OB/GYN Flashcards
1
Q
What labs/studies should you get in evaluating new diagnosis of pregnancy?
A
• UPT
• Serum pregnancy test
• UA and culture
• ABO
• TVUS
2
Q
Other than the obvious complaints that would make you suspicious for pregnancy – like missed period, vaginal bleeding – what other things should prompt a UPT?
A
GI complaints: abdominal pain, vomiting, nausea, constipation/diarrhea
GU complaints: dysuria, UTI, urinary urgency, vaginal discharge
Neuro complaints: headache, sleep trouble
Cardiovascular: HTN, dyspnea
Constitutional: weight gain, fatigue
3
Q
A 1st trimester pregnant woman presents with vaginal bleeding. What workup do you order?
A
CBC (blood loss)
UA (UTI)
G/C swab (infection as a trigger of AUB)
ABO (if they are Rh-negative then Rhogam may be indicated)
Serum bHCG and TVUS for ectopic r/o
4
Q
If you are concerned about pregnancy and the UPT is negative, what are your options for follow-up?
A
Repeat UPT in one week (if no concern for acute complications)
Serum bHCG (more sensitive that UPT)
5
Q
What (non-pregnancy) OB emergency do you need to remember every time you see a woman with abdominal pain?
A
Ovarian torsion: Abrupt onset pain. Can be on/off (due to torsion-detorsion). Usually unilateral lower quadrant. Pain on bimanual exam.
6
Q
What two drugs treat chlamydia?
A
Doxycycline
Azithromycin
Due to rising rates of resistance to azithromycin, doxycycline is now first line.
7
Q
True or false: US is sensitive for detecting placental abruption.
A
False
It can catch it but has poor sensitivity. If you are suspicious for abruption (based on abdominal pain, vaginal bleeding, and history of cocaine/trauma/HTN), then consult OB/GYN for further assessment.
8
Q
If a woman presents with a concerning story for ovarian torsion and the US is negative, what should you be thinking of?
A
Intermittent torsion
A negative US only tells you that there was no torsion when the study was done. Particularly if her pain resolved or abated when the study was done.
9
Q
What increases risk of ovarian torsion?
A
Masses on the ovaries – particularly cysts and teratomas
10
Q
What two aspects of the primary survey are affected by pregnancy?
A
- Hypervolemia in the third trimester can mean that pregnant women can lose more blood without tachycardia or hypotension
- Pregnant women have physiologic respiratory alkalosis so a “normal” PCO2 can signify respiratory distress.
11
Q
The normal WBC in pregnant women is ______________ (increased/decreased) compared to non-pregnant women.
A
increased
The normal range is 5-12 in pregnant women.
12
Q
How is the pH buffer system different in pregnant women?
A
Pregnant women have a physiologic respiratory alkalosis with normal arterial pH 7.40 - 7.45, normal PaCO2 25-30, and normal bicarb 17-22.
13
Q
Fibrinogen is _____________ (increased/decreased) in pregnancy.
A
increased
Normal range is 400-450 in the third trimester (compared to normal of 150 - 400 in non-pregnant women).
14
Q
Blood pressure is physiologically _______________ (increased/decreased) in the second trimester.
A
decreased
It returns to normal by term.
15
Q
True or false: ectopic beats during pregnancy warrant workup for peripartum cardiomyopathy.
A
False
Ectopic beats are common in pregnancy and only warrant workup if significantly symptomatic.
16
Q
True or false: BUN rises during the third trimester.
A
False
Creatinine and BUN fall to about 1/2 their pre-pregnancy levels during pregnancy.
17
Q
Glucosuria warrants what workup in pregnancy?
A
None
Glucosuria is a common physiologic finding in pregnancy and doesn’t warrant workup by itself.
18
Q
Why do you need to assess the type of seatbelt used by pregnant women in MVCs?
A
Lap belts increase risk of placental abruption
19
Q
Pregnant women getting intubated from traumas should have early placement of ________________.
A
naso/orogastric tubes to decrease the stomach, because the gravid uterus pushes up on the stomach and delays gastric emptying – both of which increase risk of aspiration
20
Q
In the setting of a maternal trauma, what signs on FHR indicate urgent obstetrical intervention?
