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Deck of Secret Knowledge > OB Proper (Abnormal) > Flashcards

OB Proper (Abnormal) Flashcards

0
Q

Abortion in the 1st Trim

Common causes

A

80% of abortion in the first 12 weeks.
Usually fetal cause (aneuploidy)
2nd most common: Monosomy X

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1
Q

Termination of pregnancy prior to 20 weeks gestation, or fetal weight <500g

A

Abortion

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2
Q

Abortion in the second trim

A 
Maternal causes usually
Uterine abnormalities (septate uterus)
Uterine duplication
Uterine myoma
Cervical incompetence
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3
Q

Risk factors associated with abortion

A

1) Infection: TORCH
2) Chronic maternal illness
3) Thyroid autoantibodies
4) DM
5) Progesterone deficiency
6) Tobacco, Alcohol, Caffeine
7) Radiation

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4
Q

How much caffiene is associated with abortion

A

> 500mg/day.

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5
Q

What type of abortion?

Retrochoreal hemorrhage on utz, closed cervix

A

Threatened

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6
Q

What type of abortion?
Absent heart sounds
Uterine size incompatible with AOG
(+) bleeding

A

Inevitable

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7
Q

What type of abortion?
(+) retained products
(+) hemorrhagic shock

A

Incomplete

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8
Q

What type of abortion?
Empty gestational sac in blighted ovum
Closed cervix
Absent bleeding

A

Missed

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9
Q

What type of abortion?
Empty uterus, no bleeding
Incompatible uterine size

A

Complete

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10
Q

When does one do D&C for abortions?

A

Inevitable, Incomplete, Missed

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11
Q

Causes of Recurrent Pregnancy Loss

Genetic

A

Balanced translocation

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12
Q

Causes of Recurrent Pregnancy Loss

Hormonal and metabolic

A

Luteal phase defect
PCOS
DM
Hypothyroidism

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13
Q

Causes of Recurrent Pregnancy Loss

Infections

A

Toxoplasma gondii

Listeria monocytogenes

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14
Q

Causes of Recurrent Pregnancy Loss

Uterine abnormalities

A 
Septate uterus
Bicornuate uterus
Incompetent cervix
Asherman syndrome
Submucous myoma
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15
Q

What is Asherman Syndrome?

A

Aka Fritsch syndrome, condition characterized by adhesions and fibrosis of the endometrium, associated with congenital defects, previous D&C, abortion

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16
Q

Causes of Recurrent Pregnancy Loss

Thrombophilia & Autoimmune disorders?

A

Factor V Leiden

APAS

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17
Q

What is an Incompetent cervix?

A

Common cause of pregnancy loss or preterm labor in the late second trim
Defined as cervical dilation of at least 1cm, with cervical length <2cm.
Tx: McDonald Cerclage, Shirodkar cerclage

Risk factors: previous incompetent cerclage, hx of conization, DES exposure, uterine anomalies

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18
Q

When does ovulation resume after an abortion?

A

after 2 weeks

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19
Q

GTD

Karyotype of Incomplete mole? Complete?

A

Incomplete: 69, XXY, extra paternal set
Complete: 46, XX, paternally derived chromosomes

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20
Q

GTD
Hydropic villi with severe trophoblastic hyperplasia
Size large for age
Theca Lutein cyst in 25% of cases

A

Complete Mole

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21
Q

GTD

Focal hydropic villi, minimal trophoblasts, size equals date, slightly elevated HCG

A

Incomplete/partial mole

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22
Q

UTZ differences between complete and partial mole?

A

Complete: snow storm pattern
Incomplete: Swiss cheese pattern

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23
Q

Treatment of hydatidiform moles

A

Suction D&C
Hysterectomy if >35 yo and undesirous of future pregnancy
HCG measurements every 2 weeks until with 3 consecutive negative values
OCPs for 1 year
GTN prophylaxis (controversial)

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24
Q

Signs of very high HCG (>100,000)

A

Pre-eclampsia before 20 weeks AOG
Hyperemesis gravidarum
Thyrotoxicosis
Presence of Theca Lutein cysts

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25
Q

Components of the WHO Prognostic scoring for GTD

A 
Age
Antecedent Pregnancy
Interval months from index event
Pretreatment HCG
Largest tumor size
Sites of metastasis
Number of metastasis
Previous failed chemotherapy / chemoprophylaxis
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26
Q

GTN
Most common GTN
Very sensitive to chemotherapy

A

Invasive mole

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27
Q

GTN

Primarily secretes prolactin and gonadotropins

A

PSTT

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28
Q

GTN

Extremely malignant form of chorionic epithelium

A

Choriocarcinoma

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29
Q

Treatment of GTN II:7 and below

A

Single agent: Methotrexate or Actinomycin D

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30
Q

Treatment of GTN III:8 and above

A

EMA-CO

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32
Q

Ectopic Pregnancy

Most recognized risk factor

A

Hx of PID

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33
Q

Ectopic Pregnancy

Rupture timings of different types?

