Andrea Crunch Time Flashcards
Factors affecting placental transfer of drugs
- Molecular Weight
- Degree of ionization
- Lipid Solubility
- Protein binding
- Fetal and placental blood flow
Complications of Rad Tracheolectomy (Long Term)
dysmenorrhea (most common) AUB recurrent candidiasis cervical suture erosion isthmic stenosis prolonged amenorrhea
Benefits of Primary Surgery vs Primary chemo/rads in 2B1 cervical cancer.
Accurate Staging
Preserve the ovaries
Option to resect bulky nodes
Considerations when arranging patient transfer
Clarify who is calling, contact info in case disconnected
Where are they located/distance to travel
Weather conditions
Who can accompany the patient
land vs air transport
what pre transfer medications might be needed
What pre transfer investigations needed
Request records to be sent ahead/along with pt
CF:
- Carrier rate
- Protein affected, pathophys effect
- Best predictor of pregnancy outcome and longterm maternal outcomes
- 1/25 caucasian
- CFTR gene mutation (affects chloride channel causing altered epithelial cell membrane transport of electrolytes)
- Pulmonary function
CF:
- Predictors of poor outcome
- Maternal risks in pregnancy
1. Predictors of poor outcome Pulmonary hypertension Cyanosis FEV 1 < 60 Poor nutrition 2. Maternal risks in pregnancy - diabetes - heart failure - pulmonary infection
CF
- why might we recommend an assited 2nd stage?
- Can they breastfeed?
- risk of pheunothoraces a/w prolonged valsalva
2. yes, need inc caloric intake due to metabolic demands of BF and malnutrition from pancreatic dysfcn.
HDoP
- What is the maximum dose of Hydralazine?
- NNT to prevent a seizure in severe preeclampsia and mild preeclampsia
- 20mg IV
2. 50 and 100
Renal Transplant
1. Feto-Maternal risks
IUGR, PTD
HDoP, infection,
Renal Transplant
1. 2 most important predictors for pregnancy
kidney function
HTN
Renal Transplant
1. Pre-conceptual recommendations before proceeding with pregnancy (a/w 90% live birth rate)
- Stable for 1-2 years post transplant
- Optimal Graft function (Cr < 130, protein < 500mg/day)
- no evidence of rejection in 1 yr
- anti rejection meds have been stable and are not teratogenic
- HTN absent or well controlled
- normal graft US
CMV infection excluded
Indications for elective CS in a patient with HIV (8)
- not on HAART
- monotherapy
- viral load > 1000
- unknown viral load, older than 1 month
- inadequate prenatal care
- Pt request
- High risk of a traumatic delivery
List 4 structural defects that would cause elevated MSAFP with a normal NIPT.
Abdominal Wall Defect (omphalocele, gastroschisis) Osteogenesis Imperfecta Sacrococcygeal Teratoma Bladder extrophy Cystic Hygroma renal anomalies urinary or intestinal obstruction
When do you assess NT and what is normal?
CRL 45-84mm or BPD < 26mm
< 3mm
What are 3 causes of thickened NT
Aneuploidy Single gene disorders (Noonan's) - Skeletal Dysplasia - TTTS - Structural anomalies (cardiac, cystic hygroma, diaphragmatic hernia)
In Cystic Hygroma what is the chance of structural anomalies elsewhere and what 2 systems are involded?
50%
cardiac, renal
- What is the likelyhood ratio of T21 with Thickened Nuchal Fold
- What is a normal nuchal fold at 16-18 weeks, 18-24 weeks
- 17
- 16-18 weeks: < 5mm
18-24 weeks: < 6mm
What are the soft markers for T21 and their LRs (8)
What are 2 other US findings specific to T21?
Thickened NT (17)
Ventriculomegaly (9)
Echogenic Bowel (6)
EIF (2)
CPCs *(7 for T18)
Hypoplastic nasal bone (LR51)
AVSD ( 50% risk in T21)
What are 4 complications of doing amnio too early? When should it be done?
- oligo
- club feet
- ROM
- failed culture
15-20 weeks
DDx of a fetal neck mass
Fetal Goiter
Cervical Teratoma
Cervical hemangioma
Thyroid cyst
In Omphalocele what 2 investigations should be done?
