OB OME Flashcards
Define and treat chronic htn in pregnancy
^140/^90 before 20 wks gestation
Tx alphamethyldopa
Can consider hydralazine and labetalol
((Avoid typical thiazide diuretics, acei’s, arb’s, ccb’s - teratogenic))
Define and manage mild preeclampsia
^140/^90 after 20 wks gestation
^300mg/dL proteinuria
Mag and deliver if ^36 wks
Wait and allow dev/growth if v36 wks
Define and manage severe preeclampsia
^140/^90 after 20 wks gestation
^5Gg/dL proteinuria
With sx (abdominal pain, headache, visual changes, ankle edema)
Mag and deliver emergently
Treat eclampsia
Stabilize seizure with mag
Emergent delivery
Treat HELLP
Emergent delivery
Epigastric pain in pregnancy
Think
Gerd (common)
Eclampsia HELLP Preeclampsia (Life-threatening)
tf
14 wk preggy htn to 145/95 first time recognized in office, treat?
F
To dx and tx htn, need 2 separate readings from 2 separste locations at least 2 weeks apart
So f/u 2 weeks for remeasurement
Can consider alphamethyldopa then
Most common cause of bilateral ankle edema in pregnancy
Vena cava compression
Signs of magnesium toxicity (eg to look for in mag check in preeclamptic preggy)
Mag mechanism
Treat toxicity
Hyporreflexia first
Respiratory depression next
Death
Mag blocks nmda channels, countering calcium flux
So give calcium carbonate to reverse toxicity
Route of mag administration for eclampsia
IV
Severe features of preeclampsia
BP ^160/110 Thrombocytopenia v100 AST and ALT elevated x2 uln Cr ^1.1 renal insufficiency Pulmonary edema New onset cerebral or visual disturbances
tf
Eclampsia always requires c-section
F
Not always – can induce labor as long as mom amd baby are stable
Quad screen for downs
HCG and Inhibin A UP
msAFP and Estriol DOWN
Quad screen for edwards
HCG and Inhibin A DOWN
msAFP and Estriol DOWN
Edward is down for everything
Inhibin A in triple screen
Inhibin A
Up in downs
Down in edwards
Variable in patau
Most common cause of elevated maternal serum AFP
Other causes
Mis-estimated gestational age
Neural tube defects
Abdominal wall defects
Multiple gestation
Elevated msAFP on prenatal screen
Next steps
Ultrasound to rule out mis-estimated geststional age
Chorionic villus sampling
Or Amniocentesis
To assess for chromosomal abnorm or ntd
Amniocentesis vs chorionic villus sampling
Both can be done after triple/quadruple screen and nuchal translucency ultrasound suggest a trisomy
Chorionic villus sampling can be done after 12wks to inform a 1st trimester abortion, higher risk to fetus
Amniocentesis can be done after 16wks to inform an early 2nd trimester abortion, lower risk than chorionic villus sampling
Percutaneus umbilical blood sampling
Done after fetal transcranial ultrasound to assess anemia and transfuse baby
Follow up a decreased nuchal translucency ultrasound
Chorionic villus sampling if ^12wks
Amniocentesis if ^16 wks
If clinical use eg elective termination or risk planning
cfDNA screens for
Downs
Rh mismatch
Sex determination maybe
Sheehan’s syndrome
Pres
Pathophys
Etiology
Vague symptoms of lethargy, weight gain, fatigue
Orthostasis, thinning hair, delayed dtr’s… weeks-months after giving birth
Panhypopituitarism
no ACTH driving Cortisol
no TSH driving T4
Lack of LH FSH and GH not as symptomatic with contributions to fatigue and amenorrhea
Ischemic necrosis of pituitary with INTRAPARTUM BLEED or POST-PARTUM HEMORRHAGE
Symptoms of panhypopituitarism
Vague symptoms of lethargy, weight gain, fatigue
Orthostasis, thinning hair, delayed dtr’s, amenorrhea
no ACTH driving Cortisol
no TSH driving T4
Lack of LH FSH and GH not as symptomatic with contributions to fatigue and amenorrhea
No-Drugs teratogenic list in pregnancy CV drugs Psyche drugs Abx Neuro drugs Acne drugs Antineoplastic/immunosuppressives
CV - ACEI's and ARBs Psyche - Lithium Abx - Tetracyclines eg Doxy Neuro - antiepilepticS espec phenytoin Acne drugs - Isoretinoin Vit A Antineo/immunosup - Thalidomide, MTX
Why do levothyroxine levels need to be increased for hypothyroid pt who gets pregnant?
Prenancy increases thyroglobin… which binds T4 keeping it reserved but inactive
And probably need increases… that is why the increase in thyroglobin? Helps the euthyroid mama keep up with demand?
