OB (part 2)- Exam 3 Flashcards

Question

# ⭐️ Spontaneous Abortion (Stillbirth) * What is it? * Occurs when usually? * Usually frome what?

Answer 1

* Spontaneous expulsion of fetus prior to 20 weeks gestation (miscarriage) and is most common complication of pregnancy * 80% occur within the first 12 weeks * 50% result from chromosomal defects (fetus wouldn’t have been viable anyway) ## Footnote 20% of pregnancies terminate in spontaneous abortion

Answer 2

15% infections, medical disorders (DM, obesity, thyroid disease, SLE), substance abuse (esp. cocaine and tobacco), medications * Trauma seldom causes first-trimester miscarriage * Major abdominal trauma can cause fetal loss, more likely as pregnancy advances * Dietary deficiency of one nutrient or moderate deficiency of all does not appear to increase risk (hyperemesis gravidarum)

Answer 3

* Cervix is dilated some products of conception remain. Tissue may remain entirely in the uterus or partially extrude through the cervix * SSX: Mild cramping. Bleeding, may persistent and excessive

Answer 4

* Products lying loosely in cervical canal can be easily extracted. Prompt removal to stop bleeding and decrease risk infection * With incomplete expulsion: curettage, expectant management or misoprostol (last two not options in clinically unstable women or those with infection)

Answer 5

Products of conception passed. Cervix closed. May have spotting.

Answer 6

Pregnancy ceases to develop and symptoms of pregnancy disappear Laboratory Findings: * Low or falling levels hCG * CBC if bleeding heavy * Rh Type, give Rh(D) immune globulin if Rh-negative * Tissue recovered should be sent to pathology, may be sent for genetic analysis

Answer 7

Transvaginal Ultrasound: * Crown-rump length of 7 mm or more and no heartbeat * Mean sac diameter of 25 mm or more and no embryo Treatment: * Surgical or medical evacuation; * Expectant observation; underperforms medical or surgical evac, 15-50% failure

Answer 8

* Preterm premature rupture of membranes (PPROM) at a previable gestational age (<22 weeks) * Rupture may be spontaneous or may follow invasive procedure such as amniocentesis or fetal surgery

Answer 9

* Risks: prior PPROM, prior second-trimester delivery, tobacco use * Confirmation with STERILE speculum exam; pooling; amnionic fluid will fern on a microscope slide or have pH>7; oligohydramnios on sonography

Answer 10

* Iatrogenic: higher in uterus, may self seal; amniopatch * First trimester: almost always followed by uterine contractions or infection; termination is typical

Answer 11

* If no pain, fever, or bleeding, fluid may have collected previously between amnion and chorion, Observation is reasonable; recheck 48 hours, if no additional amniotic fluid, resume ambulation and pelvic rest at home * 40-50% deliver within first week, average 2 weeks; High risk chorioamnionitis, endometritis, sepsis, placental abruption, retained placenta, if bleeding cramping, fever MUST EVACUATE UTERUS

Answer 12

* Induced abortion * Within 9 weeks of LMP, medical termination is an option * Mifepristone: antiprogesteronal steroids that works by blocking the activity of progesterone, thereby ending pregnancy * Methotrexate: Methotrexate interferes with the growth of the placenta, which allows it to separate from the endometrium (type of chemotherapy - antifolate)

Answer 13

* First trimester and early second trimester, D&C with conception products removed via suction or sharp curette * In second trimester, destructive grasping forceps may be used

Answer 14

Fertilized ovum implants outside the endometrial cavity * >95% in the fallopian tube (tubal pregnancy) * endocervical canal (cervical pregnancy) * ovary (ovarian pregnancy) * Scar from prior cesarean (cesarean scar pregnancy) * In peritoneal cavity (abdominal pregnancy

Answer 15

* Leading cause of pregnancy-related death in the first trimester; 4-10% of all pregnancy-related deaths * Risk Factors: PID (damage, obstruction adhesions), Assisted Reproductive Technology (ART), Smoking, 5% of IUD pregnancies are ectopic but IUD does not elevate risk, use of clomiphene, advanced maternal age

