Case files Flashcards
(361 cards)
1
Q
Scalp stimulation inducing an acceleration highly correlated to what
A
a normal umbilical cord pH (>/= 7.2)
2
Q
Late decelerations suggest what
A
Fetal hypoxia, and if recurrent (>50% of uterine contractions) can indicate fetal acidemia
3
Q
How long should the latent phase of labor last
A
- less than 18-20 hours for Nullipara
- less than 14 for multipara
4
Q
The most common decelerations are variable, caused by what
A
cord compression
5
Q
definition of postpartum hemorrhage
A
blood loss of >500 mL with a vaginal delivery
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
7
Q
When is RhoGAM administered
A
at 28 weeks and at delivery (if baby is Rh positive)
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
9
Q
most common cause of postpartum hemorrhage with a firm uterus
A
genital tract laceration
10
Q
normal Active phase labor parameters
A
continued progress
11
Q
What may safely reduce the rate of cesarean for repetitive variable decelerations
A
amnioinfusion
12
Q
Serum screening for neural tube defects or Down syndrome are usually performed when
A
-between 16 and 20 weeks gestation
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
14
Q
Normal fetal heart rate at baseline
A
between 110 and 160
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
16
Q
When do yvbn ou screen for gestational diabetes
A
26-28 weeks
17
Q
First trimester screening for trisomies
A
- PAPP-A
- BhCG
- Nuchal translucency
18
Q
When late decelerations occur together with decreased variability, then what is strongly suggested
A
acidosis
19
Q
If a pregnant women with syphilis is allergic to penicillin then what
A
desensitization and then penicillin
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
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
22
Q
what kind of vaccines are contraindicated in pregnancy
A
live attenuated (like rubella)
23
Q
how long should third stage of labor last
A
less than 30 min
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
25
When a labor abnormality is diagnosed, what should be evaluated
- The 3 P's
| - Power, Passenger, Pelvis
26
Category I heart rate pattern
-Reassuring: normal baseline and variability, no late or variable deceleration
27
Active phase of labor starts when cervix is dilated to what
6 cm
28
Acceleration are episodes of fetal heart rate that increase above the baseline how much and for how long
at least 15 bpm and last for at least 15 seconds
29
In every pregnancy greater than 20 weeks gestation, the patient should be questioned about symptoms of preeclampsia such as what
- headaches
- visual disturbances
- dyspnea
- epigastric pain
- face/hand swelling
30
C section to avoid birth trauma/shoulder dystocia should be limited to estimated fetal weigh of what
- 5000 g or more in nondiabetic woman
| - 4500 g or more in diabetic
31
What murmurs are fairly common in pregnancy women and why
Systolic flow murmurs due to increased cardiac output
32
What is the most common cause of postpartum hemorrhage
Uterine atony
33
How long should second stage of labor last
- Less than 3 hours or less than 4 w/ epidural for Nulli
| - Less than 2 or less than 4 w/ epidural for multi
34
This is loss of the cervical mucus plug and is often a sign of impending labor
Bloody show
35
What can differentiate bloody show from antepartum bleeding (from placenta previa, placental abruption, and vasa previa)
Sticky mucus admixed with blood
36
ACOG and AAP recommend against deliver before how many weeks?
39 without a medical indication
37
what is the best plan for prolonged latent phase
Continued observation on oxytocin
38
Uterine contraction pattern of excessive number of contractions like 7 in a 9 minute window is tachysystole. What could be used for this
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
39
Definition of anemia is a pregnant woman
Hb less than 10.5
40
This is a vaso-occlusive disease of the lungs (maybe from sickle cell), leading to a new pulmonary infiltrate, acute dispnea, and hypoxia
Acute chest syndrome
41
Acute chest syndrome that is severe is usually treated with what
a partial exchange transfusion
42
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?
-uterine inversion
43
most likely complication of uterine inversion
postpartum hemorrhage
44
What are the 4 signs of placental separation
- gush of blood
- lengthening of the cord
- globular and firm shape of the uterus
- The uterus rises up to the anterior abdominal wall
45
What is the best method of avoiding uterine inversion
to await spontaneous separation of the placenta from the uterus before placing traction on the umbilical cord
46
This is a abnormally adherent placenta, which is a risk factor for uterine inversion
placenta accreta
47
Describe how to react to uterine inversion
- 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
48
What position of placenta predisposes to uterine inversion
fundal
49
After 30 minutes, the placenta is abnormally retained. What should happen next
manual extraction
50
Describe the mechanism of how an inverted uterus causes hemorrhage
- 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
51
What is the best initial therapy for a nonreducible uterus
-A uterine relaxing agent (such as halothane anesthesia)
52
When should the umbilical cord be clamped after delivery of preterm infant
-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
53
Delayed cord clamping also improves iron stores in TERM infants, but may also lead to a higher risk of what
hyperbilirubinemia
54
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?
