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USMLE Step 3 - ALL > OB > Flashcards

OB Flashcards

1
Q

Anticoagulation in Pregnancy

A 
Preconception = Warfarin 
During pregnancy = LMWH 
Last few weeks of preg = UFH 
Stop anticoagulation at onset of labor and during delivery 
Postpartum = Warfarin

Warfarin also ok in 2nd/3rd trimester if pt is high risk (eg. has mechanical valves)

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2
Q

Medical CIs to Pregnancy (6) –> must terminate pregnancy if have these

A 
EF <40%
Previous peripartum cardiomyopathy
CHF class III-IV 
Severe obstructive lesions 
Eisenmenger syndrome (severe Pulm HTN) 
Unstable aortic dilation >40mm
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3
Q

First Trimester Routine Tests (9)

A 
CBC 
Type and cross (test for Rh; if Rh (-) = get Rh Ab titer)
UA/urine cx 
Pap smear 
Chlamydia/gonorrhea
Hep B 
HIV 
Rubella 
Syphilis
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4
Q

Third Trimester Routine Tests (4)

A

DM –> 24-28 wk
Anemia –> 24-28 wk
Indirect Coombs test (for anti-D Abs in Rh - moms) –> 28 wk
GBS screening (vaginal and rectal cx) –> 35-37 wks

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5
Q

Trisomy 21 - Quad Screen Results

A

“HIgh”

↓ AFP
↓ Estriol
↑ hCG
↑ Inhibin A

FOR ↓ AFP DO AMNIOCENTESIS TO GET KARYOTYPE

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6
Q

Trisomy 18 - Quad Screen Results

A

“HEA is low”

↓ AFP
↓ Estriol
↓ hCG
N Inhibin A

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7
Q

Trisomy 13 - Quad Screen Results

A

“AFPatau is high” - looks like NTD/multiple gestations/ventral wall defect

↑ AFP
N Estriol
N hCG
N Inhibin A

FOR ↑ AFP DO AMNIOCENTESIS TO GET AMNIOTIC FLUID AFP AND ACH-ESTERASE ACTIVITY (increased AF-AFP = open NTD)

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8
Q

Evaluation of Gestational DM (weeks 24-28)

A

1 hr 50g OGTT (gluc. load test) –> POSITIVE is ≥ 140mg/dL –> confirm (+) test w/ 3 hr 100g OGTT (glu. tolerance test)

NEED 2 ABNORMAL POSTGLUCOSE LOAD MEASUREMENTS FOR DX (so either fasting, 1 hr, 2 hr or 3 hr)

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9
Q

GBS (AKA: Strep Agalactiae) Tx in mom

A

Immediate tx w/ amoxocillin or cephalexin THEN

Intrapartum IV PCN G as ppx (if PCN allergic = IV clindamycin or IV erythromycin) –> give 4 hrs before delivery

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10
Q

RFs for Abruptio Placenta (5)

Complication of Abruptio Placenta

A 
HTN (chronic, preeclampsia, eclampsia) 
Trauma
Cocaine use 
Smoking during pregnancy 
Previous abruption

Complication = DIC

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11
Q

sudden PAINLESS vaginal bleeding

h/o trauma, coitus, pelvic exam

A

Placenta Previa

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12
Q

RFs for Placenta Previa (4)

Complication

A

Previous placenta previa
Previous C-section/ uterine surgery
Fibroids
Multiparity

Complication = placenta accreta/iincreta/percreta

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13
Q

Tx for Abruption Placenta and Placenta Previa

A 
Emergency C-section (if pt/mom unstable) 
Vaginal delivery (if pt/mom stable and greater than 36 wks; can do in placenta previa if placenta is >2 cm from internal os)
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14
Q

Painful vaginal bleeding w/ previous h/o uterine scar

Assc. w/ placenta previa, prior C-section

A

Placenta Accreta, Increta, Percreta

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15
Q

Tx for Placenta Accreta, Increta, Percreta

A

Cesarean Hysterectomy

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16
Q

Triad:

  • rupture of membranes
  • painless vaginal bleeding
  • fetal tachycardia then bradycardia (sinusoidal pattern)

Mom stable

A

Vasa Previa

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17
Q

Tx for Vasa Previa

Complication

A

Emergency C-section

Fetal exsanguination and death

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18
Q 
sudden onset vaginal bleeding and abdominal pain 
loss of electronic fetal HR 
NO uterine contractions 
abnormal bump in abdomen 
recession of fetal head during labor
A

Uterine Rupture

  • abnormal bump in abdomen = fetal part coming out of tear in uterus (“irregular mobile mass in RUQ”)
  • placental abruption has uterine contractions and they’re painful
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19
Q

RFs for Uterine Rupture (5)

A 
previous C-section 
uterine myomectomy (for fibroids) 
placenta percreta 
excessive oxytocin 
grand multiparity
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20
Q

Tx for Uterine Rupture

A

Immediate laparotomy and delivery

May need hysterectomy for uncontrolled bleeding

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21
Q

causes of vaginal bleeding in 1st trimester

A

ectopic preg
spon. abortion
subchorionic hematoma

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22
Q

vaginal bleeding in 1st trimester OR

incidental finding in U/S (crescent, hypoechoic lesions adjacent to gestational sac)

A

subchorionic hematoma

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23
Q

Tx for subchorionic hematoma

Complications

A

Expectant management

Complications: 
spon. abortion 
abruptio placenta 
preterm PROM 
preterm delivery
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24
Q

How GBS dx in 1st trimester?

