MedEd Videos Flashcards
1
Q
Physiology of pregnancy:
what happens to:
1) MAP
2) SVR
3) HR
4) SV
5) DL CO2
6) Hgb
A
1) MAP –> DECREASE
2) SVR –> DECREASE
3) HR –> 15% increase
4) SV –> INCREASE PRELOAD, no change in contractility
5) DL CO2 –> INCREASE (more RBCs)
6) Hgb –> increase RBCs, but BIG INCREASE in PLASMA (overall decrease in Hgb)
MAP = CO x SVR CO = HR x SV SV = preload and contractility DLCO2 = CO x Hgb x %SaO2 Hgb = [RBC]/[Plasma]
2
Q
Physiology of pregnancy:
what happens to:
1) Minute Ventilation
2) FEV1
3) PaO2
4) FRC
A
1) Minute Ventilation –> INCREASE Tidal Volume = increase MV (no change in RR)
2) FEV1 –> no change
3) PaO2 –> no change
4) FRC –> DECREASE
Minute ventilation = TV x RR
3
Q
Physiology of pregnancy:
what factors are increased in the clotting cascade? decreased?
A
1) increase vWF
2) Increase factor 7, 8, 10
3) increase inhibitors of tPA
4) decrease in protein C and S
OVERALL INCREASE IN CLOTTING
4
Q
Physiology of pregnancy:
what is a normal Cr?
what can happen because of significantly increased GFR during pregnancy?
A
Cr = 0.4-0.8
Significantly increased GFR –> obstructive uropathy at pelvic rim
5
Q
What is normal weight gain during pregnancy?
A
1) BMI < 18.5 –> 1 lb/wk = 28-40 lbs
2) BMI 18.5-25 –> 0.75 lb/wk = 25-35 lbs
3) BMI 25-30 –> 0.5 lb/wk = 15-25 lbs
4) BMI > 30 –> 0.25 lb/wk = 10-20 lbs
6
Q
What are GI side effects of pregnancy?
how to treat them? (5)
A
1) GERD –> PPO
2) Nausea –> ondansetron
3) constipation –> stool softeners + motility agents
4) Iron deficiency –> iron supplement + stool softener
5) Gallbladder disease –> remove in 2nd trimester unless emergent
7
Q
Downs
Edwards
Patau
chromosome?
A
Downs = 21 Edwards = 18 Patau = 13
8
Q
1st trimester screening tests?
A
1) US for nuchal translucency ( trans < 2 mm)
2) PAPP-A
3) hCG
9
Q
2nd trimester tests
A
Triple screen = hCG, AFP, Estriol
Quad screen = add Inhibin-A
10
Q
Pattern of 2nd trimester tests in Downs vs. Edwards
A
Downs is UP (INCREASE hCG, decrease AFP, decrease estriol, INCREASE inhibin A)
edwards (decrease hcg, AFP, estriol, inhibin A
11
Q
Combined screen
A
1st + 2nd trimester screening done before doing any confirmatory tests = increased sensitivity, but decreased options because later in pregnancy
12
Q
Sequential screen
A
1st tri tests
1) if positive –> invasive test
2) if negative –> 2nd tri tests
Increases number of invasive tests and thus increased fetal loss
increased options though also
13
Q
Pre-Conception…what do you think about?
A
1) Safety (genetics, maternal age, DV, abuse)
2) Vitamins (FOLATE!)
3) Vaccines ( flu, HBV, MMRV –> want MMRV BEFORE pregnancy, because can’t give after pregnant - live vaccine)
4) Lifestyle (smoking, ETOH)
5) optimize other disease (HTN, DM, hypoT)
14
Q
what does GPA and TPAL stand for?
