Case files Flashcards
MC cause of PPH:
MC cause of PPH in a firm, well-contracted uterus:
MC cause of PPH: uterine atony
MC cause of PPH in a well-contracted uterus: genital tract laceration
32yo woman has severe PPH that does not respond to medical therapy. she desires future childbearing.
which artery is ligated to achieve therapeutic goals?
hypogastric artery
-decreases pulse pressure to the uterus
MC cause of late PPH (after first 24 hours):
subinvolution of the uterus
contraindication for ergot alkaloids:
contraindication for PGF2a:
contraindication for ergot alkaloids: hypertension
contraindication for PGF2a: asthma
MC cause of abnormal serum screening:
wrong dates
- U/S at 20 weeks reveals hydramnios with AFI of 30 cm
- fetal abdomen reveals cystic masses in both R and L abdominal regions
most likely associated condition?
“double bubble” sign of duodenal atresia
associated with Down syndrome
pregnancies with elevated AFP, which after evaluation are unexplained, are at increased risk for: (4)
- increased risk for stillbirth
- growth restriction
- preeclampsia
- placental abruption
next step in the evaluation of abnormal triple screening:
basic ultrasound
up to 95% of neural tube defects are detectable by:
targeted sonography
- 32yo G1P0 pregnant with triplets
- arrives at L&D at 30 weeks with preeclampsia
- complains of dyspnea, 82% on room air
tx?
IV furosemide
- pt likely has pulmonary edema due to the preeclampsia as well as the increased plasma volume due to the multiple gestations
- pt should be placed on IV furosemide to decrease intravascular volume, magnesium sulfate for seizure prophylaxis, and plans made for delivery
causes rapid fetal demise after rupture of membranes
vasa previa
prenatal diagnosis of vasa previa is best made by:
mgmt: planned cesarean (before/after) rupture of membranes
U/S with color Doppler
mgmt: planned cesarean BEFORE rupture of membranes
rationale for oral acyclovir therapy at the primary outbreak:
decrease viral shedding and the duration of infection
postcoital spotting is a common complaint in a pt with placenta ______
postcoital spotting is a common complaint in a pt with placenta PREVIA
the best plan for placenta previa at term is:
cesarean delivery
diagnostic test of choice in assessing placenta previa, and should be performed before speculum or digital exam:
U/S
placenta previa, in the face of prior cesarean deliveries, increases the risk for placenta _______
placenta previa, in the face of prior cesarean deliveries, increases the risk for placenta ACCRETA
T/F
when placenta previa is dx’d at an early gestation, such as the 2nd trimester, repeat sonography is warranted since many times the placenta will move away from the cervix (transmigration)
TRUE
major risk factors for placental abruption: (3)
HTN (MC)
trauma
cocaine use
MC cause of antepartum bleeding with coagulopathy:
placental abruption
- abnormal adherence of placenta to uterine wall due to an abnormality of the decidua basalis layer of the uterus
- the placental villi are attached to the myometrium
placenta accreta
abnormally implanted placenta invades into myometrium
placenta increta
- abnormally implanted placenta penetrates entirely through the myometrium to the serosa
- often invades into bladder
placenta percreta
risk factors for placenta accreta: (6)
- low-lying placentation or placenta previa
- prior cesarean scar
- uterine curettage
- fetal Down syndrome
- age ≥35 y
- markedly increased risk if multiple cesareans with placenta previa
T/F
placenta accreta is more common with increasing number of cesareans and placenta previa
TRUE
T/F
In general, myomectomy incisions on the serosal (outside) surface of the uterus do not predispose to accreta because the endometrium is not distrubed.
TRUE
However, the risk of accreta is not decreased due to the myomectomy either..
the usual mgmt of placenta accreta is:
hysterectomy
placenta accreta is assoc with a defect in the _______ _______ layer
placenta accreta is assoc with a defect in the DECIDUA BASALIS layer
T/F
Low-lying or marginal placenta previa diagnosed in the 2nd trimester will often resolve later in pregnancy, so repeat sonography is prudent.
TRUE
T/F
Ovarian torsion is the most frequent and serious complication of a benign ovarian cyst.
TRUE
tx of ovarian torsion:
if reperfusion cannot be restored:
tx of ovarian torsion: untwisting adnexa (reperfusion restored!) –> ovarian cystectomy
if reperfusion cannot be restored: oophorectomy
leading cause of maternal mortality in the first and second trimesters:
ectopic pregnancy
T/F
Typically, the pain of a degenerating fibroid is localized over the leiomyoma.
TRUE
Fibroids of the uterus can be assoc. with red or carneous degeneration during pregnancy due to the estrogen levels leading to rapid growth of the fibroid. The fibroid outgrows is blood supply leading to ischemia and pain.