A

w/ clean catch urine cx

at 35-37 wks = rectovaginal cx

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25
Q

vertical transmission of GBS causes what in neonate?

A

PNA and sepsis (50% mortality rate)

GBS meningitis NOT related to vertical transmission (it’s a hospital acq’d infxn)

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26
Q

When do you give GBS ABX ppx in moms?

A

Previous BABY (NOT MOM) w/ GBS sepsis

If GBS status unknown + have any of these:

  • maternal fever
  • rupture of membranes ≥ 18 hrs
  • preterm delivery (< 37 wks)
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27
Q

When do you NOT give GBS ABX ppx in moms?

A

If pt getting planned C-section w/o ROM (even if cx +)

Negative cx during this pregnancy (+ cx in prev preg doesn’t matter)

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28
Q

preg mom in SOUTH AMERICA handling cat feces or litter boxes OR drinking raw goat milk OR eating raw meat
Mild mononucleosis-like syndrome

A

Toxoplasmosis (Toxoplasma gondii)

DX: IgM (active infxn) or IgG (past infxn, protective) levels

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29
Q

if have maternal Varicella, what’s the tx in MOM vs NEONATE?

A 
MOM= PO acyclovir + VZIG 
NEONATE = VZIG
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30
Q

Tx of congenital Varicella in neonate?

A

IV acyclovir + VZIG

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31
Q

Postexposure Varicella PPX if have previous h/o chickenpox or evidence of immunity (varicella Abs)

A

Nothing - observe

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32
Q

Postexposure Varicella PPX if have NO previous h/o chickenpox or evidence of immunity ( NO varicella Abs) AND Immunocompromised

A

IVIG

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33
Q

Postexposure Varicella PPX if have NO previous h/o chickenpox or evidence of immunity ( NO varicella Abs) AND Immunocompetent

A

Varicella vaccine

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34
Q

Postexposure PPX for Rubella in preg woman

A

None available

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35
Q

What do you do if preg woman has negative IgG titers for Rubella during 1st trimester routine screening?

A

Nothing –> have to wait until after delivery to give her Rubella vaccine (b/c it’s live vaccine)

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36
Q

how is CMV (HHV 5) transmitted?

A

via body fluids

Avoid transfusion w/ CMV positive blood

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37
Q

Tx for CMV + neonate

A

ganciclovir or foscarnet

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38
Q

Does ganciclovir cure CMV infxn?

A

NO! It just stops viral shedding and prevents hearing loss

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39
Q

How is HSV transmitted to baby from mom?

A

via contact w/ active maternal genital lesions

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40
Q

Active genital herpes in preg woman is indication for?

A

C-section

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41
Q

Tx for mom w/ active HSV

A

Acyclovir

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42
Q

How is HSV in preg pt Dx?

A

HSV cx from vesicle/ulcer OR HSV PCR

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43
Q

acute, symmetric arthralgias/arthritis
red, lacy rash on trunk and extremities
flulike sxs

A

Parvovirus B19 in preg pt

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44
Q

Dx of parvovirus B19 in preg pt (Immunocompromised vs Immunocompetent)

A 
Immunocompromised = NAAT for B19 DNA 
Immunocompetent = B19 IgM Abs
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45
Q

Dx of parvovirus B19 in fetus

A

PCR analysis of amniotic fld for B19 DNA

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46
Q

how do you monitor a fetus w/ parvovirus B19 infxn

A

do serial U/S for hydrops fetalis

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47
Q

when do HIV + preg pts need antiretroviral therapy?

A

all the time REGARDLESS of CD4 count, RNA load, gestational age

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48
Q

Recommended HIV therapy in preg pt? What should you avoid?

A 
use zidovudine + lamivudine + protease inh
AVOID Efavirenz (NNRTI) --> avoid before 8 wks gestation; can use after 8 wks gestation --> if pt already on Efavirenz before preg continue it during preg even during first 8 wks
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49
Q

Indication for C-section in HIV preg pt?

A

viral load > 1000 at time of delivery

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50
Q

What does baby of HIV preg pt get? and for how long?

A

zidovudine during delivery and for 6 wks postpartum

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51
Q

Can HIV + mom breastfeed?

A

NO (breast milk transmits virus)

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52
Q

Does C-section prevent vertical transmission of syphilis?

