ABOG Flashcards
At what week is amniotic fluid composed of urine?
20w
before that it comes through fetal skin
How much does atypical ductal hyperplasia increase the risk of breast cancer?
4-5 fold risk
What percentage of patients with atypical ductal hyperplasia have concurrent cancer?
30%
Clinical diagnostic factors of APAS?
personal h/o VTE or pregnancy morbidity:
missed at >10w
delivery at <34w d/t PIH
3+ SABs at <10w
Lab diagnositc factors of APAS?
Anti-cardiolipin antibodies
Anti beta 2 glycoprotein
lupus anticoagulant
(x2 12 w apart- same lab abnormality)
How do you dx APAS?
one lab abnormaility (12w apart) and 1 clinical factor
What medication should patients take when pregnant with APAS? Which is most helpful?
heparin and aspirin from pregnancy through 6w PP
Heparin reduces VTE and fetal loss
At what spinal level does the abdominal aorta exist?
T12 to L4
What is the order of vessels off the abdominal aorta from top to bottom
Celiac Trunk
SMA
Ovarians
IMA
What do the ovarian veins drain into?
Right ovarian > IVC
Left ovarian > left renal
What is add back therapy?
Norethindrone 5 mg daily
Prolongs use of lupron from 6 mo to 12 mo
What is the biggest worry with prolonged lupron use?
decrease in bone density
Definition of arrest of labor
> 6 cm with ROM
with adequate ctx x4h (200 MVU)
without adequate ctx x6h
What is the definition of prolonged latent phase of labor?
Nullip: >20h
Multip: > 14h
3 signs of AFE
hypoxia
hypotension
coagulopathy
What happens to the heart in an early stage AFE? Late phase AFE?
Early phase: right ventricular failure
Late phase: left ventricular failure
What should you limit in management of an AFE?
Limit excessive fluid resuscitation to avoid pulmonary edema
How do you calculate an anion gap? What is normal?
Na - (Cl+HCO3)
Normal: 12 +/- 4
What is the risk of ovarian cancer in the general public?
1.5%
What is the risk of ovarian cancer in a BRCA1 patient? BRCA2 patient?
Ovarian cancer
BRCA1 40%
BRCA2 15%
What is the risk of breast cancer in a BRCA1 patient? BRCA2 patient?
What types of breast cancer develop?
Breast cancer
BRCA1 60%- triple negative
BRCA2 50%= ER/PR +
What percentage of term pregnancies will be breech?
2-3%
Breech maneuvers: what is the pinnard manuever?
Deliver legs
Breech maneuvers: What is the Loveset maneuver?
resolve nuchal arm
Breech maneuvers: What is the Mauiceau-Smelli-Veit maneuver?
maxillary pressure
Breech maneuvers: What is the Prague maneuver?
flexing neck by supporting body
Criteria for breech delivery of second twin?
EFW >1500g
A larger than B
EFW cut off for breech delivery of singleton?
EFW > 2500g
Most common “mortal complication” of laparoscopy?
1) anesthesia
2) vessel injury
3) bowel injury
Repair of bowel injury at time of laparoscopy: serosal abrasion
no repair
Repair of bowel injury at time of laparoscopy: serosal and muscularis injury
oversew
Repair of bowel injury at time of laparoscopy: Veress needle
conservative management
Repair of bowel injury at time of laparoscopy: Defect <6 mm
closure in layers with 3-0 vicryl or PDS
Repair of bowel injury at time of laparoscopy: Full thickness defect > 2cm
double layer closure
Repair of bowel injury at time of laparoscopy: injury >1/2 of lumen or affecting mesenteric blood supply
bowel resection
Repair of bowel injury at time of laparoscopy: thermal injury
resection with 5 cm margin to prevent future perforation
Repair of bowel injury at time of laparoscopy: needle stick
irrigation, suction, ABX
Amsel’s criteria for BV
3 out of 4:
1) thin grey discharge
2) pH >4.5
3) + whiff amine test (10% KOH)
4) clue cells on >20% of epithelial cells
True or false. It is inappropriate to screen or treat asymptomatic pregnant women for BV w/o h/o PTD.
true
Contraindications to breast feeding
active herpes on breast (continue to pump) HIV Ebola Infant with galactossemia Meth use
Which aspect of the BPP indicates chronic fetal well being?
MVP
BPP. At what week GA does tone develop?
8w
BPP. At what week GA does gross movements develop?
9w
BPP. At what week GA does breathing develop?
21w
BPP. At what week GA does FHR reactivity develop?
26-32w
What is the order of disappearance in BPP?
breathing, FHR
decrease movement
decreased tone
At what BPP score should you deliver? At what score should you crash?
deliver at 4/10
crash at 0 or 2/10
Components and definitions of aspects of BPP
Breathing: 1+ episode >30 seconds Movement: 3+ limb movements Tone: 1+ extend/flex ext or open/close hand MVP >2 cm NST reactive
What is needed for a contraction stress test?
3 ctx (lasting 40 sec) per 10 minutes
What is a + CST?
FAIL
lates after >50% of ctx
What is an equivocal CST?
