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OBGYN Step 2 > OB Meded > Flashcards

OB Meded Flashcards

1
Q

CV changes in pregnancy

A

DECREASED MAP (BP) overall
^HR and ^Preload but decreased SVR due to placental circulation
decreased Hgb (^RBC but ^^plasma volume)
^IVC compression, turn on Left side!

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2
Q

respiratory changes in pregnancy

A

^tidal volume, decreased FRC (she takes deeper breaths but is unable to “store” as much air)
FEV1 and RR is SAME

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3
Q

coagulatory changes in pregnancy

A

HYPERCOAGULABLE
^vWF, ^fibrinogen and d-dimer, ^Factors 7, 8, 10, ^tPa-inhibitor
decrease protein C, S
good for preventing hemorrhage, ^risk DVT/PE

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4
Q

renal changes in pregnancy

A 
^GFR (more blood flow overall)
decreased Cr (0.4-0.8)
obstructive uropathy at pelvic brim
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5
Q

weight changes in pregnancy

A

BMI less than 18.5: 28-40 lbs
18.5-25: 25-35
25-30: 15-25
30+: 10-15

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6
Q

GI changes in pregnancy

A

GERD, nausea, constipation, Fe deficiency

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7
Q

pre-conception visit

A

safety
folate
vaccines: flu (IM), Hep B, MMRV (live attenuated, can’t give after pregnant)
lifestyle: smoking, etOH, drugs
optimization of disease: DM, HTN, hypothyroid (may need to increase dose)

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8
Q

1st trimester evaluation

A 
10 weeks
vitals, weight, safety
Gs and Ps, History, risk factors
dx: UCG, U/S, intrauterine, gestational age, multiple
do not need serum hCG
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9
Q

Gs and Ps

A

G TPAL
Gravid (# pregnancies)
Term, Preterm, Abortions, Living

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10
Q

blood tests to get at 1st trimester visit

A

ABO, Rh-Ab, Hbg/Hct
HIB, Hep B, RPR
titers: varicella, rubella

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11
Q

urine tests to get at 1st trimester visit

A

U/A and urine culture
tx asymptomatic bacteruria
proteinuria baselines (eclampsia)
Gc/Chlamydia

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12
Q

cytology at 1st trimester visit

A

pap smear

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13
Q

genetic screens at 1st trimester visit

A

CF

HgbSS (SCD)

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14
Q

how often to see pregnant female

A

q4 weeks until 28 weeks
q2 weeks until 36 weeks
q1 weeks until delivery

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15
Q

aneuploidy

A

Down’s: 21
Edward’s: 18
Patau’s: 13
^risk in AMA, but prevalence highest in younger women

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16
Q

aneuploidy screening test

A

1st trim: U/S for nuchal translucency (less than 3 mm), PAPP-A, hCG
2nd trim: triple: hCG, AFP, Estriol +Inhibin-A for quad

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17
Q

Down’s quad screen

A

^hCG, low AFP, low estriol, ^Inhibin-A

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18
Q

Edward’s quad screen

A

LOW hCG, low AFP, low estriol, LOW Inhibin-A

ALL LOW

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19
Q

new genetic screen

A

cell-free DNA:

fetal DNA in maternal blood

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20
Q

disease to look for at 20-28 weeks of preganancy

A

Gestational DM
Alloimmunization
Maternal Anemia

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21
Q

Gestational DM

A

DM +20 weeks gestation

^risk: BMI 30+, GDM hx, pre-diabetic

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22
Q

GDM tests

A 
1-hr glucose tolerance test (50g) positive if 140+
move onto 3-hr GTT:
fasting: 90+
1 hr: 180+
2 hr: 155+
3 hr: 140+
need any 2 to be +
NOT HbA1C or 2 hr GTT
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23
Q

GDM tx

A

insulin
post-prandial sugars less than 180
some oral hypoglycemics starting to be used

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24
Q

how mom becomes alloimmunized

A

Rh-Ag - with previous Rh-Ag+ baby, mom is now Rh-AB +
will attack next Rh-Ag+ baby and cause fetal anemia
screen for Rh-Ab+
if Rh-Ab- and baby could be Rh-Ag+, give RhoGAM at 28 weeks and within 72 hrs of delivery

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25
Q

if mom has Rh-AB+ and baby could be Rh-Ag+ and mom has ^titers and right type, what to do to assess for fetal anemia

A 
transcranial doppler (TCD)
PUBS is incorrect (used to transfuse baby)- percutaneous umbilical blood sampling
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26
Q

normal Hgb/Hct at 28 weeks

A

10/30
may have iron deficiency, get CBC at 28 weeks
folate does not typically cause anemia in pregnant women

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27
Q

reasons to get U/S in pregnancy

A

1st trimester: determine IUP, GA, multiple preg.