Echo: cardiac anomalies 50-70%
karyotype - 30-70% a/w with aneuploidy, if liver in body
T18 findings
CPCs
Rocker Bottom Feet
Overlapping digits
AVSD
most common cause of Keyhole Bladder on US
- most common cause of mortality
Posterior Urethral valves
pulmonary hypoplaisa,
longterm renal failure
3 risks of single umbilical artery
renal anomaly
cardiac anomaly
IUGR
What causes cloverleaf skull
- thanatophoric dysplasia, lethal skeletal dysplasia
- MTX
What can cause a FP Kleihaur Betke?
any of the hemaglobinopathies
What fraction of twins overall are monozygotic
What are the abn doppler findings in Quintero stage 3
1/3 vs 2/3
Donor: UAPI A or REDF
Recipient: DV a wave reversal
T13 findings (3)
Holoprosencephaly
Polydactyly
Cyclopia
What does a diaphragmatic hernia look like on US?
How do they stratify prognosis?
Other associated risks?
- heart and lung in same pic, heart next to something echoic.
- lung to head ratio
- aneuploidy, cardiac anomalies, also renal
- Toxoplasmosis triad
- Diagnosis
- Treatment
- Hydrocephalus, IC calcifications, chorioretinitis
- T gondii present in amniotic fluid
- Prophylaxis: Spyramycin
Mat/Fetal infection:
- Pyrimethamine
- Sulfadiazine
- folinic acid rescue
Rubella
- What is the risk of CRS < 12 weeks and > 16 weeks?
- 3 manifestations of CRS at birth
1. < 12 weeks 90% > 16 weeks 0% 2. - Purpura (blueberry muffin rash) - chorioretinitis - sensorineural hearing loss - cardiac defects - microcephaly
- what is the most common cause of IU perinatal infection?
- CMV
CMV
- Whats the risk of transmission with primary infection and secondary infection?
- What percentage of congenitally infected infants have symptoms at birth? What are they?
- Of the Asymptomatic how many develop later sequelae?
- when do you do the Dx amnio?
30-40%
1%
2. 10-15% chorioretinitis sensorineural hearing loss HSM microcephaly petechia
up to 15%
> 21 weeks GA, 7 weeks after maternal infection
HSV
- risk of transmission in recurrent HSV with and without lesions at time of delivery
- Benefits of suppressive Tx
2-5%
0.02-0.05% (< 1%)
- less clinical lesions
- less asymptomatic shedding
- less need for CS
- maybe dec risk neo HSV
HSV suppression in pregnancy?
Acyclovir 400mg PO TID starting at 36 weeks.
3 ways to test for Syphilis
- non treponemal (screening, VDRL)
- direct visualization spirochetes (darkfield microscopy)
- treponemal antibody test (TPPA)
3 causes of FP VDRL
SLIMHART
- SLE
- Lyme Disease
- Infectious mono
- Malaria
- HIV, Hep B
- APLAS
- Rheumatic Fever
- Tropical Eosinophilia
Features of Congenital Syphilis
Hepatic dysfcn: - Jaundice - HSM - thrombocytopenia - purpuric skin lesions Placentomegaly rhinitis pneumonia myocarditis nephrosis
Late: hutchison’s teet, saddle nose, saber shins, mulberry molars
Treatment of Syphilis
alternative if allergy testing + and unable to desensitize
What reaction is caused by release of spirochetes systemic post treatment?
- Pen G 2.4 mu IM x 1 (can do second dose 1 week later)
- Doxycycline
- Jarisch-Herxheimer
2 maternal indications for newborn treatment in Gestational Syphilis
- untreated
- serologic evidence relapse/infection
- treatment was with erythromycin (as does not cross placenta)
- treatment within 1 month of delivery
- insufficient FU in pregnancy
- baby gets aqueous Pen G
features of congenital varicella (3)
- chorioretinitis
- micropthalmia
- cerebral cortical atrophy
- IUGR
- hydronephrosis
- limb hypoplasia
- cicatricial skin lesions
- hydronephrosis
Treatment of varicella in pregnancy?
- VZIG within 96h of exposure to 5 days
- IV Acyclovir if hospitalized with pneumonia
- What is the risk of fetal loss in Parvovirus?
- What is the most common maternal symptom?