If ctx last too long or occur too often > decels
What is an equivocal-suspicious CST?
“occasional” decels
What is a negative CST?
PASS!
What kind of virus is CMV?
Double stranded DNA
What is the incubation period of CMV?
28-60 days
How do you test a mother who might have CMV?
maternal IgG and IgM (M can be elevated x9-12 mo)
How does CMV manifest in fetuses?
Intracranial calcifications Hydrocephalus Microcephaly Hepatosplenomegaly FGR Echogenic bowel Hydrops
What percentage of deliveries are affected by chorio?
2-5%
What is the treatment for chorio (with dose)
amp 2g q6h +
gent 5 mg/kg daily
What are the most common presentations of chorio in order?
1) maternal fever
2) leukocytosis (supportive but not diagnostic)
3) maternal tachycardia
4) fetal tachycardia
What is the most common type of fetal malformation?
VSD (accounts for 50%)
What is the least common type of fetal cardiac anomaly?
Truncus arteriosus
What fetal anomalies does T2DM put you at risk for the most (in order)
1) Cardiac
2) spina bifida
3) sacral agenesis
What affect does uncontrolled T2DM have on the risk of fetal anomalies?
HgbA1c 10+ = 20-25%risk of fetal cardiac anomalies
How is cervical cancer staged?
clinically
What is a rad hyst?
taking uterines at their origin
all ligaments at their attachments
top 1/3 of vagina
What are normal cord gases?
pH 7.28 +/- 0.05 pCO2 50 +/- 8 pO2 20 +/- 16 HCO3 20 +/- 2 Base deficit 4 +/-3
What level of base deficit indicates metabolic acidosis?
12
Which cardiac disease is most associated with death during delivery? when?
aortic stenosis. (often from bicuspid aorta)
at CLE placement (2/2 decrease in preload)
NY class of CHF
1: normal
2: no symptoms at rest, starts at 2 blocks
3: dyspnea with any activity, okay at rest
4) dyspnea at rest
Karyotype of CAH
46 XX
How is CAH inherited?
Autosomal recessive
Most common cause of CAH?
21-hydroxylase deficiency causes increase in 17-OHP
Cholestasis of pregnancy presentation?
intense pruitis without rash
What increases your chance of cholestasis? by how much?
Hep c by 20%
How is CF inherited?
AR
Which chromosome is CF mutation on?
Chromosome 7, delta 508
What is CF?
mutated CL channel in epithelial cells
Cerclage indications:
1) Hx indicated: h/o 2t SAB without labor or abruption OR h/o cerclage due to cervical insufficiency
2) Physical exam: rescue cerclage. Cervical insufficiency in 2T
3) US indicated: h/o PTD <34w AND CXL <25mm at <24w
How long will a rescue cerclage prolong pregnancy?
4w
Cardinal Movements of labor
Engagement Descent Flexion Internal Rotation Extension External rotation (restitution) Expulsion
At what glucose level should you check ketones?
200
What is the goal potassium during DKA? How to keep it there?
K= 3.3-5.3
if <3.3 hold insulin and give K
if >5.3 trend q2h
What does insulin do to potassium?
drives K into cells, so in DKA patient’s K will look okay, but will actually need repletion
What is the dose (bolus and maintenence) of insulin for a patient in DKA?
Bolus: 0.1 unit/kg
Maintainence: 0.1 unit/kg/hr
Goal glucose for patient in DKA
<200
Soft Markers for Down’s Syndrome on 1T scan
cystic hygroma
thickened nuchal tranlucency
Soft Markers for Down’s Syndrome on 2T scan
echogenic cardiac focus pyelectasis echogenic bowel ventriculomegaly choroid plexus cyst short femur
When is the highest risk for DVT?
6 weeks PP
How long should a patient stay on AC for a provoked DVT/ Unprovoked DVT?
Provoked: 3 months
Unprovoked (or with active cancer): indefinitely
How long does lovenox need to be help prior to CLE placement?
PPX dose: 12h
Therapeutic dose: 24h
What is the immediate treatment for an acute DVT?
IV heparin: bolus 80u/kg + maintenance 18u/kg/hr
Then transition to warfarin (or lovenox 1 mg/kg BID)
- DVT x3 mo
- PE x6 mo
What percentage of US adults have T2DM?
15%
When should screening for T2DM start?
at age 45yo
OR in patient with BMI >25 with other risk factors (sedentary life style)
How oftern do you screen for T2DM?
q3y
What lab values are diagnostic of T2DM?
HgbA1c 6.5%+
fasting >126
2h >200
random >200* only if pt has polyuria/polydypsia
HgbA1c cut offs?
normal: <5.7
Pre-DM: 5.7-6.5
DM: 6.5
Delivery timing for diabetic who is CONTROLLED by insulin?
up to 39w6d, not past 40w
How much does obesity increase your risk of endometrial cancer?
2-4x
What is the false negative rate of an EBx?
1%
What percent of the endometrial cavity does an EBx sample?
