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Case files Flashcards

1
Q

Scalp stimulation inducing an acceleration highly correlated to what

A

a normal umbilical cord pH (>/= 7.2)

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2
Q

Late decelerations suggest what

A

Fetal hypoxia, and if recurrent (>50% of uterine contractions) can indicate fetal acidemia

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3
Q

How long should the latent phase of labor last

A
  • less than 18-20 hours for Nullipara

- less than 14 for multipara

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4
Q

The most common decelerations are variable, caused by what

A

cord compression

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5
Q

definition of postpartum hemorrhage

A

blood loss of >500 mL with a vaginal delivery

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6
Q

Category III tracings are abnormal and require prompt intervention; if prompt intrauterine resuscitative maneuvers are not curative, imminent delivery is prudent because these tracings are associated with what

A
  • low pH
  • Hypoxia
  • Encephalopathy
  • Cerebral palsy
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7
Q

When is RhoGAM administered

A

at 28 weeks and at delivery (if baby is Rh positive)

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8
Q

What are the prenatal lab tests that should be done

A
  • CBC
  • Blood type and Rh
  • HBsAg
  • Rubella titer
  • RPR or VDRL
  • HIV test
  • Urine culture or UA
  • Pap smear
  • Assays for chlamydia trachomatis and/or gonorrhea
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9
Q

most common cause of postpartum hemorrhage with a firm uterus

A

genital tract laceration

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10
Q

normal Active phase labor parameters

A

continued progress

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11
Q

What may safely reduce the rate of cesarean for repetitive variable decelerations

A

amnioinfusion

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12
Q

Serum screening for neural tube defects or Down syndrome are usually performed when

A

-between 16 and 20 weeks gestation

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13
Q

Define arrest of active phase

A
  • No progress in the active phase of labor (6 or more cm) with ruptured membranes for 4 hours WITH adequate contractions
  • Or 6 hours of inadequate contractions
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14
Q

Normal fetal heart rate at baseline

A

between 110 and 160

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15
Q

A vulvar mass at the 5:00 or 7:00 o’clock positions can suggest what

A

a bartholin gland cyst or abscess

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16
Q

When do yvbn ou screen for gestational diabetes

A

26-28 weeks

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17
Q

First trimester screening for trisomies

A
  • PAPP-A
  • BhCG
  • Nuchal translucency
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18
Q

When late decelerations occur together with decreased variability, then what is strongly suggested

A

acidosis

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19
Q

If a pregnant women with syphilis is allergic to penicillin then what

A

desensitization and then penicillin

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20
Q

What is cephalopelvic disproportion and what must be considered

A
  • When the pelvis is thought to be too small for the fetus (either due to abnormal pelvis or an excessively large baby)
  • C section
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21
Q

Clinically adequate uterine contractions are defined as what

A
  • contraction every 2-3 minutes, firm on palpation, and lasting for 40-60 seconds
  • 200 Montevideo units
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22
Q

what kind of vaccines are contraindicated in pregnancy

A

live attenuated (like rubella)

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23
Q

how long should third stage of labor last

A

less than 30 min

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24
Q

Category III heart rate pattern

A
  • Ominous and indicates a high likelihood of severe fetal hypoxia or acidosis
  • Examples: absent baseline variability with recurrent late or variable decelerations or bracycardia, or sinusoidal heart rate pattern
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25
Q

When a labor abnormality is diagnosed, what should be evaluated

A
  • The 3 P’s

- Power, Passenger, Pelvis

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26
Q

Category I heart rate pattern

A

-Reassuring: normal baseline and variability, no late or variable deceleration

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27
Q

Active phase of labor starts when cervix is dilated to what

A

6 cm

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28
Q

Acceleration are episodes of fetal heart rate that increase above the baseline how much and for how long

A

at least 15 bpm and last for at least 15 seconds

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29
Q

In every pregnancy greater than 20 weeks gestation, the patient should be questioned about symptoms of preeclampsia such as what

A
  • headaches
  • visual disturbances
  • dyspnea
  • epigastric pain
  • face/hand swelling
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30
Q

C section to avoid birth trauma/shoulder dystocia should be limited to estimated fetal weigh of what

A
  • 5000 g or more in nondiabetic woman

- 4500 g or more in diabetic

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31
Q

What murmurs are fairly common in pregnancy women and why

A

Systolic flow murmurs due to increased cardiac output

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32
Q

What is the most common cause of postpartum hemorrhage

A

Uterine atony

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33
Q

How long should second stage of labor last

A
  • Less than 3 hours or less than 4 w/ epidural for Nulli

- Less than 2 or less than 4 w/ epidural for multi

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34
Q

This is loss of the cervical mucus plug and is often a sign of impending labor

A

Bloody show

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35
Q

What can differentiate bloody show from antepartum bleeding (from placenta previa, placental abruption, and vasa previa)

A

Sticky mucus admixed with blood

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36
Q

ACOG and AAP recommend against deliver before how many weeks?

A

39 without a medical indication

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37
Q

what is the best plan for prolonged latent phase

A

Continued observation on oxytocin

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38
Q

Uterine contraction pattern of excessive number of contractions like 7 in a 9 minute window is tachysystole. What could be used for this

A

beta-mimetic agent such as terbulatine which will bring about uterine relaxation and hopefully resolve the late decels
-The tachysystole is likely due to excessive oxytocin, thus this should be turned off

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39
Q

Definition of anemia is a pregnant woman

A

Hb less than 10.5

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40
Q

This is a vaso-occlusive disease of the lungs (maybe from sickle cell), leading to a new pulmonary infiltrate, acute dispnea, and hypoxia

A

Acute chest syndrome

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41
Q

Acute chest syndrome that is severe is usually treated with what

A

a partial exchange transfusion

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42
Q

A 31 year old G4P3 soman has a normal vaginal delivery of her baby; after slight lengthening of the cord, a reddish mass is noted bulging in the introitus. Most likely dx?

A

-uterine inversion

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43
Q

most likely complication of uterine inversion

A

postpartum hemorrhage

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44
Q

What are the 4 signs of placental separation

A
  • gush of blood
  • lengthening of the cord
  • globular and firm shape of the uterus
  • The uterus rises up to the anterior abdominal wall
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45
Q

What is the best method of avoiding uterine inversion

A

to await spontaneous separation of the placenta from the uterus before placing traction on the umbilical cord

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46
Q

This is a abnormally adherent placenta, which is a risk factor for uterine inversion

A

placenta accreta

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47
Q

Describe how to react to uterine inversion

A
  • Anesthesia: a uterine relaxation anesthetic agent, such as halothane and/or emergency surgery may be necessary
  • If placenta has separated, the inverted uterus may sometimes be replaced by using the gloved palm and cupped fingers.
  • 2 IV lines should be started ASAP and preferably prior to placental separation since profuse hemorrhage may follow placental removal
  • Terbutaline or magnesium sulfate can also be utilized to relax the uterus if necessary
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48
Q

What position of placenta predisposes to uterine inversion

A

fundal

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49
Q

After 30 minutes, the placenta is abnormally retained. What should happen next

A

manual extraction

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50
Q

Describe the mechanism of how an inverted uterus causes hemorrhage

A
  • An inverted uterus makes it impossible for the uterus to establish its normal tone, and to contract
  • thus, the mymetrial fibers do not exert their normal tourniquet effect on the spiral arteries
  • The endometrial placental bed pours out blood, which previously gad been perfusing the intervillous space
  • Thus, Uterine atony is the most common reason for hemorrhage in inverted uterus
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51
Q

What is the best initial therapy for a nonreducible uterus

A

-A uterine relaxing agent (such as halothane anesthesia)

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52
Q

When should the umbilical cord be clamped after delivery of preterm infant

A

-b/t 30 and 60 seconds due to increasing total iron stores and Hb levels, and decreasing the risk of intraventricular hemorrhage in the infant

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53
Q

Delayed cord clamping also improves iron stores in TERM infants, but may also lead to a higher risk of what

A

hyperbilirubinemia

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54
Q

a 25 year old obese G2P1 women is delivering at 42 weeks gestation. The fetus appears clinically to be 3700 g (average weight). After a 4 hour first stage of labor and a 2 hour second stage of labor, the head delivers but the shoulders do not easily deliver. Next step in management?

