OB Flashcards
1
Q
What is the reason for increased CO and RBF in pregnancy?
A
Progesterone
2
Q
Acid base status in pregnancy and reason?
A
Chronic rep alkalosis with metabolic compensation, increase PaO2 and decrease PaCO2. Progesterone stimulates resp center to increase TV and Minute ventilation
3
Q
Highest accuracy for detecting gestational age is when and how?
A
7-10 weeks measuring crown rump length with accuracy +/- 3 days
4
Q
Diagnosis and tx of PMS?
A
Menstrual diary. SSRI
5
Q
In immature early HPG, what is cause of irregular menstrual cycles with lack of periodicity?
A
Not enough hormone generated such as LH/FSH to INDUCE OVULATION
6
Q
Trisomy 18 vs Trisomy 21 MSAFP, B-hCG, Estriol, Inhibin A?
A
Trisomy 18-AFP (decrease), hCG (decrease), Estriol (decrease), Inhibin A (normal)
Trisomy 21-AFP (decrease), hCG (increase), estriol (decrease), inhibin A (increase)
7
Q
Nonpathologic cause of increased MSAFP?
A
multiple gestation
8
Q
1st trimester combined test timing?
A
9-13 wks
9
Q
Quad screen timing?
A
second trimester. 15-20 wks.
10
Q
Chorionic villous sampling timing, advantages and disadvantages?
A
10-13 weeks. definitive karyotypic analysis, pain, vaginal spotting, risk of pregnancy loss
11
Q
Amniocentesis timing, advantages, and disadvantages?
A
15-20 weeks, definitive karyotypic analysis, pain with risk of bleeding and amniotic fluid leak, risk of injury to fetus, placenta and maternal bowel or bladder
12
Q
Second trimester U/S timing, advantages and disadvantages?
A
18-20 weeks, noninvasive and measures growth, anatomy, and position, disadvantage includes not identifying all abnormalities, soft markers are U/S finding of uncertain significance
13
Q
Cell-free fetal dna timing, advantages and disadvanges?
A
greater than 10 weeks; can be confirmed via chorionic villi. Noninvase and highly sensitive and specific for aneuploidy but not diagnostic is a disadvangage.
14
Q
Criteria for chronic HTN with superimposed preeclampsia?
A
Chronic HTN (less than 20 weeks) and 1 of following: new onset proteinuria or worsening of current proteinuria, worsening of current HTN, or signs of end organ damage
15
Q
Tx of hyperemesis gravidarum?
A
Ginger, fluid replacement, dietary modification, pyridoxine +/- doxylamine
16
Q
Greatest risk factor for uterine rupture?
A
PRevious uterine surgery
17
Q
cessation of uterine contraction and sudden onset vaginal bleeding?
A
uterine rupture
18
Q
painless vaginal bleeding with ROM?
A
vasa previa
19
Q
diagnosis and management of placenta previa?
A
diagnosis: first transabdominal NO TRANSVAGINAL. C-section at 36-37 weeks and pelvic rest (no digital vaginal exam and no intercourse)
20
Q
top cause of placental abruption?
A
maternal HTN
21
Q
diagnosis and management of placenta abrupto?
A
diagnosis: transabdominal U/S. management-IV crystalloid and left lateral decubitus to maximize CO and displace uterus off aortocaval vessels
22
Q
Placental adherence and hemorrhage at time of attempted placental delivery?
A
Placenta accreta
23
Q
Fetal effects of eclampsia?
A
3-5 minutes of fetal bradycardia during seizure followed by compensatory tachycardia and loss of variability
24
Q
What is intrauterine fetal demise?
A
Death after 20 weeks and before onset of labor
25
Management and complications of intrauterine fetal demise and confirmation?
Management-Coagulation studies normal (watchful waiting), coagulation abnormal (induction of labor). Perform autopsy if possible to prevent in future
Complications-DIC from TF release from bleeding decidua into maternal circulation (same complication in placenta abruption)
Confirmation-real time ultrasonography
26
Unique to each 2nd and 3rd trimester delivery options for fetal death>20 wks?
D+C up till 24 weeks and repeat C-section in 3rd trimester. otherwise introduction of labor or spontaneous labor same for both.
27
Test to evaluate cervical insufficiency and finding?
