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OB Flashcards

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1
Q

Discriminatory zone

A

b-hCG 1500-2000 - 5 weeks

when gestational sac should be visible on TVUS

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2
Q

Naegele’s rule

A

1st day of LMP + 7 days - 3 mo + 1 yr

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3
Q

Gs and Ps

A 
G - number pregnancies
P - number of births
-F - term births
-P - preterm births less than 37 wks
-A - abortions before 20 weeks
-L - living children
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4
Q

Physiologic changes in pregnancy

A

BMR increases 10-20% - need 100-300 more calories/day

Plasma volume increases 30-50%, RBC mass increases 20-30%

  • > physiologic anemia
  • > systolic murmur, S3

Cardiac output increases 30-50%

BP decreases in early pregnancy -> nadir at 24-26 wks, return to normal by term

Relaxation of the lower esophageal sphincter -> GERD

Increase GFR -> decreased BUN and Cr

Increased procoagulation factors -> hypercoaguable state through first few weeks postpartum

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5
Q

Age of viability

A

24 weeks

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6
Q 
Wt gain in pregnancy - 
Underweight - BMI less than 18.5
Normal 
Overweight (BMI 25-29.9)
Obese (BMI >30)
A

Under - 28-40
Normal - 25-35
Overwt - 15-25
Obese - 11-20

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7
Q

Chorionic villus samping

A

10-13 weeks

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8
Q

Quad screen, amniocentesis

A

15-20 weeks

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9
Q

Screen for gestational diabetes

A

24-28 weeks

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10
Q

Administer anti-D immune globulin in Rh(D) negative

A

28 weeks

Or anytime risk fetomaternal hemorrhage

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11
Q

Screen for group B strep

A

35-37 weeks

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12
Q

Check for lung maturity

A

Lecithin-Splingomyelin ratio >2:1

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13
Q

Fetal alcohol syndrome

A

Dysmorphic facial features: short palpebral fissures, smooth philtrum, thin vermillion border
growth retardation
CNS abnormalities: microcephaly, intellectual deficits, behavioral problems, Learning disabilities (MC cause), impaired executive functioning

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14
Q

Hyperemesis gravidarum

A

N/V severe enough to cause wt loss of more than 5% of prepregnancy wt, dehydration, ketosis, and/or abnormal labs

Vitals: Weight, HR, orthostatic blood pressure
-tachycardia and hypotensive with dehydration

Labs:
hypokalemic, hypochloremic, metabolic alkalosis
Ketonuria

U/S: r/o gestational trophoblastic disease and multiple gestation -> higher level of hormones

Tx:
IVF
Electrolyte and thiamine repletion
Antiemetics
NG tube feeds, parenteral nutrition
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15
Q

Infant complications in pre-gestational diabetes

A 
Spontaneous abortion/stillbirth
Macrosomia
Neonatal hypoglycemia
Congenital malformations
-cardiac defects
-caudal regression syndrome - sacral agenesis
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16
Q

Maternal complications in pre-gestational diabetes

A

Preeclampsia
Polyhydramnios
DKA
Worsening of retinopathy, nephropathy

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17
Q

Management of pre-gestational diabetes

A

HgbA1c, urine protein:Cr, ECG, dilated eye exam
Insulin
DM diet - monitor glucose

2nd trimester: US and fetal echo

3rd trimester: fetal surveillance, US: look for macrosomia

Consider C/S if EFW more than 4500g
Induction at 39-40 weeks

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18
Q

Infant complications in gestational diabetes

A

still birth
macrosomia
neonatal hypoglycemia

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19
Q

Maternal complications in gestational diabetes

A

preeclampsia

polyhydramnios

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20
Q

Management of A1 diabetes in pregnancy

A 
diet/exercise
3rd trimester US
consider C/S if EFW more than 4500 g
Induction at 40-41 weeks
Post partum OGTT - 2 hour, 75 g
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21
Q