A

-McRoberts Maneuver (Hyperflexion of the maternal hips onto the maternal abdomen and/or suprapubic pressure

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55
Q

a 25 year old obese G2P1 women is delivering at 42 weeks gestation. The fetus appears clinically to be 3700 g (average weight). After a 4 hour first stage of labor and a 2 hour second stage of labor, the head delivers but the shoulders do not easily deliver. Likely complication

A
  • Maternal: postpartum hemorrhage

- Neonate: brachial plexus injury such as an Erb palsy

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56
Q

What are the prenatal risk factors for shoulder dystocia in order of significance?

A
  • Prior shoulder dystocia
  • Fetal macrosomia
  • Maternal Gestational Diabetes
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57
Q

Describe ERB palsy, a potential outcome of shoulder dystocia

A
  • A brachial plexus injury involving the C5-C6 nerve roots, which may result from the downward traction of the anterior shoulder
  • The baby usually has weakness of the deltoid and infraspinatus muscles as well as the flexor muscles of the forearm
  • The arm often hangs limply by the side and is internally rotated
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58
Q

What are the common maneuvers for treatment of shoulder dystocia

A
  • McRoberts maneuver (hyperflex maternal thighs)
  • Suprapubic pressure
  • Wood’s corkscrew maneuver
  • Delivery of the posterior arm
  • Zavanelli maneuver (cephalic replacement and cesarean)
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59
Q

A 22 y/o G3P2 woman at term is in labor with a cervical dilation of 5 cm; the vertex is at -3 station. Upon artificial rupture of membranes, persistent fetal bradycardia to the 70 to 80 bpm range is noted for 3 minutes. What is next step?

A

Vaginal exam to assess for umbilical cord prolapse

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60
Q

Should you rupture membranes with an unengaged fetal presentation?

A

No . . . risk of cord prolapse

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61
Q

If a vaginal exam is done and a rope like structure is felt then what is next step

A
  • Elevation of presenting part and

- immediate C section . . . cord prolapse

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62
Q

What is trendelenburg position

A

head down

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63
Q

definition of fetal bradycardia

A

Baseline fetal heart rate of < 110 for > 10 minutes

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64
Q

The onset of fetal bradycardia should be confirmed either by internal fetal scalp electrode or U/S, and distinguished from the maternal pulse rate. The initial steps should be directed at improving maternal oxygenation and delivery of cardiac output to the uterus. These maneuvers include what?

A
  • Placement of the patient on her side to move the uterus form the great vessels, thus improving blood return to the heart
  • IV fluid bolus if pt is possibly volume depleted
  • Administration of 100% oxygen by face mask
  • stopping oxytocin if it is being given
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65
Q

In women with prior Cesarean delivery, what may manifest as fetal bradycardia?

A

uterine rupture

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66
Q

What is the most common finding in a uterine rupture

A

a fetal heart rate abnormality, such as fetal bradycardia, deep variable decelerations, or late decelerations

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67
Q

Prolonged fetal decelerations or fetal bradycardia associated with misoprostol cervical ripening is typically associated with what etiology?

A

uterine hyperstimulation

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68
Q

Next step in therapy for postpartum hemorrhage due to uterine atony

A
  • Dilute IV oxytocin
  • bedside uterine massage
  • and compression
  • If this is ineffective, then intramuscular prostaglandin F2-alpha (Hemabate) or rectal misoprostol
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69
Q

What agent used to treat uterine atony is condraindicated in HTN

A

-Methylergonovine maleate (Methergine): an ergot alkaloid agent that induces myometrial contraction as a treatment of uterine atony

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70
Q

what is a compound that stimulated myometrial contraction and can be used in the treatment of uterine atony but is contraindicated in asthmatic patients

A

Prostaglandin F2-alpha

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71
Q

risk factors for uterine atony

A
  • Magnesium sulfate
  • oxytocin during labor
  • rapid labor and/or delivery
  • Overdistention of the uterus (macrosomia, multifetal pregnancy, and hydramnios)
  • Intraamniotic infection (chorioamnionitis)
  • prolonged labor
  • high parity
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72
Q

Secondary (late) post partum hemorrhage, defined as occurring after the first 24 hours, may be caused by this, which usually occurrs at 10 to 14 days after delivery. IN this disorder, the eschar over the placental bed usually falls off and the lack of myometrial contraction at the site leads to bleeding

A

subinvolution of the placental site

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73
Q

Ligation of what are methods for decreasing the pulse pressure to the uterus nad can help in post partum hemorrhage

A

the ascending breanch of the uterine arteries and the internal iliac (hypogastric)
-Ligation of utero-ovarian ligaments can be performed in addition to ligation of uterine arteries, which can diminish further blood flow to the uterus

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74
Q

A 20 y/o G1P0 woman at 16 weeks gestation by a fairly certain LMP has received a serum maternal alpha-fetoprotein that returned as 2.8 MOM (multiples of median). Next diagnostic step?

A

Basic U/S to assess for dates and multiple gestations

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75
Q

Purpose of msAFP (maternal serum)

A

-to assess the risk for a fetal open neural tube defect and can also be used to assess for the risk of aneuploidy such as fetal down or trisomy 18

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76
Q

low msAFP may be associated with what disorder

A

fetal Down syndrome

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77
Q

At 16 weeks, the fundus is usually where?

A

midway between the symphysis pubis and the umbilicus

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78
Q

at 20 weeks, the fundus is usually where

A

at the level of the umbilicus

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79
Q

this is a glycoprotein made by the fetal liver, analogous to the adult albumin

A

alpha-fetoprotein

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80
Q

Although the triple screen may be offered to women over the age of 35, or advanced maternal age, what provides more diagnostic information

A

genetic amniocentesis

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81
Q

AFP levels of what are suspicious for neural tube defects and warrant further evaluation

A

> 2.0 to 2.5 MOM

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82
Q

What trisomy has all the serum markers in quad screen decreased

A

trisomy 18 (Edwards)

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83
Q

What teratogen? -Masculinization of female fetus

-Labial fusion

A

Androgens

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84
Q

What teratogen? -Fetal alcohol syndrome

  • IUGR
  • microcephaly
A

alcohol

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85
Q

What teratogen? Fetal hydantoin syndrome

  • IUGR
  • microcephaly
  • facial defects
A

Phenytoin

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86
Q

What teratogen? -Heart and great vessel defects (Ebstein anomaly)

A

Lithium carbonate

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87
Q

What teratogen? -Skeletal defects

-limb defects

A

Methotrexate

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88
Q

What teratogen? -Facial defects

-neural tube defects

A

-Retinoic acid (vitamin A)

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89
Q

What teratogen? -Skull anomalies

  • limb defects
  • miscarriages
  • renal tubule dysgenesis
  • renal failure in neonate
  • Oligohydramnios
A

ACEI

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90
Q

What teratogen? -CNS and skeletal defects

A

Warfarin

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91
Q

What teratogen? Neural tube defects

A

Valproic acid and carbamazepine

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92
Q

What is double bubble found on fetal U/S . . .cystic masses in both right and left abdomen

A
  • Duodenalatresia
  • The hydramnios results from the inability of the baby to swallow
  • Duodenal atresia is strongly associated with fetal down syndrome
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93
Q

Pregnancies with elevated msAFP, which after evaluation are unexplained are at increased risk for what?

A
  • Stillbirth
  • growth restriction
  • preeclampsia
  • placental abruption
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94
Q

Twin pregnancy. upon ROM, there is moderate vaginal bleeding noted. Twin A has a fetal tachycardia and now a sinusoidal heart rate pattern. Most likely diagnosis?

A

-Twin gestation with vasa previa

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95
Q

Twin pregnancy. upon ROM, there is moderate vaginal bleeding noted. Twin A has a fetal tachycardia and now a sinusoidal heart rate pattern. Cause of this condition?

A
  • exact mechanism not know but it is associated with a velamentous cord insertion, accessory placental lobes, a seconday trimester placenta previa
  • The incidence of vasa previa is increased in pregnancies conceived by in vitro fertilization
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96
Q

Twin pregnancy. upon ROM, there is moderate vaginal bleeding noted. Twin A has a fetal tachycardia and now a sinusoidal heart rate pattern. Next step

A

-STAT C section and alert pediatricians for likelihood of anemia in twin A

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97
Q

This is when umbilical vessels separate before reaching the placenta, protected only by a thin fold of amnion, instead of by the cord or placenta itself. These vessels are susceptible to tearing after rupture of membranes

A

Velamentous cord insertion

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98
Q

This is when umbilical vessels that are not protected by cord or membranes, which cross the internal cervical os in front of the fetal presenting part; this most commonly occurs with a velamentous cord insertion or a placenta with one or more accessory lobes

A

Vasa previa

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99
Q

What is the best treatment for Twin Twin transfusion syndrome

A

Laser ablation of the shared vessels

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100
Q

Twin gestation at 30 weeks gestation and signs and symptoms of preeclampsia and pulmonary edema . . best next step

A

induce labor immediately

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101
Q

A 31 y/o G3P2 woman at 39 weeks gestation is in labor and her ROM was 2 hours ago. She has a history of HSV infections and is taking oral acyclovir suppressive therapy. She has a 1 day history of tingling in the perineal area. Next step?

