratory compromise due to mechanical pressure on the maternal diaphragm • fetal mortality • macrosomia.

CMV infant complications

Complications of affected infants with congenital CMV infection include - jaundice - petechiae ("blueberry muffin baby") -thrombocytopenia - hepatosplenomegaly, as well as late complications, such as - hearing loss - mental retardation - delay in psychomotor development - chorioretinitis, - optic atrophy - seizures - expressive language delays, and learning disabilities SOGC: Although most infants with cCMV are healthy at birth, approximately 15% to 20%have permanent neurologic sequelae, most commonly sensorineural hearing loss (SNHL); other sequelae include intellectual disability, cerebral palsy, visual impairment, and seizures

ACOG/OU indications for delivery preeclampsia

Conditions which preclude expectant management of preeclampsia: o Uncontrolled severe range blood pressures o Persistent headache, unresponsive to medication and unaccounted for by alternative diagnoses o Persistent right upper quadrant or epigastric pain, unaccounted for by alternative diagnoses o Vision changes, unaccounted for by alternative diagnoses o Stroke o Myocardial infarction o HELLP syndrome o New or worsening renal dysfunction (serum creatinine ≥1.1 mg/dL, or doubling of baseline serum creatinine) o Pulmonary edema o Eclampsia o Suspected acute placental abruption or vaginal bleeding in the absence of placenta previa o Non-reassuring fetal testing o Persistent reversed end-diastolic flow or absent diastolic flow in the umbilical artery o Fetus without expectation of survival at the time of maternal diagnosis (i.e. extreme prematurity, life-limiting anomaly) o Fetal death

Maternal HSV testing

Confirm diagnosis by laboratory testing - Swab performed on mucocutaneous lesion either 2 ways 1. PCR = more sensitive, results in 1-2 days ... PCR is able to detect HSV at MUCH lower concentrations, is 3-5x more likely to be positive than culture 2. Viral culture = low sensitivity as vesicular lesions ulcerate/crust, results 7-14 days..... "A negative test in the presence of active lesions does not rule out HSV because viral shedding is intermittent" Note: A primary infection will be positive for viral culture or PCR.... but non specific IgG will be negative at the initial onset (too early for IgG production) -3. Serology testing - "If there are no active lesions but exposure to HSV is suspected, serologic testing may be used. IgG to HSV1/2 (AKA, non specific HSV IgG) develops before type-specific IgG to HSV-1 and HSV-2 glycoproteins, which take an average of 2-3 weeks and up to 6 months to develop. If the suspected exposure was particularly recent, IgG to HSV-1/2 should be tested first, with reflex to the type-specific antibodies. If the exposure was in the past, type-specific testing for IgG to HSV-1 and HSV-2 glycoproteins alone can be performed. Note: RCOG advises that "For women presenting with first episode genital herpes in the third trimester, particularly within 6 weeks of expected delivery, type specific HSV antibody testing (immunoglobulin G [IgG] antibodies to HSV-1 and HSV-2) is advisable. For these women, characterising the infection will influence the advice given regarding mode of delivery and risk of neonatal herpes infection. The presence of antibodies of the same type as the HSV isolated from genital swabs would confirm this episode to be a recurrence rather than a primary infection and elective caesarean section would not be indicated to prevent neonatal transmission....... However, it should be noted that it may take 2-3 weeks for the results of this test to become available. It is therefore recommended that an initial plan of delivery should be based on the assumption that all first episode lesions are primary genital herpes. This plan can then be modified if HSV antibody test results subsequently confirm a recurrent, rather than primary, infection.

how can mom transmit CMV ?

Congenital infection CMV can also be transmitted from mother to child through exposure to CMV-infected maternal blood or genital secretions during birth or, most commonly, through breastfeeding after birth. This is called postnatal infection and is more common than congenital infection Postnatal infection is not associated with adverse infant outcomes.... except among very-low-birthweight infants, who may present with: - end-organ disease and a sepsis-like syndrome - may develop chronic lung disease - may have neurocognitive sequelae. However, the risk of long-term effects remains controversial..... Therefore, breastfeeding is considered safe in patients with CMV infection during pregnancy.

EFM reduces what ?

Continuous EFM was associated with a 50% reduction in neonatal seizures with no clear differences in longterm sequelae, including cerebral palsy, infant mortality, or other standard measures of neonatal well-being Continuous EFM was associated with higher rate of cesarean deliveries and operative vaginal births. There was no significant difference in perinatal/neonatal morbidity and mortality.

contraindications to TOLAC

Contraindication to vaginal delivery 1. prior classical or T incision 2. Major uterine reconstruction (full thickness myomectomy, repair of mullerian anomaly, cornuel resection) 3. prior uterine rupture 4. non-vertex presentation (although external cephalic version is not contraindicated) 5. medical or obstetric complications which would otherwise preclude vaginal delivery 6. h/o more of 3 or more CS (can try with 2) 7. unavailability of staff to perform emergency CD (ob and anesthesia) Maternal request

pregnancy after rubella vaccination What are contraindications to the vaccine ?

Contraindications to rubella vaccinations include febrile illness certain immunodeficiencies and systemic immunosuppression history of an anaphylactic reaction to neomycin, pregnancy. Rubella vaccine virus has the potential to cross the placenta and infect the fetus..... However, there has been no report of CRS in the offspring of women inadvertently vaccinated during early pregnancy..... Therefore, pregnancy termination is not recommended for these patients. Given the potential risks to the fetus, women are advised not to become pregnant for a period of 28 days after immunization.

Complicated Variable Decelerations

Cord compression leading to baroreceptor response in fetus with limited oxygen reserves; may have additional physiology factors (e.g., chemoreceptor component) - failure to return to baseline - Abrupt decel to < 60 bpm lasting > 60 sec.... OR a drop of 60 BPM (ie, 150 to 90) - overshoot (20 bpm x 20 secs) after the decel - accompanied with minimal or absent variability - accompanied with baseline tachycardia/bradycardia Abnormal if repetitive, > or = to 3 complicated variables occur

normocytic anemia workup

Creatinine Hemolysis (reticulocytes, LDH, bili, haptoglobin) B12/folate

fetal blood sampling criteria and contraindications

Criteria to consider FSBS include: -Cephalic presentation -Gestational age >34 weeks gestation -Delivery is not imminent -Facilities and expertise exist to perform the analysis in a timely manner -Membranes are ruptured, and cervix is at least 2−3 cm dilated -Consent was obtained to perform the procedure -Facilities exist to respond to an abnormal result Contraindications to FSBS include: -Face/brow or unknown presentation -Known or suspected fetal bleeding disorder (hemophilia, thrombocytopenia) -Family history of a bleeding disorder (hemophilia, von Willebrand) -Active maternal infection (HIV, genital herpes, hep B/C, known or suspected intrauterine sepsis)

fibronectin twins

Currently, there is no basis for incorporating fetal fibronectin screening into the routine prenatal management of twin pregnancies.

# cystic hygroma

Cystic hygroma (CH) refers to the finding of marked skin thickening extending along the entire length of the fetus during early ultrasonography and in which septations are clearly visible....... . The etiology behind the ultrasound findings is that of dilated lymphatics from venous-lymphatic malformations, that typically form in the neck, clavicle, and axillary regions. They are most commonly found in young infants or on prenatal ultrasound, and depending on the anatomical site, have the potential to obstruct the airway. associated with 50% risk of aneuploidy.... of the remaining 50% of euploid, hslf of those with have major malformations (cardiac, skeletal) (75% total are aneuploid or major structural) all pregnancies should have either : - CVS/Amnio/NIPT - DETAILED anatomy scan and/or fetal echo first trimester= down syndrome is most common second= turner syndrome more common aneuploidy

steroids SLE pregnancy

D. Management of SLE exacerbation 1. Mild to moderate exacerbations a. If the patient is taking glucocorticoids, increase the dosage to at least 20 to 30 mg/d. b. If the patient is not taking glucocorticoids, start 15- to 20-mg prednisone daily. Alternatively, intravenous methylprednisolone (1000 mg daily) for 3 days may avoid the need for daily maintenance doses of steroids. c. If the patient is not taking hydroxychloroquine, initiate 200 mg twice daily. 2. Severe exacerbations without renal or CNS manifestations a. Rheumatology consultation and consider hospitalization. b. Glucocorticoid treatment 1.0 to 1.5 mg/kg. Expect clinical improvement in 5 to 10 d. c. Taper the glucocorticoids once the patient demonstrates clinical improvement. d. If the patient cannot be tapered off high doses of glucocorticoids, consider starting cyclosporine or azathioprine. 3. Severe exacerbations with renal or CNS involvement a. Hospitalization and rheumatology consultation. b. Maintain patient on 1.0 to 1.5 mg/kg of oral prednisone. c. When the patient responds, taper the glucocorticoid. d. For unresponsive patients, consider immunosuppressive agents and/or plasmapheresis.

where can DVT in pregnancy occur? SOGC Whichleg ?

DVT in pregnancy generally presents in the lower extremities, with a predisposition for the left leg (70 to 80%). In contrast to their presentation in non-pregnant patients, DVTs are often isolated to the iliac and/or femoral vein during pregnancy (61%). US to the level of the iliac vein. Compression from femoral to popliteal vein. If there is suspicion of DVT and initial test is negative, repeat in 1 week.

treat ITP pregnancy

Daily prednisone IV-IG if that fails ε-Aminocaproic acid 0.5-2 mg/kg/day of prednisolone is given for 2-4 weeks, followed by a gradual tapering off to the lowest effective dose. Intravenous immunoglobulins (IVIg) provide a more rapid increase in platelets, but are costly and have limited availability. It is typically administered as a once off dose of 1 g/kg, which may be repeated if necessary. Differences between glucocorticoids and IVIG include: IVIG works more rapidly (range, 1 to 3 days) than glucocorticoids (range, 2 to 14 days) Efficacy (both short term and long term) is similar, as discussed below. Glucocorticoids are generally easier to administer. Glucocorticoids are less expensive. For critical bleeding, a glucocorticoid and IVIG are given together RHOgam While the FDA-approved dose of 50 mg/kg has documented efficacy in increasing platelet counts in approximately 80% of children and 70% of adults, a higher dose of 75 μg/kg has been shown to result in a more rapid increase in platelet count without a greater reduction in hemoglobin

what other agents can be given in heparin allergic patients?

Danaparoid and fondaparinux are injectable heparanoid molecules that do not cross-react with HIT antibodies. Both are treatment options for pregnant women with evidence of HIT or allergic reactions to heparins Works via anti-Xa does not affect platelets

other common teratogens

Danazol, ACE inhibitors lithium thalidomide phenytoin isotretinoin

Cord drainage during 3rd stage of labor

Decreases the length of third stage Slight decrease in blood loss when utilizing blood drainage Drained blood should not be counted in maternal blood loss (fetal blood is drained) BUT Placental cord drainage cannot be recommended as a routine practice since the evidence for a reduction in the duration of the third stage of labour is limited to women who did not receive oxytocin as part of the management of the third stage

determine zygosity... how does it affect rates of down syndrome ??

Definitive zygosity determination relies on genetic markers such as blood group testing or, preferably, polymerase chain reaction analysis of variable microsatellite markers using DNA extracted from a skin biopsy specimen, umbilical cord tissue, or buccal smear recent studies have shown that maternal age-dependent observed-to-expected rate of trisomy 21 in twin pregnancies is reduced, especially in monozygotic pregnancies. DCDA- can be either mono or dizygotic MCDA/MCDA- always monozygotic

consequences of fetal hypoxemia

Depressed neonatal vital signs: Apgar ≤3 at 5 minutes •Neonatal neurological sequelae, neonatal encephalopathy (NE): hypotonia, irritability, seizures •Neonatal multiorgan dysfunction •Renal: oliguria, anuria, azotemia •Lung: respiratory distress syndrome, pulmonary hypertension •Gut: necrotizing enterocolitis •Liver: hypoglycemia, elevated liver enzymes, coagulopathy •Hematologic: thrombocytopenia, leukopenia •Cardiac: cardiomyopathy, patent ductus arteriosus •Biochemical evidence of severe metabolic acidosis •Umbilical artery pH <7.0 •Umbilical artery base deficit (BD) ≥12 mmol/L

Number of yolk sacs

Determines amnionicity (not chorionicity) Best performed 8-10 weeks GA 2 yolk sacs- dichorionic (usually) 1 yolk sac- likely monochorionic, but not always .... Prompt a follow up scan Two fetal poles with two yolk sacs in a monochorionic gestation suggests diamnionicity whereas the presence of two fetal poles with only one yolk sac suggests a monoamniotic gestation If separate echogenic rings are not visible, monochorionicity is likely. In such situations, counting the number of yolk sacs may assist in establishing amnionicity. Two fetal poles with two yolk sacs in a monochorionic gestation suggests diamnionicity, whereas the presence of two fetal poles with only one yolk sac suggests a monoamniotic gestation. However, the specificity of this finding for monoamnionicity is uncertain

postpartum endometritis

Diagnosis Endometritis is diagnosed based on clinical criteria. Abdominal pain and malaise are symptoms associated with the diagnosis. An elevated white blood cell count is supportive evidence, but the diagnosis should be made in the postpartum period when two or more of the following criteria are present: • Fever (temperature of 38ºC or higher at least twice, 4 hours apart, or 39ºC once) • Fundal tenderness • Tachycardia (HR >100 bpm) • Foul-smelling and/or purulent lochia polymicrobial, treat with clindamycin + gentamicin Add amp if failure to improve after 48-72 hours (covers enterococcus) If adding amp doesnt work: -substitute vancomycin for ampicillin if already on ampicillin -consider CT scan of the abdomen and pelvis to assess for abscess. Other possible causes of a poor response to treatment include: - pelvic abscess septic pelvic vein thrombophlebitis drug reaction. Drug reaction should be suspected if the patient has a peripheral blood eosinophilia and if the temperature elevation corresponds with the time of drug administration. In these individuals, discontinuation of the antibiotic usually results in prompt resolution of fever. If the patient has renal insufficiency, substitute aztreonam 2 g IV every 12 hours for gentamicin. For the uncommon patient with concomitant sepsis, consider the possibility of myometrial necrosis due to infection with : - group A streptococci - gas-forming organism like Clostridium. "Source control" (hysterectomy) may be needed in these patients.

criteria for early pregnancy failure

Diagnostic for pregnancy failure (non viable IUP) -CRL >7mm and no HR - mean sac diameter >25mm and no embryo -Absence embryo with FHR >2 weeks after scan that showed a gestational sac without a yolk sac -Absence of embryo with FHR 11 days after scan that showed a gestational sac that contained a yolk sac

uterine artery notching

Normally the waveform is assessed on both sides, but can be omitted on the opposite side of a lateral placenta to avoid false-positive mean PI results.

Preeclampsia vs SLE flare How to treat SLE flare?

Difficult to assess difference as many overlapping features ○ Thrombocytopenia ○ Hemolytic anemia ○ Proteinuria ○ Seizures• With lupus flare, expect to see ○ ↑anti -ds DNA titres ○ ↓ C3 and C4 (consumption) ○ Active urine sediment (casts)..... • May have normal BP with lupus flare - direct Coombs is positive - leukopenia Treat with corticosteroids o Example: Prednisone taper of 30 mg daily x 1 week, 20 mg daily x 1 week, 10 mg daily x 1 week o Severe flare (e.g. renal involvement): hospital admission, 125 mg methylprednisolone daily x 3 days, and consultation with rheumatology

Direct maternal death vs indirect maternal death

Direct maternal death - The death of the mother that results of obstetrical complications of pregnancy, labour or the puerperium and from interventions, omissions, incorrect treatment or a chain of events resulting from any of these factors. Ex death from exsanguination after uterine rupture Indirect maternal death - A maternal death that is not directly due to an obstetrical cause. Death results of previously existing disease or a disease developing during pregnancy, labour or the puerperium that was aggravated by maternal physiological adaptation to pregnancy. Ex maternal death from complications of mitral valve stenosis

gonorrhea pregnancy complications

Disseminated gonococcal infection (DGI) amniotic infection syndrome preterm PROM chorioamnionitis preterm birth intrauterine growth restriction neonatal sepsis postpartum endometritis. Most patients with pharyngeal N. gonorrhoeae infection are asymptomatic. When symptoms are present, they include a purulent or mucopurulent cervical exudate, edema, and easily induced cervical or endocervical bleeding. If they are symptomatic, the most common finding (besides cervicitis) is a paryngitis- mild sore throat and erythema; lesions and exudates may also be present

tricuspic regurge pregnancy

Diuretics may be helpful

adalat side effects

Do NOT use with aortic stenosis !! h Dizziness, flushing, weakness, swelling ankles/feet, constipation, and headache may occur

Intrauterine transfusion (IUT)

Done after 20 weeks a unit that is *CMV negative - lacks the antigen - leukoreduced Use prophylactic ABX, consider tocolytics perform the amnio - obtain a sample from umbilical vein for hematocrit Paralyze with vecuronium transfuse EFW(g) x 0.02 to increase HCT by 10% ie, 1000g fetus x 0.02= 20 cc to increase HCT 25% to 35% Perform a final check of the HCT Continuous EFM until baby starts moving.

treat asymptomatic bacteriuria

Duff does 3 days for first.... 7 days in recurrent Suppressive third onward avoid septra in first trimester (and late 3rd)

how often to do IA ?

Every hour in latent labor Every 30 mins in active labor and passive second stage When pushing, do after EACH contraction (or q 5 mins)

indications for EFM

Fetal factors Maternal factors Uterine factors Complications of pregnancy Regional Anesthesia Elective monitoring

asymptomatic bacteriuria species

E-coli is in both asymptomatic bacteriuria and UTI (cystitis and pyelonephritis) in approximately 70 to 90% of cases. Other organisms responsible for UTI included B Streptococcus (10%), Klebsiella and Enterobacter species (3% each) Proteus and Staphylococcus saprophyticus (2% each). Some urea-splitting bacteria, including Proteus, Coagulase-negative Staphylococcus, Klebsiella, Pseudomonas, alkalinize the urine and may be associated with struvite stones. Chlamydial infections are associated with sterile pyuria and account for more than 30% of atypical pathogens. Isolation of more than one species or the presence of Lactobacillus or Propionibacterium may indicate a specimen contaminated by vaginal or skin flora. However, repeated isolation of Lactobacillus with high colony counts (≥105 cfu/mL) can be eligible for treatment. Infections caused by extended-spectrum beta-lactamase (ESBL)-producing strains are increasing in number, even in uncomplicated UTI,

workup peripartum cardiomyopathy

ECG CXR (cardiomegaly and pulmonary edema from heart vailure)) TTE nt-BNP CK-MB, Trop-i TSH During the evaluation, other causes of heartfailure must be ruled out, such as hypertension, coronary artery disease, valvular disease, history of cardiotoxic chemotherapy or thoracic radiotherapy, lupus, and thyrotoxicosis.

Cardinal movements of labor

ED FIRE REX 1. Engagement 2. Descent 3. Flexion 4. Internal Rotation 5. Extension 6. External Rotation 7. Expulsion

Pseudothrombocytopenia (PTCP)

EDTA antibodies As a means of double checking the results, the patient's blood sample is often *examined under a microscope. If the clumping is visible and the number of platelets appears normal, pseudothrombocytopenia may be concluded*. A second sample run with a different anticoagulant such as citrate (blue top tube) to confirm the finding of pseudothrombocytopenia may be requested if there are doubts or concerns

FGR definitions

EFW or AC <10 Early = <32 weeks FGR is defined as the failure of the fetus to meet its growth potential due to a pathological factor, most commonly placental dysfunction The definition of SGA makes no distinction between a constitutionally small but healthy fetus and a fetus with growth restriction. In a given population of fetuses, 10% will have a birthweight <10th percentile, and this group is considered to be SGA. From a biologic point of view, it is implausible to assume that all fetuses whose size is <10th percentile suffer from growth restriction and that none with a weight >10th percentile do. The second limitation of any definition based purely on a point estimate of fetal size is that it does not take into account that fetal growth velocity may slow while the absolute fetal size is still >10th percentile..... particularly in LATE FGR

early dating scan

Earliest scan where there is either - 7 weeks GA - 10mm CRL (FIGO and SOGC) Crown-rump length (CRL) should be used during the 11-14 week prenatal sonographic examination unless the CRL is more than 84 mm....... When the CRL is greater than this length, other biometry indices can be used (head circumference, biparietal diameter, abdominal circumference, or femur length). If multiple first-trimester sonographic examinations have been performed, the earliest exam after 7 weeks gestation or after a CRL of 10 mm has been measured should be used to determine the expected delivery date If second trimester (or >84mm) use multiple second and third trimesters, estimation of gestational age is accomplished by measuring the biparietal diameter head circumference abdominal circumference femur length

early vs late listeria

Early-onset listeriosis occurs in utero, and is associated with a high rate of stillbirth and a high neonatal mortality rate. It appears to occur more frequently in low-birth-weight infants Late-onset listeriosis occurs either intrapartum, or nosocomial... it eventually (days to weeks) manifests as meningitis, usually in term infants born to mothers with uneventful perinatal courses. Neurologic sequelae, such as hydrocephalus and mental retardation, are common with late-onset disease

# ashkenazi Jews

Eastern and central European Jews. Screen them for: - tay- sachs - canavan disease - familial dysautonomia as well as cystic fibrosis

echogenic bowel diagnosis

Echogenic bowel is defined as bowel that appears as bright as bone on ultrasound imaging. When echogenic bowel is suspected, a low-frequency transducer (≤ 5MHz) should be used, and the image gain should be turned down as low as possible to allow for comparison between the echogenicity of small intestine and bone. Evaluation In patients with a fetus found to have echogenic bowel, we recommend the following evaluation: • Specialized anatomy survey • Maternal carrier screening for cystic fibrosis (CF) • Aneuploidy screening (e.g. cell free DNA) • Consideration of amniocentesis, particularly if additional markers of aneuploidy or evidence of congenital CMV infection are noted (e.g., growth restriction, intracranial calcifications, ventriculomegaly, structural anatomic abnormalities) o If amniocentesis is performed, obtain - FISH -karyotype - chromosomal microarray - polymerase chain reaction (PCR) testing for CMV; if maternal CF carrier screening has not already been performed, obtain CF testing from the amniotic fluid

echogenic bowel

Echogenic bowel is known to be associated with a variety of pathologies including - congenital viral infection (particularly cytomegalovirus [CMV]) - cystic fibrosis (CF) - aneuploidy - gastrointestinal pathology - intra-amniotic bleeding. In the absence of other abnormalities, echogenic bowel can also be a normal variant. (especially third trimester, when there is meconium in the colon) Multiple studies have shown that the risks of fetal growth restriction and fetal demise are increased with echogenic bowel, even when noted as an isolated finding.

what drug MAY prolong hellp pregnancies?

Eculizumab a targeted inhibitor of complement protein C5 1200 mg IV- Measure levels to ensure therapeutic.... likely will give once a week. give meningococcal vaccination (due to the small risk of Neisseria meningitidis with complement inhibition)

postpartum anticoagulation

Either unfractionated heparin or LMWH can be restarted six hours after vaginal delivery or 12 hours after cesarean delivery. This should be continued until at least six weeks postpartum. If the patient has a history of VTE, long‐term prophylaxis is required as there is as high as a 30% recurrence risk for VTE in an aPL‐positive patient with a prior VTE....... In this case, warfarin is to be started on day 2, and both heparin and warfarin are to be continued for five days and until the INR is therapeutic (2-3) for two consecutive days.

dopamine agonists

Ergot—Bromocriptine Non-ergot (preferred)—carbergoline also, Quinagolide is available in Canada (not US) They decrease prolactin levels rapidly (days), but may take weeks to reduce tumor size. When compared directly cabergoline is more effective than bromocriptine in normalizing prolactin (83% vs 59%), restoring ovulatory cycles, inducing pregnancy, and reducing tumor size. Patients are less likely to be resistant to the effects of cabergoline, and cabergoline is effective in 70% of patients who are unresponsive to bromocriptine But, Bromocriptine has a shorter half life, is better studied in terms of safety profile. Quinagolide is a non ergot.... it is associated with an increase in congenital malformations and should NOT be used if pregnancy is desired.

# how much to transfuse

Estimated fetal blood volue in mL X [ desired Hct - initial Hct] goal is HCT of ~30%... note: estimated fetal blood volume is 100 ml per KG If hydrops has developed, the hematocrit is usually 15 percent or lower. The red cells transfused are -type O - D-negative - cytomegalovirus-negative - packed to a hematocrit of approximately 80 percent to prevent volume overload - irradiated to prevent fetal graft-versus-host reaction - leukocyte- poor. The fetal-placental volume allows rapid infusion of a relatively large quantity of blood. Before transfusion, a paralytic agent such as vecuronium may be given to the fetus to minimize movement. In a nonhydropic fetus, the target hematocrit is 40 to 50 percent In the severely anemic fetus at 18 to 24 weeks' gestation, a smaller volume is transfused initially, and another transfusion may be planned or approximately 2 days later. Subsequent transfusions take place every 2 to 4 weeks, depending on the hematocrit.

Tobacco and pregnancy

FGR, low birth weight - preterm birth - placenta previa and abruption - fetal demise anomalies (cleft lip/palate) Nicotine crosses the placenta and concentrations in neonatal blood exceed maternal blood- decreases UA flow, and increases UA resistance - carbon monoxide crosses placenta, shifts curve to the left, less O2 to baby - other toxins

when to suspect maternal heart rate artifact?

FHR abruptly changes or improves without explanation, particularly when there have previously been consistently atypical or abnormal FHR features; •shows accelerations during contractions and/or maternal pushing; •demonstrates wide variations, changes in baseline heart rate, or an abrupt change in variability; •demonstrates halving or doubling in the baseline heart rate; •is similar to the MHR; •is difficult to interpret (for example, decelerations may appear "cut off" as a result of MHRA).

Abnormal FHR

FHR pattern that reflects an unfavorable physiological response to the maternal fetal environment. FHR < 100 FHR > 160 for 80 mins Erratic baseline Min variability for 80 mins, or marked variability for 10 mins Sinusoidal fhr Accels do NOT change the classification Repetitive (3+ in a row) complicated varriables Recurrent (> 50%) lates in 20 mins Prolonged decel 3-10 mins

moderate risk thrombophilias

Factor V leiden HETERO-zygotes Protrombin heterozygotes Protin C deficiency Protein S deficiency antithrombin deficiency (and NO fam hx of thrombosis)

NSAIDs risk pregnancy

Fetal closure of ductus with subsequent pulmonary HTN oligohydramnios Neonatal Acute and chronic renal insufficiency Bronchopulmonary dysplasia Severe intraventricular hemorrhage Necrotizing enterocolitis Pulmonary hypertension

CMV ultrasound prediction

Fetal abnormalities may become evident late, change or disappear during pregnancy, and women should be informed that ultrasound abnormalities can appear 12 weeks or more after maternal infection.... so detailed ultrasound follow up (every 2-4 weeks) is indicated. Ultrasound detects fetal abnormalities in only 8.5% of women with primary CMV infection, and in 15% of congenitally CMV-infected fetuses If fetal ultrasound abnormalities are detected, symptomatic CMV infection is present in 35% of neonates of primary-infected mothers, and 78% of congenitally infected neonates among infected fetuses/neonates who had normal prenatal ultrasound(s), the risk of symptomatic infection was 1.5%, the rate of neurodevelopmental anomalies was 3.1%, and the occurrence of hearing problems was 6.5% not all features of congenital inclusion disease are detectable by ultrasound, and normal antepartum ultrasounds and/or MRI examinations do not completely rule out neonatal sequelae, especially hearing outcomes

factors that affect variability

Fetal sleep (most common). In a healthy term fetus this is usually <40 minutes. If there is reduced variability for >40 minutes, the fetus should continue to be assessed by EFM for well-being. •Medications such as: - ○Narcotics, sedatives, and beta blocker - ○Magnesium sulphate (bolus can lead to a transient decrease in variability) - ○Steroids (betamethasone and dexamethasone may affect variability and fetal movements for 3 days and then return to normal) •Prematurity (variability by 32 weeks is usually moderate) •Fetal tachycardia •Congenital anomalies •Maternal smoking

radioiodine in pregnancy by gestation

Fetus begins producing thyroid hormone at 10-12 weeks Therefore, radioiodine under 10-12 weeks will not be transfered to the fetus, and is unlikely to affect fetal thyroid after this, it will cause fetal hypothyroid

thyroid storm presentation

Fever, tachycardia/arrhythmia, vomiting, dehydration, coma, tachypnea, delirium

asthma severity and treatment (chronic)

First line: 1) b2 agonist (Salbuterol aka albuterol aka Ventolin) - 2-4 puffs q4h PRN 2) add inhaled corticosteroids (flovent aka fluticasone) daily.... PLUS the Ventolin - medium = >250 to 500 mcg daily - high = 500-2000 mcg daily ie: flovent 220- 1 puff BID .... up to 4 puffs BID NOTE: Flovent takes days to work (it's a steroid) 3) combination low-dose ICS-formoterol daily (Symbicort) and 1 to 2 inhalations Albuterol/Ventolin as needed up to 12 inhalations/day (preferred option) For Symbicort, start with 160 mcg 1 puff, BID... then 160 mcg 2 puff BID 4) Add a LAMA atrovent (Ipartopium) 2 puffs QID with the Symbicort and ventolin 5) Add steroids PO Worsening: MgSO4 Intubations1th2

Williams aneuploidy screening

First trimester (NT, hCG, PAPP-A) triple screen (MS AFP, hCG, E2) is second trimester Quad screen (MS AFP, hCG, E2, inhibin A) is second trimester .... mnenomic= Down low (unless they are HI) (low AFP, E2... high hCG, inhibibA)

what else to supplement with in obesity

Folic acid (400) vitamin D Check folate, B12, hemoglobin Calcium

vanishing twin findings

Following early first-trimester demise, a twin may vanish completely without leaving any morphologic residue. In such cases genetic evidence of a resorbed twin may be detectable in the form of a restricted placental chimerism. In other cases remnants of a second gestation may be present as a plaquelike thickening within the membranes or on the fetal surface of the placenta of the surviving co-twin

Which cardiac conditions should have hypovolemia ?? Which require nonmovolemia?

For many cardiac conditions, especially - severe pulmonary hypertension and severe aortic stenosis, relative hypervolemia rather than fluid restriction, and avoidance of hypotension are the key intrapartum man- agement principles. Mitral stenosis and some cases of cardiomyopathy are the main exceptions to this principle

Gastric changes in pregnancy

Gastric secretion acidity declines Gastric volume increases LES relaxation, Increased intra-abdominal pressure, combined with a decrease in gastric and intestinal motility, this leads to the "full stomach" effect that puts pregnant women at increased risk of aspiration. This, combined with increased airway edema, increases the risks of general endotracheal anesthesia during pregnancy. ....Thus, for anesthesia purposes, all pregnant women are considered to have a full stomach. decrease in colonic motility and an increase in water absorption, leading to constipation

thyroid storm treatment in pregnancy !! (MCQ's)

Generally, to progress to thyroid storm, you need a second insult (such as surgery, sepsis etc.). 1) 800 mg PTU PO (or NG) immediately .... then 200mg q4-6 hours 2) give a iodide IV to suppress thyroid production - sodium iodide - potassium iodide (Potassium iodide 5 drops orally every 8 hours) - lugol's 3) symptoms with beta blockers (if tachycardia, and in the absence of hypotensive or in heart failure) Propranolol 20-80 mg PO.... or 1mg IV q5 mins (up to 6mg) 4) consider dexamethasone (Corticosteroids inhibit peripheral conversion of T4 into T3) - Hydrocortisone 100 mg IV every 8 hours for 3 doses

what to avoid in renal injury chorio?

Gent !!! Avoid if creatinine clearance < 40

insulin dose calculator pregnancy (per day)

Give 1-2 weeks to try diet and exercise Insulin requirements: 0.8u/KG - first trimester 0.8- 1u/KG- 2nd 1- 1.2u/KG- 3rd

what to give before ECV

Give terbutaline 250 mcg 30 mins prior nitro 50mcg IV

Monitor graves in pregnancy

Goal of antithyroid drugs: target a free T4 within 10% of the non-pregnant upper limit Check TSH and free T4 at least every trimester. Those who are taking anti-thyroid drugs should have TRAb's checked late in pregnancy. If high tiers, they can cross placenta and cause neonatal HYPERthyroid (with side effects includiging: -tachycardia - arrhythmia - heart failure - growth restriction - Goiter Too high a dose of PTU/Meth can cause fetal HYPOthyroid, and fetal goiter. If previous Radioiodine therapy or thyroid surgery, assess for TSH-antibodies (TRAb's) in early and late pregnancy to evaluate for the risk of fetal hyperthyroid.

risk factors for placenta previa

Grand multiparity Prior cesarean Prior uterine curettage Previous placenta previa Multiple gestation maternal age, chronic hypertension, diabetes, smoking and cocaine use during pregnancy, use of assisted reproductive technology

sogc second stage dystocia

Greater than 1 hour of active pushing without descent of the presenting part.

nausea and vomiting tests

H-pylori

hep B vertical transmission and consequences

HBV DNA is found in the umbilical cord blood and placental cells of mothers with detectable viral load and the hepatitis B "e" antigen (HBeAg) can pass through the placenta from mother to fetus where it induces fetal T‐cell tolerance in utero. Because of this in utero tolerance, up to 90% of infants exposed to HBV perinatally or in early childhood develop chronic HBV infection with progression to cirrhosis and hepatocellular carcinoma Adults have less than 5% chance

microcephaly

HC of 3 SD below the mean Causes: unknown - 40% genetic- 30% brain injuries- 30% CMV- most common toxoplasmosis, rubella, herpes, syphilis, human immunodeficiency virus, and Zika virus. Non-infectious causes of microcephaly include maternal exposure to heavy metals or toxic chemicals, such as arsenic or mercury; alcohol; radiation; smoking; and pre- and perinatal injuries to the developing brain (hypoxia-ischemia, trauma). Genetic causes: PKU Congenital serine

manage autonomic dysreflexia

HOB elevate 90 degrees, loosen constrictive clothing assess for full bladder or bowel impaction, (trigger) administer antihypertensives (may cause stroke, MI, seizure) Neuraxial analgesia is effective at decreasing the risk of autonomic dysreflexia f autonomic dysreflexia is thought to be exacerbated by labour, labour may need to be expedited by proceeding to a cesarean or operative vaginal delivery.

SLE history

HPI • When disease diagnosed • Presentation • Flares: Most recent flare, how often flares, most severe flare • What symptoms usually have • Any current symptoms • Any renal involvement (>50% pts) • Other organs involved? • Known antiphospholipid Abs • Anti SSA (Anti-Ro) or SSB +ve (Anti-La) • Current medications - doses stable? POB/GynHx • GTPAL • Outcomes of any previous pregnancies • Neonatal complications of previous pregnancies • Pregnancy complications suggestive of APAS ○ Recurrent SA ○ T2 or T3 IUFD ○ Severe pre-eclampsia or IUGR <34wks • Pap Hx • STIs • Current contraception PMHx & PSHx • VTE • Renal disease • Hypertension Meds & Allergies • Steroids, NSAIDs, hydroxychloroquine, azathioprine • C/I = cyclophosphamide, MTX (MUST STOP) • Taking PNV with 1mg folic acid SHx • Smoking/Etoh/Drugs FHx • Genetic/chromosomal/congenital anomalies • VTE/HTN

Timing of maternal HSV

HSV may cause anomalies and miscarriage, but no strong data. microcephaly, hepatosplenomegaly, IUGR,and IUFD Risk is highest in primary episode in third trimester beause there is trans placental passage and the mom does not have antibodies

Peripartum cardiomyopathy (revisit this chapter)

Heart failure with no identifiable cause can develop between last month of pregnancy to 5 months postpartum Risk factors: Multiparity, age > 30, multiple gestations, preE • Heart failure secondary to left ventricular systolic dysfunction with left ventricular ejection fraction (LVEF) <45%. presence of an elevated N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) >300 is an aid

cardiac changes of pregnancy (MCQ)

Hemodynamic changes in pregnancy that have been well established include an - increase in HR and cardiac output - decrease in both systemic and pulmonary vascular resistance. Blood volume, plasma volume, and erythrocyte volume all increase, with a greater relative increase in plasma volume, resulting in a dilutional lowering of hematocrit and other blood indices . There is also a redistribution of cardiac output with an increase in flow to the uterus, kidneys, skin, and breasts cardiac output in pregnancy indicated that cardiac output peaks in the early third trimester at 31% higher than nonpregnant values and quickly returns to baseline in the early postpartum period The physical findings of pregnancy are caused by expected hemodynamic alterations with increase in heart rate, fluid retention, expanded blood volume, and decreased afterload. Inappropriate sinus tachycardia may be present at rest, especially during the third trimester. The cardiac examination in pregnancy may be notable for a hyperdynamic, diffuse precordial impulse that becomes displaced to the left as pregnancy progresses. The right ventricular impulse may be more prominent. The first and second heart sound may increase. Heart murmurs are heard in nearly 96% of pregnant women; classically, it is a mid-systolic murmur that is heard best along the left sternal border. This is probably the result of increased transvalvular flow from expanded blood volume. There may be a venous hum or a supraclavicular systolic murmur from the brachiocephalic arteries. Tricuspid regurgitation has been noted during pregnancy.

diagnose hemoglobinopathies Who to screen?

Hemoglobin electrophoresis results will vary with the disease state present. Normal hemoglobin electrophoresis results show 95-98% HbA 2-3% HbA2, 0.8-2% HbF. S sickle cell disease, sickle cell trait, and beta‐thalassemias will be diagnosed on electrophoresis. Alpha‐thalassemia cannot be diagnosed by electrophoresis and instead requires genetic testing!!! ACOG recommends that ALL moms be screened for a hemoglobinopathy during first pregnancy through electrophoresis, or molecular genetic testing If both the patient AND the partner are carriers, then recommended to check fetal status through amnio/cvs

HELLP syndrome Tennessee

Hemolysis: LDH > 600 OR T. Bili > 20 umol/l (≥1.2 mg/dL) LFT's > 2x normal Platelets 100

Hep B risk factors

Hepatitis B •birth in area with HBV prevalence >2% (intermediate to high endemicity) •travel to countries with intermediate to high endemicity •sexual contact and /or living with an individual with HBV infection •intravenous drug use •multiple male sexual partners •history of receiving blood transfusions without appropriate infectious screening •exposure to infected blood or body fluids through contact with needles or medical devices (health care workers)

forceps stations in pelvis (MCQ)

High (> 0) fetal head not engaged with station above ischial spines contemporary practice does not support the use of vacuum or forceps for delivery at high station Mid (0 to +2) fetal head IS engaged.... no more than 1/5th palpable above the pubic brim per abdomen leading bony point of fetal skull is above station +2 cm but not above spines rotation ≤ 45 degrees from OA rotation > 45 degrees from OA (incl OP) Low (+2) leading bony point of fetal head at station ≥ +2 cm rotation ≤ 45 degrees from OA rotation > 45 degrees from OA (incl OP) Outlet fetal scalp visible at introitus without separating labia fetal skull has reached pelvic floor sagittal suture in anterior position or rotation < 45 degrees

why are infants big in GDM ?

High glucose = high insulin High insulin stimulated IGF 1 and IGF 2 If these genes are knocked out (mice), way less

Alpha Thalassemia

High risk groups = African, Mediterranean, South Asian, West Indian Normal is αα/αα 1. If 1 allele is deleted, this is a silent carrier....., patient is asymptomatic. (αα/α-) 2. If 2 alleles are deleted, this is known as alpha thalassemia minor..... The patient will develop a mild hypochromic anemia with increased RBC count. This is not a clinically significant anemia. a) Cis-deletions (same chromosome) of 2 alleles are prevalent in Asian populations (αα/- - ) . This is WORSE than trans-deletion because it increases the risk of hydrops fetalis and severe α-thalassemia in offspring. b) Trans-deletions (α-/α- ) of 2 alleles are prevalent in African populations." "3. If 3 alleles are deleted (α- /- -) this is called HbH disease - the patient will develop a severe microcytic, hypochromic anemia. The β-globin chains form β2β2- tetramers (HbH) which precipitate and damage RBCs. Note, HbH is detectable by electrophoresis. 4. If 4 alleles are deleted (- -/ - - ) , hydrops fetalis (!!!) will develop which is lethal in-utero!! (poor oxygen delivery, congestive heart failure, death)If 4 alleles are deleted, γ-globin chains form tetramers (Hb Barts) which precipitate and damage RBCs. Note, Hb Barts is detectable by electrophoresis. !!!!!!!!!!!