A
- Sustained abnormal FHR
- Repetitive decelerations
- Absence of accelerations
- Absence of beat-to-beat variability
21
Q
Pregnant trauma patients should be evaluated for what pregnancy-specific treatment?
A
Rh immunoglobulin
Give this to all Rh-negative patients.
22
Q
If a woman is at term and is having irregular contractions and she is < 4 cm dilated, then you should recommend what disposition?
A
Discharge and reassess when contractions become regular
If contractions are regular and the woman is 4-5 cm, then you can have her walk around and reassess.
If contractions are regular and the woman is 6 cm or more dilated then admit for labor.
23
Q
What three tests assess ROM?
A
Pooling on SSE
Nitrazine
Ferning
24
Q
A woman presents with third trimester vaginal bleeding. What do you need to make sure of before you do a SVE?
A
Ensure she does not have previa
25
For FHR variability, what are the parameters for the following:
- Absent
- Minimal
- Moderate
- Marked
- Absent: 0 BPM
- Minimal: 0-5 BPM
- Moderate: 6-25 BPM
- Marker: > 25 BPM
26
An acceleration is defined as _______________.
15 BPM above baseline for 15 seconds (if 32 weeks or greater) or 10 BPM above baseline for 10 seconds (if less than 32 weeks)
27
What is a late deceleration?
When the FHR decreases with a nadir that is after the peak of the contraction.
28
What things can help late decelerations?
- Turn down/off Pitocin
- Mom on L side
- Maternal oxygen
29
Review VEAL CHOP.
- Variable decelerations are Cord compression
- Early decelerations are Head compression
- Accelerations are Ok
- Late decelerations are Placental insufficiency
30
When the deceleration reaches its nadir at the same time as the contraction peak, it's called an _______________.
early deceleration
31
When the deceleration reaches its nadir at variable times as the contraction peak, it's called _______________.
variable contractions
32
What makes category I tracings?
All of the following:
- Baseline 110 - 160 BPM
- No variable or late decelerations
- Moderate variability
33
What makes category III tracings?
Any of the following:
- Bradycardia
- Absent variability
- Recurrent late or variable decelerations
34
What makes category II tracings?
Not meeting the category I tracings but not having any category III features.
35
The generic name of Hemabate is ____________.
carboprost
36
The generic name of Cytotec is _____________.
misoprostol
37
The generic name of Methergine is ___________.
methylergonovine
38
What are the criteria needed for AROM?
Active phase of labor (6 cm or greater and regular contractions) and station 0 or lower
39
When is GBS treatment needed?
- Positive in the last 5 weeks
- Unknown with risk factors (less than 37 weeks, prior infant with GBS disease, or ROM > 18 hrs)
40
What are the treatments options for chorioamnionitis?
- Ampicillin and gentamicin if vaginal delivery
- Ampicillin, gentamicin, and clindamycin if LTCS
41
Why should you start progesterone-only containing oral contraceptives in the postpartum period (as opposed to combined OCPs)?
Pregnancy is a clotting risk and the estrogen in combined pills would be too much of a DVT risk.
42
Why does gestational diabetes usually go away quickly after delivery?
Gestational diabetes happens because of human placental lactogen, a hormone made by the placenta. This hormone increases maternal insulin resistance to drive up maternal blood sugar so that babies get adequate glucose delivery.
43
The _______________ test is used to determine how much fetal-maternal blood mixing has happened in a trauma, delivery, or first-trimester bleed.
Kleihauer-Betke
44
A _______________ appears as a hypoechoic crescent between the gestational sac and the uterus.
subchorionic hematoma
45
Subchorionic hematoma raises the risk of what adverse outcomes?
- Spontaneous miscarriage
- Preterm labor
- PROM
- Placental abruption
46
Why should you evaluate for prolapse (with a Valsalva exam) for a post-menopausal woman with AUB?
Pelvic organ prolapse (POP) can cause AUB from irritation to the cervix and fornices that leads to AUB.
47
True or false: US is needed to diagnose endocervical polyps.
False
They usually are visible on SSE.
48
A woman who is in her first trimester with transaminitis and thrombocytopenia. Why should you be skeptical about the diagnosis of HELLP?