Management of A2 diabetes in pregnancy

A 
Insulin
3rd trimester fetal surveillance, US
Consider C/S if EFW more than 4500 g
Induction at 39 weeks
Post partum OGTT
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22
Q

Asx bacteriuria in pregnancy

A

screen of Ucx at first visit

treat positive Ucx
-PO: 
nitrofurantoin (MC)
amoxicillin
Cephalexin
Fosfomycin

Repeat Ucx 1 week after completion

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23
Q

Cystitis in pregnancy

A

S/S:
Dysuria, frequency, urgency
Suprapubic pain
Hematuria

UA: bacteriuria, pyuria, leukocyte esterase, nitrate
+ UCx

-PO: 
nitrofurantoin (MC)
amoxicillin
Cephalexin
Fosfomycin

Repeat Ucx 1 week after completion

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24
Q

Pyelonephritis in pregnancy

A

Risk: progesterone -> smooth muscle relaxation -> dilation of ureters

S/S:
Dysuria, frequency, urgency
Suprapubic pain
Hematuria
Fever/chills
N/V
Flank pain
CVA tenderness
Pulmonary edema -> SOB

UA: bacteriuria, pyruia, leukocyte esterase, nitrite, WBC casts
Positive UCx

Tx:
Admit
IV Abx:
ampicillin + gentamicin
Ceftriaxone
Meropenem
Pip-tazo

Suppresive therapy remainder of pregnancy

Complications:
Preterm birth
Sepsis -> septic shock
ARDS
Maternal death
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25
Q

HELLP syndrome

A

Hemolysis, elevated liver enzymes, low platelets

pre-eclampsia + RUQ pain + bleeding

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26
Q

Amniotic fluid embolism

A

Amniotic fluid enters maternal circulation -> CV collapse, possible death

Features:
Hypotension - cardiogenic shock
Respiratory failure
Unresponsiveness
Excessive/prolonged bleeding (DIC)
(looks like PE with DIC)

Occurs during Labor and delivery or a immediately postpartum

Dx of exclusion

Tx: ACLS protocols

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27
Q

Toxoplasmosis

Historical clues:
Infant findings:

A

Historical clues:

  • exposure to cat feces
  • ingestion of undercooked meat

Infant findings:

  • chorioretinitis
  • intracranial calcifications (diffuse)
  • hydrocephalus (big head)

Tx: spiramycin
After 18 weeks: Pyrimethamine + sulfadiazine + folinic acid

pre-pregnancy infection offers immunity if reinfected during pregnancy

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28
Q

CMV

Historical clues:
Infant findings:

A

Historical clues: mono-like illness in mom

Infant findings:

  • sensorineural hearing loss
  • intracranial calcifications (periventricular)
  • Microcephaly (small head)

MC congenital infection

No immunity from prior infection

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29
Q

Rubella

Historical clues:
Infant findings:

A

Historical clues:
Maternal infection - mild fever and rash - starts in and face and spreads to trunk/extremities
ppx - MMR virus - contraindicated 1 mo prior to conception and during pregnancy

Infant findings:

  • sensorineural hearing loss
  • cataracts
  • patent ductus arteriosus
  • pulmonary artery stenosis
  • “blue berry muffin” rash
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30
Q

Parvovirus B19

Historical clues:
Infant findings:

A

Historical clues:
Maternal infection - fever and “slapped cheek” rash; arthritis

Infant findings:

  • severe anemia
  • cardiac failure
  • hydrops fetalis

tx:
Serial U/S
Intrauterine blood transfusion

Prior infection offers immunity

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31
Q

Listeriosis

Historical clues:
Infant findings:

A

Historical clues: deli meats; mom infection - flu-like illness

Infant findings:

  • granulomatous infantiseptica - rash, (widespread internal abscesses)
  • stillbirth