SOGC high dose folic acid

High-dosage folate supplementation (oral dosage of 4-5 mg/d) should be used only for women at high risk; 1) women who can become pregnant and who have had a previous pregnancy affected by a neural tube defect 2) have had a neural tube defect themselves 3) have a first-degree relative with a neural tube defect (strong, moderate). The high daily dose should only be offered to women with other medical or surgical conditions associated with a risk of folic acid deficiency if these women have a pre-conception low serum or red blood cell folate value that persists after 1-2 months of daily supplementation with 1.0 mg of folic acid. These conditions include pre-gestational diabetes mellitus; gastrointestinal pathologic conditions or history of gastric bypass surgery; use of medications with anti-folate physiological effects (e.g., methotrexate, phenytoin, carbamazepine, valproate, sulfasalazine); alcohol use disorder; and history of non-compliance with oral medication that may affect the woman's ability to achieve an adequate folate supplementation level.

SOGC stillbirth workup

History family history - familial disorders - VTE - previous anomalies or karyotypes - inherited conditions Mateal diseases VTE, DM (A1C), HTN, APS, autoimmunne Hb electrophoresis Maternal risks AMA, smoking, diabetes, Fetal causes FGR , abruption, maternal.fetal hemorrhage, anomalies CMV, listeria, B19

hTN tests

History Physical exam (BP, heart for murmurs, peripheral edema, fundoscopy) Labs (PIH labs) Ancillary (EKG)

High risk thrombophilias

Homozygous Factor V Leiden, Homozygous for prothrombin mutation antithrombin deficiency (and WITH fam hx of thrombosis) APLS combined thrombophilias

caveat to tetracyclines in pregnancy (SOGC)

However, extensive literature on and experience with doxycycline use in pregnancy has demonstrated no such risk. A recent systematic review of doxycycline in pregnancy and early childhood found (1) no teratogenicity during pregnancy, (2) no permanent tooth staining from in utero exposure or use by children under 8 years old, (3) no hepatotoxicity, and (4) no permanent inhibitory effects on bone growth

urgent delivery with Previa hemorrhage

However, if antepartum hemorrhage results in: - maternal hemodynamic compromise = abnormal fetal heart rate pattern, - there is significant antepartum hemorrhage delivery at ≥34 weeks gestation, urgent delivery is warranted

postpartum rubella vaccination

However, it should be noted that postpartum vaccination with MMR is contraindicated for women receiving systemic immunosuppression with biologics like anti-tumour necrosis factor agents or long term high-dose steroid treatment (prednisone equivalent of ≥20 mg/day for ≥14 days). Another consideration is to delay postpartum vaccination if the patient received any immunoglobulin-containing preparations, including Rh immune globulin, IVIG, or blood products, during pregnancy or the peripartum period, as vaccine effectiveness may be reduced. The recommended interval between receipt of Rh immune globulin or blood products and subsequent administration of MMR or MMRV will typically vary between 3 and 6 months, but it may need to be as long as 11 months for women who received large doses of IVIG. Exception: washed RBC's If there is a need to vaccinate a postpartum woman without delay, such as in cases of recent exposure to rubella, risk of pregnancy within 3 months postpartum, or potential loss to follow-up, the vaccination should still be given before hospital discharge, but serological testing to confirm immunity is recommended.

HIV risk factors

Human immunodeficiency virus (HIV) •intravenous drug use •male sexual partner with HIV •male sexual partners who have had male-to-male sexual contact •sexual activity with multiple partners without using condoms •transactional sex •history of sexually transmitted infections in self or partners

two types of hydrops

Hydrops fetalis = two or more fetal effusions- pleural, pericardial or ascites - or one effusion plus anasarca (general swelling- skin >5mm ) Usually accompanied by placentomegaly and polyhydraminos as it progresses. Clinically significant edema = sonographically > 5 mm skin thickness Clinically significant placentomegaly = sonographically placental thickness - > 4 cm in the second trimester or > 6cm in the third trimester. Hydrops is divided into two categories: Immune hydrops occurs when the mother's immune system attacks and destroys the baby's red blood cells due to incompatible maternal and fetal blood types. This form of hydrops is uncommon today because of medication available to prevent the condition (for the D-antigen). Non-immune hydrops, the most common type, is caused by a fetal medical condition or birth defect that affects the body's ability to manage fluid. Up to 90% of all cases of hydrops today are non-immune hydrops.

Active TB treatment pregnancy

INH + B6

moderate vs severe pyelo treatment

IV antibiotics to start moderate- ceftriaxone (1g IV q48h) is preferred.... or amp/gent 14 day course of PO antibiotics .. Finish with Septra DS ( 1 tab BID 160/800) preferred if e-coli (avoid keflex due to poor coverage) Severe- piptazo (3.375g q6h) extended-spectrum beta-lactamase (ESBL) organisms (usually E-coli/klebsiella) - do metro/erta - Ertapenem is q24 hours, does not cover Pseudomonas, and Enterococci..... - Meropenem is q8hours, and does cover them... therefore, meropenem is preferred. ultrasound (septic stone or perinephric abscess) After completion of therapy for acute pyelonephritis during pregnancy, - 30% to 40% of women have recurrent bacteriuria. If this infection is left untreated ... approximately 25% develop recurrent pyelonephritis..... therefore, treat with daily suppressive therapy suppressive therapy with: Macrobid 100mg PO QHS - except for proteus and pseudodomas... use Keflex here Note: (500 mg qhs also acceptable)

dating twins

IVF- use conception date - When there is size discordance between the twins, gestational age can be estimated by: - using the biometry of the larger OR smaller fetus - using the average biometry of the 2 fetuses. The common clinical practice is to use the biometry of the larger twin, erring on the side of overestimation of gestational age, in order to avoid missing intrauterine growth restriction in the smaller twin. However, this overestimation may also lead to iatrogenic prematurity. n the first trimester, there is no significant difference in crown-rump length (CRL) discordance between monochorionic and dichorionic twins suggesting the same rule could apply to both. In the first trimester, many studies involving ART have shown that the size of the smaller twin has the best correlation to the known gestational age the foregoing discussion supports dating of twin gestation based on biometry of the smaller twin in the first trimester and the larger twin in the second trimester.

Causes of polyhydramnios

Idiopathic Maternal Fetal: - esophageal atresia - duodenal atresia - congenital diaphragmatic hernia - chest masses • CNS defect, e.g., Arnold-Chiari malformation, holoprosencephaly, sacrococcygeal teratoma. • Thoracic mass, e.g., diaphragmatic hernia, pulmonary sequestration, cystic adenomatoid malformation. • Gastrointestinal tract obstruction, e.g., duodenal atresia, esophageal atresia. • Sonographic markers of aneuploidy. • Placental abnormalities including large chorioangiomas. • Positioning of fetal hands and feet to evaluate for arthrogryposis syndromes. • Fetal growth. While idiopathic polyhydramnios may be associated with macrosomia, fetal growth restriction associated with polyhydramnios presents a high risk for an underlying fetal abnormality, including trisomy 13 or 18. Fetuses with central nervous system (CNS) anomalies such as anencephaly and holoprosencephaly may develop polyhydramnios from altered CNS function and altered swallowing function Fetal causes include: Congenital infection, red blood cell alloimmunization, and placental chorioangioma are less frequent etiologies. Infections that may present with hydramnios include cytomegalovirus, toxoplasmosis, syphilis, and parvovirus. Hydramnios is often a component of hydrops fetalis, and several of the above causes Specific etiologies include - the recipient twin in twin-twin transfusion syndrome - alloimmunization - parvovirus infection, - fetal-maternal hemorrhage. Even with idiopathic polyhydramnios, the degree of excess amniotic fluid is associated with an increased risk of perinatal mortality.

causes of high prolactin

Idiopathic Physiologic Prolactinoma Drugs (anti-emetics, anti-psychotics) Pregnancy/Lactation (up to 1 year is normal) Stress Hypothyroidism Renal/liver failure Stalk compression can also cause raised prolactin (both pituitary tumors and non-pituitary tumors). Chest wall lesions/damage (mammoplasty, trauma, herpes zoster) ... they mimic suckling Infiltrative disorders (sarcoid, TB)c

hep B testing if positive

If HBsAg+, test for HBsAb, eAg eAb cAb. Also test quantitative HBV-DNA level in early third trimester Women who are known to be or found to be chronically HBV infected (HBsAg+) should also be screened for prior hepatitis A virus infection (test: HAV-IgG) and vaccinated if nonimmune because coinfection with other hepatitis viruses has additive morbidity.

diagnose parvovirus in mom

If IgG positive + IgM negative, the woman is immune and should be reassured that she will not develop infection and that the virus will not adversely affect her pregnancy . (II-2A) - If both IgG and IgM are negative (and the incubation period has passed), the woman is not immune and has not developed the infection. She should be advised to minimize exposure at work and at home. Absence from work should be considered on a case-by-case basis . NOTE: IgM usually appears 10-14 days... and persists ~4 months. However, reliance on a negative IgM serologic result alone can be misleading in a patient with a significant exposure history, because in some instances maternal IgM levels may be below the detection limit. In such cases, PCR of B19 DNA can be useful. In a study utilizing serum samples from 101 pregnant women with confirmed B19-induced fetal hydrops, 15 percent of the patients who were seronegative for B19 IgM antibodies had evidence of viremia by maternal B19 DNA testing. IgG positive and IgM positive Maternal parvovirus B19 IgM antibodies can be detected approximately 3-10 days after exposure and typically persist as long as four months. proceed to evaluation

how to act when you suspect maternal heart rate artifact ?

If MHRA is suspected during intermittent auscultation, initiate continuous electronic fetal monitoring. .Optimize the position of the external FHR transducer(s). Initiate continuous monitoring of the MHR with a pulse oximeter if not already started. (This is more accurate than the MHR sensors available with some tocodynamometers.) use point-of-care sonography, if available, to directly visualize the FHR and further optimize the position of the external FHR transducer .consider applying a fetal scalp electrode if there are no contraindications (preferred); if a fetal scalp electrode is contraindicated and there is ongoing suspicion of MHRA, then augment continuous external fetal monitoring with continuous or repeated point-of-care sonography (an alternative to fetal scalp electrode), if available, to monitor the FHR over time, but note that this technology has major limitations

how much can winrho reduce incidence of sensitiviation

If Rh-negative mothers do not receive postpartum anti-DIgG prophylaxis after an Rh-positive baby, the incidence of sensitization during the next pregnancy is 12% to 16%, compared to 1.6% to 1.9% in mothers receiving postpartum prophylaxis

treat varicella exposure in pregnancy

If UNDER 20 weeks, treat with VariZIG for prevention of congenital varicella syndrome. If OVER 20 weeks, there is no risk of congenital varicella...... BUT, pregnant women are immunosupresed, and VZV has a very high risk of causing pneumonia, and high risk of morbidity and mortality, and 10% need intubation...... so *still get varicella IgG for maternal benefit!!!* treated within 72 to 96 hours (ideally.... but can be within 10 days) with one of two agents to prevent active infection. 1) (VariZIG), given IM, The dose is 125 units per 10 kg given intramuscularly, with a maximum dose of 625 units. 2)If VariZIG is not available, consider administering a single dose (400 mg/kg) of intravenous immune globulin (IVIG) ≤10 days of exposure. 3) Another alternative is An alternative is to administer oral acyclovir (800 mg, five times daily for 7 days) or oral valacyclovir (1000 mg, three times daily for 7 days). pregnant women who develop varicella despite immunoprophylaxis should be treated with oral acyclovir or valacyclovir in the same dose as outlined for prophylaxis. Patients who have evidence of: - pneumonia - encephalitis - disseminated infection - immunocompromised should be hospitalized and treated with intravenous acyclovir for 10 days). - 10mg/kg IV q8h If women get ANY viral illness in pregnancy they get high fever, and high fever is risk of preterm labor!!!!!!!!!!!!!!! 3) At 39 weeks, and the Chickenpox infection occurs within 5 days of delivery......* give BOTH the mom Varicella IgG... AND give the baby varicella igG.*

black lambda sign

In a monochorionic twin pregnancy, an "empty" or "black" lambda sign can sometimes be seen. In this case, the inter-twin membrane is split at the insertion site; however, this appearance is because the inter membrane space is filled with hypoechoic fluid instead of echogenic chorion. This fluid filled space usually resolves later in pregnancy and the T sign is established. This finding should not be confused with dichorionic placentation.

conception on HIV with cART

If condomless sex or sperm washing is the intended conception method for serodiscordant individuals, conception should be delayed until the partner with HIV is on cART with at least 2 viral load measurements at least 1 month apart below the level of detection. Preferably, full viral suppression is also recommended for a minimum of 3 months prior to conception attempts, with at least 6 months of viral suppression being even better. In circumstances of rapid viral suppression that may become more common with the use of newer antiretroviral agents, conception using condomless sex or sperm washing could be recommended earlier with 2 undetectable viral loads at least 1 month apart, but waiting 3 to 6 months is still preferable.

When to screen for short cervix ?

If history, screen at 16 weeks.... Routine at 18-20 weeks. Reproducible measurement of cervical length usually becomes possible at approximately 14 weeks of gestation it is consistently possible by 16 to 18 weeks when the cervix normally becomes distinct from the lower uterine segment Cervical length measurements before 14 weeks of gestation have limited clinical value

Switch anticoagulation APS pregnancy (low molecular weight to unfractionated)

If low molecular weight heparin (LMWH) is used in the antepartum period, one may consider or earlier if preterm delivery is expected since it has a shorter half‐life than LMWH. Protamine may fully reverse the anticoagulant effects of unfractionated heparin. If the aPTT for patients on unfractionated heparin is normal or vaginal or cesarean delivery occurs more than 12 hours after the last dose of unfractionated LMWH, patients should not experience anticoagulation‐related problems with delivery.

how to start insulin in pregnancy

If the hyperglycemia follows a meal, than rapid-acting insulin or regular insulin should be initiated before that meal (begin with 1 u of insulin for 10-15 g of carbohydrates). If hypoglycemia is fasting, go up on basal. Sometimes both fasting and postprandial glycaemia are elevated, thereby needing MDI: 3 mealtime insulin and basal insulin

manage uterine inversion

If the uterine inversion occurs before separation of the placenta, it is important that the placenta be left in situ, as manual removal or separation of the placenta will lead to additional hemorrhage. Management involves - maternal hemodynamic stabilization with fluid - replacement of the uterus to its proper orientation. Replacement often requires uterine relaxants such as -nitroglycerin (50mcg x1) - halogenated anesthetics - terbutaline (0.25mg sc x1) - magnesium sulfate. Once the uterus is relaxed, manual pressure is applied internally to reposition the uterine fundus. After repositioning, uterotonic agents should be administered to control maternal bleeding and prevent recurrence of the inversion. If manual repositioning is unsuccessful by a vaginal approach, laparotomy or laparoscopy may be indicated to correct this condition. Two procedures have been described for these circumstances. 1) Huntington procedure (using Babcock or Allis clamps on the cephalad- most portion of the round ligaments to apply upward traction on the fundus) 2) Haultain procedure (incising the posterior cervix in the sagittal plane, allowing for digital repositioning of the uterus, with subsequent repair of the incision) Both procedures are then followed by uterotonic therapy.

how often are IUT's performed?

If under 24 weeks, we only correct half the hematocrit .... do a second procedure 48 hours later. In other cases, the hCT decrease is around 1% per day, so probably around q 2-3 weekly. (monitor with MCA PSV) Deliver around 38/39 weeks.

diagnose toxoplasmosis pregnancy in mom

IgG antibodies usually appear within two weeks of infection and persist in the body indefinitely. IgM antibodies often remain positive for up to one to two years. A positive IgM antibody test result at any time does not necessarily mean the infection was acquired recently; ......this needs to be confirmed at a reference laboratory. Only approximately 22%-40% of positive IgM results obtained at nonreference laboratories in the United States are deemed to have had a recent acute infection If IgG negative and IgM negative, this indicates the absence of infection or extremely recent acute infection. positive IgG and negative IgM , this indicates an old infection (infection greater than 1 year ago). IgG positive and IgM are positive this indicates either a - recent infection - false-positive test result - pastinfection - Repeat this in 2-3 weeks The Sabin-Feldman dye test (SFDT) is still considered the "gold standard". It detects the presence of anti-TG-specific antibodies (total Ig). The absolute antibody titer is also important: values over 250 IU/mL are considered highly suggestive of recent infection. Maternal infection is diagnosed by sending maternal serology to a reference laboratory ..... It is best to make the diagnosis based on two different serum specimens collected at least four weeks apart. Usually, the reference laboratory reports serologic results with a high possibility of infection if there is the following: • Seroconversion during pregnancy • Increase in both specific IgG titer (>3-fold) and dye test titer (>3-fold) • Presence of specific IgM and dye test ≥300 IU/mLv In recent decades, Toxo IgG avidity assay has been used as a standard diagnostic technique for a better estimation of the infection acquisition time and identification of the primary T. gondii infection during pregnancy. Avidity is described as the aggregate strength; by which, a mixture of polyclonal IgG molecules reacts with multiple epitopes of the proteins. This parameter matures gradually within 6 months of the primary infection

PPROM immediate vs delayed delivery

Immediate Lower chorio higher RDS, NICU, mehanical ventilation, cesarean, endometritis Neonatal sepsis similar (if GBS neg)

mirror syndrome findings

In a systematic review of 12 reports of Mirror syndrome in 82 patients, common maternal signs were -edema (62 percent) - hypoalbuminemia (55 percent) - anemia (39 percent) - new-onset hypertension (39 percent) Six studies (47 patients) reported maternal complications, such as : - postpartum hemorrhage (45 percent) - hemorrhage requiring transfusion (19 percent) - intensive care unit admission (13 percent) - heart failure (11 percent) - pulmonary edema (8.5 percent) - kidney dysfunction (8.5 percent). In 39 cases, perinatal outcomes included stillbirth (67 percent) and neonatal or infant death (26 percent)

Other anomalies in TRAP

In addition to - subcutaneous edema - absent craniofacial structures - and incomplete spine - hypoplastic thorax malformations in acardiac twins include intestinal atresia, imperforate anus, and renal or hepatic agenesis. The heart may be completely absent (holoacardius), rudimentary (pseudoacardius), or relatively well formed; less than 20% have some identifiable (nonfunctional) cardiac tissue. Lung development is variable.

thalassemia pregnancy

In all patients with any form of thalassemia, regular monitoring for anemia should be performed. Iron supplementation should not exceed normal prophylactic doses of iron unless laboratory evidence of iron deficiency is noted. . Per ACOG, pregnancy in women with beta‐thalassemia is only recommended for those with normal cardiac function and who have undergone prolonged hypertransfusion therapy with iron chelation. These patients are at risk of fetal growth restriction and should be monitored with serial growth ultrasounds.

risk of epidural What are side effects ?

In cephalic labour, epidural analgesia increases the need for oxytocin augmentation impairs maternal pushing efforts prolongs the second stage increases the need for assisted vaginal birth. Side effects: - hypotension (sympathetic blockade causes vasodilation and low venous return) - fever - shivering - urinary retention - pruritis

what characteristic makes monochorionic dangerous?

In contrast to fused dichorionic placentas, almost all monochorionic placentas (>95%) exhibit intertwin vascular anastomoses crossing the intertwin membrane vascular communications between monochorionic twins can be artery-to-artery (AA) vein-to-vein (VV) artery-to-vein (AV) AV anastomoses are obligatorily unidirectional. AA and VV anastomoses are bidirectional and allow flow in either direction, depending on pressure gradients between twins. Superficial AA and VV anastomoses are thus believed to be able to compensate for flow imbalances generated by nonequilibrated AV anastomoses.

differences in mirror syndrome vs preeclampsia

In contrast to preeclampsia, the maternal hematocrit is often low (hemodilution) rather than high (hemoconcentration) amniotic fluid volume is often high (polyhydramnios) rather than low (oligohydramnios) and the fetus always shows signs of hydrops

vanishing twin affecting pregnancy

In general, the first trimester demise of a dichorionic twin has no negative affect on the surviving twin First trimester demise of a monochorionic twin may also have no effect on the co-twin; however, second and third trimester demise can have serious adverse effects

gallstone risk pregnancy

In pregnancy, stone formation is accelerated by the high levels of circulating progesterone. The latter causes gallbladder hypomotility, resulting in bile stasis which allows for supersaturated cholesterol to form crystals, which eventually leads to biliary sludge, then macroscopic gallstones.

placental edge in previa

In presence of a placenta previa, the presence of a thick placental edge >1cm is associated with a higher risk of -antepartum hemorrhage - cesarean delivery - PAS

major causes of OB sepsis

In the UK Obstetric Surveillance System, clinical laboratory testing identified the causative microorganism in only 64% of maternal sepsis cases, and the clinician identified the source in only 74%. In 16%, neither the inciting organism nor the source of sepsis was identified These figures are consistent with the overall experience of sepsis in a general adult population, in which: - blood cultures are negative in two-thirds of patients - and cultures from all sites are negative in one-third. The most frequently isolated organisms in maternal sepsis are - Escherichia coli - group A and group B Streptococcus. However, staphylococci, gram-negative and anaerobic bacteria, and many other organisms have been reported. Mixed infections are also possible; in 15% of maternal sepsis deaths in which organisms could be identified, the infection was polymicrobial.

latent TB in pregnancy treatment

In the absence of risk factors (HIV, immunosuppression, TB infection within 2 years) .... then it could be okay to wait until post partum. .....Treatment of choice is Isoniazid (+B6) for 9 months If there are risk factors (HIV, immunosuppression, infection within 2 years) .... then treatment is start Isoniazid (+B6) for 9 months after first trimester

amniotic fluid volume

In the first half of pregnancy, the majority of amniotic fluid is a result of active transport of sodium and chloride across the amniotic membrane and fetal skin, with water moving passively in response. In the second half of pregnancy, the majority of amniotic fluid consists of fetal urine. The amniotic fluid volume is not stagnant but is completely turned over at least once daily. All of these methods also demonstrate that AF volume increases progressively between 10 and 30 weeks of gestation. Typically, volume increases from less than 10 mL at 8 weeks, 630 mL at 22 weeks and 770 mL at 28 weeks' gestation. After 30 weeks, the increase slows, and AF volume may remain unchanged until 34 weeks..... when it tends to decrease. As a pregnancy proceeds past the due date, AF volume decreases sharply, averaging 515 mL at 41 weeks

treat ebola

In the situation of a confirmed case of Ebola, the focus of therapy is on supportive care with - maintenance of intravascular volume - correction of electrolyte and metabolic abnormalities - correction of coagulation abnormalities, nutrition - antimicrobial therapy of secondary bacterial infections. Currently no proven antiviral therapies or vaccines are available for clinical use; however, corrections of electrolyte and metabolic abnormalities are usually effective in supporting the individual through this self-limited viral illness

Hyperreactio Luteinalis

In this condition, one or both ovaries (usually BILATERAL) characterized by ovarian enlargement with multiple, large-follicle cysts, corpora lutea, or both, and with marked edema of the stroma. Cysts are caused by luteinization of the follicular theca interna layer, and most are stimulated by exceptionally high hCG levels . Thus, they are more common with: - gestational trophoblastic disease - twins - fetal hydrops - other conditions with increased placental mass (Nassr, 2018). Maternal but NOT fetal virilization may develop (~30%) Usually occurs 3rd trimester. As with any condition with mass effect, there is a risk of - torsion - cyst rupture

DIC (disseminated intravascular coagulation) labs

Increase in PT/ PTT D-dimer fibrin LOW fibrinogen

early FGR

Increased Doppler PI in the umbilical and uterine arteries, a sign of placental insufficiency, is much more frequent in early suspected FGR and comparatively rare in late suspected FGR

Risks of Twin Pregnancy compared to singleton

Increased rate of congenital anomalies increased miscarriage PTB growth restriction IUFD Cord entanglement Cerebral palsy Cesarean Hyperemesis Hypertension diabetes Possibly IHCP, fatty liver Anemia Abruption PPROM PPH

renal transplant pregnancy

Increased risk for HTN preeclamspia C/S (60% rate, obstructed kidney obstructs labor)

obesity and pregnancy complications

Infertility OR 1.7-2 Miscarriage rates OR 1.31 Recurrent miscarriage OR 1.75, Decreased live birth rate following IVF OR 0.85 Prenatal/Medical Chronic hypertension OR 2-3 Gestational hypertension OR 2.5-3.2 Pre-eclampsia OR 3.15 (2.69-3.35).... Risk increases with increasing class of obesity Gestational diabetes OR 1.4-20 Venous thromboembolism OR Obstructive sleep apnea OR 1.12 Respiratory issues (e.g. asthma exacerbations) OR 1.3 Depression OR 1.12 OR 4.9 class III Urinary tract infections OR 1.4 Urinary Incontinence OR 1.53 (1.28-1.83) Obstetric Spontaneous pregnancy loss OR 1.7 Indicated preterm birth OR 1.3 Includes overweight Spontaneous preterm birth OR 1.24 Lower accuracy of ultrasound 25-48% detection Residual anomaly risk after ultrasound in obese 1% Progressively worse with increasing BMI Difficulty with fetal testing (e.g. FH monitoring) Failure to progress OR 2.6 Class II Induction of labor OR 2.2 [ Fetal distress OR 1.3 Class II (BMI >35) Lower success of TOLAC OR 0.53-2.0 Excessive weight gain lowers success—Class III Rupture/dehiscence after TOLAC OR 5.6 Postterm birth (less likely to go into spontaneous labor) OR 1.7 Increasing incidence with increasing BMI Lower rates of breastfeeding (Failure to start and sustain) OR 2.6 Class III [4] Late prenatal care OR 1.56 [8] Fetus/Neonate Congenital fetal defects Neural tube defects OR 1.7-2.8 OR 3-4 class II-III [29, 32, 330] Congenital heart disease OR 1.3-1.5 Increases with increasing BMI [33, 49, 51, 78, 330] Cleft lip/palate OR 1.13 (1.04-1.23) [78, 330, 331] Anorectal atresia OR 1.5 [78, 330] Hydrocephalus OR 1.7 [78] Limb reduction defects OR 1.3 [330] Down syndrome 1.12-1.56 [332] IUGR 2.1 [333] Gastroschisis OR 0.17 Reduced risk in the obese [330] Macrosomia (>4000 g) OR 1.7-2.36 [4, 8, 22, 99, 149] Birth injury, shoulder dystocia OR 1.51-3.1 Associated most with macrosomia [12, 47, 99] Low Apgar scores OR 1.4 (1.27-1.54) Increases with increasing obesity class [4, 50, 334] Fetal death OR 2.0-3.6 [40, 41-43] Neonatal mortality OR 1.15-1.3 OR 3.4 class III [16, 330] Childhood obesity BMI >95 percentile and metabolic syndrome OR 1.62-4.47 Increases with increasing levels of obesity and GWG anesthetic complications

consent for drug testing

Informed consent needs to be obtained and documented in the medical record before any maternal or neonatal drug testing is performed (except in life-threatening situations for which informed consent is impossible). If the mother refuses, this should be documented, and testing should not be performed.

SOGC GBS infant monitoring

Initial signs of sepsis may be subtle and include respiratory distress, temperature instability, tachycardia, seizures, hypotonia, lethargy, poor peripheral perfusion, hypotension and acidosis. Recommendations for infants: - Infants delivered by women who have received intrapartum antibiotics at least 4 hrs before delivery, do not need a septic workup. These infants should be observed in hospital for the first 24 hrs for signs of infection, but do not need additional therapy or investigations. - Infants who appear well despite their mothers being GBS colonized & not receiving adequate antibiotics (<4 hrs) should be observed for 48 hrs and evaluated or treated if signs of sepsis develop. -Infants of mothers with chorioamnionitis should undergo a diagnostic evaluation for sepsis & be treated with antibiotics. (Sepsis workup includes a complete blood-cell count & differential, blood culture, and chest radiograph, including a lumbar puncture if feasible.)

respond to tachysystole

Initiate BEFORE the 30 mins (after 10 mins) continue EFM stay with patient Reduce or shut off pit.... or remove prostaglandin assess for abruption Notify staff, anesthesia, NICU, charge nurse Consider tocolysis (nitroglycerin)

pregnant trauma considerations

Insert NG tube (gastric aspiration) Maintain sats of 95% Insert chest tube 1-2 intercostal spaces higher avoid vasopressors

Marginal cord insertion

Insertion of the umbilical cord within <2 cm from the placental margin Whereas lateral insertion of the umbilical cord >2 cm from the placental margin is described as eccentric cord insertion. A marginal cord insertion is where this distance is reduced to a minimum, but the insertion site is supported by very little placental tissue. V

Glyburide vs insulin

Insulin is preferred Insulin is better at achieving euglycemia, lower neonatal weight, less neonatal hypoglycemia, less maternal weight gain.

how do twins grow compared to singletons?

Intrauterine growth of twins is similar to that of singletons until 30 to 32 weeks' gestation, when the abdominal circumference measurements of twins begin to lag behind those of singletons. The use of twin-specific charts is associated with a marked decrease in the diagnosis of: - small for gestational age or FGR with their associated consequence.... without affecting the rate of stillbirth, adverse perinatal outcomes, or long-term morbidity. Thus, when assessing sonographic biometry of dichorionic twins for growth velocity, the use of specific charts for twins is recommended.

manage septic shock

Intravenous fluid administration should be titrated in accordance with the patient's pulse, blood pressure, and urine output. If the initial fluid infusion is not successful in restoring hemodynamic stability, a central venous heart catheter should be inserted. Treatment goals of fluid resuscitation include a: - central venous pressure of 8 to 12 mm Hg - a mean arterial pressure of 65 mm Hg or higher - urine output of 0.5 mL/kg or greater per hour - a mixed venous oxygen saturation of 70% or greater. if fluid resuscitation alone does not restore adequate tissue perfusion, vasopressors should be administered. In addition, patients should be treated with intravenous corticosteroids (hydrocortisone, 200 to 300 mg/d for 7 days in three or four divided doses or by continuous infusion) - amp/gent/clinda Patients also should receive prophylaxis for deep venous thrombosis with low-molecular-weight heparin stress ulcer prophylaxis with histamine 2 receptor blockers

Investigate AFE

Investigate.... note, AFE is a diagnosis of exclusion, so other causes for collapse should be ruled out. -CBC (note, leukocytosis in labor is expected, as is anemia from pregnancy) - ABO - D-dimer, fibrinogen - PT/INR + PTT - VBG - Tryptase (may be high as marker of mast cell degranulation) - complement C3-C4 (may be low due to complement activation) - CK/TnI- nt-BNP (rule out cardiomyopathy) - cardiac monitoring via anesthesia

implications of IDA in pregnancy

Iron-deficiency anemia in pregnancy has been associated with an - increased risk of low birth weight - prematurity - perinatal mortality - postpartum depression Severe anemia (less than 6 g/dL) has been associated with - abnormal fetal oxygenation - abnormal fetal heart rate patterns - reduced amniotic fluid volumes - cerebral vasodilation - fetal death. Transfusion may be indicated for fetal indications in the case of anemia of this severity

isolated maternal fever vs clinical chorioamnionitis

Isolated fever = - a single oral temperature of 39°C or greater, or -an oral temperature of 38-38.9°C that persists when the temperature is repeated after 30 minutes. Chorio = these PLUS one of - maternal leukocytosis (> 15) -purulent cervical drainage -fetal tachycardia. (160 for 10 mins) Most sensitive invasive test = IL-6 (less specific) Gram stain = less sensitive, more specific Low glucose from fluid also can be tested on amniocentesis

types of fetal demise

It is more useful to distinguish between 1) preembryonic pregnancy loss (gestational sac without an embryo - previously referred to as "blighted ovum"), 2) embryonic demise (embryo without cardiac activity at less than 10 weeks of gestation) 3) early fetal demise (fetus without cardiac activity after 10 weeks of gestation). 4) Fetal death occurring after 20 weeks or greater in gestation is often referred to as stillbirth

47 XYY

Jacobs syndrome (male)

syphillis reaction

Jarisch Herxheimer- acute, febrile reaction with headadche, myalgias.... Due to massive lysis of treponemes.

Renal changes in pregnancy

Kidney size increases. GFR, renal plasma flow, Cr clearance increase (thus, creatine and BUN will decrease) . Calyceal and ureteral dilatation (R>L due to dextrorotation from sigmoid). Some normal glucosuria may occur (even without GDM). Ureters elongated, displaced, and compressed by uterus. Decreased bladder capacity. Therefore, pregnancy is characterized by an increase in total body electrolyte stores, albeit with decreases in serum levels.

Types of Chlamydia

L1, L2, L3 cause lymphogranuloma venereum. A, B, C - endemic blinding trachoma (types A, B, Ba, and D, E, F, G, H, I, J, K - inclusion conjunctivitis, newborn pneumonia, urethritis, cervicitis, endometritis, pelvic inflammatory disease, and the acute urethral syndrome

where to place epidural? level of epidural

L4-L5

what is the anticoagulation of choice in pregnancy ? How to treat for VTE? What is target?

LMWH heparin. If on therapeutic, then check platelets initially, and then again in 1 week. Treat a minimum of 3 months . Target anti Xa of 0.6-1.0 units/mL, 4 hours after dose Following initial treatment, anticoagulation intensity can be decreased to intermediate or prophylactic dose for the remainder of the pregnancy and for at least 6 weeks postpartum

which twin is which ?

Labeling each twin — It is important to use a consistent strategy for identifying and labeling each twin over serial examinations in the second and third trimesters. The majority (80%-90%) of twins are laterally (right/left) oriented, rather than vertically (top/bottom) oriented SOGC: In laterally oriented twins, the twin on the maternal right should be assigned the label twin A. In vertically oriented twins, the inferior twin should be assigned the label twin A. Twins should be assigned labels at the first sonographic scan, and labelling should be maintained for all subsequent scans. During the scan, the location of the twins (right/left, anterior/posterior, superior/inferior) should be documented, as well as other discriminating features that can help with the accuracy of labelling, including relative fetal biometry, structural anomalies or variants, sex, location of the inter-twin membrane, placental location, and placental cord insertion. 22 Documentation of the sites of placental implantation (anterior, posterior, lateral) and of the sites and types of placental cord insertion (eg, marginal versus central, normal versus velamentous) is also useful. Twins may not deliver in the order expected from antenatal ultrasound (termed perinatal switch), especially when delivered by cesarean.

emergency BP meds What are side effects/contraindications?

Labetalol -20, 40, 80, 80 q 10 mins. - -sides, heart block/bradycardia, neonatal brady/hypoglycemia, - block maternal awareness of hypoglycemia Adalat -10, 20, 20 q 20 mins - headache and reflex tachycardia hydralazine - 5-10 IV/IM q 20 mins -sides = hypotension, maternal / fetal tachycardia

trauma labs

Laboratory assessment following a major trauma should include CBC UA CMP type and screen PT/PTT fibrinogen UDS fetal screen with KB if indicated (if Rh -).

Latent syphilis

Latent Syphilis [6,8-10] • In latent syphilis, by definition, the patient is completely asymptomatic active disease although disease remains detectable by positive specific treponemal serologic tests [FTA-ABS (fluorescent treponemal antibody absorption) Latent syphilis is further subdivided into stages based on the duration of infection: early latent, late latent, and latent of unknown duration. Early Latent Syphilis • Early latency is defined as the time period within one year of initial infection. • 90% of relapse occurs during this time period; mucocutaneous lesions are most common. Patient is infectious when lesions are present. • Patients are believed to be potentially infectious in the absence of lesions. • Vertical transmission of infection may occur. Late Latent Syphilis • Initial infection has occurred greater than one year previously. • Associated with host resistance to reinfection. • Sexual transmission is unlikely. • Transplacental infection of the fetus can occur but is less likely than with earlier stages of disease. • Infection via blood transfusion is possible. Latent Syphilis of Unknown Duration • Date of initial infection cannot be established as having occurred within the previous year and patient is aged 13 to 35 years and has a nontreponemal titer ≥1:32.

trichomoniasis pregnancy

Linked with PPROM, PTB, low BW and postpartum endometritis oral metronidazole, 2 g in a single dose. An alternative regimen is metronidazole, 500 mg PO twice a day for 7 days.

Nugent score

Looks at swabs for - lactobacilli (gram positive rods) - Mobiluncus (gram neg rods) - Gardnerella 0-3= normal 4-6 = indeterminate 7+ = BV

Lugol's iodine mechanism

Lugols iodine takes advantage of the Wolff-Chaikoff effect whereby injecting large amounts of iodine decreases release of circulating T3 and T4 regardless of TSH level. Iodine should be given at least 1 hour after PTU so that the circulating iodine is less likely to be taken up and used to synthesize more thyroid hormones.