Transvaginal U/S (gold standard) w cervix length should be >25 mm at 24 weeks. if
28
Management of preterm labor
tocolytic (ca2+ channel blocker), mag sul for neuroprotection, and corticosteroids for fetal lung maturity (antenatal corticosteroids)
29
Indications for post-term pregnancy C-section?
Fetal distress, oligohydramnios
30
Diagnosis of acute appendicitis in pregnant patientS?
U/S with graded compression technique. Presence of non-compression and dilation of appendix are diagnositic
31
15 hours after delivery, woman has fever, leukocytosis and bloody vaginal discharge that is non purulent?
Normal postpartum complication with lochia. If foul smelling, consider endometritis
32
Heroin vs methadone NAS child presentation?
Heroin-within 48 hours. Methadone-48-72 hours
33
What reflex is lost on affected side of infants with clavicular or humeral fracture during delivery? What is preserved?
Moro. Biceps and grasp
34
Lost reflex and preserved in erb duchenne?
decrease of biceps and moro. Preserved is grasp
35
Lost of reflex and preserved in klumpke?
intact moro and biceps. absent grasp
36
Tx of endometritis?
broad spectrum (clindamycin and gentamicin)
37
Primary amenorrhea work up?
1) Uterus present or absent (ultrasound or pelvic exam)
2) Uterus present do FSH (low FSH do cranial MRI, high FSH do karyotype (turner)
3) Uterus asent do karyotype and serum testosterone (karyotype XX and normal female testosterone levels means mullerian agenesis, Karyotype XY and normal male levels means AIS)
38
Age you have to have workup for primary amenorrhea with and without secondary sex characteristics?
With-age 16, without-age 14
39
1st test for secondary amenorrhea?
b-HCG
40
#1 consequence of secondary hypogonadotropic hypogonadism?
Low bone density and osteoporosis secondary to decreased estrogen
41
Tx infertility in premature ovarian failure?
in vitro fertilization and donor oocytes
42
Amenorrhea needs to only be how long to diagnose premature ovarian failure?
3 months. DONT WAIT TILL 1 year to avoid osteoporosis at young age.
43
Gonad management timeline for cryptorchid gonads?
| Unilateral cryptorchid testes in XY male, AIS gonads, turner syndrome?
```
Unilateral cryptorchid testes-orchipexy
AIS gonads (testes in phenotypic females)-after puberty to allow for growth have gonadectomy
Turner syndrome-earlier gonadectomy because higher risk of malignancy from streak ovaries
```
44
Cause of transverse vaginal septum?
Malformation of urogenital sinus and mullerian ducts
45
Congenital aromatase deficiency presentation and problems with puberty?
Ambiguous genitalia. Decrease estrogen causes primary amenorrhea, osteoprosis, and tall stature because low estrogen delays growth plate closure
46
management of hemorrhage at 18th week from vagina with US showing active FHR?
Ressurance and ultrasonogram 1 wk later
47
Finding on U/S of septic abortion?
Thick endometrial stripe
48
Incomplete, inevitable or missed abortion management for hemodynamically unstable (heavy bleeding) and hemodynamically stable (mild bleeding)?
Unstable-D+C
| Stable-expectant management, prostaglandins e1 (misoprostol), or surgical evacuation
49
Septicabortion managmenet?
broad spectrum abx, urgent suction curretage for hemodynamically unstable, and hysterectomy if no response to abx, develoment of abscess, or signs of clostridial infection
50
Ovarian torsion vs ruptured ovarian cyst presentation
Ovarian torsion acute onset with nausea and vomiting, tender adnexa on bimanual and decreased blood flow with doppler US. Ovarian cyst acute onset after strenous activity or sex with fluid around ovary.
51
What must be done before someone can be worked up for PID if present with fever, chills, new vaginal dischare, lower abdominal pain, dysuria?
Transvaginal U/S to look for tuboovarian abscess
52
Tx of ovarian/adnexal torsion?
laparoscopy for urgent detorsion. if necrotic or malignant mass, salpingooophorectomy
53
Palpable breast mass workup
| Less than 30 and greater than 30
Less than 30: Ultrasonography; if simple cyst can do needle aspiration (but can reaccumulate so should return in 2-4 months for follow-up). if complex cyst/mss (image guided core biopsy)
Greater than 30: Ultrasonography and mammogram; if suspicious for malignancy, core biopsy
54
How does fat necrosis present and tx?