-McRoberts Maneuver (Hyperflexion of the maternal hips onto the maternal abdomen and/or suprapubic pressure
55
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
- Maternal: postpartum hemorrhage
| - Neonate: brachial plexus injury such as an Erb palsy
56
What are the prenatal risk factors for shoulder dystocia in order of significance?
- Prior shoulder dystocia
- Fetal macrosomia
- Maternal Gestational Diabetes
57
Describe ERB palsy, a potential outcome of shoulder dystocia
- 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
58
What are the common maneuvers for treatment of shoulder dystocia
- McRoberts maneuver (hyperflex maternal thighs)
- Suprapubic pressure
- Wood's corkscrew maneuver
- Delivery of the posterior arm
- Zavanelli maneuver (cephalic replacement and cesarean)
59
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?
Vaginal exam to assess for umbilical cord prolapse
60
Should you rupture membranes with an unengaged fetal presentation?
No . . . risk of cord prolapse
61
If a vaginal exam is done and a rope like structure is felt then what is next step
- Elevation of presenting part and
| - immediate C section . . . cord prolapse
62
What is trendelenburg position
head down
63
definition of fetal bradycardia
Baseline fetal heart rate of < 110 for > 10 minutes
64
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?
- 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
65
In women with prior Cesarean delivery, what may manifest as fetal bradycardia?
uterine rupture
66
What is the most common finding in a uterine rupture
a fetal heart rate abnormality, such as fetal bradycardia, deep variable decelerations, or late decelerations
67
Prolonged fetal decelerations or fetal bradycardia associated with misoprostol cervical ripening is typically associated with what etiology?
uterine hyperstimulation
68
Next step in therapy for postpartum hemorrhage due to uterine atony
- Dilute IV oxytocin
- bedside uterine massage
- and compression
- If this is ineffective, then intramuscular prostaglandin F2-alpha (Hemabate) or rectal misoprostol
69
What agent used to treat uterine atony is condraindicated in HTN
-Methylergonovine maleate (Methergine): an ergot alkaloid agent that induces myometrial contraction as a treatment of uterine atony
70
what is a compound that stimulated myometrial contraction and can be used in the treatment of uterine atony but is contraindicated in asthmatic patients
Prostaglandin F2-alpha
71
risk factors for uterine atony
- 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
72
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
subinvolution of the placental site
73
Ligation of what are methods for decreasing the pulse pressure to the uterus nad can help in post partum hemorrhage
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
74
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?
Basic U/S to assess for dates and multiple gestations
75
Purpose of msAFP (maternal serum)
-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
76
low msAFP may be associated with what disorder
fetal Down syndrome
77
At 16 weeks, the fundus is usually where?
midway between the symphysis pubis and the umbilicus
78
at 20 weeks, the fundus is usually where
at the level of the umbilicus
79
this is a glycoprotein made by the fetal liver, analogous to the adult albumin
alpha-fetoprotein
80
Although the triple screen may be offered to women over the age of 35, or advanced maternal age, what provides more diagnostic information
genetic amniocentesis
81
AFP levels of what are suspicious for neural tube defects and warrant further evaluation
>2.0 to 2.5 MOM
82
What trisomy has all the serum markers in quad screen decreased
trisomy 18 (Edwards)
83
What teratogen? -Masculinization of female fetus
| -Labial fusion
Androgens
84
What teratogen? -Fetal alcohol syndrome
- IUGR
- microcephaly
alcohol
85
What teratogen? Fetal hydantoin syndrome
- IUGR
- microcephaly
- facial defects
Phenytoin
86
What teratogen? -Heart and great vessel defects (Ebstein anomaly)
Lithium carbonate
87
What teratogen? -Skeletal defects
| -limb defects
Methotrexate
88
What teratogen? -Facial defects
| -neural tube defects
-Retinoic acid (vitamin A)
89
What teratogen? -Skull anomalies
- limb defects
- miscarriages
- renal tubule dysgenesis
- renal failure in neonate
- Oligohydramnios
ACEI
90
What teratogen? -CNS and skeletal defects
Warfarin
91
What teratogen? Neural tube defects
Valproic acid and carbamazepine
92
What is double bubble found on fetal U/S . . .cystic masses in both right and left abdomen
- Duodenalatresia
- The hydramnios results from the inability of the baby to swallow
- Duodenal atresia is strongly associated with fetal down syndrome
93
Pregnancies with elevated msAFP, which after evaluation are unexplained are at increased risk for what?