Lymphogramuloma venereum

Lymphogranuloma venereum (LGV) is a disease caused by Chlamydia L1, L2, L3 Primary manifestation of lymphogranuloma venereum infection is painless penile or vulvar inflammation and ulceration at the site of inoculation; often not noticed by the patient. Secondary stage typically occurs weeks after development of the primary lesion; presents as painful, unilateral, inguinal or femoral lymphadenopathy (often referred to as 'inguinal syndrome'). Without treatment, LGV may cause obstruction of lymph flow and chronic swelling of genital tissues. Treatment: Doxycycline 100mg po bid x3 wks Erythromycin 500mg po qid x3 wks Azithromycin 500mg po od x3 wks

role of MRI in accreta

MRI is reported to more accurately stage the extent of the disease, especially when placental extension into either the bladder, posterior uterus, cervix, and/or parametrium is suspected. MRI can be used selectively in units where ultrasound imaging and interpretation are of high volume and quality. Conversely, MRI may be more accurate when a PAS disorder is suspected in the absence of placenta previa, especially with a posterior or fundal placental location Lack of gadolinium is the main factor

TTTS

MUST BE monochorionic (1 placenta) --> sharing 1 blood supply. TTTS traditionally refers to an often severe, chronic condition and needs to be distinguished from several acute forms of intertwin transfusion. chronic fetofetal blood transfusion from one twin (donor) to the other (recipient) through placental vascular communications. This unbalanced shift of blood volume results in hemodynamic imbalance: Larger twin --> Polycythemia & Polyhydramnios. Smaller twin --> Anemia and Oligohydramnios. (so-called twin oligohydramnios-polyhydramnios sequence). Normally, a paired artery and vein supplying and draining a placental cotyledon .... here, this does NOT develop. Instead, an arteriovenous (AV) anastomosis occurs on the placental surface, whereby a: - single unpaired artery carrying blood from the donor twin to a placental cotyledon connects directly into a single unpaired vein carrying blood from that cotyledon back to the recipient twin An intuitive, albeit simplistic, model of TTTS proposes that the primary event is flow imbalance from donor to recipient across unbalanced unidirectional AV anastomoses. If this flow imbalance is significant and not fully compensated by bidirectional AA anastomoses, the donor becomes hypovolemic and anemic, whereas the recipient develops polycythemia and hypervolemia. These volume changes are believed to induce modulation of a variety of hormonal and biochemical regulators in both twins. The renin-angiotensin system is upregulated in the donor twin and downregulated in the recipient twin. addition, concentrations of atrial natriuretic peptide brain natriuretic peptide endothelin-1 are higher in the amniotic fluid of recipient twins compared with donor twins

# hemoglobin composition

Made of heme (iron and protoporphyrin) + globin

alternative seizure prophylaxis options than magnesium

Magnesium is the most effective medication for seizure prophylaxis in preeclampsia and is the preferred agent; however, in situations in which magnesium sulfate is contraindicated, other alternatives may be considered o At OU, we use the following regimen: fosphenytoin IV loading dose of 1000mg, followed 12 hours later by phenytoin 500mg PO every 12 hours

contraindications to magnesium

Magnesium sulfate is contraindicated in the following settings: o Myasthenia gravis o Cardiac ischemia o Heart block o Myocarditis • Special circumstances: o Renal failure or renal insufficiency See "Chronic Renal Disease" guideline for magnesium dosing guidelines Also consider adjusting magnesium dosing for patients with oliguria (<30cc/h over 4 hours) o Use caution with magnesium in patients with pulmonary edema

prevent headaches in pregnancy

Magnesium, coenzyme Q, Propranolol is the drug of choice

# trisomy 21 malformations

Major malformations: - cystic hygroma (first trimester) - cardiac defects (ASD, VSD, tetralogy) - duodenal atresia Minor: - nuchal thickening - mild ventriculomegaly - echogenic bowel - renal pyelectasia - short long bones - echogenic intracardiac focus - hypoplastic nasal bones - brachycephaly - clinodactaly growth restriction sandal toes Cardiac defects: Complete AVSD endocardial cushion defects GI Hirschprung disease esophageal/duodenal atresia

manage AFE

Manage by:- place mom in left-lateral position, preferably try and perform assisted manual left uterine displacement to facilitate venous return by avoiding IVC compression. - Administer 100% O2 via non-rebreather mask... but have anesthesia secure the airway ASAP as mom will likely need mechanical ventilation - manage hypotension, but NOTE that hypotension is almost always due to cardiac failure. and NOT hypovolemia... therefore fluids should be given in SMALL doses (250ml) rather than typical 1L bolus'. - have a low threshold for vasopressor support (norepinephrine first line) - Call for code bleed Obstetrics (risk of DIC is very high > 80%... if there is worrisome evidence of bleeding (ie, uterine atony), call for a code bleed, it will very likely be needed) If possible, deliver fetus ASAP... if this happens in labor (as it usually does), then attempt operative vaginal delivery if fully dilated and at least +2 station. If a cesarean delivery has to be performed urgently, blood, fresh frozen plasma, platelets, and cryoprecipitate should be available in the operating room and should be administered if there is any evidence of impaired coagulation (eg, persistent bleeding without clotting from incision or needle sites)Be prepared for uterotonics.... if at cesarean section, may consider prophylactic hemostatic surgical techniques such as uterine artery or internal iliac ligation. Case reports of "A-OK" protocol (Atropine, ondanestron, ketorolac) being very helpful Atropine (0.2mg) (prevents vagus nerve overstimulation and therefore preventing both systemic hypotension and pulmonary vasoconstriction.... possible prevention of arrhythmia and heart blocks ) Ondansetron (8mg): Blocks 5-HT3 serotonin receptors inhibiting release of further mediators which contribute to pulmonary vasospasm and hypertension) Ketorolac (15mg): Blocks thromboxane production preventing coagulopathy and emoboli formation) Case report of C1 esterase inhibitor (1000u ) being helpful to prevent the excess complement activation once resolved, target O2 saturation of ~95% on pulse ox (hyperoxia may worsen the ischemia-reperfusion injury).

manage scleroderma pregnancy

Management Patients with active renal disease, PAH or significant cardiac compromise should avoid pregnancy due to high maternal risk and those with early diffuse disease should defer pregnancy due to higher risk of scleroderma renal crisis. Patients should be followed for evidence of deteriorating renal function and worsening hypertension. Presence of co‐existing aPL and anti‐Ro/SSA and/or La/SSB antibodies should be assessed and, if detected, managed as described for SLE. Fetal surveillance should follow the paradigm outlined for SLE above. The cornerstones of scleroderma management in pregnancy include the following. • Avoidance of medications known to be teratogenic or for which data are inconclusive. • Baseline and serial assessment of 24‐hour urine collection for creatinine clearance and total protein, and serial assessment of serum creatinine. • Frequent monitoring of blood pressure, with antihypertensive therapy as needed (calcium channel blockers); avoid ACE inhibitors unless confirmed scleroderma renal crisis. • Low‐dose prednisone for concomitant myositis. • Antacids and other pregnancy‐compatible medications for reflux esophagitis. • Physiotherapy for hand or other contractures. • Fetal surveillance as described for patients with SLE, including early dating ultrasonography, serial scans for growth, and nonstress tests and/or

Aberrant attachment

Marginal cord insertion velementous

risks of impacted fetal head

Maternal •Inferior or lateral extensions of the uterine incision •Injury to the bladder •Hemorrhage •Endometritis •Wound infection •Future PPROM and PTB Neonatal •Low Apgar scores •Neonatal intensive care unit admission •Fetal injuries including long bone fractures, skull fracture, and lacerations

diagnose NAIT at OU

Maternal and paternal blood samples needs to be drawn (father of the baby will need to be registered as a patient) • NAIT testing—Blood Center of Wisconsin • two separate orders are placed by clinic staff (one for patient, one for father of baby) • Samples are sent for paternal and maternal platelet antigen evaluation as well as maternal antibody testing • Turnaround time of 10 days

chorio (triple I)

Maternal fever > 39 - T > 38 x 2 (30 mins) - FHR > 160 for 10 mins - WBC > 15 - abnormal discharge

Uterine Activity Assessment

Maternal perception Palpation External using tocodynamometer Internal using intrauterine pressure catheter (montevideo units) MVU's= peak - baseline, add up over 10 mins adequate = 200 over 10 mins adequate individual- 50/60 mm Hg Assess: Frequency (over 10 mins) duration intensity (mild, moderate, strong... or mmHg on IUPC) resting tone

materlal drug tests Which one has the longest detection time ?

Maternal urine and hair and fetal urine, hair, and meconium samples are sensitive biological markers of substance use. UDS can detect only recent substance exposure, whereas neonatal hair and meconium testing can document intrauterine use meconium (second trimester) and neonatal hair (third trimester)

menstrual dating vs ultrasound dating

Menstrual dating underestimates the ultrasound-based EDD by an average of 2 to 3 days. Ultrasound dating alone was significantly better in predicting the actual date of delivery than any of the dating policies using menstrual dates alone or in combination with ultrasound

metformin vs insulin and glyburide

Metformin causes less maternal weight gain, less macrosomia Compared to insulin, meformin is not as good at controlling glycemia and neonatal weight. If insuin use is high ( > 1.1 IU/kg), adding metformin PLUS insulin may -improve glycemia control - reduce maternal hypoglycemia and baby hypoglycemia - reduce maternal weight gain -

treat BV pregnancy

Metronidazole 500 mg PO bid for 7 days or OR 2g at once Clindamycin 300 mg PO bid for 7 days Symptomatic pregnant women with BV can be treated safely in any trimester with oral metronidazole or clindamycin. Metronidazole gel 0.75% one full applicator (5 g) intravaginally, once a day for 5 days OR Clindamycin cream 2% one full applicator (5 g) intravaginally at bedtime for 7 days Routine screening and treatment of BV in asymptomatic women at low risk for preterm birth is not recommended (US Preventive Services Task Force: D recommendation). • Screening for BV and treating affected patients may be considered in asymptomatic women at high risk for preterm birth, such as those with a previous preterm birth; however, there are insufficient data to recommend this as a routine practice. SOGC: retest in 1 month

CATUION meds with heart failure

MgSO4 - (with aortic stenosis) Ergot (with aortopathies) Pitocin TXA

what to consider in preterm covid delivery

MgSO4 could increase pulmonary edema, resp depression

Anemia of chronic disease

Microcytic anemia with ↓ serum iron, ↓ total iron-binding capacity (TIBC), and normal or ↑ ferritin. elated to the persistent release of inflammatory mediators.HEPCIDIN, a liver peptide hormone that strongly regulates iron, is high in inflammation because Inflammatory state → IL-6 production which - ↑ hepcidin. high levels of hepcidin 'locks' iron into storage sites by reducing the expression of FERROPORTIN on enterocytes and macrophages in the bone marrow. Ferroportin is a transmembrane protein that transfers intracellular iron into circulation !!!! this limits iron transfer from macrophages in bone marrow, so we have impaired production of heme (despite the fact that iron stores are in fact adequate) !

complete mole placenta

Microscopically, the molar component shows the typical characteristics of a complete hydatidiform mole: - hydropic and avascular villi - hyperplastic, often circumferential, and lacelike trophoblast - associated with large amounts of degenerating trophoblast

mono-mono twins determination

Monochorionic/monoamniotic - - Visualization of intertwined umbilical cords (M-mode with two different heart rates in adjacent loops of cord) is diagnostic of monoamniotic twins. - cord entanglement is not always detected. Another finding is that the intertwin membrane is absent in a monochorionic/monoamniotic twin pregnancy. They also must be same sex.

when is cerclage not placed?

Most clinicians avoid placing a cerclage after approximately 24 weeks of gestation since the procedure may cause accidental rupture of the fetal membranes leading to early preterm delivery of a viable infant, with its attendant high risk of neonatal morbidity and mortality. However, each case must be individualized, weighing the risks of the procedure against the likely outcome with expectant management.

DKA in pregnancy

Most common cause = infection defined by: - high glucose (>250) ... though may be lower in pregnancy - serum ketones (>3) - urine ketones (+2) - acidosis (<7.3) serum bicarbonate is ≤15 mmol/L the anion gap is >12 mmol/L Note, the FHR is often abnormal. Must correct it before interpret it. Perinatal mortality rate is VERY high, - 35%

CMV infection

Most common congenital infection It is a HERPES virus, so it can remain latent Clinical findings — ASYMPTOMATIC in approximately 90% of cases. The incubation period ranges from 20 to 60 days, after which a mild mononucleosis-like syndrome ensues, with fever lasting 2 to 3 weeks, lymphadenopathy, high lymphocyte count, and abnormal liver enzyme results. Primary CMV infection may cause a mild febrile illness and other nonspecific symptoms (rhinitis, pharyngitis, myalgia, arthralgia, headache, fatigue), Rare complications include hepatitis, Guillain-Barré syndrome, and myocarditis CMV mononucleosis can be accompanied by dermatologic manifestations in approximately one-third of patients including macular, papular, maculopapular, rubelliform, morbilliform, and scarlatiniform eruptions. Non-primary CMV reactivation of endogenous (latent) virus, or re-infection from another CMV strain

Congenital Rubella Syndrome

Most common effect of rubella vertical transmission is FGR Classic triad: - sensory-neural deafness - eyes congenital cataracts (white pupils) or retinopathy - Cardiac= PDA most common, (but supravalvular pulmonic stenosis is perhaps the most pathognomonic. ) - CNS defects Could potentially also result in microcephaly and mental retardation four most common anomalies associated with CRS are: - deafness (affecting 60% to 75% of fetuses) - eye defects (such as cataracts or retinopathy) (10% to 30%) - CNS defects (10% to 25%) - cardiac malformations (10% to 20%). The most common cardiac abnormality is PDA, though Other possible abnormalities include microcephaly, mental retardation, pneumonia, FGR, In addition, there may be severe disease during the newborn period - including thrombocytopenia - bleeding - hepatosplenomegaly - pneumonitis - myocarditis. Rubella transmission rates -In the first trimester, fetal infection rates as high as 81 percent have been observed - dropping to 25 percent in the late second trimester - increasing again in the third trimester from 35 percent at 27 to 30 weeks - nearly 100 percent for fetuses exposed beyond 36 weeks The risk of major fetal damage varies with the time of maternal infection: - 80-90% in the first three months of pregnancy - 10% in the fourth month - 6% in the fifth month, often as isolated hearing impairment. There is minimal risk in late gestation, only IUGR . non-pregnant females should be vaccinated with the live MMR vaccine prior to pregnancy.

maternal diseases and FGR

Most maternal vascular diseases, such as chronic hypertension, preeclampsia, chronic renal disease, and systemic lupus erythematosis with renal involvement, are known to be associated with FGR. This is likely the result of failure to expand maternal plasma volume and diminished uteroplacental blood flow. Defective trophoblastic invasion of the uterine vascular bed results in relatively intact musculoelastic vessels that resist the normal decrease in uterine vascular resistance. Because maternal body mass and plasma volume are correlated, reduced plasma volume or prevention of plasma volume expansion could lead to decreased cardiac output and uterine perfusion and a resultant decrease in fetal growth. 8990

nephrotic syndrome pregnancy

Nephrotic syndrome • Defined as >3.5 g of proteinuria in 24 hours in non-pregnant adults • Associated with edema, VTE, and hypoalbuminemia • Most commonly caused by focal segmental glomerulosclerosis, membranous nephropathy, and minimal-change disease • Except in the case of membranous glomerulonephritis, pregnancy not typically associated with worsening of nephrotic syndrome in the absence of hypertension • Antepartum and intrapartum care should be similar to that of patients with chronic renal insufficiency. • Thromboprophylaxis (e.g. enoxaparin 40 mg/day) should be considered with proteinuria >3.5 g/day.

Phenytoin teratogenic effects

Neural tube defects, microcephaly, orofacial clefts, dysmorphic facial features, distal digit/nail hypoplasia

high spinal how to manage ?

Most often, high or total spinal blockade follows: - administration of an excessive dose of local anesthetic - inadvertent injection into the subdural or subarachnoid space. Subdural injection manifests as a high but patchy block even with a small dose of local anesthetic agent, whereas subarachnoid injection typically leads to complete spinal blockade with hypotension and apnea. The signs and symptoms include a rapid ascending sympathetic, sensory, and motor block with associated: - bradycardia - hypotension - dyspnea - difficulty with swallowing or phonation. Symptoms can progress to unconsciousness (due to brainstem hypoperfusion and/or brainstem anesthesia), and respiratory depression (secondary to respiratory muscle paralysis and brainstem hypoperfusion). These conditions must be immediately treated to prevent cardiac arrest. In the undelivered woman: (1) the uterus is immediately displaced laterally to minimize aortocaval compression; (2) effective ventilation is established, preferably with tracheal intubation (3) intravenous fluids and vasopressors are given to correct hypotension. If chest compressions are to be performed, the woman is placed in the left-lateral position to allow left uterine displacement.

first trimester aneuploidy testing for twins

NIPT for Down syndrome using cell-free fetal DNA may be challenging with multiple gestation because cell-free fetal DNA in the maternal circulation derives from each fetus. Because it is impossible to determine which twin is abnormal based on cell-free fetal DNA analysis alone, results are reported for the entire pregnancy, and invasive testing is required to distinguish which twin, if either one, is affected. An additional challenge in twin pregnancy is that the amount of cell-free fetal DNA contributed by each twin is lower than in singleton pregnancies and may be quite different for the two fetuses in cases of dizygotic twins

neutrophil, lymphocyte ratio

NLR is the ratio of neutrophils/lymphocytes. Physiologic stress increases neutrophil count and reduces lymphocyte count, causing the NLR to increase. This likely involves some combination of endogenous cortisol and catecholamine secretion. Sepsis stimulates lymphocyte apoptosis, so this may cause especially dramatic elevation of the NLR compared to other forms of physiologic stress Some very rough numbers: ~1-3 is normal. ~6-10 suggests mild stress (e.g., uncomplicated appendicitis). ~10-15 suggests moderate stress (e.g., most critically ill patients.... sepsis is very likely). >15 suggests severe stress (e.g., sepsis with gram negative bacteremia).

# order of BPP affected

NST becomes less reactive.... Then breathing, movement, Tone is last

anomalies with obesity

NTD Cardiac anal atresa Limb anomalies partially due to reduces odds of detecting anomalies also

Calculate anion gap

Na - (Cl + HCO3) Normal = 12 +/- 4

Spinal/epidural block for cesarean

Need T4-6 surgical anesthesia level in case of c-section Extend it down to T10 if risk of autonomic dysreflexia (damage T6 and up)

Cerebral palsy associated with intrapartum events

Neonatal Signs Consistent With an Acute Peripartum or Intrapartum Event ▪ Evidence of a metabolic acidemia in fetal umbilical cord arterial blood obtained at delivery (pH <7.00 and base deficit ≥12 mmol/L) ▪ Apgar score of <5 at 5 and 10 minutes ▪ Neuroimaging evidence of acute brain injury seen on MRI consistent with hypoxia-ischemia ▪ Presence of multisystem organ failure consistent with hypoxic-ischemic encephalopathy Type and Timing of Contributing Factors Consistent With an Acute Peripartum or Intrapartum Event ▪ Sentinel hypoxic or ischemic event occurring immediately before or during labor and delivery such as a severe placental abruption ▪ Fetal heart rate monitor patterns consistent with an acute peripartum or intrapartum event ▪ Timing and type of brain injury patterns based on imaging studies consistent with an etiology of an acute peripartum or intrapartum event ▪ No evidence of other proximal or distal factors that could be contributing factors ▪ Developmental outcome is spastic quadriplegia or dyskinetic cerebral palsy

adalat contraindications

Nifedipine is the most common calcium channel blocker used for tocolysis, and some research suggests it be considered the initial tocolytic agent in the man- agement of preterm labor. Calcium channel blockers, mainly nifedipine, can significantly prolong pregnancy Nifedipine is a vasodilator that can cause maternal nausea, flushing, dizziness, and palpitations. Nifedipine is contraindicated in women with hypotension and preload-dependent cardiac lesions, such as aortic insufficiency.

criteria for breech delivery (contraindications)

No contraindication to vaginal delivery Weight: 2500/2800 - 4000 g (avoid growth restriction and CPD) Footling breech presentation (has to be either complete or frank) Fetal anomaly likely to interfere with delivery Clinically inadequate maternal pelvis (weak; very low) Hyperextended fetal head (weak; low) Should also have: -Center with a skilled obstetrician comfortable with breech delivery - center able to perform urgent cesarean - Preferable to have adequate analgesia (in that case) - Anesthesia and pediatrics there for the delivery - Continuous EFM in labor SOGC says: - consider passive second stage for up to 90 minutes - Delivery should be at least imminent within 60 mins of pushing You can use oxytocin

other maternal deaths

Non maternal death - death of the mother that results from accidental or incidental causes not related to pregnancy. Ex, MVA or concurrent malignancy. Pregnancy-associated death. The death of a woman, from any cause, while pregnant or within 1 calendar year of termination of pregnancy, regardless of the duration and the site of pregnancy. Pregnancy-related death. A pregnancy-associated death that results from: (1) complications of pregnancy itself, (2) the chain of events initiated by pregnancy that led to death, or (3) aggravation of an unrelated condition by the physiological or pharmacological effects of pregnancy and that subsequently caused death.

COVID treatment options

Non severe: Paxlovid- (Nirmatrelvir-ritonavir) 300 mg nirmatrelvir (two 150 mg tablets) + one 100 mg ritonavir tablet PO q12h for 5 days. It should be initiated as soon as possible following COVID-19 diagnosis and within five days of symptom onset (symptom onset is day 0), Severe: -dexamethasone Recommended for mechanically ventillated AND supplemental oxygen 6mg IV q12h x 4 doses - THEN, switch to a steroid that does not cross the placenta - oral prednisolone 40 mg once daily for 8 more days (10 days total) Remdesivir 200mg IV day 1 then 100mg IV day 2-5

cannabis sexual functioning

Nonetheless, cannabis use before sex has been self-reported to enhance aspects of sexual functioning among women, including sex drive, orgasm, and sexual pleasure, while decreasing pain. However, as most of the research involving humans has been survey-based and is susceptible to memory and expectancy biases, this evidence is of low quality. low to moderate may increase, high may decrease.

American heart association AHA blood pressure categories

Normal < 120/80 Elevated = 120-129/80-89 Stage 1 = 130-139/80 Stage 2 = > 140/90

placental fibrin deposition

Normal Uterine artery doppler normal BP High risk of recurrence

fetal growth phases

Normal fetal growth occurs in three phases. The first phase is characterized by cellular hyperplasia and occurs in the first half of pregnancy. . The second phase is characterized by both hyperplasia and cellular hypertrophy (increase in cell size). The final phase (last 6 to 8 weeks of pregnancy) is characterized by hypertrophic growth. With this pattern of growth in mind, a clinically useful method of classifying FGR takes into account fetal body size and length and the observation that there are two main types of infants with FGR: (1) infants of normal length for gestational age (biometry demonstrating normal skeletal dimensions and head size) whose weight is below normal owing to decreased subcutaneous tissue and abdominal circumference (asymmetrically small) and (2) infants whose weight and skeletal dimensions are both below normal (symmetrically small).

PAS accreta

Normal placentation is when the blastocyst is implanted to the inner decidua (pregnancy transformed endometrium).... placenta adheres to myometrium (absent decidua) Increta- invades into myometrium Percreta- through the uterine serosa to other structures

Hemoglobin electrophoresis values

Normal= 97% A, 2% A2, 1% F Sickle cell (HbSS)= 3% A2, 90% S, 7% F Sickle trait HbSA = 70% A, 29% S, 2% F Sickle (HbSC) -C = 40% S, 60% C Sickle S beta thal= 3% A, 7% A2, 75% S, 15% F

Thrombocytopenia in pegnancy What is the workup?

Normally, platelets are around 10% less in pregnancy Platelet counts typically 70 - 149 x109 CBC citrated platelets CMP LDH Haptoglobin Retic HIV Hep B/C direct antiglobulin test (DAT) IgG

sickle cell anemia

Normocytic anemia. Due to formation of HbS, due to a mutation at codon 6 where normal glutamic acid (hydrophillic) is replaced with valine (hydrophobic) on the B-globin gene .... HydroPHOBIC interactions occur and cause RBC's to sickle, stiffen and hemolyse. extravascular hemolysis leads to anemia, jaundice, high UCB, high LDH, and low haptoglobin !!!!

OU cesarean antibiotics

Not in Labor; Intact Membranes or Ruptured for Less than Four Hours Cefazolin 2 grams IV once In Labor and/or Membranes Ruptured for Four Hours or Longer Cefazolin 2 grams IV once, and Azithromycin 500 mg IV once Women with Anaphylactic Reactions to Penicillin; Not in Labor and Intact or ROM <4 Hours Clindamycin 900 milligrams IV once, and * Gentamicin 1.5 milligrams/kilograms IV once Women with Anaphylactic Reactions to Penicillin; In Labor and/or ROM ≥4 Hours Clindamycin 900 milligrams IV once, and * Gentamicin 1.5 milligrams/kilograms IV once, and Azithromycin 500 mg IV once Antibiotic Regimen for Women with Chorioamnionitis (Assume already on ampicillin and gentamicin ) Add clindamycin 900 milligrams IV once, and Azithromycin 500 milligrams IV once For all patients, if the procedure lasts more than 4.5 hours or if blood loss exceeds 1500 mL, repeat the doses of all medications in the regimen.

diabetic vs optimal glucose levels

Note, in pregnancy, the metabolic demands increase the risk of hypoglycemia, so more of a drop off and hypo episodes

SOGC moderate risk factors for preeclampsia

Nullips multifetal Age > 40 Prior FGR Prior Stillbirth Prior abruption

things in a room for twin delivery

OR.... ready for cesarean. anesthesia Ready for PPH Ultrasound Pipers Can do an ECV, or IPV

antenatal sickle cell management

Obtain baseline maternal serum labs including CBC, reticulocyte counts,lactate dehydrogenase, liver function tests, renal function tests, iron studies, urinalysis/urine culture. • Maternal echocardiogram if the patient has a history of multiple crises and/or acute chest syndrome as these patients are at increased risk of pulmonary hypertension. • Paternal screening (hemoglobin electrophoresis and/or alpha‐thalassemia genetic screening) if not previously completed for risk assessment of fetal genetic inheritance. • Referral to genetic counseling if father is a carrier or if paternity is unknown/unable to be tested. • Early ultrasound to confirm viability of the regnancy. • Pregnancy options counseling. • Laboratory monitoring every trimester (CBC, urine culture). • Detailed anatomical survey at 18-20 weeks. • Serial growth ultrasounds every month; add fetal surveillance if fetal growth restriction develops. • Consider daily aspirin for preeclampsia prevention. • Maternal BP monitoring. • Lab evaluation if concern for crisis (increased pain) including CBC, reticulocyte count, lactate dehydrogenase, haptoglobin, urinalysis, urine culture. • Discuss maternal immunization as SCD causes patients to be functionally asplenic. Patients with SCD should receive the following (in conjunction with SCD provider). All below immunizations are safe in pregnancy. ⚪ Haemophilus influenzae type B (Hib) vaccine: one dose during their lifetime. ⚪ Meningococcal vaccine: two‐dose series at least eight weeks apart initially and revaccination every five years. ⚪ Pneumococcal vaccine: one dose of PCV13 followed by one dose PPSV23 at least eight weeks later. Repeat PPSV23 five years after initial PPSV23. ⚪ Yearly influenza vaccine. • Folic acid supplementation (4 mg/day).

secondary syphilis

Occurs 4-8 weeks after chancre It generally begins with a nonspecific constitutional illness that commonly includes a sore throat, low-grade fever, myalgias, and generalized lymphadenopathy. • Skin rashes are the classic and most commonly recognized lesions, but the appearance is highly variable, and differential diagnosis is often challenging. • Rash is often initially macular and nonpruritic and becomes papular by three months. • Rash frequently involves the palms of the hands and soles of the feet, and may be accompanied by mucous patches in the mouth, pharynx, or cervix and condyloma lata in the anogenital region or axilla. Condyloma lata are hypertrophic lesions resembling flat warts that occur in moist areas. • Individuals are highly contagious during this stage, especially upon contact with mucous patches or condyloma lata. • Secondary disease lasts for an average of 3.6 months and spontaneously resolves. Approximately 25% of individuals experience a relapse of secondary disease during the first year of infection.

SOGC HTN definitions

Office = 140/90 .... but home = 135/85 Therefore, white coat = >140/90 in office but <135/85 home Transient- initially high in office, but then drops Masked- Office BP <140/90 but home > 135/85

one step vs 2 step gdm

One step picks up more.... but might not improve outcomes, but does increase surveillence. There is also a "Diabetes Canada "preferred" 2 step SOGC endorses the 50g OGTT (2 step) as the primary method in women without high risk characteristics

vanishing twin syndrome vs fetus papyraceus

One twin "vanishes" in early pregnancy Increasing use of ultrasound has enabled this diagnosis Incidence - 20-27% of twins The term vanishing twin syndrome refers to the spontaneous loss of an embryo or fetus during the first trimester of a twin or multiple pregnancy. Vanishing twin pregnancies may be at an increased risk for fetal structural anomalies, FGR, and preterm birth Fetus papyraceus aka single twin demise (affects 5%) refers to the compressed, mummified remnant of a fetus of a twin or multiple pregnancy who died in utero, usually between 12 and 20 weeks' gestation (early second trimester). These pregnancies are at a higher risk of preterm birth, the latency being inversely proportionate to the gestational age at the time of single twin death (i.e., a shorter interval to delivery at a later stage of pregnancy). Dichoriodo not have higher risk of neurodevelopmental morbiditynic twins that is seen in monochorionic twins after single-twin death. Therefore, if there are no other complications or obstetric indications, these pregnancies can be delivered at term

vanishing twin syndrome

One twin "vanishes" in early pregnancy Increasing use of ultrasound has enabled this diagnosis Incidence - 20-27% of twins Vanishing twin pregnancies may be at an increased risk for fetal structural anomalies, FGR, and preterm birth Single-twin death affects approximately 6% of twin pregnancies and the surviving twin is at an increased risk of an adverse outcome they have a higher risk of preterm birth, the latency being inversely proportionate to the gestational age at the time of single twin death (i.e., a shorter interval to delivery at a later stage of pregnancy). Dichorionic twins do not have higher risk of neurodevelopmental morbidity that is seen in monochorionic twins after single-twin death. Therefore, if there are no other complications or obstetric indications, these pregnancies can be delivered at term.

treat TTTS

Options are: 1) serial reduction amniocenteses 2) amniotic septostomy 3) selective fetoscopic laser coagulation of placental anastomoses. Serial reduction amniocenteses were suggested as a path to equilibrate AFV across the dividing membrane and to reduce overall intrauterine pressure. Amniotic septostomy involves deliberate perforation of the dividing membrane, with the putative mechanism of action being equalization of fluid across the dividing membrane. However, both of these techniques have been effectively abandoned in the setting of severe TTTS because they do nothing to interfere with the underlying placental disease pathology, and because convincing data have now established the superiority of fetoscopic laser coagulation of the placental vessels

manage TAPS

Options for management include : - preterm delivery - intrauterine fetal transfusion (may worsen polycythemia of recipient) - selective fetocide - repeat laser (if occurs after TTTS).... . Repeating the fetoscopic laser procedure is also particularly challenging because of normal AFVs and the tiny size of residual anastomoses.

other similar presentations to AFE

Other possibilities: - massive PE (look for leg redness/swelling.... this is less likely cause excessive bleeding...) - cardiogenic shock (MI, peripartum cardiomyopathy.... they often have chest pain, bedside cardiac monitoring/ECHO important. ) - anaphylactic shock (often with rash from flushing, bronchospasm, stridor, angioedema... also, likely after a precipitating drug) - high spinal block (soon after epidural) - local anesthetic toxicity if inadvertently injected intra-vascular (will occur soon after epidural) - eclampsia (seizures... likely other preeclampsia sequalae) - Air embolism (extremely unlikely, would likely need precipitating surgery/arterial or central venous line insertion)- aortic dissection, tension PTX

Turner surgery

Patients with Turner should have lap BSO (gonads are dysgenic, and have a risk of gonadoblastoma) Recommended to do this at young age Then, recommended for estradiol (preferally transdermally) for puberty induction

workup if thickened nuchal

Outcomes of fetuses with increased NT and normal karyotype - Chromosomal Defects - Fetal death - Fetal abnormalities - Developmental delay - Cardiac defects - Body stalk anomaly - Diaphragmatic hernia - Exomphalos - Megacystis - Genetic syndrome - Pathophysiology: cardiac dysfunction, venous congestion in head and neck, altered composition of the extracellular matrix, failure of lymphatic drainage, fetal anemia, fetal hypoproteinemia, fetal infection, In the chromosomally normal group, a detailed scan, including fetal echocardiography, should be carried out at 14 to 16 weeks to determine the evolution of the NT, and to diagnose or exclude many fetal defects. If this scan demonstrates resolution of the NT and absence of any major abnormalities the parents can be reassured that the prognosis is likely to be good and the chances of delivering a baby with no major abnormalities is more than 95%. Persistence of unexplained increased NT at the 14 to 16 weeks scan, or evolution to nuchal edema or hydrops fetalis at 20 to 22 weeks raises the possibility of congenital infection or a genetic syndrome. Maternal blood should be tested for toxoplasmosis, cytomegalovirus, and parvovirus B19. Follow-up scans to define the evolution of the edema should be carried out every 4weeks. Additionally, consideration should be given to DNA testing for certain genetic conditions, such as spinal muscular atrophy, even if there is no family history for these conditions. In pregnancies with unexplained nuchal edema at the 20 to 22 weeks scan the parents should be counseled that there is a 10% risk of evolution to hydrops and perinatal death or a livebirth with a genetic syndrome, such as Noonan syndrome. The risk of neurodevelopmental delay is 3% to 5%. Increased fetal NT thickness at 11 to 13+6 weeks is a common phenotypic expression of chromosomal abnormalities and a wide range of fetal malformations and genetic syndromes. Possible mechanisms for in creased NT include - cardiac dysfunction in association with abnormalities of the heart and great arteries - venous congestion in the head and neck, altered composition of the extracellular matrix - failure of lymphatic drainage caused by abnormal or delayed development of the lymp

parvovirus infection by gestation

Overall, approximately 2-10% of fetuses with parvovirus B19 infection will develop hydrops fetalis. The likelihood of hydrops fetalis substantially increases when maternal primary infection occurs at less than 20 weeks' gestation 1st trimester - the risk of hydrops varies from less than 5% to approximately 10%. 2nd trimester- therisk of infection decreases to 5% or less. I> 20 weeks, the risk of fetal hydrops is 1% or less. Epidemiological studies do not support the association between parvo virus B19 infection and congenital malformations.

cesarean scar pregnancy SOGC

PAS disorders occurring in the first trimester following a prior CS delivery is described as a CS scar pregnancy. The origin of this type of disease is due to implantation within a niche at the cervicoisthmic junction of the uterus created by prior CS delivery. A diagnosis of CS scar pregnancy may be established either at - a dating ultrasound -11-13 week nuchal translucency examination. The expanding placenta and gestation project anteriorly through the deficient myometrium and may cause the empty but decidualized uterine fundus to become retroverted. There are two subtypes of CS scar pregnancy, classified by either intact (type 1) deficient (type 2) myometrium over the apex of the placenta posterior to the bladder.

postpartum blues vs depression

PP blues is within 10 days .... incidence of around 50-75% Depression is SIG E CAPS within 4 weeks..... about 15%

Effects of BV in pregnancy

PPROB PTB Chorio endometritis

when should a diabetic mother not be treated ?

People with GCK-MODY have a lifelong increased fasting glucose (5.5-8.0 mmol/L) that is regulated at this higher level Babies that do NOT inherit the mutation are exposed to their mother's hyperglycemia and have, on average, a 700 g increase in corrected birth weight On the other hand, babies that DO inherit the mutation have the same homeostatic glucose set point as their mother and sense the higher glucose levels as normal, resulting in a normal birth weight..... therefore, it is recommended that the mother not receive treatment for hyperglycemia...... treating the mother with insulin has attendant risks, is inconvenient, and can potentially lead to a reduction in birth weight A correct maternal diagnosis has wider implications: the mother does not have an increased risk of type 2 diabetes (it is the same as the general population), does not need treatment outside pregnancy, and is not at risk for the microvascular complications associated with diabetes. Furthermore, any other family members with diabetes can be tested and, if they are found to have the same GCK mutation, any glucose-lowering treatment can be discontinued.

myotonic dysdrophy pregnancy What 3 things ??

People with myotonic dystrophy with cardiac and pulmonary involvement may be very sensitive to opioids and are at high risk of aspiration under general anaesthesia. A person with myotonic dystrophy may require monitoring in an intensive care setting while under general anaesthesia.

what to give to moms to promote fetal maturity before delivery in alloimmunization ??

Phenobarbital 300mg PO TID for 7 days, starting 10 days prior to planned delivery.... enhances fetal liver maturity, decreases need for transfusions.

Sepsis physical exam

Physical examination ● ENT examination: evidence of scleral jaundice; dry conjunctivae and mucous membranes; pinpoint pupils; dilated and fixed pupils; nystagmus ● Neck examination: jugular venous distention; carotid bruits; meningeal signs ● Pulmonary system: tachypnea; shallow breaths; crackles (rales); consolidation; egophony; absent breath sounds; rub ● Cardiovascular system: irregular rhythm; tachycardia; bradycardia; S3 gallop; ventricular heave; murmurs; distant heart sounds; rub; pulsus paradoxus ● Abdomen: distention; tenderness; rebound; guarding; absence of or high‐pitched bowel sounds; pulsatile masses; hepatosplenomegaly; ascites ● Rectal examination: Decreased tone; bright red blood; melena; hemoccult positive stool ● Extremities: swollen calf; palpable cord; unequal intensity of pulses or disparity of blood pressure between upper extremities ● Neurologic examination: agitation; confusion; delirium; obtundation; coma. ● Skin: cold, clammy or warm, hyperemic skin; rashes; petechiae; urticaria; cellulitis

Midgut herniation is a normal phenomenon during which gestational weeks?

Physiologic midgut herniation is normal at 7-11 weeks; it resolves at ≥12 weeks; do not confuse with omphalocele.

influenza maternal complications

Physiological changes in pregnancy such as an elevated diaphragm, increased oxygen consumption, and decreased functional residual capacity may worsen the pulmonary complications of influenza (i.e., pneumonia). Secondary bacterial infections, particularly pneumonia, are not uncommon. Myocarditis has also been reported. Death, though rare, usually complicates influenza in patients with underlying chronic disease. There is no evidence that influenza A or B cause congenital malformations and congenital infection is negligible.

PAS on ulrasound

Placenta previa thin myometrium (<1mm) - loss of hypoechoic retroplacental space - numerous (3+) large lacunae w/ "moth eaten" appearance of placenta exophytic mass of tissue beyond uterine wall Color hypervascularity between myometrium and posterior wall of blader subplacental hypervascularity lacunae feeding vessels with high velocity flow (>15 cm/s, turbulent) from arterial vascular of myometral lakes

Contraindications to vaginal delivery

Placenta previa Vasa previa active genital herpes classic cesarean full thickness myomectomy transverse lie certain fetal anomalies Footling breech cord presentation /prolapse

AFE presentation

Presents as RAPID ONSET cardio-respiratory collapse: - hypotension (SBP <90mmHg) - O2 desaturation (<90%) - dyspnea/tachypnea - Arrhythmia, tachycardia, PEA, even asystole. - hemorrhage - - possible neurological manifestations (ie, seizure, stroke.... though these are rare and less reliable) .

Postpartum thyroiditis

Postpartum thyroiditis (PPT) is a destructive autoimmune disease occurring in the first year after delivery in women without a history of thyroid disease prior to pregnancy. Postpartum thyroiditis could cause transient or permanent thyroid disease. Three clinical presentations have been suggested for postpartum thyroiditis are as follows: (1) transient hyperthyroidism (32% of patients), (2) transient hypothyroidism (43% of patients), (3) transient hyperthyroidism -followed by hypothyroidism - then recovery which is the classic form of PPT (25% of patients). 2 phases: Williams - Phase 1 (begins one to four months after delivery and lasts two to eight weeks)= destruction-induced thyrotoxicosis with symptoms from excessive release of hormone from glandular disruption. The onset is abrupt, and a small, painless goiter is common. Although there may be many symptoms, only fatigue and palpitations are more frequent. This thyrotoxic phase usually lasts only a few months. If symptoms are severe, a B-blocking agent may be given. - Phase 2 (lasts two weeks to six months) = hypothyroidism from thyroiditis. Thyromegaly and other symptoms are common and more prominent than during the thyrotoxic phase. Treat via Thyroxine replacement given for 6-12 months..... then TAPER and check. Postpartum thyroiditis is an autoimmune disease and associated with the presence of antibodies to thyroid peroxidase (TPO). Chances of developing postpartum thyroiditis in pregnant women who have positive TPO antibodies early in pregnancy are 30% to 52%. During pregnancy level of TPO antibodies naturally decreases due to the immunosuppressed state of pregnancy. Women who remain positive for TPO antibodies in the third trimesters of pregnancy will have an 80% chance of developing postpartum thyroiditis. Screening of high-risk women for developing postpartum thyroiditis, such as a positive test for antithyroid peroxidase antibody, history of postpartum thyroiditis, type 1 diabetes mellitus, is recommended by Endocrine Society clinical guidelines..... High-risk women should be evaluated for serum TSH levels at three and six months postpartum. If they DO develop hypothyroid... consider a small dose of synthroid, and then monitor

single IUFD in multiple pregnancy

Potential fetal causes of single intrauterine fetal demise (sIUFD) include: - discordant infections - discordant structural congenital anomalies (with or without chromosomal differences) - discordant fetal growth. Placental factors involved in sIUFD include: - uneven placental sharing - placental implantation anomalies - peripheral cord insertion. Maternal factors include hypertensive disorders (e.g., preeclampsia), thrombophilia, and abruption.

SOGC deliver HTN

Preeclampsia and GHTN: 37 Chronic : 38

IOM weight gain recommendations

Preferably minimize Lbs 10 (BMI 30+) 15 (BMI 25-30) 25 (BMI 18-25) 35 (BMI < 18) each one is basically plus 10 pounds for range Ie, 10-20 15-25 25-35 30-40

# hemoglobinopathy pregnancy counseling

Pregnancies at risk of an affected fetus (including pregnancies where both parents are carriers or where one parent is a carrier and one parent is affected) should be referred for genetic counseling for full assessment of inheritance risk and discussion prenatal testing options including fetal diagnostic testing through chorionic villus sampling and amniocentesis depending on gestational age. In patients presenting for preconception counseling with a known risk for conceiving an affected fetus preimplantation genetics and in vitro fertilization is an option.

pregnancy monitoring APS

Pregnancy monitoring • Level II ultrasonography at 18 weeks. • Fetal growth should be monitored every 4-8 weeks beginning at 20 weeks for any patient on anticoagulation; ultrasonographic assessment should be more frequent if fetal growth restriction is suspected or documented; in such a case, Doppler studies may be useful in determining the optimal timing of delivery. • Office visits as often as every two weeks beginning at 20 weeks to screen for preeclampsia. • Nonstress tests (NST) and/or biophysical profiles (BPP) weekly beginning at 36 weeks in uncomplicated cases or earlier as clinically indicated.

physiologic causes of high prolactin

Pregnancy, Infant sucking, Nipple stimulation, Sexual intercourse, Physical stress (surgery, trauma, MI, hypoglycemia), poor Sleep, excessive Exercise, Food ingestion

what drug use conditions may require supervised withdrawal ?