< 20 weeks 15%
> 20 weeks 2%
75% asymptomatic, Arthralgia most common symptom
3 ways to control for counfounders
Randomization
Matching
Restriction
Post vasectomy advice
Contracept until 3 month TOC, need min 20 ejaculations
Which chemos can cause extravasation?
paclitaxel
actinomycin
doxurubicin
5 neonatal features indicative of an IP asphyxia
a. Sentinal hypoxic event intrapartum
b. Prolonged bradycardia or absence of variability and persistent late decelerations in a previously normal FHR tracing
c. Apgars 0-3 at greater than 5mins of life
d. Evidence of multi system involvement within 72 hours
e. Early imaging shows acute non focal cerebral anomaly
3 acute complications of pelvic radiation
a. Acute radiation Cystitis
b. Acute Radiation Colitis
c. Acute vaginal mucositis
4 mechanisms for drug to cross placenta
a. active transport
b. simple diffusion
c. facilitated diffusion
d. endocytosis
Respiratory Changes in Pregnancy
Reduction in
- functional residual capacity -
- expiratory reserve volume (ERV)
- residual volume (RV)
increases in
- inspiratory capacity (IC)
- tidal volume (VT).
Indications for a cone biopsy
Biopsy proven
- CIN 2
- CIN 3
- AIS
- micro invasion
Cytology:
- AGC-favor neoplasia
- AIS
- neg colpo/ECC
Cytology HSIL and histology normal or CIN 1
Classification of renal insufficiency
- Cr < 125 = mild chronic renal insufficiency
- Cr 125-250 = moderate
- Cr > 250 = severe
Vaginal Cancer Staging
I Vaginal wall II Subvaginal Tissue III Pelvic wall IV - A extension out of true pelvis, bladder/rectum - IB distant spread
Stage I Cx Cancer
1A: microinvasive
1A1 - < 3mm in, < 7mm width
1B1 - 3-5mm, < 7mm
1B: early, clinically visible
1B1 - < 4cm
1B2 - > 4cm
Stage II Cx Cancer
2A: no parametrial
- A1 < 4 cm
- A2 > 4cm
2B obvious parametrial invasion
Stage III Cx Cancer
3A
lower 1/3 vag, no pelvic sidewall
3B
pelvic sidewall, hydronephrosis/bum kidney
How does Heparin work?
Inhibits thrombin
First line tx for OAB
name 2 other options
Oxybutynin 5mg BID
- Tolterodine
- Trospium
- Solifenacin
CI to anticholinergic treatment of OAB
Absolute:
- urinary retention
- gastric retention
- uncontrolled narrow angle glaucoma
- known hypersensitivity
Relative:
- high PVR
- controlled NAG
- impaired cognition
- reduced renal or hepatic function
- ETOH abuse
- constipation
- Myasthenia Gravis
Treatment VVC
Uncomplicated:
- Clotrimazole 1% x 7 days or 2% x 3 days
- Fluconazole 150mg X 1
Recurrent: - Induction: Clotrimazole x 14 days Fluconazole 3 doses 72h apart Boric acid 300 mg 14 days
- Maintenance
Monthly Clomitrazole 500mg
Weekly Fluconazole 150 mg
Boric acid Day 1-5 of cycle - Non Albicans
Boric Acid 300mg nightly x 14 days
3 causes of non albicans VVC
Glabrata, parapsolosis,
Tropicalis
Most common benign, persistent adnexal mass in pregnancy?
Mature Teratoma
Non pharmacologic causes of hyperprolactinemia
a. Pregnancy and Breastfeeding
b. Pituitary adenoma
c. Chest Wall trauma
d. Hypothyroidism
e. Renal Failure
f. Stress
Most common causes secondary amenorrhea
PREGNANCY Hypothalamic - tumor or functional Pituitary - tumour, Shehan's Hypothyroidism Ovarian - PCOS, POI Asherman's
Hill’s Criteria for Causation
a. Reproducibility
b. Plausibility
c. Temporality
d. Specificity
e. Strength of association
f. Dose response relationship
g. Experiment
h. Coherence
3 structures not susceptible to teratogens after the embryonic period.
