Case Files - Random Flashcards
Nulliparous women dilate at what rate during active phase
1.2cm/hr
What features would suggest retained products of conception (i.e. after abortion)?
Open cervical os, lower abdominal cramping, vaginal bleeding, signs of infection
Why are we concerned about hemorrhage when performing curettage in an infected uterus?
Higher risk of perforation when infected
2 most common complications ass. with spontaneous abortion
Infection and Hemorrhage
Signs/sxs of septic abortion
Uterine bleeding and/or spotting in 1st Trimester + signs of infection. May see abdominal tenderness, cervical motion tenderness, foul-smelling vag discharge
In septic abortion, where does the infection come from/travel to?
Ascends from Vagina or Cervix. Goes to Endometrium –> Myometrium –> Perimetrium –> Peritoneum
Which organism causes septic abortion?
Polymicrobial –> Anaerobic strep, bacteroides, E coli, GBS are common
Bloody Show
A sign of impending labor that is often accompanied by the loss of the mucus plug. May present as bloody mucus in the vaginal vault.
What is the cutoff for ‘anemia in pregnancy’
10.5
Accelerations
> 15bpm above baseline for at least 15 seconds
Normal FHT range
110bpm-160bpm
Adequate Contractions
> 200 Montevideo Units in a 10min. window
Protracted Labor
Some progression but taking longer than normal (i.e. 0.5cm/hr)
Bloody Show
A sign of impending labor that is often accompanied by the loss of the mucus plug. May present as bloody mucus in the vaginal vault.
Combination of which 2 antibiotics works well for septic abortion tx 95% of the time
Gentamicin + Clindamycin (want broad spectrum with good anaerobic cover)
When do you begin uterine curettage for removal of retained products of conception/septic abortion?
4 hours after starting IV antibiotics
Why is urine output carefully observed in the setting of septic abortion?
because Oliguria = early sign of septic shock
Pelvic exam finding for Mullerian agenesis pt
blind vaginal pouch/vaginal dimple
Why does uterine inversion lead to PPH
Prevents adequate myometrial contraction
Absence of breast development points towards what hormonal state and condition?
Hypoestrogenic state –> Gonadal dysgenesis aka Turner syndrome
Next step in management after a shoulder dystocia has occurred
McRobert’s Maneuver - hyperflexion of maternal hips onto maternal abdomen and/or suprapubic pressure
Primary Amenorrhea = no menarche by age ____
16
Primary amenorrhea, normal breast, pubic, and axillary hair. Absent uterus
Mullerian agenesis
First dx test for any woman with primary or secondary amenorrhea?
Pregnancy test
T/F Fundal Pressure should be applied immediately following Dx of shoulder dystocia
False, it should be avoided due to increased risk of neonatal injury. McRoberts uses suprapubic pressure
+ whiff test
BV or Trich
Why do menses and intercourse exacerbate the fishy odor of BV?
Both introduce an alkaline substance
what are Amsel’s criteria?
3/4 indicate BV
- Homogenous, gray-white discharge
- vaginal pH>4.5
- Postive whiff test
- Clue cells on wet mount
(Gram stain is gold standard but rarely used clinically)
Strawberry cervix
Trichomonas
“Strawberries are trich-y to Cerve”
why does antibiotic use dispose to Candida vaginitis?
normal lactobacilli in vagina inhibit fungal growth (these are reduced by antibiotic)
which of the 3 vaginitis microscopic dx is assisted by KOH?
Candida: KOH lyses leukocytes and erythrocytes, can identify hypahae/pseudohyphae easier
Classic mammogram finding of breast cancer
A. Small cluster of calcifications around a small mass
or B. masses with ill-defined borders (spiculated/invasive)
or C. asymmetric increased tissue density
Next dx step if mammogram is suspicious for cancer
Stereotactic core biopsy
role of MRI in identifying breast cancer?