- Stillbirth
- growth restriction
- preeclampsia
- placental abruption
94
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?
-Twin gestation with vasa previa
95
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?
- 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
96
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
-STAT C section and alert pediatricians for likelihood of anemia in twin A
97
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
Velamentous cord insertion
98
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
Vasa previa
99
What is the best treatment for Twin Twin transfusion syndrome
Laser ablation of the shared vessels
100
Twin gestation at 30 weeks gestation and signs and symptoms of preeclampsia and pulmonary edema . . best next step
induce labor immediately
101
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?
Counsel the patient about risks of neonatal HSV infection and offer a C section
102
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
-HSV recurrence with prodromal symptoms
103
Describe the Herpes Simplex virus prodromal symtpoms
Prior to the outbreak of the classic vesicles, the patient may complain of burning, itching, or tingling
104
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?
US
105
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?
-Placenta previa
106
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?
- Expectant management as long as the bleeding is not excessive
- C section at 34 weeks gestation
107
Definition of antepartum vaginal bleeding
vaginal bleeding occurring after 20 weeks gestation
108
Premature separation of a normally implanted placenta
Placenta Abruption
109
The placenta completely covers the internal os of the uterine cervix
placenta previa
110
What are the two most common causes of significant antepartum bleeding
- placental abruption
| - placenta previa
111
In antepartum bleeding what is the main differentiator between placental abruption and placenta previa
- Vaginal bleeding is painless in a previa
| - Painful in an abruption secondary to contractions
112
When placenta previa is diagnosed at an early gestation, such as second trimester, what should happen?
repeat sonography is warranted since many times the placenta will move away from the cervix (transmigration)
113
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?
Placental abruption
114
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?
- Hemorrhage
- Fetal to maternal bleeding
- Coagulopathy
- Preterm delivery
115
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?
-Delivery (at 35 weeks, the risk of abruption significantly outweigh the risks of prematurity)
116
Why is US a poor method of assessment for abruption
The freshly developed blood clot behind the placenta has the same sonographic texture as the placenta itself
117
This is bleeding into the myometrium of the uterus giving a discolored appearance to the uterine surface
Couvelaire uterus
118
When the abruption is of sufficient severity to cause fetal death, what is found in one-third or more of cases?
coagulopathy
119
Describe the Kleihauer-Betke test
-Tests for fetal erythrocytes from the maternal blood
120
What is the biggest modifiable risk of placenta abruption
smoking
121
What drug is strongly associated with the development of placental abruption and why?
cocaine due to its effect on the vasculature (vasospasm)
122
fetal demise in placenta abruption means what kind of management
vaginal delivery
123
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?
Placenta accreta
124
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?
Hysterectomy
125
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?
Infection.
| -the necrosis of the placental tissue is a nidus for infection
126
Describe the relationship b/t myomectomy limied to the serosal (outside) surface of the uterus and risk of placenta accreta?
do NOT predispose to accreta because the endometrium is not disturbed
127
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?
Torsion of the ovary
128
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
Surgery (laparotomy due to pregnancy
129
Location of the abdominal appendixin acute appendicitis in pregnancy
- 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
130
What is the most frequent and serious complication of a benign ovarian cyst
ovarian torsion
131
What is the most common cause of hemoperitoneum in early pregnancy
ectopic pregnancy
132
When the corpus luteum is excised in a pregnancy of less than 10 to 12 weeks, what should be supplemented?
progesterone
133
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?
Intrahepatic cholestatis of pregnancy (ICP)
134
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?
-Ursodeoxycholic acid (UDCA)
135
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?
-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
136
Describe the mechanism of ICP
-Bile salts are incompletely cleared by the liver, accumulate in the body, and are deposited in the dermis, causing pruritus
137
This is a common skin condition of unknown etiology unique to pregnancy characterized by intense pruritus and erythematous papules on the abdomen and extremities
Pruritic urticarial papules and plaques of pregnancy (PUPPP)
138
Rare skin condition only seen in pregnancy; it is characterized by intense itching and vesicles on the abdomen and extremities
Herpes Gestationis
139
In ICP, the risk of fetal demise and adverse fetal outcomes increases with higher what?
bile acid concentrations and increasing gestational age
140
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
Acute Fatty Liver of Pregnancy (AFLP)
141
Normal PCO2 in pregnancy and why?
- 28
| - Higher tidal volume leads to increased minute ventilation
142
Normal HCO3 in pregnancy and why?
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
143
What is the most common overall etiology for maternal mortality
embolism of all types
144
How do you manage a pregnant patient who is heterozygous for Factor V leiden and no Hx of clots
expectant management and not given anticoagulation
| -If homozygous or has hx of clots then heparin
145
What is the most common side effect of long term heparin use in pregnancy?