Answer 16

Risk: Spontaneous rupture; occurs 6-16 weeks depending on location. Symptoms: Pelvic or abdominal pain in almost 100% cases * Abnormal uterine bleeding 75% cases; light spotting to heavy * Amenorrhea; approximately half of women with ectopic pregnancies have some bleeding at the time of their expected menses and may not realize they are pregnant * Syncope, dizziness, lightheadedness; raises suspicion for intra-abdominal bleeding from a ruptured ectopic pregnancy. Kehr sign

Answer 17

Exam: * Tenderness, adnexal mass, uterine changes, HEMODYNAMIC INSTABILITY Lab: Hematocrit, quantitative beta-hCG, progesterone * Progesterone level <5 ng/mL has 100% specificity for identifying an abnormal pregnancy, but does not identify location (>20 normal pregnancy, 5-20 equivocal)

Answer 18

* Transvaginal Ultrasound: location or “pregnancy of unknown location” (may not see anything until hCG is ~2000) * Beta-hCG rises slower than with normal pregnancy * Progesterone level <5 ng/ml

Answer 19

Expectant: asymptomatic, lower starting hCG levels and evidence ectopic pregnancy is spontaneously resolving (decreasing hCG levels). 88% will experience resolution with expectant management. Medical management: with an antifolate; i.e., Methotrexate (MTX) * Hemodynamically stable with confirmed ectopic pregnancy * Cannot use if embryonic cardiac motion, gestational sac larger than 3.5cm, of hCG>5000 * Expect 15% decrease from day 4 to day 7 after MTX

Answer 20

Surgical Treatment * MAINSTAY of treatment for ectopic pregnancy; despite declining rates of surgical management, remains most definitive treatment * Laparoscopy standard approach Emergency treatment * Request blood products immediately * Deteriorate quickly * Rh (D) immunoglobulin given to any Rh-negative mother with diagnosis

Answer 21

* Concurrent of ectopic and intrauterine pregnancies * Ectopic pregnancy is treated with Laparoscopy and Salpingectomy/salpingotomy * Laparotomy in instable patients * Methotrexate is contraindicated

Answer 22

Premature separation of the placenta Risk factors: * Maternal Hypertension (Most common) * Previous placental abruption (10% after one, 25% after two) * Trauma * Polyhydramnios with decompression * Premature rupture of membranes * Short umbilical cord * Cocaine and/or Tobacco use * Folate deficiency

Answer 23

Clinical Presentation: PAINFUL VAGINAL BLEEDING (80%), uterine tenderness (66%), Fetal distress (60%), uterine hyperactivity and increased tone (34%), fetal demise (15%).

Answer 24

* Largely clinical * US may only detect 2%; may exclude placenta previa * Elevated 2nd trimester AFP associated with increased risk of abruption

Answer 25

* Maternal hemodynamic monitoring, may be rapid deterioration * Fetal monitoring, may be rapid deterioration * Serial evaluation of hematocrit and coagulation profile * Blood products on hand + Rhogam * Delivery is definitive (via C/S)

Answer 26

* Fetus at significant risk of hypoxia and death * Perinatal mortality rate 35%; 15% of third-trimester stillbirths * MOST COMMON CAUSE of DIC in pregnancy * Hypovolemic shock and acute renal failure

Answer 27

* 70% present with painless vaginal bleeding; mean 30 weeks * 20% have contractions with bleeding * 10% incidental finding on US

Answer 28

* Prior c/section or scars on uterus * Multiparity * Increasing maternal age * Prior placenta previa (4-8% risk) * Multiple gestation

Answer 29

Placental location close to or completely covering the cervical os Classified as: * Complete: the entire cervical os is covered * Partial: margin of the placenta extends across part, but not all, of the internal cervical os * Marginal: edge of the placenta lies adjacent to the internal os * Low lying: placenta is located near but not adjacent to the internal os

Answer 30

* US, transvaginal almost 100% accurate, transabdominal 95% * 4-6% of patients have some degree of placenta previa on US before 20 weeks; upward migration of placenta, 90% resolve by third trimester * If dx in second trimester, repeat US 30-32 weeks * Partial and low-lying placenta previa often resolve by 32-35 weeks * DIGITAL EXAM IS CONTRAINDICATED prior to US due to the risk of hemorrhage