3rd: fetal well being, lie/orientation, oligo/polyhydramnios

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28
Q

accuracy of U/S in predicting gestational age

A

1st trimester: GA +/- 1 wk

2nd: GA +/- 2 wks
3rd: GA +/- 3 wks

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29
Q

when transcranial doppler used

A 
\+20 weeks in setting of fetal anemia
no risk (u/s)
^velocity of blood: anemia, sensitive but does not provide dx and tx
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30
Q

when to get amniocentesis

A

only reliable +16 wks
confirm genetic disorders
loss is about 1/300
(used to use for fetal anemia and lung maturity, no longer)

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31
Q

CVS

A

used at 10+ weeks
genetic disorders: karyotypes and genes
loss about 1/500
good for early detection and termination

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32
Q

PUBS

A 
percutaneous umbilical blood sampling
20+ wks, less than 34 wks
if fetal anemia on +TCD
used for diagnosis and fix
get Hgb and can transfuse
but typically just deliver if +TCD
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33
Q

treatment of asymptomatic bacteriuria and cystitis in pregnancy

A

AMOXICILLIN
2nd line: nitrofurantoin (macrobid) if PCN-allergic
NO bactrim or cipro!
RESCREEN pt after treatment

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34
Q

treatment of pyelonephritis in pregnancy

A

admit, IV rocephin
reassess, if have improved over 3 days: 10 ds abx
if has not improved, think perinephric abscess: abx 14 days, U/S (can’t use CT) and drain

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35
Q

treatment of hyperthyroidism in pregnancy

A

PTU, surgical removal 2nd trimester
NO iodine/radiological ablation
NO methimazole

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36
Q

treatment of hypothyroidism in pregnancy

A

levothyroxine
^TBG, so may need 25%^ dose
get TSH q4wks

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37
Q

seizure treatment in pregancy

A

Leviteracetam, Lamotrigine, phenobarbital are safer

NO valproic acid, phenytoin, carbamezipine

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38
Q

BP goal in preg

medications to use

A 
less than 140/80
safe meds: a-methyldopa, labetalol, hydrazine, nifedipine
"HTN moms love nifedipine"
no ACE-i, ARBs, CCB, diuretics
tight ecclampsia screening
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39
Q

insulin requirements in pregnancy

A

increase (with increased hormones)
basal-bolus insulin (transition before becoming pregnancy)
target post-prandial sugars
decrease insulin after delivery (need sugars!)

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40
Q

uncontrolled sugars early on

A

transposition of great vessels

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41
Q

uncontrolled sugars later on

A

macrosomia, shoulder dystocia, delivery complications

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42
Q

Labor stage 1

A

latent: dilation 0 cm to 6 cm (6 cm is critical point, after which cervix will rapidly dilate to 10 cm)
active: dilation from 6 cm to 10 cm
20 hrs nulli (1.2 cm/hr)
14 hrs multi (1.5 cm/hr)

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43
Q

Labor stage 2

A

10 cm (max) to delivery of fetus
3 hrs nulli
2 hrs multi

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44
Q

Labor stage 3

A

delivery of fetus to delivery of placenta

30 minutes

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45
Q

cervical change

A

breakage of disulfide bonds with infusion of water
softening, effacement (shorter), dilation (wider), position
happen in response to fetal head engagement

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46
Q

fetal station

A

use ischial spine (point 0)

  • 5: 5 cm deeper than ischial spine
    5: 5 cm out
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47
Q

fetal position

A

longitudinal cephalic
aligned with mom, head down
malalignment: longitudinal breech or transverse

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48
Q

how to determine fetal position

how to move baby

A

Leopold maneuver
can also use u/s
external version to move baby, if fails to align consider C-section

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49
Q

breech definitions

A

frank: hips flexed, knees extended
complete: hips and knees flexed
footling: either

50
Q

delay in active labor

A

no change in 4 hrs or progress takes longer than 5 hrs

51
Q

how to engage cervix in latent phase

A

balloon
amniotomy (rupture sac)
misoprostal (prostaglandin)
oxytocin* (used in active phase as well)

52
Q

3 Ps

A

passenger
pelvis
power: can augment with oxytocin

53
Q

adequate contractions

A

200 mV units in 10 minutes measured with IUPC
augmentation (oxy) not likely to help if sufficient
(good: 3 in 10 minutes, bad: less than 3 in 30 minutes)

54
Q

if oxytocin fails in active phase?

if in stage III?