A

Counsel the patient about risks of neonatal HSV infection and offer a C section

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102
Q

A 31 y/o G3P2 woman at 39 weeks gestation is in labor and her ROM was 2 hours ago. She has a history of HSV infections and is taking oral acyclovir suppressive therapy. She has a 1 day history of tingling in the perineal area. Most likely Dx

A

-HSV recurrence with prodromal symptoms

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103
Q

Describe the Herpes Simplex virus prodromal symtpoms

A

Prior to the outbreak of the classic vesicles, the patient may complain of burning, itching, or tingling

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104
Q

32 weeks gestation complains of painless vaginal bleeding. Four weeks previously, she experienced some postcoital vaginal spotting. The abdomen is soft and uterus nontender. Fetal heart tones are in normal range. Next step?

A

US

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105
Q

32 weeks gestation complains of painless vaginal bleeding. Four weeks previously, she experienced some postcoital vaginal spotting. The abdomen is soft and uterus nontender. Fetal heart tones are in normal range. Most likely diagnosis?

A

-Placenta previa

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106
Q

32 weeks gestation complains of painless vaginal bleeding. Four weeks previously, she experienced some postcoital vaginal spotting. The abdomen is soft and uterus nontender. Fetal heart tones are in normal range.Long term management?

A
  • Expectant management as long as the bleeding is not excessive
  • C section at 34 weeks gestation
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107
Q

Definition of antepartum vaginal bleeding

A

vaginal bleeding occurring after 20 weeks gestation

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108
Q

Premature separation of a normally implanted placenta

A

Placenta Abruption

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109
Q

The placenta completely covers the internal os of the uterine cervix

A

placenta previa

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110
Q

What are the two most common causes of significant antepartum bleeding

A
  • placental abruption

- placenta previa

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111
Q

In antepartum bleeding what is the main differentiator between placental abruption and placenta previa

A
  • Vaginal bleeding is painless in a previa

- Painful in an abruption secondary to contractions

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112
Q

When placenta previa is diagnosed at an early gestation, such as second trimester, what should happen?

A

repeat sonography is warranted since many times the placenta will move away from the cervix (transmigration)

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113
Q

35 weeks gestation complains of abdominal pain and moderate vaginal bleeding. ON exam, her blood pressure is 150/90 and HR is 110. The fundus reveals tenderness. US normal. fetal heart tones are in the range of 160 to 170. Most likely Diagnosis?

A

Placental abruption

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114
Q

35 weeks gestation complains of abdominal pain and moderate vaginal bleeding. ON exam, her blood pressure is 150/90 and HR is 110. The fundus reveals tenderness. US normal. fetal heart tones are in the range of 160 to 170. Complications that can occur?

A
  • Hemorrhage
  • Fetal to maternal bleeding
  • Coagulopathy
  • Preterm delivery
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115
Q

35 weeks gestation complains of abdominal pain and moderate vaginal bleeding. ON exam, her blood pressure is 150/90 and HR is 110. The fundus reveals tenderness. US normal. fetal heart tones are in the range of 160 to 170. Best management?

A

-Delivery (at 35 weeks, the risk of abruption significantly outweigh the risks of prematurity)

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116
Q

Why is US a poor method of assessment for abruption

A

The freshly developed blood clot behind the placenta has the same sonographic texture as the placenta itself

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117
Q

This is bleeding into the myometrium of the uterus giving a discolored appearance to the uterine surface

A

Couvelaire uterus

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118
Q

When the abruption is of sufficient severity to cause fetal death, what is found in one-third or more of cases?

A

coagulopathy

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119
Q

Describe the Kleihauer-Betke test

A

-Tests for fetal erythrocytes from the maternal blood

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120
Q

What is the biggest modifiable risk of placenta abruption

A

smoking

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121
Q

What drug is strongly associated with the development of placental abruption and why?

A

cocaine due to its effect on the vasculature (vasospasm)

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122
Q

fetal demise in placenta abruption means what kind of management

A

vaginal delivery

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123
Q

pt with prior history of myomectomy and C section delivery is undergoing a vaginal delivery. The retained placenta is firmly adherent to the uterus when there is an attempt at manual extraction. Most likely diagnosis?

A

Placenta accreta

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124
Q

pt with prior history of myomectomy and C section delivery is undergoing a vaginal delivery. The retained placenta is firmly adherent to the uterus when there is an attempt at manual extraction. Next step in management?

A

Hysterectomy

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125
Q

The best management of placenta accreta is hysterectomy due to the great risk of hemorrhage if hte placenta is attempted to be removed. When the patient refuses hysterectomy, then ligation of the umbilical cord as high as possible and attempt at IV methotrexate therapy has been attempted with limited success. Other than hemorrhage, the other complication to be concerned about is what?

A

Infection.

-the necrosis of the placental tissue is a nidus for infection

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126
Q

Describe the relationship b/t myomectomy limied to the serosal (outside) surface of the uterus and risk of placenta accreta?

A

do NOT predispose to accreta because the endometrium is not disturbed

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127
Q

16 weeks gestation with an 8 cm ovarian cyst complains of a 12 hour history of colicky RLQ pain and N/v. The abdomen is tender in RLQ with significant involuntary guarding. Most likely Dx?

A

Torsion of the ovary

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128
Q

16 weeks gestation with an 8 cm ovarian cyst complains of a 12 hour history of colicky RLQ pain and N/v. The abdomen is tender in RLQ with significant involuntary guarding. Best treatment for this condition

A

Surgery (laparotomy due to pregnancy

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129
Q

Location of the abdominal appendixin acute appendicitis in pregnancy

A
  • superior and lateral to the McBurney point
  • This is due to the effect of the enlarged uterus pushing on the appendix to move it upward and outward toward the flank, at times mimicking pyelonephritis
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130
Q

What is the most frequent and serious complication of a benign ovarian cyst

A

ovarian torsion

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131
Q

What is the most common cause of hemoperitoneum in early pregnancy

A

ectopic pregnancy

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132
Q

When the corpus luteum is excised in a pregnancy of less than 10 to 12 weeks, what should be supplemented?

A

progesterone

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133
Q

A 24 y/o G1P0 at 28 weeks gestation complains of a 2 week duration of generalized pruritus. She is anicteric and normotensive. The skin is without rashes. The fetal heart tones are in the range of 140. Most likely diagnosis?

A

Intrahepatic cholestatis of pregnancy (ICP)

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134
Q

A 24 y/o G1P0 at 28 weeks gestation complains of a 2 week duration of generalized pruritus. She is anicteric and normotensive. The skin is without rashes. The fetal heart tones are in the range of 140. Best treatment?

A

-Ursodeoxycholic acid (UDCA)

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135
Q

A 24 y/o G1P0 at 28 weeks gestation complains of a 2 week duration of generalized pruritus. She is anicteric and normotensive. The skin is without rashes. The fetal heart tones are in the range of 140. Management of hte pregnancy?

A

-Fetal testing such as a biophysical profile once a week with consideration of delivery at 37 to 38 weeks due to increased risk of stillbirth associated with ICP

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136
Q

Describe the mechanism of ICP

A

-Bile salts are incompletely cleared by the liver, accumulate in the body, and are deposited in the dermis, causing pruritus

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137
Q

This is a common skin condition of unknown etiology unique to pregnancy characterized by intense pruritus and erythematous papules on the abdomen and extremities

A

Pruritic urticarial papules and plaques of pregnancy (PUPPP)

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138
Q

Rare skin condition only seen in pregnancy; it is characterized by intense itching and vesicles on the abdomen and extremities

A

Herpes Gestationis

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139
Q

In ICP, the risk of fetal demise and adverse fetal outcomes increases with higher what?

