Divine Intervention Flashcards
Most important risk factor for endometritis
Cesarean delivery
Most important risk factor for chorioamnionitis
Prolonged rupture of membranes (>18 hr)
Baby was stillborn. Abscesses found in multiple parts of the body on autopsy.
What is the likely etiology?
Granulomatosis infantiseptica
Congenital lysteriosis
If a patient has been ROMed for ~18 hours, you may to go ahead and give ___ if she has not already received it
Penicillin
Just incase GBS finds its way in there
“Mask of pregnancy”
Blotchy pigmentation of the face
Physical exam sign of pregnancy, like Chadwick’s sign
Shown in the R on this picture
Why are pregnant women at increased risk of UTI?
Mostly due to urinary stasis induced by progesterone
Maybe a slight argument for increased glycosuria, but it is not that significant
Only serum protein that decreases in pregnancy
Albumin
In the case of intrauterine fetal demise at term, ___ is NEVER worth it
In the case of intrauterine fetal demise at term, C section is NEVER worth it
You can NEVER justify this, the surgery is too dangerous for mom. But, you also can’t leave the fetus in there as it will cause DIC.
Vaginal delivery is the correct treatment here. Labor may need to be induced with oxytocin or misoprostol the same way it is for a live infant.
Why is urinalysis part of the standard first prenatal visit?
Screening for asymptomatic bacteriuria
If present, treat w/ amoxicillin or nitrofurantoin
Treatment of pyelonephritis in the pregnant patient
IV ceftriaxone, then repeat urinalysis (to ensure clearance) and suppressive nitrofurantoin for the rest of pregnancy
Timing for RhD Ig in an Rh- female
28 weeks
Timing for GBS vaginal swave
35-37 wks
Timing for 50g OGTT
24-28 wks
Timing for chorionic villus sampling
10-13 wks
Timing for screening ultrasound for NTDs
18-20 wks
Timing for amniocentesis quad screen
15 weeks and beyond, usually before 20 weeks
Remember, amniotic fluid isn’t even produced until about 15 weeks
Timing for cfDNA screen
Any time after 10 weeks
When performing amniocentesis or villus biopsy, you may want to give mom. . .
. . . Rhogam
These invasive procedures may sensitize her to RhD if present.
L:C ratio
If lecitin:sphingomyelin is >2, fetal lungs are mature
Having a cerclage is a contraindication to __ in a pregnant woman
Having a cerclage is a contraindication to exercise in a pregnant woman
Gestational diabetes complications vs Chronic diabetes complications
- Chronic* diabetes complications: Cardiac problems (HOCM), sacrum anomalies, lower limb anomalies (sirenomelia, aka fusion of the legs), caudal regression syndrome + Gestational diabetes complications
- Gestational* diabetes complications: Preeclampsia, neonatal hypoglycemia, neonatal hypocalcemia, neonatal polycythemia, macrosomia, polyhydrmanios
Idiopathic premtaure ovarian failure is . . .
. . . autoimmune
It may be associated with Hashimoto’s, T1DM, Addison’s, etc
pH cutoff for the vagina
4.5
Less than 4.5, and vaginitis is probably Candida
More than 4.5, and vaginitis is probably BV or Trichomonas vaginalis
Obesity increases the risk of osteo___, but decreases the risk of osteo___.
Obesity increases the risk of osteoarthritis, but decreases the risk of osteoporosis.
Treatments for hyperemesis gravidarum
- Ondansetron
- Metoclopramide
- Doxylamine-pyridoxine
Plus fluids if necessary
Hypertensive Moms Love Nifedipine
Hydralazine
Methyldopa
Labetalol
Nifedipine
Most important risk factor for preeclampsia
Prior history of preeclampsia
“Severe features” in preeclampsia
BP: >160/110
Signs of end organ dysfunction
(as opposed to >140/90 and proteinuria for just plain-old preeclampsia)
This is when you begin prophylaxis with magnesium sulfate
Magnesium and immediate delivery is the 100% first-line agent for eclamptic seizures. But, if magnesium alone fails, what do you add?
