OB (part 2)- Exam 3 Flashcards

Question 1

Q

Vaginal Tears
* What is first and second degree tear?

Answer

A

First-degree tear: The least severe of tears, this small injury involves the first layer of tissue around the vagina and perineal area.
Second-degree tear:The most commonly seen tear during childbirth. The tear is slightly bigger here, extending deeper through the skin into the muscular tissue of the vagina and perineum.

Question 2

Q

Vaginal Tears
* What is third and fourth tear?

Answer

A

Third-degree tear:Tear extends from your vagina to your anus. This type of tear involves injury to the skin and muscular tissue of the perineal area, as well as damage to the anal sphincter muscles.
Fourth-degree tear: The least common type of tear during childbirth. Extending from the vagina, through the perineal area and anal sphincter muscles and into the rectum, this injury is the most severe type of tear

Question 3

Q

Postpartum Care
* Monitor what?
* What is postpartum infections? What are the 7 Ws?

Answer

A

Monitor for hemorrhage: blood loss in excess 500 mL immediate post partum
Postpartum infection: fever of 100.4 on two or more times during first 10 days postpartum, exclusive of first 24 hours.
7 Ws: Womb, Wound, Wind (atelectasis, pneumonia), Water (UTI), Wonder drug (drug allergy), Walk (thrombophlebitis), Woman’s breast (Mastitis)

Question 4

Q

Postpartum Care
* What type of counseling?
* What will after with BP after birth?
* What type of resources?
* What will change shape?

Answer

A

Contraceptive Counseling
Postpartum Hypertension; pregnancy induced HTN will usually return to normotensive range within a few days of delivery.
Breast feeding and resources
Cervical os changes in shape post vaginal delivery

Question 5

Q

Metritis
* what is it?
* Aka what?
* Ascending infection from where?
* MC infection after what?

Answer

A

Infection of the uterine cavity and adjacent tissue
AKA: endomyometritis, endometritis, metritis with cellulitis
Ascending infection from the lower genital tract
Most common infection after C/Section

Question 6

Q

Metritis
* How do you dx it?
* How do you tx it?

Answer

A

Dx: Fever (post-op day 1 or 2) and uterine tenderness

Tx: IV ABX until patient is asymptomatic and afebrile for 24 hours
* Clindamycin(900 mg every eight hours) plus gentamicin(1.5 mg/kg every eight hours)
* Add ampicillinor vancomycin if patient has not improved in 48-72 hours

Question 7

Q

What is Puerperium?

Answer

A

period following delivery to 6 weeks post partum

Question 8

Q

Puerperium:
* What happens to Maternal reproductive organs and physiology?
* Uterus size?
* What happens to the cervix?
* What regains their former tone?

Answer

A

Maternal reproductive organs and physiology return toward pre-pregnancy state
Uterus decreased from about 1000g at delivery to 100 to 200 g at 3 weeks
Cervix loses its elasticity and regains firmness
Supportive tissues of the pelvic floor gradually regain their former tone

Question 9

Q

Puerperium
* What happens to cardiovascular?
* Psych changes?
* Menstrual flow usually returns when?

Answer

A

Cardiovascular: immediately following delivery, marked increase in peripheral vascular resistance, cardiac output and plasma volume return to normal during first 2 weeks
Psychosocial changes: “postpartum blues”, “baby blues”, emotional and hormonal factors.
Menstrual flow usually returns 6-8 weeks, ovulation may not occur for several months, particularly in nursing mothers, contraception emphasized

Question 10

Q

Postpartum Care: postpartum blues
* Either who?
* _
* Which gender is most common?
* Starts when?

Answer

A

Either parent
Transient
50-80% of women
Starting 2-3 days after delivery and remitting within a few days to 2-3 weeks

Question 11

Q

Postpartum Care
* What is postpartum depression?
* What is postpartum psychosis?

Answer

A

Postpartum Depression
* Major depressive disorder occurring in the first postdelivery weeks.

Postpartum psychosis- life threatening
* Sudden onset usually within the first 2 weeks postpartum
* 5% risk of suicide/ 4% risk of infanticide

Question 12

Q

Postpartum Care
* Follow up when?
* What counseling?

Answer

A

Follow up in 6 weeks
Newborn care counseling

Question 13

Q

⭐️

Postpartum Changes
* What happens to the discharge? What are the different types? (3)

Answer

A

Lochia: postpartum discharge, very heavy for 2-3 days, lasts for several weeks
* Lochia rubra – menses like bleeding
* Lochia serosa – less blood
* Lochia alba – whitish discharge

Question 14

Q

⭐️

Postpartum Changes
* Perineum txt?

Answer

A

Oral analgesics (NSAIDS)
Ice packs
Topical anesthetics
Sitz baths 24 hours after delivery

Question 15

Q

⭐️

Postpartum Period
* What happens to the breast? What is the txt?