A

bile acid concentrations and increasing gestational age

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140
Q

This is a rare, serious condition involving microvesicular steatosis of the liver thought to be due to mitochondrial dysfunction in the oxidation of fatty acids, which leads to its accumulation in liver cells

A

Acute Fatty Liver of Pregnancy (AFLP)

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141
Q

Normal PCO2 in pregnancy and why?

A
  • 28

- Higher tidal volume leads to increased minute ventilation

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142
Q

Normal HCO3 in pregnancy and why?

A

19
-Renal excretion of bicarbonate to partially compensate for respiratory alkalosis, leads to lower serum bicarbonate, making the pregnant woman more prone to metabolic acidosis

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143
Q

What is the most common overall etiology for maternal mortality

A

embolism of all types

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144
Q

How do you manage a pregnant patient who is heterozygous for Factor V leiden and no Hx of clots

A

expectant management and not given anticoagulation

-If homozygous or has hx of clots then heparin

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145
Q

What is the most common side effect of long term heparin use in pregnancy?

A

Osteoporosis

146
Q

After a DVT or PE is dx, anticoagulation is indicated for how long

A

at least 3 months

147
Q

19 y/o G1P0 woman at 29 weeks gestation has acute onset of severe dyspnea, RR of 40 breaths per minute and labored, new onset severely elevated BP of 160/114 and elevated protein/creatinine ratio, and elevated liver function tests. The prenatal records show normal BPs in the pregnancy with a borderline elevated BP and 1+ proteinuria at the last visit (26 weeks). Most likely diagnosis?

A

Preeclampsia with severe features

148
Q

19 y/o G1P0 woman at 29 weeks gestation has acute onset of severe dyspnea, RR of 40 breaths per minute and labored, new onset severely elevated BP of 160/114 and elevated protein/creatinine ratio, and elevated liver function tests. The prenatal records show normal BPs in the pregnancy with a borderline elevated BP and 1+ proteinuria at the last visit (26 weeks). Immediate next step?

A

-The highest priority must be to improve oxygenation. Sufficient oxygen must be provided to raise the O2 sat >94% and if the patient is tiring, ventilator support may be required. The second priority is to lower the BP with IV antihypertensive agents. If pulmonary edema is confirmed, IV diuresis such as furosemide should be given

149
Q

19 y/o G1P0 woman at 29 weeks gestation has acute onset of severe dyspnea, RR of 40 breaths per minute and labored, new onset severely elevated BP of 160/114 and elevated protein/creatinine ratio, and elevated liver function tests. The prenatal records show normal BPs in the pregnancy with a borderline elevated BP and 1+ proteinuria at the last visit (26 weeks). Priority lab tests?

A

CBC with platelet count and renal function test (creatinine)

150
Q

19 y/o G1P0 woman at 29 weeks gestation has acute onset of severe dyspnea, RR of 40 breaths per minute and labored, new onset severely elevated BP of 160/114 and elevated protein/creatinine ratio, and elevated liver function tests. The prenatal records show normal BPs in the pregnancy with a borderline elevated BP and 1+ proteinuria at the last visit (26 weeks). Management?

A
  • Stabilize maternal status (optimize oxygenation, lower BP to safe level below 160/110)
  • Stabilize fetal status
  • administer corticosteroids for fetal lung maturity
  • start magnesium sulfate for seizure prophylaxis
  • move toward delivery
151
Q

In the absence of proteinuria, HTN with one of the following findings would be preeclampsia

A
  • thrombocytopenia
  • impaired liver function tests
  • renal insufficiency
  • pulmonary edema
  • cerebral disturbances
  • visual impairment
152
Q

This is a cliniconeurological syndrome with headache, encephalopathy, seizures, cortical visual disturbances, usually diagnosed with clinical features and MRI showing enhancement in the posterior parietal areas.

A

Posterior revervislble encephalopathy syndrome (PRES)

153
Q

Diagnosis of preeclampsia

A
  • New onset HTN (140/90) twice over 6 hours with any one of
  • Proteinuria (>300 mg/24 hrs, or Protein/Cr >.3 mg/dL, or dipstick of 1+ or greater)
  • Thrombocytopenia (platelets < 100,000)
  • Impaired LFT (2x normal)
  • Renal insufficiency (Cr >1.1 mg/dL)
  • Pulmonary edema
  • New onset cerebral disturbances or visual impairment
154
Q

Severe features of preeclampsia is any one of the following

A
  • BP > 160/110 on two occasions 4 hours apart
  • Platelets < 100,000
  • Impaired LFT (2x normal) or severe epigastric or RUQ pain
  • Progressive pulmonary edema
  • New onset cerebral or visual disturbance
155
Q

In an unstable patient with severe preeclampsia, what may elevate the BP in postpartum period and should be avoided

156
Q

What is the most common cause of maternal death due to eclampsia?

A

intracerebral hemorrhage

157
Q

How can PRES syndrome be quickly diagnosed

158
Q

In a patient with IUGR, the next step would be to evaluate possible fetal compromise how?

A

with BPP and umbilical artery doppler studies

159
Q

Healthy woman at 29 weeks gestation complains of intermittent abdominal pain. Vitals normal. FHT normal. uterine contractions every 3 to 5 minutes. 3 cm dilated/ 90% effaced, -1 station. Most likely dx?

A

preterm labor

160
Q

Healthy woman at 29 weeks gestation complains of intermittent abdominal pain. Vitals normal. FHT normal. uterine contractions every 3 to 5 minutes. 3 cm dilated/ 90% effaced, -1 station. Next step in management?

A
  • Tocolysis
  • try to identify a cause of the preterm labor
  • antenatal steroids
  • antibiotics for GBS prophylaxis
161
Q

Healthy woman at 29 weeks gestation complains of intermittent abdominal pain. Vitals normal. FHT normal. uterine contractions every 3 to 5 minutes. 3 cm dilated/ 90% effaced, -1 station. Test of vaginal fluid?

A

Fetal fibronectin assay . . if positive, may indicate risk of preterm birth
-in contrast, a negative assay is strongly associated with no delivery within 1 week

162
Q

Healthy woman at 29 weeks gestation complains of intermittent abdominal pain. Vitals normal. FHT normal. uterine contractions every 3 to 5 minutes. 3 cm dilated/ 90% effaced, -1 station. medication for neuroprotection?

A

-Magnesium sulfate may be given for pregnancies of < 32 weeks when there is imminent delivery

163
Q

what week are steroids no longer helpful

164
Q

A careful search should be undertaken to identify an underlying cause of perterm labor, such as what?

A
  • UTI
  • cervical infection
  • BV
  • Generalized infection
  • trauma or abruption
  • hydramnios
  • multiple gestation
165
Q

In preterm labor, what is helpful in case the tocolysis is unseccuessful to reduce the likelihood of GBS sepsis in the neonate

A

IV antibiotics (penicillin)

166
Q

In preterm labor, at what weeks does starting magnesium help with neurodevelopment of the preterm baby, reducing cases of cerebral palsy

A

<31 and 6/7

167
Q

Tocolysis is the use of pharmacologic agents to delay delivery once preterm labor is diagnosed. What are the most commonly used agents?

A
  • indomethacin
  • nifedipine
  • terbutaline
  • ritodrine
168
Q

Cervical length less then what results in an increased risk of preterm delivery

169
Q

what is the method of action of magnesium

A

competitively inhibits calcium

170
Q

Side effects of magnesium

A
  • pulmonary edema

- respiratory depression

171
Q

What infection is strongly associated with preterm delivery

A

Gonococcal cervicitis

172
Q

This is a relative contraindication for tocolysis because this pathology may extend

A

suspected abruption

173
Q

Side effects/complications of Terbutaline and Ritodrine?

A
  • Pulmonary edema
  • increased pulse pressure
  • Hyperglycemia
  • Hypokalemia
  • tachycardia
174
Q

side effects/complications of indomethacin

A

-closure of fetus ductus arteriosus, which would lead to pulmonary HTN and oligohydramnios (could cause cord compression&raquo_space; variable decels)

175
Q

What is given weekly from 16 to 36 weeks gestation in women with a history of prior spontaneous preterm births and decreases the risk of preterm birth by one third

A

Progesterone (17-OHP)

176
Q

30 weeks gestation. admitted 2 days ago for Premature ROM. temp 100.8. Uterine fundus slightly tender. Persistent fetal tachycardia in the range of 170 to 175. Most likely dx?