Which of the following is the earliest indicator of hypovolemia?
A. Tachycardia B. Hypotension C. Positive tilt D. Lethargy and confusion E. Decreased urine output
E. Decreased urine output
- Renal blood flow is decreased with early hypovolemia as reflected by decreased urine output
- Compensatory mechanism to make blood volume available to the body
- (+) tilt test is typically noted before tachycardia or hypotension
- By the time hypotension is noted at rest in a young, healthy pt, 30% of blood volume is lost
when the corpus luteum is excised in a pregnancy of less than 10 to 12 weeks gestation, what should be supplemented?
progesterone
Placenta does not take full responsibility till at least 10 weeks gestation.
T/F
Intrahepatic cholestasis in pregnancy may be assoc. with increased perinatal morbidity, especially when accompanied by jaundice.
TRUE
Aside: Women with ICP may have slightly elevated liver enzymes, but almost never in the thousands.
T/F
PUPPP is not thought to be assoc. with adverse pregnancy outcomes.
TRUE
T/F
Neonatal lesions are sometimes seen with herpes gestationis caused by IgG Abs crossing the placenta, and these lesions will resolve.
TRUE
Which of the following is most consistent with acute fatty liver of pregnancy?
A. elevated serum bile acid levels
B. Hypoglycemia requiring multiple D50 injections
C. Proteinuria of 500 mg over 24 hours
D. Oligohydramnios
B. Hypoglycemia requiring multiple D50 injections
Because of the liver insufficiency, glycogen storage is compromised leading to low serum glucose levels, which often require multiple doses of dextrose.
MC cause of maternal mortality:
thromboembolism
most important method of preventing DVT after cesarean:
early ambulation
MC side effect of long-term heparin use in pregnancy:
osteoporosis
accurate method to diagnose DVT:
venous duplex Doppler sonography
which tocolytic is assoc with decreased amniotic fluid and oligohydramnios? –> cord compression –> repetitive variable decels
indomethacin
SEs of ß-agonist tocolysis: (4)
- tachycardia
- widened pulse pressure
- hyperglycemia
- hypokalemia
the earliest sign of chorioamnionitis is usually:
fetal tachycardia
T/F
Labor is the most common complication assoc with PROM.
TRUE
T/F
Listeria may induce chorioamnionitis without rupture of membranes.
TRUE
When fetal lung maturity is demonstrated on vaginal amniotic fluid by the presence of phosphatidyl glycerol (PG), what is the next best step when there is leakage of fluid?
delivery (induction of labor)
T/F
MC finding with PPROM is variable decels.
and why?
TRUE
variable decels likely due to oligohydramnios from the rupture of membranes
- insufficient fluid to “buffer the cord” from compression
- often alleviated by changing pt’s position
pregnancies complicated by PPROM and chorioamnionitis should be tx with:
broad-spectrum abx and delivery
like ampicillin and gentamicin
T/F
Clinical infection is a contraindication fro corticosteroid use.
TRUE
One of the earliest signs of fetal hydrops is:
hydramnios, or excess amniotic fluid
- uterine size may be greater than dates
- fetal parts difficult to palpate
sinusoidal heart pattern assoc with:
severe fetal anemia or asphyxia
T/F
Rh isoimmunization can lead to significant fetal anemia is the baby is Rh(+).
TRUE
T/F
hydramnios is assoc with problems with fetal swallowing or intestinal atresias, or assoc with hydrops.
TRUE
MC method to diagnose acute fifth dz (Parvovirus infection):
IgM and IgG serology
MC cause of conjunctivitis in the first month of life:
chlamydial conjunctivitis
T/F
Chlamydia has a propensity for columnar and transitional epithelium, and it is a leading cause of preventable blindness worldwide.
T/F
Chlamydia is an obligate intracellular organism assoc with late postpartum endometritis and has a long replication cycle.
TRUE x2
tx for preventing gonococcal eye infection vs. chlamydial infection:
gonococcal eye infection: erythromycin eyedrops
chlamydial infection: systemic erythromycin
best tx of chlamydial cervicitis in pregnancy: (3 options)
erythromycin
azithromycin
amoxicillin
the postpartum pt is unique in that the cause of hyperthyroidism is usually:
lymphocytic thyroiditis, NOT Graves dz
-therefore, antimicrosomal and antiperoxidase Abs are present
MC cause of septic shock in pregnancy is:
pyelonephritis
when dyspnea occurs in a pregnant woman who is being treated for pyelonephritis, ____ should be considered
when dyspnea occurs in a pregnant woman who is being treated for pyelonephritis, ARDS should be considered
cause of ARDS assoc with pyelonephritis:
endotoxin release from gram(–) bacteria (eg, E. coli)
next diagnostic test performed on cesarean pt whose fever persists despite triple abx therapy:
CT - looking for septic pelvic thrombophlebitis (SPT)
tx for SPT:
antibiotic therapy + heparin
the presence of fluctuance in a red, tender, indurated breast suggests:
tx?
abscess
tx: surgical drainage
T/F
Breast engorgement rarely causes high fever persisting more than 24 hours.