HELLP usually occurs in the third trimester
49
Describe the diagnosis of vulvodynia.
This is a rule-out diagnosis of vaginal pain. The diagnostic criteria are chronic vulvar pain (3 months or more) often described as burning in the setting of a normal physical exam and negative infectious workup (UA, wet prep, KOH prep).
The buzz words are "can't wear tight pants" and positive Q-tip test. The Q-tip test is when a woman has sharp pain with gentle application of a Q-tip to the vulva.
50
What defines a prolonged second stage of labor? That is, what defines arrest of descent?
- Nulliparous women without epidural: 3 hours
- Nulliparous women with epidural: 4 hours
51
What antiepileptics should women on OCPs not take?
Any that increase cytochrome P-450: phenytoin and carbamazepine
Increased cytochrome P-450 leads to the increased breakdown of OCPs and the loss of their effectiveness. This is especially worrisome since both of the above lead to increased risk of NTDs.
52
Review the management algorithm for breast masses.
- Women younger than 30: US first. If complex then biopsy. If cyst then can offer drainage.
- Women older than 30: mammogram first. If complex then biopsy.
53
Other than pregnancy test, what is the first set of tests for secondary amenorrhea?
TSH, FSH, LH, and estrogen
This can rule out thyroid dysfunction, prolactinemia, and primary ovarian failure.
54
Which kind of IUD is associated with increased vaginal bleeding?
Copper
55
What are risk factors for adenomyosis?
- Age greater than 40
- Uterine surgery
- Multiparity
56
List two different regimens for partpartum endometritis.
- Most common: clindamycin and gentamicin
- Unasyn and gentamicin
The big picture is you want anaerobic coverage and broad spectrum coverage.
Note: chorioamnionitis is less associated with anaerobic infections so ampicillin and gentamicin is the first line therapy.
57
The most significant risk factor for postpartum endometritis is _____________.
C-section, particularly after a trial of labor
58
True or false: valproate is the least teratogenic of all the AEDs.
False
It is the most teratogenic.
59
Why should you never change seizure medicines during pregnancy?
Seizures are very bad for fetuses. They increase risk for preterm labor, placental abruption, and miscarriage. IF you switch medicines you increase risk of seizure. Furthermore, by the time most women discover that they are pregnant organogenesis has already occurred and the damage is likely to be done.
60
True or false: women on antiepileptics should not breastfeed.
False
Some AEDs can pass into the breastmilk and cause symptoms in the infant (like benzodiazepines or phenobarbital), but the benefits to breastfeeding usually outweigh the side effects to baby.
61
Why is mammography the standard evaluation tool for breast masses in women older than 30 but US is the standard for women younger than 30?
Denser breast tissue (which younger women tend to have) causes a higher rate of false-positive mammograms.
62
HELLP can also occur in the __________ period.
postpartum
63
True or false: IUD has the best typical-use pregnancy prevention rate.
False
Progestin implants are more successful.
64
How long do progestin implants last?
3 years
65
In addition to post-menopausal women, lichen sclerosus also affects ____________.
pre-pubertal girls
66
Pregnant women who have GBS bacteriuria should be treated ______________.
with amoxicillin for the bacteriuria and with penicillin during labor
67
How does pregnancy affect the symptoms of appendicitis?
It causes upward displacement of the appendix.
68
What can cause false-positive cell-free DNA?
Demised twin
Placental mosaicism
Recent blood transfusion
69
PCOS causes __________ testosterone and ___________ estrogen.
elevated; elevated
70
The first-line treatment for PCOS is ___________.
weight loss
Second-line therapies:
- OCPs for menstrual irregularity
- Letrozole for fertility
71
Letrozole has what mechanism of action?
Aromatase inhibition
72
How does letrozole help with fertility in those with PCOS?
Letrozole is an aromatase inhibitor. Aromatase converts androgens to estrogen. Inhibiting this enzyme leads to decreased circulating estrogen which improves ovulation in women with PCOS.
73
In addition to amenorrhea, women with functional hypothalamic amenorrhea (from strenuous exercise or calorie restriction) are likely to have what problem that requires medical intervention?