Answer 31

* Goal to obtain fetal maturity via amniocentesis without compromising mother’s health * If bleeding is excess, Cesarean delivery regardless of gestational age * If bleeding not profuse or repetitive, expectant management; 70% will have recurrent bleeding and require delivery before 36 weeks

Answer 32

Rupture of the amniotic sac before labor begins * Before 37 weeks it is Preterm PROM (PPROM) Etiology and Risk factors * Vaginal and cervical infections * Abnormal membrane physiology * Incompetent cervix or multiple gestation * Nutritional deficiencies ## Footnote 8-10% of pregnancies

Answer 33

* Vaginal loss of fluid and confirmation of amniotic fluid in the vagina; nitrazine paper or ferning on slide * Sterile vaginal exam * US to assess fetal anomalies, assess gestational age and amniotic fluid level

Answer 34

* Risks of preterm delivery vs risks of infection and sepsis * PPROM: Conservative expectant management while watching for signs of infection; gram stain of amniotic fluid * PROM 36 weeks or later, induce labor if no spontaneous contractions 6-12 hours

Answer 35

Amniotic fluid * Protects against infection, trauma and cord prolapse * Allows for fetal movement and breathing Major Risks of PROM * Intrauterine infection (chorioamnionitis) * Cord prolapse * Placental abruption – premature detachment from uterine wall

Answer 36

* Preterm Labor: presence of regular uterine contractions associated with w/cervical changes prior to 37 weeks * Preterm Delivery: delivery before 37 weeks * Spontaneous: 40-50% with intact membranes & 25-40% with preterm rupture of membranes * Multigestation is the most common risk factor

Answer 37

* Bronchopulmonary dysplasia * Visual or hearing impairment * Developmental delays * Cerebral palsy

Answer 38

* fFN a "trophoblast glue" binds the uterine-placental and decidual-fetal membrane * It is released into cervicovaginal secretions when the cellular matrix of these structures is disrupted * Rise may be associated with increased risk of birth between 22 and 34 weeks ## Footnote Test secretions for this trophoblastic glue. - if its not present – unlikely to go into preterm laborr.

Answer 39

* Measured by transvaginal u/s between 16 and 28 weeks * Cervical length ≤20mm before 25weeks requires vaginal progesterone supplementation * Weekly IM injections of progesterone from 16-20 weeks through 36 weeks (also if documented hx of preterm birth) * No intervention has been proven beneficial in multiple gestations with a short cervical length, monitoring is not recommended in this population

Answer 40

* Cervical dilation and effacement before week 24 without contractions, vaginal bleeding, ruptured membranes or infection * Once dilated to 4 cm, active uterine contractions or rupture of membranes may occur * Risk factors: Congenital disorders of collagen synthesis, hx cone bx, hx deep cervical laceration (vaginal or cesarean), Prior excessive or rapid dilation with instruments, Mullerian duct defects, >=2 prior fetal losses during 2nd trimester, multiple gestations

Answer 41

* Pelvic exam; eval cervix, see if amniotic sac has begun to protrude (Prolapsed fetal membranes) * Transvaginal US to evaluate length of cervix and membrane protruding * Lab: may do amniocentesis to rule out infection of the amniotic sac and fluid (chorioamnionitis)

Answer 42

* Cerclage for a viable IU pregnancy less than 24 weeks, purse-string suture around cervix. May be done before week 14 prophylactically for patients with hx of premature birth. Suture removed last month of pregnancy, before labor * Progesterone supplementation in second and third trimester

Answer 43

* 2-7 day delay * Goal is to allow time for administration of corticosteroids for fetal lung maturity * Magnesium sulfate, terbutaline or nifedipine

Answer 44

* Advanced labor – not going to stop it * Mature fetus * Intrauterine infxn * Significant vaginal bleeding * Severe preeclampsia

Answer 45

* Pulmonary system is among the last of the fetal organ systems to mature * Not indicated if delaying delivery will place the mother or fetus at significant risk * No assessment before 32 weeks because we are assuming prematurity

Answer 46

* Indicated before elective deliveries that are, or may be, less than 39 weeks of gestation * Amniotic fluid is obtained by amniocentesis or, in women with ruptured membranes, from fluid pooled in the posterior vaginal fornix * Testing for components of fetal lung secretions in amniotic fluid (surfactant)