A
Gravid (number of times with something in your uterus)
Para (deliver events)
Abortions
Term
Preterm
Abortions
Living
15
Q
Initial tests in 1st trimester (around week 10)
A
1) urine preg
2) US –> confirms IUP, gestational age, if there are multiple gestations
3) serum B-HCG (confirm if too soon for US)
16
Q
Labs at 1st trimester
A
Blood:
1) ABO type
2) Rh-Ag
3) Hgb/Hct
4) HIV, HBV, RPR
5) titers (varicella, rubella)
Urine:
1) UA + cx
2) proteinuria
3) GC/Chlamydia
17
Q
Main things to screen for in third trimester (3)
A
1) Gestational DM
2) Alloimmunization
3) Maternal anemia
18
Q
Gestational DM
A
DM starts AFTER 20 wks
- Risks = increased BMI, GDB before, pre DM
- TX with insulin
19
Q
DX of gestational DM
A
1-hr glucose tolerance test (GTT) –> > 140 after 1 hour
3-hr GTT –> fasting > 90, 1hr > 180, 2hr > 155, 3hr >140 - must have 2/4 abnormal
20
Q
Alloimunization (Rh Ag Status)
A
- Rh-Ag (-) mom + Rh-Ag (+) baby + Rh-Ag (+) baby #2
- Rh-Ag (-) mom develops Rh-Ab (+)
IF mom is Ab positive already and baby is Rh-Ag (+) –> transcranial doppler to r/o fetal anemia
IF mom is Rh-Ab negative still –> RHOGHAM at 28 weeks and within 72hrs of delivery to prevent mom from ever developing antibodies
21
Q
normal maternal Hgb
A
Hgb > 10 or Hct > 30%
22
Q
Treatment of UTIs in pregnancy
A
1) use amoxicillin (1st line) or Nitrofurantoin (2nd line) for asx bacteruria or cystitis
2) use CTX and admit if pyelo (cannot use TMP-SMX or cipro like usual outpatient)
23
Q
Treatment of:
- HYPO thyroid
- HYPER thyroid
in pregnancy
A
HYPO thyroid –> levothyroxine (more thyroid binding globulin –> must increase dose, f/u TSH Q4wks)
HYPER thyroid –> PTU, surgery (2nd trimester)
24
Q
what anti-epileptic drugs should be used in pregnancy
A
ideally none…if you have to use them then use Leviteracetam or lamotrigine
DO NOT use phenytoin, valproic acid, carbemazepine
TX of status –> phenobarbital
25
HTN treatment during pregnancy
goal <140/<80
a-methyl dopa (1st line), labetalol, hydralazine = SAFE in pregnancy
increase frequency of screening for eclampsia
26
DM before, during and after pregnancy
```
Before = A1C < 7%, change from oral to insulin
During = increased insulin requirement, use basal-bolus based on post-pradial BS target
After = decreased insulin requirements
```
27
what happens if DM is out of control during pregnancy?
1) transposition of great vessels
2) Macrosomia --> shoulder dystocia
3) increased risk C section
28
Stages of normal labor
1) Stage I, latent (0-6 cm)
2) Stage I, active (6-10 cm)
3) Stage II (10 cm - fetus delivered)
4) stage III (fetus - placenta delivered)
29
Normal speed of Stage I latent and active?
```
latent = < 20 hrs (NP) or < 14 hrs (MP)
Active = 1.2 cm/hr (NP) or 1.5 cm/hr (MP)
```
30
Normal speed of stage II and III
stage II = < 3hr (NP), < 2 hr (MP)
| stage III = 30 minutes
31
what cervical changes take place
- Breakage of disulfide bonds --> water
| - softening, effacement, dilation, position --> 2/2 fetal head engagement (+ prostaglandins, oxytocin)
32
Fetal station
level of fetus from -5 (uterus) to +5 (vaginal opening) with O being in the center of the ischial spines
the more (-) = more likely to do c section
33
3 possible fetal positions?
1) Long cephalic (nml)
2) long breach
3) transverse
34
breach types?
1) Frank - hips flexed, knee extended
2) complete - hips flexed, knee flexed
3) Footling - hips extended, knees anyway
35
How to speed up latent stage I?
engagement of fetal head...
1) balloon
2) amniotome
3) induce with misoprostol or oxytocin (increase frequency and strength of contractions)
36
How to speed up active stage I?
oxytocin --> can proceed to c-section if contractions are already adequate
37
how to speed up stage II?
oxytocin -->
- if baby in + fetal station (closer to vaginal opening) --> forceps, vacuum
- if baby in - fetal station (closer to uterus) --> c-section
38
how to speed up stage III?