Bone mineral loss (give vitamin D and calcium)
74
What is the generic name of Plan B?
Ulipristal
75
How does ulipristal work?
It is a progesterone inhibitor.
76
What medicines need to be considered for women presenting after sexual assault?
PID meds (ceftriaxone and a macrolide or doxycycline) if she has signs of PID.
HIV meds (typically tenofovir-emtricitabine-raltegravir)
HBV meds if unvaccinated
77
HIV prophylaxis can be offered up to ________ hours after intercourse.
72
78
If a woman has had documented anaphylaxis to penicillin, she should get what for syphilis in pregnancy?
Penicillin desensitization
If she fails this then she can get ceftriaxone or a macrolide, but those are less studied than penicillin and should only be given in desensitization failure.
79
How should you manage a laboring woman who is discovered to have extensive vaginal warts?
Normal vaginal delivery
Although HPV lesions during delivery carry a small risk of respiratory papillomatosis in the child, it is not significant enough to warrant cesarian or other management.
80
Describe ovarian hyperstimulation syndrome (OHSS).
OHSS is a rare side effect of fertility treatment. It occurs 1-2 weeks after. woman has received exogenous hCG. The hormone hCG induces fluid shifts that lead to ascites, intravascular volume depletion, and in severe cases multiorgan failure.
81
Describe ovarian hyperstimulation syndrome (OHSS).
OHSS is a rare side effect of fertility treatment. It occurs 1-2 weeks after. woman has received exogenous hCG. The hormone hCG induces fluid shifts that lead to ascites, intravascular volume depletion, and in severe cases multiorgan failure.
82
Any woman with an EF less than ______ should be advised that pregnancy is not recommended due to high risk of maternal death.
40
The fluid shifts and increase in SVR in the postpartum period frequently lead to HFrEF exacerbations in women with CHF that can be fatal.
83
What criteria warrant cerclage placement?
History of 2 or more spontaneous preterm losses in the second trimester
Note: a short cervix is not needed for diagnosis of cervical insufficiency.
84
Review the management of molar pregnancy.
When a molar pregnancy is confirmed (by positive hCG and TVUS showing molar features), a suction curretage is indicated. Following that, serial hCG measurements should be drawn. If they downtrend to undetectable then they can be discontinued. If they rise then you need to be concerned about choriocarcinoma because molar pregnancy can be a premalignant lesion.
85
Review the testing for gestational diabetes.
First, between 24 and 28 weeks a 50 gram bolus of sugar is given and glucose is measured at 1 hour. If it's greater than 140 you proceed to a fasting glucose followed by 100 gram glucose load with serial measurements at each hour for 3 hours. Any two of the following is positive:
- Fasting greater than 95
- 1 hour greater than 180
- 2 hour greater than 155
- 3 hour greater than 140
86
Review the blood glucose goals for dietary management of gestational diabetes.
- Fasting: less than or equal to 95
- 1-hour post-prandial: less than or equal to 140
- 2-hour post-prandial: less than or equal to 120
87
True or false: all pregnant women should get thyroid studies.
False
Only those with a prior diagnosis of thyroid dysfunction or new symptoms.
88
When should women receive urine culture during pregnancy?
At the initial prenatal visit and then only a subsequent one if the first was positive or if they develop a UTI
89
True or false: gestational thrombocytopenia often causes PPH and IVH in newborns.
False
It is a benign diagnosis that is thought to be caused by hemodilution and perhaps accelerated destruction of platelets.
90
What is the discriminatory zone?
It is the range of hCG at which you should be able to see an IUP. Most times this is > 1,200 to 1,500 mIU/mL.
91
How does preeclampsia affect intravascular volume?
t causes intravascular volume depletion from proteinuria-induced third spacing.
92
Preeclampsia is defined by a UPC greater than ______________.
0.30
93
Levothyroxine doses may need to be __________ in a woman who starts taking OCPs.
increased
This happens because estrogen stimulates increased TBG (thyroxine-binding globulin)
94
Dysuria, post-void dribbling, dyspareunia, and an anterior vaginal mass suggest what pathology?
Urethral diverticulum
Risk factors are multiparity, repeat UTIs, and urologic/vaginal manipulation.