Pregnant women who are dependent on - alcohol - opioids - high-dose benzodiazepines (>50 mg daily diazepam equivalent) may require medical detoxification under the supervision of a physician Women who are in withdrawal from other substances, such as cocaine or marijuana, may also benefit from a supportive admission to a non-medical withdrawal management service, if available, for relapse prevention and counselling.

benefits of exercise

Prenatal physical activity was associated with a reduction in the odds of - GDM (38%; ]), preeclampsia (41%; ]), gestational hypertension (39%; ]), prenatal depression (67%;]), macrosomia (39%;]) without increasing the odds of adverse outcomes including preterm birth, low birth weight, miscarriage, and perinatal mortality

appendicitis workup pregnancy

Presentation includes low grade fever, nausea, vomiting, abso pain Ultrasound is first step, if positive, appendectomy. If negative (But suspicion is very high), then do a CT or MRI

nec fasc presentation

Presentation: • Fever • pain out of proportion • crepitus • cellulitis • skin discoloration • blood blisters • weeping skin • increased WBCs • Subcutaneous aid on x-ray, septic shock

Delayed cord clamping benefits

Preterm singleton 60-120 secs DCC decreases mortality by approximately 30% in both extremely preterm infants (gestational age [GA] ≤28 weeks) and preterm infants overall Reduced morbidity - IVH -NEC - Less need for : -transfusion - inotropic support Risks - higher bili and polycytmemia... but no risk of exchange transfusion Longer benefits -less risk of death - long term neurologic Term singletons up to 60 secs improves hematologic parameters (Hb, irom ferritinm transferrin) - maybe better motor skills Beyond 60 secs increases risk of hyperbilirubinemia requiring transfusion Term twim evidence is less, but may be interpreted as similar

pregnancy preterm categories

Preterm: ≤ 37 weeks' gestational age Very Preterm: < 32 weeks' gestational age Extremely Preterm: < 28 weeks' gestational age

contraindications to progesterone

Previous hypersensitivity to it hormone-sensitive cancer liver disease uncontrolled hypertension Active arterial or venous thromboembolism or severe thrombophlebitis, or a history of these events.... (no evidence for it)

HSV treatment Primary, recurrent, disseminated

Primary acyclovir 400 mg po tid 7-10 days valacyclovir (Valtrex) 1 g po Bid × 7-10 days Recurrent Acyclovir 800mg PO TID x 2 days Valacyclovir 500mg PO BID X 3 days.... OR 1g daily x 5 days Suppressive (at 36w) (treatment can be extended in case of incomplete healing) and receive suppression with - acyclovir 400 mg po tid - valacyclovir 500 mg po bid at 36 weeks until delivery. Women with HIV co-infection may require a longer duration of treatment. Those with severe or disseminated HSV are given IV acyclovir, 5 to 10 mg/kg every 8 hours or 2 to 7 days until clinically improved. This is followed by oral antiviral drugs to complete at least 10 days of total therapy SOGC on recurrent outbreaks during pregnancy: For women with recurrent outbreaks during pregnancy, antiviral therapy is not recommended prior to 36 week.... but if manifestations are very severe and/or unacceptable to the woman, therapy can be individualized

hsv transmission

Primary first-episode infection, defined as HSV confirmed in a person without prior HSV-1 or HSV-2 antibodies, can lead to a 25% to 50% vertical transmission rate if vaginal delivery Vaginal delivery during recurrent infection is associated with a <1%-3% incidence of neonatal HSV infection. Regarding mode of delivery: ◦ If any genital lesion suspicious for HSV is seen at the time of labor, a CD should be performed. SOGC: perform even if prodrome with recurrent due to risk of asymptomatic shedding. (risk is around 1% transmission) An indicated CD for active genital HSV should be performed before membrane rupture or as soon as possible (ideally within 4-6 hours) following rupture of membranes Avoid FBS, scalp electrodes

macroadenoma pregnancy

Prolactin - the endocrine society guidelines recommend against measuring prolactin during pregnancy because it can be difficult to distinguish the normal pregnancy-associated rise in prolactin from that associated with adenoma growth. However, it may be measured every 3 months during pregnancy because it is reassuring if it does not increase above 400ng/mL. If greater than 400ng/mL then visual field testing should be performed. visual field testing - routine visual field testing not indicated, however women with visual symptoms should have visual field testing. In addition, women whose macroadenomas extend above the sella should have visual field testing every 3 months in pregnancy even if no visual symptoms pituitary MRI - Routine MRI not indicated but non contrast MRI should be done if the woman develops severe headaches or visual field abnormalities Dopamine agonists - If the adenoma has enlarged to a degree that could account for headaches or visual field defect, the patient should be treated with a dopamine agonist throughout the remainder for the pregnancy and she should be seen at least once a month to reevaluate symptoms and visual fields. This treatment will decrease the size of the adenoma and alleviate the symptoms. We suggest using the same dopamine agonist the patient took and tolerated previously (cabergoline vs bromocriptine). The safety of bromocriptine in pregnancy is well established. The safety profile is less well known for cabergoline. This drug is increasingly use in nonpregnant women because it is better tolerated and more effective. Cabergoline is generally considered safe or use in pregnancy Surgery - If cabergoline is not successful in alleviating severely compromised vision after several weeks we suggest transphenoidal surgery in the second trimester. In contrast in the third trimester, surgery for persistent visual symptoms should be deferred until after delivery if possible.

treat graves in pregnancy

Propranolol for 2-4 weeks for symptomatic relief until the anti-thyroid peroxidase enzymes kick in. PTU has ALSO effect of decrease t4-t3 Methimazole has rare teratogenicity PTU causes hepatotoxicity Start with PTU. ( 100-150 mg orally every 8 hours ) .. switch to meth in 2nd trimester. (5-10mg PO BID-TID) Propylthiouracil (PTU) has been historically preferred because it partially inhibits the conversion of T4 to T3 and crosses the placenta less readily than methimazole. Radioiodine therapy is second line in non-pregnancy, but it is CONTRAINDICATED in pregnancy Propranolol for tachycardia- 20-40 mg per day split into 2-3 doses (typically 10mg BID-TID)

pros/cons of EFM

Pros: continuous recording can be centrally monitored external Cons: record maternal HR - artifact difficult in obese, poly -does not measure CTX strength

pros/cons of IA

Pros: less restrictive lower intervention without (much) proven benefit less cumersome/costly cons harder with high BMI more intervention

natural anti-coagulants

Protein C Protein S Anti-thrombin 3

quantitative fluorescence PCR vs microarray

QF-PCR and microarray analyses have superior diagnostic yield compared with traditional karyotyping quantitative fluorescence (QF) polymerase chain reaction (PCR) for the most prevalent trisomies chromosomal microarray analysis search for copy number variants of genomic segments, including those caused by deletions or duplications.

consequences of TTTS

Recipient fetuses demonstrate: -polyhydramnios - polycythemia - biventricular hypertrophy - diastolic dysfunction, which tends to be progressive without definitive therapy - tricuspid regurgitation, and cardiac failure. Donor twin: oligohydramnois anemia growth restriction pallor (baby & placenta) oliguria oligohydramnios 'stuck twin' contractures pulmonary hypoplasia

Rh status and screening in fetus

Recommend to screen at first, AND to screen at 28 weeks. If Rh neg mom, and dad is known Rh neg also, then impossible the baby is Rh +.... (unless weak) Cell free DNA can screen for fetal Rh status. 40% of RhD‐negative women who are pregnant, their fetus will be RhD negative as well and therefore antenatal RhIG is unnecessary.

unfractionated heparin pregnancy

Recommended if GFR <30 target aPTT 1.5 -2.5 pregancy baseline

sickle cell transfusions

Recommended when : HbS is >40% and Hb concentration is <10 g/Dl RBC transfusions required by ~50% with SCDgiven the high frequency of transfusion in these patients, it is imperative to ensure appropriate cross‐matching for minor blood antigens to avoid both transfusion reactions and antibody development to antigens which may limit future availability of blood products for these patients. Overall alloimmunization development rates have ranged between 6% and 85% depending on the study. It is reasonable to attempt strict cross‐matching and consider leuko‐reduced and/or cytomegalovirus (CMV)‐negative blood to limit transfusion reactions and infections in this patient population

SOGC relative contraindications to exercise

Relative contraindications to exercise are the following: •Recurrent pregnancy loss •Gestational hypertension •A history of spontaneous preterm birth •Mild/moderate cardiovascular or respiratory disease •Symptomatic anemia •Malnutrition •Eating disorder •Twin pregnancy after the 28th week •Other significant medical conditions

progesterone teratogen

Risk of teratogenesis - A possible increase in risk of hypospadias in male offspring exposed to exogenous progestins before 11 weeks of gestation has been described...... Even if confirmed, the concern is not relevant to patients with prior preterm delivery since they will receive the drug after 16 weeks of gestation.

risks of vacuum what are rules to stop?

Risks of vacuum - subgaleal hemorrhage (almost exclusively with vacuum) - cephalohematoma - bleeding from subgaleal/cephalohematoma may result in higher hyperbili/jaundice - retinal hemorrhages - lower rates of success -Skull fracture may be higher in forceps (not well established) - Intracranial hemorrhage may be higher with vacuum (not well established), especially if <34 week...... vacuum at this GA is not recommended <34 weeks. Vacuum stop- 3 pop offs - 3 pulls over 3 contractions with no progress - 30 mins Forceps Stop- No similar "rules", but should have good descent with each, delivery by 3-4 pulls.

when to perform amnio for infection ?

Routinely, when the cervix is ≥2 cm dilated on manual or speculum examination, as the incidence of intraamniotic infection in these patients is approximately 20 to 50 percent ●On a case-by-case basis, when: -Ultrasound findings are consistent with inflammation (eg, debris in the amniotic fluid [sludge or biofilm] (image 1)) - Membranes are visible and exposed at the external os, as sludge is associated with an increased risk for preterm birth and prolapsed membranes are associated with a poor perinatal prognosis [14,15].

ECG changes in pregnancy with PE

S1Q3T3 RBBB

indications for vaginal progesterone (!!)

SINGLETON : 1)- women with a sonographic short cervix (≤25 mm on transvaginal ultrasound assessment between 16 and 24 weeks),..... (200mg) 2) - previous spontaneous preterm birth (weak) Twins: Very weak evidence multi-fetal and short cervical length (≤25 mm by transvaginal ultrasound between 16 and 24 weeks), vaginal progesterone therapy for prevention of spontaneous preterm birth is recommended .... 400mg as oppossed to 200 Go up to 34-36 weeks

SIRS vs quick SOFA

SIRS = 2+ of the following cardinal signs: (1) a body temperature <36 °C or >38 °C; (2) a pulse rate >90 beats per minute (bpm); (3) tachypnea manifesting as a respiratory rate >20 breaths per minute or a PaCO2 < 32 mmHg; and/or (4) a circulating leukocyte count <4000/μL, >12,000/μL, or >10% immature forms on the differential count. qSOFA= 2/3 of ● Systolic blood pressure ≤100 mmHg ● Respiratory rate ≥22/min ● Altered mental status. SOFA attached

treat neonatal heart block

SMFM- We recommend that steroids not be routinely used for the treatment of fetal heart block due to anti-SSA/SSB antibodies given their unproven benefit and the known risks for both the pregnant patient and fetus

if patient has HIV, what else should you test for??

STI's (chlamydia, gonorrhea, syphillis) Hep A, B, Hep C Toxoplasmosis, CMV TB

HIV screening in pregnancy

Screen all women first antenatal visit. Ideally, start treatment ASAP, Previously recommended to start just after 1st trimester (15-20w) baseline viral load - repeat this every trimester at least ..... definitely do around 35-36 weeks -also do CD4 note, screening is VOLUNTARY

oligohydramnios workup

Screening with BP, physical exam Speculum Ultrasound, assess placental function/doppler Autoimmune with Coombs test and APS testing Torch testing amnio (if anomalies found)

Factor V leiden testing

Screning via Activated Protein C resistance confirm by DNA testing

Cephalohematoma

Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines.

sedative drugs in labor

Sedative and hypnotic drugs do not provide pain relief and may increase respiratory depression when given in conjunction with opioids. However, in women with high levels of anxiety not alleviated by support and reassurance, sedative drugs can reduce episodes of nausea/vomiting and enhance the analgesia obtained with opioids.

Septic shock presentation (early and late)

Septic shock can be identified within a clinical construct of sepsis with - persistent hypotension requiring vasopressors to maintain mean arterial pressure (MAP) ≥65 mm Hg and - a serum lactate level >2 mmol/L despite adequate volume resuscitation. Early (warm) shock- characterized by a hyperdynamic circulation and decreased SVR. ● Altered mental status ● Peripheral vasodilation (warm skin, flushing) ● Tachypnea or shortness of breath ● Tachycardia ● Temperature instability ● Hypotension ● Increased cardiac output and decreased peripheral resistance Late (cold) shock- abnormal tissue perfusion and oxygenation due to regional (peripheral) vasoconstriction and myocardial dysfunction ● Peripheral vasoconstriction (cool, clammy skin) ● Oliguria ● Cyanosis ● ARDS ● Decreased cardiac output and decreased peripheral resistance Secondary (irreversible) shock is frequently a terminal condition associated with multiple‐organ system dysfunction. Each phase represents a continued downward progression in the course of this disease process. ● Obtunded mental status ● Anuria ● Hypoglycemia (due to impaired hepatic function and reduced gluconeogenesis) ● Disseminated intravascular coagulation ● Decreased cardiac output and decreased peripheral resistance ● Myocardial failure Although there may be a transient increase in circulating blood glucose levels due to catecholamine release, hypo- glycemia is more likely to prevail later due to hepatic dys- function and a reduction in gluconeogenesis.

manage B19 infection

Serial ultrasounds are used to screen for fetal anemia and signs of hydrops, beginning at 22 weeks' gestation. Fetal anemia can be suspected with MCA PSV < ≥1.50 multiples of the median (MoM) If the MCA PSV values are <1.50 MoM, it is suggested to continue screening with weekly ultrasounds for 12 weeks after exposure If MoM > 1.5 but no hydrops, increase u/s to 2-3x a week for hydrops If hydrops is noted, fetal transfusion is warranted if it is confirmed by cordocentesis. Fetal transfusion is typically limited to 20-35 GA; the procedure is technically difficult before 20 weeks' gestation, and there exists excessive fetal risk compared to delivery beyond 35 weeks' gestation.... so deliver by 35 if hydrops.

uptodate hep b

Serologic testing for multiple viral antigens and the corresponding antibodies allows for identification of both acute and chronic infections. In the setting of acute infection, hepatitis B surface antigen (HBsAg), hepatitis B e antigen (HBeAg), and hepatitis B DNA (HBV DNA) are present, and IgM anti-HBc (antibody against the hepatitis B core antigen) appears shortly thereafter. The presence of IgM anti-HBc and HBsAg, without anti-HBsAg is diagnostic of acute infection (see Table 1 for summary of interpretation of serologic results). Recovery after acute infection is marked by the reduction of serum HBV DNA and seroconversion to anti-HBe and anti-HBs (accompanied by disappearance of HBeAg and HBsAg, although rarely HBsAg and anti-HBs may coexist (1.2% in a study by Lee et al)..... Class switching of the IgM anti-HBc to IgG anti-HBc also occurs after initial infection. Therefore, individuals with a prior history of natural infection will have IgG anti-HBc as well as anti-HBs. Conversely, the presence of only anti-HBs without anti-HBc is indicative of a vaccinated individual. Individuals with a chronic infection may have persistent HBeAg, with continued circulation of HBsAg (and HBV DNA), with IgG but not IgM anti-HBc, without anti-HBs. Detection of HBsAg for longer than six months after acute infection is diagnostic of chronic infection. Although quantitation of serum HBV DNA may be used clinically to assess ongoing HBV replication, serum HBV DNA may be negative in inactive chronic HBV. Since recovery from acute infection is accompanied by disappearance of HBV DNA, PCR testing for quantitation of serum HBV DNA occurs more frequently in the assessment of chronic infection rather than the acute setting or during initial screening. Hepatitis B e Antigen and Chronic Hepatitis B Infection The hepatitis B e antigen (HBeAg) is a marker of replication and infectivity. In the setting of acute infection, conversion from HBeAg to anti-HBe typically occurs before the transition from HBsAg to anti-HBs. However, in the setting of chronic hepatitis B infection, seroconversion may not be observed. Chronic HBV infection is divided into multiple phases In the immune-tolerant phase, HBeAg is positive, HBV DNA l

maternal adaptations to twins

Serum levels of progesterone, estradiol, estriol, human placental lactogen, human chorionic gonadotropin (hCG), and alpha fetoprotein (AFP) are all significantly higher in multiple than in singleton gestations

tests to CONSIDER in miscarriage

Several investigators report an association between heritable thrombophilias such as the: - factor V Leiden mutation (SOGC says no) - 2010A prothrombin (SOGC says no) gene mutation - hyperhomocysteinemia - protein C deficiency, protein S deficiency - antithrombin III deficiency and fetal death. However, the association is controversial and routine screening is not currently advised for isolated cases of fetal demise. Consider testing for antiphospholipid syndrome with lupus anticoagulant screen and testing for anticardiolipin antibodies + B2 glycoprotein if - there is evidence of placental insufficiency, and/or the patient has recurrent pregnancy loss, thromboembolism, or autoimmune disease. Consider ToRCH, syphillis HbA1c Parvo listeria Anti-Ro/LA (SSA-SSB) is indicated if there is evidence of hydrops, endomyocardial fibroelastosis, or atrioventricular node calcification at postmortem 8.Karyotype on both parents (in cases with 3 or more recurrent spontaneous abortions, or previous or current fetus or newborn with congenital malformations or dysmorphic features) 9.Hemoglobin electrophoresis (in cases where the fetus is hydropic, the mother is anemic, or α-thalassemia is considered in the differential diagnosis) 10.Coagulation times and plasma fibrinogen levels (in cases of a massive placental abruption as the cause of intrauterine fetal death, or fetal death more than 4 weeks) 11Toxicology screen to rule out cocaine, cannabis, or other illicit drugs 12.Bile acids and liver enzymes if patient reports symptoms of cholestasis

WHO risk groups

Severe : Pulmonary HTN Eisenmenger syndrome NYHA class 4 Previous peripartum cardiomyopathy with heart failure <40% Marfan with aortic root >

complications of oligo

Severe and long‐standing oligohydramnios, especially when documented prior to 16-24 weeks of gestation, inhibits fetal lung growth and promotes limb positional defects such as club foot and arm contractures ROM at 16-20 weeks GA is the worst, as that is when there is alveolar proliferation. Can also have Meconium Cord compression

fetal growth discordance in monochorionic

Severe fetal growth discordance in monochorionic gestations is variably defined as more than 20% discrepancy between estimated fetal weights or birth weights of twins in a pregnancy not complicated by TTTS. This definition includes or implies severe intrauterine growth restriction of one twin. The most important determinant of selective (non-TTTS-related) growth discordance in monochorionic twin pregnancies is unequal placental sharing (usually associated with abnormal cord insertion of one or both twins). placentas of monochorionic twin pregnancies complicated by selective growth discordance have a higher frequency of uneven placental sharing or peripheral (marginal or velamentous) cord insertion of at least one twin

growth discordance in dichorionic

Severe growth discordance in dichorionic twins is variably defined as more than 20% discordance between estimated fetal weights or birth weights of twins. Larger weight - smaller weight ....then divide by the larger weight..... and multiply by 100 an international expert consensus defined selective FGR in dichorionic twins as: - an EFW less than the third centile in one twin ...... or ..... at least 2 of the following 3 parameters: EFW < 10th centile in the smaller twin - EFW discordance of ≥ 25% - umbilical artery pulsatility index of the smaller twin > 95th percentile.

# ductus arteriosis

Shunts 90% of the blood from the pulmonary artery to descending aorta.... 10% reaches the fetal lungs

# Risk of antidepreessants

Small risk May have atrial or ventricular septical defects..... may be isolated to Paxil. May have SGA, PTB

stages of TTTS

Stage I: MVP >8 and <2 - Donor twin bladder still visible, fetal Doppler values normal Stage II: Donor twin bladder no longer visible, fetal Doppler values normal Stage III: Donor twin bladder no longer visible, fetal Doppler values critically abnormal Stage IV: Presence of hydrops Stage V: Intrauterine death of one or both fetuses Fetuses with TTTS may not show an orderly progression through these stages. The ultimate prognosis does not appear to be directly related to the stage at initial diagnosis. Diagnosis of stage I TTTS does not necessarily imply that disease progression will occur, with progression rates between 10% and 45% for stage I disease.

sogc moderate risk folic acid

Standard care: Women at low or moderate risk of folic acid-sensitive anomalies should take either a daily 0.4 mg folic acid supplement (low-risk women) or a daily 1.0 mg folic acid supplement (moderate-risk women).h

Warfarin Embryopathy

Stippled vertebrae Stippled epiphyses Flattened nasal bridge Nasal hypoplasia Choanal Atresia The actual risk of warfarin embryopathy is difficult to estimate, but is probably in the range of 4% to 10%. There is good evidence that embryopathy is less likely if the warfarin dose is 5 mg/d or less. The fetal risks continue beyond the first trimester, because warfarin increases the possibility of both fetal and intrauterine bleeding.

crohn's What meds to use?

Stop methotrexate Common medications and their use in pregnancy (not an exhaustive list): o 5-ASA (mesalamine, sulfasalazine, balsalazide, olsalazine): may be continued throughout pregnancy and can be given both orally and rectally (may be difficult for the patient to self-administer rectally in the third trimester). o Thiopurine therapy (azathioprine): may be continued throughout pregnancy. o TNF-alpha inhibitors (tumor necrosis factor, e.g. infliximab, adalimumab, certolizumab, etanercept): may be continued throughout pregnancy. Last dose may be timed such that the next dose is soon after delivery o Cyclosporine A: may be continued in pregnancy. o Corticosteroids: may be continued throughout pregnancy and may be started during pregnancy for an acute flare and/or to induce symptom regression. Although the lowest effective dose should be used, there may be an increased risk of cleft lip/palate with use in the first trimester and gestational diabetes in the second and third trimester. o Metronidazole: is the antibiotic of choice for flare. • For those hospitalized with a flare, VTE prophylaxis should be prescribed. • In women with suspected IBD or an IBD flare, we recommend flexible sigmoidoscopy or colonoscopy, with sedation as deemed appropriate, if the results will affect antenatal management of IBD. Similar to other procedures in pregnancy, positioning should be considered to avoid compression of the maternal IVC (recommend left pelvic tilt rather than supine positioning).

nausea and vomiting conservative treatment

Suggested dietary changes include frequent small meals every 1-2 hours small high‐protein, low‐fat snacks, and avoiding an empty stomach. Drinking cold, clear, carbonated or sour drinks in small amounts between meals such as ginger ale . Avoiding triggers such as strong odors, perfumes, chemicals in cleaning products, coffee, smoke, spicy and fatty foods, high‐sugar snacks, or heat and humidity may help to reduce symptoms in some women. Powdered ginger appears safe and effective in relieving symptoms of mild nausea and vomiting. Typical treat-ment consists of 250 mg ginger capsules four times daily.

cystic hygroma management

Summary of antenatal management -Consultation with Maternal-Fetal Medicine and Genetic Counselor -Recommend diagnostic testing for fetal aneuploidy (amniocentesis or CVS) -Specialized anatomy ultrasound (aka detailed, aka Level II) at 18-20 weeks -Fetal echocardiogram at 22-24 weeks -Serial growth ultrasounds every 4 weeks starting at 28 weeks -Weekly BPP at 32 weeks -Deliver at 39 weeks unless indicated sooner

Gyne HSV suppressive therapy indications (SOGC)

Suppressive treatment is suggested for patients who have •at least 6 recurrences per year •significant complications, but fewer than 6 recurrences per year •their quality of life significantly affected •social and sexual dysfunction - Immunocompromised •to lower the risk of transmission to a sexual partner or fetus/neonate (II-B).

pregnancy for HIV men or couples

Surrogacy is not currently an option in Canada for single men with HIV or men with HIV in a same-sex couple. Sperm donation by men with HIV is restricted by Canadian law; however, it may be possible through the Donor Semen Special Access Program when the recipient is known to the donor. Additional information is available from Assisted Human Reproduction Canada and fertility specialists. Individuals and couples with HIV who require sperm donation, egg donation, or a surrogate are likely to require legal advice and contracts. For serodiscordant couples in which the man is living with HIV and is on combination antiretroviral therapy with virologic suppression, the Canadian HIV Pregnancy Planning Guidelines Development Team recommends: a) attempting timed condomless sex for 6 to 12 months (I-A) or b) referral to a fertility specialist for consideration of sperm washing or use of donor sperm with intra-uterine insemination (II-2A) as the preferred initial methods of conception.

Dx of AFLP

Swanson criteria (6 or more) Vomiting • Abdominal pain • Polydipsia or polyuria • Encephalopathy • Elevated bilirubin level (>0.16 mg/dL) • Hypoglycemia (<72 mg/dL) • Elevated urea level (>3.8 mg/dL) • Leukocytosis (>11 × 109/L) • Ascites or bright liver on ultrasound • Elevated transaminase levels (AST or ALT >42 IU/L) • Elevated ammonia level (>0.53 mg/dL) • Renal impairment (creatinine >1.7 mg/dL) • Coagulopathy (PT >14 sec or aPTT >34 sec) • Microvascular steatosis on liver biopsy serum ammonia + hypoglycemia are the laboratory evaluations most characteristic of acute fatty liver of pregnancy and useful to make the diagnosis in the context of confusion and disorientation.

Mumps symptoms

Swelling and pain on both sides of face Sore throat Fever Aches and pains Very contagious for up to 7 days before symptoms show and 10 days after symptoms start Symptoms may last 10 days

microcytic anemia workup and causes

TAILS "1) iron deficiency anemia 2) Anemia of chronic disease 3) sideroblastic anemia- problem with protoporphyrin. 4) thalassemia- problem with the globin chains!! 5) lead poisoning - If low iron, there is microcytic anemia (iron deficiency anemia)- if Iron is locked away in macrophages because of chronic inflammation, it is low (anemia of chronic disease)- Any circumstance which decreases production of protoporphyrin (sideroblastic anemia) - decreased production of globin chain (thalassemia)

Antiphospholipid Syndrome

THE major acquired thrombophilia is antiphospholipid syndrome (APS aka APLA ). Antiphospholipid antibodies (aPL) are autoantibodies directed against proteins bound to negatively charged phospholipids. They are present in up to 20% of individuals with venous thromboembolism (VTE), and affected patients have a 5% risk of VTE during pregnancy and the puerperium despite treatment. However, antiphospholipid antibody (APA)‐related thrombosis can occur in any tissue or organ and can be either venous or arterial. In addition, APS is linked to placental insufficiency and higher rates of associated complications such as preeclampsia, abruption, fetal growth restriction, and fetal loss.

Twin Reversed Arterial Perfusion Sequence (A-cardiac Twinning)

TRAP sequence is a severe form of chronic twin-to-twin transfusion in monochorionic twin pregnancies characterized by lack of cardiac development or function, or both, and usually striking malformations of the so-called a-cardiac twin. In this typical constellation of twin and placental anomalies, a twin with circulatory failure (the a-cardiac twin) is perfused in a paradoxical retrograde fashion by a structurally normal "pump" twin through a usually single superficial AA anastomosis—hence the name reversed arterial perfusion. The acardiac twin loses its vascular connections to the placenta, resulting in a bypass of placental villous parenchyma, and depends on the co-twin (donor or pump twin) for all blood supply. The pump twin shunts part of its cardiac output toward the parasitic acardiac co-twin through retrograde flow into its umbilical artery or arteries via the intertwin AA anastomoses, resulting in reversed circulation for the acardiac twin. Because the blood flows in a retrograde fashion through the umbilical artery (a branch of the internal iliac artery) or, in some cases, directly into the abdominal aorta, the lower body of the acardiac twin is supplied preferentially with partially deoxygenated blood. This results in relatively better development of the lower body in most acardiac twins. Two conditions need to be present: - acardiac twin has a structural or functional heart issue... diagnosed early - the placenta must have a specific angioarchitecture, defined by at least one direct AA (and usually also VV) intertwin anastomosis, to support the development of an abnormal (acardiac) twin that would be unable to develop independently.

workup for hyperthyroid

TSH T3/T4 Radioiodine uptake test- Normal/elevated uptake = graves check TSI-antibodies (thyroid stimulating immunoglobulins) TSH receptor antibodies p

thyroid hormones and placenta

TSH does not cross the placenta. Thyroid-releasing hormone (TRH) and iodide do cross the placenta Small amounts of T4 and T3 pass the placenta

thyroid hormones pregnancy

TSH levels decline in T1 in >80% pregnant patients, but remain within the normal range for non-pregnant women (due to high serum bhCG causing thyroid stimulation) TBG increases until 20 wks, then stabilizes (due to E2 stimulating hepatic production and decreased metabolism rates), which results in total T3 and T4 increasing sharply in T1 with a plateau at 18 wks free T4 and T3 physiological levels are not affected by increased TBG free T4 levels rise slightly in T1 and peak with bhCG due to increased production of thyroid hormones and associated glandular hyperplasia and increased vascularity, the thyroid is moderately enlarged but does not cause significant thyromegaly (investigate any goiter in pregnancy) Thyroid-binding globulin increases due to stimulation of synthesis by estrogen as well as decreased hepatic clearance. Because TBG increased, there is an increased TOTAL thyroxine (TT4) and triiodothyronine (TT3) ...... while resin triiodothyronine uptake (RT3U) decreases. Serum TSH and hCG levels vary with gestational age (Fig. 4-17) (Burrow, 1994). As discussed in Chapter 5 (p. 96), the α-subunits of the two glycoproteins are identical, whereas the β-subunits, although similar, differ in their amino acid sequence. As a result of this structural similarity, hCG has intrinsic thyrotropic activity, and thus, high serum hCG levels cause thyroid stimulation. Indeed, TSH levels in the first trimester decline in more than 80 percent of pregnant women, however, they still remain in the normal range for nonpregnant women." "Early in the first trimester, levels of the principal carrier protein— thyroid-binding globulin (TBG)—rise. They reach their zenith at about 20 weeks' gestation. Concentrations stabilize at approximately double baseline values for the remainder of pregnancy (see Fig. 4-17). The greater TBG concentrations result from both higher hepatic synthesis rates—due to estrogen stimulation—and lower metabolism rates due to increased TBG sialylation and glycosylation. These elevated TBG levels increase total serum T4 and triiodothyronine (T3) concentrations, but do not affect the physiologically important serum free T4 and free T3 levels. Specifically, total serum T4 levels rise sharply beginning between 6 and 9 weeks' gestation and reach a plateau at 18 weeks. Serum free T4 levels rise only slightly and peak along with hCG levels, and then they return to normal." Iodine requirements during pregnancy increase by greater than 50% due to increased maternal thyroxine production to maintain maternal and fetal euthyroidism and increased renal iodine clearance . Plasma iodine levels decrease. This is associated with an increase in the size of the maternal thyroid gland( 10%-30%)

TTP vs HUS

TTP- ADAMTS13 deficiency -fever - purpura - neurologic symptoms (headache, stroke, alteration in mental status, seizures, hemiplegia, paresthesias, visual disturbance, and aphasia.) HUS- renal failure - less likely fever, purpura, or neurologic

SOGC cervical length screening

TV screening is not recommended without hx of PTB In women with LEEP/uterine anomalies /D&E , may screen just like you would previous PTB If there is a Hx of PTB, then measure at 16w, and q 2 weeks

treat influenza

Tamiflu 75mg PO BID x 5 days for anyone with either suspected or confirmed influenza consider procalcitonin to rule out bacterial

Alcohol use in pregnancy

Teratogens Growth restriction Preterm birth, Fetal demise

Toxoplasmosis transmission

The 3 main routes of transmission are 1)(main mechanism) ingestion of cysts - from raw or undercooked meats , water, food, 2) exposure to oocysts - from infected cats or contamimated soil 3) vertical transmission. Overall, the vertical transmission rate ranges from approximately 20% to 50%. Of congenitally infected fetuses who are PCR positive by amniocentesis, 74% to 81% manifest only subclinical infection (only serologically positive) whereas 19% to 26% have fetal/childhood illness even if they received treatment Infection is most serious in first trimester

SOGC soft markers

The 5 ultrasound soft markers previously recommended for aneuploidy screening were -enlarged nuchal fold -echogenic bowel mild ventriculomegaly -echogenic heart focus choroid plexus cysts. Of these, increased nuchal fold is the most powerful marker, with an LR of 23 (but only 3.8 if isolated) for T21, whereas choroid plexus cysts are only associated with a minimally increased risk of fetal T18." -

phenotype of TRAP

The acardiac twin shows a wide range of significant structural anomalies, usually featuring relative preservation of the lower limbs associated with underdevelopment of upper body and head . Types: acardius acephalus (60% to 75%; well-developed pelvis and lower limbs but no cranial or thoracic development and often no upper limbs) acardius anceps (15%; well-developed body and extremities but only partial cranial development); acardius amorphus (rare; least differentiated, amorphous tissue mass without recognizable features) acardius acormus (very rare; only cephalic development).

second trimester screening aka MSS aka maternal serum screening

The blood test for STS will measure the amount of 4 different hormones (or chemicals) that are present in your blood: human chorionic gonadotropin (hCG) - a hormone made by the placenta during pregnancy alpha-fetoprotein (AFP) - a protein made by the baby's liver inhibin-A - a protein made by the baby and the placenta unconjugated estriol (uE3) - a form of estrogen that increases during pregnancy The blood test for STS can be done from 14 weeks 0 days to 20 weeks 6 days of pregnancy.

SOGC borderline viability

The borderline of viability is classically defined as the period between 22+0 and 25+6 weeks. Most centres will advocate for active intervention beyond 25+0 weeks, and few will offer active intervention at 22+0 weeks. The period of ambiguity of intervention is greatest prior to and including 24+6 weeks.

presentation of candida vaginitis

The clinical manifestations of VVC in pregnancy are similar to those in the nonpregnant state: - pruritus, burning, dysuria, dyspareunia, fissures, excoriations with secondary infection, and pruritus ani. The vaginal discharge is usually thick, white, and curdlike (similar to cottage cheese).

approach of FHR monitoring in labor summary

The correct protocol for conducting intrapartum FHS includes ALL of the following steps: 1.Obtain interpretable data. 2.Classify IA/EFM tracing. 3.Interpret within context of overall clinical picture. 4.Communicate effectively with the interdisciplinary team. 5.Respond appropriately. 6.Document.

manage FNAIT

The current preferred approach recommends 75% respond to weekly IVIG, with a 98.7% success rate for preventing ICH For those that do not response, half of patiets will improve with the addition of high-dose prednisone Management is based upon the risk of ICH, stratified between standard, high, and very high risk. • Standard risk: Previous child with thrombocytopenia without intracranial hemorrhage • High risk: Previous child with an intracranial hemorrhage ≥28 weeks • Very high risk: Previous child with an intracranial hemorrhage <28 weeks

when does an ovum enter the uterus When does it implant ??

The developing fertilized ovum enters the uterine cavity on about the 4th day after fertilization. During its journey through the fallopian tube, its cells proliferate in the zona pellucida 2-1), and shortly before entering the uterus, a blastocyst cavity is formed. he adjacent trophoblastic cells enlarge and secure implantation, which is assumed to take place on about the 6th or 7th day after fertilization

diagnose FNAIT What are indications for testing for it?

The diagnosis is most often made retrospectively after delivery of an infant with thrombocytopenia or fetal/neonatal ICH. Occasionally FNAIT may be diagnosed via family history if the mother's sister had an affected child or if prenatal screening was performed. Indications for testing • Neonate with petechiae and ecchymosis, unexplained thrombocytopenia. • Fetus with unexplained ICH, hydrocephalus, or porencephalic cyst. • Woman incidentally found to be HPA-1a negative. • Family history of NAIT. Diagnostic criteria platelets < 150,000 AND plus identification of - a paternal, fetal, or neonatal platelet antigen WITH identification of maternal antibodies to that specific antigen. Therefore, diagnosis is made if mother is antibody positive (specific to father and fetal platelet antigen) and antigen negative. The father's antigen zygosity determines the risk of recurrence in subsequent pregnancies: 100% if father is homozygous, 50% if heterozygous.

maternal CMV testing

The diagnosis of CMV infection is confirmed by viral culture or PCR. The highest concentrations of virus are in - plasma - urine - saliva with most cultures becoming positive within 72 to 96 hours of onset of infection. (saliva and urine are most common)b PCR methodology permits identification of viral antigen within 24 hour. When a patient's previous immune status is unavailable, a combination of testing for CMV immunoglobulin M (IgM), CMV IgG, and CMV IgG avidity (where available) is recommended. Seroconversion of CMV (IgG) in paired labs 3 to 4 weeks apart is diagnostic of a new acute infection. - rising igG titers suggestive (not diagnostic) (4 fold increase) The presence of CMV immunoglobulin M (IgM) is not helpful for timing the onset of infection because (1) it is present in only 75 to 90 percent of women with acute infection (2) IF it is there (big "IF")... it can remain positive for over one year after an acute infection (3) it can revert from negative to positive in women with CMV reactivation or reinfection with a different strain (4) it can become positive in response to other viral infections, such as Epstein-Barr virus. In the absence of documented recent seroconversion, it is difficult to distinguish between primary infection, reactivation, reinfection, and quiescent disease since all are associated with IgG and IgM antibodies, and rising titers alone are not diagnostic. Determination of IgG avidity is helpful to better assess the acuity of the infection and thus the risk of in utero transmission High anti-CMV IgG avidity suggests that the primary infection occurred more than six months in the past; The combination of low IgG avidity and positive CMV IgM is suggestive of infection within the prior 3-4 months IgG avidity is low in early CMV infections, becoming high 5 to 6 months following primary infection

Iliac management in accreta

The effectiveness internal illiac ligation in the context of PAS is limited by the development of extensive collateral arterial blood supply either from branches of the external iliac arteries or the aorta. It does increase OR time an alternative to intraoperative IIA ligation is the transfemoral bilateral preoperative placement of flow balloons into the same location, followed by intraoperative inflation after delivery.

feeding in nausea and vomiting

The first-line treatment for nutritional support should be enteral tube feeding through either nasogastric or nasoduodenal tube while continuing with antiemetic pharmacotherapy. Total parenteral nutrition is associated with significant morbidity, mostly resulting from central catheters and should be reserved for women who cannot tolerate enteral tube feedings. A complication rate of up to 50% has been reported with peripherally inserted central catheters, including - line infection - cellulitis - pain - superficial thrombophlebitis and line failure.

goal of multifetal reduction

The goal of first-trimester MFPR is to reduce the number of fetuses in a higher order multiple gestation so as to decrease the chance of premature delivery and thereby improve the outcome for the remaining fetuses. Higher order multiple gestations are associated with a significant and proportional risk for delivery before viability. Fetuses that reach viability have a significant risk for birth before 28 weeks' gestation, when serious long-term neonatal morbidity is likely.

treat prolactinoma

The goals of therapy are to - normalize prolactin - reduce tumor size - restore gonadal function and fertility, the treatment of choice is a dopamine agonist. Previously, transsphenoidal surgery was the mainstay of therapy for prolactinomas. ..... success rates range from 73% to 90% for microadenomas and 30% to 50% for macroadenomas..... surgery is indicated when visual symptoms OR failed medical treatment. Recurrence of hyperprolactinemia after surgery is common but is not usually associated with radiographic evidence of tumor regrowth

gonorrhea skin lesions

The lesions appear initially as small vesicles vessicles then become pustules and develop a purplish-red hemorrhagic base. This happens from micro-abscess around embolized bacteria Such lesions can occur anywhere on the body but are most frequently present on the volar aspects of the arms, hands, and fingers. They fade without residual scarring

PPCM presentation

The major clinical finding in peripartum cardiomyopathy is general heart failure. Other findings may include dyspnea, orthopnea, fatigue, dependent edema, nonproductive cough, tachypnea, tachycardia, palpitations, and chest pain. Blood pressure may be normal or increased;in later stages, hypotension is common. Oxygen desaturation may occur. left heart failure (dyspnea, orthopnea, PND, fatigue , weakness and right heart failure (edema, HSM, JVD) some present with arrhytmia, cardiogenic shock

manage pulmonary edema in pregnancy (hypertensive)

The management of hypertensive acute pulmonary oedema in pregnancy. The goals of treatment are: 1 Reduce left ventricular preload. 2 Reduce left ventricular afterload. 3 Reduce⁄prevent myocardial ischaemia. 4 Maintain adequate oxygenation and ventilation withclearance of pulmonary oedema. Urgent reduction of critically high blood pressure with an intravenous antihypertensive agent is necessary. Nitroglycerin (glyceryl trinitrate) is recommended as the drug of choice in pre-eclampsia associated with pulmonary edema, it is given by 1) intravenous infusion starting at 5ug.min, gradually increasing every 3-5 min to a maximum of 100g.min. 1b) Nitroglycerin can also be administeredby sublingual spray (400ug, 1-2 puffs every 5-10 min). An alternative agent, sodium nitroprusside, is recom-mended in severe heart failure and critical hypertension; however, it should be used only with caution and by experienced clinicians. The typical dose by infusion is 0.25-5.0 ug/kg/min). Reduction in systolic and diastolic blood pressure should occur at a rate of approximately 30 mmHg over 3-5 min followed by slower reductions to blood pressures of approximately 140⁄90 mmHg. Intravenous furosemide (bolus 20-40 mg over 2min) is used to promote venodilation and diuresis, with repeated doses of 40-60 mg after approximately 30 min if there is an inadequate diuretic response. Goal is a brisk diuretic response (1-2 L over a few hours) Oxygen may be given by nasal cannula at rates of up to 4 L/min. Flow rates above this do not increase the inhaled oxygen fraction and can cause nasal irritation. Face‐mask oxygen can be given with a non‐rebreathing mask using flow rates of up to 15 L/min. Noninvasive PPV may be given with a nasal mask or the better tolerated oro‐nasal mask.

what patients may be at very high risk of anomalies, thus should have early screening (11-16w)

The most common conditions that increase the risk of fetal malformations include, but are not limited to, the following: (1) increased NT ≥3 mm; (2) suspected anomalies during the NT scan or markers of anomalies such as absent Intracranial translucency or NB (3) history of anomalies in previous pregnancies, especially, but not limited to, cardiac anomalies ; (4) family history of hereditary disorders or associated malformations or anomalies that can be detected by ultrasound; (5) maternal TORCH (toxoplasmosis, other [syphilis, varicella-zoster, parvovirus B19], rubella, cytomegalovirus, and herpes) infections with risk for fetal transmission; (6) maternal medical conditions with increased risk for fetal anomalies such as pre-gestational diabetes mellitus; (7) exposure to teratogenic agents; and (8) obese patients who are also at increased risk for fetal malformations and disruptions or anomalies and in whom early transvaginal ultrasound scanning may provide an opportunity to have a more complete assessment of fetal anatomy compared with transabdominal scanning at 18 to 22 weeks.

magnesium toxicity symptoms

The most common findings of early-onset toxicity are diarrhea, nausea and vomiting, flushing/warmth, headache, muscle weakness, and hypotension However, as levels continue to rise patients experience: - loss of deep tendon reflexes - respiratory paralysis - Then sinoatrial (SA) or atrioventricular (AV) node blocks (low HR), - eventually, cardiac arrest. Monitor urine output !!! (oliguria)

Factor V Leiden mutation

The most common inherited cause of hypercoagulability. The leiden mutation causes resistance to protein C ,

Rubeola (measles)

The most common signs and symptoms are fever, malaise, coryza, sneezing, conjunctivitis, cough, photophobia, and Koplik spots (blue-gray specks on a red base that develop on the buccal mucosa opposite the second molars). Patients typically develop a generalized nonpruritic maculopapular rash that begins on the face and neck and then spreads to the trunk and extremities. The rash usually appears about day 14 after exposure. It usually lasts for about 5 days and subsequently recedes in the same sequence in which it appeared. The duration of illness is approximately 7 to 10 days (hence the name "10-day measles").

benign adnexal masses in pregnancy

The most frequent types of ovarian masses are - corpus luteum cysts - endometriomas - benign cystadenomas - mature cystic teratomas (dermoid cyst)"- - Most common ovarian MASS in pregnancy = dermoid/teratoma > Cystadenoma > CL > other benign > malignant simple follicular cysts are probably the most common, if that counts.

stillbirth workup

The most important and useful tests in the work‐up of fetal death are : - perinatal autopsy - placental histology - karyotype OR chromosomal microarray. (array costs more) If possible, these tests should be performed in all cases. Also, a test for fetal-maternal hemorrhage should be done since it is only helpful for a few weeks after the demise. The remaining tests can be accurately performed later, and need only be done if prompted by clues in the clinical history, autopsy, etc.