Osteoporosis
146
After a DVT or PE is dx, anticoagulation is indicated for how long
at least 3 months
147
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?
Preeclampsia with severe features
148
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?
-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
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?
CBC with platelet count and renal function test (creatinine)
150
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?
- 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
In the absence of proteinuria, HTN with one of the following findings would be preeclampsia
- thrombocytopenia
- impaired liver function tests
- renal insufficiency
- pulmonary edema
- cerebral disturbances
- visual impairment
152
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.
Posterior revervislble encephalopathy syndrome (PRES)
153
Diagnosis of preeclampsia
- 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
Severe features of preeclampsia is any one of the following
- 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
In an unstable patient with severe preeclampsia, what may elevate the BP in postpartum period and should be avoided
NSAIDS
156
What is the most common cause of maternal death due to eclampsia?
intracerebral hemorrhage
157
How can PRES syndrome be quickly diagnosed
MRI
158
In a patient with IUGR, the next step would be to evaluate possible fetal compromise how?
with BPP and umbilical artery doppler studies
159
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?
preterm labor
160
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?
- Tocolysis
- try to identify a cause of the preterm labor
- antenatal steroids
- antibiotics for GBS prophylaxis
161
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?
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
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?
-Magnesium sulfate may be given for pregnancies of < 32 weeks when there is imminent delivery
163
what week are steroids no longer helpful
34 weeks
164
A careful search should be undertaken to identify an underlying cause of perterm labor, such as what?
- UTI
- cervical infection
- BV
- Generalized infection
- trauma or abruption
- hydramnios
- multiple gestation
165
In preterm labor, what is helpful in case the tocolysis is unseccuessful to reduce the likelihood of GBS sepsis in the neonate
IV antibiotics (penicillin)
166
In preterm labor, at what weeks does starting magnesium help with neurodevelopment of the preterm baby, reducing cases of cerebral palsy
<31 and 6/7
167
Tocolysis is the use of pharmacologic agents to delay delivery once preterm labor is diagnosed. What are the most commonly used agents?
- indomethacin
- nifedipine
- terbutaline
- ritodrine
168
Cervical length less then what results in an increased risk of preterm delivery
< 25 mm
169
what is the method of action of magnesium
competitively inhibits calcium
170
Side effects of magnesium
- pulmonary edema
| - respiratory depression
171
What infection is strongly associated with preterm delivery
Gonococcal cervicitis
172
This is a relative contraindication for tocolysis because this pathology may extend
suspected abruption
173
Side effects/complications of Terbutaline and Ritodrine?
- Pulmonary edema
- increased pulse pressure
- Hyperglycemia
- Hypokalemia
- tachycardia
174
side effects/complications of indomethacin
-closure of fetus ductus arteriosus, which would lead to pulmonary HTN and oligohydramnios (could cause cord compression >> variable decels)
175
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
Progesterone (17-OHP)
176
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?
Intra amniotic infection (chorioamnionitis)
177
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?
IV antibiotics (ampicillin and gentamicin) and induction of labor
178
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?
ascending infection from vaginal organisms
179
What are the two most common acute complication of preterm premature rupture of membranes
infections and labor
180
This is rupture of membrane prior to the onset of labor
Premature ROM
181
This is rupture of membranes in a gestation < 37 weeks, prior to the onset of labor
Preterm premature ROM
182
What is the most accurate method to confirm intra-amniotic infection
Amniotic fluid gram stain by amniocentesis
183
What organism may induce chorioamnionitis without ROM
Listeria
184
Fetal lung maturity is demonstrated on vaginal amniotic fluid by presence of what?
```
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
What is the most common FHT abnormality with PPROM
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
What is the earliest sign of chorioamnionitis
fetal tachycardia
187
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?