95
New-onset ascites and a uterine mass are most likely what?
Uterine sarcoma
96
What is the treatment for trichomoniasis?
Single-dose of oral metronidazole 2 g
Note: if a woman is breastfeeding, then have her express and discard milk for 24 hours.
97
Polyhydramnios is diagnosed by an amniotic fluid index greater than _______.
24 cm
98
Preeclampsia typically causes ______-hydramnios.
oligo
99
In a suspected first trimester miscarriage, why is visualization of the cervical os so important?
Retained products in the os can prevent the os from closing and lead to ongoing bleeding. Failure of the os to close can also lead to vasovagal symptoms, so think of this if a woman has bradycardia and vaginal bleeding.
100
Review two risk factors for ovarian torsion.
Cysts greater than 5.0 cm and artificial fertility treatments
101
All patients that you are discharging with PID should be recommended to do what two things after discharge?
- See their PCP or OB/GYN in 72 hours to assess treatment response
- Tell all sexual partners in the last two months to get tested
102
A woman in her third trimester presents with painless vaginal bleeding. What diagnosis can you not miss?
Placenta previa
103
True or false: placental abruption is usually painless.
False
104
If you are concerned that a preterm woman may deliver soon, you should give steroids if she is less than ____ weeks gestation.
34
105
Why do you check reflexes in a woman with preeclampsia?
Hyperreflexia portends seizure
106
A pregnant woman is actively seizing. Which antiepileptic should you give first?
Magnesium sulfate 4 gm IV
Benzodiazepines can be given if no IV is available.
107
__________ contractions are more likely to be felt in the anterior abdomen.
Braxton-Hicks
108
True or false: Braxton-Hicks contractions are more likely to be provoked by movement.
False
True labor contractions are more likely to be provoked by movement.
109
Which tocolytic has a black-box warning?
Terbutaline
It can cause arrhythmia, pulmonary edema, and cardiac ischemia.
110
What is the pH of amniotic fluid (which is part of nitrazine testing)?
7.1 - 7.3
111
Review the types of breech presentation.
- Complete breech: hips flexed, knees flexed
- Frank breech: hips flexed, knees extended
- Footling: hip extended, knee extended (can be one -- called incomplete footling -- or both)
- Kneeling: hip extended, knee flexed (ditto to the above parenthetical statement)
112
In which two circumstances does the CDC state that PEP should be given after sexual assault?
Multiple assailants
HIV positive status known
If the HIV status of a single assailant is unknown, then have a risks benefit discussion with the patient and assess risk factors.
113
A woman who is s/p PPH is having difficulty lactating. She most likely has what syndrome?
Ischemic pituitary necrosis (Sheehan syndrome)
114
Describe the maneuvers that can be done for shoulder dystocia.
First: McRoberts (hips flexed to abdomen, knees flexed)
Second: suprapubic pressure
Third: Jacquimier (deliver the posterior shoulder by reaching your finger in and sweeping the forearm across the chest)
Fourth: Rubin/Woodscrew (rotate the shoulders to 30° for the Rubin or 180° for the Woodscrew)
Note: you should build these up, meaning the mom should be in McRoberts and having suprapubic pressure while you try Jacquimier, Rubin, and Woodscrew.
115
True or false: uterine prolapse is an indication for urgent surgery.
False
Uterine prolapse does not typically cause any emergent or urgent problems, so outpatient gynecologic referral is appropriate.
116
A baby is delivered. The mother had no prenatal care and the baby presents with SGA, peeling skin, a long body, long fingers, and long fingernails. Meconium is present. What is most likely going on?
Fetal post-maturity or dysmaturity syndrome
SGA infants can go post-dates more often, and when they are they have the described skin and finger findings.
117
Vaginal bleeding in a woman who has had a hysterectomy can be caused by __________.
Cuff dehiscence
118
Why should you not manipulate a cervical polyp?
They are vascular and bleed easily.
119
Protrusion of the glandular cells of the endocervix is called ________.
Ectropian
120
Progesterone is the dominant hormone in the _______________ phase of the menstrual cycle.
luteal
121
What is considered HTN in pregnancy?
