CaseFiles_3

Question 1

What are risk factors for placental abruption? (x9) What are the three main risk factors?

Answer 1

1) HYPERTENSION
2) COCAINE USE
3) TRAUMA
4) short umbilical cord
5) uteroplacental insufficiency
6) submucosal leiomyomata
7) sudden uterine decompression (hydramnios)
8) cigarette smoking
9) preterm premature rupture of membranes

Question 2

Bleeding into the myometrium of the uterus giving a discolored appearance to the uterine surface is known as

Answer 2

Couvelaire uterus.

Associated with abrupt placentae

Question 3

What is a “concealed abruption”?

Answer 3

When the bleeding of placental abruption occurs behind the placenta with no external bleeding noted

Question 4

When placental abruption causes fetal death, it causes the complication of _________, which is secondary to hypofibrinogenemia, in 1/3 of the cases. The fibrinogen level would be below _____ mg/dL

Answer 4

coagulopathy

fibrinogen 100-150 mg/dL (normal 200-400)

Question 5

The Kleihauer-Betke test is used to test which phenomenon common with placental abruption?

Answer 5

fetal to maternal hemorrhage

Question 6

Many women who deliver due to placental abruption will manifest what after volume replacement (keeping Hct 25-30% and urine output 30 mL/hr at least)?

Answer 6

hypertension or preeclampsia, necessitating mag sulfate for eclampsia prophylaxis

Question 7

T/F: Ultrasound is sensitive in diagnosing placental abruption.

Answer 7

FALSE! The clot in the placenta is the same sonographic texture as the placenta itself.

Question 8

T/F: A prior cesarean delivery can predispose a patient to placenta pre via with an associated accrete in future pregnancies.

Answer 8

True

Question 9

What is the most significant fetal risk associated with breech presentation?

Answer 9

Cord prolapse, which can lead to significant oxygen deprivation to the fetus

Question 10

Placenta accreta is abnormal adherence of the placenta to the uterine wall due to an abnormality of which layer of the uterus?

Answer 10

decidua basalis (of the endometrium)

Question 11

WHat is the difference between placenta accrete, increta, and percreta?

Answer 11

penetration into the uterus!

accreta: into uterine wall
increta: into myometrium
percreta: into myometrium to the serosa (bladder involvement with “blue tissue” is not uncommon!)

Question 12

What are risk factors for placental adherence? (x5)

Answer 12

1) low-lying or anterior placentation or placenta previa
2) prior C section or uterine curettage
3) prior myomectomy (but not if only on the serial surface!)
4) fetal down syndrome
5) age >35y

Question 13

IF a patient refuses hysterectomy, then what is the best management for placenta accreta? What are 2 major complications?

Answer 13

Ligation of the umbilical cord as high as possible and IV MTX therapy. Hemorrhage and infection (necrotic placenta can be a nidus for infection) are two major complications.

Question 14

Where is the pain associated with appendicitis in pregnant women and why is it different than in the general population?

Answer 14

Not in the RLQ, but superior and lateral to the McBurney point. This is due to enlarged uterus pushing on the appendix to move it upward and outward toward the flank, at times mimicking pyelonephritis.

Question 15

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

Answer 15

ovarian torsion

Question 16

Patients with known or newly diagnosed large ovarian masses are at risk for

Answer 16

ovarian torsion

Question 17

What is the leading cause of maternal mortality in the first and second trimesters?

Answer 17

ectopic pregnancy

Question 18

Corpus luteum cyst rupture (associated with unilateral cramping and lower abdominal pain fora few weeks before sudden onset of pain) usually occurs between days ___ and ___ of the menstrual cycle.

Answer 18

days 20 and 26

Question 19

What is the timeline with regards to the main source of progesterone in pregnancy? WHat does this mean if the corpus luteum is removed prior to 10-12 weeks of gestation?

Answer 19

first 7 weeks: corpus luteum (hCG maintains the luteal function)
weeks 7-10: corpus luteum and placenta
10 weeks on: placenta

If the corpus luteum is removed before 10-12 weeks of gestation, exogenous progesterone is needed to sustain the pregnancy. IF it is removed afterwards, no supplemental progesterone is required.