- Hydramnios, with probable fetal hydrops due to parvovirus B19 infection
- Fetal anemia due to neonatal parvovirus infx, which inhibits bone marrow erythrocyte production
188
typical presentation of parvovirus B19 infx in adults
- malaise
- arthralgias
- myalgias
- reticular (lacy) faint rash that comes and goes
- up to 20% of adults will have no symtoms
189
typical presentation of parvovirus B19 infx in children
- classic "slapped cheek"
| - high fever
190
What is one of the earliest signs of fetal hydrops
hydramnios or excess amniotic fluid
191
What are classic signs of hydramnios
- uterine size greater than predicted by her dates
| - fetal parts difficult to palpate
192
How is dx of parvovirus B19 infx made
serology
193
other name for parvovirus B19 infx
erythema infectiosum
194
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
Hydrops fetalis
195
What fetal heart pattern is associated with severe fetal anemia or asphyxia
sinusoidal pattern
196
Describe the effects of CMV on infants born infected
- Microcephaly
- Periventricular calcifications
- deafness
- chorioretinitis (blindness)
- seizures
- Interstitial pneumonia
197
Describe the time frame and transmission of CMV infx in pregnancy
- Transmission is highest in the third trimester
| - neonatal effects are worse in first trimester
198
Describe how to prevent CMV infx in pregnancy
- careful handwashing
| - avoid sharing utensils especially with children
199
What is the best method for dx of Toxoplasmosis
PCR
200
pregnant women infected with toxo are treated with what
- spiramycin to reduce transplacental transfer
| - Fetal infection is treated with pyrimethamine and sulfadiazine
201
Describe the fetal presentation of toxo
- Most neonates are asymptomatic at birth but can later develop chorioretinitis and hearing loss
- The classic triad is: HYDRDOCEPHALUS, INTRACRANIAL CALCIFICATIONS, AND CHORIORETINITIS
202
Presentation of rubella infx
- Classic triad: cataracts, sensorineural deafness, and cardiac defects
- also microcephaly and thrombocytopenia
203
Middle cerebral artery doppler studies indicated increased velocity of flow are consitent with what
significant fetal anemia
204
Describe the interpretation and management of a pregnant patient with suspected parvavirus B19 infection but IgM and IgG negative
- 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
A pregnant woman who is diagnosed with parvovirus infx will have weekly US exam for how long and to assess for what?
- for 12 weeks
| - to assess for fetal hydrops/hydramnios
206
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?
-Oral erythromycin, azythromycin, or amoxicillin
207
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
-Either western blot confirmation, or polymerase chain reaction (PCR) confirmation
208
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?
- Assessment of stage of HIV infection
- Initial HAART
- offer elective C section
- oral zidovudine to the neonate
209
What can a maternal chlamydial infection cause in the neonate
conjunctivitis and pneumonia
210
Erythromycin eye ointment given at birth prevents against what
GONOCOCCAL conjunctivits
211
Tetracyclines taken by pregnant women can lead to what in the fetus
staining of fetal teeth
212
What is the most common cause of conjunctivitis in the first month of life
chlamydia
213
Late postpartum endometritis, occurring 2 to 3 weeks after deliver, is associated with what infection
chlamydia
214
Disseminated gonococcal disease is more common in the pregnant woman, presenting as what
- pustular skin lesions
- arthralgias
- septic arthritis
215
Can a neonate acquire HIV from breast milk
yes
216
Describe how the viral load of HIV should be monitored in pregnancy
should be evaluated monthly until it is no longer detectable
217
What is the viral load goal in pregnancy
to maintain a viral load under 1000 RNA copies/mL
218
In women with HIV viral loads exceeding 1000, what has been shown to significantly reduce the risk of vertical infection?
scheduled C section prior to labor or ROM
219
Those HIV infected women who choose to deliver vaginally should receive what?
- IV zidovudine during labor
- Breast feeding should be discouraged
- the neonate should also receive oral zidovudine syrup
220
Patients on HAART therapy should have regular monitoring of what?
- Liver function tests and
| - blood counts to detect toxicity
221
Antiviral therapy shows no increase in congenital anomalies with the exception of what
- efavirenz
| - an NNRTI, which is associated with neural tube defects
222
Those pregnancy women with HIV and co infection with Hep B should be treated with what antiviral agent
Tenofovir and lamivudine
223
What type of epithelium does chlamydia have a propensity for
columnar and transitional
224
This is a obligate intracellular organism associated with LATE postpartum endometritis and has a LONG replication cycle
Chlamydia
225
how to manage an HIV pregnancy with no prenatal care at term who has begun labor and ROM
- 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
Best management for thyroid storm in pregnancy
- A Beta-blocker (such as propranolol)
- corticosteroids
- PTU (preferred for rapid onset) or methimazole
227
What is the most commonly used medication for hyperthyroidism in pregnancy
Methimazole after first trimester due to the possibility of liver toxicity with PTU
228
Which drug for hyperthyroidism is NOT used in first trimester
methimazole
229
What are the three phases of postpartum thyroiditis . . peak onset at 6 months post delivery
- Hyperthyroid
- Hypothyroid
- euthyroid (although some will remain hypo)
230
Describe in general what the high estrogen levels of pregnancy do to thyroid panel levels?
- 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
Failure to identify fetal thyrotoxicosis can result in what
nonimmune hydrops and fetal demise
232
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?
-antimicrosomal and antiperoxidase
233
Hyperparathyroidism in pregnancy presents as what?