A

NO (b/c infxn happens through placenta before birth)

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53
Q

Tx for syphilis + mom (assume primary/secondary stage)

A

Benzathine PCN IM x 1

If PCN allergic = desensitize

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54
Q

Tx for congenital syphilis

A

Aqueous PCN G IV q8-12h x 10 days

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55
Q

Next step after + VDRL test in preg pt?

A

FTA-ABS (NOT PCN –> start after confirmation)

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56
Q

How does neonate get HBV infxn?

A

gets it from mom who has primary infxn in 3rd trimester OR from ingestion of infected genital secretions during vaginal delivery

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57
Q

Tx for preg pt w/ Hep B infxn

A

get tx for Hep B + vaccine

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58
Q

If mom + for Hep B, what tx do you give neonate?

A

HBIG + vaccine (w/in 12 hrs of delivery)

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59
Q

PPX for preg pt w/ (-) HBsAg BUT RFs for Hep B infxn

A

Vaccine during preg

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60
Q

Hep B Postexposure PPX for preg pt

A

HBIG + vaccine

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61
Q

Do infants who acquire acute Hep B go on to develop chronic hep B?

A

YES!
90% infants develop chronic Hep B
(acute to chronic transformation is based on age; high age = decreased chance of chronic transformation)

In ADULTS –> 90% w/ acute Hep B recover and ONLY 5% or less get chronic Hep B

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62
Q

What is the standard does of RhoGAM?

A

300 micrograms (increase dose if have severe hemorrhage)

Protection from RhoGAM is dose dependent

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63
Q

When do you give RhoGAM?

A

any time mom bleeds during preg, during 28 wks gestation and after delivery (if baby Rh +)

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64
Q

When is pt considered sensitized to Rh Abs?

A

if titer is more than 1:4

titer < 1:16 = no tx
titer > 1:16 = serial amniocentesis to evaluate for fetal anemia and hydrops fetalis

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65
Q

Can you give RhoGAM to sensitized pts?

A

NO

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66
Q

What is Kleihauer -Betke test?

A

Helps determine RhoGAM dose req’d
Determines incidence and size of fetal transplacental hemorrhage (in test, mom’s RBCs turn pale and fetus RBCs remain unstained)

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67
Q

H/o elevated BP before preg OR before 20 wks gestation OR beyond 12 wks postpartum

A

Chronic HTN

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68
Q

Elevated BP after 20 wks gestation and returns to normal baseline by 6 wks postpartum

A

Gestational HTN

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69
Q

Mild Preeclampsia (occurs in 3rd trimester) Criteria (3)

A

BP >140/90
Proteinuria 1+/2+; >300mg (24 hr urine); protein:Cr ratio ≥ 0.3
Edema (hands, feet, face)

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70
Q

Severe Preeclampsia (occurs in 3rd trimester) Criteria (3)

A

BP >160/110
Proteinuria 3+/4+; >5g (24 hr urine)
Warning signs

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71
Q

Warning signs of Severe Preeclampsia

A

Headache
Epigastric pain
Vision changes
Pulmonary edema (from ↑ SVR, ↑ cap. perme., ↓ albumin)
Oliguria
↓ PLTs, ↑ LFTs, ↑ Cr (> 1.1) = signs of HELLP

NOTE: In preg, ↑ GFR = ↓ Cr so if see ↑ Cr = bad

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72
Q

HIGH RFs for Preeclampsia

A 
previous preeclampsia
CKD 
chronic HTN 
DM 
multiple gestations
autoimmune disease

High risk pts should receive low dose Aspirin to prevent preeclampsia (start at 12 wks gestation)

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73
Q

MILD RFs for Preeclampsia

A

obesity
nulliparity
advanced maternal age

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74
Q

Preeclampsia features + tonic-clonic seizures

A

Eclampsia

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75
Q

Goal BP for Preeclampsia/Eclampsia Tx

A

140-150/90-100

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76
Q

MDXs for MAINTENANCE THERAPY for BP Control in Preeclampsia/Eclampsia

A

“Hypetensive Moms Love Nifedipine”

First line = Methyldopa, Labetalol
Second line = nifedipine (slow onset; sedative at high doses)

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77
Q

MDXs for ACUTE BP Control in SEVERE Preeclampsia/ Eclampsia

A

IV hydralazine or labetalol

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78
Q

MDX for Seizure management in Eclampsia

A

IV MgSO4

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79
Q

Signs of MgSO4 toxicity (3)

Tx

A

respiratory depression
loss of DTRs
cardiac arrest

Tx: stop Mg and give calcium gluconate

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80
Q

ABSOLUTE TX for SEVERE Preeclampsia or Eclampsia (at any gestational age)

A

Delivery (≥ 34 wks if severe preeclampsia; ≥ 37 wks if mild preeclampsia)

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81
Q

Who gets HELLP syndrome? and when?