A

Ampulla: 8-12 weeks
Isthmus: 6-8 weeks
Interstitial: 16 weeks

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34
Q

Ectopic Pregnancy

Best Predictor of resorption

A

HCG < 1000 at time of diagnosis

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35
Q

Ectopic Pregnancy

Greatest risk factor

A

Documented tubal pathology & Previous ectopic pregnancy

36
Q

Ectopic triad

A

Amenorrhea
Vaginal bleeding
Abdominal pain (most common)

37
Q

Signs of Unruptured Ectopic Pregnancy

A

Cervical motion tenderness

Unilateral adnexal tenderness

38
Q

Signs of Ruptured Ectopic pregnancy

A

Hypotension, tachycardia

Peritoneal signs

39
Q

HCG level when a gestational sac is expected

A

1500

Presumptive evidence of ectopic pregnancy esp if with TV-UTZ w/o evidence of sac

40
Q

Serum level of progesterone for normal pregnancies

A

> 25ng/L

If <5ng/L, consider ectopic pregnancy

41
Q

Gold standard for diagnosis of ectopic pregnancy

A

laparoscopy

42
Q

Medical Management of Ectopic Pregnancy

Requisites

A

Methotrexate 50mg/m2 IM

1) < 3.5 cm
3) Absence of fetal cardiac act
4) B-HCG < 1500
5) Unruptured

43
Q

Surgical Management of Ectopic pregnancy

A

ExLap with salpingiectomy

1) Severely damaged tube
2) Recurrent ectopic preg
3) Uncontrolled hemorrhage
4) Desire for sterility

44
Q

Best indicator for the success of medical management

A

BHCG levels before treatment, best if <1000.

14% failure rate at 5000-10000.

45
Q

Late Pregnancy Bleeding

A 
Third Trimester Bleeding
Postpartum Hemorrhage (PPH)
46
Q

Painful Causes of 3rd trim bleeding? Painless? Non-obstetric causes?

A

Painless: placenta previa, vasa previa
Painful: uterine rupture, abruptio placenta (most common)
Non-obstetric: cervical polyp, vaginal lesions

47
Q

Risk factors for Placenta Previa

A

Multiparity
Increased maternal age
Mult. abortions
Previous CS

48
Q

Bleeding due to the velamentous insertion of the umbilical cord

A

Vasa previa

Tx: expectant management up to 37th week, emergency CS

49
Q

Cause of bleeding in placenta previa vs. vasa previa

A

PP: Avulsion of anchoring villi of a low implanted placenta - maternal blood
VP: vessels may pass over the cervical OS and rupture - fetal blood

50
Q

Key pathophysiologic feature of Abruptio Placenta

A

Hemorrhage into the Decidua basalis

51
Q

Major risk factors for abruptio

A

Pre-eclampsia
Short umbilical cord
Trauma
Cig. smoking, alcohol, advanced age

52
Q

Management of Abruptio

A

Diagnostic: UTZ - retroplacental clots, Amniotomy - bloody amniotic fluid

Fetus alive: CS under GA
Fetus dead, patient not in DIC: Vaginal delivery under pudendal block
Fetus dead, patient in DIC: CS under GA

53
Q

Complications of Abruptio

A

1) Couvelaire uterus - uterine apoplexy
2) Acute renal failure
3) DIC

54
Q

Most common cause of uterine rupture

A

Previous CS scar

Other causes: Oxytocin stimulation during labor

55
Q

Tx of Uterine rupture

A

Repair of rupture

Hysterectomy

56
Q

PPH

4 major causes

A

Tone: Abnormal uterine contractility
Tissue: Retained products of conception
Trauma: Genital tract trauma
Thrombin: Abnormalities of coagulation

57
Q

PPH
Abnormal Uterine Contractility
High yield card

A 
Overdistended uterus (mult. gest, polyhydramnios, macrosomia)
Uterine muscle fatigue (prolonged, augmented labor)
Chorioamnionitis
Uterine distortion (placenta previa, myoma)
Uterine relaxants (B-mimetics, MgSO4, anesthesia)
58
Q

PPH
Retained products of Conception
High yield card

A

Accreta (placenta adherent to myometrium)
Increta (placenta invades myometrium)
Percreta (placenta perforates past the myometrium)
Risk factors: scarred uterus, previa, multiparity

Retained products of conception: Manual placental removal, succinturiate lobe

59
Q

PPH
Genital tract trauma
High yield card

A 
Cervical/vaginal laceration (precipitous delivery, macrosomia, dystocia, operative delivery, forceps, episiotomy)
Extension of CS (deep engagement, malposition, malpresentation)
Uterine rupture (Scarred uterus)
Uterine inversion (fundal placenta, grand multiparity, excessive traction on the umbilical cord)
60
Q

PPH
Coagulation abnormalities
High yield card

A 
Preexisting clotting anomalies (Hemophilia, von Willebrands disease, etc)
Acquired in pregnancy (Sepsis)
DIC (IUFD)
HELLP (Hemorrhage/Pre-eclampsia)
APAS
61
Q