Answer

A

Breast engorgement – takes 2-3 days for milk to come in after engorgement
* Ice packs
* Analgesia
* Supportive undergarment
* Discourage manual expression of milk if lactation suppression is desired

Question 16

Q

⭐️

Postpartum Period
* What happens to the milk?
* Breasting is recommended how?

Answer

A

Colostrum: small amounts, first few days and nutrient dense; slowly replaced by milk
Breastfeeding is recommended exclusively for 6 months (AAP and WHO), and supplement with breast milk for 2 years.

Question 17

Q

LY

Question 18

Q

⭐️

Drugs in Breastmilk
* What are the safe drugs?(5)

Answer

A

Alpha/Beta blockers, CCBs, ACEI, HCTZ (may reduce milk supply)

Question 19

Q

⭐️

Drugs in Breastmilk
* What are the drugs that are bad?

Answer

A

Retinoid
Valproic acid ⭐️
Antineoplastics/cancer (pump and dump 15 days)
HIV Antiviral
HIV is contraindicated to breastfeeding in the US
Amiodarone (if used >5 days)
Immunosuppressants
Antibiotics (Doxycycline, ciprofloxacin, gentamicin)

Question 20

Q

⭐️

Postpartum Period: Contaception
* What may inhibit milk supply?
* What is the only safe option? When do you start it?
* IUD?

Answer

A

Combined oral contraceptives may inhibit milk supply

Progestin only preparations are “safe” for breastfeeding
* Initiate at 6 weeks if breastfeeding exclusively
* Initiate at 3 weeks if not breastfeeding exclusively

Initiate at 3 weeks if not breast feeding (any method)

IUD 4-6 weeks postpartum

Question 21

Q

⭐️

Postpartum Period
When do patients start sexual activity?
* What might need to be necessary for sex?
* Initiate what prior to intercouse?
What happens with weightloss?

Answer

A

Sexual activity
* Can resume as soon as the patient is comfortable (general advice is 6 weeks)
* External lubrication may be necessary
* Initiate contraception prior to intercourse

Weight loss
2 lbs per month will not affect lactation

Question 22

Q

⭐️

Threatened Abortion
* What is it?
* What are the sxs?

Answer

A

Vaginal bleeding without tissue passage through a closed cervical os during first 20 weeks.
* 50% proceed to spontaneous abortion
Sx: suprapubic discomfort, mild cramps, pelvic pressure, persistent low backache.

Question 23

Q

⭐️

Threatened Abortion
* Must be differentiated from what?
* What is the tx?
* Single pregnancy loss does not what?

Answer

A

Must be differentiated from implantation bleeding (bleeding at time of expected menses); 1/4 women have bleeding in early gestation
Tx: No proven treatment; Observation; Tylenol for discomfort-> NSAIDs?
Single pregnancy loss does not significantly increase risk of future pregnancy loss

Question 24

Q

Question 25

Q

⭐️

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

Answer

A

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)

20% of pregnancies terminate in spontaneous abortion

Question 26

Q

⭐️

Spontaneous Abortion (Stillbirth)
* What are other causes besides chromosomal defects?

Answer

A

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)

Question 27

Q

⭐️

Inevitable/Incomplete abortion:
* What is it?
* What are the sxs?

Answer

A

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

Question 28

Q

⭐️

Inevitable/Incomplete abortion:
* What is the txt?

Answer

A

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)

Question 29

Q

⭐️

What is complete abortion?

Answer

A

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

Question 30

Q

⭐️

Missed Abortion
* What is it?
* What disappears?
* What are the lab findings? (4)

Answer

A

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

Question 31

Q

⭐️

Missed Abortion
* What does the transvaginal US?
* What is the txt?

Answer

A

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

Question 32

Q

⭐️

Inevitable Abortion
* What is it?
* Rupture may be what?

Answer

A

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

Question 33

Q

⭐️

Inevitable Abortion
* What are the risks? (3)
* Confirmation with what?

Answer

A

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

Question 34

Q

⭐️

Inevitable Abortion
* What is the txt for iatrogenic and first trimester?

Answer

A

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

Question 35

Q

⭐️

Inevitable Abortion
* What is the txt for second trimester?

Answer

A

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

Question 36

Q

⭐️

Pregnancy Termination (Therapeutic)
* Another term?
* how far along can you have this?
* What are the two medications? What do they do?

Answer

A

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)

Question 37

Q

⭐️

Pregnancy Termination (Therapeutic)
* First trimester and early second trimester, what are the options?
* In second trimester, what is the option?

Answer

A

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

Question 38

Q

Ectopic Pregnancy
* What happens?
* Where are many of them?

Answer

A

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

Question 39

Q

Ectopic Pregnancy
* Leading cause of what?
* What are risk factors?(4)

Answer

A

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

Question 40

Q

Ectopic Pregnancy
* What does it increase the risk of?
* What are the sxs?