A

C-section

if stage 3, may use forceps or vacuum if baby is positive position, C-section if negative

55
Q

delay of stage 3

A

is a problem with power (just placenta coming out)

start with uterine massage, then try oxytocin, THEN manual extraction (not D&C)

56
Q

delivery ranges

A

nonviable: 0-20/24 weeks
preterm: 24-37 weeks
term: 37-42 weeks
post-dates: +42 weeks
“treatment age”: 34 weeks

57
Q

PROM

A

Premature ROM:
term, before contractions (think GBS) if GBS+ or unknown give ampicillin
and wait for delivery

58
Q

duration of labor should not exceed

A

18 hrs

if +18: prolonged rupture of membranes

59
Q

how to determine ROM

A

nitralazine blue test : amniotic fluid turns it blue
slide shows ferning
U/S: oligo (less fluid)

60
Q

P-PROM

A

preterm premature ROM: before term, no contractions
if +34 weeks: deliver
if less than 24: abortion
in between: give steroids for lung maturity
may lead to prolonged ROM

61
Q

prolonged ROM

A 
18+ hrs
worry about GBS
endometritis (baby out) and chorioamnionitis (baby in)
mom will be feverish and toxic
Do NOT get vaginal cx
get U/A, CXR, blood CX
tx: amp and gent WITH clindamycin
62
Q

risk factors for prematurity (defined by contractions AND cervical change and before term)

A

smoking, young maternal age, multiple gestations, preterm ROM, anatomical abnormalities

63
Q

if preterm and between 20 and 34 weeks

A

give steroids and tocolytics

64
Q

post-date problems

A

40+ weeks by conception
42+ weeks by dates
macrosomia, dystocia, dysmaturity

65
Q

transient HTN

A

nonsustained +140/80

follow up with ambulatory BP log

66
Q

chronic HTN

A

sustained +140/80
onset before 20 weeks
no U/A findings, no symptoms
tx: a-methyldopa, may also use labetelol, hydralazine
f/u: close monitoring for pre-E (U/A, U/S)

67
Q

gestational HTN

A

sustained +140/90 AFTER 20 weeks
no U/A changes or symptoms
tx and f/u: same as chronic HTN
may progress to pre-E

68
Q

mild pre-eclampsia (PEC: pre-E without severe features)

A

sustained +140/90 after 20 weeks
+300mg/dL proteinuria on 24hr (1+ or 2+ on dipstick)
NO symptoms, some edema (hands, feet, face)
tx: deliver if 37+ wks
f/u: frequent screening and visits

69
Q

severe pre-eclampsia (SPEC: pre-E with severe features)

A

sustained + 160/110 after 20 weeks
+5g/mL proteinuria 24-hr (3+ dipstick), WITH symptoms (AMS, vision, liver), generalized edema
tx: Mg+ and deliver via induction

70
Q

eclampsia

A

SPEC with seizures

tx: Mg+ and deliver (C-section)

71
Q

HELLP syndrome

A

Hemolysis, Elevated Liver enzymes, Low platelets

tx: same was as eclampsia: Mg+ and deliver

72
Q

if giving Mg+ check for ?

A

decreased DTRs, may lead to decrease RR and resp. failure

tx: Ca2+ as antidote

73
Q

severe features of eclampsia

A

RUQ pain, low plts, ^LFTs, hemolysis, ^Cr (+1.1 or doubling), pulmonary edema, HA, vision changes, BP +160/110

74
Q

if twins are different genders

A

dizygotic gestation
dichorionic, diamniotic
2 fertilizations
risks: preterm delivery (4 wks for each visit), malpresenation (^risk C-section), postpartum hemorrhage

75
Q

if twins are same gender and 2 placentas are present

A

may be monozygotic gestation
dichorionic, diamniotic
(“identical twins”)
split in 0-3 days (tubal phase)

76
Q

if same placenta but 2 sacs

A

monozygotic
monochrorionic, diamniotic
split in 4-8 days (blastocyst phase)
risk: same blood supply so twin-twin transfusion (donating twin will do better than receiving twin)

77
Q

if same placenta and 1 sac

A

monozygotic, monochorionic, monoamniotic
split 9-12 days
risk: conjoined twins (if split +12 days), cord entanglement (also twin-twin transfusion)

78
Q

post partum hemorrhage

A

+500 cc in vaginal delivery
+1000 cc in C-section
pregnant females can tolerate more blood loss

79
Q

PPH and uterus is absent?