Answer 47

* Accelerate development of alveolar cells responsible for the production and secretion of surfactant * Induce enzymes that stimulate synthesis and release of surfactant * Indicated between 23-34 weeks gestation

Answer 48

* Betamethasone (two doses of 12 mg given IM 24 hours apart) * Dexamethasone (four doses of 6 mg given IM 12 hours apart)

Answer 49

Administered at 23 to 34 if increased risk of preterm delivery within the next seven days Avoid after 34 weeks of gestation * Low risk of severe respiratory morbidity * Lack of consistent evidence of corticosteroid efficacy * Theoretic potential for long-term harm following late exposure

Answer 50

Administered to all women at high risk for preterm delivery unless "impending" delivery (birth expected within an hour or two) is anticipated

Answer 51

* Fetal buttocks or lower extremities present into the maternal pelvis * Prior to 28 weeks, about 25% of fetuses are in breech presentation, most resolve by 34 weeks

Answer 52

* Major factor is prematurity * 20-30% low birth weight * Fetal structural anomalies (such as hydrocephalus) restrict ability to present as vertex 6% * Other: uterine anomalies (bicornuate uterus), multiple gestation, placenta previa, hydramnios, contracted maternal pelvis, pelvic tumors

Answer 53

* Complete (25%): both thighs flexed, one or both knees flexed (squat position) * Incomplete/footling (10%): one or both thigs extended, one or both knees or feet lying below the buttocks * Frank (65%): both thighs flexed and both lower extremities are extended at knee

Answer 54

* Leopold examination (aka external cephalic version) * Ultrasound * Vaginal exam in labor

Answer 55

* Exclude fetal and uterine anomalies: Ultrasound * External cephalic version (ECV) at 37 weeks: manually converts breech fetus to vertex, about 60% successful; 2% may revert to breech (lessen by waiting to 37 weeks) * Vaginal delivery depends on “experience of the health-care provider”, presentation, facility, maternal anatomy and health; Standard of care is cesarean section * If unable to perform cesarean, assisted breech delivery

Answer 56

* Dystocia 30% * Repeat cesarean 25-30% * Breech presentation 10-15% * Fetal distress 10-15% * Absolute indication “classical” cesarean delivery incision through myometrium of the uterus * Complications from placenta previa

Answer 57

* Prior classical or T-shaped uterine incision * Previous uterine rupture * Medical or obstetrical complications that preclude vaginal birth (eg, placenta previa/breech presentation) * Inability to perform emergency cesarean delivery due to factors related to the facility, including availability of the surgical, anesthesia, or nursing staff

Answer 58

* ANY Blood loss at time of vaginal or c/s delivery CAUSING signs and symptoms of hypovolemia; or 10% decrease in hematocrit * May occur immediately postpartum or slowly over the first 24 hours * Leading cause of maternal mortality worldwide

Answer 59

*** Uterine atony (75-80%)** * Genital tract trauma * Retained placental tissue * Low placental implantation * Uterine inversion * Coagulation disorders * Abruptio placentae * Amniotic fluid embolism * Retained dead fetus

Answer 60

Dx: Identification of cause with systematic approach: * Palpate the uterus to determine presence or absence uterine atony * Inspect vagina and cervix for lacerations * Uterine inversion or pelvic hematoma * Manual exploration of the uterine cavity (gloved hand) * If not cause of bleeding found; coagulopathy

Answer 61

* Treat underlying cause * Stop source of bleeding * Atony: Oxytocin to increase uterine tone, bimanual compression and massage; IR intervention with thrombolytics, hysterectomy or ligation of the uterine arteries. * Remove retained products of conception * Uterine inversion; rapid shock, volume expansion, replace uterus after separated placenta completely removed * Thrombocytopenia: platelets

Answer 62

Placenta accreta: abnormal adherence of the placenta to the superficial lining of the uterus (doesn’t separate easily) Placenta increta: placental penetration into the uterine muscle Placenta percreta: complete invasion of the placenta through the uterine muscle

Answer 63

Disruption of hemostasis * Systemic activation of blood coagulation, results in generation and deposition of fibrin and formation of microvascular thrombi in the small blood vessels through the body (thrombosis) and activation of plasmin (fibrinolysis and hemorrhage), eventually leading to multiple organ dysfunction * Widespread clotting depletes the platelets and clotting factors that are needed to control bleeding, excessive bleeding often occurs