A

Preeclamptic pts get HELLP

In 3rd trimester OR 2 days after delivery

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82
Q

TX for HELLP

A

Immediate delivery (regardless of gestational age)

  • IV MgSO4 for seizure ppx
  • IV corticosteroids when PLTs < 100,000 (keep giving until PLTs > 100,000)
    • -> needed for lung maturation if <36 wks gestation
  • PLT transfusion if PLTs <20,000 (if C-section being performed, transfuse if PLTs < 50,000)
  • BP ≥160/110 = IV hydralazine
83
Q

Most dangerous cardiac D in preg pt

A

2 = Eisenmenger syndrome

Peripartum cardiomyopathy (EF < 45%)

84
Q

When do you get peripartum cardiomyopathy?

SXs

A

Last month of preg to 5 months postpartum

SXs: SOB, edema, palpitations, fatigue

85
Q

5 yr mortality rate in peripartum cardiomyopathy

A

50%

LV dysfxn reversible and short term (if doesn’t improve need cardiac transplant)

86
Q

Tx for peripartum cardiomyopathy

A

Same as dilated cardiomyopathy

- ACE-inh, ARBs, B-blockers, spirinolactone, diuretics, digoxin

87
Q

Pts with DVT/PE in prev preg or h/o underlying thrombophilic condition get PPX w/ what?

A

LMWH throughout preg AND warfarin 6 wks postpartum

88
Q

Maternal thyroid changes in 1st trimester of preg

A

↓ TSH (best initial screening test)
↑ Total T4 (b/c of ↑ TBG) –> preferred over free T4
N Free T4

89
Q

HYPERthyroidism in preg causes what?

A

IUGR

still birth

90
Q

HYPOthyroidism in preg causes what?

A

Intellectual deficits

Miscarriage

91
Q

Hormone replacement (T4) in pts w/ HYPOthyroidism during preg

A

INCREASE dose of thyroid hormones by 25-30%

92
Q

Drug of choice for symptomatic HYPERthyroidism

A

B-blockers

1st trimester: PTU
2nd/3rd trimester: methimazole

CI in preg = radioactive iodine

93
Q

Neonatal thyrotoxicosis - Definition AND SXs

A

maternal anti-TSH receptor Abs bind to fetal TSH receptors = increased TH release

SXs:

  • fetal tachycardia
  • goiter
  • growth restriction
  • poor feeding
  • warm, moist skin
94
Q

TX for Neonatal thyrotoxicosis

A

Resolves spont in 3 mo after mom’s Abs gone

95
Q

Target glucose levels for preg pt w/ Gestational DM

A

FBS ≤ 95
1 hr after meal ≤ 140
2 hr after meal ≤ 120

96
Q

Tx of gestational DM

A

First line: diet and exercise
Second line: Insulin (can use metformin and glyburide as well); d/c insulin after delivery

Order 2 hr 75g OGTT 6-12 weeks postpartum to determine if DM resolved

97
Q

When do you start weekly NSTs and AFI (via U/S and BPP) in pt with gestational DM?

A

32 weeks

27 weeks if pt has poor glycemic control or small vessel disease present

98
Q

Insulin requirements during preg

A

Increased during preg
Decrease after preg (Pts w/ DM I/II require 1/2 of their pregnancy insulin in postpartum period)

During delivery, give 5% dextrose in water + insulin drip
Turn off insulin infusion after delivery –> maintain gluc levels w/ sliding scale insulin

99
Q

Target delivery gestational age in pts w/ gestational DM

A

39 wks (after this, induce labor)

100
Q

Indication for C-section in pt w/ gestational DM

A

fetus >4500 g

101
Q

L/S ratio of fetal lung maturity

102
Q

Complication of Appendicitis in 1st, 2nd and 3rd Trimester?

A

1st: abortion (1/3 of pts)
2nd: premature delivery (14% pts)
3rd: If appendix PERFORATED –> fetal death, abscess formation and pylephlebitis (infectious thrombosis of portal veins)

103
Q 
Intractable noctural pruritus on palms/soles w/out rash
common in European women 
Associated w/ multiple pregnancies 
Increased bile acids 
Increased LFTs 
Jaundice
A

Intrahepatic Cholestasis of Pregnancy

104
Q

Tx of Intrahepatic cholestasis of preg

Complication

A

ursodeoxycholic acid or cholestyramine for sxs relief
delivery at 37 wks

Complication: risk of intrauterine demise

105
Q

Tx of asymptomatic bacteriuria or acute cystitis during preg

A

First line: PO nitrofurantoin x 7 days (repeat cx 1 wk after tx)
Second line: Cephalexin or amoxocillin

Don’t use bactrim in 1st or 3rd trimester

106
Q

Complications of asymptomatic bacteriuria/ acute cystitis/ pyelonephritis during preg

A

preterm birth
low birth weight
ARDS

107
Q

Tx of pyelonephritis during preg

A

Hospitalize, IVFs, IV ceftriaxone, tocolysis

  • -> after afebrile for 48 hrs, switch to PO ABXs for 10-14 days
  • -> after tx completion, pt gets daily ppx w/ either PO nitrofurantoin or cephalexin
  • -> ppx continued until 6 wks postpartum
108
Q

