What infection is caused by caused by urinary stasis and glucosuria?

What is the patho behind the infection?

UTI

•Stasis-caused by progesterone affect on the smooth muscle of the ureters, mechanical compression of ureters at the pelvic brim, and compression of bladder and ureteral orifices.

What is the most common organism for UTI infections?

What are treatment options?

E. Coli

•Treatment options

–Ampicillin 500mg 500mg bid

–Macrodantin 50 mg qid

–Gantrisin 1g qid

Why ar eyou treating all pregnant women with a UTI?

What are you concerned about?

Bc higher rate of premature babies and ruptured membranes

–Escherichia coli

–Klebsiella

–Proteus species

–Group B streptococci (rare)

What infection OTHER THAN UTI are you concerned about in pregnant woman?

What is the treatment?

Why are you concerned?

ACUTE PYELONEPHRITIS

–Associated with premature labor

–Hospitalization

–IV antibiotics

fever, pain, getting dehydrated, when uterus (muscle) gets dehydrated could cramp up and lead to immature labor

Pt presents with profuse, thin gray white discharge. You notice a very unpleasant fish-like odor.

Pt complains of itching too.

What could it be?

What is the organism causing symptoms?

How do you diagnose?

How do you treat?

What could it be? bacterial vaginosis

What is the organism causing symptoms? gardnerella vaginalis

How do you diagnose?

•Pelvic exam

•Wet mount clue cells

•“Whiff Test” KOH

How do you treat?

•Metronidazole 500 mg po BID x 7d or Metronidazole gel 0.75% intravaginally QD x 5

•Clindamycin cream 2% intravaginally qhs x 7 or Clindamycin 300mg po BID x 7

This medication:

need to wait till pregnany lady is in her second trimester to give?

If you see clue cells...

THINK what?

Pt complains of white, thick, curdy discharge. There is only pain when urine hits her vulva.

What could it be?

What do you think her pH probably is?

How do you diagnose?

What could it be? Candidiasis

What do you think her pH probably is? <4.5

How do you diagnose? Wet mount

True or false.

Gestational DM is reversible.

Lab work...

If patient has preexisiting DM...what lab do you need to do?

If you want to test for gestational DM- how do you test?

If patient has preexisiting DM...what lab do you need to do? Hgb A1C

If you want to test for gestational DM- how do you test?

•Glucose challenge test non-fasting 50g Glucola, drawn after one hour at 24-28 weeks.

•If ≥ 140mg/mL then 3 hour test after 100 g glucose load-fasting

•Glucose challenge test non-fasting 50g Glucola, drawn after one hour at 24-28 weeks.

•If ≥ 140mg/mL then 3 hour test after 100 g glucose load-fasting

When do you start insulin treatment in patient?

What does glucose level need to be?

What defines someone as having gestational DM?

105 mg/dL or > START INSULIN RIGHT AWAY

Defines gestational DM:

•Two or more abnormal values = GDM (gestational DM)

what is the management for pt with gestational DM?

What is diet (ie calorie intake)?

What type of home glucose monitoring?

What should medications be?

What is diet (ie calorie intake)?

 •2300 – 2400 calorie diet

What type of home glucose monitoring?

•AM fasting: 90 – 100 mg

•2 hour post-breakfast:  <120 mg

What should medications be?

–Insulin-combo NPH and regular

–Glyburide 2.5 mg BID, max 10 mg BID

What defines anemia during pregnancy? (ie. hct, hgb)?

what increases during pregnancy?

What is the most common type of anemia during pregnancy?

What defines anemia during pregnancy? (ie. hct, hgb)?

defined as a hematocrit less than 30% or a hemoglobin of <10g/Dl. 

what increases during pregnancy?

 plasma

What is the most common type of anemia during pregnancy?

Iron deficiency Anemia

What is the cause of iron deficiency anemia in the pregnant lady?

When do you start tx?

What is important to ask pts?

What type of weird behavior may use see?