Answer 64

* Acute peripartum hemorrhage (uterine atony, cervical and vaginal lacerations, uterine rupture * Placental abruption * Preeclampsia/eclampsia/HELLP * Retained stillbirth * Septic abortion and intrauterine infection * Amniotic fluid embolism * Acute fatty liver of pregnancy

Answer 65

* Prompt diagnosis and treatment of causative problem * Stop bleeding: Administer whole blood * Antibiotics: Broad Spectrum * Evacuation of the uterus

Answer 66

(H) Hemolysis, (EL) Elevated Liver Enzymes, (LP) thrombocytopenia Occurs in 4 – 12% of patients with preeclampsia or eclampsia (risk factor) Delivery is the only proper way to treat HELLP syndrome * Also, correct coagulopathy

Answer 67

Spectrum of disorders benign or malignant, nonmetastatic or metastatic; arising from abnormal placental (trophoblastic) proliferation * More likely age >35 and in smokers * 80-90% benign course, dx remitting spontaneously

Answer 68

* Chorioadenoma: invasive mole, can metastasize * Choriocarcinoma (20%): frankly malignant, metastatic

Answer 69

Hydatidiform Mole: Benign but tissue can embolize to lungs 2 types * Complete Mole: An abnormal pregnancy when sperm fertilizes an egg that does not contain any genetic material. Molar pregnancy. (46XX). Most common and is paternal in origin. * Incomplete or Partial Mole: normal egg fertilized by two sperms (69XXY)-> Focal trophoblastic proliferation

Answer 70

* Uterine size mismatch (larger/double) to dates on exam * Bleeding and absence of fetal heart tone.

Answer 71

Lab: * High serum beta-hCG (high normal to millions), higher levels in complete mole Imaging: * Dx confirmed by US, “cluster of grapes” or “Snowstorm” * CXR to r/o pulmonary metastases

Answer 72

* Evacuation and sharp curettage of uterine cavity, regardless of duration of pregnancy * Weekly serum beta-hcg; should fall to normal within 12-16 weeks; * Initiate chemo if beta-hcg plateaus or rises: Methotrexate or Actinomycin D

Answer 73

* Locally invasive; may penetrate the entire myometrium, rupture through the uterus, and result in hemorrhage into the broad ligament or peritoneal cavity * 5-10% of molar pregnancies, usually those with persistent beta-hcg levels after molar evacuation * Treatment: Chemotherapy, Hysterectomy

Answer 74

* Presents with symptoms of metastatic disease; hemoptysis, cough, dyspnea, headaches, dizzy spells, “blacking out”, acute abdomen, neurologic signs * Dx: Beta-hCG, CT abdomen, pelvis, brain; LP for early detection brain mets * TX: Chemotherapy

Answer 75

* Normal pregnancy, insulin sensitivity decreases to ensure a steady stream of glucose delivery to the fetus * GDM believed to be exaggeration of the pregnancy-induced physiologic change; alternatively, pregnancy may unmask an underlying propensity for glucose intolerance and that it will declare itself in the future

Answer 76

* 50% of GDM will have diagnosis of DM in their lifetime * Risk: excessive fetal growth, increased maternal and perinatal morbidity; increased risk shoulder dystocia; increased cesarean delivery and preeclampsia (both overt DM and GDM)

Answer 77

Diagnosis is made if 2 of the 4 values are increased

Answer 78

* Diet and exercise is usually sufficient * Insulin is the only approved treatment * If insulin cannot be used, metformin next line * Patient education: Nutrition counseling and Pregnancy Risks

Answer 79

Risks associated with GDM: * Macrosomia (>4500 g) * Shoulder dystocia * Increased risk for c-section Consider induction in well controlled patients w/o complications at 38 to 39 wks

Answer 80

* Consider C-section if estimated fetal weight >4500g * Recurrence of gestational diabetes in 60%-90% of subsequent pregnancies

Answer 81

* Severe HTN increases mother’s risks MI, cardiac failure, CVA and renal failure * Fetus and neonate increased risk from complications from poor placental insufficiency, fetal growth restriction, preterm birth, placental abruption, stillbirth, and neonatal death

Answer 82

* Chronic HTN – before 20 weeks gestation * Gestational hypertension (aka Pregnancy Induced HTN): elevated blood pressure diagnosed for the first-time during pregnancy at or beyond 20 weeks, without proteinuria * Preeclampsia is onset of hypertension, proteinuria or other sequelae, typically after 20 weeks, usually third trimester.