Safe vs unsafe SSRIs in pregnancy

A

SAFE: sertraline, fluoxetine
UNSAFE: paroxetine

109
Q

focal pruritus (eg. abd); no rash
no increase in bile acids
mild increased in LFTs

A

Pregnancy Induced Skin Changes

TX: expectant management, oatmeal baths, UV light, antihistamines

110
Q

pruritic, red papules that begin w/in abd striae and spread to extremities
face, palms/soles, periumbilical region spared
happens in 3rd semester or postpartum

A

Polymorphic Eruption of Pregnancy

111
Q

disseminated eczematous or papular rash in pts w/ h/o atopy (eg. seasonal allergies, atopic dermatitis)

A

Atopic Eruption of Pregnancy

112
Q

Acute Fatty Liver of Pregnancy

A

Happens in 3rd trimester or postpartum

RUQ pain 
N/V
malaise
↑ LFTs, ↑ bilirubin 
↓ glucose 
possible DIC 
Risk of hepatic coma
113
Q

Tx of acute fatty liver of pregnancy

Prognosis

A

IVFs
Glucose
FFP (no Vit K b/c liver not working)

Prognosis: If pt survives, liver dysfxn will resolve on its own

114
Q

red plaques surrounded by sterile pustules that spread outward in flexural regions
no itching

A

Pustular Psoriasis of Pregnancy (Impetigo Herpetiformis)

115
Q

get pruritus then truncal rash
periumbilical urticarial papules and plaques that develop into bullae and vesicles
rash spreads over entire body but spares mucous membranes

A

Pemphigoid Gestationis (Herpes Gestationis)

In 2nd/3rd trimester
Autoimmune disorder

116
Q

Dx and Tx of Pemphigoid Gestationis

A

DX: clinical but can be confirmed w/ skin bx

TX:
high potency topical steroids (triamcinolone)
antihistamines

117
Q

Prognosis and complications of Pemphigoid Gestationis

A

Prognosis:
Resolves after delivery but increased risk of recurrence w/ subsequent pregn

Complications:
prematurity
IUGR
neonatal Pemphigoid Gestationis

118
Q

woman w/ strong desire to be pregnant comes w/ all sxs of pregnancy but U/S is normal and preg test is (-)

A

Pseudocyesis

Need psych evaluation and tx

119
Q 
pt w/ ≥ 2 first trimester abortions 
thromboses 
assoc w/ SLE 
false + VDRL/RPR 
↓ PLTs 
↑ PTT
N PT and INR
A

Antiphospholipid Syndrome

Abs = anticardiolipin and lupus anticoagulant

120
Q

Dx of Antiphospholipid Syndrome

A

Initial test: Mixing study (PTT doesn’t correct b/c of Ab)

Most specific: Russell viper venom test (prolonged)

121
Q

Tx for Antiphospholipid Syndrome

A

Asymptomatic Ab found = no tx

DVT/PE = Heparin

122
Q

PLTs 70,000 to 150,000
no h/o thrombocytopenia
no assco w/ fetal thrombocytopenia

A

Gestational Thrombocytopenia

resolves after delivery (reevaluate postpartum to ensure resolution)

123
Q

Gradually worsening headache (worse w/ awakening and Valsalva like maneuvers - cough, sneeze)
focal deficits (hemiparesis)
seizures
confusion

Assoc w/ pregnancy, combined OCPs, malignancy, infxn, head trauma

A

Cerebral Venous Sinus Thrombosis

Life threatening –> formation of bld clot in dural sinuses which drain CSF and venous bld from brain = signs of increased ICP

124
Q

Dx of Cerebral Venous Sinus Thrombosis

A

MRI brain w/ magnetic resonance venography

125
Q

Tx for Cerebral Venous Sinus Thrombosis

CI

A

LMWH

No increased risk of brain hemorrhage w/ this tx

CI: labor induction CI b/c it increases ICP and risk of intracranial hemorrhage

126
Q

MDXs for medical abortion

A 
PO mifepristone (progesterone antagonist) 
PO misoprostol (prostaglandin E1 analogue)
127
Q

U/S Finding:
no products of conception
cervix closed

A

Complete Abortion

TX: f/u w/ B-hCG

128
Q

U/S Finding:
some products of conception present
cervix closed

A

Incomplete Abortion

TX: D&C

129
Q

U/S Finding:
products of conception present
cervix dilated
intrauterine bleeding

A

Inevitable Abortion

TX:
medical induction (if pt stable and minor bleeding) OR
D&C (if pt unstable and actively bleeding)

130
Q

U/S Finding:
products of conception present
cervix NOT dilated
intrauterine bleeding

A

Threatened Abortion

TX: bed rest (no hospitalization req’d)

131
Q

U/S Finding:
Fetus dead but in uterus
cervix closed
no bleeding

A

Missed Abortion

TX: medical induction or D&C

132
Q 
U/S Finding: 
retained products of conception 
increased vascularity 
echogenic material in cavity 
thick endometrial stripe
A

Septic Abortion

TX: D&C + IV levofloxacin + metronidazole

133
Q

fever
chills
lower abd pain
bloody or purulent foul-smelling vaginal d/c
boggy and tender uterus w/ dilated cervix

A

Septic Abortion

RF: h/o elective abortion in non-sterile setting (not hospital)

134
Q

Complication of fetal demise and management

A

DIC

After dx of fetal demise, get coagulation profile –> if values are low-normal, suspect coagulopathy = DELIVER ASAP
If values normal, wait or induce labor

135
Q

When can you see intrauterine pregnancy on transvaginal vs abdominal U/S (at what B-hCG levels)?

