OBGYN Oral Boards - OB Flashcards
List the 7 Cardinal Movements of Labor
- Engagement
- Descent
- Flexion
- Internal rotation
- Extension
- Restitution and External Rotation
- Expulsion
Likelihood (out of 1000) of stillbirth after a negative NST, CST, BPP, modified BPP, or UA doppler?
< 2/1000
Category III tracings are defined by [1] variability plus any of the following: [2,3,4,5]
- absent
- recurrent late decels
- recurrent variable decels
- bradycardia
- sinusoidal pattern (Cat III alone, no other findings needed)
Define failed induction
Failure to generate regular contractions with cervical change after at least 24 hours of oxytocin with AROM
Define arrest of dilation, or first-stage arrest
Dilation > or = to 6 cm with ROM and no cervical change for > or = to 4 hours of adequate contractions (MVU >200) or > or = to 6 hours of inadequate contractions
Define arrest of descent, or second-stage arrest, for nulliparous vs multiparous
- Nulliparous - 4h with epidural, 3h without
2. Multiparous - 3h with epidural, 2h without
Definition of PPH
Blood loss (EBL) > 1000 cc or signs/symptoms of hypovolemia in first 24 hours postpartum
Definition of massive blood transfusion
> 10 units PRBC in 24 hours or 4 units PRBC in 1 hour with ongoing need for additional blood products
- Incidence of TAH ureteral injury?
2. Incidence of LAVH / TLH ureteral injury? What is most likely cause?
- > 1% and < 2.2%
2. Greater risk; from 0.2% to 8.3%; most likely secondary to electrocautery dissection
What is LOCAL anesthesia dose and med used for emergency CS? What is max dose?
7 mg/kg 0.5% lidocaine with epinephrine
Max dose is 60cc
What is uterine rupture risk for:
a. Previous lower uterine segment rupture
b. Previous upper segment rupture
c. Classical CS
d. Induction with misoprostol in hx of prior CS
e. Induction with misoprostol in hx of prior CS for 2nd trimester loss
a. 6%
b. 32%
c. 10%
d. 15%
e. <1%
What is mag sulfate units? What is solution concentration? What is therapeutic range? At what toxic range is there risk for loss of reflexes, respiratory arrest, and cardiac arrest? What is the antidote?
mg/dL. Typically 40g in 1000ml. 4-8 mg/dL 10/16/22 (increments of +6) 1g calcium gluconate (10 cc IV over 2 minutes)
What is cut off value for 1h GTT?
Cutoff values for 3h GTT? What is Carpenter/Coustan criteria?
140
105/190/165/145
95/170/155/140
What is the most common peripheral nerve injury reported after abdominal GYN surgery? What is incidence rate?
Femoral nerve; 10%
Describe anatomy of obturator nerve
Originates from anterior rami of L2-L4. Courses through psoas muscle and exits at medial border near pelvic brim. Travels along anterior obturator internus muscle down to obturator notch along with the obturator artery and vein, and exits the pelvis through the obturator foramen.
What percentage does FDA report mesh graft erosion?
What is risk of erosion with retropubic sling?
Risk with TOT?
5-19%!
Retropubic (TVT) 1.4%
TOT 2.2%
Describe mechanism of action of mifepristone vs misoprostol
selective progesterone receptor modulator (anti-progesterone) vs progesterone analogue
Describe lichen simplex chronicus features
non scarring with intense pruritus especially at night; may be associated with allergies; can be primary or secondary to other vulvar conditions such as applied topical products; typically clinical dx - high potency steroids
Describe lichen sclerosus
SCARRING condition with unclear etiology, possibly dysfunction of cell-mediated immunity, may be related to autoimmune disorders in 1/3 of patients; most prevalent in prepubertal and postmenopausal females; white plaques, thin, white, or cigarette paper-like appearance - biopsy commonly performed to rule our 5% risk underlying SCC - high potency steroids
Describe lichen Planus
SCARRING condition affecting skin, oral mucosa, and vulvovaginal areas, affects predominantly postmenopausal women; papulo-squamous lesions white, fernlike; poor demarcation; prognosis poor and complete control rare - high dose steroids
Risks of ECV
placenta abruption
umbilical cord prolapse
ROM
materno-fetal hemorrhage
In case of eclampsia seizure refractory to magnesium sulfate infusion, what can you use?
Sodium amobarbital 250 mg IV over 3 minutes
OR
thiopental
OR
phenytoin 1250 mg IV at rate of 50 mg/min
Treatment drug name for interstitial cystitis?
Pentosan polysulfate
Dose of IV estrogen for acute hemorrhage/bleeding?
IV estrogen 25 mg every 4-6 hours for 24 hours
* beware of contraindications!
When is glucose/FBS screening indicated?
Every 3 years beginning age 45 or annually at any age if high risk
When is lipid profile screening indicated
Every 5 years age beginning age 21
What is screening acronym for alcohol abuse (4 letter)
TACE T "Tolerance" A "Annoyed" C "Cut Down" E "Eye-opener"
What is screening acronym for smoking assessment (5 letters)
Ask Advise "quit" Assess "willingness" Assist "counseling, resources" Arrange "follow up"
Acronym for Sexual Assault screening
S screen all
A ask direct questions, non judgement
V validate patient
E evaluate, educate, refer
What is first, second, and third line treatment for immune thrombocytopenia in pregnancy?
- Prednisone 0.5-2.0 mg/kg daily for 21 days then tapered (for not urgent case)
- IVIG 1 g/kg x1 dose w repeat as necessary; initial response 1-3 days and peak response 2-7 days (for more urgent plt increase, more expensive)
- Splenectomy
Platelet transfusion should only be used during life threatening hemorrhage or prior to urgent CS - 2-3x platelet w/ high dose steroids or IVIG from 30 mins to 8 h
What is “periviable” gestation?
