Mehl. Risk factors 6: Obstetrics Flashcards
(94) 28F + pregnant at 35 weeks’ gestation + cocaine use + painful contractions of abdomen + vaginal bleeding; Dx + risk factors?
abruptio placentae; risk factors are cocaine use and deceleration injury (i.e., fall or car accident). Presents as painful third-trimester bleeding.
(95) 28F + pregnant at 35 weeks’ gestation + painless vaginal bleeding; Dx + risk factors?
placenta previa; notable risk factor is previous C-section (on Obgyn CMS form); implication is, if lining of uterus has been disturbed, it makes sense that there would be future risk of abnormal implantation. Presents as painless third-trimester bleeding.
(96) 28F + post-partum hemorrhage + placenta is seen attached to myometrial layer; Dx + risk factor?
placenta accreta (placental attachment to surface of myometrium); risk factor is previous C-section, as well as concurrent placenta previa (latter sounds weird but is asked on Obgyn form) – i.e., placental attachment over the internal os increases risk of deeper attachment. Same deal holds true for placenta increta (attachment into myometrium) and percreta (attachment through myometrium). Should be noted in general that the most common cause of post-partum bleeding is uterine atony.
(97) 34F + giving birth + fetal anterior shoulder caught behind mother’s pubic symphysis; Dx + risk factor?
shoulder dystocia; risk factor is fetal macrosomia due to maternal diabetes (causes big baby). This can cause clavicular fracture in the newborn.
(98) Above 34F + experiences excessive vaginal bleeding despite McRobert’s maneuver to deliver in setting of shoulder dystocia; Dx + risk factor?
vaginal laceration due to macrosomia from maternal diabetes.
In short: maternal diabetes causes fetal macrosomia -> results in shoulder dystocia -> results in fetal clavicular fracture + maternal vaginal laceration during delivery.
(99) 32F + one-year Hx of amenorrhea + had dilation & curettage performed to remove miscarriage last year; Dx + risk factor?
Asherman syndrome; uterine synechiae (scarring) due to instrumentation within the uterus; NBME likes amenorrhea as the major symptom.
(100) 30F + 38 weeks’ gestation + fever 103F + CVA tenderness; Dx + risk factor?
pyelonephritis; uterus can compress ureters in third trimester, increasing risk for pyelo; in addition, progesterone slows ureteral peristalsis.
(101) 30F + pregnant + severe epigastric pain after meals starting during third-trimester; Dx + risk factor?
cholelithiasis; progesterone slows biliary peristalsis (causing biliary sludge) + estrogen upregulates HMG-CoA reductase (increasing cholesterol concentration within bile).
(102) 4-month-old girl + small amount of blood in stool + exclusively breastfed until age 2 months + on formula since; Q wants to know biggest risk factor for this patient’s condition?
answer = “not being exclusively breastfed until 6 months of life”;
diagnosis is milk-protein allergy;
for whatever reason it can cause blood in the stool, but this is a HY part of the vignette and confuses students; Tx is switching to a hydrolyzed casein formula; switching to soy formula is wrong answer as there is an allergy crossover in up to 25% of cases (literature varies on exact %). Vignette can also mention kid is started right away on soy formula (not cow-milk-based); answer is still switch to hydrolyzed casein formula. I talk about this stuff in high detail in my HY Pediatrics PDF.
(103) 2M + iron deficiency anemia + drinks lots of cows milk; what is risk factor for anemia?
answer = drinking greater than 24 oz of cows milk daily; sounds weird, but 2CK Peds component wants you to know that is a risk factor for iron deficiency in kids under age 2.
(104) 2M + recent viral infection + now has intermittent vomiting and crying with blood in the stool; Dx + risk factor?
intussusception; risk factor is recent viral infection; can cause adenitis of bowel leading to telescoping; almost all intussusceptions occur under age 2; if elderly, can be colorectal cancer.
(105) 67 + chest pain when arguing with wife + blood in stool; Dx + risk factor?
angiodysplasia;
risk factor is aortic stenosis (combo of angiodysplasia + aortic stenosis + acquired vWD = Heyde syndrome);
angiodysplasia is tortuosity of superficial vessels within the colon that are prone to painlessly bleed; third most common cause of GI bleeding in elderly after diverticulosis and cancer; Q on offline Step 1 NBME gives old guy arguing with his wife + gets chest pain + blood in stool; answer = angiodysplasia.
(106) 35F + Hx of recurrent miscarriages + positive VDRL test; Dx + risk factor?
SLE causing antiphospholipid syndrome, resulting in recurrent miscarriages due to uteroplacental microthromboses; antiphospholipid syndrome can cause a false (+) VDRL syphilis test.
(107) 35F + pregnant + fetus shows intrauterine growth restriction; risk factor?
often uteroplacental insufficiency, e.g., from smoking, cocaine use, HTN, SLE.
(108) Family Med Q shows glowing red rash on face in someone being treated for acne; Q asks best way to minimize this condition?
answer = avoidance of sun exposure; topic tretinoin (vitamin A) can cause photosensitivity (usually red rash); oral tetracycline sometimes used for acne tends to cause more of a blistering photosensitivity. Oral isotretinoin (high-dose vitamin A used for severe acne) is big risk teratogen; must do pregnancy test + recommend contraception before commencing.
(109) Neonate born with small right ventricle; risk factor?
lithium during pregnancy is risk factor for Ebstein anomaly (atrialization of right ventricle).
(110) Neonate born with spina bifida in mother who takes various medications; risk factor?
anti- epileptics (especially valproic acid) cause B9 (folate) malabsorption and neural tube defects.
(111) 35F + pregnant + abnormal AFP measurement; risk factor?
dating error is most common cause of abnormal AFP measurement;
next best step is fetal ultrasound to get correct dates (i.e., crown-rump length); re-measure AFP is wrong answer (the lab result wasn’t wrong, just the ultrasound date estimate was).
(112) 35F + pregnant + high AFP measurement despite correct dates; Dx + risk factor?
likely neural tube defect (i.e., spina bifida) due to folate (B9) deficiency; B9 required during first 3-4 weeks of gestation for neural tube development; high AFP can also be due to anencephaly, multiple-gestation pregnancy, omphalocele, or gastroschisis.
(113) 40F + pregnant + low AFP + low estriol + high b-hCG + high inhibin A; Dx + risk factor?
Down syndrome due to increased maternal age.
!! (114) Neonate + duodenal atresia and/or Hirschsprung; risk factor? –>
Down syndrome is HY cause of these
two findings.
(115) Young child born to mother age 41 + long, smooth philtrum + widely spaced eyes + single palmar
crease + slanted palpebral fissures; risk factor?
fetal alcohol syndrome; Down syndrome is wrong answer -> if Q mentions any change whatsoever regarding the philtrum, the answer is fetal alcohol syndrome, not Down; there is a hard Q on the 2CK Psych CMS form that sounds like Down syndrome, but answer is FAS due to the philtrum changes.
(116) 8F + long Hx of recurrent pulmonary infections + 6-month history of peripheral neuropathy; Dx + risk factor?
cystic fibrosis resulting in vitamin E deficiency (can present as neuropathy). This sounds low-yield and weird, but it’s all over the NBME exams for Step 1 (i.e., vitamin E deficiency due to CF).