A

Transvaginal U/S –> B-hCG >1500

Abdominal U/S –> B-hCG >6500

136
Q 
amenorrhea
U/L lower abd pain or pelvic pain 
vaginal bleeding 
adnexal mass
hypotension, tachycardia, abd rigidity/guarding
A

Ectopic Pregnancy

Signs of rupture = hypotension, tachycardia, abd rigidity/guarding

137
Q

what is B-hCG is <1500, how do you manage?

A

wait 48-72 hrs and measure B-hCG again (appropriate rise is ≥ 35% every 48 hrs)

B-hCG decreased = failed preg (f/u hCG until it’s zero)
B-hCG increased appropriately = do transvaginal U/S when it’s > 1500
B-hCG increased inappropriately= D&C
–> (-) chorionic villi = ectopic
–> (+) chorionic villi = failed intrauterine preg

138
Q

Management if pt has B-hCG <1500 but signs of ruptured ectopic preg

A

Laparatomy (don’t wait for B-hCG to be > 1500)

139
Q

Tx for unruptured ectopic preg

A

methotrexate OR laparoscopy

140
Q

RFs for cervical insufficiency

A 
h/o preterm birth 
h/o 2nd trimester abortion 
h/o cervical surgery (LEEP or cone bx) 
h/o deep cervical laceration 
uterine abn (septate uterus, bicornuate uterus)
DES exposure
141
Q

Cervical insufficiency management

A

Elective cerclage placement –> weeks 14-16 (esp. w/ h/o previous unexplained miscarriages)

Urgent cerclage ONLY AFTER labor and chorioamnionitis ruled out AND there is cervical dilation

Remove cerclage –> weeks 36-37 (after lung maturity)

142
Q

preg woman w/ NO previous h/o preterm birth is found to have short cervix (≤ 2 cm) in 2nd trimester U/S–> what to do?

A

get serial transvaginal U/S during 2nd trimester to keep eye on cervical length and to evaluate for cervical dilation

can also give vaginal progesterone to prevent preterm birth

143
Q

preg woman w/ previous h/o preterm birth is found to have short cervix –> what to do?

A

elective cerclage placement

144
Q

Pt at 28 wks gestation has contractions and cervical dilation

A

preterm labor

145
Q

pt at 28 wks gestation has painless cervical dilation but NO contractions or signs of labor

A

cervical insufficiency/ incompetence

146
Q

tools used to assess for risk of preterm birth

A

U/S for cervical length AND fetal fibronectin (if + = increased risk of birth in next 2 wks)

147
Q

Preterm labor management in following gestational wks:

1) 24-33 wks
2) 34- 36 6/7 days
3) 37 wks

A

1) betamethasone, tocolytics; if pt also <32 wks then give MgSO4 (for protection against cerebral palsy)
2) betamethasone
3) deliver

148
Q

Examples of tocolytics (4)

A
  • Indomethacin (use only if <32 wks gestation)
  • MgSO4 (CI in myesthenia gravis)
  • CCBs (eg. nifedipine)
  • Terbutaline (beta adrenergic receptor agonist) –> can cause pulm edema
149
Q

Causes of symmetric IUGR (all body parts decreased in measurement)

IUGR means weight <2500 g

A

Fetal causes (early in preg) –> intrinsic factors

  • aneuploidy
  • infection (eg. TORCH)
  • structural anomalies (eg. CHD, NTD)
150
Q

Causes of asymmetric IUGR (abd small, head normal)

A

Maternal or placental causes (late in preg) –> extrinsic factors

  • preeclampsia/ HTN
  • DM
  • tobacco, alcohol, drug use
  • SLE, antiphospholipid sydrome
  • malnutrition
  • placental abruption/ infarction
151
Q

Next step if suspect macrosomia

152
Q

Indication for C-section in macrosomia

A

weight >4500g in DM pt OR

weight >5000 in non-diabetic pt

153
Q

Definition and causes of oligohydraminos

A

Defn: AFI <5cm

Causes:

  • renal anomalies (Potter’s syndrome)
  • NSAIDs (decrease renal bld flow = oliguria)
  • uteroplacental insufficiency
  • preeclampsia
  • abruptio placenta
154
Q

Definition and causes of polyhydraminos

A

Defn: AFI ≥ 24cm

Causes:

  • esophageal/duodenal atresia
  • anencephaly (abn fetal swallowing)
  • congenital infxn (eg. parvovirus)
  • DM
  • multiple gestation
155
Q
  • pooling of clear amniotic fld in posterior fornix
  • fld is nitrazine positive
  • fld is ferning positive
A

Premature Rupture of Membranes (PROM)

156
Q

what to do if Biophysical Profile is abnormal (score <4)?