Post trauma/surgery with a firm, irregular mass that has ecchymosis and skin/mipple retraction that can look radiographically similar to breast cancer. Biopsy showing fat globules and foamy histocytes in fat necrosis. NO TREATMENT
55
Most common underlying breast cancer found in paget disease?
Adenocarcinoma
56
Pain, itching and burning of the nipple that has no resolution with steroids?
Mammary paget disease
57
Premenopausal woman with bloody discharge from one breast without any palpable mass?
Intraductal papilloma
58
HER2 positivity for breast cancer predicts reponse to what drugs?
Trastuzumab and anthracycline
59
Nipple discharge evaluation?
Unilateral, bloody serous, or milky with palpable lump or skin changes-ultrasound and/or mamography (>30)
Milk without palpable lump or skin changes-likely physiologic (check tsh, pregnancy, prolactin, guiac, and maybe mri pituitary)
60
Most common location of metastases of choriocarcinoma and tx?
Lungs. Presenting with hemoptysis and multiple nodules on CXR. Can also go to brain. This is the metastatic form of Gestational trophoblastic dz. methotrexate or daptinomycin
61
Pelvic pain, enlarged uterus, and irregular vaginal bleeding?
GTD
62
Triad of ectopic pregnancy and diagnosis and tx?
Abdominal pain, amenorrhea, vaginal bleeding. Transvaginal U/S showing adnexal mass, empty uterus. Tx. methotrexate or surgical
63
Define infertility
conceive for greater than 1 year with age less than 35 or greater than 6 months with age greater than 35
64
Imaging workup for infertility
hyesterosalpinogram (used to diagnose anatomic cause such as tubal obstruction from prior pelvic obstruction)
65
Pelvic mass evaluation imaging and follow up from studies
Transvaginal u/s and CA-125.
- greater than 10 cm and elevated CA-125, nodular or fixed mass, ascites or evidence of metastasis needs gyn onc evaluation
- non elevated ca-125 or simple cyst less than 10 cm is followed conservatively
66
Tx of vaginal foreign body
removal with calcium alginate swab or warm water irrigation AFTER local anesthetic is applied
67
Lichen sclerosus presentation, management, and tx?
- Pruritic vulva with dysuria, dyspareunia, and painful defecation
- Exam: procelein white atrophy with premalignant lesion that must be biopsied to rule out SCC
- Tx topical corticosteroids
68
Most significant maternal benefit of breastfeeding?
decrease risk of ovarian and breast cancer
69
6 maternal contraindications to breast feeding?
1) Active TB (can breast feed 2 weeks after start of antituberculin therapy)
2) Maternal HIV
3) Alcohol or drug abuse actively!!
4) Varicella infection less than 5 days before or 2 days after delivery
5) Herpetic breast lesions
6) Chemo or ongoing radiation
70
Diagnosis of chorioamnionitis anx tx?
Maternal fever greater than38C (100.4) PLUS more than 1 of following (tach>100, uterine tenderness, WBC higher than 15 K, malodorous or purulent vaginal discharge). clinda/genti, antipyretics and DELIVERY with oxy
71
Tx of uterine inversion?
1) manual uterus replacement followed by placenta removal and uterotonic drugs (oxytocin/misoprostal) that cause contraction and stop hemorrhaging
72
MCC hypermagnesemia and tx?
Renal insufficiency. IV calcium gluconate
73
Neonatal HSV infection management for active vs hx in mother?
Active-C-section for active genital herpes, Hx in mother-acyclovir or valacyclovir at 36 wks for NOT ACTIV but has history
74
Preeclampsia triad?
HTN, proteinuria, edema
75
Endometriosis gold standard diagnosis?
Laparoscopy showing chocolate appearing material representing old blood
76
End organ damage for preeclampsia vs severe features
End organ-headache, ruq pain, renal insuff, pulm edema
Severe features-greater than 160/110 on 2 times 4 hours apart, plt less than 100k, elevated transaminase, pulm edema, new onset visual/cerebral, creatinine greater than 1.1
77
Management of severe preeclampsia features?
IV or IM mag sul. to decrease seizure risk. HTN greater than 160/110 needs IV hydralazine, IV labetolol or nifedipine PO
78
Irregular enlarged uterus of a nulliparous women with with urinary incontinence imaging and diagnosis?