1) uterine massage
2) oxytocin
3) manual extraction
39
what are 3 possible causes of delayed stage progression?
3 P's:
1) passenger
2) Pelvis
3) Power
if its a passenger or pelvis problem --> proceed to c-section
if its a power problem --> oxytocin
40
what is considered "adequate" contractions?
200 MV per 10 min (measure with IUPC)
41
What is considered preterm? term?
24-37 weeks = preterm
37-42 = term
>42 wks = post dates
42
What is considered prolonged rupture of membranes?
> 18 hrs
43
Rupture of Membranes
amniotic sac fluid released
- spontaneous, artificially, or pathologic (usually infection)
- can be stained with meconium, bloody, or clear
44
How do you diagnose ROM
treatment?
speculum exam --> see pooling
nitralazine --> blue
on a slide you see FERNING
TX:
- term --> deliver
- < 20 wks --> deliver
- >20 wks --> term (risks/benefits - infection vs. maturation of baby)
45
```
Premature ROM (PROM)
-causes? (2)
```
-usually 2/2 infection, GBS
| + ROM, +term, NO contractions
46
pre-term premature ROM (pPROM)
-usually 2/2 infection, GBS
+ROM, NOT TERM, NO CONTRACTIONS
If > 34 weeks --> DELIVER
if < 24 weeks --> abortion
in between --> steroids
47
Endometritis/Chorioamnionitis
path: vaginal flora ascends
Chorio = infection of the membranes and amniotic fluid surrounding the fetus. Most common precursor to neonatal sepsis.
Endo = most common cause of post-partum fever. infection of endometrium
it is endo if baby is OUT, chorio if baby is IN
-pt is febrile and toxic looking
DX - UA, CXR, blood cx (r/o other causes)
TX gram- and anaerobes --> AMP + GENT +/- CLINDA
48
Prolonged ROM
vaginal flora and infection can get in (e.g. GBS)
-when > 18hrs after delivery
TX = delivery
f/u endometritis/chorioamnionitis
49
Risks of preterm delivery
smoking, decreaed maternal age, multiple gestations, pPROM, anatomical
50
What is preterm delivery, what do you do?
+ contractions AND cervical change, but NOT term
-TX --> > 34 wks = deliver
< 20 wks --> abortion
in between --> steroids, tocolytics (gives you hours/days)
51
Post Dates
increased risk of macrosomia, shoulder dystocia
pt > 40 wks conceptions and > 42 wks by dates
-TX depends on how sure you are on dates...if cervical is favorable positioning? Use NST, US, BAP
52
Treatment of chronic HTN in pregnancy
sustained HTN before 20 wks
- use a-methyldopa, labetalol, hydralazine
- need more frequent f/u for UA, frequent US
53
Gestational HTN
BP > 140/80 sustained, onset after 20 wks
no urinary or alarm sx.
f/u for progression to pre-eclampsia
54
Mild pre eclampsia
> 140/80, sustained after 20 wks.