a. Spine
b. Heart
c. Palate
Risk Factors for endometrial cancer
a. Obesity
b. Infertility
c. Anovulation
d. Exogenous estrogen
e. Nulliparity
f. Age > 60
g. Family history of BRCA or Lynch syndrome
Plan in fertility sparing treatment of FIGO Gr I endo Ca
a. MRI to assess depth of invasion
b. Consider D & C due to 30% risk higher grade disease than indicated on biopsy
Couselling
i. 30% risk disease is more aggressive than indicated on biopsy
ii. Chance the disease will progress on progestin treatment
iii. If it does respond, 25% chance of recurrence
Treatment
i. High dose progestins (Megace 160 mg daily) x 3 months
ii. Pelvic US and endometrial biopsy q3months
e. Definitive management post childbearing (Hysterectomy BSO)
Risk Factors for Placenta Previa
Previous Placenta Previa Previous CS Previous myomectomy Age > 35 Multiparity Multiples Smoking IVF
Risk Factors for Placenta Accretta
Previous Placenta previa Previous CS Previous myomectomy Age > 35 Submucosal Fibroid Asherman's Syndrome
Wickham striae
mucous membrane involved
VV
Lichen Planus
Treatment of vulvodynia
Treat underlying cause Pelvic floor physio Meds: - Topical xylocaine - tricyclic antidepressants - Gabapentin - SSRIs Surgery if refractory
Most common cancers in pregnancy
Breast
Thyroid
Cervix
Medical complications of a Dermoid
Struma ovarii
Carcinoid Syndrome
NMDA-receptor encephalitis
How to diagnose maternal Rubella
- 4-fold increased in IgG titres between acute and convalescent serum
o titres best done within 7-10d of rash and repeated 2-3 weeks later - positive rubella-specific IgM
- positive rubella culture (viral)
o nasal, throat, urine, CSF
o may be positive from 1 week before to 2 weeks after rash
Risk of transmission to fetus with HSV
Primary infection in T3: 30-50%
Recurrent, with lesion 2-5% (SVD)
Recurrent, without lesion 0.02-0.05% (SVD)
Treatment for Placental Site Trophoblastic Tumor
Hyst only unless mets
Dose of epinephrine in acute anaphalactic reaction
Epinephrine 0.3-0.5ml of 1:1000 (1mg/ml) IM or SC
Causes of total hair loss
Alopecia areata (universalis) Telogen effluvium Chemotherapy Radiation therapy Thyroid disease Lupus
In hyst for CPP and no identifiable pelvic pahtology, what percentage of women will have ongoing pelvic pain?
40%
Mullerian Agenesis - other anomalies
a. renal anomalies (double collecting system)
b. skeletal anomalies (cervical vertebral anomalies)
c. unilateral hearing loss
d. cardiac anomalies (VSD)
3 causes of CAH
- 21 hydroxylase deficiency
- 11B hydroxylase deficiency
- 3B hydroxysteroid dehydrogenase Type 2 deficiency
3 causes 46XX DSD
- CAH
- gestational hyperandrogenism (maternal luteoma, placental aromatase enzyme deficiency)
- ovotesticular DSD (formerly true hemaphrodism)
3 causes 46XY DSD
- Partial gonadal dysgenesis (Incomplete/Partial AIS)
- Ovotesticular DSD (formerly true hemaprhodism)
- uncommon forms of CAH
- 5 alpha reductase deficiency
4 histologic criteria for diagnosis of endometriosis?