Can detect early breast cancers missed by mammography, especially in younger pts or BRCA pts
Name this method of breast cancer workup: Computerized,digital 3-D view of breast allows us to direct the needle to the biopsy site
Stereotactic Core Biopsy (needle localization is also acceptable)
Name this method of breast cancer workp: Multiple mammographic views of the breast allow us to localize the lesion with assistance of a sterile wire
Needle Localization
Digital mammogram has better sensitivity than film in which conditions:
Age<50, premenopausal, dense breasts
What is the cutoff for ‘anemia in pregnancy’
10.5
Iron Deficiency Anemia
Low Iron, Low Ferritin, High TIBC
Microcytic Anemias
Iron Def., Thalassemia
Where does vessel ligation occur to decrease pulse pressure to the uterus and help with PPH
Ascending Branch of Uterine Arteries, or Internal Iliac (Hypogastric) Artery
Genetics of Sickle Cell
AR
Pregnant woman with anemia, jaundice, and thrombocytopenia.
HELLP Syndrome
Best Method to avoid uterine inversion
Await spontaneous separation of the placenta
1 risk factor for uterine inversion
Placenta Accreta
What implantation site predisposes to uterine inversion?
Fundal
After 30min. the placenta isn’t delivered, what do you do next
Manual Extraction
Why does uterine inversion lead to PPH
Prevents adequate myometrial contraction
Best therapy to relax the uterus to reduce it so in can be “un”-inverted
Halothane or anesthetics like Terbutaline/Mag Sulfate
Next step in management after a shoulder dystocia has occurred
McRobert’s Maneuver - hyperflexion of maternal hips onto maternal abdomen and/or suprapubic pressure
Risk to the fetus of shoulder dystocia
Erb Palsy - Brachial Plexus Injury (C5-C6)
Precautionary signs that might signify an impending shoulder dystocia
GDM, Obesity, Fetal Macrosomia, Prolonged Second Stage of Labor
Turtle Sign
When the fetal head retracts back towards the introitus (signifies shoulder dystocia)
T/F Fundal Pressure should be applied immediately following Dx of shoulder dystocia
False, it should be avoided due to increased risk of neonatal injury. McRoberts uses suprapubic pressure
When is AROM contraindicated
Fetal Head not engaged (ballotable), Transverse Fetal Lie, Footling Breech
4 Steps to improving fetal bradycardia
1) Maternal Repositioning (usually on the side)
2) IV Fluid Bolus
3) 100% O2
4) Stop Oxytocin
In women with prior C/S, fetal bradycardia may manifest due to what
Uterine Rupture
Diminished variability can be due to what
sedating medications to the mother, or fetal acidosis
Epidurals can cause hypotension leading to late decels, what is the best immediate next step
Push IVF and give ephedrine (vasopressor)
Most common finding with Uterine Rupture
Fetal Heart Rate Abnormality (Late Decels or Bradycardia)
CI to Methergine
Hypertension
CI to Hemabate (Prostaglandin-F2 alpha)
Asthma/Bronchospasms
First steps in management of Uterine Atony
Uterine Massage and Dilute Oxytocin
If medical therapy fails whats the next step for Uterine Atony
Two Large-bore IV lines, Foley, Blood should be ordered, and patient moved to OR
After blood replacement and IV’s put in, whats next step in mgmt of Uterine Atony if continuous bleeding
Bakri Balloon or Embolization of the Uterus
(Uterine Atony) If continuous bleeding refractory to all prior trx (medical, IV, balloon) what are your remaining options
B-lynch Stitch or Ligation of Blood vessels (if future pregnancy desired); otherwise Hysterectomy
Late PPH defined as occurring after the first 24 hours may be caused by what
Involution of the Placental Site (usually occurs 10-14 days later)
Signs of Retained Products of Conception (PP)
Uterine Cramping and Bleeding, Fever, and/or foul-smelling lochia
Bleeding from multiple venipuncture sites following placental abruption suggests what
Coagulopathy
Where does vessel ligation occur to decrease pulse pressure to the uterus and help with PPH
Ascending Branch of Uterine Arteries, or Internal Iliac (Hypogastric) Artery
At 16 weeks gestation what is the approximate level of the fundus
Midway between the pubic symphysis and umbilicus
Elevated msAFP is associated with
Neural Tube Defects
Low msAFP is associated with
Down Syndrome
Most common cause of elevated msAFP
Errors with dating (underestimation of gestational age)
Other causes include: Multiple gestation, Oligo, and others
What level of Multiples greater than the Median (MOM) is associated with neural tube defects
Greater than 2.0-2.5
Down Syndrome Quad Screen
Elevated hCG, Inhibin-A; Decreased msAFP, Estriol
Follow-up for abnormal prenatal screen
US to determine correct gestational age
Trisomy 21 on first trimester screen
Elevated hCG; Decreased PAPP-A
Risks of amniocentesis
AROM, Chorioamnionitis, Fetal Demise (0.5%)
What percent of maternal serum is fetal cell-free DNA
~13%
Double Bubble sign (duodenal atresia) is associated with which birth defect
Down Syndrome; affected fetuses typically have polyhydramnios due to their inability to swallow
Pregnancies with unexplained elevation of msAFP are at increased risk for what
stillbirth, growth restriction, pre-E, and placental abruption
During what gestational ages are teratogenic effects considered ‘all or nothing’
Prior to 2 weeks teratogens either result in fetal death or recovery.