- urine has > 300 ng/dL protein
- NO alarm sx
IF > 37 wks, deliver, IF < 37 wks, wait with Q weekly f/u
55
Severe pre eclampsia
> 160/110
urine + for 5g/dL protein
-+ ALARM SX
TX = give Mg2+ and deliver via induction
56
What are the severe features in eclampsia? (7)
```
increased Cr
HA
change in vision
decreased platelets
increased LFTs
RUQ abd pain
pulmonary edema
```
57
Eclampsia
> 160/110
SEIZURES**
Give Mg2+ and deliver
58
HELLP
Hemolysis
Elevated liver enzymes
low platelets
59
Magnesium
used to prevent seizures in eclampsia/pre-eclampsia
- must assess for decreased DTRs --> can progress to decreased RR if too much Mg2+
- -> give Ca if this happens to reverse Mg2+
60
Dizygotic, dichorion, diamnion
2 placentas, 2 sacs, 2 zygotes
babies can be different genders - 2 different fertilizations
-increased risk of preterm birth, breach birth (1 extra baby = 4 weeks early), increased post-partum hemorrhage
61
Monozygotic, dichorion, diamnion
- 2 placentas, 2 sacs
| - 1 zygote fertilization that splits at 0-3 days
62
Monozygotic, monochorion, diamnion
- 1 zygote that splits at day 4-8 (blastocyst stage)
- 1 placenta, 2 sacs
- increased risk of twin-twin transfusion **same blood supply
63
Monozygotic, monochorion, monoamnion
1 zygote that splits (split on day 9-12 --> non-conjoined, split on day >12 --> conjoined)
- 1 placenta, 1 sac
- increased of conjoined or cord entanglement
64
Post partum hemorrage (PPH)
> 500cc for vaginal delivery
>1000cc for c-section
causes: 1. uterine inversion, 2. uterine atony, 3. retained placenta, 4. vaginal lac
65
Uterine inversion
ABSENT uterus
-uterus "births" itself --> deliver with oxytocin or traction can cause this
TX:
- manual inversion
- tocolytics (calm uterus down) --> oxytocin to contract it in place
66
Uterine atony
BOGGY uterus
-tired uterus after long labor, oxytocin, tocolytics
TX:
- massage
- restart oxytocin (if pt was induced)
- methergine, hemabate, or PGE drug
- Surgery
67
Retained placenta TX?
FIRM uterus
- D+C --> hysterectomy
- f/u with B-HCG to make sure all products gone (decrease risk of chorio)
68
Unexplained, ongoing bleeding
2 large bore IVs, bolus IVF, transfuse, call surgeons, IV estrogen
Surgery --> uterine artery ligation/embolization, total abdominal hysterectomy
69
DIC
```
decreased platelets --> give platelets
decreased Hgb --> give pRBCs
increased schistocytes
decreased fibrinogen
increased INR --> give FFP
```
70
Placenta accreta
placenta partially implanted into superficial myometrium instead of the decidua
- increased risk of accreta with placenta previa
- makes up 80% of abnormal placental implantation
-Risks = endometrial inflammation, scarring from prior C-section
71
Placenta percreta
placental invasion through the myometrium into the uterine serosa
72
Placenta increta
placental invasion into the uterine myometrium
73
Algorithm for decreased fetal movement
1) NST
2) NST + VAS (vibro-acoustic stimulation)
3) BPP (biophysical profile)
4) CST (contraction stress test)
74
Non-Stress Test (NST)
look at fetal HR, variability, and accelerations
nml HR = 110-160 with moderate variability
-want 2 or more accelerations in HR (at least 15 bpm) that last 15 seconds at a time
*2 in 20
75
Biophysical profile (BPP)
```
do if failed NST w/VAS
scoring system: each one 0-2 points = total 10
-NST
-AFI (amniotic fluid index)
-Breathing
-Movement
-Tone
```
76
AFI (amniotic fluid index)
< 5 = oligohydramnios
>25 = polyhydramnios
8-25 is IDEAL
77
Contraction stress test (CST)
can be done if contractions are present
| -look for brady and late decels with decreased variability
78
Early decels
--> head complression (benign)
decels line up with contractions
79
Variable decels
--> cord compression (benign)
80
Late decels
utero-placental insufficiency
**BAD
-HR devels begin after peak of contraction