A

Intra amniotic infection (chorioamnionitis)

177
Q

30 weeks gestation. admitted 2 days ago for Premature ROM. temp 100.8. Uterine fundus slightly tender. Persistent fetal tachycardia in the range of 170 to 175. Best management for this patient?

A

IV antibiotics (ampicillin and gentamicin) and induction of labor

178
Q

30 weeks gestation. admitted 2 days ago for Premature ROM. temp 100.8. Uterine fundus slightly tender. Persistent fetal tachycardia in the range of 170 to 175. etiology of this condition?

A

ascending infection from vaginal organisms

179
Q

What are the two most common acute complication of preterm premature rupture of membranes

A

infections and labor

180
Q

This is rupture of membrane prior to the onset of labor

A

Premature ROM

181
Q

This is rupture of membranes in a gestation < 37 weeks, prior to the onset of labor

A

Preterm premature ROM

182
Q

What is the most accurate method to confirm intra-amniotic infection

A

Amniotic fluid gram stain by amniocentesis

183
Q

What organism may induce chorioamnionitis without ROM

184
Q

Fetal lung maturity is demonstrated on vaginal amniotic fluid by presence of what?

A 
Phosphatidyl glycerol (PG) . . . so delivery is next step after ROM
-corticosteroids suppress immune system so would not want to do this after ROM if lungs are mature
185
Q

What is the most common FHT abnormality with PPROM

A

variable decels likely due to oligohydramnios from the ROM

  • there is insufficient fluid to “buffer the cord” from compression
  • A change of the patient’s position often alleviates the decels
186
Q

What is the earliest sign of chorioamnionitis

A

fetal tachycardia

187
Q

woman at 22 weeks gestation complains of an episode of myalgias and low grade fever 1 month ago. Her 2 y/o son had high fever and “red cheeks”. The fundal height is 28 cm and fetal parts are difficult to palpate. Most likely dx?
Most likely mechanism?

A
  • Hydramnios, with probable fetal hydrops due to parvovirus B19 infection
  • Fetal anemia due to neonatal parvovirus infx, which inhibits bone marrow erythrocyte production
188
Q

typical presentation of parvovirus B19 infx in adults

A
  • malaise
  • arthralgias
  • myalgias
  • reticular (lacy) faint rash that comes and goes
  • up to 20% of adults will have no symtoms
189
Q

typical presentation of parvovirus B19 infx in children

A
  • classic “slapped cheek”

- high fever

190
Q

What is one of the earliest signs of fetal hydrops

A

hydramnios or excess amniotic fluid

191
Q

What are classic signs of hydramnios

A
  • uterine size greater than predicted by her dates

- fetal parts difficult to palpate

192
Q

How is dx of parvovirus B19 infx made

193
Q

other name for parvovirus B19 infx

A

erythema infectiosum

194
Q

This is defined as excess fluid located in two or more fetal body cavities, and many times is associated with hydramnios; pregnancies <20 weeks gestation are at particular risk

A

Hydrops fetalis

195
Q

What fetal heart pattern is associated with severe fetal anemia or asphyxia

A

sinusoidal pattern

196
Q

Describe the effects of CMV on infants born infected

A
  • Microcephaly
  • Periventricular calcifications
  • deafness
  • chorioretinitis (blindness)
  • seizures
  • Interstitial pneumonia
197
Q

Describe the time frame and transmission of CMV infx in pregnancy

A
  • Transmission is highest in the third trimester

- neonatal effects are worse in first trimester

198
Q

Describe how to prevent CMV infx in pregnancy

A
  • careful handwashing

- avoid sharing utensils especially with children

199
Q

What is the best method for dx of Toxoplasmosis

200
Q

pregnant women infected with toxo are treated with what

A
  • spiramycin to reduce transplacental transfer

- Fetal infection is treated with pyrimethamine and sulfadiazine

201
Q

Describe the fetal presentation of toxo

A
  • Most neonates are asymptomatic at birth but can later develop chorioretinitis and hearing loss
  • The classic triad is: HYDRDOCEPHALUS, INTRACRANIAL CALCIFICATIONS, AND CHORIORETINITIS
202
Q

Presentation of rubella infx

A
  • Classic triad: cataracts, sensorineural deafness, and cardiac defects
  • also microcephaly and thrombocytopenia
203
Q

Middle cerebral artery doppler studies indicated increased velocity of flow are consitent with what

A

significant fetal anemia

204
Q

Describe the interpretation and management of a pregnant patient with suspected parvavirus B19 infection but IgM and IgG negative

A
  • the patient typically will not be infected or susceptivle, provided sufficient time elapsed past incubation period
  • In this case, the patient has some symptoms of parvovirus infection in a high risk setting, so although both IgG and IgM are negative, it would be wise to repeat it in 4 weeks to ensure that the incubation period (up to 20 days) has elapsed and antibodies have formed
205
Q

A pregnant woman who is diagnosed with parvovirus infx will have weekly US exam for how long and to assess for what?

A
  • for 12 weeks

- to assess for fetal hydrops/hydramnios

206
Q

22 weeks gestation has a positive Chlamydia DNA assay of the endocervix, and a positive HIV ELISA test. denies lower abdominal pain and is afebrile. abdomen nontender and gravid. gonococcal culture negative. Next step in therapy?

A

-Oral erythromycin, azythromycin, or amoxicillin

207
Q

22 weeks gestation has a positive Chlamydia DNA assay of the endocervix, and a positive HIV ELISA test. denies lower abdominal pain and is afebrile. abdomen nontender and gravid. gonococcal culture negative. Next diagnostic step for HIV

A

-Either western blot confirmation, or polymerase chain reaction (PCR) confirmation

208
Q

22 weeks gestation has a positive Chlamydia DNA assay of the endocervix, and a positive HIV ELISA test. denies lower abdominal pain and is afebrile. abdomen nontender and gravid. gonococcal culture negative. optimal treatment of HIV infection in pregnancy?

A
  • Assessment of stage of HIV infection
  • Initial HAART
  • offer elective C section
  • oral zidovudine to the neonate
209
Q

What can a maternal chlamydial infection cause in the neonate

A

conjunctivitis and pneumonia

210
Q

Erythromycin eye ointment given at birth prevents against what

A

GONOCOCCAL conjunctivits

211
Q

Tetracyclines taken by pregnant women can lead to what in the fetus

A

staining of fetal teeth

212
Q

What is the most common cause of conjunctivitis in the first month of life

213
Q

Late postpartum endometritis, occurring 2 to 3 weeks after deliver, is associated with what infection

214
Q

Disseminated gonococcal disease is more common in the pregnant woman, presenting as what

A
  • pustular skin lesions
  • arthralgias
  • septic arthritis
215
Q

Can a neonate acquire HIV from breast milk

216
Q

Describe how the viral load of HIV should be monitored in pregnancy

A

should be evaluated monthly until it is no longer detectable

217
Q

What is the viral load goal in pregnancy

A

to maintain a viral load under 1000 RNA copies/mL

218
Q

In women with HIV viral loads exceeding 1000, what has been shown to significantly reduce the risk of vertical infection?

A

scheduled C section prior to labor or ROM

219
Q

Those HIV infected women who choose to deliver vaginally should receive what?

A
  • IV zidovudine during labor
  • Breast feeding should be discouraged
  • the neonate should also receive oral zidovudine syrup
220
Q

Patients on HAART therapy should have regular monitoring of what?

A
  • Liver function tests and

- blood counts to detect toxicity

221
Q

Antiviral therapy shows no increase in congenital anomalies with the exception of what

A
  • efavirenz

- an NNRTI, which is associated with neural tube defects

222
Q

Those pregnancy women with HIV and co infection with Hep B should be treated with what antiviral agent

A

Tenofovir and lamivudine

223
Q

What type of epithelium does chlamydia have a propensity for

A

columnar and transitional

224
Q

This is a obligate intracellular organism associated with LATE postpartum endometritis and has a LONG replication cycle

225
Q

how to manage an HIV pregnancy with no prenatal care at term who has begun labor and ROM

A
  • IV Zidovudine and minimizing trauma to the baby

- Elective C section will NOT affect vertical transmission . . would need to be done before ROM or labor

226
Q

Best management for thyroid storm in pregnancy

A
  • A Beta-blocker (such as propranolol)
  • corticosteroids
  • PTU (preferred for rapid onset) or methimazole
227
Q

What is the most commonly used medication for hyperthyroidism in pregnancy

A

Methimazole after first trimester due to the possibility of liver toxicity with PTU

228
Q

Which drug for hyperthyroidism is NOT used in first trimester

A

methimazole

229
Q

What are the three phases of postpartum thyroiditis . . peak onset at 6 months post delivery

A
  • Hyperthyroid
  • Hypothyroid
  • euthyroid (although some will remain hypo)
230
Q

Describe in general what the high estrogen levels of pregnancy do to thyroid panel levels?