Influenza vaccine reaction history

The only contraindication to the influenza vaccine is previous severe allergic reaction to the influenza vaccine. Patients with an egg allergy manifested by rash only can receive the influenza vaccine in the usual outpatient setting. Patients who have had more severe reactions such as hives, respiratory distress, angioedema, significant emesis, or required epinephrine or medical intervention may receive the vaccine. However, consideration should be given to administration in an inpatient setting or an outpatient setting that would allow for sufficient monitoring and intervention if indicated. Here at OU, patients with more severe reactions receive the influenza vaccine in the OB Emergency department with anesthesia aware to assist with a severe reaction if necessary. The overall rate of anaphylaxis after vaccines has been found to be 1.31 per million doses given. For a patient with history of Guillian-Barre, care should be individualized to determine if she is a candidate for the influenza vaccine.

Parvovirus effects on fetus

Transient, isolated pleural and pericardial effusions are thought to be secondary to direct inflammation. Severe fetal anemia from aplastic crisis results in tissue hypoxia. Hydrops fetalis eventually develops from high‐output cardiac failure, which can lead to fetal death. It also affects platelets, and in those with hydrops, thombocytopenia is seen in up to 1/3 of cases

TAPS pathogenesis

The pathogenesis of TAPS has been linked to its unique placental angioarchitecture, characterized by the presence of only a few small anastomoses. These few minuscule intertwin anastomoses are believed to allow chronic, slow transfusion of blood from donor to recipient twin. This gradual net transfusion results in highly discordant hemoglobin levels, causing the donor twin to become anemic and the recipient twin to become polycythemic. The chronic, gradual character of intertwin blood transfusion in TAPS is believed to allow time for hemodynamic compensatory mechanisms in the absence of hormonal imbalance, thus preventing the development of oligohydramnios and polyhydramnios in donor and recipient

selective reduction vs multifetal reduction

The phrase "selective termination" refers specifically to deliberate termination of an anomalous fetus in a multiple gestation, typically in the second trimester. Selective termination is performed to optimize outcome for the normal fetus(es) and to prevent delivery of an abnormal fetus. This differs from "multifetal reduction," which refers to a nonspecific reduction in the number of fetuses present in a higher order multiple gestation, almost always in the first trimester, to lower the risk for prematurity for the remaining fetuses

placenta in TRAP

The placenta is diamniotic-monochorionic (in 50% to 60% of TRAP cases) or monoamniotic-monochorionic (40% to 50%). The umbilical cords of the pump and acardiac twin are usually inserted close together or may have a common insertion site. The most common cord anomaly is a single umbilical artery of the acardiac twin; however, single umbilical artery of the pump twin, marginal or velamentous cord insertion, and cord entanglement are also seen. The two cords have direct vascular large AA (and often VV) anastomoses, which allow reversed flow in the single umbilical artery of the acardiac twin and thus support its development

Preeclampsia review physiology

The placental villus is lined by two layers of trophoblast: 1) the multinucleated syncytiotrophoblast,which covers the entire placenta and is in direct contact with maternal blood 2) the cytotrophoblast, which formed the extravillous trophoblast and anchors the placental villus to the maternal decidua via cell columns..... Extravillous trophoblasts invade from cell columns into the upper third of the myometrium from as early as 14 days after implantation..... until 18 weeks of gestation, when placentation is largely completed. The two-stage model of pre-eclampsia proposes that pre-eclampsia results from placental dysfunction causing syncytiotrophoblast stress (stage 1), which leads to the maternal clinical manifestation of pre-eclampsia (stage 2) Poor spiral artery remodelling, which is associated with shallow extravilious trophoblast invasion, is proposed to drive syncytiotrophoblast stress by causing an ischaemic blood supply to the placenta. The abnormal placental histopathological findings common in preterm pre-eclampsia are relatively uncommon in term disease. It is hypothesized that placental development is normal in term pre-eclampsia and that syncytiotrophoblast stress is initiated later in gestation. It is proposed that there are two mechanisms by which syncytiotrophoblast stress arises in term pre-eclampsia: 1) compression of chronic villus when there is insufficient space for the larger placenta in late pregnancy 2) syncytiotrophoblast senescence associated with premature placental ageing Syncytiotrophoblast stress increases as gestation proceeds, even during an uncomplicated pregnancy, driven by the increasing mismatch between normal maternal perfusion and the metabolic demands of the placenta and fetus, leading to the hypothesis that preeclampsia is inevitable if gestation continues beyond the capacity of the placenta.

ultrasound findings of conjoined twins

The prenatal diagnosis should be straightforward and is confirmed by: - failure to visualize two fetuses separately in what appears to be a single amniotic sac. - bifid appearance of the first-trimester fetal pole - more than three umbilical cord vessels - heads persistently at the same level and body plane - failure of the fetuses to change position relative to each other over time.

Quinolones in pregnancy

The quinolones are not approved for use during pregnancy because of concerns regarding their teratogenic effect on fetal cartilage. However, use of fluoroquinolones for highly resistant microorganisms is appropriate. In such instances ciprofloxacin, 250 mg twice daily, or levofloxacin, 250 mg daily for 7 to 10 days, may be used.

congenital toxoplasmosis transmission

The rates were much higher if acute maternal infection was acquired later in pregnancy - 15%, 44%, 71% after maternal acute primary infection at 13, 26, and 37 weeks, respectively. Fetal/neonatal transmission is inversely proportional to time of primary infection. Disease is less common but more severe if maternal infection occurs in the first trimester,

can mom's become alloimmunized What screening test?

The rationale for a repeat screen at 28 weeks is to identify the0.18% or fewer women who have become alloimmunized since the first prenatal screen, in order to care for the fetus. It has been suggested that a second blood sample shouldbe sent even from the Rh-positive woman at 27 to 28 weeks'gestation "to confirm that she is Rh-positive and that atypical blood group antibodies have not developed."" SOGC: All pregnant women (D-negative or D-positive) should be typed and screened for alloantibodies, with an indirect antiglobulin test at the first prenatal visit and againat 28 weeks

risks influencing condomless HIV

The relative risk of sexual HIV transmission involved in condomless sex as a means of conception is dependent on : -the plasma viral load of the partner with HIV - the length of time the partner living with HIV has been on cART -the frequency of intercourse -the presence of concurrent sexually transmitted infections - which partner is infected For couples using timed condomless sex as a method of conception, the HIV-negative partner should be counselled about clinical signs of seroconversion and should undergo regular testing for HIV seroconversion to avoid delay in diagnosis. Finally, if conception is not achieved within 6 to 12 months, couples should be referred to a gynaecologist and/or fertility specialist for appropriate investigations he addition of PrEP in the case of condomless sex and timed condomless sex is not routinely recommended at this time given that the incremental benefit of adding PrEP to prevent horizontal transmission of HIV is small in a situation in which the partner with HIV is consistently using cART and is virologically suppressed. However, as previously discussed, if these criteria cannot be ensured with confidence, there may be a role for institution of PrEP in the form of daily dosing of tenofovir and emtricitabine. The decision of whether to prescribe PrEP must be individualized and take into account each couple's clinical situation, tolerance of risk, personal choice, and ability to afford PrEP

Ebola transmission

The reservoir for Ebola virus appears primarily to be in fruit bats, but the spread to humans likely occurs through the consumption or handling of meat from infected animals such as rodents or primates. Human-to-human transmission can then occur, through very direct contact with the secretions and excretions of infected symptomatic patients or cadavers. The virus requires a mucosal surface or break/abrasion in the skin, or parenteral spread..... It is not spread through the aerosol route Individuals incubating Ebola virus who do not yet have symptoms (sudden fever, fatigue, muscle pain, headache, sore throat, and gastrointestinal symptoms of nausea, vomiting, diarrhea, and abdominal pain) are not infectious Frst symptoms include the sudden onset of fever (usually high at>38.6 °C), fatigue, muscle pain, headache, sore throat, and gastrointestinal symptoms of nausea, vomiting, diarrhea, and abdominal pain. Other less common features include cough, maculopapular rash, and conjunctival injection. Towards the end of the first week of symptomatic disease, hemorrhagic features of petechia, blood loss from venipuncture sites, bruising, and gastrointestinal bleeding may occur in up to 18% of patients. Laboratory findings include leukopenia, thrombocytopenia and elevated liver enzymes. PT and PTT can be prolonged and fibrin degradation products can be elevated. As the disease progresses, severe hypovolemic shock and multi-organ failure occurs, usually between days 6 and 16 from symptom onset. 15. Seizures and coma usually precede death in those with terminal illness.

how to do laser fetoscopic

The surgical technique involves placement of a 2-mm fetoscope into the polyhydramniotic recipient twin's sac under ultrasound guidance with local or regional anesthesia, and the vessels on the surface of the placenta are inspected. Whereas a straight fetoscope is used for posterior placental locations, fetoscopes with angled lenses or curved sheaths have been specifically developed for anterior placentas. AV anastomoses are easily identifiable as a single unpaired artery coming from the donor side and entering a foramen on the placental surface, together with a single unpaired vein exiting the same area on the placental surface with blood flowing toward the recipient twin. Selective laser coagulation involves placement of a 0.4-mm laser fiber through the fetoscope and ablating all visible anastomoses that communicate between the fetuses. It is critical that all vascular communications that connect the two fetal circulations be ablated, because this should prevent reverse fetal transfusion and reduce neurologic injury in the surviving fetus if one fetus dies. This selective approach to laser ablation also involves leaving intact those vessels that drain an area of placenta both to and from one particular fetus. Such paired placental vessels do not contribute to the TTTS pathologic process and may be critically important to the survival of the donor fetus in particular. Amnioreduction is also performed as part of the same procedure, and as mentioned previously, diagnostic amniocentesis can take place at this time.

screen for cervical length in twins

The technique of sonographic measurement of cervical length in multiple gestations does not differ from that described for singleton gestations. The optimal interval at which to perform sonographic assessments of cervical length during multifetal gestation is unclear. Our practice has been to measure cervical length every 2 weeks from 16 to 24 weeks' gestation in the cases of multiple gestation deemed to be at highest risk for preterm delivery (e.g., higher order multiple gestations, maternal history of a preterm singleton birth). For all other multiple gestations, we perform sonographic assessment of cervical length at the time of sonography for fetal anatomy or growth SOGC we recommend that cervical length be routinely assessed in dichorionic twin pregnancies at the anatomy scan.... and preferably once again before 24 weeks, with subsequent assessment in women with additional risk factors (e.g., history of preterm birth, uterine over-distention, prior cervical surgery

vaginal pessary theory

The theory behind use of vaginal pessaries is that they alter the axis of the cervical canal and displace the weight of the uterine contents away from the cervix. By changing the angle of the cervix in relation to the uterus, the pessary also obstructs the internal os and thus may provide protection against ascending infection.

risks of CMV

Transmission usually occurs from close contact, with contamination from urine, saliva, blood, semen, and cervical secretions , with the virus being acquired at mucosal sites or by blood-borne , transmission. Biggest risk = kids. Most women practice behaviors that may place them at risk when interacting with children (e.g., kissing on lips, sharing utensils, sharing food, changing diapers, wiping child's nose, handling child's toys) . Compared with no prevention, preventative measures are acceptable to pregnant women including: - avoiding intimate contact with children - frequent handwashing - gloves can impact behavior, and have the potential to reduce CMV in pregnancy. Compared with no prevention, prevention is associated with an 84% decrease in CMV seroconversion during pregnancy, especially in women in contact with children in day care facilities Risk factors are low socioeconomic status, exposure to infective individuals, multiple partners, extremes of age, multiparity, and blood transfusion. Only cellular blood products that contain leukocytes are capable of transmitting. Using leukoreduced blood products, the risk of transmission from a transfusion is approximately 0.2-3% in immunocompetent recipient

treat fetal toxoplasmosis

The time for transition from the acute infective tachyzoite form of the parasite, which is responsible for tissue destruction in the fetal brain, to the dormant bradyzoite form contained in tissue cysts is clinically important because the cysts are not susceptible to antibiotics. This time (ideally <3 weeks from seroconversion) is considered the therapeutic "window of opportunity" when maternal administration of antibiotics may prevent or reduce fetal neurologic damage the general consensus to use: - spiramycin when therapy is begun in the first trimester (<14 weeks) (1g TID) (note, requires FDA approval!!) - pyrimethamine-sulfadiazine when therapy is begun thereafter (≥14 weeks) If AF PCR is positive, start : - sulfadiazine (initial dose of 75 mg/kg, followed by 50 mg/kg every 12 hours with a maximum of 4 g/day) - pyrimethamine (50 mg every 12 hours for two days followed by 50 mg daily) and folinic acid (leucovorin) 10 to 20 mg with each dose of pyrimethamine (decreases bone marrow toxicity) and one week after completion of pyrimethamine therapy [8] . Length of therapy is controversial and has varied for a minimum of 28 days (with ½ dose until term) versus continuing therapy as is until term. Treatment with pyrimethamine and sulfadiazine to prevent fetal infection is contraindicated during the first trimester (pyrimethamine is teratogenic), but at this time, sulfadiazine can be used alone This treatment should be stopped in the last few weeks of pregnancy. Check CBC weekly

opioid half lives in labor

The use of meperidine is discouraged (half life of 2-3 days), whereas other opioids with a shorter half-life, such as morphine or fentanyl, are preferred. It is important to note that even though fentanyl is a short-acting opioid, it has a long half-life once maximum doses have been used.

specific FNAIT antibodies

There are 24 recognized platelet specific antigens. These are classified as HPA-1, HPA-2, etc.... The nomenclature is further divided into subcategories, with "a" for high frequency and "b" for low frequency. The majority of cases are caused by HPA-1a antibodies. The small minority of women who do not express HPA-1a platelet antigens, and are therefore at risk of developing HPA-1a antibodies, are at highest risk for having an infant with NAIT.

diagnose congenital rubella

There is no gold standard for antenatal diagnosis of rubella congenital infection. Rubella PCR, rubella culture, and fetal IgM can be performed following CVS, fetal blood sampling, or amniocentesis. Amniocentesis is recommended at least 6 weeks after known maternal infection and after the 20th week of gestation. Prenatal tests need to be interpreted with caution: CVS has been associated with contamination with maternal tissue resulting on false-positive PCR, and false negative-fetal IgM is common until late in pregnancy.

acute TTTS

This form of acute twin-to-twin transfusion is mediated mainly through large-sized AA or VV anastomoses. Acute peripartum (or perinatal) TTTS may occur during birth and is caused by acute shifts of blood volume between twins resulting from blood pressure differences associated with uterine contractions, delayed cord clamping, or changes in fetal position around the time of delivery..... The clinical presentation of acute peripartum TTTS may range from subtle intertwin differences in hemoglobin levels without obvious effects to frank hypovolemic shock in the donor twin and polycythemia in the recipient. Similar to other forms of acute TTTS, acute peripartum TTTS is believed to be facilitated by large superficial AA and VV anastomoses. Acute peripartum TTTS is distinct from the more common postpartum placentofetal (as opposed to twin-to-twin, or fetofetal) transfusion that occurs when cord clamping of one twin directs blood from the entire placenta to the remaining twin through vascular anastomoses.

hypothyroid treatment pregnancy

Treating mild subclinical hypothyroid (4-10) Does not improve live birth of early pregnancy outcomes Definitely treat when TSH > 10 synthroid ~75-150 (take 2-3 hrs apart from multi-vitamins !!!) Initiate levothyroxine 1-2 μg/kg orally daily o Recheck TSH every 4 weeks while making medication adjustments o Adjust levothyroxine dose by 25-50 μg o In women with pre-existing hypothyroidism, doses may need to be increased and TSH levels should be checked at the first prenatal visit o Goal for treatment is a normal TSH At OU, we use a goal of < 2.5 mu/L, but trimester specific goals can be used as well o Once stable, check TSH at least once per trimester Immediately post-delivery, the dosage of levothyroxine should be reduced to the pre-pregnancy dose, and TSH levels should be measured 6 weeks postpartum, and follow-up with medical doctor/endocrinologist.

maternal vascular malperfusion

Tried of: 1) Abnormal bilateral uterine artery doppler 2 ) Morphology- .... a normal normal placenta is long and thin, here in MVM, the placenta is smaller and often regresses. 3 ) low PlGF - malperfused villi are ischemic, secrete low PlGF... but secrete very high amounts of sFLT-1

TAPS

Twin Anemia-Polycythemia Sequence TAPS is a recently described form of chronic twin-to-twin transfusion in monochorionic pregnancies, characterized by the presence of a large intertwin difference in hemoglobin and reticulocyte levels in the absence of oligohydramnios and polyhydramnios TAPS may occur: - spontaneously (spontaneous TAPS; estimated incidence 3% to 6% of monochorionic twin pregnancies) - iatrogenically following laser treatment for TTTS (postlaser TAPS). In contrast to TTTS, which involves a severe discordance in amniotic fluid, TAPS is characterized by a severe discordance in hemoglobin levels. TAPS can be diagnosed when: - the middle cerebral artery peak systolic velocity is greater than 1.5 MoM in one fetus (usually an anemic ex-recipient fetus) - is less than 0.8 MoM in the other fetus

treat chlamydia

Tx: Azithromycin 1g, Doxycycline 100mg BID x 7days or Cipro 500mg BID x 3days are acceptable in non pregnant, but are CONTRAINDICATED in pregnant do a test of cure in 1 month

treat gonorrhea

Tx: Ceftriaxone 500mg IM and Azithromycin 1g (co treat chlamydia) if disseminated- to 1g ceftriaxone IV l.....We agree with the United States Centers for Disease Control and Prevention guidelines to continue antibiotic therapy for at least seven days as long as the clinical signs of infection are gone or nearly gone....... If susceptibility testing demonstrates full sensitivity to cefixime, patients who lack septic arthritis and who respond promptly to parenteral therapy can complete their seven-day course of therapy with oral cefixime (400 mg twice daily). Alternative if severe penicillin allergy OR cephalosporin allergy Gentamicin 240 mg IM in a single dose PLUS Azithromycin 2 g orally in a single dose Do a test of cure in 1 month Re-test in T3 if risk factors

toxoplasmosis ultrasound

Ultrasound findings associated with TG congenital infection can include intracranial calcifications, microcephaly, ventricular dilatation and hydrocephalus, ascites, hepatosplenomegaly, and increased placental thickness [19]. the so-called classic triad of congenital toxoplasmosis consists of -chorioretinitis -hydrocephalus - intracranial calcifications. However, the classic triad occurs in <10 percent of cases Diagnostic significance in the absence of prenatal screening — In the absence of maternal serologic screening, one or more of the ultrasound findings described above may lead to suspicion of congenital toxoplasmosis. However, the sonographic signs are nonspecific, so prenatal ultrasound cannot reliably distinguish between congenital toxoplasmosis and other congenital infections (eg, cytomegalovirus, Zika virus) or various genetic diseases (eg, ventricular dilation can be related to trisomy 21, echogenic bowel can be related to cystic fibrosis). Therefore, when toxoplasmosis is suspected because of ultrasound findings rather than a prenatal screening protocol, maternal serology for toxoplasmosis and cytomegalovirus, at a minimum, should be performed as these are the two most common infectious causes for these findings (panels including cytomegalovirus and Toxoplasma are available)

neonatal sypilis ultrasound

Ultrasound findings suggestive of congenital syphilis infection include hepatomegaly, placentomegaly, polyhydramnios, ascites, anemia, and nonimmune hydrops. Neonatal congenital syphilis is characterized by macopapular rash, hepatosplenomegaly, osteochondritis/periostosis (do X ray of long bones: 95% of these infants will have osteochondritis),

tocolysis options

Under 32 weeks, use indomethacin 100mg PO initially..... then 25mg PO q6h After 32 weeks, give Adalat 10 mg PO q6h

HIV monitoring pregnancy

Viral load and CD4 monthly until supressed.... then at least q3 months

Tertiary syphilis

Usually becomes clinically manifest after a period of 15 to 30 years of untreated infection. • Without treatment at earlier stages of disease, tertiary syphilis eventually develops in 30% to 40% of infected patients. gummas (chronic granulomas) arotitis (vasa vasorum destruction) neurosyphilis (tabes dorsalis) Argyll Robertson pupil (small pupils that accomodate to convergence, but do not constrict/react to light) Signs: Broad-based axilla Positive Romberg Charcot joints Stroke w/o HTN

Diagnose Syphilis

Usually screen with NON-treponemal tests include RPR or VDRL But, these can have FALSE NEGATIVES with PRIMARY syphilis, due to time to seroconvert and produce antibodies (as well as false positives for RPR, ie, SLE, HIV). ..... so, lesions suspicious for syphilis should be sampled for detection of spirochetes and submitted to the laboratory for dark-field microscopy and fluorescent antibody staining. in patients who have reactive VDRL or RPR results....Then, TREPonema-specific tests are used to confirm the diagnosis of syphilis (FTA-ABS or Trep-pallidum particle agglutination assay aka TP-PA Recently, a different sequence of testing for syphilis has been described (and is now preferred) In this testing algorithm: - the initial test is an enzyme immunoassay, for Trep IgM and IgG antibody (put ST a) If this test is negative, no further testing is indicated. b ) If it is positive, then a quantitative RPR is performed. (for RPR titers) - If the RPR is negative, then the TP-PA assay is performed. A negative TP-PA assay indicates that the patient is uninfected. A positive test confirms that the patient is infected, but it remains positive and therefore does no distinguish precisely between acute versus chronic infection (these tests are positive for life). VDRL or RPR titers should be monitored and they correlate with disease activity This includes those with very early syphilis, those with prior treated syphilis, and those with late or late latent syphilis whose nontreponemal test has become nonreactive over time. Treponemal tests are more sensitive than RPR in early syphilis, allowing earlier diagnosis and treatment...... also has a higher sensitivity in late latent in which the non-trep tests will become non-reactive over time. (this can happen in up to 30% of late latent ) They are also automated and less costly to perform than the RPR. The reverse sequence algorithm can be used only for diagnosing a first syphilis infection because treponemal test results usually remain positive for life. Diagnostic confirmation of subsequent infections is reliant on significant changes in RPR titer. If history of syphilis, use the conventional screening. Management of history of Syphili

Subinvolution of the uterus How long to return to pre-pregnancy size

Uterus remains enlarged, soft, with continued lochial discharge which may result in postpartum hemorrhage 2 most common causes 1) infection 2) RPOC Returns to pre-pregnancy size in 4 weeks

hematologic changes in pregnancy (MCQ) what clotting factors increase?

V, VII, VIII, IX, X, fibribogen Decrease FREE protein S Activated protein C AT is unchanged

vaginitis

Vaginitis is the common term for conditions causing vulvovaginal symptoms, such as - itching -burning - irritation - discharge The most common causes in reproductive-aged women are: - bacterial vaginosis - vulvo-vaginal candidiasis - trichomoniasis. For postmenopausal women, atrophic changes associated with lack of estrogen are also possible causes of vulvovaginal symptoms

diagnose maternal varicella

Varicella, or chickenpox, usually is CLINICALY diagnosed based on the findings of a classic pruritic, vesicular rash, so laboratory testing is not needed. If lab testing is needed: - detection of viral VZV DNA by QUALITATIVE PCR testing of skin scrapings from the base of the vesicle is the most sensitive method for confirming a diagnosis of varicella...... Vesicular lesions or scabs, if present, are the best for sampling. QUANTative rt-PCR may be used for the detection and quantitation of VZV, but is generally reserved for specific settings, and not as widely available as qualitative testing. Monitoring of VZV viral load in blood and CSF may be useful in complicated cases which fail to respond to antiviral treatment. Other tests: Direct Fluorescent Antibody Stains PCR testing is preferred to DFA stains. DFA testing is limited by the sample quality and has generally low sensitivity. If an insufficient number of infected cells is present, the results may be invalid or falsely negative. Confirmation with PCR testing or viral culture may be necessary. Serology Serology has limited utility for laboratory diagnosis of VZV and should only be used when suitable specimens for PCR testing are not available..... - serology may be potentially confusing since the assays vary in sensitivity and specificity Viral Culture Viral culture of VZV is not recommended for initial diagnosis because its slow turnaround time may adversely impact clinical management. Culture may be used to confirm DFA results.

Velamentous insertion

Velamentous cord insertion is diagnosed when the umbilical vessels insert into the membranes before they reach the placental margin. This results in the umbilical vessels lacking the protection of Wharton's jelly for the section between the insertion and the placental margin.

Ribavirin

Virazole Evidence shows that a combination therapy of ribavirin plus interferon clears hepatitis C virus from the blood in about 40% of patients with chronic hep C It is ideal to treat and cure a woman's hepatitis C prior to attempts at conception. There is no evidence that these agents affect sperm and can, therefore, be used in the preconception period for men. Ribavirin should not be used in individuals for at least 6 months prior to conception. The contraindication of using ribavirin in the preconception period also applies to men because this drug has been found to affect male gametes; the exact mechanism of its effect is not known.

warning signs to discontinue exercise

Warning Signs to Discontinue Exercise While Pregnant • Vaginal bleeding • Regular painful contractions • Amniotic fluid leakage • Dyspnea before exertion • Dizziness • Headache • Chest pain • Muscle weakness affecting balance • Calf pain or swelling

heparin vs low molecular weight heparin

Way I remember: - Both bind to Anti-thrombin III - Both inhibit Xa - "Fractionated" (LMWH) heparin only inhibits a small "fraction" of thrombin (thus, it works selectively on Xa) (remember, monitor Xa levels on therapeutic doses)

ITP bleeding treatment

We use the following definitions, with selected examples: Critical bleeding - Bleeding into a critical anatomical site or bleeding that causes hemodynamic instability or respiratory compromise. Includes intracranial, intraspinal, intraocular, retroperitoneal, pericardial, or intramuscular bleeding with compartment syndrome. Severe bleeding - Bleeding that results in a fall in hemoglobin of 2 or more g/dL or requires transfusion of 2 or more units of pRBCs but does not meet the definition of critical bleeding. Minor bleeding - Bleeding that does not meet criteria for severe or critical bleeding. Examples include skin bleeding or non-severe mucous membrane bleeding. Severe The glucocorticoid for critical or severe bleeding typically is dexamethasone, 40 mg intravenously daily for 4 days. Critical methylprednisolone 1 gram intravenously once per day for 3 days for critical bleeding; oral prednisone for minor bleeding). Platelets The typical dose is one apheresis unit or four to six units of pooled platelets.

delivery considerations available for previa (!!)

When deciding the location of delivery - consider timely availability of an obstetrician - access to a second qualified surgeon - immediate access to an anaesthesiologist -availability of a urologist/vascular surgeon/interventional radiologist local readiness for a massive transfusion protocol.

cannabis and infertility

Women- may impair fertility Men reduces sperm count and concentration, induces abnormalities in sperm morphology, reduces sperm motility and viability, and inhibits capacitation and fertilization capacity in humans and that cannabis results in testicular atrophy with reduced libido and sexual function in animal models

manage prolactinoma infertility

When fertility is the goal, 0.625 mg of bromocriptine should be initiated at bedtime with a snack. After 1 week, twice-daily dosing can be begun with the addition of a morning dose of 1.25 mg. The dose should be slowly increased (1.25 mg/wk) until a daily dose of 5 mg is reached. After the patient has taken 5 mg daily for 6 to 8 weeks a prolactin level should be repeated. The dose should be increased until normalization of prolactin or restoration of menses occurs. Most patients require 5 mg of bromocriptine daily. During therapy women should use a mechanical form of contraception and continue it until at least 2 regular menstrual cycles have occurred. Bromocriptine should be discontinued as soon as a pregnancy is confirmed. In a woman who is resistant to or intolerant of bromocriptine it may be necessary to use cabergoline instead of bromocriptine to induce fertility. In these cases cabergoline should be initiated at a dose of 0.25 mg weekly. After 7 days, twice-weekly dosing should be initiated by adding 0.25 mg. At weekly intervals the dose should be increased to 0.5 mg twice weekly. A prolactin level should be obtained after 6 to 8 weeks and the dose should be adjusted until the prolactin normalizes or menses are restored. Most patients require 1 mg weekly. Although not first-line therapy, transsphenoidal surgery is also an option in women who are resistant to or intolerant of both dopamine agonists. Although the overall success rate of transsphenoidal surgery is around 70%, higher rates of success are seen with: - experienced surgeons - selected young patients - prolactin levels less than 200 μg/L - small tumors short duration of amenorrhea.

primary syphilis manifestations in mom

When present, the initial manifestation of the immune reaction is the primary chancre, which appears approximately three weeks after infection. Without treatment, the chancre resolves spontaneously in 4-6 weeks. The chancre may occur on the cervix, vagina, or vulva, so a thorough physical exam is necessary when syphilis is diagnosed...... note, up to 40% have multiple chancres ~25% of these are cleared

laser TTTS

When severe TTTS (Quintero stages II to IV) is diagnosed prior to 24 to 26 weeks' gestation, the most effective management option is selective fetoscopic laser coagulation of the anastomotic vessels on the surface of the placenta,

# rheumatic disorders and pregnancy principles

While the focus here is on SLE, rheumatoid arthritis (RA) and scleroderma, almost all rheumatological diagnoses present some degree of challenge in the setting of pregnancy. General management principles include the following. • Disease should be well controlled for about six months on pregnancy ‐ compatible medications before attempting pregnancy. • Patients with severe disease‐related internal organ damage (for example, those with pulmonary arterial hypertension, renal failure, cardiomyopathy or severe valvular disease) should avoid pregnancy due to high maternal risk. • Patients likely to have anti‐Ro/SSA and/or anti‐La/SSB antibodies or antiphospholipid antibodies (aPL) (i.e., those with SLE, RA, Sjögren syndrome, or scleroderma) should be tested for these antibodies prior to, or early in, pregnancy to guide therapy and management

creatinine and magnesium dose

With Cr ≤1.1, do not need to adjust dose o With Cr 1.2-1.3, administer a bolus of 4 g followed by a 1 g/h continuous infusion o With Cr ≥1.4, administer a bolus of 4 g with no subsequent continuous infusion rate

manage incarcerated uterus

With continued uterine growth, the incarcerated uterus can spontaneously resolve over 1 to 2 weeks. A knee-chest position assumed by the patient several times daily may assist resolution. An indwelling urinary catheter or intermittent self-catheterization resolves retention. Persistent cases require manual repositioning. For this, after bladder catheterization, the uterus can usually be pushed out of the pelvis when the woman is placed in a knee-chest position. Often, this is best accomplished by digital pressure applied through the rectum or vagina. Intravenous sedation or spinal analgesia aids comfort and allows sufficient dislodging forces (Hire, 2019). Afterward, insertion of a soft, space-filling pessary (Gelhorn, cube, donut) for a few weeks usually prevents recurrence. "During pregnancy, women can develop urinary retention due to an incarcerated uterus. It has been suggested that women with a retroverted uterus be examined routinely at 12 to 13 weeks gestation to evaluate whether pessary placement is needed to prevent incarceration. This preventative approach has been used in subsequent pregnancies of women with a history of incarceration. In cases of incarceration, a pessary may be used to direct the cervix posteriorly, which is thought to reduce recurrence of urinary retention by resolving the acute anterior angulation of the cervix against the urethra."

GDM mechanism

Women with GDM have been found to have lower basal islet cell function, in addition to increased insulin resistance, when compared to a non-diabetic cohort. insulin resistance: - HPL progesterone GH cortisol prolactin weight gain in pregnancy

SOGC postpartum anticoagulation and risk factors

Women with ongoing and persistent risk factors should receive postpartum thromboprophylaxis for a minimum of 6 weeks postpartum. (II-3B) 62. Women with transient antepartum or intrapartum risk factors should receive postpartum thromboprophylaxis until discharged from hospital or up to 2 weeks postpartum. (III-C) Pharmacologic thromboprophylaxis postpartum is recommended in the following situations: Any 1 of the following risk factors (each with an absolute venous thromboembolism risk > 1%): a. history of any prior venous thromboembolism; (II-2A) b. any high-risk thrombophilia: antiphospholipid syndrome, antithrombin deficiency, homozygous factor V Leiden or prothrombin gene mutation 20210A, combined thrombophilia; (II-2B) c. strict bed rest prior to delivery for 7 days or more; (II-2B) d. peripartum or postpartum blood loss of > 1 litre or blood product replacement, and concurrent postpartum surgery; (II-2B) e. peripartum/postpartum infection. (II-2B) Postpartum thromboprophylaxis should be considered in the presence of multiple clinical or pregnancy-related risk factors when the overall absolute risk is estimated to be greater than 1% drawn from the following groups: a. any 2 of the following risk factors (each with an absolute risk of venous thromboembolism < 1% in isolation): i. body mass index ≥ 30 kg/m2 at first antepartum visit; (II-2B) ii. smoking > 10 cigarettes/day antepartum; (II-2B) iii. preeclampsia; (II-2B) iv. intrauterine growth restriction; (II-2B) v. placenta previa; (II-2B) vi. emergency Caesarean section; (II-2B) vii. peripartum or postpartum blood loss of > 1 litre or blood product replacement; (II-2B) viii. any low risk thrombophilia: PC or PS deficiency, heterozygous factor V Leiden, or prothrombin gene mutation 20210A; (III-B) ix. maternal cardiac disease, SLE, sickle cell disease, inflammatory bowel disease, varicose veins, gestational diabetes; (III-B) x. preterm delivery; (III-B) xi. stillbirth. (III-B) b. any 3 or more of the following risk factors (each with an absolute risk of venous thromboembolism < 1% in isolation): i. age > 35 years; (II-2B) ii. parity ≥ 2; (II-2B) iii. any assisted reproductive technology; (II-2B) iv. multiple pregnancy; (II-2B)

hemolytic anemia workup

\Hemolysis should be considered when a patient experiences acute jaundice or hematuria in the presence of anemia. CBC LDH (high) Haptoglobin (low) Unconjugated (indirect) bili (high).... Order total bili Reticulocyte count )high) Peripheral smear

thrombophilia and pregnancy outcomes... how strong a risk ?

actual results are weakly associated possible: recurrent miscarriage FGR abruption Stillbirth preeclampsia LMWH prophylaxis is not strongly associated with prevneing miscarriage with INHERITED thrombophilias

prolactinoma

a benign tumor of the pituitary gland Ninety percent of prolactinomas in women are microadenomas (<10 mm) present with menstrual dysfunction (anovulation)and infertility..... In general prolactin levels correlate with tumor size and hypopituitarism and neurologic deficits are uncommon in small tumors. Macroadenomas (>10 mm) are associated with higher prolactin levels, and usually present with neurologic dysfunction in addition to hypogonadism. Women with prolactinomas also present with low bone mass as a result of the inhibitory effect of prolactin on estrogen

Fragile X Syndrome mutations

a disorder produced by injury to a gene on the X chromosome. Increased number of CGG repeats in FMR1 gene Normal is 5-45 indeterminate - 45-55 premutation - 55-200 full mutation- 200+ with any number of repeats >45, the region can expand during gene replication in oogenesis (not spermatogenesis).... So, a female in the "indeterminate" can transmit a pre-mutation (not full mutation) A female in the pre-mutation can transmit a full mutation Full mutation implications can range from: - mild interllectual disability to severe ASD - premature ovarian failure - tremor/ataxia

SOGC pprom choices

a macrolide (erythromycin, azithromycin, or clarithromycin) alone..... or associated with GBS coverage for 2 days (if GBS status is unknown or positive), or 2)a combination of ampicillin/amoxicillin and a macrolide independently of GBS status.

define cerebral palsy What may be accompanied with it ?

a nonprogressive disorder of posture, tone, and/or movement that results from a static insult to the developing brain. may also be accompanied by: - epilepsy - disorders of sensation perception, cognition, communication, and behaviour.

neonatal lupus

a rare condition acquired from the maternal autoantibodies which can affect the skin, heart, and blood of the fetus & newborn; associated w/ a rash that appears w/in several weeks of life & may persist for about six months before disappearing Cutaneous lupus • Red, scaly plaques on scalp/face • Hematologic lupus • Anemia, leukopenia, thromobocytopenia • Congenital heart block Resolves in 6 months

necrotizing fasciitis

a severe infection, often caused by Group A strep bacteria, but maybe mixed flora It is a severe disease of sudden onset that spreads rapidly. Symptoms usually include red or purple skin in the affected area, severe pain, fever, and vomiting Life threating, must have complete debridement. Clinda (900 q8) + gent (5mg / weight q 24) + vanco (1-2 g q 8) Of greatest importance, the wound must be completely débrided and all necrotic tissue removed.

abruption and consequences

a sudden breaking off or away of the placenta usually small. complications: - preterm birth - bleeding - DIC - PPROM - FGR - abnormal FHR - fetal death

Glyburide dose

a sulfonylurea- binds to pancretic beta cells, ATP/K+ channels, so it increases insulin secretion AND sensitivity Start at 2.5 mg PO daily.... can go up to 20mg PO daily (10mg PO BID) Major side = hypoglycemia

Congenital syphilis

a syphilis infection in a newborn baby resulting from transmission from an infected mother Unlike in adults, initial infection in the fetus is systemic rather than localized. Intrauterine infection results from transplacental and then hematogenous spread of T. pallidum, occurring in: vertical transmission based on stage of disease • 70% to 100% in primary syphilis • 40% in early latent syphilis • 10% in late latent disease. When symptomatic postnatally, congenital syphilis is characterized by early and late manifestations. In early congenital syphilis, diagnosed within 2 years of life, common clinical manifestations are hepatosplenomegaly, osteochondritis or periostitis, desquamating skin rash, rhinitis, anemia, jaundice, and thrombocytopenia. Late congenital syphilis is characterized by the Hutchinson's triad - mulberry molars -notched teeth - deafness - interstitial keratitis. Developmental delay seizures, nerve palsies, and bone deformities may also result.