Dx: blood culture

Tx: ampicillin + gentamicin
or TMP-SMX

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32
Q

Early manifestations of congenital syphilis

A

First two years of life

Hepatomegaly, elevated LFTs
Disseminated maculopapular rash involving soles
Blood tinged nasal secretions - snuffles
Meningitis
Skeletal abnormalities of long bones
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33
Q

Late manifestations of congenital syphilis

A

After first two years of life

Interstitial keratitis –> corneal scarring -> blindness
Sensorineural hearing loss
Facial abnormalities- frontal bossing, saddle nose
Hutchinson teeth - notching up teeth
Perforation of hard palate
Anterior bowing of tibia - saber shins

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34
Q

Varicella-zoster virus - maternal vs fetal vs neonatal infection

A

Maternal infection: chickenpox rash, pneumona

Fetal infection:
scarring of kin in dermatomal pattern
CNS abnormalities
Chorioretinitis
Limb hypoplasia

neonatal infection:
chickenpox rash, disseminated disease
-high mortality - 30%

Tx:
Maternal exposure - varicella IG
Maternal infection - acyclovir, +PNA -> hospitalize
Maternal infection around delivery -> acyclovir + VZV IG to infant
Neonatal infection -> acyclovir

35
Q

HSV neonatal infection

A 
vesicular skin rash
Conjunctivitis
meningoencephalitis
Disseminated disease - sepsis, hepatitis, pneumonia
Untreated mortality 80%
36
Q

Group B strep

A

Vertical transmission -> sepsis, PNA, meningitis

Screen 35-37 weeks

Intrapartum ppx:
PCN G or ampicillin
allergy minor - cefazolin
risk of anaphylaxis - clindamycin insensitive, vancomycin if resistant

37
Q

Ectopic pregnancy

A 
Features:
Amenorrhea
vaginal bleeding
Ipsilateral abdominal pain
Referred pain to shoulder
urge to defecate - d/t pooling of blood in Pouch of Douglas
Dizziness, LOC
Abdominal tenderness
Adnexal mass
Rebound tenderness, guarding - if ruptures

Stable - methotrexate, monitor bhCG to zero

Unstable - ABCs, immediate surgical management

38
Q

Cervical insufficiency

A

Painless cervical dilation -> 2nd trimester loss

Dx: exam and U/S - cervical length less than 25 mm

Tx: cerclage

Associated with: Ehler’s danlos, previous trauma, LEEP

39
Q

Intrauterine fetal demise (IUFD)

A

after 20 weeks

Causes:
Fetal chromosome abnormality or congenital anomalies
Abnormal placenta or umbilical cord
Placental abruption
Rh alloimmunization
Congenital infections
Maternal complications - HTN, DM
idiopathic

Tx:
Expectant management
D&E
Induce labor - misoprostol, oxytocin

Risk DIC if wait

40
Q

Intrauterine growth restriction (IUGR)

A

Fetal wt less than 10th percentile for GSA

Causes:
Chromosomal/ congenital
Multiple gestations
TORCH infections
Placental abnormalities
low uteroplacental blood flow - HTN, DM, SLE
Low pre-pregnancy BMI
Poor wt gain during pregnancy
smoking - esp 3rd trimester
Cocaine use
Teratogens

Symmetric - entire body small - early insult
Asymmetric - small abd, normal head - late insult

Dx: U/S

Tx: serial U/S
Fetal surveillance
early delivery

41
Q

Macrosomia

A

EFW > 4500g

Risk:
Advanced maternal age
Hi prepregnancy BMI
Excessive weight gain
Post term
Maternal diabetes

Dx: U/S

Complications:
Shoulder dystocia, birth trauma
Postpartum hemorrhage
C/S
Future increased risk of metabolic syndrome

Tx: C/S if EFW >5000 g (or >4500 g in DM pt)

42
Q

Causes of oligohydramnios

A

less than 5 cm amniotic fluid index

Placental insufficiency
Obstructed urine flow - posterior urethral valves-males
B/L renal agensis -> Potter sequence

