OBGYN

Question 1

How would you treat crashing amniotic fluid embolism pt?

Answer 1

levo, inhaled epoprostenol, cryoprecipitate vs FFP (cryo preferred for less volume) if fibrinogen < 200

Question 2

What is thought to be the cause of amniotic fluid embolism?

Answer 2

Amniotic fluid embolism is thought to result from a maternal inflammatory response that occurs when fetal antigens cross the fetal-maternal barrier and enter into the maternal circulation. The overwhelming inflammatory response, similar to that of anaphylaxis, leads to massive circulatory collapse

Amniotic fluid embolism is relatively rare, affecting anywhere from 1/8,000 to 1/80,000 births per year,

Question 3

When during pregnancy can amniotic fluid embolism occur?

Answer 3

during or after labor, delivery, trauma, or pregnancy termination (anything causing maternal inflammatory response when fetal antigens cross fetal-maternal barrier and enter maternal circulation. Can occur after amniocentesis as well. Can occur after vaginal or c section delivery

Question 4

General clinical presentation of amniotic fluid embolism?

Answer 4

pts often experience episode of AMS that leads to both pulmonary and systemic HTN. Quickly devolves into hypoxia, hypotension, and profound consumptive coagulopathy.

Question 5

Differentials to consider in pregnant woman in critical distress

Answer 5

eclampsia, ACS/myocarditis, PE, amniotic fluid embolism, anaphylaxis, placental abruption

Question 6

What are classic lab abnormalities found in amniotic fluid embolism?

Answer 6

consumptive coagulopathy (ie DIC). Fibrinogen level may be low

Question 7

Treatment of amniotic fluid embolism?

Answer 7

supportive. Vasopressors, inotropic support, inhaled epoprostenol or nitric oxide, cryo>FFP,

Question 8

Key surgical differentials for pts with pelvic pain

Answer 8

uterine rupture, ectopic preg, ovarian torsion, ruptured appendicitis, incarcerated hernia, necrotizing soft tissue infection

Question 9

“Top 6” pelvic pain diagnoses

Answer 9

Preg related: ectopic, placental abruption/uterine rupture

Gyn: ovarian torsion, PID

Non-Gyn: cystitis/pyelo/stone, appendicitis

Question 10

What is considered the discriminatory zone for hcg?

Answer 10

traditionally it was 1500-2000 but ACOG now recommending increasing to 3500 to minimize misdiagnosis.

Question 11

When can hcg be used in ectopic?

Answer 11

Methotrexate can be used for stable patients without underlying hematologic, renal or hepatic issues, have beta-HCG <5,000 mUL/ml, no fetal cardiac activity on transvaginal ultrasound, not currently breastfeeding, and compliant with follow-up

Surgical intervention is required for patients who are unstable, for ectopic pregnancies advanced in development (eg, fetal cardiac activity present).

Question 12

When is peak incidence of placental abruption?

Answer 12

third trimester, >50% before 37 weeks

Question 13

Risk factors for placental abruption?

Answer 13

HTN, preeclampsia, smoking, cocaine use, trauma, multiple gestations, prior abruption, chorioamnionitis, thrombophilias

Question 14

What is the pathophysiology of placental abruption?

Answer 14

hemorrhage at the decidual-placental interface. Usually a complication of chronic pathologic vascular process of the placenta.

Thrombosis of the spiral arteries can occur as result of abnormal development, leading to infarction of the decidual vessels, necrosis, inflammation, bleeding. Cycle of hemorrhage and inflammation may lead to membrane rupture.

It is mediated by thrombin, which acts as a uterotonic, triggers the coagulation cascade, and triggers other cascades that perpetuate the cycle and can induce maternal DIC.

May also occur as result of trauma

Question 15

What is the key diagnostic test in placental abruption?

Answer 15

Tocodynamotery. As soon as pt is stable, admit or tx to OB unit for minimum of 4 hours of monitoring for contractions.

If 8 or more contractions occur within first 4 hours of monitoring, pt is very likely to be diagnosed WITH placental abruption

Question 16

Labs to send in suspect placental abruption beyond typical cbc cbmp

Answer 16

type and screen, DIC panel with fibrinogen, kelihauer-betke test

Question 17

What imaging should be ordered for suspected placental abruption?

Answer 17

US, though sensitivity poor at 60%, but can do CT if needed

Question 18

What is the bimodal incidence of ovarian torsion?

Answer 18

young (premenarcheal and reproductive) and postmenopausal

Question 19

Does pregnancy affect ovarian torsion rates?

Answer 19

yes , increases the OR 18:1 although it remains uncommon

Question 20

What is the pathophys of ovarian torsion?