Postpartum Hemorrhage
Definitions
SVD
CS

A

SVD > 500cc

CS > 1000cc

62
Q

Management of Uterine atony

A 
Conservative measures:
Uterotonics (oxytocin, methylergonovine)
Uterine massage
Ice pack
Hemostatics with blood volume replacement

Non-surgical procedures:
Bimanual compression
Balloon tamponade, uterine packing

Surgical procedures:
B-Lynch
Uterine artery ligation
Hysterectomy

63
Q

Placenta accreta pathophysiology

A

Partial or total absence of the decidua basalis
Imperfect development of the fibrinoid layer (Nitabuch layer)

Tx: Blood replacement
Prompt hysterectomy OR Uterine packing with methotrexate injection

64
Q

Puerperal hematoma
Risk factors:
Tx:

A

Nulliparity
Episiotomy
Forceps

Tx: Incision and Drainage

65
Q

Pathognomic finding of amniotic fluid embolism

A

Detection of squamous cells or fetal debris in the central pulmonary circ.
AFE is characterized by abrupt onset hypotension, DOB, and DIC

66
Q

Differentiate PROM, PPROM, Prolonged PROM

A

PROM: >37weeks AOG, ROM 1 hour before labor
PPROM: PROM 18hours before onset of labor

67
Q

Management of PROM, PPROM, PPPROM

A

PROM: Labor induction, GBS prophylaxis
PPROM: Steroids if <34 weeks, expectant management, GBS prophylaxis

68
Q

Indications for Delivery: PPPROM, PPROM

A 
Active labor
Chorioamnionitis
Non-reassuring testing
IUFD
Significant vaginal bleeding
Increased concern for cord prolapse
69
Q

Organisms Associated with preterm labor

A

Ureaplasma urealyticum, Mycoplasma hominis, Gardnerella vaginalis, peptostreptococci, and Bacteroides species

70
Q

Biochemical markers of Preterm labor

A 
Fetal fibronectin (FFn): >50ng/mL
Salivary estriol: >2.3ng/mL
71
Q

Clinical diagnosis of preterm labor

A

1 uterine contraction in 10 minutes with duration of 30 seconds or more
4 contractions in 20 minutes
Regular uterine contractions 5-8 minutes apart with:
- progressive cervical change
- cervical dilatation of 2 cm
- cervical effacement >80%

72
Q

What cervical UTZ findings suggest preterm labor

A

Cervical length <35mm (williams)
Funneling (bulging of the membranes into the endocervical canal and protruding at least 25 percent of the entire cervical length)

73
Q

Tocolytics for controlling preterm labor

A

1) MgSO4 (Williams - not of use)
- blocks calcium influx by competing at the receptor binding sites

2) Nifedipine
3) Terbutaline, Ritodrine
4) Indomethacin

74
Q

Dosing of Steroids for Fetal Lung maturity

A

Betamethasone 2 doses q24

Dexamethasone 4 doses q12

75
Q

Other benefits of Corticosteroids for premature infants

A

Decreased RDS

Decreased IVH

76
Q

Fetal lung maturity assessment

A

Surfactant-albumin ratio > 55

Lecithin-sphingomyelin ratio > 2

77
Q

Post term Pregnancy

Definition

A

42 completed weeks or more, or >294 days since 1st day of LNMP.

78
Q

Differentiate macrosomia and Dysmaturity syndrome

A

Macrosomia:
Placental fxn continued
Healthy, large fetus
Increased incidence of dystocia

Dysmaturity
Placental insufficiency
Dry parchment like skin, wasted, malnourished, meconium stained, increased alertness
Increased acidosis, oligohydramnios, cord compression, asphyxiation, and meconium aspiration

79
Q

Breech

Type of breech with highest incidence of cord prolapse

A

Incomplete / Footling

20-24% incidence

80
Q

Breech

Most common type of breech, lowest incidence of cord prolapse

A

Frank breech

81
Q 
Cord Prolapse risks
Cephalic
Frank
Complete
Footling
A

Cephalic 0.4%
Frank 0.5%
Complete 5%
Footling 15%

82
Q

Methods of vaginal delivery

A

SBD - no traction/support
Partial breech extraction - unassisted up to umbilicus
Total breech extraction - entire body extracted

83
Q

Maneuvers for breech

Delivery of posterior shoulder

A

Lovesets

84
Q

Maneuvers for breech

Preferred delivery method for the aftercoming head

A

Pipers forceps

85
Q

Maneuvers for breech

Index and middle finger placed on fetal maxilla to maintain flexion, then traction with other hand

A

Mauriceau

86
Q

Maneuvers for breech
aka Breech decomposition
Frank breech converted to footling

A

Pinard’s

87
Q

Maneuvers for breech
Used for persistent fetal back
legs grasped and body is swung over abdomen

A

Prague maneuver

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