Tx: amnio infusion

43
Q

Potter Sequence

A

“POTTER”

Pulmonary hypoplasia
Oligohydramnios
Twisted skin (wrinkled skin)
Twisted face (facial deformities)
Extremities (limb deformities)
Renal agenesis
44
Q

Causes of polyhydramnios

A

> 24 cm amniotic fluid index

esophageal/duodenal atresia
Anencephaly
Multiple gestation
Uncontrolled maternal diabetes
Congenital infections - parvovirus B19
Fetal anemia d/t RH alloimmunization

Tx: amnioreduction
Indomethacin (decrease renal a. flow)
-risk early PDA, limit to short term use, not in 3r trimester

45
Q

Accelerations - fetal heart rate tracing

A

Increases of heart rate of more than 15 bpm for more than 15 seconds

46
Q

Normal (reactive) nonstress test

A

At least 2 accelerations in 20 minutes - 15x15

if less than 32 weeks - 10x10

47
Q

Biophysical profile

A 
Nonstress test
Amniotic fluid volume
Fetal breathing
Fetal movement
Fetal tone - flexion and extension

score 2 if normal, 0 if abnormal
total of 8-10 reassuring

48
Q

Early deceleration

A

mirrors contraction - nadir with nadir

head compression

49
Q

Variable deceleration

A

V shaped
no relationship to contraction

umbilical cord compression

50
Q

Late deceleration

A

U shaped
FHR nadir after contraction nadir

uteroplacental insufficiency
Fetal hypoxia

51
Q

Sinusoidal pattern to FHR

A

severe fetal anemia

52
Q

management of non-reassuring FHR tracing

A

administer maternal O2, turn to left lateral decubitus

DC oxytocin, consider correction of hyperstimulation (tocolytic)

IVF bolus

Sterile vaginal exam - check for cord prolapse

Consider immediate delivery - C/S

53
Q

Twin to twin transfusion syndrome

A

complication of monochorionic twin pregnancies

Vascular anastomoses link the fetal circulations -> blood from one twin flows to the other twin

Donor twin - anemia, growth restriction, oligohydramnios

Recipient twin: polycythemia, volume overload, heart failure, polyhydramnios

54
Q

Erythroblastosis fetalis

A

Rh(D) negative mom with IgG antibodies against Rh(D)

Ab cross placenta, attack fetal RBCs -> hemolytic disease of fetus

55
Q

Hydatidiform mole (molar pregnancy)

A

S/S:
Amenorrhea, positive pregnancy test, S/S of pregnancy
Vaginal bleeding
Pelvic pain/pressure
Uterine size does not match gestational age
Hyperemesis gravidarum
hyperthyroidism - hCG activates TSH receptor
preeclampsia before 20 weeks
passage of tissue with grapelike appearance

Dx:
Quant hCG
US: snowstorm - abnormal or absent fetus
-Theca-lutein ovarian cysts

Tx: D&C
follow hCG to zero
Wait at least 6 months before trying to conceive- to detect recurrence

56
Q

Choriocarcinoma

A

Malignant form after gestational trophoblastic disease

  • half arise from complete moles
  • SBAs, ectopic pregnancy, normal pregnancies

Mets: lung (MC), vagina, brain, liver

Presentation:
Recent pregnancy
Persistent brown, bloody discharge
Pulmonary sxs - SOB, cough, hemoptysis

Dx:
pelvic exam
Quant hCG - extremely high
US: uterine mass with areas of necrosis and hemorrhage
CXR

Tx: methotrexate
+/- surgery
Follow hCG levels to zero
Wait at least one year before attempting to conceive

57
Q

Placenta previa

A 
Risk factors:
Increasing maternal age
Multiparity
Multiple gestations
History of uterine surgery
History of C-section

