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OB- GYN !
Revalida Review 2017
Camille S. Lopez, MD
Obstetrics
• Prenatal
check-‐up
• Commonly
encountered
cases
at
the
OPD
• Hypertension
in
Pregnancy
•
Gestational
Diabetes
Mellitus
•
Thyroid
Diseases
• Previous
CS
First
prenatal
check-‐up
ü
MENSTRUAL
HISTORY
-‐
M.I.D.A.S.,
PMP/
LMP
ü SEXUAL
HISTORY
-‐
Coitarche
-‐
number
of
partners
-‐
symptoms
(PCB/dyspareunia)
ü OBSTETRICS
HISTORY
-‐
GP
(T.P.A.L)
-‐
manner
of
delivery
(if
CS
indicaFon),
BW,
place
of
birth,
ComplicaFons
-‐
Family
planning
(barrier,
withdrawal
etc)
ü
Determine
the
AOG
-‐
LMP,
UTZ
-‐
EsFmated
date
of
Delivery
(Naegele’s
Rule)
+
7(days)
-‐3(
mos)
Example:
LMP:
December
15,
2016
12
(-‐3)
à
Sept;
15
(+7)
à
22
EDD:
Sept
22,
2017
PHYSICAL
EXAMINATION
ü Hepatitis
B
screening
Recommended Dietary
Allowances
Maternal
Nutrition
1.
IRON
• 27
mg
of
elemental
iron
supplement
daily
• 300
mg
of
iron
transferred
to
the
fetus
and
placenta
• 500
mg
incorporated
into
the
expanding
maternal
hemoglobin
mass
2.
CALCIUM
• 400-‐900mg
Calcium
supplementation
• 30
g
deposited
in
the
fetus
Maternal
Nutrition
3.
ZINC
• recommended
daily
zinc
allowance
is
12
mg/day
4.
IODINE
• recommended
daily
iodine
allowance
is
220
μg
5.
FOLATE
• Contributing
factor
for
anemia;
350mcg/day
FOLIC
ACID
• Daily
intake
of
400
μg
throughout
the
periconceptional
period
• 4-‐mg
folic
acid
supplements
the
month
before
conception
and
during
the
first
trimester
if
with
previous
child
with
NTD
(reduce
2-‐5%
recurrence
risk
by
70%)
REMEMBER
• The
mean
duration
of
pregnancy
calculated
from
the
first
day
of
the
last
normal
menstrual
period
is
very
close
to
280
days
or
40
weeks
• Preeclampsia
• BP
≥
140
mmHg
systolic
or
≥
90
mmHg
diastolic
after
20
weeks
gestation
on
2
occasions
at
least
4
hours
apart.
and
• Proteinuria
≥
300mg/24
hours
• Protein/creatinine
ratio
≥
to
0.3
• Dipstick
reading
of
+1
• Or
in
the
absence
of
proteinuria
• Serum
creatinine
>
1.1mg/dl
or
doubling
of
the
serum
creatinine
concentration
in
the
absence
of
renal
disease
• Platelets
<
100,00/ul
• Elevated
LDH
(3x)
,
ALT
or
AST
(2x)
• Pulmonary
edema
• Cerebral
or
visual
symptoms
Classification
of
Hypertensive
Disorders
• Preeclampsia
• Without
severe
features
• With
severe
features
Severe
Features
of
Preeclampsia
• BP≥160/110
mmHg
• Thrombocytopenia
• Elevated
liver
enzymes
• Renal
insufficiency
• Pulmonary
edema
• New
onset
Cerebral
or
visual
disturbances
Classification
of
Hypertensive
Disorders
• Chronic
Hypertension
• BP
≥
140/90
mmHg
before
pregnancy
or
diagnosed
before
20
weeks
gestation
• Hypertension
first
diagnosed
after
20
weeks
gestation
and
persistent
after
6
weeks
postpartum
Classification
of
Hypertensive
Disorders
• Superimposed
Preeclampsia
• New
onset
proteinuria
≥
300mg/24
hrs
in
hypertensive
women
but
no
proteinuria
before
20
weeks
gestation
• Eclampsia
• Seizures
that
cannot
be
attributed
to
other
causes
in
women
with
preeclampsia
RISK
FACTORS
Pathophysiology
Prevention
• Dietary manipulation
• Calcium supplementation
• Fish oil supplementation
• Antioxidant (Vit. C & E )
• Low dose aspirin
CARDINAL
PRINCIPLES
• 1.
Prevention
of
convulsions
• 2.
Control
hypertension
• 3.
Delivery
at
an
optimum
time
and
mode
Drugs
for
Urgent
Control
of
Severe
Hypertension
in
Pregnancy
DRUG
ROUTE
AND
DOSING
IV
Nicardipine
D5W
90
mL
+
Nicardipine
10
mg
in
soluset
Concentration
=
0.1
mg/mL
Start
drip
at
10
ugtts/min
(equivalent
to
1
mg/hr)
Titrate
every
hour
(increments
of
1
mg/hr)
Maximum
dose
10
mg/hr
Nifedipine
(C)
Tablets
recommended
only:
10
to
30
mg
PO,
repeat
in
45
minutes
if
needed
Hydralazine
(C)
5
mg
IV
or
IM,
then
5
to
10
mg
every
20-‐40
minutes;
once
BP
controlled
repeat
every
3
hours;
for
infusion:
0.5
to
10.0
mg/
hr;
if
no
success
with
20
mg
IV
or
30
mg
IM,
consider
another
drug
Labetalol
(C)
10
to
20
mg
IV,
then
20
to
80
mg
every
20-‐30
minutes,
maximum
of
300
mg;
for
infusion:
1
to
2
mg/min
Methyldopa
250-‐500mg/tab
OD
to
TID
Hypertensive
Disorders
in
pregnancy;
Roberts
et
al;
ACOG;
2013
What
blood
pressure
is
the
aim
of
anF-‐
hypertensive
therapy?
ASSESSMENT?
PLAN?
Anemia
in
Pregnancy
o Fetal
surveillance
ü NST
ü BPS
Treatment Plan for GDM
• Diet
• Exercise
• Self monitoring of blood
glucose (SMBG)
• Insulin
• Oral hypoglycemic agents
(OHA)
INSULIN TREATMENT
Insulin
Type
Onset
Peak
(hr)
Duration(hr)
Short
Acting
Lispro
<15
min
0.5-‐1.5
3-‐4
Aspart
<15
min
0.5-‐1.5
3-‐4
Regular
30-‐60
min
2-‐3
4-‐6
Long
Acting
NPH
1-‐4
hr
6-‐10
10-‐16
Glargine
1-‐4
hr
mininal
Up
to
24
Timing of Delivery
• Good Glucose Control
- Expectant management