A
  • increased levels of thyroid-binding globulin and total T4
  • but the active or free T4 and TSH remain unchanged
  • In general, pregnancy is a euthyroid state
231
Q

Failure to identify fetal thyrotoxicosis can result in what

A

nonimmune hydrops and fetal demise

232
Q

Overall, the most common cause of hyperthyroidism in the US is Graves disease. However, in the postpartum period, women with hyperthyroidism are more likely to have destructive lymphocytic thyroiditis. This is because the high corticosteroid levels in pregnancy suppress the autoimmune antibodies, and a flare occurs postpartum when the corticosteroid levels fall after the placenta delivers. Often What antibodies are present?

A

-antimicrosomal and antiperoxidase

233
Q

Hyperparathyroidism in pregnancy presents as what?

A
  • kidney stones
  • lethargy
  • or pain
234
Q

What is the treatment of choice for hyperparathyroidism in pregnancy in the second trimester

235
Q

Once IUGR is diagnosed, The fetal US parameters are broadly categorized as symmetric or asymetric. what does this mean

A
  • symmetric: head affected

- asymmetric: head spared

236
Q

The most common cause of asymmetric IUGR is what

A

-a maternal vascular disorder such as HTN disease, smoking, or illicit drug use

237
Q

In IUGR, after an attempt is made to determine symmetric vs. asymmetric, fetal assessment should be undertaken to assess risk of fetal death. what tests are helpful?

A
  • BPP
  • assessment of amniotic fluid volume
  • Doppler flow studies of the umbilical artery
238
Q

definition of IUGR

A

birthweight less than the 10th percentile for Gestational age

239
Q

End-diastolic flow is the flow through the umbilical artery. Reverse end-diastolic flow is associated with what within 48 hours?

A

high stillbirth rate

240
Q

29 weeks gestation is undergoing treatment of pyelonephritis with an appropriate antibiotic regimen and now complains of shortness of breath. Most likely Dx?

A

Acute respiratory distress syndrome (ARDS)

241
Q

29 weeks gestation is undergoing treatment of pyelonephritis with an appropriate antibiotic regimen and now complains of shortness of breath. Mechanism of injury?

A

Endotoxin-mediated pulmonary injury

242
Q

This is alveolar and endothelial injury leading to leaky pulmonary capillaries, clinically causing hypoxemia, markedly increased alveolar-arterial gradient, and loss of lung volume

243
Q

What is the most common cause of sepsis in pregnant women?

A

pyelonephritis

244
Q

A urine culture revealing > how many CFUs of a single uropathogen is diagnostic

245
Q

Pregnant women with acute pyelonephritis should be hospitalized and given IV antibiotics. Which ones are usually effective?

A
  • Cephalosporins, such as cefotetan or ceftriaxone

- or combo of Amp and Gent

246
Q

After treatment of acute pyelonephritis in pregnancy, suppressive therapy should be given for the remainder of pregnancy with what?

A

oral nitrofurantoin 100 mg

247
Q

in acute pyelo in pregnancy, if clinical improvement has not occurred after 48 to 72 hours of appropriate antibiotic therapy, what should be suspected?

A
  • urinary tract obstruction

- perinephric abscess

248
Q

ARDS may induce transient elevation of what labs

A

-serum creatinine as well as liver enzymes

249
Q

woman who underwent an uncomplicated C section 1 week ago has fever up to 102, myalgias, comiting, hypotension, confsion, and a skin incision that is infected with underlying tissue revealing a brawny texture and crepitance. She has evidence of hemoconcentration and renal insufficiency. Most likely Dx?

A

Necrotizing fasciitis

250
Q

woman who underwent an uncomplicated C section 1 week ago has fever up to 102, myalgias, comiting, hypotension, confsion, and a skin incision that is infected with underlying tissue revealing a brawny texture and crepitance. She has evidence of hemoconcentration and renal insufficiency. Next step in therapy

A
  • Isotonic IV fluids
  • broad-spectrum antibiotics
  • immediate surgical debridement
251
Q

Rapidly progressing infection of the episiotomy or C section incision (“flesh-eating bacteria” syndrome)

A

Group A streptococcal toxic shock syndrome

252
Q

Condition of circulatory insufficiency where tissue perfusion needs are not met

253
Q

Describe the broad spectrum antibiotics and other therapy used to treat septic shock

A
  • penicillin
  • Gentamicin
  • and metronidazole or other anaerobic agent
  • Dopamine or dobutamine is sometimes required when fluids alone are insufficient to maintain BP
254
Q

woman has C section 2 days ago for arrest of labor, now has a fever of 102. She denies cough or dysuria. There are no abnormalities of breasts, lungs, CVA, or skin incision. The fundus is somewhat tender. Most likely Dx?

A

Endomyometritis

255
Q

woman has C section 2 days ago for arrest of labor, now has a fever of 102. She denies cough or dysuria. There are no abnormalities of breasts, lungs, CVA, or skin incision. The fundus is somewhat tender. Most likely etiology of the condition?

A

-Ascidning infection of vaginal organisms (anaerobic predominance but also Gram-negative rods)

256
Q

woman has C section 2 days ago for arrest of labor, now has a fever of 102. She denies cough or dysuria. There are no abnormalities of breasts, lungs, CVA, or skin incision. The fundus is somewhat tender. Best therapy for the condition

A

IV antibiotics with anaerobic coverage (e.g. gentamicin and clindamycin)

257
Q

What is the most common cause of fever for a woman who has undergone C section

A

endomyometritis

258
Q

Differential dx for a women post C section with a fever

A
  • endomyometritis
  • mastitis
  • wound infection
  • atelectasis (if general anesthesia)
  • pyelonephritis
259
Q

This is a bacterial infection of pelvic venous thrombi, usually involving the ovarian vein

A

Septic pelvic thrombophlebitis (SPT)

260
Q

If post C section patient with fever treated sufficiently and fever doesn’t improve in 48 hours then what

A
  • entoerococcal infection may be on reason for nonresponse

- ampicillin is added

261
Q

If post C section patient with fever treated sufficiently and fever doesn’t improve in 48 hours then ampicillin is added. If fever persists despite triple antibiotic therapy for 48 to 72 hours what should be done?

A

CT scan of the abdomen and pelvis may reveal an abscess, infected hematoma, or pelvic thrombophlebitis

262
Q

The best treatment of a wound infection is what

A

opening of the wound

263
Q

What is the best treatment of septic pelvic thrombophlebitis

A

combo of antibiotics and heparin

264
Q

The major organisms responsible for post C section endomyometritis are anaerobic bacteria with the most commonly isolated organisms including what?

A
  • Peptostreptococcus
  • Peptococcus
  • Bacteroides
265
Q

20 year old breast feeding woman who is 3 weeks postpartum complains of right breast pain and fever of 2 days duration. She notes progressive pain, induration, and redness in the right breast. Her temp is 102. There is also significant fluctuance noted in the right breast. Most likely Dx?

A

Abscess of the right breast

266
Q

20 year old breast feeding woman who is 3 weeks postpartum complains of right breast pain and fever of 2 days duration. She notes progressive pain, induration, and redness in the right breast. Her temp is 102. There is also significant fluctuance noted in the right breast. Next step in therapy

A

Incision and drainage of the abscess and antibiotic therapy

267
Q

20 year old breast feeding woman who is 3 weeks postpartum complains of right breast pain and fever of 2 days duration. She notes progressive pain, induration, and redness in the right breast. Her temp is 102. There is also significant fluctuance noted in the right breast. Etiology of the condition

A

Staph aureus

268
Q

Women with mastitis should be instructed to do what in terms of breast feeding

A

continue to breast feed or drain the breast by pump

269
Q

This is a noninfected collection of milk due to a blocked mammary duct leading to a palpable mass and symptoms of breast pressure and pain

A

Galactocele

270
Q

Breast milk contains nearly all of the nutrients required with the exception of what vitamins?

271
Q

Woman has had persistent tenderness and redness of the breast despite not lactating and not having trauma to the breast. symptoms have worsened despite antibiotic therapy. Concern? and Next appropriate step?