Answer 83

Usually occurs near term Dx: * Elevated BP on 2 occasions 4 hours apart in previously normotensive woman at 20 weeks or more gestation and no proteinuria * Mild SBP >=140 or DBP >=90 (watch) * Severe SBP >=160 or DBP >=110 (treat) * Lab: hepatic transaminases, Creatinine, hematocrit and platelets, and a UA

Answer 84

Severe SBP >=160 or DBP >=110 (treat) * Methyldopa, Labetalol or Nifedipine

Answer 85

* Over 25% will develop preeclampsia * Mild gestational HTN not at increased risk of preterm birth, abruption or stillbirth * Severe: at risk of all of the above.

Answer 86

* Baseline US for fetal weight and amniotic fluid index as well as NST (and biophysical profile (BPP) if NST is nonreactive, * Repeat US every 3 weeks * Weekly NST (and BPP if indicated) * Daily fetal kick counts * Twice weekly maternal BP * Evaluation of proteinuria each visit * Weekly CBC, liver enzymes, serum creatinine * Delivery at 37 weeks. If any complication (i.e., preeclampsia), delivery at 34 weeks

Answer 87

* Most experience normalization of BP 2 weeks after delivery * 20% will have persistently elevated BP after 12 weeks and meet dx criteria for chronic hypertension * Recurrence 46.8% in subsequent pregnancies

Answer 88

* Occurs at or after 20 weeks gestation * Risks: Nulliparous, >35 years of age, hx previous preeclampsia, Chronic HTN, chronic renal dx, hx thrombophilia, multifetal pregnancy, IVF, DM, obesity, SLE

Answer 89

Without severe features: * fewer complaints, DBP <110, Platelet count over 100,000/mcL, fetal testing reassuring With severe features: * symptoms dramatic and persistent, HA, vision changes, SBP >160/110; thrombocytopenia (<100,000) * may progress to DIC; HELLP (Hemolysis, elevated liver enzymes, low platelets)is advanced severe preeclampsia

Answer 90

* Intrauterine growth restriction (IUGR) * Placental abruption * Maternal pulmonary edema

Answer 91

occurrence of seizure in setting of preeclampsia; manifestation of severe neuro involvement

Answer 92

Low-dose Aspirin 81mg starting at 12-28 weeks for at risk Initial eval in hospital, delivery if indicated * Home management for pts without severe features if stable, reliable, and rapid access to hospital * Induce labor or C/S at 37 weeks

Answer 93

Delivery is cure and usually indicated Magnesium sulfate IV 4-6g load over 15-20 minutes, then 2-3g/h; continues for 24 hours postpartum to prevent seizures especially if there are clinical signs of hyperreflexia * Therapeutic serum level of Magnesium is 4-6mg/ml Stabilize Blood pressure: goal to get SBP <160 and DBP<110 * Labetalol, hydralazine, nifedipine

Answer 94

* Corticosteroids for fetal lung development (If less than 34 weeks) * Hospitalization and close monitoring in tertiary center if able to stabilize mother and allow for further fetal development until 34 weeks in absence of life-threatening conditions for mother or fetus.

Answer 95

* Eclampsia * Pulmonary edema * DIC * Uncontrollable severe hypertension * Abruptio placenta * Nonviable fetus <23-24 weeks * Intrauterine fetal demise * Nonreassuring fetal status

Answer 96

* Persistent symptoms * HELLP syndrome * Fetal growth restriction that is less than 5th percentile * Severe oligohydramnios * Reversed end-diastolic flow in umbilical artery doppler studies * PPROM * Significant renal dysfunction

Answer 97

* Presence of convulsions in a woman with preeclampsia that is not explained by another neurologic disorder * Usually occur within 24 hours of delivery * Tx: Seizure precautions + delivery of fetus + Magnesium + Hydralazine/Labetalol/Nifedipine

Answer 98

Postpartum anterior pituitary necrosis stemming from excessive post-partum bleeding, hypovolemia and shock. * Higher prevalence in developing countries who have not benefited inpractical and scientific advances of maternal care

Answer 99

Pituitary is not able to produce hormones * 1st sign – absence of lactation (agalactorrhea) * Later -> amenorrhea or oligomenorrhea, hot flashes and decreased sex drive, hypothyroidism symptoms, adrenal insufficiency (hyponatremia, anemia and hypoglycemia).