What is the cause of iron deficiency anemia in the pregnant lady?

 expansion of maternal red cell mass and fetal iron needs

When do you start tx?

 at start of diagnosis of pregnancy

What is important to ask pts?

dietary history imp to ask

What type of weird behavior may use see?

PICA

What's the treatment for IDA?

What should you tell pt about their stool?

Treatment

•Ferrous sulfate 325-mg twice per day.

•Hematocrit doesn’t increase significantly, but stabilizes or increases only slightly.

Will make pt constipated- stool will be black and very hard; need to drink lots of water; more prone to hemorrhoids-imp to eat foods that will soften stools

Ferrous sulfate can be irritating to stomache so take with food. OJ can help with absorption

•The fetal and maternal growth during pregnancy requires _____mcg/day of folate

Where do you get folate (what type of foods?)

800 mcg

folate: dark, leafy vegetables

1mg of folic acid daily-given at diagnosis of pregnancy.

•This amount is contained in most prenatal vitamins.

What are the five types of spontaneous abortions?

What type of spontaneous abortion is this describing?

–Bleeding from cervix & cervix is closed.

–Uterine size consistent with gestation

What type of spontaneous abortion does this describe?

–Cervix dilates & products of conception pass thru os or profuse bleeding

what will US show?

inevitable abortion

US will show no products of conception in uterus

What type of spontaneous abortion does this describe?

–Part of POC are expelled, some remain in uterus

–Cervix dilated, bleeding.  Uterus enlarged

What type of spontaneous abortion does this describe?

–Embryo dies, but POC not expelled

–Uterus smaller than gestational age

–Dark red or brown bleeding

Pt who comes in and MAY be a spontaneous abortion:

what do you want to know?

What are you doing on PE?

What diagnostic studies?

what do you want to know?

–Sx of pregnancy & loss of symptoms

–Bleeding; degree & duration

–Cramps, pain, fever

–Attempts to induce miscarriage

What are you doing on PE?

•P.E.: vitlas, check abdomen, pelvic and bimanual

What diagnostic studies?

•Diagnostic Studies: beta quant (make sure number going up), UCG, US, transvaginal US (if very early in pregnancy), coag studies if bleeding a lot, CBC

How do you control bleeding in spontaneous abortion (name the drug)

How do you prevent infection? (name the drug)

How long can you not have sex in threatened abortion?

How do you get fetal contents out of uterus?

How do you control bleeding in spontaneous abortion (name the drug) methergine

How do you prevent infection? (name the drug) doxy

How long can you not have sex in threatened abortion? 2-3 weeks

How do you get fetal contents out of uterus? dilation and curretage or dilation and excavation

What is this called:

Ectopic pregnancy

Patho:

–Separation of the decidua from endometrium as ectopic pregnancy dies

–Direct bleeding from site of e.p.

What are the five risk factors for ectopic pregnancy?

–Previous ectopic

–Tubal repair

–Previous pelvic / tubal infections (due to scar tissue, can narrow)

–IUD users

–Maternal age (extremes of age)

Pt presents with the following..what could it be?

–Missed menses

–Bleeding

–Pelvic pain

–Positive hCG

–Low grade or absent fever

–Hypovolemia

–Uterus – normal to slightly enlarged

–Adnexal mass if pregnancy is in ovary or tube

–Quantitative beta-hCG’s (levels should be doubling if not could be ectopic)

–Serum progesterone

–Ultrasound; absence of gestational sac/ will be able to see in tube

–Laparoscopy (peritoneal signs)/severe abdominal pain

–Laparoscopic surgical removal

–Methotrexate used for very early pregnancies  (essentially chemotherapy)

The premature partial or complete separation of the placent from its normal implantation..

What is this?

–Maternal HTN

–Trauma

–Previous abruption

–Multiple gestation

–Poor nutrition

–Drug abuse (ETOH, cocaine)

–Advanced maternal age (35)

–Uterine anomalies

–Preeclampsia

–Thrombophillia

–Cigarette smoking

–Separation is initiated by bleeding into decidua basalis.