A
  • concern about inflammatory breast carcinoma

- biopsy

272
Q

Best treatment for a galactocele

A

aspiration

273
Q

When is vitamin D supplementation recommended in an exclusively breast fed infant

A

at 2 months

274
Q

What is the best treatment for cracked nipples

A

air drying and avoidance of using harsh soap

275
Q

Breast engorgement rarely causes high fever persisting more than how long

276
Q

Describe how DKA in pregnancy is different than in nonpregnancy

A

it can develop with lower blood sugars and more rapidly than nonpregnant patients

277
Q

Do you take DKA patient for an emergency C section?

A

No because the acidosis is correctable and these individuals are unstable

278
Q

This is a system of characterizing diabetes in pregnancy using letters (A, B, C, D, F, H, etc) based on duration of disease and presence of end-organ dysfunction

A

White classification

279
Q

This type of diabetes in pregnancy is associated with miscarriage and congenital anomalies

A

Pregestational

-Gestation IS NOT

280
Q

What is the leading cause of blindness in reproductive age women

A

diabetic retinopathy

281
Q

why is glycemic control critically important during labor and delivery

A

Maternal hyperglycemia can lead to neonatal HYPOglycemia after birth

282
Q

In pregnancy, Several physiological factors predispose to DKA. What are they

A
  • Increased counterregulatory hormones including hPL, progesterone, and cortisol which cause insulin resistance
  • Decreased serum bicarb levels to compensate for the primary respiratory alkalosis, which reduces the buffering capacity
  • Increased tendency for ketosis with increased lipolysis and free fatty acid and ketones
283
Q

In a diabetic pregnancy, who should be assessed for DKA by checking blood sugar and urine for ketones

A

every diabetic pregnant woman who has vague complaints

284
Q

In DKA, what will the fetal heart pattern often exhibit

A

loss of variability and late decelerations due to maternal acidosis

285
Q

All women diagnosed with Gestational DM should be screened for overt DM when postpartum and how

A

at 6 weeks post partum with a 2 hour 75 gram oral glucose tolerance test

286
Q

The most common congenital anomalies associated with pregestational diabetes are what?

A

cardiac and neural tube defects

287
Q

Prior pregnancy that resulted in abortion due to abruption at 38 weeks. How do you manage this pregnancy?

A

induction at or slightly before the time of abruption with the fetal loss, if at term.

288
Q

when indirect coombs test is positive, it is important to identify the antibody. Which antibody is not harmful and why?

A
  • anti-lewis because it is IgM and does NOT cross placenta

- “lewis lives, Kell kills, Duffy dies”

289
Q

Describe the administration of TdaP vaccine in pregnancy

A

should be given b/t 28 and 36 weeks regardless of whether it has been given in prior pregnancies

290
Q

66 y/o comes for health maintenancy. A mammogram has been performed 3 months previously. Next step?

A
  • Calculate BMI
  • send stool for occult blood
  • colonoscopy
  • Pneumococcal vaccine
  • influenza vaccine
  • tetanus and diphtheria (if not in last 10 years)
  • herpes Zoster vaccine
  • lipid profile
  • fasting blood glucose
  • thyroid function tests
  • bone mineral density screening
  • urinalysis
291
Q

66 y/o comes for health maintenancy. A mammogram has been performed 3 months previously. most common cause of mortality?

A

Cardiovascular disease

292
Q

how often should lipid profile be done in older women

A

every 5 years up to age 75

293
Q

how often should thyroid function testing be done in older women

A

every 5 years

294
Q

how often should fasting blood glucose levels be done in older women

A

every 3 years

295
Q

Describe pap smear screening in HIV-positive women

A
  • twice in first year after Dx

- then annually

296
Q

Describe the varicella zoster vaccine

A
  • Live attenuated vaccine

- recommeded for individuals aged 60 and over

297
Q

A 49 y/o woman complains of irregular menses, feelings of inadequacy, sleeplessness, and episodes of warmth and sweating. Most likely Dx?

A

-Climacteric (perimenopausal state)

298
Q

A 49 y/o woman complains of irregular menses, feelings of inadequacy, sleeplessness, and episodes of warmth and sweating. Next diagnostic step?

A

-serum FSH, LH, and TSH levels

299
Q

what is usually effective in treating Hot flushes in perimenopausal state

A

estrogen replacement therapy with progestin

-when a woman still ha her utuerus, the addition of progestin is important in preventing endometrial cancer

300
Q

what is the predominant symptom of hypoestrogenemia

A

hot flush: a vasomotor reaction associated with skin temperature elevation and sweating lasting for 3 to 4 minutes

301
Q

FSH and LH levels in perimenopause

A

elevated but will fluctuate in the perimenopause leading up to actual menopause and cannot be relied upon until persistently elevated

302
Q

The cessation of ovarian function due to atresia of follicles prior to age 40 years. At ages younger than 30 years, autoimmune diseases or karyotypic abnormalities should be considered

A

Premature ovarian failure

303
Q

What is the earliest marker to indicate decrease ovarian reserve?

A
  • Anti-mullerian hormone (AMH)
  • Inhibin B is the next marker to decrease
  • Finally estradiol falls
304
Q

Describe the mechanism of amenorrhea in PCOS

A

estrogen excess

305
Q

24 year old nulliparous brought into emergency center by police due to a sexual assault. Not currently active and does not use contraception. Experienced vaginal penetrated penile intercourse by an unknown male assailant, and was threatened with a knife. On exam the patient appears anxious and tearful. vitals normal. Medications offered?

A
  • Ceftriaxone IM
  • oral metronidazole
  • Oral azithromycin
  • and if not previously vaccinated, Hep B immune globulin and Hep vaccine
  • Emergency contraception
306
Q

mechanism of amenorrhea in excessive exercise

A

hypothalamic dysfunction

307
Q

what is the most common location of an osteoporosis associated fracture?

A

thoracic spine as a compression fracture

308
Q

24 year old nulliparous brought into emergency center by police due to a sexual assault. Not currently active and does not use contraception. Experienced vaginal penetrated penile intercourse by an unknown male assailant, and was threatened with a knife. On exam the patient appears anxious and tearful. vitals normal. Priorities in management?

A
  • Treat acute and/or life-threatening medical issues
  • Perform a careful History and physical exam
  • Order appropriate lab and STI testing
  • Arrange for emergency contraception and STI prophylaxis
  • provide psychosocial support and counseling
309
Q

Describe the HIV post exposure prophylaxis after sexual assault

A
  • risk dependent

- administer 28 days of Zidovudine within 72 hours of assault

310
Q

This syndrome is characterized by an acute disorganized phase, then a delayed phase of organization. The acute phase lasts days to weeks and is characterized by physical reactions such as body aches, alterations of appetite and sleeping, and a variety of emotional reactions including anger, fear, anxiety, guilt, humiliation, embarrassment, self-blame, and mood swings, The later phase occurs in the weeks and months following and is characterized by flashbacks, nightmares, and phobiase as well as somatic and gynecologic symptoms

A

Rape-Trauma syndrome

311
Q

24 year old nulliparous brought into emergency center by police due to a sexual assault. Not currently active and does not use contraception. Experienced vaginal penetrated penile intercourse by an unknown male assailant, and was threatened with a knife. On exam the patient appears anxious and tearful. vitals normal. Medications offered?

A
  • Ceftriaxone IM
  • oral metronidazole
  • Oral azithromycin
  • and if not previously vaccinated, Hep B immune globulin and Hep vaccine
  • Emergency contraception
312
Q

After a sexual assault, serologic tests for what diseases should be performed?

A
  • Hep B
  • HIV
  • Syphilis
313
Q

After a sexual assault, when should emergency contraception be given?

A

-within 72 hours, but may be effective if given within 120 hours

314
Q

45 y/o woman who underwent total laparoscopic hysterectomy for symptomatic endometriosis 2 days previously has right flank tenderness, fever of 102, and exquisite CVA tenderness. The small incisions appear normal. Most likely Dx?