a. Endometrial glands and stroma found outside the uterus
b. Need >2 for diagnosis:
i. Endometrial epithelium
ii. Endometrial glands
iii. Endometrial stoma
iv. Hemosiderin laden macrophages
Management of PSTT
GO
Hyst
(not chemosensitive)
Maximum dose of bupivicaine
2mg/kg no EPI
3mg/kg w/ EPI
Common Chemo’s by MOA
Alkylating agents - cyclophosphamide Antitumor antibiotics - D'actinomycin - Doxorubicin Antimicrotubule agents - Taxels Topoisomerase inhibitors - Etoposide
Trade name of Diane 35
Cyproterone acetate
3 chemos that cause extravasation injury
Paclitaxel
Actinomycin D
Doxorubicin
4 pelvic shapes
Gynecoid (OA)
Anthropoid (OP)
Platypelloid (OT)
Android (heart)
Rate of malignant transformation in dermoid
0.2-2%
The blood test used to test vaginal bleeding to see if fetal or maternal (in setting of ?vasa previa)
APT test
Indications for RT in endometrial Ca (5)
a. FIGO Grade 3 endometriod Cancer (adjuvant brachy)
b. Stage II endometrioid Cancer (adjuvant brachy)
c. Recurrence at the vaginal vault (salvage radiation)
d. Lymphovascular space invasion
e. Outer 1/3 myometrial invasion
RF for endometritis (4)
a. Ceserean Section (#1 risk)
b. IP chorioamnionitis
c. Prolonged ROM
d. Manual removal of the placenta
CI to regional anesthesia
a. refractory maternal hypotension
b. maternal coagulopathy
c. Thrombocytopenia Plt < 70
d. LMWH within 12 hours
e. Untreated maternal bacteremia
f. Skin infection over site of needle placement
g. Increased IC pressure s/t mass lesion
High Spinal Management
b. Support blood pressure with vasopressors and/or inotropes as needed (anesthesiologist should be involved)
c. Left uterine displacement to minimize aorto-caval compression
d. Ventilation and O2, consider need for intubation
1 investigation needed before starting ocp
BP
4 types of meds which affect OCP effectiveness
Anticonvulsants
Antiretrovirals
Rifampicin
Griseofulvin
DDX of AUB on ocp
irregular pill taking concomittant medication use malabsorption uterine or cervical pathology pregnancy chlamydia
Advice if missed pill
< 24h no problem
During week 1:
- back up 7 days
- consider EC
During week 2/3
- skip the hormone free interval that pack
- *if 3+ pills missed you need to also back up 7 days, consider EC
Category 4 CI to OCP
CV Stuff:
- Hx Stroke
- Migraine with Aura
- Hx Ischemic heart disease
- Complicated Valvular disease (pulm htn, a fib)
- Peripartum cardiomyopathy
- HTN (> 160/100)
- Vascular disease
Clot Stuff:
- Acute DVT/PE or Hx VTE
- known thrombophilia
- SLE with + APLAS abd
Active breast Ca
Liver Stuff:
- severe cirrhosis
- hepatocellular carcinoma
- malignant hepatoma
Complicated solid organ transplantation (graft failure)
Breastfeeding:
- < 4 weeks PP (BF)
- < 21 days PP (not BF)
Smoking > 35 y/o, > 15 ciggs/day
Major Sx with prolonged immobilization
ER contraception options
Cu-IUD (7d)
UPA-EC 30mg (5d)
LNG-EI 1.5mg (5d)
Yuzpe - target 100mcg ethinyl estradiol
Risk Factors for Cx Insufficiency
a. Recurrent T2 loss
b. Prior PTB
c. Prior PPROM < 32 weeks
d. Prior short cervix < 25mm before 27 weeks
e. Cx procedures
f. Mullerian anomalies
g. DES exposure in utero
h. Maternal connective tissue d/o
Components of a systematic review
a. Focused Clinical Question
b. Comprehensive search strategy
c. Clear inclusion/exclusion criteria
d. Quality assessment of studies
e. Systematic Synthesis
Teratogenic effects of ACE (3)
a. Cardiac defects (ASD)
b. CNS malformations (hypocalvaria)
c. Renal tubular dysplasia
3 risks of advanced paternal age
Autosomal dominant conditions
- achodroplaisa
- Pfeiffer syndrome
- Crouzo syndrome
- Apert syndrome
Criteria for CPP
a. Duration > 6 months
b. Incomplete relief from most treatments
c. Interferes with activities of daily living
d. Altered family roles
e. Signs of depression
Treatment of NVP
Non Rx:
- ginger
- acupuncture
- psychotherapy
Rx:
- 1st line: Diclectin
- 2nd line: dimenhydrinate
- 3rd line: Metoclopramide or Prochlorperazine 5-10mg q6-8h
IVF if needed
Minimal safe rad dose
5 rads / 0.05 Gy
VTE risk in OCP
healthy pop age 24: 5 /10 000
- cOCP: 10 /10 000
- Pregnancy: 30 /10 000
- Post: 300 /10 000
Reasons to test for BRCA
a. Female Breast CA < 50
b. 2 or more primary breast cancers
c. Male breast ca
d. 1 or more first degree relatives with breast ca diagnosed at < 50
Conservative management Accretta
- IAL
- uterine embolization
- oversew placental bed if localized
- utero-vaginal packing
- leave placenta in place and follow
3 accepted indication for HRT in menopausal patient
1) Vasomotor symptoms
2) Osteoporosis
3) Urogenital Atrophy