Zygote division within first 72 hours (type of twins)
Di/Di
Zygote division days 4-8 (type of twins)
Mono/Di
Zygote division days 8-12 (type of twins)
Mono/Mono
Zygote division after 12 days (type of twins)
Conjoined
Type of twins associated with discordant growth and more malformations
Monozygotic
All dizygotic twins have what chorion/amnionicity
Di/Di
Fetal marker associated with twin gestation
Increased AFP
Inc. nausea and vomiting in twin gestation is due to what
Increased hCG
What causes the physiologic anemia associated with pregnancy
Increased blood volume without increasing red cell mass
Treatment for TTT
Laser ablation of shared vessels, or serial amniocentesis for decompression
Biggest complication of mono/mono twins
Cord entanglement
Risk factors for vasa previa
Succenturiate lobe, Bilobed, Low-lying placenta, Multifetal gestation, IVF pregnancy
If vasa previa is dx, when and how should u deliver
C/S at 35-36 weeks (before ROM)
Two tests that can diff. maternal and fetal blood
Apt Test and Kleihauer-Betke Test
If a “thin”-membrane is identified on US between twins what is the zygosity
Mono? (that’s what it says)
Biggest risk of neonatal HSV infection
Herpes Encephalitis
Prodromal symptoms of an HSV outbreak
Itching, Burning, Tingling
T/F If a woman is suspected of having an HSV infection while in labor, you should get a PCR to confirm the diagnosis since physical signs might not be evident (at which point you would consider C/S)
False, use your damn clinical judgement. Ain’t nobody got time for that!
T/F Any woman with a history of HSV infection should be instructed on the need for C/S to avoid neonatal transmission
False, while every patient should be counseled on the risk, unless a woman has an active infection or shedding she is still a healthy candidate for vaginal delivery
What is the rationale for Acyclovir therapy for HSV infection
Decreases duration of viral shedding and infection
Painful genital ulcers with ragged edges, a necrotic base, and inguinal adenopathy
Chancroid
Marginal Placenta Previa
Placenta buts up to the internal os
Partial Placenta Previa
Partially covers the internal os
Complete Placenta Previa
Whole damn thing is covered
Low-lying Placenta
Edge of placenta within 2-3 cm of internal os
Two most common causes of antepartum bleeding (after 20 weeks)
Placental Abruption (painful contractions) and Placenta Previa (painless)
Previa patients are referred for C/S at what GA
34 weeks
What complication leading to PPH is associated with placenta previa
Placenta Accreta
Risk factors for previa
Grand multip, Prior C/S, Prior D&C, Previous Previa, Multiple Gestation
What is the next best step when any sort of previa other than a complete is identified at 20 week US
Reassess placental position at 32 weeks since most placentas will rise as the uterus expands
Risk factors for placental abruption
Cocaine, Short umbilical cord, Trauma, UP insufficiency, Submucosal Fibroid, Hydramnios, Smoking, PPROM
T/F Placental abruption is a common cause of coagulopaty
True, leads to DIC
T/F Placenta previa is a common cause of coagulopathy
False
T/F An US is the best way to diagnose placental abruption
False, it has poor sensitivity. The best way is by clinical diagnosis
By what mechanism does cocaine lead to increased risk of placental abruption
Due to its vasospastic effect on placental vasculature
Management of Placenta Accreta
Hysterectomy
When during the pregnancy is a women most likely to present with ovarian torsion
14 weeks when the uterus rises above the pelvic brim, and immediately PP when the uterus rapidly involutes
Biggest difference in identifying appendicitis vs torsion
Appendicitis will have Fever*, Leukocytosis, and Anorexia; both have nausea and vomiting (and pain durr)
Where is appendicitis pain located during pregnancy
Superior and lateral to McBurney’s point, due to pressure from the uterus on the intestines
Ovarian Torsion is often described as what type of pain
Colicky
Progesterone is produced by the corpus luteum until when
Produced solely by the luteum until 7 weeks; from 7-10wk both the placenta and luteum produce it; 10wk on the placenta handles it all
Earliest indicator of hypovolemia
Decreased Urine Output (even before tachycardia)
When does cholestasis become concerning to the fetus
when it is accompanied by jaundice or increased bile acids ==> increased incidence of prematurity, fetal distress, and fetal loss
Herpes Gestationis
IgG Autoantibody directed at the basement membrane (No relation to HSV). Limbs affected more than the trunk. Dx by immunofluorescence of biopsy.
PUPPP
Pruritic Uritcarial Papules and Plaques of Pregnancy; begin on the abdomen and spread to the thighs, butt and arms. Erythematous and small surrounded by a pale halo. Trx = topical steroids and antihistamines
Acute Fatty Liver of Pregnancy signs/symptoms
RUQ pain, malaise, N/V, hypoglycemia, coagulopathy, acute fulminant liver failure, hyperbilirubinemia and jaundice
Acute onset of severe dyspnea and chest pain with a CLEAR lung exam would likely r/o what in pregnancy
Pulmonary Edema - would hint more towards DVT leading to PE
Best diagnostic test for a PE
Spiral CT or MR Angiography; both use a contrast agent so be wary of allergies
What studies should be ordered if we’re concerned about PE
Pulse Ox and Arterial Blood Gases
Cutoff for giving oxygen
95% O2 sat (according to Case Files but I’ve seen lower on the floor - 92%?)
Normal ABG changes in Pregancy
pH 7.4»_space;> 7.45 resp. alkalosis with met. comp.
Po2 90-100»_space;> 95-105 ^ tidal volume and minute vent.
Pco2 40»_space;> 28 ^ tidal volume and minute vent.
HCO3 24»_space;> 19 renal excretion due to met. comp.
Trx for PE
IV Heparin (Lovenox - brand name LMWH)
After dx of acute thromboembolism how long should patients be on anticoag.