5-15%
Compare Type 1 endometrial cancer to Type 2
Type 1:
- endometrioid (adeno)
- low grade, less aggressive
- white women
- estrogen dependent
Type 2:
- clear cell, pap serous
- high grade, aggressive
- non-white women
- p53 mutation
What cell is present in clear cell?
hob nail
What is the most common diagnosis associated with echogenic bowel as an isolated finding?
normal pregnancy (80-90%)
First line treatment for endo? 2nd line? Then what?
1st: NSAIDs
2nd: continuous OCP’s or progesterone only
3rd: dx l/s
What percent of women with endometriosis will still have symptoms after surgery?
15%
Where is the most common endometriosis implant?
Ovary (50%)
What is ulipristal? How long does it work? How does it work?
form of emergency contraception
effective up to 5 days
inhibits follicular rupture
How is levonorgestrel used as emergency contraception? dose, how long does it work, MOA
levonorgestrel 1.5 mg once of 0.75 mg x2
effective up to 3 days
delays follicular development
What is the most effective form of emergency contraception? How does it work and for how long?
Copper IUD
up to 5 days
affects sperm viability
How to measure EDD?
<14 weeks by CRL
>14w by growth scan
When to change EDD?
<9w: if 5+ days 9-16w: 7 days 16-22w: 10 days 22-28w: 14 days >28w: 21 days
Most common cause of endocarditis
staph aureus (>50%)
When would a woman need ABX PPD for vaginal delivery or dental procedures?
if she has a prosthetic valve to prevent endocarditis
Indications for EBx in post-menopausal women?
with VB and ES > 4mm
without VB and ES> 11mm
Indications for EBx in pre-menopausal women?
if >45yo any AUB if <45yo: obese with AUB - obese with extra estrogen exposure - Lynch syndrome - anovulatory > 6 months
When to perform EBx on patient with AGUS?
only if they are >35yo
What kind of mutation is Fragile X?
trnucleotide repeats on FMR1 mutation (CGG)
What is considered a premutation of Fragile X (vs a mutation) and why is this clinically significant?
Pre-mutation: 55-200 repeats
- 25% develop POF (<40 yo)
Mutation: 200+ repeats (not associated with POF)
- hypermethylation causes gene inactivation
What is the definition of FGR?
EFW or AC < 10%Ile
When to deliver FGR baby?
Isolated: 38-39w6
If < 3%ile: 37w
If complicated by oligo or abnormal dopplers: 32-37w6d
What is a common pregnancy outcome of women with flu?
PTD
Oseltamivir, when to give, dose
give to pregnant women with the flu within 48h of onset and + test.
75 mg x 5d
Dose of folic acid for pregnant women?
normal: 400 mg daily
h/o NTD (personal or fam hx): 4 mg (4k mcg)
How much does appropriate folic acid supplementation decrease the risk of a NTD in a high risk woman?
decrease risk by 70%
What is fetal SVT? First line treatment?
FHR > 200 bpm
1st line: digoxin (50% success rate)
Chance of VTE in pt with factor V leiden?
h/o VTE: 17%
without h/o VTE: 1%
What is the most common inherited thrombophilia?
Factor V Leiden
Diagnostic for failed IUP
CRL > 7 mm without CA
Mean sac diameter > 25 without embryo
No embryo with CA 14 days after GS without YS
No embryo with CA 11 days after GS with YS
Most common aneuploidy associated with failed IUP
trisomy 16
What percentage of women with gDM will develop T2DM?
in PP period: 1/3
in lifetime: 70%
Risk of GTN in complete mole? In incomplete mole?
complete mole: 15%
incomplete mole: 1%
How to treat GTN?
very chemosensitive:
if WHO score< 7 MTX
if WHO score > 7 EMA/CO
How to diagnose GTN?
Hcg plateau over 4w (+/- 10%)
Hcg rise 10% over 3 values in 3w
What is needed after dx of GTN?
CXR, check TSH
Which GTN has a different treatment and what is it?
Placental site trophoblastic tumor is not chemosensitive, needs hyst
When would you expect to see treatment response for genital warts?
3w
What is the treatment for genital warts in a pregnant woman?
Trichloroacetic acid
Pregnancy outcomes for women with Grave’s dz?
medically indicated preterm delivery
babies can be hyper- or hypo-thyroid
Doses of gardasil
if <15yo= 2 doses
0 and 6-12 mo
if >15yo = 3 doses
0, 1-2 mo and 6 mo
Which strains of HPV does gardasil cover?
6, 11, 16, 18, 31, 33, 45, 52, 58
Which aneuploidy is associated with holoprosencephaly?
Trisomy 13
How does holoprosencephaly present?
fused thalami single ventricle no CSP or midline facial structures cyclopia nasal agenesis
When is hysteroscopy best performed?
Early proliferative phase
Examples of electrolyte poor fluid
glycine 1.5%
sorbitol 3%
mannitol 5%
What is the max fluid deficit for electrolyte poor fluid in hysteroscopy?
1L
What is an advantage to electrolyte poor fluid in hysteroscopy?
use of monopolar energy
What is an example of high viscosity fluid in hysteroscopy and what is an adverse event it can cause?