Greater than 140/90 or 20 systolic over their baseline or 10 diastolic over their baseline
122
Why do you not do a cervical or pelvic exam (or at least consider it thoughtfully) in a third trimester heavy vaginal bleed?
You can dislodge clotted blood in the cervix and make the bleeding worse.
123
What do you do if you find a prolapsed cord?
Elevate it — i.e., push baby and cord back into uterus until c section
124
Review the stages of labor.
First stage: cervical dilation
- latent: 1-5 cm
- active: 6-10 cm
Second stage: baby delivery
Third stage: placental delivery
125
A deceleration that lasts _________________ after the contraction is worrisome.
30 seconds
126
Review breech delivery.
- Wait for mom to deliver on her own up to the umbilicus - Rotate so that baby is sacrum anterior (“butt up”)
- Release arms one by one
- Reach your hand up to the face so that your index and middle fingers are on the maxillary bones. Don’t poke the eyes. Then tuck the head down and pull.
127
Preeclampsia presenting before ______ weeks gestation typically have worse outcomes.
34
128
Chronic hypertension is HTN that presents before how many weeks gestation?
20
129
True or false: preeclampsia must have proteinuria.
False
They must have hypertension, but they can be without proteinuria and have AKI, refractory HA, HELLP syndrome, blurry vision, or other evidence of end-organ dysfunction.
130
When should you deliver a woman with preeclampsia?
- 37 weeks without severe features
- 34 weeks with severe features
An RCT showed that induction at these time points led to a 30% reduction in maternal mortality among other things.
131
The Magpie trial showed what?
That magnesium treatment for eclamptic seizures led to decreased adverse outcomes compared to benzodiazepines and phenytoin
132
Review the doses of magnesium for eclamptic seizure.
6 g bolus followed by gtt 2g/h
133
What antidepressants should breastfeeding women be offered?
SSRIs
SSRIs are secreted in breastmilk but the amount is negligible and safety data is reassuring.
134
If you're thinking that a post-menopausal woman might have atrophic vaginitis from a low-estrogen state, but you see that her thin skin extends over the anus, what diagnosis does she likely have?
Lichen sclerosis
Atrophic vaginitis is restricted to the vagina, whereas lichen sclerosis often has the "figure of 8" pattern that involves the anus.
135
When should Rh-negative women be given Rhogam in normal, uneventful gestations?
28-32 weeks and postpartum
136
How long do Mirenas and copper IUDs last?
Mirena - 7 years
Copper (Paraguard) - 10 years
137
What is the dose and duration of betamethasone for fetal lung protection?
12.5 mg IM Q24H x 48 hours
138
Ovarian _________ cells produce androgens.
theca
139
Ovarian __________ cells contain aromatase that converts androgen to estrogen.
granulosa
140
How does clomiphene work?
It antagonizes the estrogen on the hypothalamus which stimulates the release of GnRH.
141
True or false: Leuprolide is the first-line agent for the treatment of infertility in PCOS.
False
Leuprolide is a GnRH antagonist that decreases the release of LH and FSH, thereby worsening fertility.
Leuprolide is a GnRH antagonist that decreases the release of LH and FSH, thereby worsening fertility.
142
____________ is secreted by the corpus luteum.
Progesterone
143
What does spironolactone do for women with PCOS?
It treats the hyperandrogenism effects such as hirsutism and acne, but it does not affect fertility.
144
Bacterial vaginosis is characterized by a shift from ____________ bacterial to __________ bacterial.
Lactobacillus; anaerobes
145
Thin, greyish-white discharge is scene in which vaginal infection?
Bacterial vaginosis
146
Review the diagnostic criteria for bacterial vaginosis.
The Amsel criteria state that BV is diagnosed with any 3/4 of the following:
- Thin, grey or white discharge
- Presence of Clue cells
- pH greater than 4.5
- Positive Whiff test on KOH
147
Review the two treatment options for bacterial vaginosis.
- Metronidazole 500 mg BID x 7 days
- Clindamycin 300 mg BID x 7 days
148
What is the new protocol (for 2021, at least) for outpatient PID treatment?