WHO heart disease risk

a system for assessing maternal risk in the setting of heart disease. This has since been modified into risk assessment principles and subsequent applications/recommendations WHO class I and II women tolerate pregnancy with no to mildly increased risk for cardiac events while women in class III have significantly elevated risk of morbidity. Women in class IV are strongly encouraged to avoid pregnancy because of the prohibitive increase in morbidity and mortality. Pregnant women in class III or IV should be followed very closely by a multidisciplinary team, including visits to a cardiovascular specialist every 1 to 2 months

Lambda Sign AKA delta sign AKA Twin Peak Sign

a triangular extension of the placenta at the base of the membrane is indicative of a dichorionic pregnancies The lambda sign results from the chorionic tissue interspersed between the layers of the inter-twin membrane. (T - sign does NOT have this)

maternal rubella

a viral infection characterized by a low-grade fever, swollen glands, LAD, inflamed eyes, and a fine, pink rash, arthralgias "scarletiniform" rash ubella is usually characterized by a mild, self-limited disease associated with a characteristic rash. Although rubella is asymptomatic in 25% to 50% of cases, some individuals may experience mild prodromal symptoms such as low-grade fever, conjunctivitis, sore throat, coryza, headaches or malaise, and tender lymphadenopathy. These prodromal symptoms will usually last 1 to 5 days before the onset of the scarletiniform rash (innumerable small red papules that are widely and diffusely distributed), which may be mildly pruritic. The rash characteristically begins on the face and spreads to the trunk and extremities. It will usually resolve within 3 days in the same order in which it appeared (face first and then body). Polyarthritis and polyarthralgia can develop 1 week after the rash, mostly in adolescent and adult women ( Classically, hands, knees, wrists, and ankles are affected symmetrically for 1 to 4 weeks. Other manifestations, although rare, include tenosynovitis, carpal tunnel syndrome, thrombocytopenia, post-infectious encephalitis, myocarditis, hepatitis, hemolytic anemia, and hemolytic uremic syndrome. It is important to remember that rubella's clinical presentation is non-specific. Other infections can present with a nonvesicular rash, such as parvovirus B19, measles, human herpesviruses (HHV 6 and 7) and enteroviruses. Parvovirus B19 and arbovirus (dengue, Chikungunya, West Nile, and Zika) infections are also associated with rash and joint symptoms. Therefore, consideration should be made to investigate pregnant women for other infections if rubella infection is clinically

steps when microcephaly

a.Gestational age should be confirmed based on first trimester crown-rump length or fetal biometry when available. b.A complete maternal medical and surgical history should be obtained, including trauma, bleeding, illness, medication, infectious and teratogenic exposure (irradiation, alcohol, hypoxia, other). c.A detailed 3-generation family history, with documentation of both parental HCs, should be obtained. d.A detailed tertiary care level fetal ultrasound should be obtained to i.Re-evaluate and confirm the previous fetal HC measurements ii.Obtain a detailed fetal anatomic survey to uncover any additional imaging finding that may guide clinical evaluation, with particular attention to the brain (cerebral sulcation anomalies, ventriculomegaly, calcifications, haemorrhage, potential signs suggestive of neural tube defect or craniosynostosis) e.An appropriate infectious workup should be initiated. In particular congenital CMV infection should be considered, as it is the most common infectious cause of microcephaly. Congenital CMV infection is possible even with previous immunity (non-primary infection) and explains 10% to 14% of prenatally detected microcephaly cases. f.Fetal MRI, when available and if potential findings are likely to alter pregnancy management, should be offered to document any additional cerebral findings when fetal HC measurements are below 4 SD and should be considered if measurements are below 3 SD and other cerebral and/or extracerebral anomalies are present on ultrasound. Ideally, this specialized imaging should be performed at approximately 28-32 weeks gestation (most informative time point with regards to brain structure, although it could be attempted earlier [24-26 weeks]) and should be performed in a centre with expertise in fetal cerebral imaging. g.Whether isolated or in the context of additional structural anomalies, fetal microcephaly requires evaluation by a medical geneticist with expertise in fetal dysmorphology and/or through fetal autopsy, as this finding may warrant additional investigations. These include chromosome analysis through rapid aneuploidy detection, microarray (comparative genomic hybridization), or molecular investigations for single gene disorders (for example, disorders associated with neuronal migration anomalies or cortical malformations). h.For continuing pregnancies, serial ultrasound examinations for surveillance of head growth trajectory, evolving brain pathology, and fetal well-being should be planned. Should the pregnancy be terminated, fetal autopsy or, at minimum, post-termination MRI should be offered to confirm prenatal findings and pursue diagnostic investigations if not undertaken prenatally.

dx gallstones pregnancy

abdominal ultrasound. This will usually show the presence of stones. If there is any suspicion of biliary obstruction, liver function tests should be obtained. If there is suspicion of acute cholecystitis, a complete blood count should be done to rule out leukocytosis. If there are no stones visualized on ultrasound but the symptoms suggest biliary colic, gallbladder scintigraphy with a hepatobiliary iminodiacetic acid (HIDA) scan

corticosteroids and GDM screening

abnormal screening can last for up to 1 week in 50% of patients

miscarriage incidence

about 15% -20%

nuchal cord indicence

about 20-30% assoiciated with variable decels, lower pH

what reduces accuracy of NIPT

about 5% of tests fail regardless..... but failed test could mean there is reduced fetal fraction on blood - early GA- - obesity - aneuploidy These patients have a high risk of aneuploidy, a repeat is not recommended, do amnio

risk of rupture tolac

about 5-10% classic or T about 1/400 other

what level may people with spinal cord injuries not feel contractions What level is risk of autonomic dysreflexia

above t10 Pain is felt T10 to T12 people with lesions at or above T6 are at risk of autonomic dysreflexia during labour.

uncomplicated variable deceleration

abrupt drop from cord compression with baroreceptor response , with adequate O2 recovers by end of contraction often has "shoulders"

progesterone for PTB prevention after cones or uterine abnormalities

absence of cervical shortening, there is no evidence that the use of progesterone therapy is beneficial in reducing the risk of SPB in women with history of a conization procedure on the cervix or with an abnormal uterine anatomy

SLE pregnancies

affected pregnancies have higher incidence of - abortion - preterm birth - intrauterine growth restriction (IUGR) - preeclampsia. Recurrent spontaneous abortion (RSA) and fetal loss are more common in women with SLE and co‐existing antiphospholipid antibodies (aPL). (about 1/3 of SLE patients have aPL which predispose to thrombosis and pregnancy complications such as RSA, fetal loss, and preeclampsia Anti‐Ro/SSA and anti‐La/SSB antibodies, present in one‐third of SLE patients, are associated with neonatal lupus and congenital complete heart block (CHB) Evaluation The following laboratory studies should be obtained at the first visit and, generally, in each trimester. - Complete blood count - comprehensive metabolic panel, to rule out autoimmune hemolysis, thrombocytopenia, superimposed preeclampsia or HELLP syndrome. - • Urine protein evaluation (spot PCR or 24‐hour collection). - • Anti‐ds DNA antibodies and complement (CH50, or C3 and C4) levels:....these are relatively sensitive markers for flare. antiphospholipid screen with 1) Lupus Anticoagulant 2) anticardiolipin antibody (aCL) 3) anti‐beta‐2 gly coprotein I (aβ2GPI) antibodies, once prior to or early in pregnancy. • Anti‐Ro/SSA and anti‐La/SSB antibodies, once prior to or early in pregnancy. Neonatal lupus occurs in 15-20%, and CHB in 2%, in offspring of antibody‐positive mothers. Will need multidisciplicary referral - rheumatology - thrombosis (anticoagulation) - MFM, NICU - anesthesia SMFM recommends that ALL patients start/continue hydroxychloroquine, unless quiescent disease present. Fetal surveillance should include the following. • Baseline dating ultrasound scan. • Anatomy scan at 20 weeks. • Serial fetal echocardiograms between weeks 16 and 26 at regular intervals to assess for CHB, (only in women positive for anti‐Ro/SSA and/or anti‐La/SSB antibodies.) In women with a prior infant with CHB, weekly echocardiograms are suggested and patients should be co‐managed with a pediatric cardiologist. • Monthly growth scans and assessment of amniotic fluid volume. • Nonstress tests and/or biophysical profiles, weekly beginning at 36 weeks in uncomplicated cases or at 28 weeks and beyond given the presence of IUGR, aPL, lupus

when to do NIPT SMFM recommendations

after 10 weeks • Advanced maternal age • Fetal ultrasound findings concerning for aneuploidy • History of pregnancy with trisomy 21, trisomy 18, or trisomy 13 • Positive screening tests for aneuploidy • Known parental balanced Robertsonian translocation with risk of trisomy 13 or trisomy 21 Anyone who requests it

Recurrent BV treatment

after initial treatment, treat with 0.75% vaginal metronidazole gel twice weekly, for 4-6 months ,

contraction stress test

aim for >3 ctx in 10 minutes

mirror syndrome

aka triple edema It describes the unusual association of fetal and placental hydrops with maternal preeclampsia. Ballantyne syndrome has several characteristics: - edema, always a key feature - albuminuria of the mother, usually mild - preeclampsia, unusual Mirror syndrome — Mirror syndrome (also called Ballantynes syndrome) refers to a condition of generalized maternal edema, often with pulmonary involvement, that "mirrors" the edema of the hydropic fetus and placenta. Although usually associated with NIHF, it can also occur with immune-mediated hydrops. placental changes associated with pre-eclampsia, such as failure of normal spiral artery remodeling, atherosis, decidual necrosis, and thrombosis, are not uniformly identified in patients with mirror syndrome. Rather, the primary finding in mirror syndrome is one of villous edema.....It has been proposed that villous edema may lead to trophoblast villous hypoxia, resulting in the acute and potentially reversible release of placental-mediated factors like sFlt1. It may present with - rapid weight gain - increasing peripheral edema - progressive shortness of breath, or with a clinical presentation - course similar to preeclampsia with severe features.

placenta previa is a risk for what ?

all women with a placenta previa or low-lying placenta have an increased risk of vasa previa, particularly those with a marginal/velamentous cord insertion close to the cervical os or a succenturiate placental lobe PAS

EFM and oxytocin breaks

allow breaks up to 30 mins for ambulation, hydration, etc

when are all organs present?

almost all organs are present by 10 to 11 weeks' gestation (embryonic week 8-9). fetal anomalies are present in 2% to 3% of pregnancies, and most have already developed during the embryonic period and therefore can be identified in the majority of cases during early pregnancy (11-16 weeks)

treat syphilis

always pen G If allergic (even anaphylaxis), do desensitization .... usually orally in a hospital setting. Primary or early latent (1 year)- 1 dose Unknown latent, late latent or tertiary = (3 doses q weekly) Treatment Follow-up ● Obtain RPR titers every 8 weeks and on admission for delivery. ● RPR titers should fall four-fold by six months for primary/secondary syphilis, and by 12 months for latent syphilis. Retreatment would be indicated if RPR increases or fails to decrease four-fold. ● A four-fold rise after treatment is suggestive of treatment failure or reinfection, and retreatment is indicated.

EFM and tolac

always use An abnormal EFM tracing is the most consistent finding preceding (often as much as 1 hour before) in the presence of uterine rupture. This change may be sudden in onset and may not be related to contractions.

diagnose parvo in fetus

amnio can do parvo b19 PCR.... but this doesn't change management,

diagnose fetal toxoplasmosis

amniotic fluid PCR Done after 15 weeks should be offered no less than 4 weeks after suspected acute maternal infection to lower the occurrence of false-negative results (II-2D).

Amniotic infection syndrome

amniotic infection syndrome is an additional manifestation of gonococcal infection in pregnancy. This condition is characterized by placental, fetal membrane, and umbilical cord inflammation that occurs after preterm PROM and is associated with infected oral and gastric aspirate, leukocytosis, neonatal infection, and maternal fever. Preterm birth is common, and perinatal morbidity may be significant

chorioamnionitis antibiotics

ampicillin 2g IV q8h Gentamycin 5mg/kg x 24h (up to 500 mg) If penicillin allergic - substitute clindamycin for ampicillin If cesarean section - add clinda (if not on it) 900mg IV x1 + - Azithromycin 500mg IV x 1

Hashimoto's thyroiditis

an autoimmune disease in which the body's own antibodies attack and destroy the cells of the thyroid gland anti - TPO-antibodies (90%) anti- - Thyroglobulin (20-50%) Most common worldwide cause of hypothyroid is iodine defiiciency

Scan for previa

anatomy scan 32 w..... if still <2cm, repeat at 36w

SOGC cesarean antibiotics

ancef clindamycin 600 mg IV or erythromycin 500 mg IV - if anaphylactic Note: IDSA recommends both clinda, plus Gent

ovarian Luteoma

androgen producing ovarian cysts during pregnancy, will regress spontaneously after delivery High risk of maternal AND fetal virilization Luteoma — Luteoma is a non-neoplastic ovarian mass associated with pregnancy; it is essentially a corpus luteum that is solid rather than cystic. A luteoma is sometimes mistaken for a neoplasm on clinical, gross, or microscopic examination. Luteomas involute spontaneously after delivery. The diagnosis should be suspected in the presence of a solid adnexal mass and maternal hirsutism or virilization Bilateral in 30-50% of cases Management depends on the presentation, characteristics of the mass, gestational age..... but usually, opt for conservative management.

what is a person with stillbirth at risk for next pregnancy

another stillbirth growth restriction preterm birth Do serial growths starting 28 weeks

neonatal lupus heart block

anti-SSA antibodies are tropic for myocardial tissue and the conduction system of the fetal heart, leading to inflammation with mononuclear cell infiltration, and subsequent fibrosis, scarring, and calcification. When inflammation occurs in the atrioventricular and sinoatrial nodes, it can lead to CHB, which occurs in 50% of cases of NLE. Scarring of the fetal conduction system and diffuse fibroelastosis in the endocardium and myocardium may occur as a result of inflammation. In contrast to neonatal skin lesions and anemia, heart block and fibroelastosis are usually permanent. CHB typically manifests between 16 and 25 weeks of gestation as fetal bradycardia with a fetal heart rate of 60 to 80 beats per minute, and can lead to fetal hydrops and stillbirth. The prognosis for neonates with CHB is variable and related to the extent of fibroelastosis and the presence of fetal hydrops; 15% to 20% of children with NLE and CHB die within the first 3 years of life. Among survivors, approximately 60% require a pacemaker within the first few years of life, most of the remainder will require pacing before adulthood. Almost two thirds of these patients will require a pacemaker, the majority within the first 10 days of life..... However, with pacemaker implantation, most of these children have an overall good prognosis and can be expected to have a near normal life expectancy if ventricular function is preserved.

antibody titers

antibody titres are a ratio of how much antibody to solution - meaning the 1 is antibody and the second number is how much of the solution (saline) you need to make the antibody undetectable. So 1:4 is actually lower than 1:16 1:4 - you need 4 drops of saline to make the antibody undetectable 1:16 - you need 16 drops of saline to make the antibody undetectable, aka there is more antibody present because you're needing more saline to dilute it down

SOGC consider heparin

antiphospholipid antibody syndrome or known thrombophilia,

atypical FHR

any of tachysystole FHR 100-110 FHR > 160 for 30-80 mins rising baseline arrhythmia minimal variability for 40-80 mins no accels with scalp stim - repetitive (3 in a row) uncomplicated variables - non repetive (1-2), complicated variables - intermittent (<50% over 20 mins) lates - 2-3 minute decel

what is recurrence risk of accreta

around 20-30 %

risk of breech during L&D What is the acid base abnormality ?

asphyxia from cord compression In low-PNM countries, the trial showed - no difference in PNM in singleton breech births between planned CS and planned VBB (0% vs. 0.4%) - striking difference in "serious" short-term neonatal morbidity: 0.4% versus 5.1% no difference in maternal mortality or serious morbidity in the first 4 postpartum weeks, one half of neonates were followed beyond 2 years of age, at which time there was no difference in the combined outcome of PNM and abnormal long-term neurological outcome: 3.1% in the planned CS group and 2.8% in the planned VBB group. Breech infants are often depressed at birth due to respiratory acidosis secondary to cord compression during expulsion. A health care professional skilled in neonatal resuscitation should be in attendance at the time of delivery.

Labetalol Contraindications

asthma heart disease congestive heart failure labetalol elevated liver enzymes it may cause: - neonatal hypoglycemia and bradycardia

asthma vs dyspnea of pregnancy

asthma has more cough and wheeze

covid severity

asymptomatic mild- flu-like symptoms, such as fever, cough, myalgias, and anosmia without dyspnea, shortness of breath, or abnormal chest imaging Moderate disease is defined by: - evidence of lower respiratory tract disease with clinical assessment (dyspnea, pneumonia on imaging, abnormal blood gas. results, refractory fever of 39.0 °C /102.2 °F or greater not alleviated with acetaminophen) while maintaining an oxygen saturation of greater than or equal to 94% on room air at sea level Severe disease is defined by: - respiratory rate > than 30 breaths per minute (bpm), - hypoxia with oxygen saturation less than 94%, - or greater than 50% lung involvement on imaging. Critical- multi organ failure, shock, resp failure on ventilation or high flow nasal Refractory hypoxemia is defined as persistent, inadequate oxygenation and/or ventilation despite substantial and appropriate measures to optimize it and represents a further escalation of severity on the spectrum of disease

most dangerous fetal arrhythmias

atrial flutter V-tach

atypical HUS vs HELLP

atypical HUS has WAY WAY higher levels of creatinine, and LDH.

What is SLE? diagnose SLE

autoimmune disease characterized by an abnormal immune response in which auto (self) antibodies cause damage to various organ systems, including: - skin - joints - kidneys - lungs - liver - nervous system To meet criteria for diagnosis, a patient must have a) at least four of 17 criteria, including at least one of the 11 clinical criteria and one of the six immunologic criteria - b) Alternatively, biopsy-proven lupus nephritis plus positive ANA or anti-dsDNA Clinical criteria - Acute cutaneous lupus (Malar rash ) - Chronic cutaneous lupus (Discoid rash) - Non-scarring alopecia( In the absence of other causes) - Oral or nasal ulcers (In the absence of other causes) - joint disease Synovitis (in two or more joints) - Serositis (Pleural or pericardial) - Renal disease (P/C ≥ 0.5, 24-h urine protein ≥ 500 mg, or red blood cell casts) - Neurologic (Seizures, psychosis, neuropathy, myelitis, or acute confusion in the absence of other causes ) - Hemolytic anemia - Leukopenia or lymphocytopenia (WBC <4000/µL or lymphocytes <1000/µL in the absence of other causes) - Thrombocytopenia (Plt <100,000/µL in the absence of other causes) Lab criteria -ANA (Above laboratory reference range) -Anti-dsDNA Above laboratory reference range -Anti-Sm Presence at any titer -Antiphospholipid (Any of: LAC; false-positive RPR; medium- or high-titer ACL IgA, IgG, or IgM; or positive result for anti-β2-glycoprotein-1 IgA, IgG, or IgM - Low complement (C3, C4, or CH50) - Direct Coombs (Positive result in the absence of hemolytic anemia)

previable PPROM misc

aveeagr latency of 2 weeks Mortality of 95% after 20 weeks 50% risk of survival complications - stillbirth - preterm birth ... with complications -sepsis - chorio - abruption - cord prolapse - cesarean

hep C recommendations

avoid internal monitoring, episiotomy Avoid long ROM

prevent listeria

avoid shitty and processed foods (hot dogs, deli meat, unpasturized cheese) Wash produce very carefully Heat foods (refridgeration does not kill listeria)

operative delivery ITP

avoid!! up to 15% of neonates will have this

weight gain pregnancy

between 0.5 to 1 pound per week

hep D in pregnancy

can ONLY replicate with HBV presence. treat as hep B

epidural and labor

can block sympathetic afferts, decrease catecholamines. This can improve uterine contractions and and placental flow also allows higher oxytocin

AFLP coagulopathy treatment

can prophylactically be corrected with replacement of FFP, cryoprecipitate, packed red cells or platelet concentrates Nevertheless, the current literature suggests that prophylactic transfusion of blood products aiming to correct laboratory abnormalities increases the risk of acute lung injury, fluid overload, infection, immunosuppression, organ dysfunction and, therefore, should not be performed Furthermore, it is well known that the standard plasmatic coagulation screening tests represent weak predictors of bleeding in the critically ill patients and represent suboptimal tests for monitoring coagulopathy or guiding hemostatic therapy...... Strongly consider viscoelastic hemostatic assays (VHAs), namely ROTEM (Rotational Thromboelastometry)

intubation criteria

cannot maintain O2 >94 with - Greater than 15 L per minute (by common nasal cannula or mask), - Greater than 40 to 50 L per minute by high-flow nasal cannula - Greater than 60% fraction of inspired oxygen (FiO2) by Venturi mask

cardiac output pregnancy

cardiac output rises during the first few weeks of pregnancy and is 30% to 45% above the nonpregnant level by the 20th week, remaining there until term. The increase in cardiac output in the first trimester begins rapidly and peaks between the 20th and 26th week. Early in pregnancy, the dominant factor is elevated stroke volume; later, increased heart rate predominates. In late pregnancy, the enlarged uterus partially impedes venous return by compressing the inferior vena cava, accounting for lower cardiac output. This is one reason why some obstetricians prefer to manage labor with the patient in the left decubitus position.

mody

caused by a mutation in one of eleven genes in someone's DNA. MODY is passed down genetically (autosomal dominant) from parent The pancreas continues to produce insulin in people with MODY, vs T1 where insulin production is very low or stops entirely three to five years after diagnosis. (This is measured via C-peptide levels.....Very low/zero levels of C-peptide suggest that a person has type 1 diabetes.) Antibodies (proteins used by the immune system) that attack insulin-producing cells are NOT likely to be present in people with MODY.

Zika exposure

causes microcephaly, intracranial calcifications Tests 1) reverse transcriptase PCR (must test 3-7 days from onset of symptoms) 2) Zika IgM antibody

final pathway for cell injury in shock

cell death due to hypoxic injury ,all efforts should be directed at restoring tissue oxygenation as soon as possible. A useful mnemonic to achieve this goal is ORDER: Oxygenate (secure airway and oxygenate) ... Restore circulating volume Drug therapy Evaluate response to therapy Remedy underlying cause. Note: edema from fluids may make tracheal intubation difficult

cerclage in twins

cerclage may reduce the rate of preterm birth and improve perinatal outcomes in asymptomatic women with twin pregnancies and a - very short cervix (≤15 mm) before 24 weeks of gestation..... - dilated > 10mm physical-examination indicated cerclage, based on retrospective data and a recent small, randomized trial, cerclage in asymptomatic women with twin pregnancies and cervical dilatation (of 1-5 cm) before 24 weeks can decrease the risk of preterm birth and prolong the pregnancy by 5.5 weeks on average.

risks for uterine rupture

cesarean, tolac oxytocin misoprostol collagen diseases (ED) grand multip trauma uterine abnormalities Rupture in unscarred, 1 in many thousands. 1 in about 200-300 with CS

Risks for accreta (!!)

cesareans Previa (most common!) Damage to endometrium - D&C , hysteroscopy - endometritis - myomectomy or fibroids IVF

troubleshoot EFM

check equipment adjust the toco find fetal heart on ultrasound Scalp clip or IUPC

lmwh heparin monitoring pregnancy

check platelets in 1 week (if therapeutic dose) While LMWH is administered as a single daily dose for non-pregnant patients, twice a day dosing is often used in pregnancy, especially for the first month when the risk of recurrence is greatest. This practice stems from the altered renal elimination of LMWH and the impact of weight gain, both of which affect anti-Xa activity in pregnant women. Hence, for the treatment of acute VTE, especially major proximal VTE and PE, consideration should be given to initial monitoring of anti-Xa activity, during the first month of treatment only, to target a level of 0.6 to 1.0 U/mL 4 hours after injection, bearing in mind that target levels will vary with the LMWH used. check this - weekly until therapeutic - then monthly

late decels

chemoreceptor response with a secondary baroreceptor response gradual drop Onset, nadir and recovery occurs after beginning, peak and end of contraction

Varicella Zoster Virus

chicken pox and shingles (herpes zoster) highly contagious DNA virus of the herpes family. It is transmitted by respiratory droplets and by direct personal contact with vesicular fluid. The incubation period lasts 10 to 21 days, and the disease is infectious 48 hours before the rash appears and continues to be infectious until the vesicles crust over. After the primary infection, VZV remains dormant in sensory ganglia and can be reactivated to cause a vesicular erythematous skin rash known as herpes zoster aka shingles. Maternal herpes zoster infection is not associated with a significant risk of congenital varicella syndrome.

Hep C complications What is percent of vertical transmission ??

cirrhosis and hepatocellular carcinoma 20% develop cirrhosis after 20 or more years of HCV infection, and 1-5% of cirrhotic patients develop hepatocellular carcinoma per year. Vertical transmission is ~5%

Vitamin A teratogenicity

cleft palate, cardiac abnormalities brain abnormalities micrognathia ear abnormalities

lyme disease

clinical diagnosis, he development of the antibody response takes several weeks, so serology is not recommended in early Lyme disease. Therefore, the diagnosis of early localized Lyme disease is primarily clinical recognition of signs and symptoms, supported by a history of possible tick exposure or residence in or travel to an at-risk area. Prophylaxis after a tick bite with dose of 200 mg of doxycycline can be considered if the tick is identified as a blacklegged tick and is engorged (suggesting it has been attached for >24 hours) and the patient lives in or has acquired the tick in an at-risk area. 2-tiered testing (STTT) approach, which uses an enzyme immunoassay (EIA) screening test a - a confirmatory immunoblot test if the EIA is positive.

contraindications to cerclage

clinical scenarios where the procedure is unlikely to reduce the risk of preterm delivery or improve fetal outcome: - fetal anomaly incompatible with life - intrauterine infection - active bleeding - active preterm labor - preterm prelabor rupture of membranes (PPROM), and fetal demise.

cerclage and existing infection

common in physical exam indicated (~25%) Uncommon in ultrasound indicated

postnatal growth delay

common in preterm birth... normally, there is acceleration of fetal growth in the second trimester. In babies born during this time, the stress of the external environment often prevents this, causing a growth delay

acute chest syndrome

condition with sickle cell, and - chest pain - hypoxemia - infection (so patient has a temp) - chest infiltrates - tachypnea, wheeze, cough management includes: - if hypoxic, then aggressive pulmonary hygiene to keep lungs clear and maintain sats (ie, oxygen, bronchodilators ) - consider blood transfusion for mild desats, with exchange transfusion if it progresses - mechanical ventillation may be necessary CTA Also, usual management - adequate hydration - analgesia - antibiotics

Chlamydia in newborns

conjunctivitis and pneumonia

manage next pregnancies of severe alloimmunization

consider IV-Ig at 12 weeks GA (may delay onset)

PPROM and HIV weeks

consider as low as 32 weeks due to increased risk

manage subsequent pregnancies with unsuccessful cerclage

consider transabdominal or laparoscopic cervicoisthmic cerclage

anticoagulation after severe OHSS

continue for 8-12 weeks after

substance use disorder

continued substance craving and use despite significant life disruption and/or physical risk Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by two or more of the criteria within a 12-month period: 1.Taking substance in larger amounts or for longer than intended 2.Wanting to cut down or quit but not being able to decrease or discontinue use 3.Spending a great deal of time obtaining, using, or recovering from effects of substance 4.Craving or a strong desire to use 5.Repeatedly unable to fulfill major role obligations at work, school, or home 6.Continued use despite persistent or recurring social or interpersonal problems caused or made worse by substance 7.Stopping or reducing important social, occupational, or recreational activities 8.Recurrent use in physically hazardous situations 9.Continued use despite acknowledgment of persistent or recurrent physical or psychological problems related to substance use 10.Tolerance as defined by either a need for markedly increased amounts to achieve desired effect or markedly diminished effect with continued use of the same amount 11.Withdrawal manifesting as a characteristic syndrome with reduced concentration of substance after prolonged heavy use Mild: 2-3 criteria Moderate: 4-5 criteria Severe: ≥6 criteria

Epulis gravidarum

contr Due to vascular swelling Will regress after pregnancy

deliver chronic hypertension

controlled chronic = ~38-39 weeks

tocolysis in PPROM

controversial, no good evidence. may delay birth in 48 hours Worsens APGAR score, More ventillation more chorio

most common cause of death in mono

cord entanglement

Cotyledon Placenta

cotyledons, which transmit fetal blood and allow exchange of oxygen and nutrients with the maternal blood. Normal anatomic arrangement of a paired artery and vein supplying and draining a placental cotyledon (for nutrient exchange)

determine baseline in IA

count 1 full minute 30 secs x 2 15 secs x 4

pulmonary hypertension aka pulmonary arterial hypertension labor management

critical to - avoid hypotension /volume depletion, and blood loss These cause decreased venous return, hypoxemia, and then cause pulmonary edema Monitor pulse ox CONSTANTLY , keep sats >90%

heparin for preeclampsia/fgr

currently not recommended, unknown neonatal safety profile , espeically long term May reduce perinatal mortality, preterm birth and SGA

dawn vs somogyi effect

dawn = "down insulin" increase in nocturnal secretion of GH, glucose level is elevated at 3 AM, to treat, increase patient's evening insulin somogyi = "so much insulin" rebound response to nocturnal hypoglycemia, gluocse level is decreased at 3 am, decrease pt's evening insulin

abnormal aortic arch

deoxygenated blood is being shot into the baby's brain ... not really used in clinical setting.

digital exam vs ultrasound for cervial length

digital exam underestimates

fetal SVT choices

digoxin is first line - works about 50% of the time. Recommended to initiate in hospital setting with monitoring. If insufficient, try additional drugs - Flecanide -Procainamide - Verapamil

#ductus venosus

directing well-oxygenated blood from the umbilical vein to the IVC which bypasses the liver .... then it goes through the foramen ovale... which shunts right atrium to left atrium (bypassing pulmonary circulation).... then into the aortic arch, and then the brain. It has a triphasic waveform, with high velocity during ventricular systole (S wave) and diastole (D wave), and forward flow during atrial contraction (a-wave). As the ductus venosus breaks down, the blood that is getting to the left side of the heart is deoxygenated.... and this low O2 saturation causes inceased cardiac workload, which causes progressive heart failure. Note: Abnormal ductal flow—more precisely an absent or reversed a-wave—in the first trimester is associated with chromosomal defects, cardiac abnormalities, and adverse pregnancy outcomes..... Eighty percent of fetuses with trisomy 21 have abnormal flow in the ductus venosus, whereas 5% of chromosomally normal fetuses have abnormal flow

causes of dichorionic growth discordance

discordance may be linked to discordant placental characteristics such as placental size, cord insertion type and location, placental implantation and uteroplacental perfusion, and placental parenchymal pathology. In addition, the growth of dichorionic twins may be differentially influenced by nonplacental factors such as : - genetic growth potential - structural or chromosomal fetal anomalies - congenital infection Smaller placenta the smaller twin usually has the peripheral (marginal or velamentous) cord insertion Placental parenchymal lesions (infarcts, fibrin deposition, retroplacental hematoma), when present, are seen predominantly in the territory of the smaller twin.

treat peripartum cardiomyopathy

diuretics first line A vasodilator, such as an ACE inhibitor or angiotensin receptor blocker, usually is added after diuretics are initiated. Several β-blockers, especially metoprolol, carvedilol, and bisoprolol, have been shown to decrease mortality in heart failure and, therefore, are recommended for all patients with heart failure unless specific contraindications exist. They may transiently worsen fluid overload and symptoms of heart failure; therefore, they should be started after euvolemia has been achieved.

external cephalic version ( ECV ) is done when?? what are success rate and factors

done around 36-37 weeks about 60% Poor factors: - nullips - obesity -oligo - anterior placenta - tense abdomen Higher success if : - transverse lie - multips - good fluid - posterior placenta - non-obese - not engaged continuous EFM is recommended

postpartum prolactinoma

dopamine agonists inhibit prolactin, so they affect breast feeding. - The patient should follow up with an endocrinologist 2-4 weeks after delivery - In asymptomatic women, prolactin levels should be measured two months after delivery or two months after cessation of breastfeeding. The decision to restart DA will depend on the level. - In women who continue to breastfeed, MRI can be obtained in 4-6 weeks post-delivery to ensure the stability of the tumor (if ordered by an endocrinologist)

treat lyme disease in pregnancy

doxycycline 200mg still recommended as PROPHYLAXIS only (not for treatment)

treat pelvic abscess

drain amp + gent + clinda Intravenous antibiotics should be continued until the patient has been afebrile and asymptomatic for a minimum of 24 to 48 hours. Thereafter the patient should be treated with a combination of oral antibiotics that cover the major pathogens levofloxacin (750 mg every 24 hours) plus metronidazole (500 mg twice daily) to complete a total treatment course of 10 to 14 days

hypothyroid in pregnancy presentation and etiology

dry skin, weakness, weight gain, carpal tunnel, goiter, hair loss, Majority (99%) due to primary thyroid.... most commonly Hashimoto's, Women at high risk for hypothyroidismshould be screened with TSH and FT4 Add thyroid peroxidase antibodies (TPOAb) if TSH is >2.5 mU/L. TPO antibodies itself are able to cross the placenta, and they ARE a risk factor for pregnancy outcomes.

sideroblastic anemia

due to a defect in protoporphyrin synthesis, which leads to microcytic anemia. (heme= Fe+protoporphyrin)!!!! .. therefore the body is unable to manufacture hemoglobin Most common cause is (!!!) congenital defect is due to defect in enzyme aminolevulinic acid synthetase (ALAS) which is enzyme in rate limiting step (requires B6)!!!! Acquired: -Lead poisoning - Vitamin B6 deficiency (side of meds, ie, INH) Think that it is an 'iron overloaded state"" because iron keeps building up in mitochondria of erythroid precursor cell, iron causes free radical formation, cell dies, and iron leaks out. Bone marrow macrophages eat iron to store it (↑ Ferritin), but there's also high in blood- ↓ TIBC- ↑ serum iron- ↑ % saturation

fetal and neonatal alloimmune thrombocytopenia aka FNAIT

due to platelet destruction from maternal antibodies against fetal human platelet antigens (HPA) inherited from the father. It is also called neonatal Alloimmune thrombocytopenia (NAIT) alloimmune thrombocytopenia (AIT), or fetal maternal alloimmune thrombocytopenia (FMAIT). FNAIT is similar to RBC Rh disease: • Like red blood cells, platelets have specific surface proteins called antigens. • Fetus inherits paternal antigens that the mother lacks (platelet antigen incompatibility). • Mother develops antibodies (becomes sensitized) to fetal platelet antigens during pregnancy. • Maternal IgG anti-platelet antibodies cross the placenta and coat fetal platelets resulting in sequestration and destruction of platelets in the fetal reticuloendothelial system. FNAIT differs from Rh disease: • Antiplatelet IgG production can occur in first pregnancy. • Firstborn children are often affected since anti-platelet IgG production can occur in a first pregnancy; nulliparous women account for 20-60% of cases. • Maternal antibody titers do not predict pregnancy outcome The natural history of FNAIT ranges from mild asymptomatic fetal/neonatal thrombocytopenia to severe thrombocytopenia leading to intracranial hemorrhage with potentially severe perinatal morbidity and mortality. • Ninety percent affected neonates having diffuse petechiae. • Ten percent to 30% ICH • Approximately 75% occur antenatally, as early as 20 weeks.