A

Do contraction stress test

  • -> give oxytocin and measure fetal heart strip
  • -> helps to identify uteroplacental dysfxn
157
Q

Complication of PROM

A

Chorioamnionitis

158
Q

SXs of Chorioamnionitis

A 
Maternal fever and tachycardia 
uterine tenderness 
increased WBCs
fetal tachycardia 
foul odor of amniotic fld
159
Q

Tx of Chorioamnionitis

A

Get cervical cx
IV ABXs (ampicillin + gentimicin)
Deliver baby

160
Q

Stages of Labor and Normal Duration of Each Stage

A

Stage 1 (latent phase - effacement): 0-6cm dilation

  • -> Primipara: <20 hrs
  • -> Multipara: <14 hrs

Stage 1 (active phase - dilation): 6-10cm dilation

  • -> Primipara: >1.2 cm/hr
  • -> Multipara: >1.5 cm/hr

Stage 2 (descent): delivery of baby

  • -> Primipara: <3 hrs (w/ epidural = <4 hrs)
  • -> Multipara: <2 hrs (w/ epidural = <3 hrs)
Stage 3 (expulsion): delivery of placenta 
--> <30 min
161
Q

Dx and Tx of Prolonged Latent Phase

A

no cervical change in 20 hrs (primipara) or 14 hrs (multipara); common cause = analgesia

Tx: rest and hydration

162
Q

Dx of Prolonged Active Phase

A

cervical dilation of less than <1.2cm/hr (primipara) or <1.5cm/hr (multipara)

163
Q

Dx of Arrest of Active Phase

A

no cervical change in ≥ 2 hrs despite adequate contractions

164
Q

Tx of Prolonged/Arrest of Active Phase

A

If contractions NOT adequate –> give IV oxytocin
If contractions TOO many –> morphine sedation

If contractions adequate and still no dilation –> Emergency C-section

165
Q

Dx of Arrest of Second Stage

A

No delivery w/in 3 hrs (primipara) or 2 hrs (multipara) after full cervical dilation; cause = 3 P’s –> power, passenger, pelvis

166
Q

Tx of Arrest of Second Stage

A

fetal head engaged –> try forceps or vacuum

fetal head NOT engaged –> Emergency C-section

167
Q

Dx and Tx of Arrest of Third Stage

A

no delivery of placenta w/in 30 min

Tx: IV oxytocin –> if it fails, try manual extraction –> worst case = hysterectomy

168
Q

MDXs that Induce Labor

A

Dinoprostone (prostaglandin E2 analog)
Misoprostol (prostaglandin E1 analog)

SE of both MDXs = bronchospasm so don’t give to asthma pts

169
Q

MDXs that Augment Labor

A

Oxytocin
Amniotomy (artificial ROM)
Foley Balloon

170
Q

Tx for Umbilical Cord Prolapse

A

Immediate C- section

171
Q

Dx and Cause of Early Decelerations

A

Gradual decreases in FHR beginning and ending simultaneously w/ contractions

Fetal head compression

http://www.rahulgladwin.com/noteblog/obgyn/early-decelerations.png

172
Q

Dx and Cause of Variable Decelerations

A

Abrupt decreases in FHR that are UNRELATED w/ contractions

Umbilical cord compression
Indicate fetal acidosis

http://www.rahulgladwin.com/noteblog/obgyn/variable-decelerations.png

173
Q

Two Categories of Variable Decelerations and Tx

A

Severe variable decelerations –> accompany ≥ 50% contractions
—>TX: O2, change maternal position, amnioinfusion

Intermittent variable decelerations –> accompany <50% contractions
—>TX: nothing

174
Q

Dx and Cause of Late Decelerations

A

Decrease in FHR AFTER contraction started

Uteroplacental insufficiency
Indicate fetal acidosis

http://www.rahulgladwin.com/noteblog/obgyn/late-decelerations.png

175
Q

Tx for Non-reassuring Fetal Tracings

A

D/c MDXs (eg. oxytocin)
IVFs
O2
Change mom’s position (left lateral)

If nothing above works –> prepare for delivery

176
Q

PPX for woman w/ previous h/o genital herpes

A

Acyclovir at 36 wks gestation

177
Q

Optimum time for External Cephalic Version

A

37 wks gestation (if doesn’t work –> C-section)

Before 37 wks, do nothing –> baby will move own it’s own to cephalic position

178
Q

MCC of postpartum hemorrhage

A

Uterine atony (enlarged, boggy uterus)

179
Q

Tx for Uterine Atony

A 
Uterine massage AND 
Uterotonic agents: 
--> oxytocin
--> misoprostol (HTN is NOT CI) 
--> methylergonovine (causes vasospasm); CI = HTN and scleroderma 
--> carboplast (prostaglandin F2 alpha analog); CI = HTN
Intrauterine balloon tamponade 
Uterine A embolization 
Hysterectomy
180
Q