U/S. Uteroin leiomyoma (fibroids)
79
What is asymmetric vs symmetric fetal growth restriction?
Asymmetric-maternal factors where head spared in size and body smaller
Symmetric-both head and body grow smaller due to fetal factors (chromosome, congenital infection, congenital heart dz)
80
Thyroid hormone axis of pregnancy?
Increase in T4 and decrease in TSH. Increase T4 secondary to increased HCG. TBG increased with increased estrogen that increases bound T4 and minor increase in free T4. T4 suppresses TSH
81
Breast feeding mother choice of OCP and why?
Progestin only contraceptives. Avoid combination ocP because estrogen decreases prolactin that decreases the overall milk production
82
Definition of abnormal uterine bleeding?
greater than 5 days and heavy with greater than 1 pad every 2 hours with irregular freq
83
Tx of bladder atony postpartum
Early ambulation, analgesics, and bladder catheterization if these don't work
84
Overall what is the main point of biophysical profile?
assessing fetal oxygenation
85
What does abnormal BPP mean?
4 or less means fetal hypoxia due to placental dysfunction/insufficiency
86
Differentiate endometrial polyp vs fibriod where a mass is seen in cervical os?
endometrial polyp-soft polyp. small painless bleeding, fibroid-firm polyp. large heavy clots (amnormal menstrual bleeding) with pelvic pain
87
Repetitive late decelerations method of delivery?
C-section
88
MCC infertility less than 30 with normal menstruation?
PID
89
Best managment for coughing sneezing incontinence vs have to go now incontinence vs overflow.
Pelvic floor surgery (stress), antimuscurinic (urge), bethanchol (overflow)
90
Management of breech presentation?
Does not require any intervention as breech often converts to VERTEX if less than 37 weeks. and if greater than 37 weeks external cephalic version. If this fails, planned C-section
91
14 yo female having excessive prolonged menstrual bleeding with irregular cycles since start of menarche at 13 cause?
Anovulation
92
Side effects of tamoxifen and raloxifene?
Hot flashes, VTE, endometrial hyperplasia and carcinoma (tamoxifen only)
93
Endometrial hyperplasia management after endometrial biopsy for abnormal uterine bleeding?
Biopsy: if atypia, progestin therapy if considering future pregnancy or hysterectomy with no plans or failure of medical management. If no atypia than progestin therapy
94
Test before traztuzumab therapy is initiated?
Echo b/c risk of cardiotoxicity with baseline low EF
95
Number 1 reduction in developing ovarian cancer?
Bilateral salpinooophorectomy
96
Granulosa cell tumor age distribution and presentation?
Bimodal pre and post menopausal. THINK ESTROGEN INCREASE PROBLEMS. Premenopausal with precocious puberty. Postmenopausal with breast hyperplasia and uterine bleeding and absense of menopausal symptoms
97
Vaginal cancer epidemiology and location of vagina
squamous cell age greater than 60 with risk factor hpv 16,18, smoking, and dysplasia. less than 20 is due to in utero DES exposure. upper 1/3 vagina
98
Triand and tx endometriosis
Dyspareunia, infertility, dysmenorrhea. 1) NSAID/ocp 2) laparoscopy
99
origin and detection of endometrioma?
chocolate appearing old blood that is homogenous cystic mass in ovary b/c of dried up blood that is dark from ectopic endometrial tissue in endometriosis
100
1st test for abnormal uterine bleeding?
b-HCG
101
fibroid workup and tx
U/S. observation if no significant symptoms, ocp, embolization, or surgery if symptomatic
102
tx of gu syndrome of menopause?
menopause with vaginal dryness itching and pain with sex AND urinary freq, urgency, incontinence, and infection secondary to decreased estrogen.
1) vaginal moisturizer or lubricant WITHOUT urinary symptoms
2) topical vaginal estrogen WITH urinary symptoms
103
tx of neonatal thyrotoxicosis?
self resolves in 3 months becuase maternal antibody disappears. Methimazole PLUS B-blocker is another possibility
104
Testing for GDM timeline and process?
24-28 wks gestation.