Dextran can cause DIC
fluid deficit is 300 cc
Examples of electrolyte rich fluid
NS
LR
What is the max fluid deficit for electrolyte rich fluid in hysteroscopy?
2.5 L
Mechanism of active of heparin
binds anti-thrombin 3, indirectly inhibits thrombin
How to reverse heparin
Protamine sulfate
What is FDA approved for hair growth associated with hirsutism? MOA?
Eflornithine (topical)
inhibits ornithine decarboxylase
What kind of virus is Herpes?
double stranded DNA
What is the incubation period for herpes?
2-12 day
What is the treatment for herpes?
Acyclovir 400mg PO TID x 5 days
How much does suppressive treatment during pregnancy decrease herpes outbreaks at time of delivery?
decrease by 75%
What percentage of women will develop genital herpes in their lifetime?
20%
What percentage of women with herpes will have a recurrence during pregnancy?
75%
What is the gold standard diagnostic tool for herpes?
PCR of vesicular fluid
What is the percentage of herpes transmission to baby in an active outbreak? Both primary and recurrent?
Primary: 40-80%
Recurrent: 1-3%
What pregnancy outcomes can uncontrolled hyperthyroidism have during pregnancy for mom? For baby?
maternal: CHF, PIH
fetal: hydrops
What meds do you use for hyperthyroidism in pregnancy?
1T: PTU
2T: Methimazole
What adverse outcomes does PTU cause?
maternal hepatotoxicity
What adverse outcomes does methimazole cause?
cutis aplasia
esophageal atresia
What kind of virus is HPV?
double stranded DNA virus
What percentage of cervical cancer are HPV 16 and 18 responsible for?
together: 70% of cervical cancer
16: 60% of sqCC and 40% of adeno
18: 40% of adeno and 15% of sqCC
What is E6 and how does it work?
E6: oncoprotein
inhibits p53> tumor suppressor gene
What is E7 and how does it work?
E7 inhibits Rb
Rb normal induces apoptosis for damaged DNA
How fast will a woman with a normal immune system clear HPV?
90% of women will clear in 8-24 mo
Normal HgB electophoresis
HgB A: 95%
HgB A2: 3%
HgB F: 2%
Who should have a HgB screen in pregnancy?
Black women should have electrophoresis with their CBC
Mediterranean or southeast Azn need electrophoresis if their CBC is abnormal
What causes Hypoxic Ischemic Encephalopathy?
an acute hypoxic event before delivery
How do you diagnose hypoxic ischemic encephalopathy?
apgar <5 at 10 minutes
fetal umbilical arterial acidemia
multi-system organ failure
quadriplegia or CP
What imaging is used to help diagnose hypoxic ischemic encephalopathy?
MRI 2h after birth
APGAR score
Appearence: cyanotic 0/ peripheral cyanois 1/ pink 2
Pulse: 0=0/ <100=1/ 100-140=2
Grimace: no response to stimuli=0/ weak cry= 1/ cry when stimulated=2
Activity (tone): floppy: 0/ some flexion=1/ well flexed, resist extension=2
Respiration: apneic=0/ slow irreg breathing=1/ strong cry=2
What is the viral load threshold for HIV?
1000
Delivery planning for woman with HIV, viral load >1k?
CS at 38w
When is vaginal delivery okay for a woman with HIV?
viral load <1k
What is the transmission of HIV in a vaginal delivery of a woman with a viral load <1k?
1-2%
What is the vertical transmission of HIV in a woman with viral load >1k?
25%
What is the most common hemolytic dz of the newborn and how does it present?
ABO incompatibility
presents as jaundice
Which hemolytic dz of the newborn is most deadly?
Kell. Causes fetal hemolysis and anemia
What to do if a woman tested positive for Kell ab?
test dad.
if + : MCA Dopplers to assess for fetal anemia
Which anti-body does not cause hemolytic dz of the newborn and why not?
Lewis (l), IgM can’t cross placenta
Contra-indications to HRT
h/o DVT or stroke
estrogen dependent cancers
liver dz
undiagnosed vaginal bleeding
Branches of the anterior branch of the internal iliac artery
Uterine Umbilical Superior vesical Obturator Internal Pudendle Inferior Gluteal Middle Rectal Vaginal
Branches of the posterior branch of the internal iliac artery
Iliolumbar
Lateral Sacral
Superior gluteal
How to induce an IUFD with h/o CS
<28w: prostaglandins (miso 200-400 PV)
>28w: pit (OB protocol)
Best cells to send for microarray in the setting of an IUFD?
amniocentesis
Pathogenesis of ITP
IgG anti-platelet
When to treat ITP
if PLT <30
if PLT <70 before CLE
if PLT <50 before surgery
symptomatic (epistaxis)
What is the treatment regimen for ITP?
1st line: Prednisone 10-20 mg daily x21 days, then taper
OR
dexamethasone 40mg daily x4 days (no taper)
2nd line: IVIG 1 mg/kg x1 dose
When do you expect PLT to rise in a patient with ITP after treatment?