–The decidua splits and the placenta is sheared off.

–Mild abruption- no tx may be necessary

–Follow closely until fetal maturity; may be confused with premature or early labor; expect vaginal delivery.

–After abdominal trauma, patients should be observed closely for at least 24 h., put pt on monitor

Uh oh...

What do you do: three things!

Moderate to severe cases- of abruptio placenta with fetal distress, loss of fetal heart tones, or maternal signs of shock!!!!

–emergency c-section and resuscitation.

         –Type and cross for 4-6 units

        –Repeat coags and CBC- R/O DIC

Uh oh---

Pt has abruptio placenta with

–Moderate to severe cases without fetal distress or maternal hypotension

What do you do? two things

–Vaginal delivery may be attempted with gentle induction with Pitocin

–Monitor for complications post-delivery ie. hemorrhage for the mother

What are causes of placenta previa?

(6)

–Implantation affected by:

–Previous uterine surgery (c-section)

–Prior endometrial trauma (D&C, D&E)

–Abnormality of endometrial vascularity

–Delayed ovulation

–Multiparity

–Advanced age

Pt comes in and says they are spotting during the first and second trimseter.

They are now in their third trimeser and bleeding again, but they say it's PAINLESS

What could it be?

What would you expect to find on bimanual exam?

Placenta Previa

–Usually soft, non-tender uterus

–Patients with no prenatal care may present with severe vaginal bleeding

–Most previas are discovered early in prenatal care (US between 12th and 20th week)

What diagnostic studies do you do for placenta previa?

What do you NOT do?

–Pelvic US – to localize placenta

–A 2nd or 3rd US is needed to establish the degree of previa (placenta may migrate)/need to know if covering Os

–CBC

–Coags

–Amnio (lung maturity)

–Clinical examination is to be avoided  May precipitate hemorrhage

bed rest, pelvic rest, and tocolytics

–Follow closely and monitor CBC

–Steroids for fetal lung maturity

–Delivery by C-section.

Post partum hemorrhage:

Bleeding in excess of _____ mL with vaginal delivery or >____ mL with C-section.

Bleeding in excess of 500 mL with vaginal delivery or >1000 mL with C-section.

What is the most common cause of post partum hemorrhage?

Other causes?

Uterine atony – most common cause; uterus is unable to contract and control bleeding

–Severe vaginal or perineal tears, uterine rupture, placenta accreta (deep attachment through endometrium an dinto myometrium- depending on how deep may be cause for post partum hemorrhage), uterine inversion

–Congenital bleeding disorders- von Willebrand’s etc

–DIC (caused by preeclampsia or amniotic fluid embolus)

Pt presents after delivery with the following symptoms:

what could it be?

Hypovolemic shock – pale, clammy skin; low BP; thready rapid pulse

How do you diagnose?

POST PARTUM HEMORRHAGE

–Vitals

–CBC

–Periphreal blood smear

–PT, PTT, Fibrin split products, fibrinogen

–Type and cross

What do you do for the following situations?

–Uterine Atony-

–Cervical/vaginal tears-

–Placenta Accreta-

–Uterine Rupture-

–Congenital bleeding dyscrasias-

–DIC-

–All conditions require

–Uterine Atony- Pitocin and bimanual pressure until uterus contracts on its own.

–Cervical/vaginal tears- repair laceration

–Placenta Accreta- uterine artery ligation, hysterectomy or both

–Uterine Rupture- surgical repair or hyst

–Congenital bleeding dyscrasias- consult hematology

–DIC- treat underlying cause, replace clotting factors

–All conditions require volume replacement and control of bleeding

–Transient / Gestational hypertension

–Preeclampsia

–Eclampsia

•Defined as hypertension present before the 20th week of gestation or beyond 6 weeks postpartum. What is this?

•Blood pressure ____

•Placental size and function _____

•What could happen to baby?