Ceftriaxone 500 mg IM x 1
Doxycycline 100 mg BID x 7 days for cervicitis and x 14 days for PID
149
Review the three different antibiotic regimens for TOA (just the meds not the doses).
- Cefoxitin and doxycycline
- Clindamycin and gentamicin
- Unasyn and doxycycline or metronidazole
150
What are two risk factors for hyperemesis gravidarum?
Multiple gestations
Molar pregnancy
151
Thiamine is indicated in which obstetric problem?
Dehydration secondary to hyperemesis gravidarum (to prevent Wernicke's encephalopathy)
152
What vital sign abnormality is seen in those with molar pregnancy?
Hypertension
153
GDM is seen in ___% of pregnancies.
10
154
HEG can cause what endocrine abnormality?
Transient hypethyroidism
This is usually self limiting and requires only symptomatic treatment.
155
What two seizure prevention meds are first line in pregnancy?
Keppra and Lamictal
Note: both are still only class C, but they're better than valproic acid, carbamazepine, and phenytoin which are all class D.
156
If US r/o appy is negative in a pregnant woman, the next test is ____________.
MRI abdomen
157
True or false: ectopic pregnancies present with faster than normal rise in hCG.
False
Slower than normal.
158
Amniotic fluid embolism causes what physiologic abnormality?
Severe pulmonary HTN
Ultimately this leads to RV failure which then leads to LV failure and can cause cardiogenic shock.
159
When does amniotic fluid embolism typically occur?
In the immediate peripartum partum, typically within a couple hours of delivery
160
When the hCG is 5,000 mU/mL the failure rate of MTXX in ectopic pregnancy is _____%.
15
161
What medicines need to be given to those with PPROM with no signs of labor in the ED?
Penicillin and erythromycin
PPROM has a high risk of chorioamnionitis and prompt treatment is needed for GBS and other polymicrobial ascending infections that could cause chorio.
162
What route of methotrexate is usual for ectopic treatment?
IM
163
What factors increase risk for uterine atony?
Everything that distends the uterus:
- Multiple gestations
- Polyhydramnios
- Macrosomia
164
The mortality rate of peripartum cardiomyopathy is as high as ____%.
50
165
The most sensitive factor for placental abruption after a trauma is _____________.
contractions (more than three per hour)
166
Review the four emergency contraception options (including doses and frequencies).
- Ella (ullipristal acetate) 30 mg PO x1
- Plan B (levonorgestrel) 1.5 mg PO x1 or 0.75 mg PO Q12H x2
- Estradiol-levonorgestrel combination 100mcg-0.5 mg PO at 1 hour and 12 hours
- Copper IUD
167
What is the goal of treatment for BV in pregnant women?
BV does increase the risk of preterm labor and spontaneous abortion, but it's not yet known if treatment reduces the risk. Thus, treatment is primarily for symptoms.
168
True or false: asymptomatic Trichomoniasis does not warrant treatment.
False
Trichomonas is always pathogenic, and treatment for patient and partner is always indicated.
169
True or false: depot medroxyprogesterone is also called Neplanon.
False
Depot medroxyprogesterone is the Q3month IM shot. Nexplanon is the implant.
170
What are the recommended schedules for testing Pap smear and HPV?
- Younger than 21: no screening unless HIV positive
- 21 - 29: Pap smears Q3Y
- 30 - 65: either Paps Q3Y or HPV Q5Y or contesting Q5Y
- Older than 65: no testing after last negative test
171
What is the dose range of oral Provera (medroxyprogesterone)?
5 mg QD to 20 mg TID
172
Perimortem C-section should be attempted only in women who are beyond what week of pregnancy?
24 weeks (by fundal height)
Prior to this mark, the flow to the placenta is insufficient to be hemodynamically significant and the risks are thought to outweigh the benefits.
173
Patients may go to L&D triage at UNC if they are at or after ______ weeks and have vaginal bleeding or cervical dilation.
15
174
It's controversial if PID should be diagnosed in pregnancy. Some people say you should only diagnose ____________ if a pregnant woman presents with symptoms of PID.
chorioamnionitis
175
Review the diagnostic criteria of chorioamnionitis.