Steroid treatment: will rise over 2w
IVIG treatment: with rise over 1-3 days, peak at 1w
Where does the iliohypogastric nerve innervate?
sensory to skin over superior lateral glutes
Where does the ilioinguinal nerve innervate?
sensory to skin over labia majora and mons
How to avoid injuring iliohypogastric nerve and iliolumbar nerve in CS?
“smile” fascia
keep incision within borders of rectus
incision 3 cm above pubic symphysis
avoid cautery of small vessels in SubQ
What is the major cause of decreased UOP in laparoscopy?
decrease in Renin
Which entry in laparoscopy is the safest?
no data to support this
What advantage does entering laparoscopically with the Hassan (open) technique provide?
lowest vascular injury rate
What muscles make up the levator ani?
pubococcygeus
ileococcygeus
puborectalis
What causes leukorrhea of pregnancy?
increase in estrogen
What anti-bodies are associated with neonatal lupus?
anti-Ro (SSA)
anti-La (SSB)
[normally associated with Sjogren’s]
When is a lupus flare most predicative of how lupus during pregnancy will go?
within 6 months of conception.
flare within this time period is predictive of severity in pregnancy
Medication for lupus during pregnancy?
Continue plaquenil (hydroxycholoroquine)
How is Lynch syndrome inherited?
Autosomal dominant
What genes carry Lynch syndrome?
MLH1, MSH2, MSH6, PMS2, or EPCAM
*micro-satellite instability
What percentage of patient with Lynch syndrome get colon ca? endometrial ca?
Lynch syndrome
Colon Ca: 50%
Endo ca: 2%
Cancer screening for patients with Lynch syndrome
Colonoscopy q1-2y starting at 20-25 yo (or 2-5 years before earliest dx)
EBx q1-2y starting at 30-35yo
What test can you run (and when) to ensure your lovenox dosing is correct?
Anti-Xa 4 hours after administration
Goal: 0.6-1.0
Which patients need testing to make sure they are getting the right dose of Lovenox?
morbidly obese or with renal dz
When should you switch from lovenox to heparin in pregnancy?
at 36-37w
How does listeria present?
headache, fatigue, myalgias
can cause abscesses in placenta or fetus
What type of bacteria is listeria?
gram +
What is the treatment for listeria in a pregnant woman?
amp IV x14d
if PCN ALL: bactrim
What percent of lactating women will get mastitis?
5-10%
What is the most common bacteria in mastitis?
staph aureus (40%)
Treatment for mastitis? What if no response?
dicloxacillin 500 mg PO QID x10-14 days
if no response in 48-72h, US for abscess
When does mastitis present?
3-4 w PP
If you think a patient might have MRSA mastitis, what is the treatment?
clindamycin 450 PO TID x10-14d
What is another name for Mullerian Agenesis?
Myer-Roktansky-Kuster-Hauser syndrome
What is the prevalance of Mullerian Agenesis?
1 in 5k
What percent of women with Mullerian agenesis have skeletal abnormalities?
90%
What percent of women with Mullerian agenesis have renal abnormalities?
30%
What is metabolic syndrome?
3 of the 5:
1) abd obesity (waist >88cm or 35 inches)
2) Triglycerides >150
3) HDL <50
4) BP > 130/85
5) Fasting glucose >100
Who would qualify for an MRI for breast cancer screening?
those at high risk: 1st degree relative with mutation 20% lifetime chance radiation to chest at ages 10-30 yo 25-29yo with BRCA, li-frameni, Cowden, or Peutz-Jegher
What is a therapeutic level of mag?
4-7 mEq/L
What levels do mag toxicity occur?
loss of DTR 7-10 mEq/L
Respiratory depression >12
Cardiac arrest >15
What is the treatment for mag toxicity?
1 g IV Ca gluconate
What is a didelphys uterus? How does it occur? Pregnancy outcomes?
2 uteri, 2 cervixes
failed fusion of ducts
best pregnancy outcomes
What is a septate uterus? How does it occur? Pregnancy outcomes?
fundal notch < 1 cm
failed medial regression
causes repeat preg loss and PTL
What is a bicornuate uterus? How does it occur? Pregnancy outcomes?
fundal notch > 1 cm
incomplete fusion of ducts
causes repeat preg loss and PTL
What is the primary procedure for a neovagina?
vaginal dilators (80% effective)
What is the McIndoe neovagina procedure?
skin graft tube
What is the Davydov neovagina procedure?
made of bowel wall/peritoneum
What is the Vecchietti neovagina procedure?
traction to anterior abdominal wall
What is the Williams neovagina procedure?
Skin flap from labia majora
What measurement is an abnormal nuchal translucency?
> 3 mm
When do you measure nuchal translucency?
10-13w (best at 13w)
What fetal anomalies is an thickened nuchal translucency associated with?
cardiac defects (septal) abdominal wall defects diaphragmatic hernias
If a fetus has a thickened nuchal translucency, how much does this elevate its risk for aneuploidy?
increase by 50%
What percentage of normal, healthy fetuses will have a thickened nuchal translucency?