A

-Right ureteral obstruction or injury

315
Q

Describe the HIV post exposure prophylaxis after sexual assault

A
  • risk dependent

- administer 28 days of Zidovudine within 72 hours of assault

316
Q

This syndrome is characterized by an acute disorganized phase, then a delayed phase of organization. The acute phase lasts days to weeks and is characterized by physical reactions such as body aches, alterations of appetite and sleeping, and a variety of emotional reactions including anger, fear, anxiety, guilt, humiliation, embarrassment, self-blame, and mood swings, The later phase occurs in the weeks and months following and is characterized by flashbacks, nightmares, and phobiase as well as somatic and gynecologic symptoms

A

Rape-Trauma syndrome

317
Q

after sexual assault, prior to emergency contraception it is vital to assess what

A

an immediated pregnancy test

318
Q

Intimate partner violence increases in pregnancy and can lead to what

A

preterm delivery, low birth weight, and placental abruption

319
Q

45 y/o woman who underwent total laparoscopic hysterectomy for symptomatic endometriosis 2 days previously has right flank tenderness, fever of 102, and exquisite CVA tenderness. The small incisions appear normal. Next step?

A

-IV pyelogram or CT scan of abdomen with IV contrast

320
Q

45 y/o woman who underwent total laparoscopic hysterectomy for symptomatic endometriosis 2 days previously has right flank tenderness, fever of 102, and exquisite CVA tenderness. The small incisions appear normal. Most likely Dx?

A

-Right ureteral obstruction or injury

321
Q

What does endometriosis do that makes ureteral injury during surgery more likely?

A

obliterates tissue planes

322
Q

5 W’s of common causes of postoperative fever

A
  • Wind: atelectasis, pneumonia . . day 1
  • Water: UTI, day 3
  • Walking: DVT or PE . . day 5
  • Wound: wound infection . . . day 7
  • Wonder drugs: drug-induced fever . . . > day 7
323
Q

The attachments of the uterine cervix to the pelvic side walls through which the uterine arteries traverse?

A

Cardinal ligament

324
Q

A procedure in which a scope is introduced through the urethra to examine the bladder lumen and its ureteral orifices. Various procedures, such as placement of stents into the ureters, can be performed

A

Cystoscopy

325
Q

Dilation of the renal collecting system, which gives evidence of urinary obstruction

A

hydronephrosis

326
Q

55 y/o G3P3 underwent total abdominal hysterectomy. 1 month Hx of pelvic pressure and a senstation of “something falling out of her vagina”. On exam, there is vulvar atrophy. There is a mucosal bulging through the introitus. Remainder of the pelvic exam including rectal exam and Q-tip test is normal. options for therapy?

A

-Pessary device or surgical fixation of the vagina to a sturdy structure such as the sacrospinous ligament, the uterosacral ligament, or the sacrum

327
Q

During gynecologic surgeries, what is the most common location for ureteral injury?

A

at the cardinal ligament

328
Q

5 W’s of common causes of postoperative fever

A
  • Wind: atelectasis, pneumonia . . day 1
  • Water: UTI, day 3
  • Walking: DVT or PE . . day 5
  • Wound: wound infection . . . day 7
  • Wonder drugs: drug-induced fever . . . > day 7
329
Q

Overt dissection of the ureter may lead to what type of injury?

A

-devascularization injury because the ureters receive its blood supply from various arteries along its course and flows along its adventitial sheath . . . . . ureteral ischemia

330
Q

55 y/o G3P3 underwent total abdominal hysterectomy. 1 month Hx of pelvic pressure and a senstation of “something falling out of her vagina”. On exam, there is vulvar atrophy. There is a mucosal bulging through the introitus. Remainder of the pelvic exam including rectal exam and Q-tip test is normal. Mostly likely Dx?

A

Vaginal vault prolapse

331
Q

55 y/o G3P3 underwent total abdominal hysterectomy. 1 month Hx of pelvic pressure and a senstation of “something falling out of her vagina”. On exam, there is vulvar atrophy. There is a mucosal bulging through the introitus. Remainder of the pelvic exam including rectal exam and Q-tip test is normal. underlying etiology?

A

-Enterocele with small bowel in hernia sac behind the vaginal cuff

332
Q

describe the surgical repair of rectocele

A
  • a posterior colporrhaphy consisting of incision of the vaginal mucosa posteriorly
  • identification of the edges of the endopelvic fascia
  • surgical repair of these edges that have separated
333
Q

One important risk factor for subsequent vaginal vault prolapse is what?
-What is treatment?

A
  • very spacious and deep cul-de-sac

- Surgical technique of obliterating the cul-de-sac region is called culdoplasty

334
Q

Defect of the pelvic muscular support of the uterus and cervix (if still in situ) or the vaginal cuff (if hysterectomy). The Small bowel and/or omentum descend into the vagina. This is a central pelvic organ prolapse defect.

A

Enterocele

335
Q

Defect of the pelvic muscular support of the rectum, allowing the rectum to impinge into the vagina. The patient may have constipation or difficulty evacuating stool. This is a posterior Pelvic organ Prolapse defect.

336
Q

What are the risk factors for fascial dehiscence

A
  • obesity
  • Diabetes
  • cancer
  • vertical incision
  • intra-abdominal distention
  • exposure to radiation
  • corticosteroid use
  • infection
  • coughing
  • malnutrition
337
Q

muscles of the pelvic diaphragm

A
  • pubococcygeus
  • Puborectalis
  • Levatorani
338
Q

describe the surgical repair of rectocele

A
  • a posterior colporrhaphy consisting of incision of the vaginal mucosa posteriorly
  • identification of the edges of the endopelvic fascia
  • surgical repair of these edges that have separated
339
Q

One important risk factor for subsequent vaginal vault prolapse is what?
-What is treatment?

A
  • very spacious and deep cul-de-sac

- Surgical technique of obliterating the cul-de-sac region is called culdoplasty

340
Q

A disruption of all layers of the incision with omentum or bowel protruding through the incision

A

Evisceration

341
Q

Most appropriate therapy of Evisceration?

A

-Immediate surgical closure and broad-spectrum antibiotic therapy

342
Q

What are the risk factors for fascial dehiscence

A
  • obesity
  • Diabetes
  • cancer
  • vertical incision
343
Q

A separation of part of the surgical incision, but with an intact peritoneum

A

wound dehiscence

344
Q

Separation of the fascial layer, usually leading to a communication of the peritoneal cavity with the skin

A

Fascial disruption

345
Q

A disruption of all layers of the incision with omentum or bowel protruding through the incision

A

Evisceration

346
Q

What is the single most important factor in preventing a Surgical site infection

A

antibiotic prophylaxia
-typically a single dose of first gen cephalosporin such as cefazolin 1g given IV about 15 to 60 minutes prior to surgical incision

347
Q

IN patients with urge incontinence, or mixed symptoms (loss of urine with valsalva and urge to void), what can be helpful to differentiate between genuine stress and urge incontinence

A

Cystometric examination

348
Q

Fluid may appear to be serous and can be clinically indistinguishable between uring and peritoneal fluid. What may distinguish between urine and lymph?

A
  • Creatinine level

- The creatinine level would be significantl more elevated in urine

349
Q

Best treatment for superficial wound infection

A

open the wound and drain the purulence

350
Q

Are prophylactic antibiotics needed if the uterus and vagina are not entered?

351
Q

What is the best therapy for overflow incontinence (neurogenic bladder)

A

intermittent self catheterization

352
Q

Best initial treatment for genuine stress incontinence

A
  • Lifestyle modifications
  • Kegal exercises
  • bladder training
  • If unsuccessful then pessaries or surgical management
353
Q

IN patients with urge incontinence, or mixed symptoms (loss of urine with valsalva and urge to void), what can be helpful to differentiate between genuine stress and urge incontinence

A

Cystometric examination

354
Q

Overflow incontinence is loss of urine associated with an overdistended, hypotonic bladder in the absence of detrusor contractions. This is often associated with what?

A
  • DM
  • spinal cord injuries
  • Lower motor neuropathies
  • It may be caused by urethral edema after pelvic surgery
355
Q

This is investigation of pressure and volume changes in the bladder with the filling of known volumes.

A

Cystometric evaluation (urodynamics)

356
Q

Best method to diagnose vesicovaginal fistula

A

dye instillation into bladder

357
Q

What is the best therapy for overflow incontinence (neurogenic bladder)

A

intermittent self catheterization

358
Q

best treatment for urge incontinence

A

-anticholinergics (Oxybutynin)

359
Q

Gold standard for diagnosis salpingitis

A

Laparoscopy

360
Q

Nulliparites and PID risk?

A

increased risk

361
Q

After a diligent search for cause of chronic pelvic pain, a trial of what can be tried?
-if it fails then what?

A
  • NSAIDs and/or an oral contraceptive agent for 3 months

- If no response then diagnostic laparascopy

OB/GYN (2 decks)

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