Maternal fever or any two of the following:
- Maternal tachycardia
- Fetal tachycardia
- Uterine fundus TTP
- Foul discharge from the os
- Leukocytosis > 15
176
______________ is the treatment for magnesium toxicity.
Calcium
177
What percent of ectopic pregnancies are in the fallopian tube?
97%
178
What timeframe should a perimortem section be done?
Within four minutes of CPR
179
Fundus at the umbilicus is what gestational age?
20 weeks
180
HELLP and eclampsia are very uncommon before _____ weeks of pregnancy. If a pregnant woman presents with seizure or MAHA before then, suspect an alternative diagnosis such as TTP or any other cause of seizure.
24
181
How can you differentiate between gestational and immune thrombocytopenia in a pregnant woman?
Gestational thrombocytopenia typically causes platelets in the 100-150 range, so if the level is much lower than 100 suspect something else (such as ITP).
182
True or false: removal of IUD is indicated in cases of PID.
False
183
What features need to be met to use MTX in an ectopic pregnancy?
- Patient hemodynamically stable
- No signs of ectopic rupture
- No FHR
- Gestational sac < 4 cm
- Able to complete follow up doses
184
What are the doses of RhoGAM?
- Less than 12 weeks gestation: 50 mcg
- Greater than 12 weeks gestation: 300 mcg
Both IM.
185
True or false: BV stands for bacterial vaginitis.
False
It is bacterial vaginosis
186
Which two vaginal infections present with a high pH?
BV and trichomonas
Yeast is acidic.
187
Which two vaginal infections present with a high pH?
BV and trichomonas
Yeast is acidic.
188
What are the two doses of RhoGAM?
< 12 weeks = 50 mcg
> 12 weeks = 300 mcg
189
The vaginal epithelial cells in bacterial vaginosis classically have a __________ appearance.
stippled
190
HELLP syndrome can cause what pathology that leads to RUQ pain?
Hepatic rupture
191
A woman with HELLP syndrome becomes hypotension. You need to evaluate for _______________.
hepatic hemorrhage
192
Which uterotonic is contraindicated in asthmatics?
Carboprost (Hemabate)
193
True or false: methotrexate can treat molar pregnancy.
False
D&C is required.
194
Multiple small, red bumps on the cervix is most likely what pathogen?
Trichomonas
195
What is a missed abortion?
IUFD with closed os and no passage of tissue
196
Review the methods of emergency contraception.
Ulipristal: single dose up to 5 days after
Levonorgestrel: up to 3 days, less effective than ulipristal
Estrogen-progesterone: up to 5 days
Mifepristone is approved overseas up to 5 days.
197
What is the best fluid for hyperemesis gravidarum?
D5 LR
Need dextrose to reverse ketosis.
198
True or false: the first-line noninvasive therapy for ectopic pregnancy is mifepristone and misoprostol.
False
These are the agents that induce abortion for intrauterine pregnancies. Mifepristone is a progesterone antagonist that disrupts the endomtrium. Misoprostol induces uterine contraction. For an ectopic pregnancy these mechanisms will not lead to demise of the ectopic. The only medical therapy for ectopics is methotrexate.
199
How do you determine if a deceleration is late?
Look at the nadir!
If the nadir occurs after the contraction peaks then it is late.
200
What maneuver can you try if a laboring woman is having late decels?
Lateral recumbent position (to increase placental blood flow).
201
How long does beta hCG take to reach zero after treatment with methotrexate for ectopic pregnancy?
2-3 months
202
Where will you palpate uterine fundus at 12, 20, and 38 weeks?
12: pubis
20: umbilicus
38: xiphoid
203
What is the life-threatening part of ovarian hyperstimulation syndrome?
Pericardial effusion
204
Magnesium toxicity presents with the following symptoms:
- Hypotension
- Pulmonary edema
- Decreased reflexes
- _______________
Seizures
Seizures from Mg toxicity sometimes require Ca to treat.
205
True or false: cover for PID in bartholin’s abscess.
False
Bactrim.
206
What are the requirements for treating ectopic pregnancy with methotrexate?
No fetal cardiac activity
bHCG less than 5,000
Normal renal and hepatic function
Able to return in case of signs of rupture
Less than 4 cm sac