A benzodiazepine
Cartilage damage in an infant suggests teratogenicity with. . .
. . . fluoroquinolone
Stippling of the epiphyses in an infant suggests teratogenicity with. . .
. . . warfarin
Gray baby syndrome suggests teratogenicity with. . .
. . . chloramphenicol
An antibiotic effective in treating ocular infections such as conjunctivitis, blepharitis etc.
Kernicterus in the absence of late-preterm delivery or Criggler-Najjar syndrome suggests teratogenicity with. . .
. . . Bactrim
Smooth philtrum, microcephaly, thin upper lip
Fetal alcohol syndrome
IUGR, hypoplastic nails, microcephaly, cleft lip suggests teratogenicity with. . .
. . . phenytoin
Tdap vaccine in pregnancy
All pregnant women should receive a single dose of Tdap between the 27th and 36th week of pregnancy
Serology for all pregnant women at first prenatal visit
- HIV ELISA
- RPR
- HBsAg
Also, test for Chlamydia and Gonorrheae if in a high prevalence area!
“Atrialized right ventricle”
Buzz word for lithium teratogenicity, aka the Ebstein anomaly
Ways of getting staphylococcal toxic shock syndrome
- Infection of a wound
-
Using something to pack a mucous membrane
- Tampons
- Nose packing
- Vaginal packing
Treating candida in pregnancy
Topical clotrimazole is the way to go
Oral azoles are contraindicated in pregnancy
Chancre lesion vs chancroid lesion
Chancres have raised, indurated borders
Chancroid has thin borders, but a very necrotic base
Rules for preeclampsia magnesium
- Loading of 6g, then maintenance of 2g
- Give if there are severe features OR depending on local guidelines without severe features
- Continue for 24 hours postpartum (including for cesarean section)
“Beta complete”
One dose of betamethasone, 24 hours later another, then 24 hours later for that one to have its full effect
~48 hours in total from start
Breast mass with leaf-like projections on histology
Phyllodes tumor
Trastuzumab may induce this cardiac problem
Dilated cardiomyopathy
A reversible form of it!!!! Just stop taking trastuzumab.
x-year old female presenst with palpable breast mass. What is the next step?
If x < 30, breast ultrasound
If x > 30, mammogram
You palpate a mass on breast exam of a patient. Mammogram is negative. What is the next step?
Core needle biopsy
Next step if ultrasound of a breast mass in a young patient reveals a solid mass vs a cystic mass
Solid mass: Core needle biopsy (high likelihood cancer)
Cystic mass: Fine needle aspirate (low likelihood cancer)
Things that might lead you to do core needle biopsy of a cystic breast mass following FNA
- Concerning cytology
- Blood observed in FNA
- Recurrence of cystic mass on followup ultrasound
Ways of communicating that a patient has uterine rupture in ACOG exam land
- Loss of fetal station
- Palpation of unusual abdominal masses (fetal parts outside of the uterus)
Things that may cause uterine atony by the mechanism of overstretching the uterus
Multiple gestations
Macromsomia
Polyhydramnios
Dinoprost for uterine atony is contraindicated in. . .
. . . hypotension
Sheehan syndrome vs pituitary apoplexy
Think of Sheehan syndrome as ischemic stroke of the pituitary and apoplexy as hemorrhagic stroke of the pituitary
Adjuvant to utertonics in treating PPH
IV Estrogen
Estrogen can sensitize uterine tissue to uterotonics
Next best step in management PCOS question
NBME loves to ask this question.
Routine care of a PCOS patient in late 30’s to 40’s includes a screening endometrial biopsy.
The question will be framed as routine care for someone with PCOS who is asymptomatic.
If an NST is non-reactive in prenatal care, the next step is. . .