IV for 5-7 days and then subQ for 3 months(maintained at 1.5-2.5x control PTT); after 3 months prophylactic heparin is used for the remainder of pregnancy
Best diagnostic test for DVT
Doppler US
Most common side effect of long-term Heparin use in pregnancy
Osteoporosis
Main factor contributing to hypercoag. state of pregnancy
Venous Stasis
Best method for preventing DVT after C/S
Early Ambulation
Postpartum patient with Pre-E develops abdominal distention, syncope, hypotension, and tachycardia
Hepatic Rupture (ruptured hematoma that was caused due to hepatic ischemia)
How to dx Pre-E
two elevated BP’s (>140 or >90) at least 4 hours apart, and after 20 wks gestation
Proteinuria level in Pre-E
> 300mg/24 hours
Severe Pre-E dx
> 160 or >110 or >5g Protein (24 hours) or Urine Protein Dipstick of 3+/4+ (if no time for Urine Protein collection)
Underlying pathophys of Pre-E
Vasospasm and leaky vessels
Complications of Pre-E
P. Abruption, Eclampsia, Coagulopathies, renal failure, hepatic capsular hematoma, hepatic rupture, uteroplacental insufficiency (late decels)
Pre-E Labs
CBC (check platelets), 24-hour Urine Protein, Liver Function Tests (look for elevated enzymes), LDH (elevated with hemolysis)
When to deliver Pre-E patients
Induce at 37 weeks with Mag (reduce Eclampsia), risks of pregnancy outweigh risks of prematurity
When to deliver Severe Pre-E patients
Immediately regardless of Gestational Age due to risks to the fetus
Time frame for greatest risk of Pre-E ==> Eclampsia
24 hours pre- and post- delivery
What to monitor when a patient is on Mag
Urine Output, Resp. Depression, hyporeflexia,
AFLP features
N/V, icteric, hypoglycemia, coagulopathy
HELLP features
Hemolysis, LFTs up to 1000, platelets under 100k
Intrahepatic Cholestasis features
Generalized itching, Elevated LFTs, Elevated Bile Salts
Pre-E features
LFTs 100-300, Hypertension, Proteinuria, Hyperreflexia
Eclamptic seizure lead to death by what mechanism
Intracerebral Hemorrhage
T/F Patients with Mild Pre-E should still be treated with anti-hypertensive medications
False
Cervical exam dx for preterm labor in a nulliparous woman
2cm dilated with 80% effacement
What test can be done to check for preterm labor
Fetal Fibronectin (swab posterior vaginal fornix)
SE of nifedipine as a tocolytic
pulmonary edema, resp. depression, neonatal depression
CI to indomethacin as tocolytic
Premature closure of DA; leads to Oligo
CI to mag as tocolytic
Myocardial damage, Myasthenia Gravis
CI to terb as tocolytic
Arrhythmia, Hypertension, Seizure
Only approved therapy for long-term tocolysis
17-alpha-hydroxyprogesterone injections weekly as early as 16 weeks, to 36 weeks
T/F Suspected abruption is a relative CI to tocolysis
True, tocolytics can extend the separation of the placenta
Trx of pulmonary edema
IV Furosemide
Most common FHT finding in patients with PPROM