Major side effect of
Valproate
Lithium
Escitalopram
Valproate - liver tox and blood disorders
Lithium - renal tox
Escitalopram - serotonin syndrome (ssri)
How does Quetiapine cause amenorrhea and galactorrhea
Atypical antipsychotic
Can cause promactinemia
Has antidopaminergic action
Block dopamine, release prolactin
TF
Gentamycin amd ciprofloxacin are contraindicated in pregnancy
T
What happens to TSH Total T4 and free T4 in a normalpregnancy
TSH and free T4 normal
High Total T4 because estrogen induced increased thyroglobulin
Treat UTI in preggy with ___ not ___
Nitrofurantoin (Macrobid)
Not TMP-SMX (Bactrim) – contraindicated in pregnancy
TF
RPR and VDRL are specific for treponemes
How to follow up a positive
F
Can be positive with inflammation of other sorts eg lupus
So if screen positive with one of these, usually follow-up with a treponeme specific test like fta-abs, microhemagglutination, enzyme immunoassay, chemiluminescence assay, darkfield microscopu
How to act on fetal bradycardia after paracervical block with lidocaine
Watch and wait – brady will be temporary…
When to do c-section vs vacuum/forceps for arrest of active labor with adequate contractions
C-section if stuck at 0 station
Vac/forceps if stuck at +1 or +2
How does accidental subdural anesthetic present
Like shock – subdural can travel up and down spine, causing sympathetic block and diaphragmatic block – hypotension, compensatory tachycardia, tachypnea but shallow with accessory muscles from diaphragmatic block, sob, tingling in distal extremities
IUD vs BTL for contraception?
Prefer IUD… non-invasive, 5 year protection but reversible of desired, less risk of regret, surgical scarring, ectopic
OCPs increase risk of
Decrease risk of
Increase vasculopathy
-DVT most significantly, also HTN, DM, hypertriglyceridemia
Decrease
Ovarian cancer (less cyst eruption)
Endometrial cancer (less inflammation)
Benign breast disease
Emergency contraception can be used within how long of unprotected sex
120hrs 5 days
Plan B generic
Mechanism
Not effective if
Levonorgestrel (progestin)
Prevent ovulation and implantation (negative feedback on LH FSH, thickens cervical mucus, alters endometrium)
Not effective if implantation had already occured
Breast feeding mom who is married wants temporary contraception
Mini pill (progestin) Breast feeding - does not impact milk production Married - does not need sti protection Wants more kids - temporary
IUD (progestin) could also be a reasonable amswer for 5 years contraception, can be placed before discharge or at first post-partum visit
Which female hormone negatively impacts breast milk production
Estrogen
p only vs ep pill timing strictness
p only needs strict on the hour daily timing
ep is more forgiving/lax
TF
Femal condom/diaphragm protects against STI’s
T
Barrier and Sperimicidal agent coating
Tests to work up secondary amenorrhea, in order
UPT TSH PRL FSH
How does prolactin cause amenorrhea
Inhibits GnRH release
Savage syndrome
aka
pathophys
presentation
aka resistant ovary syndrome
ovaries good to go with follicles intact but do not respond to FSH and LH which are elevated for this reason
Woman too young for menopausal symptoms abated with estrogen/OCP
resistant ovary syndrome
aka
pathophys
presentation
Savage syndrome
ovaries good to go with follicles intact but do not respond to FSH and LH which are elevated for this reason
Woman too young for menopausal symptoms abated with estrogen/OCP
why does PCOS bleed with progestin challenge
because anovulation and constant estrogen leave endometrium constantly growing… finally sloughed with exogenous progestin
TF
can see ovarian follicles on US in premature ovarian failure
F
no follicles
how does premature ovarian failure present differently from savage/resistant ovary syndrome
same early menopausal symptoms but follicles not present on ultrasound in premature ovarian failure
TF
side effects of oral contraception include premature ovarian failure
F
think more DVT or weight gain
LH:FSH level in PCOS
LH:FSH level in menopause
PCOS 3:1
menopause 1:3
what does clomiphene do
induces ovulation eg in PCOS
scant vaginal fluid that is acidic and easily fractrures, classic for what phase of menstruation
early follicular
vaginal fluid descriptions
early follicular
ovulatory
mid luteal
late luteal
early follicular - scant, acidic, easily fractrures
ovulatory - thin, stretches to 6cm, ferns, higher pH
mid luteal - thickened with less stretch
late luteal - thickened with less stretch
(built to keep foreign bodies out unless ovulating
TF
in vitro fertilization or artificial insemination can be used when “uterus is inhospitible to sperm+
T
just need to bypass inhospitable cervical secretions
in vitro or artificial insem can work as long as axis is working…
Suspect PCOS, next test to dx
LH:FSH ratio ^3:1
Hint ultrasound is not a necessary or sufficient part of the diagnosis
PCOS at risk for what cancer
Endometrial
(No ovulation, no luteal/progesterone phase, unregulated estrogen (turned to testosterone peripherally) and unregulated endometrial growth
When to get dexa for menopause
Age 65
Or earlier if risk factors for osteoporosid
Role of venlafaxine in menopause Drug class Mechanism in menopause
Treat hot flashes
snri
No one knows mechanism for this use
What is AMH anti-mullerian hormone a sign of
Marker for primordial ovarian follicles / ovarian reserve