A

uterine inversion
contracting so hard it “births” itself, due oxytocin of ^traction
tx: try to put back manually, may need tocolytics and uterine tonics

80
Q

PPH and boggy uterus?

A

uterine atony
due to prolonged labor, oxytocin removed, given tocolytics
tx: massage, oxytocin, PGE, methergine, hemabate, may need sx

81
Q

PPH and firm uterus?

A

retained placenta
placenta burrows deeply, has accessory lobe, causes placental tear
tx: D+C, TAH
f/u: B-hCG, ensure no chorioamnionitis

82
Q

PPH and normal uterus?

A

vaginal laceration
due to precipitous delivery, macrosomia, episiotomy
tx: pressure, suture, look for DIC

83
Q

if can’t find cause of PPH and/or it is refractory to treatment

A

2 large bore IVs (18 gauge+), IVF, type/cross, call surgeon

may try IV estrogen but likely to be unsuccessful

84
Q

surgical treatments for refractory/unexplained PPH

A

uterine artery ligation (OB)
uterine artery embolization (IR)
TAH (OB)

85
Q

placenta probs

A

accreta: deeper into endometrium
percreta: into myometrium
increta: all the way throw myometrium, may progress to outside organs
may result in retained placenta, may see blood vessels go all the way to edge of removed part of placenta

86
Q

DIC

A

low platelets (give platelets), low Hgb (give pRBCs), less fibrinogen (give cryoprecipitate), ^INR (give FFP), schistocytes

normal fibrinogen after delivery is ABNORMAL (should be elevated)

87
Q

why no ACE-I and ARBs

A

cause fetal malformations

88
Q

high-risk pregnancy or decreased fetal movement algorithm

A

1st do NST
if non reassuring, repeat NST after vibroacoustic stimulation
if still not good BPP (0-10)
if BPP is 0-2 fetal demise imminent (deliver- C/S)
if BPP less than 8 and +37 wks: deliver vaginally
if BPP less than 8 and less than 37 wga: contraction stress test (CST)
if bradycardia or late decels: delivery imminent (C/S)

89
Q

what you want on NST

A

appropriate variability (no flat lining or too much)
accelerations: 15/15 (acceleration rises 15 bpm and last for 15 seconds), 2 in 20 min (10/10 if less than 32 wga)
no decelerations

90
Q

BPP

A

like “APGAR score” use if fail NST + VAS
look at NST, AFI, breathing, movement, tone
0-2 pts for each

91
Q

AFI

A 
divide uterus into 4 quadrants
sum of all 4, normal is +5
reassuring: 8-25
oligo: less than 5 (kidney problem)
poly: +25 (GI problem)
92
Q

CST

A

+ contractions
look for LATE decelerations and bradycardia
used in labor or if failed BPP
want 3ctx/10 minutes (200 mV units)

93
Q

Late decelerations

A

look like they start when contractions peak
utero-placental insufficiency
immediate C/S

94
Q

painless vs painful 3rd trimester bleeding

A

painless: placental problem, baby’s blood (previa, occurs with dilation)
painful: uterus problem, mom’s blood

95
Q

placenta previa dx and tx

A

baby is in transverse line on U/S, NST or CST will show fetal distress
VASA previa will only show fetal distress on NST/CST
tx: urgent (not emergent) C/S

96
Q

Rh Antibodies

A

“D” antibodies matter (Rh D IgG is antidote)
titers + if greater than 1:8
(bigger number after colon, higher titer)

97
Q

if mom has + Rh Ab titers (+1:8) and TCD shows ^flow, what to do next?

A

deliver if +32 weeks (earlier than other diseases)

if less than 32 weeks: do PUBS (determine baby Hgb and can transfuse)

98
Q

tests no longer used in Rh alloimmunization

A

amniocentesis, Liley Graph

99
Q

GBS screening

A

urine culture wk 10
rescreen wk 35
if no screening, baby will be toxic day 1 after birth
tx: ampicillin
next line (based on allergies): cefazolin, clindamycin, vancomycin

100
Q

risk factors for GBS

A

previous GBS+, prolonged ROM, intrapartum fever

101
Q

Hep B prophylaxis for baby if mom is Hep B+

A

passed through blood, do C-section, give Hep B IVIG, Hep B vaccine to baby day 1

(vaccinate mom before she gets pregnant)

102
Q

if HIV+ at 10 wk screen

A

tx: 2 NRT-i + 1 NNRT-i or Protease-i + ritonavir
NRT-i’s: Tenofovir +Emtricitabine (class B)
older/cheaper: Zidovudine + Lamivudine (class C)
NNRT-i: Nevirapine
PI: Atazanavir
NO Enfavirenze

103
Q

what to do when HIV+ mom presents in labor

A

viral load less than 1000 and on HAART can deliver vaginally!
otherwise: C-section
if do not know status and presents in labor: give AZT

104
Q

do not need ampicillin if mom is GBS+ when?