1) 50 g glucose. less than 140 ok, greater than 140 step 2
2) 100 g glucose, fasting less than 95-105, 1 hour less than 180-190, 2 hour less than 155-165, 3 hour less than 140-145 with diagnosis of GDM with greater than 2 abnormal values
105
Luteoma description, clinical features for mom, and fetal virilization risk?
yellow or yellow brown mass with areas of hemorrhage and large lutein cells with solid masses on U/S that regress after delivery and HIGH VIRILIZATION RISK
106
Theca lutein cyst description, clinical features for mom, and fetal virilization risk?
bilateral ovarian cysts associated with molar pregnancy or multiple gestation that gone after birth with low risk of virilization
107
krukenberg tumor description, clinical features for mom, and fetal virilization risk?
bilateral solid ovarian masses, metastases from primary GI cancer, and high virilization risk
108
LH and FSH and ratio in PCOS
LH:FSH greater than 3:1
109
MCC for having breach presentation?
Hx of fibroids
110
most common ovarian tumor in woman of all ages?
Dermoid containing 3 types of tissue
111
magnesium toxicity symptoms, check to confirm toxicity, and tx?
resp depression/cardiac arrest and can be caused by renal insufficiency. check dtr depressed. iv calcium gluconate
112
best form of permanent sterilization for obese patient with 3 prior c-sections?
hysteroscopic tubal occlusion (scars down the fallopian tubes)
113
What increases the pain associated with fibrocystic changes?
Caffeine
114
Contraindicated induction agent in hypertensive patients?
methylergonovine
115
Which SSRI is a teratogen?
paroxetine
116
Trial of labor contraindicated when for hx of uterine surgery?
vertical (classic) c-section, abdominal myomectomy with uterine cavity entry.
117
Routine test for all pregnant patient timeline:
Pap smear?
UA?
Urine culture?
Pap smear if patient is due. UA at first visit and every one thereafter. Urine culture at 12-16 wks for asymptomatic bacteriuria
118
Routine test for all pregnant patient timeline:
Hb/Hct
Blood type. Rh type. and antibody screen
Both at first visit
119
Syphilis test timeline for pregnant patient?
First visit
120
Rubella Ab screen for pregnant patient?
Pospartum immunization if not immune
121
Glucose screen for gestational diabetes?
first visit if risk factor (obese, family hx or older than 30) and 24-28 wks otherwise
122
Chlamydia test timeline?
First prenatal visit
123
When do you order U/S to evaluate fetus?
1) Size/date discrepancy
2) Pregnancy related problems (risk factors for diseases)
3) Fetal distress, death abortion miscarriage suspected
124
Mucopurulent cervical discharge with erythematous and friable cervix?
Chlamydia/Gonorrhoeae
125
pH for vaginal infections trich, vaginosis, candida?
trich and vaginosis greater than 4.5. candida normal from 4.0-4.5
126
asymptomatic bacteriuria or acute cystitis management?
nitrofurantoin for 7 days, amoxicillin or amoxicillin clavulante for 5-7 days, fosfomycin single dose
127
acute pyelo management pregnancy?
hospitaliztion and iv abx (eg b-lactam and meropenem)
128
tx of hpv lesions
trichloroacetic acid or podophyllin with larger lesions undergoing electrotherapy
129
painful vs painless sti?
painful-hsv and chancroid (haemophilus ducreyi). painless- treponema, chlamydia trachomatis (LGV), kepsieela granulomatis (granuloma inguinale)
130
tx hellp?
delivery vaginal if cervix favorable and fetus is vertex
131
Rh - mother has Rh + child. When should you give rhogam?
28 weeks and repeat within 72 hours of delivery.
132
setting and treatment of hemolytic dz newborn from ABO incompatibility?
o mother with A or B baby. can occur in first pregnancy because exposure in environment. Phototherapy is tx.
133
components and finding of biophysical profile?
NST (greater than 2 accelerations), amniotic fluid (greater than 2 cm deepest pocket or fluid index greater than 5 cm), movement (greater than 3 movements), greater than 1 episode of flexion/extension of fetal limb or spine), breathing (1 episode lasting 30 seconds)
134
Indication for emergent C-section
late deceleration
135
cause of early deceleration with nadir and peak of contraction are at same?
fetal head compression
136
cause of late deceleration with nadir after peak of contraction with greater than 30 second length of contraction?
uteroplacental insufficiency
137
cause of variable deceleration with abrupt less than 30 seconds and not necessarily associated with contractions?