<20%
NIPT down syndrome detection rates?
Quad: 81%
Nuchal translucency + PAPP-A: 82%
cffDNA: 99% (10w to term)
What is the first tri screen?
Nuchal translucency
Beta hcg
PAPP-A
Work-up for patient with nipple discharge (uni) if >30yo
US and mammogram then possible bx
Characteristics of nipple discharge concerning for cancer?
unilateral, uniductal
spontaneous (no manipulation required)
with mass or skin change
bloody
Cut off T and Z scores for osteoporosis
T-score < -2.5
Z-score < -2.0
When to use Z-score instead of T-score
Z-score in patients < 35yo
When to treat for osteoporosis?
if 10yr major fracture risk >20%
or hip fracture risk > 3%
When to start screening for osteoporosis and how often?
65yo
q15 y
What is an omphalocele? Where is is located? What is it associated with?
MIDLINE abdominal wall defect at >12 w
with intestines outside of body, but COVERED by peritoneum
associated with aneuploidy and males
What is gastroschisis? Where is is located? What is it associated with?
abdominal wall defect at >12w, uncovered. to the RIGHT of the umbilicus
bad outcomes, can still deliver VD
no association with aneuploidy
How does obesity change the rates of gastroschisis?
decreases rates
How does ovarian cancer spread?
“exfoliation” or transcoelomic (clockwise in peritoneal cavity)
How does rupture of ovarian cancer intra-op change management?
Up-stage to 1C, needs chemo
Stage that majority of ovarian cancer presents at?
3C (peritoneal implants >2 cm)
Where do the majority of ovarian torsions happen?
right side (64%)
What is the “whirl-pool” sign?
along with an enlarged ovary, this is ovarian torsion
What percentage of ovarian torsions will have normal blood flow on doppler?
60%
What percentage of Americans are obese?
40%
BMI cut-offs for classes of obeseity
Class I: BMI 30-35
Class 2: 35-40
Class 3: >40
What class of obesity qualifies for bariatric surgery?
Class 3 (BMI >40)
Cell marker for choriocarcinoma
hcg
Cell marker for dysgerminoma?
LDH
Cell marker for Yolk sac (endodermal sinus)
AFP
Cell marker for Epithelial ovarian cancer?
ca-125
Cell marker for granulosa cell tumor?
inhibin
Cell marker for mucinous adenoma?
CEA
Cell associated with clear cell
Hob nail
Cell associated with yolk sac (endodermal sinus)
Schiller-Duval
Cell associated with granulosa cell
call-exner bodies
What type of study is odds ratio used in
case-control (retrospective)
When does odds ratio estimate relative risk?
when prevalence is < 5%
How to calculate odds ratio?
AD/BC
At what gestational age is vaccuum assisted delivery contra-indicated?
<34w (vacuum okay)
What type of virus is Parvo?
single stranded DNA
What is Parvo virus associated with in-utero?
SAB, hydrops (from aplastic anemia)
most have NO poor fetal outcomes
How does Parvo present in women?
flu-like symptoms
How to test mom for parvo? what to do if she tests positive?
IgM and IgG for diagnosis
if positive: serial US to look for hydrops + MCA dopplers for anemia
q 1-2 weeks for 8-12 weeks after exposure
What percentage of weight loss is needed to decrease androgens in a patient with PCOS?
5%
How do OCP’s help with hirsutism in PCOS?
(not FDA approved)
increase sex-hormone-binding-globulin which binds androgens, decreased hirsuitism
What is “string of pearls” on TVUS?
+12 follicles per ovary (on periphery)
can be sign of PCOS
When does perinatal depression occur? How long does it last?
within 1 year of delivery, lasts >2w
What percentage of women get perinatal depression?
15% (1 in 7)
Wat percentage of women get PP blues? What is it (timeline)?
40-80%
feeling down within 1 week of delivery, resolves in 2 weeks
What is a normal acid-base status of pregnancy?
Respiratory alkalosis
How much does plasma volume expand at term?
45% (1.5-2L)
How much do RBC increase by at term?
25% (450cc)
How much does SVR decrease by? And how early in pregnancy?
decreased by 35-40% in 1T
How do cardiac output, stroke volume, and HR change in pregnancy?
Cardiac output increases by 20% (in 1T)
Stroke volume increases by 15% (in 1T)
HR increases
How much blood flow does the uterus get a term? in a non-gravid state?
at term: 17% (450-650 cc)
non-gravid: 2%
How much does renal blood flow increase in pregnancy?
increase by 50%
What causes physiologic dyspnea in pregnancy?
increase in tidal volume causes decrease in pCO2 which increases “awareness to breathe”
When does PP cardiomyopathy occur?
last month of pregnancy to 5 months PP
When is anticoagulation needed in PPCM?
when EF <35%
What medication reduces mortality in PPCM?
beta blockers
If unknown etiology of pelvic pain, what percentage of women will have persistent pain after hyst?
40%
How long does pelvic pain have to be there to be considered chronic?
> 6 mo
What percentage of women with chronic pelvic pain have depression?