81
Late decels
utero-placental insufficiency
**BAD
-HR decels begin after peak of contraction
82
Causes of 3rd trimester bleeding (5)
Can be split into PAINLESS (placenta, baby blood, previa) and PAINFUL (uterus, mom, NOT previa)
1) Normal
2) Placenta previa
3) Vasa previa
4) uterine rupture
5) Placental abruption
83
Placenta previa
placenta grows over the cervical opening (os)
- tears when the cervix dilates in 3rd trimester
- painless bleeding in 3rd trimester
RISK: multigravid, multi-gestations
DX: US, NST/CST --> transverse lie, fetal distress --> urgent C/S
84
Vasa previa
two accessory lobes of placenta, connected by blood vessels across os
- painless bleed, placental blood
- vessels tear when cervix dilates
--> DX: US, NST/CST --> fetal distress --> urgent C/S
85
uterine rupture
happens when women have prior C/S and are receiving oxytocin
-baby can rupture into peritoneum
- PAINFUL bleeding
- loss of fetal station*
--> crash section
86
Placental abruption
placenta tears off endometrial lining = COMPLETE
if bleed is contained = CONCEALED
occurs in severe HTN, cocaine, MVA
PAINFUL
DX: US, NST/CST, vitals, hgb, AMS in mom
TX: C/S
87
Group B strep
benign colonization of mom --> for baby is really bad
- screen women with swab and UA in wk 10 for GBS AND at week 35
- if + then treat NOW and at delivery
-if baby gets it, they will look normal and then get SAS
88
risks for GBS
1. + GBS history
2. prolonged ROM
3. intrapartum fever
89
Treatment of GBS
- ampicillin
- -> ceohazolin (if allergic) --> clinda or vanc if life threatening allergy
**don't need intrapartum ppx abx is no ROM and C/S delivery
90
HBV tx for baby and mom
C/S (avoid mixing of blood)
- baby gets HBV vaccine and HBV IVIG
- mom ideally vaccinated before pregnancy
91
HIV tx for baby and mom
Mom - maximize on HAART
NNRTI = tenofavir + emcitribine OR zidovudine + lanivudine
THEN add either nevirapine or atazanavir
BABY --> give AZT at time of delivery
92
Toxo
T. gondii, parasite found in cat feces, undercooked meat, cysts in the soil
mono-like illness in mom with acute infection (fever, malaise, lymphadenopathy)
BABY --> brain calcifications, ventriculomegaly, seizures
93
Syphilis
sx?
T. pallidum, spirochete, STI
```
primary = painless chancre
secondary = targetoid lesions on palms and soles (CONTAGIOUS!)
EL/LL = + test but no sx
Tertiary = neuro sx
```
94
Syphilis dx? tx?
```
1 = dark field microscopy, PCN IMx1
2 = RPR --> FTP-Abs confirm, PCN IMx1
3 = CSF VDRL, IV Q4hrs 7-10 days
EL = IMx1
LL = IM Qwk x3
```
95
Syphilis dx? tx?
```
1 = dark field microscopy, PCN IMx1
2 = RPR --> FTP-Abs confirm, PCN IMx1
3 = CSF VDRL, IV Q4hrs 7-10 days
EL = IMx1
LL = IM Qwk x3
```
96
Rubella
primary viremia is what hurts baby
Congenital rubella = blueberry muffin petechiae/purpura, cataracts, congenital heart problems, deafness
if 1st tri --> IUGR or abortion
97
HSV
primary viremia is what causes congenital defects.
-secondary reactivation increases risk of baby getting infected
Baby --> IUGR, preterm, blindness
DX with PCR HSV from scarping of base of ulcer
98
Risks of forceps and vacuum use
forceps --> cephalohematoma, bells palsy
| vacuum --> denuding vagina
99
Risks of forceps and vacuum use
forceps --> cephalohematoma, bells palsy
| vacuum --> denuding vagina
100
Grading of vaginal lacerations
```
1 = vagina
2 = perineal body
3 = sphincter
4 = mucosa
```
101
Cerclage
performed to preserve incompetent cervix
- risk of this with PID, repeat D+C, repeat STDs
- can cause repeat 2nd trimester loss
102
Treatment of cervical CA
if exocervical --> LEEP
| if endocervical --> cone biopsy
103
If abnormal pap --> ______ --> _______
if ASCUS --> ______ --> _______
abnormal pap --> colposcopy --> LEEP vs. cone
ASCUS --> HPV DNA reflex testing --> Pap Q6 months and colpo if not normal