Prolactinoma during pregnancy

during pregnancy there is a progressive increase in prolactin, leading to a 10-fold increase at term. In lactating women prolactin levels remain increased until about 6 weeks after delivery. The high levels of estrogen in pregnancy lead to lactotroph hyperplasia and a gradual increase in the size of the pituitary VERY small risk of significant enlargement with microadenoma..... For women with macroadenomas who achieved pregnancy using bromocriptine the risk of clinically significant tumor enlargement during pregnancy is 15% to 35% In patients with large tumors- formal visual field testing should be performed each trimester and more frequently if neurologic or visual symptoms develop .- If visual field abnormalities develop an MRI without contrast should be used to assess the pituitary.Most patients with macroadenomas who achieve fertility with bromocriptine have an uncomplicated pregnancy....... However, if significant neurologic or visual symptoms develop, there is no consensus on how to treat symptomatic tumor growth during pregnancy. Options include: 1) reinstitute bromocriptine and to continue it throughout pregnancy. Probably safe, but no great data. 2) Caebergoline-Minimal data during pregnancy, but no strong reported harm. 3) Transsphenoidal surgery is another option in the case of symptomatic tumor growth but any surgery during pregnancy is associated with a 1.5-fold increase in fetal loss in the first trimester and a 5-fold increase in fetal loss in the second trimester.

cholestasis of pregnancy

e pathogenesis secondary to effect of estrogen and progesterone in reducing expression of hepatic biliary transport proteins and reducing the function of the main hepatic bile acid receptor responsible for bile acid homeostasis, farnesoid X. This leads to a disruption in transport of bile acids from the liver and decreased excretion.

early vs late GBS

early GBS is within 7 days Late is >7 days Treatment affects early, it does not affect late

epilepsy labor

early epidural IV access IV lorazepam standing by (1mg aura, 2mg seizure)

techniques for impacted head

elevate fetal shoulders (placing the index and middle fingers over each fetal shoulder to steadily elevate the fetus.) Reverse breech carries a lower risk of fetal injury and results in less maternal tissue injury and thus less overall blood loss than the more frequently performed push technique Patwardhan Technique

Exon sequencing hydrops

exons are 1% of the genome, contain most disease causing variants. Look up Lancet 393(10173) 758-767- whole exome seqencing

HIV pre-exposure prophylaxis

emtricitabine/tenofovir (Truvada) The data on pre-exposure prophylaxis should be discussed with all patients during preconception. HIV pre-exposure prophylaxis is not routinely recommended in the context of HIV and preconception. In the situation in which adherence and viral suppression in the infected partner cannot be confirmed, but conception attempts are still intended by the serodiscordant couple, pre-exposure prophylaxis should be recommended to the HIV-negative partner (II-A) Consider in very high risk patients - known HIV positive partner - exchange of sex for money, food, drugs - IV drug/substance disorder

What US findings indicate that a fetus has reached 3rd trimester ? (ossification)

epiphyseal ossification centres of the - distal femur - proximal tibia - proximal humerus.

fetal growth restriction etiologies

etiologies that may be - placental - maternal - fetal in origin. Although the most growth‐restricted fetuses are constitutionally small, this should be a diagnosis of exclusion and an underlying etiology should be sought. When a fetus is identified to have EFW below the 10th percentile, - Constitutional (up to 70% of cases) Maternal disease affecting placental perfusion • Chronic hypertension • Other cardiovascular disease • Renal disease • Autoimmune disease • Pregestational diabetes with end‐organ involvement • Chronic anemia (sickle cell anemia) • Maternal cyanotic cardiac disease Preeclampsia/gestational hypertension Prior pregnancy with FGR or stillbirth Substance abuse • Cocaine, methamphetamine (vasoactive substances) • Heroin, other opiates/opioids Cigarette smoking Alcohol Teratogens (methotrexate, cyclophosphamide, other antineoplastic medications, immunosuppressants, maternal phenylketonuria) Severe dietary and/or nutritional restriction Placental: Placental hematoma or chronic abruption Chorioangioma of placenta Circumvallate placenta Velamentous umbilical cord insertion Single umbilical artery (controversial, some studies suggest) Fetal: Fetal genetic abnormalities (e.g., trisomy 18, other aneuploidies and syndromes) Fetal structural abnormalities (gastroschisis, hydrops, etc.) Fetal congenital infection (prevalence and risk vary) • Cytomegalovirus • Toxoplasmosis • Parvovirus • Zika • Rubella • Varicella/herpes virus • Malaria Complicated multiple gestation • Twin discordance • Selective FGR • Monochorionic twin complications: • Twin-twin transfusion sequence • Twin‐anemia‐polycythemia sequence

what is the SOGC definition of PPH

excessive bleeding in first 24 hours

risks of forceps

facial lacs facial nerve palsy (does not happen with vacuum) corneal abraisions occular trauma Neonatal skul fracture is more common Forceps has lowest indicence of neurologic complications, then vacuum, then cesarean Skull fracture is similar forceps and vacuum

SOGC glucose targets for diabetes

fasting- 5.3 1 hour- 7.8 2 hour- 6.7

Hep E and pregnancy

fecal oral transmission very high risk of liver failure (20%) in pregnancy. only supportive therapy

EFM and prostaglandin E2 time

for 30 mins before for 1-2 hours after

normal aortic arch

forward flow the entire time ... not really used in clinical setting.

what to do when cardiac anomaly found

fully detailed anomaly scan to look for extra-cardiac anomalies Fetal echo Karyotype testing- fetus and parents

Define shock

generalized physiologic state characterized by a significant reduction in tissue perfusion resulting in decreased tissue oxygen delivery. Although the effects of inadequate tissue perfusion are initially reversible, prolonged oxygen deprivation leads to: - generalized cellular hypoxia - end‐organ damage - multiple‐organ system failure - death Three broad types of shock states are recognized, characterized by one of three primary physiologic derangements: (1) decreased preload (hypovolemic shock) (2) pump failure (cardiogenic shock) (3) a severe drop in systemic vascular resistance with a compensatory increase in cardiac output (known as distributive shock) 3a) septic 3b) neurogenic 3c) anaphylacic

endometritis treatment

gentamicin + clindamycin +/- ampicillin treat until afebrile for 24 hours... no need to step down

insulin in labor

give regular insulin night before labor Hold insulin in the AM keep the maternal glucose level between 4-8 mmol (70-140) Avoid hypoglycemia! d5NS at 100-125 ml/hr 1-2 u per hour to keep 4-8 Start at glucose of 6 (110)

GDM risks in early pregnancy

glucose crosses the placenta, increased risk of : - malformations - miscarriage Risk can be >20% with HbA1C above 10 Major risks are cardiac and CNS

early pregnancy hormones

hCG also peaks at approximately 10 weeks' gestation. The reproductive hormones estradiol, progesterone, testosterone, prolactin, and 17-hydroxyprogesterone all increase significantly during gestation. Initially the corpus luteum and maternal ovarian tissue make the greatest contribution to steroid hormone concentrations, but as of 9-10 weeks' gestation, aromatization of dehydroepiandrosterone sulfate by the placenta becomes the predominant source of maternal steroids elevated estradiol levels causes: - increased hepatic SHBG and TBG -- Estrogen also induces hypertrophy and hyperplasia of pituitary lactotrophs with a resultant increase in prolactin levels corresponding to the increase in estradiol levels throughout gestation. Meanwhile, there is a reflexive decrease in FSH/LH

eFTS

hCG, PAPP-A, AFP, PlGF, NT 11-14 weeks, or CRL 44-85mm

Neonatal candida

happens with delivery oral thrush is most common. range from superficial skin infection and oral infection to severe systemic disease with hemorrhage and necrosis of the heart, lungs, kidneys, and other organs. ......These severe manifestations are extremely uncommon and would be unlikely to occur in the absence of compromised maternal immunity or extreme neonatal prematurity.

selective reduction

he method of selective termination depends on the chorionicity. In dichorionic gestations, ultrasound-guided intracardiac injection of KCl is the most common technique: in monochorionic gestations, complete ablation of the umbilical cord of the anomalous fetus is required to avoid death or neurologic injury in the normal fetus. When selective termination in a monochorionic gestation is considered in contemporary obstetric practice, ultrasound-guided cord occlusion, fetoscopic cord occlusion, or laser ablation is most commonly used.

consequences of IUFD in twins

he risk for significant neurologic morbidity is increased after intrauterine death of one fetus in a monochorionic, but not in a dichorionic, gestation. Abnormal neonatal cranial imaging is noted in 34% of monochorionic twin survivors compared with 16% of dichorionic twin survivors after single intrauterine fetal demise.

placenta trophoblast invasion

he trophoblasts invade the decidua to anchor the placenta, and a subpopulation of cytotrophoblasts invades the uterine blood vessels at the implantation site, resulting in extensive remodeling of the vessels. There is a replacement of endothelium and uterine smooth muscle cells that leads to a reduction in uterine arterial resistance and an increase in uteroplacental perfusion...... A number of reports have revealed that in many cases of FGR, particularly in early FGR, the depth of invasion by the cytotrophoblasts is shallow, and the endovascular invasion is rudimentary. as a result the mean surface area and, more importantly, the capillary surface area were reduced in the placentas of growth-restricted newborns. Apoptosis at the implantation site is increased with IUGR, and this has been suggested to be the mechanism limiting endovascular invasion.

SOGC follow closely preeclampsia

headache/ visual changes Chest pain/ SOB O2 90-97 Lab elevations Fetal: growth restriction, oligo, abnormal NST

what images in anatomy scan are tough in obesity

heart spine face extremities Perform scan minimum 20 weeks, preferably 22-24

pregnancy-associated atypical hemolytic uremic syndrome (HUS)

hemolysis, thrombocytopenia, renal failure.... NOT associated with Shigella E.Coli Corticosteroids and plasma exchange are sometimes effective, but pregnancy associated aHUS often progresses to end-stage renal disease, dialysis, or kidney transplant. Eculizumab, a monoclonal antibody against complement protein C5, is effective for treatment of aHUS

sickle cell trait

hetero-zygous HbS, largely asymptomatic. "Hb electrophoresis confirms both PRESENCE and AMOUNT of HbS. Disease: 90% HbS, 8% HbF, 2% HbA2 NO HbA!!! Trait: 55% HbA 43% HbS, 2% HbA2 <50% HbS does not usually result in sickling EXCEPT in renal medulla, due to extreme hypoxia. - patients get microinfarctions. - leads to microscopic hematuria and eventually, decreased ability (!!) to concentrate urine (!!!!!!)- Risk of Viral infection (esp. parvovirus B19) → aplastic crises with major ↓ in hemoglobin concentration

how to do multifetal reduction

hi If a monochorionic pair of fetuses exists in a higher order multiple gestation, that pair is usually selected for reduction.

major risks for hep C vertical transmission

high Hep C RNA viral load is the major risk factor prolonged ROM (if high viral load) is next major Other factors: - internal monitoring - fetal blood sampling

APS on pregnancy

high LA activity and high aCL IgG levels present the highest risk of adverse pregnancy outcomes. LA poses the highest risk for pregnancy loss which is up to 80% in untreated women. APS have high rates of placenta‐mediated obstetric complIcations. In addition to fetal death about a third have fetal growth restriction - a third have preeclampsia - a third have medically indicated preterm birth owing to these disorders.

what is most important factor in recurrent stillbirth

history of previous stillbirth but the risk of recurrence is likely to depend on the cause of the initial loss. pregnancy loss due to placental causes or preterm birth is the most likely to recur. Certain treatable causes, like antiphospholipid antibody syndrome or maternal vascular malperfusion may benefit from treatment and can result in more favourable outcomes in the future pregnancy. Women with known risk factors, such as smoking, obesity, and poorly controlled pre-gestational diabetes, may benefit from modification of these risk factors and optimization of health status prior to a subsequent conception

indications to test for a thrombophilia

hx of VTE first degree relative with inherited thrombophilia

diuretic pregnancy

hydrochlorothiazide 6.25mg PO BID to start 12.5mg PO BID is max

u/s findings of B19

hydrops Pericardial effusion pleural effusion ascites Abdo/slin edema cardiomegaly (myocarditis)

adjust insulin after celestone

hyperglycemic effects seen in ~12 hours Day 1: Increase the night insulin dose by 25% Days 2 and 3: Increase all insulin doses by 40% Day 4: Increase all insulin doses by 20% Day 5: Increase all insulin doses by 10% to 20% Days 6 and 7: Gradually taper insulin doses to pre betamethasone doses

How soon to deliver second twin ? How big should it be to do a breech extraction??

ideally, 30 mins..... unless extremely premature (can prolong) seems reasonable to offer vaginal breech delivery for the nonvertex second twin with an estimated birth weight between 1500 and 4000 g, provided it is not significantly larger than the first twin (20%).....and the head is not hyperextended. (remember, singleton size for breech is 2500)

risks for abruptiuon

idiopathic HTN Cocaine/smoking PPROM multiple gestation trauma Infection

severe HIV low CD4 prophylaxis

if CD4 under 200, give 1 tab Septra DS daily for prophylaxis against Pneumocystis and toxoplasmosis...... Can stop if >200 for 3 months For patients with a CD4 count <50 cells/microL who are initiating antiretroviral therapy (ART), we do not routinely administer antimicrobial prophylaxis to prevent Mycobacterium avium complex (MAC). The exception to this includes patients with a CD4 count <50 cells/microL who are not on fully suppressive ART. In this setting, if there are concerns that the patient may have active MAC infection (eg, fevers, weight loss), a mycobacterial blood culture should first be obtained, and prophylaxis should be delayed for 7 to 10 days, pending the results. When prophylaxis is indicated, we prefer weekly azithromycin (1200 mg once weekly) or daily clarithromycin (500 mg twice daily).

reduce unnecessary winrho

if mom is rhesis negative, then you can test the father He if is rhesus negative too, no intervention is needed. Can do NIPT on fetus for Anti-D only

Restart anticoagulation after delivery or epidural placement

if no epidural, then 4-6 hours after vaginal or 6-12 hours after cesarean

in a non pregnant patient, how should you manage varicella exposure ?

if vaccine history is not known, give the vaccine. If pregnant or immunocompromised, give VZIG

postpartum IUD timing terminology

immediate post partum expulsion = 10-20%

pathyphysiology of preeclampsia

impaired maternal vascular response to placentation and endothelial cell dysfunction impaired trophoblastic invasion and transformation Abnormal angiogenesis (more thromboxane, less prostacyclin) Hypoxia, free radicals, oxidative stress, and activation of endothelium are characteris- tic. Thromboxane (which is associated with vasoconstriction, platelet aggregation, and decreased uteroplacental blood flow) is increased, while prostacyclin (which has opposite effects) is decreased. FGR is also theorized to develop as a result of defec- tive placentation and the imbalance between prostacyclin and thromboxane.

cannabis risks

impaired motor coordination euphoria anxiety a sensation of slowed time impaired judgment social withdrawal. It is accompanied by any 2 of the following signs and symptoms: conjunctival injection dry mouth increased appetite tachycardia The intoxication affects an individual's ability to operate a motor vehicle, doubling the risk of an accident. Cannabis poisoning is the most common immediate health risk encountered with cannabis use; it is characterized by: severe anxiety paranoia nausea, and vomiting. Because of the delay in the onset of psychoactive effects, edible cannabis products carry a greater risk of cannabis poisoning than cannabis products that are inhaled

uterine artery in pregnancy invasion

in the first stage occurring before 12 weeks after fertilization, spiral arteries invade the boundary between the decidua and myometrium. The second stage occurs from 12 to 16 weeks into the pregnancy, when the spiral arteries invade the interior of the myometrium (2). Accordingly, the two-stage recasting process transforms the narrow myometrial spiral arteries into uterine placental vessels with low resistance. Notching" is a relatively common characteristic that appears during the early stages of ~50% of normal pregnancies. Like UtA-PI, the incidence of "notch" decreases after 24 weeks of pregnancy and remains stable Continuous early diastolic notch is a manifestation of abnormal uterine vascular tension, and poor placentation may increase uterine artery impedance

delivery of low lying placenta (!!)

in women with placenta previa, a cesarean delivery is recommended at around 36-38 weeks. those with the placental edge ≤10 mm from the cervical os .... 1/3 will have hemorrhage, most will not deliver. ...... deliver at 37- 39 weeks In either case, if they have a risk factor (>3 bleeds, PAS, previous C/S, thick placental edge, marginal sinus) ... then aim earlier in that target. 11 to 20 mm from the cervical os, only 5% have hemorrhage, and about 25% will deliver vaginally The use of a Foley catheter for cervical ripening/induction of labour should be avoided in women with low-lying placenta !!

what factors are associated with postpartum depression ?

incidence is about 10-20% postpartum depressive symptoms are associated with - young maternal age, -antenatal depression - unmarried status - smoking - newborns requiring intensive care - those with a history of stressors during pregnancy .....Specifically, physical or verbal abuse during pregnancy is a potent risk for postpartum depression -Finally, serious adverse obstetrical events, especially those involving the neonate, are strongly linked to postpartum depression

Lupus cerebritis

includes focal neurologic deficits, encephalopathy, seizures, stroke, psychosis, and headache. severe neurologic complications - headache - TIA - stroke - seizures - blindness - treat Full neurologic workup (CT, MTI, LP ) IvIG steroids

chlamydia pregnancy

including pelvic inflammatory disease and its sequelae of tubal factor infertility, ectopic pregnancy, and chronic pelvic pain. Chlamydial infection during pregnancy is associated with preterm birth, preterm PROM, low birth weight, and neonatal death

risks of milking

increase in IVH under 32 weeks. (very preterm) recommended to not milk in pretterm and term

epilepsy in pregnancy seizures

increase in seizures as pregnancy progresses, especially intra and post partum (lack of sleep, stress, emotions) There is a decrease in AED drug plasma concentration !!!

benefits of a support person in labor

increased SVD shorter labor lower operative birth (better encouragement pushing) decreased analgesia higher satisfaction

RAAS system

increased estrogen causes a rise in angiotensinogen , which helps maintain BP

Coagulation changes in pregnancy

increased in pro-coagulatnt : 1, 7, 8, 10, vWF, D- Dimer- fibrinogen decreased protein S decreased factor XI and XIII Resistance to protein C (levels don't secrease)

SOGC pain what are 4 dimensions ?

international Association for the Study of Pain defines pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage. four dimensions: nociceptive (noxious stimuli) sensory-discriminative (intensity) affective-motivational (the unpleasant, emotional aspect) cognitive-behavioural (behaviour).

amniocentesis and chorionic villus sampling

invasive techniques in which amniotic fluid or fetal cells are obtained for genetic analysis Typically, CVS is done at 10-12 weeks' gestation, risk of pregnancy loss of around 0.2% amniocentesis is done at 15-18 weeks' gestation

scleroderma

is a rare autoimmune disease associated with progressive fibrosis and vasculopathy that primarily affects the skin. fibroblast stimulation and overproduction -deposition and remodeling of collagen and other extracellular matrix proteins. Excess collagen causes thickening of the skin and other organs. it is classified into - diffuse (systemic sclerosis) - limited cutaneous forms. (CREST) (calcinosis, Raynaud, esophageal dysmotility, sclerodactyly, and telangiectasias). Patients may have positive - ANA - anti‐scl‐70 -anti‐RNA polymerase III - anticentromere antibodies. Diffuse findings: • Pulmonary involvement occurs in >70% patients, either interstitial lung disease (ILD) or pulmonary arterial hypertension (PAH). • Dysphagia and gastrointestinal motility disorders occur in 90% patients • Renal disease includes scleroderma renal crisis which occurs most commonly in early systemic disease and is associated with poor prognosis • Cardiac disease, including cardiomyopathy and cardiac conduction abnormalities.

complete hydatidiform mole with coexistent fetus (CHM-CF)

is a twin or multiple pregnancy that is characterized by: - the presence of a fetus with normal anatomy and karyotype - a hydatidiform molar component with no identifiable fetal parts a placenta with diploid paternal chromosomes, and the typical sonographic and histologic features of a complete mole. Usually occurs in dizygotic. The placental tissue of CHM-CF pregnancies usually shows a sharp contrast between the grapelike clusters of cysts in the molar component and the age-appropriate normal appearance of the placenta of the co-twin.

progesterone twins

it may reduce the risk of preterm birth in twin pregnancies in women with a short cervix .... A recent meta-analysis involving women with a twin pregnancy and a cervix ≤25 mm at mid-trimester found that vaginal progesterone reduced the risk of preterm birth. An RCT in women with twin pregnancies reported that universal vaginal progesterone did not reduce the incidence of spontaneous birth before 34 weeks gestation. Nevertheless, a post hoc time-to-event analysis suggested that vaginal progesterone may reduce the risk of spontaneous birth before 32 weeks gestation in women with a cervix <30 mm but may increase the risk for those with a cervix ≥30 mm

kidney response to hypovolemia

kidney will compensate for losses by activation of the renin-angiotensin-aldosterone system. Early, reversible renal injury is associated with low urine sodium concentration and high urine osmolality (>500 mOsm).

who to screen for hypothyroid ?

known hypothyroid Symptoms of hypothyroid Diabetes, or other autoimmune Family hystory Goiter Hx of neck radiation Fat people

low AED teratogen risk

lamotrigine (lamictal) levetiracetam (Keppra)

sogc corticosteroids risk

late preterm, hypoglycemia term, academic impairment possibly growth restriction

how often to do EFM

latent labor- every hour active labor/passive second stage: every 15 mins

labor management of heart failure

lateral positioning helpful Pain control maybe continuous telometry Consider ART line

postpartum diuretic and ace inhibitors

lisinopril/ hctz =20mg/12.5mg once daily Go up to 80/50

what is the type of bacteria most likely to cause bacteremia in chorio?

listeria

risks for chorio

long labor PPROM GBS BV/other infections many exams

what tests can you consider in next pregnancy with stillbirth ? SOGC

low PAPP-A Uterine artery PI (second trimester) While these tests may not be universally recommended, evidence does suggest that normal first trimester PAPP-A values and second trimester uterine artery Doppler studies provide valuable negative prediction for placentally mediated stillbirth and, particularly, placentally mediated stillbirths that occur at less than 32 weeks. A systematic review looking at the value of biochemical and Doppler markers shows that a first trimester PAPP-A value of ≥0.4 MoM reduces the risk of placentally mediated stillbirth to 0.04%. Similarly, normal second trimester uterine artery Doppler PI reduces the risk to 0.03%

low dose vs high dose epidural

low dose is as effective Less likely to cause motor blockage intervere with ambulation urinary retention less hypotension less likely assisted vaginal birth shorter second stage Relaxation of the pelvic floor musculature may result in persistent fetal head malposition. Low-dose epidurals are preferred because they lead to less motor blockade and therefore less malposition, a shorter second stage of labour, and less hypotension.

biomarkers in acreta

low hCG high PAPP-A

options to quit smoking

lower level nicotine- gum, patches, vaping Buproprion, champix (varenicline) SOGC: Controlled trials have failed to demonstrate that NRT increases smoking cessation rates, although it may reduce the number of cigarettes smoked

hypothyroidism pregnancy complications

maintain TSH 1-2 range Clinical hypothyroid- is high TSH and low T4/T3 Subclinical- elevated TSH and normal T4/T3 • spontaneous abortion and fetal demise • placental abruption • gestational hypertension and preeclampsia • idiopathic preterm birth • low birthweight • offspring developmental delay.

surgical considerations of PAS

make incision away from placental location consider iliac occlusion dissect belo placenta in plane between uterus/placenta and bladder Consider intra-op ultrasound to detect upper limit of accreta Close incision in 1 layer Partial intermittent filling of the bladder with a 3-way methylene blue dye channel facilitates accurate identification of the correct vesicouterine plane during dissection of the bladder.

Risks of chronic HTN in pregnancy

maternal worsening HTN Preeclampsia GDM Cesarean Pulmonary edema encephalopathy stroke renal injury liver injury Fetal malformations growth restriction abruption oligo PTB hypoxic brain injury death

17-hydroxy-progesterone caproate

may be more effective in HISTORY of preterm birth vaginal progesterone may be more effective in short Cx. Hydroxyprogesterone caproate (17-OHPC) 250 mg intramuscularly (IM) weekly beginning at 16 to 20 weeks of gestation and continued until 36+6 weeks

fetal movement following steroids

may be reduced for 3 days

methadone outcomes SOGC

methadone is a full-opioid agonist that has an increasing effect with higher doses.'' There are numerous benefits of methadone use during pregnancy, including improved prenatal care, longer gestation,, higher birth weight, and increased rates of infants discharged home in the care of their mothers. Although infants of methadone-treated women tend to be smaller (lower birth weight, length, and head circumference) than drug-free control infants, studies have shown a catch-up of growth by 12 months of age

thalassemias

microcytic anemias that are due to defects in synthesis (!!!!) of α- or β-globin chains of hemoglobin. Decreased globin leads to decreased hemoglobin Note: it is decreased synthesis of the chains which is a thalassemia... alterations of the globin chain (ie, sickle cell) are not considered a thalassemia!!! Clinically significant thalassemias are inherited in an autosomal recessive fashion.... divided into α-Thalassemia or β-Thalassemia

Triple-P Procedure

midline access classical CS optional ligation of the IIAs excision of adherent placenta with any overlying myometrium, and repair of the uterus popularized as the "triple-P procedure". Preoperative MRI findings may be used to select patients to counsel for this option

manage AFLP

monitor and treat hypoglycemia A continuous infusion of a 10 percent dextrose solution is administered, as needed to maintain a plasma glucose concentration above 65 mg/dL (3.6 mmol/L). - monitor and treat coagulopathy, PT, PTT, INR, fibrinogen

monitor twins

mono-di: twice a week 16 to 18 weeks' gestation by assessment of amniotic fluid volume (AFV) and fetal bladder in both twins for early detection of TTTS. Furthermore, we begin measurement of MCA PSV in both fetuses at 26 to 28 weeks for early detection of twin anemia-polycythemia sequence (TAPS). There are inadequate data to determine the optimal frequency of monitoring, but measurement once a week is reasonable, with more frequent monitoring if abnormalities are detected (e.g., discordant AFVs that do not yet meet criteria for stage I TTTS). Fetal echo is recommended!! Di-di SOGC says serial sonographic assessment every 3-4 weeks, starting at 24-25 weeks gestation, appears to be a reasonable approach for uncomplicated dichorionic twins q2 weeks if growth discordance >20%

mono-mono twins placenta

monoamniotic placental membranes form a single sac without dividing intertwin membrane. The cords of monoamniotic placentas typically insert very close to each other on the chorionic plate, and are almost always connected by large-caliber superficial vascular anastomoses (usually AA anastomoses) The cords may be fused or furcate. The cords may be entangled with each other in often complex patterns and may display gross evidence of vascular compromise such as cord narrowing, grooving, edema, or vascular thrombosis. Abnormal peripheral cord insertion and single umbilical artery (two-vessel cord) are common.

Uterine tachysystole

more than five (6+) contractions in 10 minutes..... averaged over a 30-min window OR CTX's > 90 secs OR Uterus remains firm between contractions (25 mmHg) OR Resting rate of < 30 secs

maternal benign arrhythmias

most common arrhythmias are benign, including - sinus tachycardia - SVT - PAC /PVC's

appendectomy in pregnancy How does presentation change ?

most common non OB emergency surgery Pregnancy causes the appendix to move anterior and lateral to McBurneys point US is initial test, then MRI if inconclusive High rates of delayed perforation due to difficult diagnosis

hyperthyroid in pregnancy risks

most commonly, Graves. PTB Preeclampsia FGR abruption Overt = low TSH, high free T4/T3

Peripartum cardiomyopathy prognosis

most women recover within first 6 months For prognostic purposes, an LVEF ≥30% usually means a full recovery of left ventricular function is likely, while LVEF <30% suggests a slow or incomplete recovery with respect to achieving full ventricular function

HIV Vaginal Delivery

must have low viral load <1000 IV zidovudine (AZT) during labor avoid scalp clip, episiotomy, etc All infants should receive anti-retroviral therapy for 6 weeks

Naloxone newborns

naloxone should not be administered to a newborn of an opioid-dependent mother because of the risk of precipitating acute withdrawal and seizures.

Down syndrome

nondisjunction in meiosis (95%)... usually maternal unbalanced translocation (5%).... rarely mosaic Note: TS 13 and 18 are also mostly due to non dysjunction (85%)..... but MORE mosisac (10%) than translocation (5%) Of the unbalanced tranalocations, half occur de-novo, and half inherited from a patent with a balanced translocation

types of lochia

normally lochia lasts for 4-8 weeks (6 weeks is average) 1) lochia rubra (RBC's, first few days) 2) Lochia serosa 3) lochia laba (leukocytes) If >8 weeks, could be RPOC ...evaluate with U/S also, do a hCG (could be PSTT)

SLE delivery

normally until term (37 weeks) .. Can consider beyond 34 weeks if worsening renal, liver, or CNS function, (or other issue) In life‐threatening situations, initiation of rituximab or cyclophosphamide can be considered.

risks of ASA

not linked to miscarriage small risk of - vaginal spotting - ante/intra/post partum bleeding - postpartum hematoma - small risk of neontal intracranial hemorrhage after vaginal birth stopping at 36w mitigates a lot of these

hep c testing pregnancy

not universally recommended (previously, ACOG now recommends it) 1) anti hep-C antidody if positive, do HCV RNA Diagnosis of HCV infection depends on detection of anti-HCV antibodies and HCV RNA. o A positive anti-HCV antibody result indicates one of the following: The patient has active HCV infection (acute or chronic), The patient had a past infection that has resolved, or The result is a false positive o A positive anti-HCV antibody result should be followed by a quantitative nucleic acid test for HCV RNA If a patient who tested negative for HCV RNA within the past 6 months is newly found to be viremic, acute HCV infection is confirmed. If a patient with no previous testing for hepatitis C tests positive for both anti-HCV antibodies and a quantitative HCV RNA, it is not possible based on the test results alone to distinguish acute from chronic HCV infection. If the anti-HCV antibody test result is positive and the quantitative HCV RNA test result is negative, we recommend repeating the anti-HCV antibody test during the six week postpartum visit. If positive, consult ID. If negative, assume false positive antibody testing. If a woman who may have been exposed to HCV within the last 6 months tests negative for anti-HCV antibodies, HCV RNA testing should be performed because the patient may not yet have seroconverted • For pregnant women with positive quantitative viral loads for HCV, send liver function tests. If LFTs are abnormal, obtain albumin, platelet count, and prothrombin time. To help plan future treatment, testing for HCV genotype is recommended by some groups. At OU, we defer this testing to ID/GI. • If not performed already, please screen HCV-positive pregnant women for other sexually transmitted diseases, including HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (HBV).

when to stop anticoagulation before epidural

note, most placed recommend stopping Stopping UFH 12 and LMWH 24 hour before delivery (therapeutic) Prophylactic LMWH is 12 hours

indications for WinRHO

note: try to give up to 72 hours may be some benefit beyond , some stdies 13 or 28 days

renal Factors associated with poor maternal and fetal outcomes include:

o Preconception serum Cr ≥ 2 o Preconception diastolic BP ≥ 90 mmHg o Preconception Cr clearance < 70 mL/min o Utilization of two or more antihypertensive medications for optimal control o Proteinuria >1g/24 hours send the following labs every trimester: o Serum Cr o P/C o CBC o Urine culture Unlike in patients without underlying renal dysfunction, even mild cHTN should be treated to preserve kidney function—goal diastolic pressure <90 mmHg.

vasa previa

occurs when the fetal vessels cross the internal os of the cervix and are unprotected by placental tissue or wharton's jelly 2 types: 1) velementous cord 2) connecting the lobes of a bilobed placenta, or placenta w/ accessory (succinturiate) lobe

late neonatal varicella

occurs when the mother develops acute varicella during the period from 5 days before to 2 days after delivery......If infection occurs at this time, there is no opportunity for protective antibody to cross the placenta. The neonatal infection is devastating . The manifestations of neonatal varicella include: - disseminated mucocutaneous lesions - visceral infection - pneumonia - encephalitis. In the absence of timely antiviral chemotherapy, up to 30% of infected infants die of complications of neonatal varicella. When varicella zoster immune globulin is administered to the mother, 30% to 40% of newborns still develop infection; however, the number of complications is reduced

third trimester bleeding NYD

often due to small separations of placental edge

Interstitial Keratitis

opaqueness on cornea that spreads to pupil > leads to blindness

rates of GBS outcomes MCQ !

overall, the risk of neonatal colonization following delivery to a colonized mother, in the absence of treatment, is approximately 50% . Up to 2% of these infants will develop GBS EOD SOGC Introduction of universal screening and treatment in 2002 decreased rates of early onset GBS from - 1-3 per 1000 to - 0.3-0.5 per 1000.

severe fetal acidemia

pH < 7 Base deficit > 12

signs of abruption

painful bleeding, clots hypertonic uterus FHR changes

Buprenorphine outcomes SOGC

partial agonist with ceiling effect..... The only preparation of buprenorphine readily available in Canada is Suboxone, which is a combination of buprenorphine and naloxone. USA uses buprenorphine (subutex) The main rationale for buprenorphine use for treating opioid dependence during pregnancy is reports of reduced incidence and severity of NAS Neonates exposed to buprenorphine needed 89% less morphine and spent 43% less time in the hospital and 58% less time in the hospital for NAS pharmacotherapy compared with neonates exposed to methadone.

when is metformin reasonable over insulin ?

patient refuses insulin insulin is too expensive safety/compliance issues

COVID cytokine storm

patients with temp > 39 are at risk of "cytokine storm syndrome" Associated with: - multi organ failure - unremitting fever - cytopenia - high ferritin Threshold of 169

maternal medical abnormalities that require C/S

pelvic fracture (including hx) bladder reconstruction such as significant respiratory dysfunction severe spinal or pelvic deformities

first trimester screening

performed between 11 and 13 weeks of pregnancy and involves an ultrasound and a finger stick blood test - pregnancy-associated plasma protein A (Papp-A) - a protein produced by the placenta -human chorionic gonadotropin (hCG) - a hormone made by the placenta during pregnancy - alpha-fetoprotein (AFP) - a protein produced by the baby's liver - placental growth factor (PlGF) - a protein produced by the placenta Decreased levels of PAPP-A before the 14th week of gestation are associated with an increased risk for Down syndrome and trisomy 18. Whereas increased levels of hCG are associated with an increased risk of Down syndrome. The third marker is the fetal nuchal translucency (NT, a fluid-containing area behind the fetal neck) which is performed by ultrasound.

peripartum vs dilated cardiomyopathy

peripartum is a type of it. if regular DCM, look for - infections (viral, HIV, lyme) Toxic (alcohol, cocaine) Chronic medical conditions (renal disease, scaroid, lupus)

#b12 deficiency or folate deficiency

pernicious anemia- IF antibodies gastric absorption chrons resorption

circumvallate placenta

placental condition in which the chorionic plate is smaller than the basal plate; the margin is raised with a rolled edge Circumvallate placenta is a rare condition that occurs when the amnion and chorion fetal membranes of the placenta fold backward around the edges of the placenta. circumvallate placenta the chorion periphery is a thickened opaque gray-white circular ridge composed of a double fold of chorion and amnion. Sonographically the double fold can be seen as a thick, linear band of echoes extending from on placental edge to the other. Circumvallate placenta is associated with increased risk of antepartum bleeding, abruption, fetal demise and PTB

Treat TTP

plasma exchange is mainstay, and monitor platelet count and ADAMTS13 activity once platelets above 50, start ASA, maybe heparin Do NOT NOT give platelets !!!

TTTS superficial anastomosis

pregnancies complicated by TTTS have a lower frequency of intertwin AA anastomoses in contrast to AA anastomoses, the frequency of VV anastomoses is higher in TTTS pregnancies than in non-TTTS pregnancies the role of AV anastomoses in the vast remainder of monochorionic gestations is incompletely understood. TTTS has been described even in the absence of identifiable AV anastomoses. It has been speculated that in such cases an AA anastomosis may have been converted into a functional AV anastomosis, for instance by arterial stenosis.

covid delivery

pregnant patients at or after 32 weeks of gestation with refractory hypoxemia, delivery may be considered if it will allow for further optimization of care. The severity of illness may dictate earlier delivery There may be a benefit in reducing the physiological demands of pregnancy in certain patients, such as those with COVID myocarditis, in refractory hypoxemia, or prolonged recovery.

risks of PPROM in next pregnancy

repeat PPROM (~20%) - preterm birth (~40%)

risks of ICP

preterm birth (15-45%)..... (spontaneous and iatrogenic),.... bile acids increase sensitivity to oxytocin passage of meconium (25% to 45%), nonreassuring fetal heart testing (NRFHT) 5% to 15%, respiratory distress fetal death (2% to 10%), neonatal death (1% to 2%), - postpartum hemorrhage (20% to 22%) Proposed mechanisms of IUFD include: - sudden cardiac death secondary to bile acid‐induced fetal arrhythmias - anoxia secondary to vasoconstriction of placental vasculatureh

complications of pprom

preterm labor intraamniotic infection placental abruption umbilical cord prolapse maternal sepsis Complications of PTB periventricular leukomalacia, bronchopulmonary dysplasia, necrotizing enterocolitis, retinopathy of prematurity, and adverse neurodevelopment outcomes (high).

when to give uterotonics by GA in GA

preterm- after cord clamped (concern about bolus of blood to infant) term- anterior shoulder

Risks for preterm birth

previous preterm birth cervical insufficiency (procedures, ehlers danlos) uterine anomalies endometritis UTI/bateriurua Short pregnancy interval Maternal medical conditions Stress (lots of steroids)

Congenital CMV infection risk and transmisison

primary CMV have around a 50% risk of infection to fetus .... (Around 20% of those infected infants have sequalae )

Risks for HTN in pregnancy

prior HTN Family hx pregestational HTN Obesity Twins kidney disease Black race Advanced age Sleep apnea SLE AMA (vessels suck) Endocrine cushing Conn thyroid disorders coarcation Recommend: low salt low weight gain

SOGC high risk factors for preeclampsia

prior preeclampsia BMI > 30 Chronic HTN T1/T2 diabetes CKD SLE/APS Assisted reproductive therapy

does funnelling affect PTB ?

probably not when compared to cervical length. Funelling to cerclage associated with a 50% risk of PPROM

COVID pneumonia

procalcitonin can delineate superimposed bacterial pneumonia

PAPP-A

produced by the placental syncytiotrophoblast and deciduas. It increases the bioavailability of insulin like growth factor, which in turn mediate - trophoblast invasion - modulates glucose and amino acids transport in the placenta. Low first trimester maternal serum levels are found not only in trisomy 21, trisomy 18 and trisomy 13, but also in non-Down syndrome fetal aneuploidies.

gallbladder changes in pregnancy

progesterone impairs contractility by inhibiting CCK mediated smooth muscle contraction (primary regulator of gallbladder contraction) results in reduced emptying, stasis, and increased cholesterol saturation of bile which contributes to increased prevalence gallstones in multiparas impact of pregnancy on serum bile acid concentration unclear, despite intrahepatic cholestasis of pregnancy

how does magnesnesium sulfate neuroprotect ?

promotes cerebral vasodilation, reduction in inflammatory cytokines and/or oxygen free radicals, and/or inhibition of calcium influx into cells

when to treat superficial thrombophlebitis pregnancy

prophylactic or intermediate dose LMWH for 1 to 6 weeks in symptomatic women and in women with - bilateral ST ST of 5 cm or more ST located less than 5 cm from the deep venous system. Observation alone is recommended in women with ST who are at low risk of DVT and for those who do not require symptom control. Clinical follow-up of these women should occur within 7 to 10 days, with a repeat CUS within one week.

Thioamdes

propylthiouracil and methimazole rare risk of agranulocytosis crosses placenta, causes fetal hypothyroid Aplasia cutis- where there is an area absent of both skin and hair Choanal atresia is a congenital disorder where the back of the nasal passage (choana) is blocked, usually by abnormal bony or soft tissue (membranous) due to failed hole development of the nasal fossae during prenatal development. It causes persistent rhinorrhea, and with bilateral choanal atresia and obstructed airway that can cause cyanosis and hypoxia. Choanal atresia is diagnosed based on the inability to place a nasal catheter, and radiology results (particularly CT scans). Treatment involves maintaining an open airway, and may involve surgery to reopen the airway, potentially with a stent.

SOGC manage a pregnancy with gestational HTN (monitoring)

proteinuria each visit weekly labs consider PlGF/SFT1 Fetal scan at least monthly (more frequent BPP)

ACOG massive transfusion definition

replacement of 10u in 24 hours OR 4u within 1 hour OR replacement of complete volume 1:1:1 ratio of PRBC: FFP: platelets

rheumatoid in pregnancy

proteolytic degradation of cartilage and bone. Rheumatoid factor (RF) and/or anticitrullinated peptide/protein anti-bodies are present in most, but not all, patients about 50% of RA patients improve during pregnancy; remission is almost always followed by postpartum exacerbation. Pregnancy outcomes in well‐controlled RA patients are comparable to the general population. However, women with active RA during pregnancy are at increased risk for small for gestational age (SGA) infants and preterm birth.

risks of cannabis

psychosis cognitive impairment (if used young) development of respiratory problems, including chronic cough, shortness of breath, and bronchitis, and it may increase the risk of cardiovascular events among vulnerable individuals

Disseminated gonococcal infection (DGI)

rare systemic complication brought about by the spread of infection through the bloodstream; it is a life threatening condition causing a generalized rash and severe joint pain Stages: 1- bacterimic stage- blood cultures positive around ~50% of the time - fever, chills, skin lesions - occasionally have perihepatitis, meningitism endocarditis - joint symptoms present 2. septic arthritis stage- usually sterile blood cultures Joint symptoms are frequently present during this stage, as well as in the second, septic arthritis stage. This stage is characterized by a purulent synovial effusion.

manage mirror syndrome

really depends on the presentation. If severe/critical maternal findings, then delivery is warranted. If not, may have time to workup for reversible causes: - detailed sonographic evaluation (fetus, umbilical cord, and placenta) - fetal echocardiogram - middle cerebral artery Doppler studies - determination of maternal Rh status - evaluation for maternal alloimmunization - maternal complete blood count, Kleihauer-Betke stain - serologic studies for syphilis, parvovirus B19, cytomegalovirus and toxoplasmosis - fetal karyotype. If a reversible etiology is identified, and the maternal and fetal status is stable, then attempts can be made to treat the underlying cause of hydrops (e.g. intrauterine blood transfusion for fetal anemia, maternal transplacental treatment of antiarrhythmics for fetal tachycardia etc.). Successful interventions to resolve fetal hydrops have resulted in resolution of the maternal symptoms of mirror syndrome If no cause is found, then delivery is indicated. The risk of severe maternal morbidity in mirror syndrome has been reported to be as high as 21%, with pulmonary edema being the most common severe complication. In one series describing expectant management of mirror syndrome, the median duration of pregnancy latency was 4.5 days before delivery was indicated due to maternal or fetal deterioration. Give steroids for lung maturity.