33%
What percentage of women have chronic pelvic pain?
6-25%
What does the pudendal nerve innervate?
sensory and motor of the perineum
What nerve roots does the pudendal nerve originate from?
S2- S4
What are the branches of the pudendal nerve?
clitoral
perineal
inferior hemorrhoidal
Rate of preterm delivery in US
12%
What percentage of women suffer from PP thyroiditis/
7-8%
What causes postpartum thyroiditis? (timeline)
destructive antibodies within 1y of delivery or abortion releases thyroid hormone
(can be hyper or hypo)
Why doesn’t PTU or methimazole work in PP thyroiditis?
Because it is due to antibodies causing thyroid hormone release, not overproduction
Course and treatment of PP thyroiditis?
self-limited
beta-blockers can be used to relieve symptoms
Pelvis type associated with transverse arrest
platypelloid
Pelvis type associated with vaginal delivery (most common)
gynecoid
Pelvis type associated with male pelvis, least favorable for vaginal delivery
android
Pelvis type associated with OP position
anthropoid
When is a presacral neurectomy indicated?
patient with chronic midline pelvic pain
after failure of OCP’s, NSAIDs, IUD and lupron)
What are the most common complications with pre-sacral neurectomy and how long do these complications last?
urinary retention lasts 1-2w
constipation lasts 6w
What is the dose of rhogam?
300 mcg
How much whole fetal blood dose a regular dose of rhogam cover? How much fetal RBC’s?
Rhogam covers 30 cc of fetal whole blood
15 cc of fetal RBC’s
When should you give PP rhogam?
within 72h of delivery (up to 4w)
How much fetal blood can cause alloimmunization?
0.1 cc
At what gestational age does fetal blood form?
7w3d
How is sickle cell inheritied?
autosomal recessive
Where is the sickle cell mutation?
beta globulin gene
thymine instead of adenine
What is the risk of regret after sterilization?
7%
Which type of sterilization has the highest risk of ectopic pregnancy?
bipolar coagulation (3cm of isthmus)
What are benefits to permanent sterilization apart from contraception?
Decreases ovarian cancer risk
Decreases rates of PID
When does a small bowel obstruction normally present?
4-6w post abdominal surgery
What is the ideal imaging if you suspect SBO?
KUB
or CT with IV and PO contrast
What will show on imaging of an SBO?
dilated loops of bowel with air-fluid levels.
Proximal dilation with distal collapse
What physical exam finding differentiates SBO from ileus?
bowel sounds
hyperactive (high pitched) in SBO
absent in ileus
What is the primary management of SBO?
NG tube and IVF hydration
What is the definition of 2nd stage arrest of labor?
Primip without CLE >3h
Primip with CLE >4h
Multip without CLE >2h
Multip with CLE >3h
When is a steroid taper required?
taking steroids for 3+ weeks or 5+ mg/day
What is a typical steroid burst and taper at delivery?
hydrocortisone 25mg IV q6h.
Bolus at delivery of 100mg IV
then taper to baseline over 3d
What does warfarin do to a fetus and when is it most susceptible?
nasal/midline facial hypoplasia
stippling vertebrae
worst around 8w
What does lithium do to a pregnancy?
ebstein’s anomaly: downward displacement of tricuspid valve
What does valproic acid due to a pregnancy?
NTD
What does meth do to a pregnancy?
FGR
What do Thalidomides do to a pregnancy?
limb abnormalities
What does lisinopril do to a pregnancy and when?
renal agenesis
2 and 3T
When it comes to teratogens, what are the GA cut-offs for when things are occurring that you should keep in mind?
0-4 w: “all or nothing”
4-11 w: organogenesis
12-15 w: CNS
How should you adjust synthroid in a pt with hypothyroidism upon confirmation of pregnancy and why?
increase dose by 25% because hcg in T1 will decrease TSH (T4 stays unchanged)
How often do you follow TSH in pregnancy in a woman with hypothyroidism?
q-4-6w
What pregnancy outcomes can hypothyroidism have on a pregnancy? on a fetus?
SAB
PTD
abruption
PIH
demise
LBW
neurodevelopmental delays
What is the most common TORCH infection?
CMV
What pregnancy outcomes can toxo cause?
microcephaly
Intracranial calcifications
What pregnancy outcomes can varicella cause?
FGR
limb hypoplasia
microcephaly
What pregnancy outcomes can rubella cause?
FGR
cardiac defects
hepatosplenomegaly
What pregnancy outcomes can CMV cause?
FGR venticulomegaly hydrops retinitis intracranial calcifications
What pregnancy outcomes can HSV cause?
FGR
microcephaly
hepatosplenomegaly
What percentage of pregnant women with CMV are asymptomatic?
90%
When is the risk of congenital CMV infection the highest? When is CMV infection the most common?
Highest risk in 1T
Most common in 3T
What is the transplacental transmission rate of CMV?
30-40%
If a pregnant woman gets chicken pox (varicella) at term, what is the treatment?
PO acyclovir within 24h of rash
How much do multifetal gestations increase the risk of PTD?
twins: 6x
triplets: 10x
What is considered discordant growth?