2 other common causes of postpartum hemorrhage

A

Lacerations (see enlarging hematoma)

Retained products of conception/ placenta (tx w/ manual extraction or uterine curretage)

181
Q

lower abdominal pain
round mass protruding through cervix
can’t palpate uterine fundus
hemorrhagic shock

A

Uterine Inversion

182
Q

Tx of Uterine Inversion

A
  • IVFs
  • manual replacement of uterus (need relaxed uterus so stop oxytocin) –> if doesn’t work give uterine relaxants (NG, terbutaline) and try again
  • laparotomy (if manual replacement fails)
  • placental removal and uterotonic drugs after uterus replacement
183
Q

postpartum mom develops:

  • sudden SOB
  • hypotension
  • tachypnea
  • chest pain
  • DIC
A

Amniotic Fld Embolism

TX: CPR

184
Q

Postpartum mom who had postpartum hemorrhage presents w/:

  • inability to breastfeed (no breast milk produced)
  • amenorrhea
  • loss of pubic hair
  • weight gain
  • fatigue
  • hypotension, hypo Na+
A

Sheehan Syndrome (ischemic necrosis of anterior pituitary)

185
Q

Tx for Sheehan Syndrome

A

Estrogen and progesterone replacement

Thyroid and adrenal hormone supplementation

186
Q

Postpartum Contraception in breastfeeding mom

A

Doesn’t need contraception till 3 mo after delivery
DO NOT use combined OCPs b/c they decrease lactation
Progestin ALONE safe during breastfeeding

187
Q

CIs to breastfeeding

A 
HIV 
active TB 
active herpes lesions on breast 
Galactosemia in baby 
active substance use 
receiving chemo
188
Q

breastfeeding decreases risks of which cancers?

A

breast and ovarian

189
Q 
Postpartum period: 
high fever
uterine tenderness 
foul smelling lochia 
purulent vaginal d/c
tachycardia
A

Endometritis (polymicrobial infxn)

190
Q

RFs for Endometritis

A

C-section
PROM
many vaginal exams

191
Q

TX of Endometritis

A

IV gentimicin + clindamycin

Continue until pt afebrile for ≥ 24 hrs

192
Q

Postpartum period:
Persistent fever even w/ ABXs
H/o prolonged labor

A

Septic Thrombophlebitis

193
Q

Tx for Septic Thrombophlebitis

A

IV Heparin x 7-10 d

194
Q

Postpartum period:
U/L breast tenderness
Breast erythema and edema
H/o nipple cracking and trauma

A

Infectious mastitis

Cause: S. aureus from baby’s mouth

195
Q

Tx for Infectious mastitis

A

PO oxacillin or dicloxacillin or cephalexin
Continue breastfeeding

If ABXs don’t help or get breast induration/fluctuant mass = breast abscess (get U/S and then I&D)

196
Q 
Postpartum period: 
Low grade fever 
B/L breast tenderness 
Breasts warm to touch 
H/o baby not feeding well
A

Breast engorgement

197
Q

Tx for Breast engorgement

A

NSAIDs
Cold compresses
Breast pumping

198
Q

Physiologic Changes in Pregnancy - CARDIOLOGY

A

↑ CO

↓ SVR

199
Q

Physiologic Changes in Pregnancy - PULMONOLOGY

A

↓ total lung capacity (b/c of diaphragm elevation)

↑ minute ventilation (from ↑ tidal volume) = compensated Resp. Alkalosis

200
Q

Physiologic Changes in Pregnancy - GI

A

Morning sickness
GERD b/c stomach pushed by uterus
Constipation

201
Q

severe, persistent vomiting
ketosis, dehydration
weight loss ≥ 5% of pre-preg weight

A

Hyperemesis Gravidarum

RFs: Previous hyperemesis gravidarum, molar pregnancy, multiple gestations

TX: IVFs, electrolyte replacement, antiemetics

202
Q

Physiologic Changes in Pregnancy - ENDOCRINE

A

↑ TBG (↑ total T3/T4, N free T3/T4)
↓ TSH
↑ estrogen

203
Q

Physiologic Changes in Pregnancy - RENAL

A

↑ risk of pyelonephritis (b/c uterus compresses ureters)

↑ GFR (b/c of ↑ plasma volume) = ↓ BUN/Cr

204
Q

Physiologic Changes in Pregnancy - HEMATOLOGY

A

Dilutional anemia (b/c of ↑ plasma volume)

  • 1st/3rd semester: Hg 11
  • 2nd semester: Hg 10.5
↑ RBCs
↑ WBCs (from preg stress and labor) 
↓ PLTs
↑ Coagulation factors 
N PT/PTT/INR/bleeding times 
↑ ESR 
↑ Alkaline phosphotase

USMLE Step 3 - ALL (9 decks)

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