Answer 20

twisting of ovary around infundibulopelvic ligament and the utero-ovarian ligament. Adnexal torsion refers to the twisting of the adnexal components - the overay and fallopian tube - and is the MOST COMMON type.

Twisting of ovary and/or fallopian tube impairs blood flow through ovarian artery and other vessels causing ischemia

Question 21

Does Doppler flow in suspected ovarian torsion rule it out?

Answer 21

No, flow can be observed in up to 60% of cases, so normal imaging does not rule it out

IF STILL IN PAIN, CALL OB

Question 22

What US sign is suspicious for ovarian torsion?

Answer 22

whirlpool sign - twisted pedicle vessels. High sensitive and predictive.

Question 23

What testing method is preferred for N gonorrhoeae and C trachomatis?

Answer 23

nucleic acid amplification tests (can be completed on first-catch urine or provider or self-administered swab. Similar sensitivities with both methods, however should not replace pelvic exam

Question 24

Antibioitics for PID outpt/inpt as of 2023?

Answer 24

Outpt: CTX IM x 1 (500 mg if <150kg), Doxy 100 mg BID x 14 days, Flagyl 500 mg BID

Inpt: CTX+DOXY+FLAGYL

Question 25

What is the pathophysiology of appendicitis?

Answer 25

believed to be from obstruction of appendix by fecalith/parasite/hyperplasia of tissue (lymphoid/fibrotic/neoplastic tissue).

Obstruction of the lumen causes increased pressure, resulting in lymphatic and venous stasis, in turn leading to mural inflammation and infection

Question 26

EMRAP rapid approach to breech presentation?

Answer 26

1. Place in lithotomy position
2. Allow pt to push without assistance until fetal umbilicus is visualized
3. MAINTAIN HANDS OFF THE BREECH; do not pull from below
4. Once umbilicus visualized, assist with delivery of legs/arms/head as needed.
5. Resuscitate baby/mom prn

Question 27

Should you ever pull fetus from below during breech presentation?

Answer 27

No, best managed by allowing spontaneous delivery with no assistance until the fetal umbilicus is delivered. Pulling can lead to extension of head with subsequent entrapment and asphyxiation.

Question 28

What is the Pinard maneuver for breech delivery assistance of legs?

Answer 28

1. Hands off delivery until umbilicus is seen
2. place 2 fingers behind fetal femur
3. slightly abduct and flex hip
4. flex knee to release the leg
5. repeat on other side
6. remainder of trunk and abdomen will usually deliver spontaneously

(look up picture of this maneuver)

Question 29

In breech presentation, when the fetus reaches level of scapula, how should you deliver arms?

Answer 29

1. gently rotate fetus to one side, slide 1-2 fingers over the anterior shoulder
2. Follow the humerus down and flex elbow
3. Sweep arm across chest to deliver elbow then forearm/hand
4. rotate fetus 180 degrees and repeat. Take care not to extend head

Question 30

How do you deliver head in breech presentation using Mauriceau-Smellie-Veit maneuver?

Answer 30

1. Support fetal body on one forearm with the fetal leg on either side. Place the second and third fingers of this hand on the fetal maxilla, on either side of nose
2. Place the opposite hand on fetal back using middle finger to flex the fetal head down, chin to chest
3. Keeping the fetal head inflexion, the body of the fetus is lifted upward and outward

Question 31

If fetal head is trapped in breech delivery, what can be given as a medication?

Answer 31

uterine relaxant (tocolytic)
-terbutaline 2.5-5 mcg/min infusion. Or 0.25 mcg SQ q20 mins
-hold terbutaline for HR >120

-can also use ntg 100-200 mcg IV bolus q2m prn

Question 32

What is Frank breech vs complete breech vs incomplete breech?

Answer 32

Frank: both hips flexed and both knees extended such that feet are next to fetal head. This is most common type

Complete: both hips and knees flexed

Incomplete: one or both hips not completely flexed

Question 33

When you should begin placing pregnant pts in left lateral tilt position?

Answer 33

> 20 weeks

Question 34

Critical diagnoses to consider in chest pain during pregnancy?

Answer 34

PE, aortic dissection, spontaneous coronary artery dissection, AMI

Question 35

Is thrombolytics contraindicated in pregnancy with a massive PE?

Answer 35

No.

-Thrombolectomy has increased risk of fetal demise.

Question 36

Are DOACs or coumadin contraindicated in PE during pregnancy?

Answer 36

Yes. First line is LMWH, second line is heparin.

Question 37

Though aortic dissection is rare in pregnancy, what trimester is it most common in?

Answer 37

third. Type A is more common.