SOGC prediction of preeclampsia

recommend clinical (maternal risks) with biochemical (PlGF, SfLT-1) and sonographic (Uterine artery PI 11-14 weeks) is a good way .... especially if uterine artery notching Sensitivity of 75% for preterm preeclampsia, 50% for term PlGF or UA PI is around 70% PAP-A is not helpful (without PlGF) Important risks uterine artery pulsatility index, mean arterial pressure, PAPP-A, serum-free PlGF, body mass index, and presence of nulliparity or previous pre-eclampsia revealed that at a 5% false-positive rate, the detection rate for early pre-eclampsia was 93.1%; more impressively, the positive LR was 16.5, and the negative LR was 0.06 Uterine artery alone isn't that predictive.

recurrent CMV

recurrent CMV Recurrent infections during pregnancy are most often asymptomatic and primarily caused by the reactivation of the endogenous virus, but can also be caused by a low-grade chronic infection or reinfection by a different strain of CMV - is around 2% risk to fetus (and 10% of those have sequalae) The actual sequalae of primary CMV vs non-primary (recurrent) congenital CMV is the same, not less mild. but due to the high seroprevalence of CMV worldwide, 50-90% of congenital CMV is a result of recurrent infection .... SOGC: Screening for maternal CMV serologic status in pregnancy is controversial, because of the absence of reproducibleand readily interpretable diagnostic tests, and because non-primary CMV maternal infections pose a risk of cCMVsimilar to that of primary infections. Duff: Approximately 50% to 80% of adult women in the United States have serologic evidence of past CMV infection. Unfor- tunately, however, the presence of antibodies is not perfectly protective against either reinfection or vertical transmission of infection from mother to fetus. Therefore either recurrent or primary infection in a pregnant woman poses a risk to the fetus. Congenital infection results from hematogenous dissemination of virus across the placenta and poses the greatest risk to the fetus. Dissemination is much more likely in the presence of a primary maternal infection Pregnant women who experience recurrent or reactivated CMV infection are much less likely to transmit infection to their fetus. If recurrent infection develops during pregnancy, approximately 5% to 10% of infants become infected; however, none of these neonates will be symptomatic at birth. The most common sequelae are hearing loss, visual deficits, and mild developmental delays, typically diagnosed in early childhood

magnesium benefits

reduced eclampsia (60%) reduced abruption (40%) reduced death (50%) other agents could include: phenytoic, nimodipine 400 women who need to be treated to prevent eclampsia for mild pre-eclampsia 71 for severe pre-eclampsi 36 for preeclampsia with central nervous system (CNS) symptoms.

benefits of ASA

reduction of preeclampsia (especially severe) reduced gestational HTN Reduction of PTB reduction of SGA

accels

refers to accelerations or increases in the fetal heart rate as compared with baseline; normally occurs when fetus moves & is to be expected ABRUPT increase in FHR (< 30 secs), > 15 bpm for 15 secs (up to 2 mins) 10/10 < 32 weeks if accel > 10 mins, it is a baseline change

contraindications to epidural

refractory maternal hypotension maternal coagulopathy thrombocytopenia LMW heparin within 12 hr untreated bacteremia skin infection at injection site increased intracranial pressure causes by mass lesion

when does the cervix shorten?

relatively stable for 2 trimesters. (until around 30-32 weeks) Average around 35mm until 28 weeks

pathway of preterm birth

release of cytokines, prostaglandins and proteases.... as well as a functional reduction of progesterone

renal conditions associated with oligohydramnios

renal agenesis ureteropelvic junction obstruction multicystic dysplastic kidneys autosomal recessive polycystic kidney disease posterior urethral valves prune‐belly syndrome.

when is VQ scan recommended most?

renal insufficiency, since it avoids ionized contrast

Beta Thalassemia

results from mutations (NOT DELETIONS) in β-globin genes. There are 2 copies of the β-globin gene, one on each copy of chromosome 11. Mutations can result in - absent (β0- aka 'beta null') production of β-globin chains. - decreased (B+- aka 'beta plus') production of β-globin chains So, patient can theoretically have many variations of (β, β+, β0) β-thalassemia minor (β/β+) is the mildest form and is usually asymptomatic. Hb electrophoresis (best diagnostic test for thalassemias!!!!) shows:- slightly decreased HbA (below 97% which is normal levels!!!)- increased HbA2 3.5%-5% (normal is 2.5%)- increased HbF to 2% (normal is 1%) # beta thalassemia major " Most severe form- has a gene signature of (β0/β0), meaning that both β-thalassemia alleles are non-functioning. As a result, there is zero β-globin production. "no β chains, so α-globin chains form α2α2 tetramers which precipitate and damage RBCs. These damaged RBCs then undergo extravascular hemolysis in spleen. They also cause ineffective erythropoiesis, which usually occurs in central axial skeleton, but because there is such severe anemia, we have massive EPO release, and hematopoeisis is expanded (extramedullary) into marrow of skull, facial bones, liver, spleen. β-thalassemia major (β0/β0) presents with severe anemia approximately 6 months after birth because the HbF (A2Y2) does not require β-globin!!! Once they swtich to HbA after 6 months (A2B2), they get side effects!!! Blood smear shows microcytic, hypochromic RBCs with target cells and nucleated RBCs. Note, extramedullary hematopoiesis results in nucleated RBCs.Hb electrophoresis shows: (!!!!!) little or no HbA (no B-chains)!!!!with increased HbA2increased HbF.

failed induction

ruptured membranes Pit for 24 hours

sFlt-1

sFlt-1 binds the angiogenic factors VEGF (vascular endothelial growth factor) and PlGF (placental growth factor), reducing blood vessel growth through reduction of free VEGF and PlGF

cordocentesis

sampling of fetal blood drawn from the umbilical vein and performed under ultrasound guidance Performed for: - cytogenetic diagnosis (though NIPT, CVS, amnio performed earlier).... Usually performed when quick turnaround is required, like when nearing age of termination or when it may affect mode of delivery (ie, anomaly) - congenital infection - ... though rare, most dx's are - anemia (precursor to transfusion)

T-ACE

screening for at-risk perinatal alcohol use

Congenital toxoplasmosis

sequelae of congenital toxoplasmosis may be severe and include ventriculomegaly, increased placental thickness, hepatomegaly, ascites, intracranial calcifications, hydrocephalus, microcephaly, and hepatosplenomegaly In the neonate, TG congenital infection is associated with neonatal chorioretinitis (most prevalent consequence of TG), deafness, decreased IQ, and subsequent blindness, seizure disorders, and delay in neuropsychomotor development At birth, infected children may have a maculopapular rash, hepatosplenomegaly, seizures or hydrocephalus. In the setting of acute primary maternal infection, the risk of maternal to child transmission in early pregnancy was <5%.

Lupus nephritis

serious complication of SLE Renal damage occurs because of inflammation associated with immune-complex deposition and complement activation. Laboratory features of lupus nephritis include: -increased levels of anti-dsDNA antibodies - decreased levels of complement -elevated serum creatinine, and the presence of urinary red-cell cast abnormal urinalysis (protein, RBC, cellular cast)

Dx of cholecystitis

severe RUQ pain - fever - murphy sign (pain with inspiration) -u/s shows: - gallstones - thickened gallbladder wall Workup - CBC - CMP - Tbili - lipase/amylase If LFT's and Tbili are elevated, order MCRP for choledocolithiasis.

risks for bleeding from placenta previa (!!!)

short cervix thick placental edge marginal sinus previous cesarean invasive placentation >3 bleeds

short latency in PPROM

short cervix multiparity oligo positive amniotic fluid cultures

misoprostol time to peak concentration by route

shorter time to peak concentration with oral and sublingual as opposed to vaginal/rectal (longer administration sublingual is most rapid onset, highest peak

preeclampsia outpatient management

should live close to hospital htn is well controlled no evidence of signifcant disease or progression Consider NST 2x weekly (1x weekly GHTN)

# foramen ovale

shunts blood right atrium to left atrium/ventricle, bypassing pulmonary circulation

VTE risk in pregnancy

similar in T1 and 2 Increases in T3 and third trimester. (first 3-6 weeks post partum especially)

placental findings in early FGR

small placenta, abnormally shapes 2) 'hyperinflated' placenta .... poorly formed villi will rupture, and accumulate maternal blood. This gives a large, 'circular' placenta that resembles a fibroid.... the cord is sometimes 'burried' 3) Breus mole - basically a 'birthday cake' with a 'layer of blood' on top - placental tissues are soft/compressed, and do not work

sperm washing HIV

sperm washing is a well-established, effective, and safe risk reduction fertility option for serodiscordant couples in which the man is HIV positive and the woman is HIV-negative and for seroconcordant couples when super-infection is a concern. Semen is centrifuged to separate -live sperm (which do not carry HIV) from seminal plasma and non-germinal cells (which may carry HIV) and then inseminated into the female partner at the time of ovulation. This practice is well established in the literature to be an effective method to minimize horizontal transmission. The risk of the sample having detectable HIV is 1.5% to 7.7% from failure of the centrifugation to remove all of the seminal plasma and leukocytes. IUI, IVF, and ICSI are fertility techniques that can reduce the risk of HIV transmission to the uninfected partner. IUI involves placing prepared sperm directly into the uterus during ovulation. For couples who wish to further reduce the risk of horizontal HIV transmission or for those who have fertility issues, sperm washing can be combined with ovulation induction and IVF or ICSI.

Methyldopa dose

start 250mg BID Up to 2g a day Note: methyldopa may be more likely to require an additional anti-hypertensive

benzo withdrawal treatment

start at around 2/3 to 3/4 of the benzo dose taper 10% daily

Indications for chromosomal analysis

stillbirth abnormal phenotype low birth weight or early evidence of failure to thrive; any indication of developmental delay, in particular mental retardation; abnormal (dysmorphic) features of the head and face, such as microcephaly, micrognathia, and abnormalities of eyes, ears, and mouth; abnormalities of the hands and feet congenital defects of various internal organs. 2-3 first trimester miscarriages

choledocolithiasis

stones in the common bile duct - fever, chills, RUQ pain... and obstructive jaundice!! can cause obstructive jaundice.... elevated conjugated bili and ALP U/S shows dilated common bile duct MRCP confirms it ERCP used to remove the stone

treat magnesium toxicity

stop Mg 10ml 10% calcium gluconate (1g) IV Calcium chloride 5 to 10 mL of a 10 percent solution (500 to 1000 mg) intravenously over two to five minutes is an acceptable alternative, but is more irritating and more likely to cause tissue necrosis in the event of extravasation.

what dose of estrogen in contraceptive in the obese

tablet containing 20-30 μg of ethinyl estradiol should be considered if this is the contraception of choice. The risk of VTE must be assessed prior to initiation of use of estrogen-containing contraceptives

sides of oxytocin

tachysystole uterine rupture FHR changes water retention- use concentrated oxytocin hypotension - avoid IV bolus

ECMO (extracorporeal membrane oxygenation)

takes blood out of the lungs (VV aka venovenous ECMO)... or heart + lungs (VA aka venoarterial ECMO) oxygenates it & puts it back in the lungs; last line treatment for ARDS

hep B treatment

tenofover 300 mg po daily.... starting 28 weeks -do this with high HBV viral load !! ( > aka 200,000 copies/mL) -HBeAg positivity (critial in third trimester) -Start 24-28 weeks - treat 3 months post partum Patients who are co‐infected with human immunodeficiency virus (HIV) must have triple‐agent highly active antiretroviral therapy which can include tenofovir or lamivudine to treat both HIV and HBV

postpartum GDM testing

test between 6 weeks to 6 months use the 75g 1 step OGTT Consider re-testing every 1-3 years Breastfeeding strongly recommended to decrease risk of neonatal hypoglycemia and progress to T2DM

ebola testing what else to test for ?

testing for the Ebola virus in blood by reverse transcription PCR is the most definitive and rapid test and will return a positive result within 3 days of the onset of symptoms. Time to get this result back will vary from site to site depending on access to trained laboratory personal and transportation of specimens (the test itself takes approximately 4 hours). This results in a potential clinical window in which results of PCR testing in an infected person may be negative (in the first 3 days of symptoms). Therefore, in probable cases of infectionrepeating PCR testing in 3 to 4 days is recommended. It is important to consider other diagnoses for high fevers found in travelers returning from West Africa, such as -malaria - typhoid. In Canada, influenza and other seasonal viral illnesses are common and should also be ruled out.

cervical insufficiency

the inability of the uterine cervix to retain a pregnancy in the second trimester in the ABSENCE of clinical contractions, labor, or both" ...... Although it may occur in a single pregnancy, the diagnosis is confirmed when it recurs in consecutive pregnancies........ Often has ●No or minimal mild symptoms ●Cervical dilation and effacement on physical examination inconsistent with the degree of uterine activity (no or minimal contractions) causes: Most important is cervical trauma!! - prior cervical or uterine surgery (eg, dilation and curettage, hysteroscopy, cone biopsy) - lacerations at delivery - (rarely) a congenital abnormality ( uterine abnormalities) - connective tissue disorders - decidual inflammation/infection, bleeding at the interface of the decidua and placenta.... or uterine overdistension. -short interpregnancy interval These other disorders can initiate biochemical changes in the cervix that lead to premature cervical shortening and often a single (ie, nonrecurrent) second-trimester birth/loss 1) History based 2) ultrasound based 3) exam based

AFLP

the prodromal maternal symptoms of acute fatty liver of pregnancy are often vague and include malaise, anorexia, and fatigue over several days to weeks. These symptoms progress to include nausea, vomiting, abdominal pain, jaundice, icterus, headache, polydipsia, pruritis, edema, ascites, encephalopathy, asterixis, hypertension, and bleeding diatheses Approximately half of women also present with hypertension. One of the hallmark findings in patients with acute fatty liver of pregnancy is multiorgan fatty infiltration. Widespread microvesicular fatty steatosis of the liver impairs hepatic production of: - fibrinogen - coagulation factors and decreases bilirubin conjugation and clearance. Direct fatty infiltration of the kidney likely contributes to acute renal impairment, although in most cases of acute fatty liver of pregnancy, kidney dysfunction is multifactorial related to hypoperfusion, and in some advanced cases, hepatorenal syndrome has been implicated. fatty acid metabolites are toxic to pancreatic tissue and likely play a role in the etiology of acute fatty liver of pregnancy-associated pancreatitis. Placental dysfunction may stem from increased fatty acids within the placenta itself, resulting in impaired oxygen delivery to the fetus

CMV transmission and severity

the rate of transmission increases with increase in gestational age (highest in the third trimester)..... but the severity of disease is instead inversely proportional to gestational age (the infant is most affected when maternal infection is in the first trimester).

corpus luteum

the remains of the ovarian follicle that has released a mature ovum during ovulation Endocrine tissue which produces hormones, estrogen, and progesterone which prepares the uterine lining for receiving an embryo .... dominant until 10 weeks made up of - - syncytiotrophoblast (hCG) - theca cells (secrete progesterone, androgens) - granulosa cells (majority of estrogen, inhibin A, some progesterone) LH stimulates hCG, continues progesterone secretion.

maternal HSV presentation aka herpes

the typical clinical manifestations include The systemic manifestations include flu-like symptoms (fever, headache, myalgia), difficulty in initiating urine or bowel movement, and genital pain. - unilateral or bilateral vesicular lesions, with an erythematous base, ocated in the area of the sacral dermatome (usually S2, S3)and which can, therefore, be on the genital skin or adjacent areas. They often evolve into - pustules - then ulcerations - finally, if on keratinized skin, crusted lesions. Although this is the classic presentation, atypical presentations are common, including minor erythema, fissures, pruritus, and pain with minimal detectable signs. some individuals will never show clinical manifestations but can be demonstrated to be episodically shedding virus

Parvovirus mechanism

the virus preferentially targets rapidly dividing cells. By replicating in erythroid progenitor cells of the bone marrow and blood, parvovirus B19 destroys erythroid precursors and inhibits erythropoiesis Vertical transmission occurs, and the fetus is especially susceptible due to - rapid cell turnover - shorter RBC half life - immature immune system (cannot control the infection) it can also directly affect the myocardial cells.

AFLP labs

ther laboratory findings that may be present include: ●Elevated serum bilirubin levels ●Low serum glucose ●Elevated serum creatinine ●Elevated white blood cell count ●Elevated ammonia level ●Elevated urate level ●Prolonged prothrombin time, international normalized ratio, activated partial thromboplastin time ●Increased thrombin time ●Reduced levels of coagulation inhibitors (eg, antithrombin) ●Low platelet count ●Low fibrinogen (DIC) ●Fragmented red blood cells and burr cells ●Proteinuria ●Low cholesterol

SOGC when is therapeutic anticoagulation recommended/

therapeutic recommended -Long term therapeutic anticoagulation prior to pregnancy - history of multiple VTE's Intermediate OR therapeutic can be considered for - Hx of VTE, AND a high risk thrombophilia prophylactic - all the rest Consider if there are multiple pregnancy related risk factors in women admitted for bed rest

analgesic labor options for opioid users What is the drug of choice? What should be avoided ?

these patients have issues, including: increased pain sensitivity inadequate analgesia difficult intravenous access anxiety about experiencing pain due to their history of addiction chance of relapse if inappropriate control of pain -recommended to continue their medication - Epidural analgesia is an ideal choice for pain management for opioid-dependent women. Agonist-antagonist medications (e.g., butorphanol, nalbuphine, and pentazocine) should not be used in opioid-dependent individuals because of the risk of precipitating acute withdrawal.

pathogenesis of peripartum cardiomyopathy

thought to be due to - placental factors like increased SFLT-1 - prolactin cleaved by Cathespin D to a 16 kDA fragment, causing endothelial apoptosis - Genetics

Septic Pelvic Thrombophlebitis description

thrombosis/inflammation due to pelvic infection - usually after C/S The most commonly described disorder is: - acute thrombosis of one (usually the right) or both ovarian veins (ovarian vein syndrome). .... Affected patients typically develop a moderate temperature elevation in association with lower abdo pain in 2-4 days after delivery On physical examination, the patient usually manifests tachycardia, tachypnea, and dyspnea. Stridor may be evident if septic pulmonary embolization has occurred. The abdomen is tender, and bowel sounds often are decreased or absent. Most patients have voluntary and involuntary guarding, and 50% to 70% have a tender, rope-like mass that originates near one cornua and extends laterally and cephalad toward the upper abdomen. he second presentation of septic pelvic vein thrombophlebitis has been termed enigmatic fever. These patients usually have been treated for presumed puerperal endometritis. Subsequently they experience some subjective improvement, with the exception of persistent fever. They do not appear to be seriously ill, and positive findings are limited to persistent fever and tachycardia.

HSV vertical transmission

transplacental infection is rare. First-episode primary infection during pregnancy can lead to microcephaly, ventriculomegaly, spasticity, echogenic bowel, hepatosplenomegaly, and flexed extremities

what incision when the pannus is so big the umbilicus is below the pubic symphysis ?

transverse infraumbilical or supraumbilical incision can be considered

mom with ebola exposure

treat as if not pregnant If a woman is near term and has been exposed to Ebola virus but is not yet infected, induction of labour or elective Caesarean section should be considered in order to deliver the infant prior to the onset of viremia and maternal illness. If the woman subsequently becomes ill with EVD, the infant should be isolated from the mother, breastfeeding should be discontinued, and the mother should be cared for without the complications of pregnancy impeding medical management

ovarian vein thrombosis

treat via broad spectrum antibiotics for at leadst 48 hours after fever Therapeutic anticoagulation for 1-3 months

HIV treatment during pregnancy

triple therapy is promptly initiated !!!! - dual nucleoside reverse transcriptase inhibitor (NRTI) with either: - integrase strand transfer inhibitor or -ritonavir protease inhibitor (PI)

amnio in women with HIV, hep B/C

try and avoid. Base on NIPT, or serum markers with US if possible When performing sonography-guided amniocentesis for women with a chronic hepatitis B, hepatitis C, and/or HIV infection, every effort should be made to: avoid the amniocentesis needle going through the placenta or within 1 to 2 cm of the implantation placental edge Avoid CVS if possible in Hep B, C, HIV... use amnio Pregnancy loss rates with HIV can be high, 2-20% no risk of vertical transmission if low viral load

manage TRAP (refine)

try and salvage the pump twin.... as the pump twin is at risk for development of hydrops or congestive cardiac failure 1) fetoscopy (with bipolar cord coagulation or laser ablation) alternatively, 2) use of radiofrequency thermoablation, thermocoagulation, or a harmonic ultrasound scalpel to the acardiac twin's cord.

migraine headache in pregnancy termination

try conservative measures first. Dark room, ice packs, remove stimuli. First line: Tylenol Codeine NSAIDs in short duration Gravol/Maxeran sumatriptan

TAPS anastomosis

typical angioarchitectural pattern associated with TAPS consists ofL sparse (three or four per placenta, on average) and small-sized (diameter <1 mm) AV anastomoses. AA anastomoses occur in only 10% to 20% of TAPS placentas and, when present, are smaller (diameter <1 mm) than in TTTS placentas or in placentas of uncomplicated monochorionic twin pregnancies. VV anastomoses are even less frequent.

Adult Varicella

typical clinical manifestation of varicella is a disseminated, pruritic, vesicular rash..... The lesions typically occur in crops and evolve in sequential fashion from papule to vesicle to pustule, eventually crusting over to form a dry scab. Varicella is almost always a mild, self-limited infection in children. However, approximately 20% of pregnant infected adults develop pneumonia, and approximately 1% develop encephalitis. Both of these complications can cause serious morbidity and even mortality.

suspicion for fetal hyperthyroid from Graves

ultrasound to look for fetal goiter in indicated (goiter can occur in either hyper or hypo) Other findings - growth restriction - advanced bone age - craniosynostosis (skull bones fused) Possible consequences - cardiac failure, hydrops, stillbirth

retained placenta after vaginal delivery (?focal accreta)

umbilical cord should be cut and ligated short with an absorbable suture, with administration of prophylactic antibiotics, continued intravenous access with an oxytocin infusion, and no oral intake for an initial observation period of 12-24 hours, in case there is a need for general anaesthesia Discharge home with elective weekly follow-up for a period of 4-6 weeks will permit pelvic devascularisation. Timed interval removal of retained placental tissue should be considered by experienced surgeons in institutions with the ability to convert to hysterectomy as needed and to provide massive blood transfusion support. Options to managed delayed placental extraction include: •removal of placental tissue using ultrasound guidance •hysteroscopic-guided tissue removal •laparoscopic monitoring, including ligation of the anterior divisions of the IIAs within the posterior broad ligaments •preparation to convert to laparotomy in case of excessive bleeding or complications, such as uterine perforation •availability of an intrauterine tamponade balloon device •administration of intravenous antibiotics and tranexamic acid

ACOG delyed PPH

up to 12 weeks post partum

Post partum GHTN/preeclampsia

up to 25% of all hypertensive disorders Should resolve in 6 weeks, but sometimes takes longer. If > 6 months, look for secondary causes

oranisms in PPROM

ureaplasma Strep (GBS) Bacteriodes E-Coli Gardnerella Listeria

Magnesium sulfate hourly monitoring (SOGC)

urine output resp rate reflexes don't do serum levels

hep C infected male fertility

use IVF/ICSI after sperm washing/separation

When to use inotropes and vasopressors

use these AFTER volume resuscitation has been achieved , if hypotension is refractory Inotropes are drugs that increase myocardial contractility (inotropy) — e.g. Dobutamine, dopamine Vasopressors cause vasoconstriction resulting increased systemic and/or pulmonary vascular resistance (SVR, PVR) — e.g. Epinephrine, Norepinephrine, vasopressin, When required, inotropic agents are administered first, followed by vasopressors in refractory cases

maternal risks of diabetes

usual diabetes stuff (microvascular and macrovascular disease.... retinopathy, nephropathy, cardiovascular, neuropathy, gastroparesis etc) infections from hyperglycemia and immune supression (ie, urinary infections, chorio, skin infections) -preeclampsia/eclampsia - cesareans - T2 dm in life - other cardovascular risks in life

treat aortic stenosis pregnancy

usually due to congenital bicuspid valve Activity restriction and diuretics can improve symptoms in some cases of AS, but surgical valve intervention may be warranted during pregnancy for those with severe or refractory disease.

Treat mitral stenosis pregnancy

usually due to rheumatic heart disease.... prevents blood from going LA to LV .... this causes backup and pulmonary edema beta blockers Diuretics if pulmonary edema Anticoagulation if a-fib Very important to avoid fluid overload and tachycardia (allow more filling time)

risks of leaving placenta in situ

vaginal bleeding coagulopathy Sepsis repeat surgery eventual hyst pro-active surgical measures, following an initial 4-6-week period of recovery and devascularization, include a) hysteroscopic resection of placenta tissues under ultrasound or laparoscopic guidance and b) total hysterectomy by laparoscopy or laparotomy.

clinical pelvimetry

vaginal palpation of specific bony landmarks and is used to estimate the size of the birth canal

highest risk of teratogens epilepsy

valproic acid (neural tube) Manage this by - serum AFP (neural tube - ultrasound (also cleft lip, palate)

parvovirus transmission rates to fetus

when maternal parvovirus infection occurs during pregnancy, the virus can cross the placenta and infect red cell progenitors in the fetal bone marrow..... this suppresses erythropoiesis, thereby resulting in severe anemia and high-output congestive heart failure it can also directly affect the myocardial cells. Fetal infection with parvovirus B19 can result in - miscarriage - severe fetal anemia - myocarditis, - hydrops - fetal death. Approximately 25-30% of fetuses of mothers with primary parvovirus B19 infection will become infected themselves through vertical transmission. Of these, 80-95% will have no sequelae and 5-20% will develop fetal anemia. In most cases, the anemia is transient...... but in severe cases, treatment is required.

thalassemia screening

will have - microcytic anemia - normal iron studies Electrophoresis is first step.... if this comes back normal, they need molecular genetic testing to rule out alpha thalassemia

ABO incompatibility and Rhesus

without prophylaxis if ABO-compatible with newborn mother has 16% likelihood of developing alloimmunization vs 2% if ABO-incompatible (due to erythrocyte destruction)

Postpartum contraception in the obese

women with obesity and no comorbidities, progestin-only contraceptives and intrauterine devices (IUDs) are acceptable. Medroxyprogesterone acetate (DMPA) is considered safe for most women with obesity; however, there is an association with weight gain and potential for menstrual irregularities. Estrogen-containing contraceptives should be considered after careful review of additional risk factors for VTE and should not be started before 4-6 weeks postpartum, according to guidelines. Obesity itself and age >35 are not contraindications to considering estrogen-containing contraceptives if there are no other contraindications to these medications.

does winrho cross the placenta ?

yes Anti-D crosses the placenta and binds to fetal red blood cells, without causing hemolysis, anemia, or jaundice

can you TOLAC with twins ?

yes... but it's unknown.

Parvovirus IgG prevalene

~50-75% of women have it.. most common infection is late winter, early summer

questions for a patient with galactorrhea or high prolactin

· Galactorrhea (bilateral/unilateral, color, consistency, blood, associated mass/pain) · Mass effect of macroadenoma: - headache -visual field loss (bitemporal hemianopsia) - seizure - cranial nerve abnormalities · Hyperandrogenism: increased DHEA production by adrenals hirsutism, acne · Hypothyroidism symptoms: cold intolerance constipation, brittle hair, lethargy, significant weight changes · PGynHx: Oligomenorrhea/amenorrhea, decreased libido, infertility, recurrent pregnancy loss · PMHx: recent pregnancy/breastfeeding/nipple stimulation, PCOS, renal disease, seizures, chest wall lesions, liver disease, osteoporosis (from hypogonadism of hyperPRL) · Thorough medication history · Allergy, social history, family history

Management of women with a short cervix (no prior PTB)

— We manage women with risk factors for but no previous preterm birth who have a short cervix with vaginal progesterone No indication for cerclage unless <10mm (maybe)

Ultrasound role in twins

• Confirming a diagnosis of multiple gestation • Determining chorionicity and placental location • Detecting fetal anomalies • Guiding invasive procedures • Evaluating fetal growth • Measuring cervical length • Confirming fetal well-being • Evaluating fetal circulation and amniotic fluid • Assessing fetal position and presentation • Preparing for the delivery

GBS treatment regimens

• The recommended dose for penicillin G is 5 million units initially, then 2.5 to 3.0 million units every 4 hours intravenously until delivery. - Ampicillin is an equally effective alternative. The dose is 2 g intravenously initially, followed by 1 g every 4 hours until delivery. Patients with penicillin allergy should be treated as follows: - If not at high risk for anaphylaxis, administer cefazolin, 2 g intravenously, then 1 g every 8 hours until delivery. • If at high risk for anaphylaxis and GBS is known to be susceptible, administer clindamycin, 900 mg intravenously every 8 hours. • If at high risk for an anaphylactic reaction to penicillin or ampicillin and GBS is resistant to clindamycin or of unknown susceptibility, administer vancomycin, 1 g every 12 hours.

rheumatoid pain meds pregnancy

• Acetaminophen is the analgesic of choice but will not reduce joint swelling or disease activity. • Nonsteroidal antiinflammatory agents (NSAIDs) may be used sparingly in the first or second trimesters, but not in the third trimester due to risk of premature closure of the ductus arteriosus. • Hydroxychloroquine and sulfasalazine may be effective for mild RA and are compatible with both pregnancy and breastfeeding. • Azathioprine is rarely used for RA but is compatible with pregnancy and breastfeeding and may be added if other agents are inadequate. • TNF inhibitor therapy may be continued at least until the end of the first trimester and through the second or even third trimesters. It is recommended they be stopped, if possible, at the start of the third trimester due to high transplacental passage. • Non‐TNF biologic medications for RA such as tocilizumab, abatacept, rituximab, and anakinra are generally stopped at the time of pregnancy diagnosis; they may be resumed during breastfeeding. • If patients have been treated with leflunomide within two years of conception, a cholestyramine washout protocol is necessary due to the long drug half‐life (8 g TID × 11 days with subsequent documentation of neg ative metabolite levels). • Novel small molecule therapies for RA, including tofacitinib, baracitinib and others, are not well studied in pregnancy and are thought likely to pass through the placenta due to their low molecular weight. They are not suggested for use in pregnancy or breastfeeding. UTD: Uptodate NSAIDs, including aspirin - In patients whose RA becomes active during pregnancy, nonsteroidal antiinflammatory drugs (NSAIDs) can be used and are generally considered safe until week 20; however, from 20 weeks on, NSAIDs should be avoided, with the exception of low-dose aspirin being given for obstetric-related indications, because of the rare risk of fetal renal compromise and oligohydramnios. After week 30, there is an increased risk of premature closure of the ductus arteriosus and inhibition of labor. Glucocorticoids - In patients in whom NSAIDs are inadvisable or inadequate, we use the lowest dose of prednisone necessary for disease control.

manage APS pregnancy

• Assessment of serum creatinine and urine protein:creatinine (UPC) ratio. • Platelet count since APS is associated with autoimmune thrombocytopenia. • Assessment of aPL including LA, IgG, and IgM anticardiolipin antibodies (aCL), and IgG and IgM antibodies to beta‐2‐glycoprotein‐1 if the diagnosis is uncertain. There is no benefit to serial assessment of antibodies during pregnancy once a diagnosis is made. • Early sonogram for accurate determination of gestational age. - OU does growth q4w at 28 weeks, and weekly BPP at 32 weeks

Prevent toxoplasmosis

• Avoid raw or undercooked meat or eggs of any origin • Use gloves when in contact with soil • Wash fruits and vegetables before eating • Avoid changing cat litter, wash hands after handling cats/litter • Keep pet cats indoors and use commercial pet food

Indomethacin contraindications

• Contraindications: Gestational age 32 weeks and greater, platelet dysfunction or bleeding disorder, hepatic dysfunction, GI ulcerative disease, renal dysfunction, and aspirin-induced asthma • Side effects: Maternal nausea, acid reflux, and gastritis; there have been reported cases of fetal/neonatal complications including in utero constriction of the ductus arteriosus, oligohydramnios, and necrotizing enterocolitis (NEC) and pulmonary hypertension in preterm newborns, however the greatest risk is in those exposed to prolonged (>48 h) courses of indomethacin

sickle cell vaccines

• Discuss maternal immunization as SCD causes patients to be functionally asplenic. Patients with SCD should receive the following (in con junction with SCD provider). ⚪ Haemophilus influenzae type B (Hib) vaccine: one dose during theirlifetime. ⚪ Meningococcal vaccine: two‐dose series at least eight weeks apart initially and revaccination every five years. ⚪ Pneumococcal vaccine: one dose of PCV13 followed by one dose of PPSV23 at least eight weeks later. Repeat PPSV23 five years after initial PPSV23. ⚪ Yearly influenza vaccine.

HPV testing

• HPV DNA Test: Digene Hybrid Capture 2 High-Risk HPV DNA Test cervical cells with the given brush added to the detection medium identifies 13 high risk types • Used in conjunction with Pap • Not a substitute for Pap • Directs follow-up plan if certain pap abnormalities, ie. ASCUS

# preconceptual sickle cell testing

• Referral to maternal‐fetal medicine to discuss maternal/fetal risks during pregnancy. • Paternal screening (hemoglobin electrophoresis and/or alpha‐thalassemia genetic screening) for risk assessment of fetal genetic inheritance. • Discontinuation of hydroxyurea and ACE inhibitors prior to conception. • Evaluate for chronic opioid use; counsel accordingly regarding the risk of neonatal abstinence syndrome. • Maternal screening for end‐organ damage and baseline lab assessment including CBC, reticulocyte counts, liver function tests, renal function tests, type and screen, rubella and varicella immunity screening, EKG, and echocardiogram (if numerous crises/history of acute chest syndrome). • Ensure patient has established care with a SCD provider/hematologist for chronic disease care and health maintenance. • Recommend folic acid supplementation (4 mg/day).

treat SLE pregnancy

• The most important tenet of treatment is for patients to have quiescent disease on medications compatible with pregnancy for several months prior to conception. Contraindicated medications such as angiotensin converting enzyme (ACE) inhibitors, mycophenolate mofetil, cyclophosphamide, methotrexate (3 months), and leflunomide should be discontinued prior to pregnancy. In women who require immunosuppressive therapy for disease control, transitioning to a pregnancy‐compatible immunosuppressive agent such as - azathioprine - tacrolimus - Hydroxychloroquine - baby ASA - Prednisone (if not taking prior to conception, avoid in the first trimester) should be done prior to conception and patients should be observed for several months to make sure that their disease is stable. • Continuing hydroxychloroquine (HCQ) during pregnancy reduces the risk of disease flare and improves pregnancy outcome, and data suggest HCQ may reduce risk of CHB in women with anti‐Ro/SSA and anti‐La/SSB antibodies. All lupus patients should be encouraged to take HCQ during pregnancy unless contraindicated. - If the patient is not currently taking HCQ, 200 mg twice daily should be prescribed. If necessary, the dosage can be increased to 400 mg twice daily Low dose ASA • Low molecular weight heparin (LMWH) should be used in SLE patients with APS in prophylaxis or therapeutic doses (.... though, ASA if they ONLY have antibodies for APS, and not full on criteria) F

diagnose antiphospholipid SYNDROME

• Thrombosis diagnosed by diagnostic imaging or histology involving one or more venous, arterial, or small vessels but not including superficial venous thrombosis; or • Adverse pregnancy outcome including: - one or more unexplained fetal death at 10 weeks of gestation or more of a morphologically normal fetus - one or more preterm birth(s) prior to 34 weeks due to preeclampsia or placental insufficiency - three or more unexplained embryonic losses at less than 10 weeks gestation AND • At least one of the following laboratory criteria on two or more occasions at least 12 weeks apart and no more than five years prior to clinical manifestations. ○ IgG and/or IgM anticardiolipin antibodies (aCL) (greater than 40 GPL or MPL units or more than 99th percentile for the testing laboratory); or ○ Antibodies to beta‐2‐glycoprotein‐1 of IgG or IgM more than 99th percentile for the testing laboratory; or ○ Lupus anticoagulant (LA) activity detected according to published guidelines.

SOGC meds that reduce folic acid activity

•Chloramphenicol •Methotrexate •Metformin

complications of PPCM

•Heart failure is most common •20% arrhythmia, 4% V-tach, 2% have arrest •~7% chance of VTE

contraindications to scalp clip

•Human immunodeficiency virus (HIV) •Hepatitis (B, C, D, E) •Active genital herpes •Caution if any intrauterine infection •Fetal bleeding diathesis suspected •Amniotomy not appropriate •Prematurity less than 32 weeks, in which case it is preferable to avoid fetal scalp electrode •Presenting part uncertain •Face presentation •Placenta previa

SOGC medical conditions that affect folic acid

•Medications: antiepileptic or other folate-inhibiting medications •Gastrointestinal conditions: malabsorption or inflammatory bowel disease; Crohn disease; active celiac disease; gastric bypass surgery; advanced liver disease •Diabetes: pre-gestational diabetes (type 1 or 2) •Maternal obesity: body mass index >30 kg/m2 or pre-pregnancy weight ≥80 kg •Renal: kidney dialysis

DCM

•NORMAL thickness of ventricular walls...... a progressive dilation of all 4 chambers of the heart that leads to decreased contractility and heart failure from systolic dysfunction, so cardiac output decreases... can cause symptoms of both left AND right heart failure • •Left failure - disease of symptoms of pulmonary congestion (rather than signs like in RHF)... blood regurges backwards into the lungs, increases hydrostatic pressure and leads to pulmonary edema ... have -dyspnea on exertion - orthopnea -PND -fatigue weakness. •Right heart failure- disease of signs. right ventricle cannot pump blood from the venous system into the lungs, causing blood to accumulate behind it..... -Peipheral edema (from venous hydrostatic pressure) - hepatosplenomegaly JVP. Often can disrupt the electrical system, causes arrhythmias. Systolic dysfunction in dilated cardiomyopathy manifests as a reduced ejection fraction (<40%) and can be detected during physical exam as a narrow pulse pressure (<40) and S3 heart sound

insulin pumps

•Usually fast acting insulin like aspart/lispro (can use regular) •Continuous SC infusion •Implantable or external •Programmable •Glucose levels monitored at least daily 50/60% dose is basal rate, remainder bolus with meals/snacks Advantages: - •Decrease risk of severe hypoglycemia/maintains glucose control Disadvantages - cost is major one - pump may malfunction

ultrasound findings in TTTS

•Presence of a single placenta •Sex concordance •Significant growth discordance (approximately 20%) •Discrepancy in AFV between the two amniotic sacs (usually oligohydramnios and polyhydramnios) •Absence of bladder in donor twin •Discrepancy in size of the umbilical cords •Presence of fetal hydrops or cardiac dysfunction •umbilical artery Doppler findings, such as absent end-diastolic flow in the donor fetus

sogc meds that reduce folic acid levels

•Sulfasalazine •Phenobarbital •Phenytoin

prep for impacted head

•The anesthesiologist must be aware of the possible need for uterine relaxation or change in patient or operating room table position, as well as the associated possibilities of greater than average blood loss and longer operating time. •Neonatal resuscitation personnel must be present. Positioning: lower the operating room table or have standing stools available so that the delivering surgeon can direct pressure on the fetal head in an upward manner and not toward himself or herself to avoid lateral tears of the uterine incision. - Consider placing the woman in the Trendelenburg position and/or the modified lithotomy (Whitmore) position (aka frog) Incision Make the uterine incision relatively high (in the upper portion of the possibly distended lower uterine segment). This may help avoid inadvertent entry through the cervix or into the vagina when a cesarean delivery is performed at or near full dilatation. Extension of the incision as a "J" or "inverse T" incision may facilitate reverse breech extraction Uterine relaxation nitroglycerin (50-200 μg intravenously), followed by a period of uterine palpation inside the abdomen until adequate relaxation is achieved...... Relaxation occurs within 30-45 seconds, and the effect lasts 2 minutes.

IA and epidural

•There are no maternal-fetal risk factors for adverse perinatal outcomes and/or obstetrical considerations. •Pre-pregnancy BMI is <35. Women with pre-pregnancy BMI ≥35 have increased incidence of hypotension and FHR abnormalities. •Frequency of assessment is increased (e.g., IA increased to every 5 minutes for 30 minutes after the initial dose of an epidural and following any epidural boluses [top-ups]). •Maternal vital signs (including BP) are stable post epidural. In general, epidural or spinal anaesthesia in the absence of maternal hypotension or uterine tachysystole causes minimal FHR changes. •Patient controlled epidural anaesthesia (PCEA) is used, because PCEA uses a dilute local anaesthetic and opioid solution. Maternal-fetal assessments are not required after a self-administered bolus. IA should be done according to the usual obstetrical protocols. The use of EFM in this circumstance should be based solely on obstetrical risk factors. •EFM, not IA, should be used when combined spinal-epidural analgesiaa (CSE) is used because CSE is associated with a higher risk of an atypical or abnormal fetal heart pattern than with the use of epidural alone.

alcohol withdrawal treatment

•Thiamine 100 mg po od × 3 days, folic acid 5 mg po od •Diazepam 20 mg po q1-2 h until minimal symptoms •Lorazepam 2-4 mg sl/po q2-4 h prn during labour •Monitor hydration status and electrolyte levels

hep C risk factors

•intravenous drug use •co-infection with HIV •exposure to infected blood or body fluids through contact with needles or medical devices (health care workers) •history of long-term hemodialysis •blood transfusion or organ transplant before 1992 - sex workers (or partner) - incarceration