20 0/7 weeks to 25 6/7 weeks of gestation
Pathophys of Type 1 DM (early age onset)
pancreatic beta cell destruction
Pathophys of Type 2 DM (later age onset)
peripheral resistance
Hyperglycemia in pregnancy risks
SAB, congenital birth defect, macrosomia, shoulder dystocia, C section, PTL, preeclampsia, IUFD, increased neonatal morbidity
DKA presentation and management
abdominal pain, N/V, loss of consciousness
low arterial pH, serum bicarb, positive serum ketones
may be associated with FHR decel
Mgmt: hourly blood testing, IV regular insulin, glucose and potassium
Which hirsutism drug is FDA approved?
Eflornithine
What is starting dose of Letrozole?
2.5 mg/day x 5 days starting day 3 of menstrual cycle. If no ovulation, can increase to 5 mg/day then 7.5 mg/day
What is recurrence rate for 1 and 2 prior ectopic pregnancies?
10% for 1 prior ectopic pregnancy
25% for 2 prior ectopic pregnancies
What is nerve innervation of labor pain in first stage? In second stage?
First stage: T11-T12
Second stage: S2-S4 (pudendal)
Describe course of pudendal nerve?
Exits pelvis through greater sciatic notch, travels lateral to ischial spine and re-enters pelvic through lesser sciatic notch. Found within Alcock’s canal and does not pierce muscle.
How do you measure the diagonal conjugate? (pelvic inlet)
How do you measure obstetrical conjugate? What is adequate?
How about AP diameter? (mid pelvis)
How about interspinous diameter?
Measure with fingers from pubic symphysis to sacral promontory.
OB conjugate is diagonal conjugate minus 2 cm. Adequate is at least 10 cm.
AP diameter is sacrum to symphysis, nl is 11.5 cm or more.
IS diameter is smallest diameter, nl is 10 cm or more
What are BPP components?
- NST (reactive, may be omitted if all 4 US components normal)
- AFI (>2cm vertical pocket)
- Breathing (1 episode breathing > 30s)
- Movement (x3)
- Tone (1 episode flexion/extension)
What are APGAR score components?
- Activity (muscle tone) flaccid, mild flexion, active motion
- Pulse (HR) 100
- Grimace (reflex irritability) none, grimace, vigorous cry
- Appearance (color) blue, pink/blue, pink
- Respiration (RR) absent, slow/irregular, crying
All scored 0 to 2
Apgar does not predict neonatal mortality/morbidity
What are Bishop score components?
Dilation 0-3 Effacement 0-3 Station 0-3 Consistency 0-2 Position 0-2
> 8 means probability of vaginal delivery is same as woman in spontaneous labor
Max score is 13
Which face presentation requires CS?
Mentum POSTERIOR
What is fetal head engagement?
largest diameter of presentation part is AT or BELOW the level of the ischial spines
What are indications for operative vaginal delivery?
- Prolonged 2nd stage of labor
- Suspected impending fetal compromise
- Shorten 2nd stage for maternal indication
Risk of shoulder dystocia without macrosomia? With macrosomia? With macrosomia and diabetes?
Without macrosomia: 1.5%
With macrosomia: 15%
With macrosomia AND diabetes: 25%
Risk of brachial plexus injury without macrosomia? With macrosomia? How many permanent?
Without macrosomia: 0.1%
With macrosomia: 5%
10% permanent
What are risk factors for fetal macrosomia? How can you decrease risk?
- History of macrosomia
- maternal obesity or excess weight gain in pregnancy
- GA > 40 weeks
- Positive 1h GTT and NEGATIVE 3h GTT
- diabetes
Decrease risk by:
- regular exercise
- well controlled BG in diabetic pt
- preconception bariatric surgery
What are side effects of lidocaine?
In order of increasing toxicity:
- Metallic taste in mouth
- Perioral numbness
- Tinnitus
- Slurred speech / blurred vision
- Altered consciousness
- Convulsions
- Cardiac arrhythmias
- Cardiac arrest
Neonatal surgical following maternal cardiac arrest at <5 minutes, 15 minutes, and 16-25 minutes
<5 mins: best outcomes
15 mins: >67% survival
16-25 mins: <40% survival
What are clinical and lab criteria for preeclampsia with severe features?
Clinical:
- severe range BP > 160/110 with or without proteinuria
- cerebral disturbance (HA, seizure, visual disturbance)
- pulmonary edema (acute SOB)
- RUQ pain, persistent N/V
- oliguria
Labs:
- platelets < 100,000
- Cr 1.1+ or double baseline
- AST/ALT double baseline
Differential diagnosis for seizure during labor:
- eclampsia
- stroke
- brain aneurysm
- AVM
- seizure disorder
- less likely brain tumor
How would you treat preeclamptic patient with myasthenia gravis for seizure prevention?
Dilantin (with EKG) or Valium (be able to intubate prn)
Causes of chronic hypertension:
- essential HTN
- Cushing’s disease
- pheochromocytoma
- renal disease or renal artery stenosis
- coarctation of aorta
- primary hyperaldosteronism
- sleep apnea
- drug use
When is early 1h GTT indicated?
- obesity BMI >30
- history of gestational diabetes
- history of macrosomia/shoulder dystocia
- prior macrosomic stillbirth
- family history of DM
List white classification of DM
A1: diet controlled GDM
A2: insulin controlled GDM
B: age>20 at onset with <10 years duration
C: age 10-19 at onset with 10-19 years duration
D: age <10 at onset with >20 years duration, benign retinopathy
F: proliferative nePHropathy
H: heart disease
R: proliferative retinopathy