- kidney stones
- lethargy
- or pain
234
What is the treatment of choice for hyperparathyroidism in pregnancy in the second trimester
surgery
235
Once IUGR is diagnosed, The fetal US parameters are broadly categorized as symmetric or asymetric. what does this mean
- symmetric: head affected
| - asymmetric: head spared
236
The most common cause of asymmetric IUGR is what
-a maternal vascular disorder such as HTN disease, smoking, or illicit drug use
237
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?
- BPP
- assessment of amniotic fluid volume
- Doppler flow studies of the umbilical artery
238
definition of IUGR
birthweight less than the 10th percentile for Gestational age
239
End-diastolic flow is the flow through the umbilical artery. Reverse end-diastolic flow is associated with what within 48 hours?
high stillbirth rate
240
29 weeks gestation is undergoing treatment of pyelonephritis with an appropriate antibiotic regimen and now complains of shortness of breath. Most likely Dx?
Acute respiratory distress syndrome (ARDS)
241
29 weeks gestation is undergoing treatment of pyelonephritis with an appropriate antibiotic regimen and now complains of shortness of breath. Mechanism of injury?
Endotoxin-mediated pulmonary injury
242
This is alveolar and endothelial injury leading to leaky pulmonary capillaries, clinically causing hypoxemia, markedly increased alveolar-arterial gradient, and loss of lung volume
ARDS
243
What is the most common cause of sepsis in pregnant women?
pyelonephritis
244
A urine culture revealing > how many CFUs of a single uropathogen is diagnostic
100,000
245
Pregnant women with acute pyelonephritis should be hospitalized and given IV antibiotics. Which ones are usually effective?
- Cephalosporins, such as cefotetan or ceftriaxone
| - or combo of Amp and Gent
246
After treatment of acute pyelonephritis in pregnancy, suppressive therapy should be given for the remainder of pregnancy with what?
oral nitrofurantoin 100 mg
247
in acute pyelo in pregnancy, if clinical improvement has not occurred after 48 to 72 hours of appropriate antibiotic therapy, what should be suspected?
- urinary tract obstruction
| - perinephric abscess
248
ARDS may induce transient elevation of what labs
-serum creatinine as well as liver enzymes
249
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?
Necrotizing fasciitis
250
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
- Isotonic IV fluids
- broad-spectrum antibiotics
- immediate surgical debridement
251
Rapidly progressing infection of the episiotomy or C section incision ("flesh-eating bacteria" syndrome)
Group A streptococcal toxic shock syndrome
252
Condition of circulatory insufficiency where tissue perfusion needs are not met
shock
253
Describe the broad spectrum antibiotics and other therapy used to treat septic shock
- penicillin
- Gentamicin
- and metronidazole or other anaerobic agent
- Dopamine or dobutamine is sometimes required when fluids alone are insufficient to maintain BP
254
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?
Endomyometritis
255
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?
-Ascidning infection of vaginal organisms (anaerobic predominance but also Gram-negative rods)
256
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
IV antibiotics with anaerobic coverage (e.g. gentamicin and clindamycin)
257
What is the most common cause of fever for a woman who has undergone C section
endomyometritis
258
Differential dx for a women post C section with a fever
- endomyometritis
- mastitis
- wound infection
- atelectasis (if general anesthesia)
- pyelonephritis
259
This is a bacterial infection of pelvic venous thrombi, usually involving the ovarian vein
Septic pelvic thrombophlebitis (SPT)
260
If post C section patient with fever treated sufficiently and fever doesn't improve in 48 hours then what
- entoerococcal infection may be on reason for nonresponse
| - ampicillin is added
261
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?
CT scan of the abdomen and pelvis may reveal an abscess, infected hematoma, or pelvic thrombophlebitis
262
The best treatment of a wound infection is what
opening of the wound
263
What is the best treatment of septic pelvic thrombophlebitis
combo of antibiotics and heparin
264
The major organisms responsible for post C section endomyometritis are anaerobic bacteria with the most commonly isolated organisms including what?
- Peptostreptococcus
- Peptococcus
- Bacteroides
265
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?
Abscess of the right breast
266
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
Incision and drainage of the abscess and antibiotic therapy
267
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
Staph aureus
268
Women with mastitis should be instructed to do what in terms of breast feeding
continue to breast feed or drain the breast by pump
269
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
Galactocele
270
Breast milk contains nearly all of the nutrients required with the exception of what vitamins?
K and D
271
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?
- concern about inflammatory breast carcinoma
| - biopsy
272
Best treatment for a galactocele
aspiration
273
When is vitamin D supplementation recommended in an exclusively breast fed infant
at 2 months
274
What is the best treatment for cracked nipples
air drying and avoidance of using harsh soap
275
Breast engorgement rarely causes high fever persisting more than how long
24 hours
276
Describe how DKA in pregnancy is different than in nonpregnancy
it can develop with lower blood sugars and more rapidly than nonpregnant patients
277
Do you take DKA patient for an emergency C section?