20%
How to calculate growth discordance?
smaller - larger / larger
Which type of zygosity is more common?
dizygotic twins (paternal) are more common than monozygotic twins
If one twin demises >14w, what is the chance of the 2nd twin dying? What is the chance of neurologic deficit? In both mono and di twins?
mono:
chance of death: 15%
chance of neuro deficit: 18%
di:
chance of death: 3%
chance of neuro deficit: 1%
When should you check chronicity in twins?
around 13w
If you have mono twins, when should you start screening for TTTS and how often?
16w, q 2w
Sign for di-di twins? For mo-di twins? Mo-Mo’s?
Di-Di: lamba (Twin peak)
Mo-Di: T sign (thinner)
Mo-Mo: no sign, same sac
When is delivery indicated for mo-mo twins?
32-34w
When is delivery indicated for mo-di twins?
34-37w6
When is delivery indicated for di-di twins?
38w
When do the fetuses separate for each type of twin? (days and cell stage)
Di-di: 1-3 days (morula)
Mo-di: 4-8 days (blastocyst0
Mo-mo: 8-13 days (implanted blastocyst)
conjoined: 13-15 days (embryonic disk)
Definition of thrombocytopenia
PLT < 150
Typical PLT level for ITP?
PLT <100
What percentage of patient with ITP will have severe PPH?
1%
What is the most common type of thrombocytopenia?
gestational
How does gestational thrombocytopenia present?
PLT <150, but greater than 85
incidental finding on routine CBC
What percentages of thrombocytopenias in pregnancy are gestational?
80%
What is 2nd most common cause of thrombocytopenia in pregnancy?
Pre-eclampsia
How often should you repeat labs in a pregnant woman with thrombocytopenia?
q3-4 w
What is the most common acquired thrombophilia?
APAS
What is the most thrombophilic thrombophilia?
Antithrombin deficiency
Which factor in the clotting cascade is decreased in pregnancy (cannot test for this)?
Protein S
Which thrombophilias can you not test if a patient is on anticoagulation?
Factor V leiden
protein C or S deficiency
anti-thrombin deficiency
What percentage of mo-di twins have TTTS?
15%
What are the stages of TTTS
1 = poly-oly 2= absent bladder in donor twin 3= doppler abnormalities 4= hydrops 5= death
What is the treatment for a TOA?
Cefoxitin 2g IV q6h +
Doxy 100 mg PO or OV q6h
If no improvement of TOA after 72h of ABX, what is the next step?
IR drainage
Who needs anticoagulation in pregnancy?
Women with a personal h/o VTE AND anti-thrombin deficiency will need lovenox during preg and 6w PP
Women with a personal h/o VTE AND all other def will need it PP for sure, intra-partum is per case
Most common presenting signs of urethral diverticulum?
dribbling
dyspareunia
dysuria
What percent of women will have recurrent UTI’s?
3-5%
What is the definition of recurrent UTI’s?
> 2 UTI’s in 6 mo
or
3 UTI’s in 1 year
What is the most effective treatment to prevent recurrent UTI’s?
1) macrobid 50-100mg PO daily (or postcoital)
2) bactrim 40/200 daily
After ABX PPX, what other evidence based methods exist for preventing recurrent UTI’s?
drink >1.5 L per day vaginal estrogen (if postmenopausal)
What is the Cr level of urine?
> 17
What is the gold standard to diagnose ureterovaginal fistula?
IV Pyelogram
What is the gold standard to diagnose urethrovaginal fistula?
cysto
What dose of Vit D is in PNV?
400 IU (but need 600 IU daily)
What dose of iodine is needed daily in pregnancy?
220 mcg
What is the most important prognostic factor in sqCC of the vulva?
lymph node invasion!
inguino-femoral
What is the most important prognostic factor in melanoma of the vulva?
depth of invasion
How does vaginal cancer spread?
direct
lymphatically
and hemotogenously
Which lymph nodes do the lower 1/3 of the vagina drain into? The upper 2/3?
lower 1/3: inguinal nodes > femoral nodes
upper 2/3: external/internal iliac nodes
What risk factors of vulvar abscess necessitate I&D + IV ABX?
DM, immunosuppression of patient
>5 cm
involving other compartments
recurrent
**cover for MRSA
Recommended weight gain in pregnancy
Under weight BMI <18.5: 28-40#
Normal BMI 19-25: 25-35#
Overweight BMI 25-30: 15-25#
Obese: BMI >30: 11-20#
5 W’s and timeline of post-op fever
Wind (PNA, atelectasis): POD#1-2 Water (UTI): POD#2-5 Wound (SSI): POD#5-7 Walking (DVT) : POD#5+ Wonder drugs: anytime
What antigen is associated with Kell alloimmunization? Where does it come from?
K1 antigen, comes from blood transfusions
If a pregnant woman tests + for Kell ab, what next?
Test dad.
If negative, no work-up.
If positive, MCA doppler’s q2w (from 18w-35w)
What abnormal MCA doppler level necessitates a fetal transfusion?
MoM > 1.5