•Defined as hypertension present before the 20th week of gestation or beyond 6 weeks postpartum. CHRONIC HTN

•Essential

•Blood pressure 140/90 mg Hg or >

•Placental size and function decreased

•What could happen to baby? Fetal hypoxia, malnutrition, and IUGR

Pre-Eclampsia:

HTN associated with ____ or ________

More common in who (5)

•HTN with proteinuria or pathologic edema (or both)

•More common in young, primigravida females with twin or molar pregnancies, family Hx, smokers

•Mild

–No evidence of end-organ damage

–Normal m.s.e, DTR’s, abdominal exam, LFT and coag studies

•Severe

–Systolic > 160, diastolic > 100

–Proteinuria 2+ or more on dipstick

–CNS effects

–Abnormal liver fx and renal fx

What labs do you want to do for mom with pre-eclampsia?

What type of labs for the fetus?

Mom

–CBC

–Platelet count

–PT, PTT

–LFT’s

–RF studies

–24 hour urine for creatinine clearance

–Baseline magnesium

Fetal

–ultrasound

–Fetal weight & growth

–Amniotic fluid volume

–Placental status

–NST

–Biophysical Profile

NST with ultrasound- fetal breathing, fetal movement, quali amniotic fluid level,

Normal 8-10

Equivocal 6

<4 needs intervention

What is the management for mild preeclampsia?

What is managemetn for severe preeclampsia?

•Management: Mild preeclampsia & immature fetus

–Bedrest

–Daily weight, fetal movement & BP readings

–Pt education & instructions

–hospitalization

•Management:  Severe preeclampsia / eclampsia

–Hospitalization

–Magnesium sulfate-seizure prophylactic, 4g loading dose IV over 20-30 min., then 1-3g/hr. infusion, frequent eval of respirations and patellar reflex

–Anti-hypertensive-Hydralazine, Nifedipine, Labetalol

–Fetal monitoring

–Steroids

–Delivery: this is the cure!

What is HELLP syndrome?

What is it associated with?

Associatd with Pre-eclampsia

•HELLP syndrome (always check CBC and monitor platelets)

–Hemolysis

–Elevated liver enzymes

–Low platelets

•PT, PTT and fibrinogen levels all normal

True or false.

How do you manage pt with eclampsia?

–O2, IV access

–Magnesium sulfate 4g IV over 20-30 min.

–Diazepam may be given, not first line

•Thiazide

•Methyldopa

•Hydralazine

•Propranolol

•Labetalol

•Nifedipine

What should be avoided if you suspect preterm, premature, rupture of membranes?

What should be performed?

What shoudl be given?

What should be signed?

•Digital vaginal examinations should be avoided.

•Ultrasonography should be performed to confirm gestational age, estimated fetal weight, presentation, amniotic fluid index, and fetal anatomy if not already fully evaluated.

•Antibiotics need to be given based on present evidence.

•Corticosteroids should be given to accelerate lung maturity between 24 and 34 weeks.

•Informed consent should be obtained for expectant management versus delivery with careful documentation in the chart.

taking a proper medical history, a GYN exam using a speculum, nitrazine, cytologic (ferning) tests, and ultrasound. Amniotic fluid, when dried for 10 minutes on a slide and then viewed under a microscope, shows a characteristic fernlike pattern. Cervical mucus can also show ferning, but the fern-like shapes are usually smaller.

What should be performed daily in PPROM?

What should happen after 34 weeks to the mother?

What should happen at term?

•Fetal monitoring should be performed at least daily until delivery, and fetal well being and growth should be evaluated periodically with ultrasonography.

•After 32 weeks and certainly after 34 weeks' gestation, the appropriateness of expectant management of PPROM should be reevaluated individually for each case.

•PROM at term should be managed by delivery unless reasons exist to consider waiting for spontaneous labor. Large enough studies to document neonatal safety of expectant management of PROM at term do not exist.

•Maternal chorioanmionitis or sepsis. Fetal factors include prematurity, infection, cord prolapse, or malpresentation.