Presentation:
Painless vaginal bleeding late in pregnancy

Dx: US before pelvic exam - risk massive hemorrhage

Tx:
Asx - pelvic rest, serial u/s, C/S 36-37 weeks
Bleeding previa:
-resuscitation - IVF, blood transfusion
-FHR monitoring
-glucocorticoids to promote lung maturity
-inpatient bed rest if bleeding resolves
-if continues or abnormal FHTs -> C/S
58
Q

Vasa previa

A

Unprotected fetal vessels overlie cervical os

Ruptured membranes -> compression or laceration of fetal vessels -> fetal hypoxia or hemorrhage/exsanguination

Dx: US
Suspect if ROM followed by bleeding and nonreassuring FHT

Tx: C/S 34-35 wks

59
Q

Placental abruption

A 
risk factors:
Prior abruption
Hypertension
Trauma
Smoking
Cocaine

Features:
Sudden onset, painful vaginal bleeding late pregnancy
contractions
Fetal distress - bradycardia, late/prolonged decels
DIC possible complication

Dx: US, clinical

tx: emergent C/S

60
Q

Test to confirm ruptured membranes

A

Sterile speculum exam - pooling fluid in posterior vaginal vault

Nitrazine paper test - blue in amniotic fluid

Microscopy - ferning pattern

Amnisure

US: low amniotic fluid volume

61
Q

Management of PROM less than 34 weeks

A

Admit
Betamethasone or dexamethasone for fetal lung maturity
Abx:
IV ampicillin 2g q6hr + gentamicin 250 mg q6 hr x 48 hours
PO amox 250 q8hr + azithromycin 233 mg q8 hr x5 days

62
Q

Management of PROM greater than 34 weeks, or evidence of infection

A

induce labor - oxytocin

63
Q

Complications of premature rupture of membranes

A

Chorioamninitis if greater than 18 hrs
cord prolapse
placental abruption
preterm labor

64
Q

Preterm labor

A

less than 37 weeks
Contractions -> cervical changes

Less than 34 weeks:
Admit
Corticosteroids for lung development
Consider tocolysis
Mag sulfate for neuroprotection under 32 weeks
\+/- PCN for GBS

over 34 weeks: allow labor

Risk:
Placental abruption
PROM
Prior preterm birth
Multiple gestations
UTI/STI
uterine abnormality
cervical insufficiency
65
Q

Chorioamnionitis

A

Infection of fetal membranes, placenta, and amniotic fluid

Risk factors:
PROM longer than 18 hrs
Prolonged labor
Multiple cervical exams
Meconium fluid
Internal monitors

Dx: clinical

Features:
Maternal fever
Maternal/fetal tachycardia (fetal >160)
Uterine tenderness
Purulent amniotic fluid

Tx:
IV ampicillin + gentamycin
Delivery

66
Q

Methods to induce labor

A

Cervical ripening - mechanical cervical dilators, misoprostol (PGE1),
-dinoprostone (PGE2) -> tachysystole - too strong contractions, fetal distress

IV oxytocin - stop if tachysystole

Amniotomy - risk cord prolapse

Membrane stripping
Nipple stimulation

67
Q

Signs of placental separation

A

Sudden gush of blood
Lengthening of the umbilical cord
uterus rises to anterior abdominal wall
Uterus becomes firmer and more globular in shape

68
Q

1st stage of labor

A

latent phase - onset of regular contractions to 6 cm
-nulliparous - less than 20 hours
-multiparous - less than 14 hrs
management of protraction/arrest: expectant mgmt, amniotomy +/- oxytocin

Active phase - 6 cm to 10 cm
management of protraction -> oxytocin; arrest -> C/S

69
Q

2nd stage of labor

A

10 cm -> delivery

Nulliparous 3 hrs or less
Multiparous 2 hrs or less
+1 hr if epidural

Protraction/arrest:
expectant mgmt, oxytocin, operative vaginal delivery, rotation of fetal occiput, C/S