Answer 100

May present as pan-hypopituitarism or as selective loss of pituitary function * Symptoms can become evident months to years after initial shock.

Answer 101

Anterior pituitary hormones (FSH, LH, GH, PRL, ACTH, TSH) * GH tends to be the first one affected, TSH is last. Should also evaluate the secondary effects (CBC/BMP, TSH, FSH, LH, prolactin, estrogen, cortisol)

Answer 102

Lifelong replacement of affected hormones * TSH – levothyroxine * Cortisol – prednisone * Gonadotropin * If uterus present -> estrogen and progesterone * If uterus absent -> estrogen * GH – refer to endocrinologist

Answer 103

Worst complications: Addisonian crisis and Myxedema coma leading to death

Answer 104

Nearly 20% of women experience violence during pregnancy * Adolescents and unintended pregnancies have unequally higher prevalence Violence does not have to be physical (verbal/emotional, manipulative, financial) * Credit score is a strong coefficient to intimate partner violence (IPV)

Answer 105

1 in 5 women who experience IPV later develop PTSD during pregnancy * Women with PTSD are at higher risk for pre-term delivery, low birthweight and postpartum depression/anxiety * ASD/PTSD should be screened during perinatal and postnatal periods

Answer 106

Postpartum phenomenology is characterized by a range of emotions from transient mood lability, irritability, and weepiness, to marked agitation, delusions, confusion, and delirium leading to maternity or postpartum blues, puerperal or postnatal depression, or postpartum psychosis.

Answer 107

Link noted to decrease in gonadal steroids in postpartum period * Progesterone drops in second stage of labor, estrogen drops with expulsion of placenta * Estrogen affects monoaminergic system which directly affects serotonin (affective symptoms) and dopamine (psychotic symptoms)

Answer 108

Primigravida; unmarried mother; cesarean sections; family hx or personal hx of psychiatric disorders or IPV

Answer 109

* Frequent crying episodes, irritability, confusion, and anxiety * Experienced by most mothers (~85%) to some extent with higher incidence in developed countries (lack of family support) * Symptoms arise within 10 days and peak at 3-5 days post childbirth * Symptoms do not interfere with social or occupation functioning * Treatment is supportive and if symptoms persist >2 weeks, high alert should be placed to identify postpartum depression

Answer 110

* Personal Hx of depression raises incidence by 25%, where past PD in previous pregnancies increases risk by 50%. * Negative thoughts are typically related to the newborn * Pervasive depressed mood, disturbances of sleep and appetite, low energy, anxiety, and suicidal ideation

Answer 111

* Symptoms appear within a few days to weeks, but generally 2-3 months after childbirth * Pharmacotherapy is reserved for moderate symptoms or postpartum psychosis

Answer 112

* Typically appears within 2 weeks of delivery, at most 3 months after childbirth * Past Hx of psychosis or Bipolar d/o are major risk factors

Answer 113

Typical Sxs: elation, lability of mood, rambling speech, disorganized behavior/hyperactivity, and hallucinations or delusions (persecution) * Delusions revolve around the infant, especially that the infant is possessed, has special powers, is divine, or is dead Should be regarded as psychiatric emergency * Infanticide and suicide are observed in 4% and 5% respectively, therefore enquiring about suicidal and infanticidal thoughts is crucial during the assessment

Answer 114

* May utilize “Edinburgh Postnatal Depression Scale,” and the “Mood Disorder Questionnaire” to improve awareness * Exclude organic etiology: Sheehan

Answer 115

Psychotherapy (CBT) Pharmacotherapy (most will spill into breastmilk) * Psychotropics: fluoxetine, sertraline, paroxetine, and nortriptyline * Atypical antipsychotics or lithium in postpartum psychosis: Valproic acid or carbamazepine may be used Electroconvulsive therapy