104
Tx of endometrial hyperplasia
progesterone
105
Types of ovarian cancers
1) Germ cell
2) Epithelial
3) Stromal
106
Germ cell ovarian tumors
1) dysgerminoma (LDH, chemo)
2) Endometrial sinus (AFP)
3) Teratoma (not malignant, stroma ovarii)
4) Choriocarcinoma (B-HCG)
107
Epithelial cell ovarian tumors
1) serous
2) mucinous
3) endometroid
4) Brenners
1-3 are cystadenocarcinomas
track w/CA-125, tx w/ TAH+BSO and paclitaxel
if BRCA1 or 2 --> can screen with TVUS and Ca-125 @age 35, can do ppx TAH+BSO
108
Stromal cell tumors
1) granulosa theca cell tumors --> estrogen
2) Sertoli-leydig cell --> testosterone
present w/endocrine sx
109
Complete mole
only paternal DNA (46XX, XY)
- NO fetal parts
- good fertilization, bad egg
- sx:
1) size-date discrepancy
2) increased B-HCG (usually >100,000)
3) HyperT or hyperemesis
4) Grape-like mass protrudes through cervix
DX: TVUS shows snowstorm pattern
-HIGHER risk of chorio
110
TX of complete mole
suction curetage
| follow B-hcg for 6 months while on OCPs
111
Incomplete/Partial mole
egg +2 sperm (69XXY, XYY)
- good egg, bad fertilzation
- same sx, dx, and tx as complete mole
- LOWER risk of chorio
112
Suspensory ligament of the ovary
contains ovarian artery and vein
| --> ovarian torsion cuts off blood supply
113
Uterosacral ligaments
Removed w/hysterectomy
| -look like ureters
114
Cardinal ligament
connect uterus to sidewall
| --> cystocele, rectocele, uterine inversion occurs w/pelvic floor relaxation
115
W/u of simple vs. complex cysts
Simple = small, unilocular, no septations, anechoic, homogenous
Complex = big, +septations, loculated, multiechoic, heterogenous
if < 3cm --> nothing
if < 10 cm --> repeat imaging (remove if it grows)
if > 10 cm --> removed w/ laparoscopy
116
Complex cyst could be...(6)
1) tuboovarian abscess
2) teratoma
3) cancer
4) endometrioma
5) ectopic
6) torsion
117
how high should B-hcg be for you to see a pregnancy on TVUS
1,500-2000 B-HCG --> should see IUP on TVUS
118
Tuboovarian abscess
path: GC/CT or vaginal flora
pt: abd pain/pelvic pain
--> CMT, adnexal tenderness, uterine tenderness
+ fevere, leukocytosis
WBC of wet prep
119
Tx of tuboovarian abscess
IV abx --> cefoxatin + doxy + mtz OR clinda + mtz
120
progression of abortion
IUP --> threatened abortion --> inevitable --> incomplete --> complete
OPEN cervical os with inevitable and incomplete
121
Causes of vaginal bleeding in a non-pregnant reproductive age woman (9)
Polyps
Adenomyosis
Leiomyoma
Malignancy
```
Coagulopathy
Ovarian dysfunction
Endometrium
Iatrogenic/IUD
Not yet classified
```
122
Mullerian agenesis
nml 46(XX)
nml testosterone
nml FSH, LH
NO uterus/ovaries
nml external genitalia
123
Androgen insensitivity syndrome / testicular feminization
-46 (XY)
-increased testosterone (resistant to testosterone)
-external female genitalia
+ TESTES
NO uterus
124
Kallman's
low FSH and LH, anosmia
deficiency of hypothalamic function
uterus and tubes nml, NO secondary sex characteristics
TX w/estrogen and progesterone
125
Turner syndrome
45XO --> increased FSH and LH
STREAK ovaries
NO secondary sex characteristics
uterus present, normal external genitalia
126
Causes of secondary amenorrhea
1) pregnancy
2) hypothyroid --> TRH inhibits ant.pit.
3) Prolactin --> prolactin inhibits GnRH
4) Meds
5) HPO axis
127
Problems with anterior pituitary causing secondary amenorrhea
adenoma, sheehan's syndrome, apoplexy (tumor outgrows blood supply and necroses)
128
Problems with ovary causing secondary amenorrhea
Savage syndrome, menopause, premature ovarian failure if < 40 yrs
129
Problems with endometrium causing secondary amenorrhea
ashermann's, ablation
130
Workup of Congenital adrenal hyperplasia
BL adrenal hyperplasia
17-hydroxy progesterone INCREASED in urine
TX with cortisol or fludrocortisone