No because the acidosis is correctable and these individuals are unstable
278
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
White classification
279
This type of diabetes in pregnancy is associated with miscarriage and congenital anomalies
Pregestational
| -Gestation IS NOT
280
What is the leading cause of blindness in reproductive age women
diabetic retinopathy
281
why is glycemic control critically important during labor and delivery
Maternal hyperglycemia can lead to neonatal HYPOglycemia after birth
282
In pregnancy, Several physiological factors predispose to DKA. What are they
- 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
In a diabetic pregnancy, who should be assessed for DKA by checking blood sugar and urine for ketones
every diabetic pregnant woman who has vague complaints
284
In DKA, what will the fetal heart pattern often exhibit
loss of variability and late decelerations due to maternal acidosis
285
All women diagnosed with Gestational DM should be screened for overt DM when postpartum and how
at 6 weeks post partum with a 2 hour 75 gram oral glucose tolerance test
286
The most common congenital anomalies associated with pregestational diabetes are what?
cardiac and neural tube defects
287
Prior pregnancy that resulted in abortion due to abruption at 38 weeks. How do you manage this pregnancy?
induction at or slightly before the time of abruption with the fetal loss, if at term.
288
when indirect coombs test is positive, it is important to identify the antibody. Which antibody is not harmful and why?
- anti-lewis because it is IgM and does NOT cross placenta
| - "lewis lives, Kell kills, Duffy dies"
289
Describe the administration of TdaP vaccine in pregnancy
should be given b/t 28 and 36 weeks regardless of whether it has been given in prior pregnancies
290
66 y/o comes for health maintenancy. A mammogram has been performed 3 months previously. Next step?
- 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
66 y/o comes for health maintenancy. A mammogram has been performed 3 months previously. most common cause of mortality?
Cardiovascular disease
292
how often should lipid profile be done in older women
every 5 years up to age 75
293
how often should thyroid function testing be done in older women
every 5 years
294
how often should fasting blood glucose levels be done in older women
every 3 years
295
Describe pap smear screening in HIV-positive women
- twice in first year after Dx
| - then annually
296
Describe the varicella zoster vaccine
- Live attenuated vaccine
| - recommeded for individuals aged 60 and over
297
A 49 y/o woman complains of irregular menses, feelings of inadequacy, sleeplessness, and episodes of warmth and sweating. Most likely Dx?
-Climacteric (perimenopausal state)
298
A 49 y/o woman complains of irregular menses, feelings of inadequacy, sleeplessness, and episodes of warmth and sweating. Next diagnostic step?
-serum FSH, LH, and TSH levels
299
what is usually effective in treating Hot flushes in perimenopausal state
estrogen replacement therapy with progestin
-when a woman still ha her utuerus, the addition of progestin is important in preventing endometrial cancer
300
what is the predominant symptom of hypoestrogenemia
hot flush: a vasomotor reaction associated with skin temperature elevation and sweating lasting for 3 to 4 minutes
301
FSH and LH levels in perimenopause
elevated but will fluctuate in the perimenopause leading up to actual menopause and cannot be relied upon until persistently elevated
302
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
Premature ovarian failure
303
What is the earliest marker to indicate decrease ovarian reserve?
- Anti-mullerian hormone (AMH)
- Inhibin B is the next marker to decrease
- Finally estradiol falls
304
Describe the mechanism of amenorrhea in PCOS
estrogen excess
305
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?
- Ceftriaxone IM
- oral metronidazole
- Oral azithromycin
- and if not previously vaccinated, Hep B immune globulin and Hep vaccine
- Emergency contraception
306
mechanism of amenorrhea in excessive exercise
hypothalamic dysfunction
307
what is the most common location of an osteoporosis associated fracture?
thoracic spine as a compression fracture
308
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?
- 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
Describe the HIV post exposure prophylaxis after sexual assault
- risk dependent
| - administer 28 days of Zidovudine within 72 hours of assault
310
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
Rape-Trauma syndrome
311
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?
- Ceftriaxone IM
- oral metronidazole
- Oral azithromycin
- and if not previously vaccinated, Hep B immune globulin and Hep vaccine
- Emergency contraception
312
After a sexual assault, serologic tests for what diseases should be performed?
- Hep B
- HIV
- Syphilis
313
After a sexual assault, when should emergency contraception be given?
-within 72 hours, but may be effective if given within 120 hours
314
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?