Cord compression, oligohydramnios, cord prolapse
138
Patient has recurrent variable decleration with greater than or less than 50% of contractions problem and tx?
Can result in fetal acidosis. maternal repositioning is first followed by amnioinfusion. less than 50% just needs observation without any intervention
139
What is arrest of labor diagnosed in first stage?
cervical dilation is greater than 6 cm with ruptured membranes and 1 of following. no cervical change for greater than 4 hours despite adequate (200 montevideo units for greater than 2 hours) contraction OR no cervical change for greater than 6 hours despite inadequate contractions
140
tx intrahepatic cholestasis of pregnancy?
ursodeoxycholic acid and early delivery at 37-38 wks or less than 37 weeks in severe or recurrent cases
141
tx acute fatty liver of pregnancy?
prompt delivery
142
period you should avoid conception after live vaccine (eg mmr, varicella, intranasal influenza)
4 weeks
143
Routine vaccine given in pregnancy?
Tdap and influenza
144
Vaccine given in special cirucmstance in prgnancy?
hep b/hep a for liver disease for example, pneumococcus or influenza for asplenic, meningococcus if 19-21 in college dorm and not vaccinated before)
145
contraceptive for breast cancer patients?
copper iud
146
most effective vs most accessible emergency contraception?
copper iud most effective, levonorgesterl, ullipristal delay ovulation
147
cv side effect of epidural?
hypotension from sympathetic nerve fibers responsible for vascular tone are blocked so you have venous pooling, decrease venous return, and decrease CO
148
tx of pph?
uterine massage, iv fluids, uterotonic (IV oxytocin followed by methylerogonovine, and misoprostol?
149
contraindicated tx of pph in asthma patients?
carboprost
150
managmeent of lithium in pregnant women?
slow tapering because high relapse risk
151
management vasa previa?
emergency c-section
152
nagale rule for estimation of delivery date?
LMP-3 months +7 days
153
fetal movement and anatomy detection timeline?`
16-20 wks, 18-20 wks GA
154
Gravidy is ? and parity is broken down into what?
Gravidy-number of pregnancy
| Parity-FPAL
155
best initial most accurate test pregnancy diagnosis?
b-hcg, ultrasound
156
when and at what hcg level should gestational sac be seen on u/s?
4-5 weeks or with 1500 iu/mL
157
hypercoaculability in pregnancy from what?
increase fibrinogen/fibrin split factor
158
someone presents with braxton hicks next best step
check cervix
159
when is fetal blood sampling done?
for rh isoimmunization when need a fetal cbc
160
ectopic pregnancy management?
ectopic confirmed not rupture either medical (cbc, liver test, type and screen and than methotrexate) or surgery
ruptured always SURGERY. if stable, direct surgery or fluids and resuscitation than SURGERY
161
exclusion criteria methotrexate for ectopic?
hepatotoxicity, noncompliant, immunodeficiency, cbc problem, kideny function because it is excreted through kidney
162
most common monozygotic and dizygotic chorion and amnion presentation?
mono-monochorionic diamniotic
| di-dichorionic diamniotic
163
absolute indications for delivery in which preterm labor should not be stopped (6)?
greater than 4 cm dilation, preeclampsia/eclampsia, preexisting maternal cardiac disease, abruptio or DIC, fetal death, or chorioamnionitis
164
indications for gbs tx neonatal?
- prior birth to infant affected with early onset GBS
- GBS bacteriuria or gbs uti anytime during current
- gbs positive within 5 weeks
- unknown gbs status PLUS 1 of following: less than 37 weeks, intrapartum fever, rupture of amniotic membrantes greater than 18 hours
165
preterm fetus tx without chorio?
betamethasone, tocolysis, and abx (ampicillin and 1 dose azithro and if allergic to ampicillin use cefazolin (low risk anaphylaxis) or clindamycin (high risk anaphylaxis)
166
3rd trimester vaginal bleeding contraindicated exam?
digital vaginal exam
167
When should you not use terbutaline, mag sulfate, and indomethacin for pre term labor?
terbutaline or ritrodrine(b agonist) not used in diabetics, mag sul not used in myasthenia gravis patients, and indomethacin not used for labor after 33 weeks
168
mechanism of mag sulf as tocolytic?
competes with calcium entry into cell
169
betamethasone advantages besides lung protection?
decrease risk nec and intracerebral hemorrhage