Variable decels due to oligo ==> cord compression
T/F After 32 weeks any PPROM patient should be induced
Mostly true, as long as chorioamnionitis isn’t present.
Most common chorio organisms that affect the fetus
GBS and E. Coli
Common chorio-inducing organism affecting a mom who has not ruptured yet
Listeria (through unpasteurized milk and transplacental spread); may induce chorio without ROM
Dx Chorio
Amniocentesis with Gram Stain
Management of PPROM prior to 32 weeks
Expectant Mgmt
Earliest sign of chorio
Fetal tachycardia
T/F Chorio infection is a CI to steroid use
True
How does Parvovirus present in adults
Malaise, Arthralgia, and Myalgia
Earliest signs of Fetal Hydrops
Hydramnios leading to difficulty palpating fetal parts
Sinusoidal FHTs are associated with what
Fetal anemia or asphyxia
Treatment for Fetal Ophthalmologic Chlamydial Infection
14 days of Erythromycin PO
Untreated gonococcal ophthalmia can lead to what
Corneal scarring and blindness
What is the goal viral load during pregnancy
Under 1000 RNA copies per mL
T/F Chlamydia is associated with late PP endometritis
True
T/F Chlamydia is an obligate intracellular organism
True
At what point does C/S not reduce vertical HIV transmission
After ROM
Most common mode of transfer of HIV to women
Heterosexual Intercourse
Hallmark of Thyroid Storm
Autonomic Instability (elevated BP, Temp., disorientation)
Thyroid Storm trx
B-blockers (propranolol), Corticosteroids and additional PTU (both reduce peripheral conversion of T4 to T3)
Risks of PTU for Thyroid Storm Therapy
Bone Marrow Aplasia ==> Leukopenia ==> Sepsis
Thyroid Storm Symptoms
Altered mental status, Hyperthermia, Cardiac Arrhythmia, HTN, Vomiting and Diarrhea
What causes Thyroid Storm
Usually some type of stressor in pts. with hyperthyroidism
Pregnancy Thyroid Changes
Increase in Total T4 and TBG
Decrease in Active/Free T4 and TSH
*overall a EUTHYROID state
Best screening test for hyperthyroid
TSH level
Hyperthyroidism PP is most often caused by what
Lymphocytic Thyroiditis (would see antimicrosomal and antiperoxidase ab). Generally Graves’ disease is #1, however due to the high corticosteroid levels of pregnancy, it suppresses autoimmune antibodies
Symmetric vs Asymmetric IUGR is in reference to what
Whether or not the head is spared
Most common cause of asymmetric IUGR
Maternal Vascular Disorder (smoking, HTN, or drug use)
Definition of IUGR
Birth weight less than the 10th percentile for GA
Neonatal morbidities associated with IUGR
NEC, Meconium, Hypoglycemia, Resp. Distress, Hypothermia, and Thrombocytopenia
Early onset IUGR (<20 weeks) is associated with what illness
CMV
Polyhydramnios + IUGR
chromosomal and structural abnormalities
Oligohydramnios + IUGR
highest perinatal mortality rate, incidence of anomalies
What test can be used to determine morbidity
Doppler Flow studies of Umbilical artery. Absence or Reverse Diastolic Flow = bad.