70
Q

3rd stage of labor

A

delivery of infant to delivery of placenta

less than 30 min
-otherwise manual removal

71
Q

adequate uterine contractions

A

200 montevideo units or more

add amplitude of each contraction in 10 minutes

72
Q

labor arrest vs protraction

A

labor protraction - slower than normal

Labor arrest - not progressing at all
no cervical change in patient 6 cm + and ruptured membranes despite:
-at least four hours of adequate contractions or
-at least six hours of inadequate contractions + oxytocin

73
Q

Cardinal movements of labor

A 
Engagement
Descent
Flexion - chin to chest
Internal rotation (towards midline)
Extension - of head
External rotation
Expulsion
74
Q

Uterine rupture

A

Risk:
Prior uterine surgery (C/S)
Labor induction/augmentation

Features:
Fetal bradycardia (less than 110)
Maternal abdominal pain - constant
Loss of fetal station
Change in shape of uterus
Maternal tachycardia and hypotension

Tx:
emergent C/S with repair or hysterectomy

75
Q

Management of shoulder dystocia

A

suprapubic pressure

McRoberts maneuver - hyperflex legs

Delivery of posterior arm/shoulder - Barnum’s maneuver

Rubin manuever - rock shoulders side to side
Wood maneuver - rotate posterior shoulder 180 degress may release it

Intentional fracture of clavicle

Zavanelli maneuver - last resort - push back in with STAT C/S

76
Q

Indication for C/S

A 
Arrested labor
Abnormal fetal heart tracing
Malpresentation - breech
prior C/S
Abnormal placentation - previa, accreta, increta, percreta
Acute placental abruption
uterine rupture
multiple gestation
suspected fetal macrosomia
HIV load >1000, active HSV lesions
prior vaginal delivery with 4th degree tear
77
Q

Postpartum hemorrhage definition

A

500 ml vaginal

1000 ml c/s

78
Q

Causes of postpartum hemorrhage

A 
Uterine atony (MC) - open spiral arteries
Retained placental tissue
Placenta accreta/increta/percreta
genital lacerations
uterine rupture
coagulopathy
79
Q

Uterine atony

A 
Risk:
overdistended uterus
chorioamnioitis
induced/augmented labor
prolonged labor

Presentation:
bleeding continues after placenta delivered
Big, soft, “boggy” uterus

Tx:
fundal or bimanual massage
Exam uterus for placental fragments or large blood clots

Uterotonic agent: oxytocin, methylergonovine (contra in HTN), carboprost (contra in asthma), misoprostol, dinoprostone

IVF, blood
Consider uterine artery ligation or hysterectomy
Intrauterine balloon to tamponade

80
Q

Sheehan syndrome

A

massive postpartum hemorrhage -> hypotension -> underperfusion of pituitary gland -> pituitary necrosis -> hypopituitarism

S/S of deficiencies in:

FSH/LH - amenorrhea, breast atrophy, loss of pubic/axillary hair
ACTH - hypotn, hyponatremia
TSH - fatigue, cold intolerance, wt gain, constipation, dry skin
Prolactin - failure to lactate
GH - decrease in lean body mass

81
Q

Postpartum endometritis

A 
Risk factors:
C/S
Chorioamnionitis
Prolonged labor/PROM
multiple cervical exams
internal monitoring
manual removal of placenta
Features:
fever
tachycardia
urterine tenderness
Foul-smelling lochia

Dx: clinical

Tx: ampicillin + gentamicin +/- clindamycin (anaerobic coverage)

82
Q

Contraindications to breastfeeding

A 
HIV infections
Drug or alcohol abuse
Active TB
active herpes on breast
chemotherpay
Infant with galactosemia
83
Q

mastitis

A

S. aureus (MC)

Features:
tender, erythematous, swollen area
fever
myalgias
malaise

Dx: clinical
US r/o breast abscess

Tx:
continue breastfeeding/pumping
Abx:
dicloxacillin - antystaph
if MRSA suspected - clindamycin, TMP-SMX, vancomycin

If abscess - I&D

DIT Level 2 (49 decks)

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