TRUE
all women with gestational DM should have a screening test at 6 weeks postpartum.. what is the optimal test?
2-hour 75-g GTT
first line therapy for GDM:
gold standard tx for those who fail dietary tx:
first line therapy for GDM: diet!
gold standard tx for those who fail dietary tx: insulin
reasonable approach to avoid repeat abruption:
induction at 37-38 weeks
T/F
The thyroid gland is not affected by hyperprolactinemia; rather, hypothyroidism can lead to hyperprolactinemia.
TRUE
tx for uncomplicated cystitis:
TMP/SMX (3-day course)
T/F
Asymptomatic bacteriuria has a high incidence in women with sickle cell trait.
TRUE
tx of choice for women with symptomatic uterine leiomyomata who DESIRE pregnancy:
myomectomy
tx for women with symptomatic uterine fibroids when future pregnancy is UNDESIRED:
hysterectomy
rapid growth of leiomyoma or h/o prior pelvic radiation should raise the index of suspicion for:
leiomyosarcoma
a progesterone level greater than __ reflects a normal IUP
a progesterone level greater than 25 reflects a normal IUP
best contraception for pt who is breast-feeding:
progestin-only pill
minipill
best contraception for pt with sickle cell dz or epilepsy:
injectables
eg, depot medroxyprogesterone acetate
OCPs decrease the risk of _______ and ___________ cancer
OCPs decrease the risk of OVARIAN and ENDOMETRIAL cancer
T/F
The contraceptive patch may be assoc with a greater risk of DVT.
TRUE
most important risk factor for breast cancer:
age
when the fluid from a breast cyst is straw-colored or clear and the mass disappears, what’s the next step?
when the fluid is a different color (eg, bloody):
or mass persists:
straw-colored or clear and mass disappears: no further therapy is needed
different color (eg, bloody): send fluid for cytology mass persists: biopsy
MC cause of unilateral serosanguineous nipple discharge from a single duct:
intraductal papilloma
accepted methods of assessing suspicious mammographic nonpalpable masses:
stereotactic core biopsy
needle-localization excisional biopsy
definitive diagnosis of IUA can be made with: (2)
gold standard for the establishment of the diagnosis and extent of intrauterine adhesions (Asherman syndrome):
ideal tx for Ashermans:
definitive dx: saline infusion sonohysterogram (SIS) or hysterosalpingogram
gold standard: hysteroscopy
ideal tx: operative hysteroscopy (resection)
T/F
Primary hypothyroidism can lead to hyperprolactinemia.
TRUE
tx with thyroxine
elevated prolactin levels (stimulate/inhibit) GnRH pulsations from the hypothalamus –> ?
elevated prolactin levels INHIBIT GnRH pulsations from the hypothalamus –> decreased release of FSH and LH –> no estrogen or progesterone released from ovaries –> amenorrhea
most sensitive imaging test to assess pituitary adenomas:
MRI
MC causes of secondary amenorrhea after postpartum hemorrhage:
Sheehan syndrome intrauterine adhesions (Asherman syndrome)
primary mgmt for irregular cycles (and also help to decrease androgen levels):
combined OCPs
what diagnostic test should be considered in pts with long-standing anovulation and unopposed estrogen?
endometrial biopsy
tx for infertility assoc with PCOS:
clomiphene citrate
which hormone would be elevated in a female with gonadal dysgenesis (Turner syndrome)?
why?
FSH
streaked ovaries –> no estrogen production (causes elevated FSH)
tx for idiopathic precocious puberty:
GnRH agonist therapy
most important initial test for any female with primary or secondary amenorrhea:
pregnancy test
next step in diagnosis for mullerian agenesis:
serum testosterone, or karyotype
- normal breast development
- normal axillary and pubic hair
- absent uterus and blind vagina
- normal testosterone level
- 46,XX
- renal anomalies
Dx?
mullerian agenesis
- normal breast development
- scant or absent axillary or pubic hair
- absent uterus and blind vagina
- high testosterone levels (male range)
- 46,XY
- need gonadectomy
androgen insensitivity syndrome
testicular feminization
MC causes of primary amenorrhea in a woman with normal breast development:
androgen insensitivity (scant axillary and pubic hair) mullerian agenesis (assoc with renal anomalies)