A

planned C/S with NO ROM with onset of labor

105
Q

brain calcifications, ventriculomegaly, seizure, what to ask and what should have done?

A

did mom have a “mono-like” illness? think Toxo

should have gotten Toxo-Ab screen: if + no worries, if - at risk of contracting during pregnancy, avoid cat litter

106
Q

syphilis stages and dx

A

1: painless chancre (Darkfield microscopy)
2: targetoid lesions (palms and soles) (RPR, FT-Abs)
latent: + but no symptoms (2)
3: neuro symptoms (CSF: VDRL or RPR*)

107
Q

syphilis tx

A 
all stages get PCN
1, 2, EL: IMx1
LL: IM qwk for 3 wks
3: IV q4hrs for 7-10 ds
(even if PCN-allergic)
108
Q

congenital syphilis

A

1st trim: dead baby

3rd trim: snuffles, saber shines, saddle nose, hutchinson’s teeth

109
Q

congenital rubella

A

if mom has primary viremia
blueberry muffin rash
cataracts, congenital heart disease, deafness
(IUGR/abortion if 1st trim)
give MMRV 3 months prior to getting pregnant!

110
Q

congenital HSV

A 
primary viremia in mom with painful, burning prodrome, then vesicles 
IUGR, preterm delivery, blindness
dx: HSV PCR from scraping of rash
tx: val or acyclovir
C-section if active lesions
111
Q

urgent vs emergent C-section

A

urgent: prolonged labor, arrest of labor, ecclampsia?
emergent: hemodynamic instability, fetal distress

112
Q

vaginal birth after C-section?

A

low risk: 2 or less C/S with low transverse cuts (attempt to VBAC, if fail called TOLAC)
high risk: greater than 2 C/S with any that were not low transverse cuts (planned C/S)

113
Q

when to use vacuum/forceps

A

fetal distress and prolonged or arrest of labor
need full effacement, +2 station
risk: denuding vagina with vacuum, cephalohematoma or Bell’s palsy with forceps

114
Q

episiotomy types

A

medial: most common, easy to re-suture, more painful and risk of grade 4
mediolateral: hurts less, harder to repair, no risk grade 4

115
Q

laceration grades

A

1: only vagina
2: involves perineal body
3: into anal sphincter but not mucosa
4: invades into anal mucosa, may form rectovaginal fistula

116
Q

cerclage

A

used to prevent incompetent cervix (repeat STIs, dilations, PID, D/C), see 2nd trimester losses
put in week 14 (risk of ROM)
take out week 36 (may cause rupture if leave in)

117
Q

anesthesia

A

general: opiates, avoid in latent phase stage 1, may prolong and may need to give baby naloxone upon delivery
epidural: requires tocometer and coach (risk: hypotension and death if lidocaine into subdural)

118
Q

injected anesthetics

A

paracervical: stage 1: prevents pain of dilations (fetal HR may drop)
pudendal: stage 3: helps pain of delivery

119
Q

long acting reversible contraception (LARC)

A

non-IUD (under skin): Explanon, Implanon, last 3 yrs
IUD:
hormonal: 5 yrs (E+P so may ^DVT risk, decrease bleeding overall)
copper: 10 yrs (may ^bleeding)
both ^risk PID (get genital cx prior to placement)

120
Q

“Ingestion” contraception in decreasing order of efficacy

A

injections: Depo-provera (last 3 mos)
patches: ortho-Evra (1 mo) (highest risk of DVT/PE)
rings: Nuva-ring (1 mo)
OCPs: (E+P) good for dysf. bleeding, chorio, GTD, molar
mini pill: progesterone only (less DVT risk) requires higher compliance down to hr

121
Q

DVT risk

A

estrogen contraception
smoking
age (+35)

122
Q

Plan B

A

Levonogestrel
used within 72 hrs
not abortifactant

OBGYN Step 2 (5 decks)

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