-Right ureteral obstruction or injury
315
Describe the HIV post exposure prophylaxis after sexual assault
- risk dependent
| - administer 28 days of Zidovudine within 72 hours of assault
316
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
Rape-Trauma syndrome
317
after sexual assault, prior to emergency contraception it is vital to assess what
an immediated pregnancy test
318
Intimate partner violence increases in pregnancy and can lead to what
preterm delivery, low birth weight, and placental abruption
319
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?
-IV pyelogram or CT scan of abdomen with IV contrast
320
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?
-Right ureteral obstruction or injury
321
What does endometriosis do that makes ureteral injury during surgery more likely?
obliterates tissue planes
322
5 W's of common causes of postoperative fever
- 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
The attachments of the uterine cervix to the pelvic side walls through which the uterine arteries traverse?
Cardinal ligament
324
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
Cystoscopy
325
Dilation of the renal collecting system, which gives evidence of urinary obstruction
hydronephrosis
326
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?
-Pessary device or surgical fixation of the vagina to a sturdy structure such as the sacrospinous ligament, the uterosacral ligament, or the sacrum
327
During gynecologic surgeries, what is the most common location for ureteral injury?
at the cardinal ligament
328
5 W's of common causes of postoperative fever
- 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
Overt dissection of the ureter may lead to what type of injury?
-devascularization injury because the ureters receive its blood supply from various arteries along its course and flows along its adventitial sheath . . . . . ureteral ischemia
330
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?
Vaginal vault prolapse
331
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?
-Enterocele with small bowel in hernia sac behind the vaginal cuff
332
describe the surgical repair of rectocele
- 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
One important risk factor for subsequent vaginal vault prolapse is what?
-What is treatment?
- very spacious and deep cul-de-sac
| - Surgical technique of obliterating the cul-de-sac region is called culdoplasty
334
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.
Enterocele
335
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.
rectocele
336
What are the risk factors for fascial dehiscence
- obesity
- Diabetes
- cancer
- vertical incision
- intra-abdominal distention
- exposure to radiation
- corticosteroid use
- infection
- coughing
- malnutrition
337
muscles of the pelvic diaphragm
- pubococcygeus
- Puborectalis
- Levatorani
338
describe the surgical repair of rectocele
- 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
One important risk factor for subsequent vaginal vault prolapse is what?
-What is treatment?
- very spacious and deep cul-de-sac
| - Surgical technique of obliterating the cul-de-sac region is called culdoplasty
340
A disruption of all layers of the incision with omentum or bowel protruding through the incision
Evisceration
341
Most appropriate therapy of Evisceration?
-Immediate surgical closure and broad-spectrum antibiotic therapy
342
What are the risk factors for fascial dehiscence
- obesity
- Diabetes
- cancer
- vertical incision
343
A separation of part of the surgical incision, but with an intact peritoneum
wound dehiscence
344
Separation of the fascial layer, usually leading to a communication of the peritoneal cavity with the skin
Fascial disruption
345
A disruption of all layers of the incision with omentum or bowel protruding through the incision
Evisceration
346
What is the single most important factor in preventing a Surgical site infection
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
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
Cystometric examination
348
Fluid may appear to be serous and can be clinically indistinguishable between uring and peritoneal fluid. What may distinguish between urine and lymph?
- Creatinine level
| - The creatinine level would be significantl more elevated in urine
349
Best treatment for superficial wound infection
open the wound and drain the purulence
350
Are prophylactic antibiotics needed if the uterus and vagina are not entered?
No
351
What is the best therapy for overflow incontinence (neurogenic bladder)
intermittent self catheterization
352
Best initial treatment for genuine stress incontinence
- Lifestyle modifications
- Kegal exercises
- bladder training
- If unsuccessful then pessaries or surgical management
353
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
Cystometric examination
354
Overflow incontinence is loss of urine associated with an overdistended, hypotonic bladder in the absence of detrusor contractions. This is often associated with what?
- DM
- spinal cord injuries
- Lower motor neuropathies
- It may be caused by urethral edema after pelvic surgery
355
This is investigation of pressure and volume changes in the bladder with the filling of known volumes.
Cystometric evaluation (urodynamics)
356
Best method to diagnose vesicovaginal fistula
dye instillation into bladder
357
What is the best therapy for overflow incontinence (neurogenic bladder)
intermittent self catheterization
358
best treatment for urge incontinence
-anticholinergics (Oxybutynin)
359
Gold standard for diagnosis salpingitis
Laparoscopy
360
Nulliparites and PID risk?
increased risk
361
After a diligent search for cause of chronic pelvic pain, a trial of what can be tried?
-if it fails then what?
- NSAIDs and/or an oral contraceptive agent for 3 months
| - If no response then diagnostic laparascopy