Answer

A

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

Question 41

Q

Ectopic Pregnancy
* What does the exam show?
* what does the lab show?

Answer

A

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)

Question 42

Q

Ectopic Pregnancy
* How do you dx it?

Answer

A

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

Question 43

Q

Ectopic Pregnancy
* What is the txt?

Answer

A

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

Question 44

Q

Ectopic Pregnancy
* What is the surgical txt?
* What is the emergency txt?

Answer

A

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

Question 45

Q

Heterotopic Pregnancy
* What is it?
* How is the extopic pregnancy treated with?
* What in instable patient?
* What is contraindicated?

Answer

A

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

Question 46

Q

Abruptio placentae
* What is it?
* What are the risk factors?

Answer

A

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

Question 47

Q

Abruptio placentae
* What is the clinical presentation?

Answer

A

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

Question 48

Q

Abruptio placentae
* how do you dx it?
* What can be elevated?

Answer

A

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

Question 49

Q

Abruptio placentae
* What is the txt?

Answer

A

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)

Question 50

Q

Abruptio placentae
* What are the fetus and maternal fetal risks?
* What does it cause?

Answer

A

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

Question 51

Q

⭐️

Placenta Previa
* What is the clinical presentation?

Answer

A

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

Question 52

Q

⭐️

Placenta previa:
* What are the risk factors? (5)

Answer

A

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

Question 53

Q

⭐️

Placenta Previa
* What is it?
* What are the classifications? (4)

Answer

A

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

Question 54

Q

⭐️

Placenta Previa
* how do you dx it?
* What is contraindicated?

Answer

A

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

Question 55

Q

⭐️

Placenta Previa
* What is the txt?

Answer

A

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

Question 56

Q

Premature Rupture of Membranes (PROM)
* What is it?
* What are the RFs? (4)

Answer

A

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

8-10% of pregnancies

Question 57

Q

Premature Rupture of Membranes (PROM)
* how do you dx it?

Answer

A

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

Question 58

Q

Premature Rupture of Membranes (PROM)
* how do you txt it?

Answer

A

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

Question 59

Q

PROM and PPROM
* What is amniotic fluid for? (2)
* What are the major risks of PROM? (3)

Answer

A

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

Question 60

Q

Preterm Labor and Delivery
* What is preterm labor?
* What is perterm delivery?
* Spontaneous with what? (2)
* What is the most common risk factor?

Answer

A

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

Question 61

Q

Preterm Labor and Delivery
* What are the effects of preterm delivery? (4)

Answer

A

Bronchopulmonary dysplasia
Visual or hearing impairment
Developmental delays
Cerebral palsy

Question 62

Q

Prediction of Preterm Labor: Fetal fibronectin
* What is fFN?
* When it is released?
* Rise may be associated with what?

Answer

A

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

Test secretions for this trophoblastic glue. - if its not present – unlikely to go into preterm laborr.

Question 63

Q

Prediction of Preterm Labor: Cervical length
* Measured by what?
* Cervical length ≤20mm before 25weeks requires what?
* Weekly IM injections of what?
* No intervention has been proven beneficial in who?

Answer

A

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

Question 64

Q

Incompetent Cervix: “Silent” cervical dilation
* What is it?
* What are the risk factors?

Answer

A

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 63

A

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 64

A

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 65

A

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

Answer 66

A

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

Answer 67

A

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 68

A

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 69

A

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 70

A

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

Answer 71

A

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 72

A

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

Answer 73

A

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 74

A

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 75

A

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 76

A

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

Answer 77

A

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 78

A

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 79

A

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 80

A

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 81

A

* 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 82

A

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 83

A

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 84

A

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 85

A

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 86

A

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 87

A

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

Answer 88

A

(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 89

A

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 90

A

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

Answer 91

A

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 92

A

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

Answer 93

A

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 94

A

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 95

A

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 96

A

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 97

A

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 98

A

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 99

A

Diagnosis is made if 2 of the 4 values are increased

Answer 100

A

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 101

A

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 102

A

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

Answer 103

A

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 104

A

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 105

A

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 106

A

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

Answer 107

A

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 108

A

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 109

A

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 110

A

ACEI, ARB

Answer 111

A

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 112

A

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 113

A

Intrauterine growth restriction (IUGR)
Placental abruption
Maternal pulmonary edema

Answer 114

A

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

Answer 115

A

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 116

A

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 117

A

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 118

A

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

Answer 119

A

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 120

A

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 121

A

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 122

A

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 123

A

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

Answer 124

A

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 125

A

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 126

A

Worst complications: Addisonian crisis and Myxedema coma leading to death

Answer 127

A

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 128

A

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 129

A

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 130

A

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 131

A

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

Answer 132

A

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 133

A

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 134

A

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 135

A

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 136

A

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 137

A

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

Answer 138

A

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