When to deliver IUGR patients
@37 weeks if no other complications
Circumstances for delivery of a 32-36 week IUGR patient
Severe HTN Despite therapy, Absence of growth over 2-4 weeks, Non-reassuring fetal testing, absent or reversed EDF
Circumstances for delivery of a <32 week IUGR patient
Reverse EDF, Persistent non-assuring fetal testing despite measures to optimize placental perfusion, and significant or ominous fetal testing results
Pathophys of ARDS
Leaky capillaries; occurs after antibiotics have begun to lyse bacteria leading to endotoxemia
Most common cause of septic shock in pregnancy
Pyelonephritis
Crepitance
Gas in soft tissue
First step in mgmt of septic shock
BP mgmt with IVF
Pathophys of Septic shock
Vasodilation usually due to endotoxins
Signs of Nec. Fascitis
Gas in the tissue (crepitance)
Febrile morbidity post C/S
Endomyometritis
Trx for endomyometritis
broad spectrum + anaerobic (Genta + Clinda)
If enterococcus is i.d. for infection PP what is trx
Penicillins (Amp)
Septic Thrombophlebitis dx
MRI or CT
Septic Thrombophlebitis trx
Typically you would have already been treating with abx (genta, clinda, amp) and then you add heparin
Most common organism associated with endomyometriits
Anaerobic (Bacteroides)
Fluctuance of Breast Tissue
Breast Abscess
Cause of Physiologic Breast Engorgement PP
Vascular Congestion and Milk Accumulation (usually during the 1st week)
Persistent fever of 48 hours in a woman with Mastitis is suggestive of what
Abscess
Difference in presentation between galactocele and abscess
No erythema with galactocele
Which Vitamins does breast milk NOT contain
Vit. K & D
Maternal Benefits of Breast Feeding
Weight Loss, Dec. Breast Cancer, Dec. DM
Fetal Benefits of Breast Feeding
Dec. Diarrhea, NEC, LRI, Otitis Media, Bacteremia, UTI,
Inflammatory Breast Disease ultimate dx
Biopsy
Labs to order if suspected maternal DKA
ABG, Blood Sugar, Electrolytes + Gap, Serum Ketones
Diagnostic criteria for DKA in pregnancy
pH < 7.35, Blood Sugar >200, Ketones >5, Bicarb <18, Ketonuria
Type of diabetes associated with miscarriage and congenital anomalies
Pregestational (also at risk for vascular and renal disease)
Hormones the placenta releases to create an insulin-resistant state
GH, CRH, hPL, and Progesterone
T/F Diabetic Retinopathy is the leading cause of blindness in reproductive age women
True
Glycemic control targets for fasting, 1-hour, 2-hour
Less than 105, 140, 120 respectively
How long PP should gDM women get a screening test
6 weeks (2-hour screening test for DM)
Risk factors for gDM
obesity, PCOS, family hx, previous gDM, fetal macrosomia,
what GA do you give first dose of RhoGam
28weeks