Question 20

Right abdominal pain that radiates to the right shoulder with nausea and vomiting is classic for what in pregnancy?

Answer 20

cholelithiasis

Question 21

Pain associated with ovarian torsion is associated with pain that is (constant/colicky).

Answer 21

Colicky

Question 22

What is a degenerating leiomyoma and what does it present with?

Answer 22

A degenerating leiomyoma is due to a fibroid outgrowing its blood supply (due to rapid growth via the estrogen levels in pregnancy). It presents with localized tenderness over the fibroid.

Question 23

What is the earliest indicator of hypovolemia?

Answer 23

Decreased urine output

Question 24

What is Pruritic Urticarial Papules and Plaques of Pregnancy?

Answer 24

unique to pregnancy (and rare! <1% of pregnancies) characterized by intense prutitus and erythematous papules on the abdomen and extremities; spreads from abdomen to buttocks. negative for IgG and complement levels.
Usually occurs in first pregnancy around 35-36 weeks, but does NOT recur!

Question 25

What is Herpes Gestationis?

Answer 25

rare skin condition only seen in pregnancy; characterized by intense itching and vesicles on the abdomen and extremities. No relationship to HSV, but IgG autoantibody against the BM. Can sometimes be seen in baby due to IgG crossing the placenta.

Question 26

In which trimester does intrahepatic cholestasis of pregnancy (pruritus with or without jaundice and no skin rash) occur?

Answer 26

third trimester

Question 27

How are LFTs affected by intrahepatic cholestasis of pregnancy?

Answer 27

They’re not! Usually unaffected. But levels of circulating bile acids are elevated

Question 28

What is the treatment of of intrahepatic cholestasis of pregnancy?

Answer 28

Ursodeoxycholic acid decreases pruritus (and tolerated better than cholestyramine, which leads to vit K deficiency); antihistamines, cornstarch baths

Question 29

WOmen with acute fatty liver of pregnancy are often heterozygous for

Answer 29

long chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) deficiency

Question 30

Acute fatty liver of pregnancy is associated with acute renal failure, n/v, coagulopathy, fulminant liver failure, and (hypo/hyper)glycemia.

Answer 30

hypoglycemia (due to liver insufficiency, glycogen storage is compromised, leading to low serum glucose levels).

Question 31

T/F: Cholestatic jaundice in pregnancy may be associated with adverse pregnancy outcomes.

Answer 31

True: prematurity, fetal distress, fetal loss

Question 32

What is the management of acute fatty liver of pregnancy?

Answer 32

immediate delivery!

Question 33

Compared to nonpregnant individuals, pregnant women have pH, PCO2, and HCO3 that is higher or lower?

Answer 33

pH: higher (7.45)
PCO2: lower (28 vs 40)
HCO3: lower (19)
respiratory alkalosis with partial metabolic compensation

Question 34

T/F: Helical CT or MR angiography invovle a lot of radiation to the fetus and should not be used to diagnose PE in a pregnant woman.

Answer 34

FALSE Very little radiation to the fetus

Question 35

What is the treatment for a PE in a pregnant woman?

Answer 35

Full IV anticoag tx for 5 to 7 days; usually switched to subQ for 3 mo after event to maintain aPTT 1.5 to 2.5 times higher

Question 36

What tests are conducted in a pregnant woman with a PE?

Answer 36

protein C and S; antihrombin III, Favtor V Leiden mutaiton, hyperhomocysteinemia, antiphospholipid syndrome

Question 37

What is the most common cause of maternal mortality?

Answer 37

Embolism (thromboembolism/hypercoaguability and amniotic fluid embolism)

Question 38

How id Depo-Provera different from estrogen containing oral contraceptives with regards to DVT?

Answer 38

Since it is a progestin, it is not a major cause of DVT (unlike estrogenic OCPs)

Question 39

The platelet count is (higher/lower) in preganncy?

Answer 39

Lower (120K, vs 150K at lower end of normal)

Question 40

A PO2 of less than ___ in a pregnant woman is abnormal. A sat of 90% corresponds to ____ mm Hg O2.

Answer 40

less than 80 = abnormal

90% = 60

Question 41

THe most common locations for DVT after gynecologic surgery are

Answer 41

lower extremities and the pelvic veins