. . . biophysical profile
NST, amniotic fluid volume, fetal breathing, movement, fetal tone
You see a sinusoidal pattern on FHRT. What is the next step?
Percutaneous umbilical blood sampling to check hematocrit and O2 sat of the fetus
Presentation and treatment of choriocarcinoma
Often presents with either pulmonary symptoms (due to high pulmonary metastasis rate) or hyperthyroidism (due to extremely high bHCG)
May follow molar pregnancy
Methotrexate is highly effective as treatment
Woman comes to first prenatal visit and is found to be Rh- and anti-RhD positive. What is the next step?
Check dad’s Rh status
If he is Rh-, you are all set.
If he is Rh+, you will need to check the fetus. If it is Rh+, regular MCA flow screenings are indicated to assess fetal status. May require intrauterine transfusions to prevent hydrops fetalis.
Management of detected placenta previa prior to 32 weeks
No need for immediate delivery as it may change position, however we should administer drugs to hedge our bets against prematurity now. So, give betamethasone and Mg.
Plan to deliver ~34 weeks if it persists by this time.
An obviously, mom needs pelvic rest – nothing in the vagina.
What is the downside of indomethacin as a tocolytic?
Possibility of premature ductus arteriosus closure
NBME loves to test this fact.
Highly tested risk factors for preterm labor
Perineal Infection (BV, UTI)
Bicornuate uterus
Polyhydramnios associations
Maternal diabetes
Duodenal atresia (double bubble sign)
Anencephaly (no swallowing center)
Esophageal atresia
Spontaneous abortion vs IUFD
Spontaneous abortion is before 20 wks gestation and is treated with D&C
IUFD is after 20 weeks and is treated with D&E (induce labor, effectively)
After you place a cerclage, the patient should not. . .
. . . exercise
“Machine like murmur in a newborn” along with features of teratogenciity should make you think. . .
. . . Rubella
CMV can present very similarly to Toxo, but in CMV the calcifications will be. . .
. . . periventricular
Meningitis, pneumonia, or sepsis in the month of life
Group B strep
Ovarian cancer with Psammoma bodies
Serous cystadenocarcinoma
“Anterior mediastinal masses”
Often dermoid cysts / mature teratomas
Amniotomy
Fancy word for artificial rupture of membranes
May be performed prior to moving to pitocin if a patient is arrested in the active phase of labor and has not SROMed.
If AROM and pitocin fails to induce progression, Cesarean delivery is indicated.
Blood per vagina and signs of fetal distress following ROM indicates. . .
. . . vasa previa or placental abruption
If mom has symptoms too (particularly pain), abruption is likely, especially if she had polyhydramnios.
If mom has no symptoms, vasa previa is likely.
“Bloody show”
Small amount of mucousy vaginal bleeding that may occur with onset of labor due to cervical irritation
Not clinically significant, very common
Most frequent cause of preterm labor
Idiopathic
Don’t be fooled when they put “cervical insufficiency” or “infection” as answers.
Contraindications to tocolytics
Magnesium sulfate: Mysasthenia gravis
Terbutaline: Diabetes (causes hyperglycemia)
Indomethacin: EGA >/= 33 wks (premature ductus closure)
Nifedipine: Hypotension
Preterm labor with chorioamnionitis is an indication for. . .
. . . augmentation of labor (oxytocin)
If fibronectin is negative, you don’t need to give ___
If fibronectin is negative, you don’t need to give steroids
___ decelerations may be amenable to amnioinfusion, but ___ decelerations will not be
Variable decelerations may be amenable to amnioinfusion, but late decelerations will not be
Fetal stimulation
Can be performed simply by rubbing the crown of baby’s head
Done to elicit an acceleration in a fetus with minimal variability and no accelerations. If elicitable, this indicates a normal fetal blood pH and no further testing is required unless FHT changes further.
If this fails, allis clamp stimulation or fetal scalp pH are indicated.
