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Step 2 > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Diagnosis

Present with
- first-trimester vaginal bleeding
- uterine size greater than gestational age
- markedly elevated β-hCG levels (eg, >100,000 mIU/mL)
- ultrasound with a “snowstorm” appearance and no fetus

A

Complete hydatidiform moles

Treatment is suction curettage

Due to the risk of malignant transformation (choriocarcinoma), patients are followed with serial monitoring until the hCG level is undetectable

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2
Q

Diagnosis, may present with:

  • intense abdominal pain
  • vaginal bleeding
  • fetal heart rate tracing abnormalities (recurrent variable and late decelerations)
  • Loss of fetal station
  • Fetal parts palpable abdominally (irregular protuberance).
A

Uterine rupture

tx: emergency Laprotomy and C-section

Hx of prior uterine surgery (eg, cesarean delivery) increases risk of uterine rupture (s/t a disruption of the uterine wall from contractions)
may have a palpable,** irregular abdominal mass **(ie, protruding fetal parts) and fetal decelerations

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3
Q

Maternal vitamin D deficiency is associated with fetal ___

A

growth restriction

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4
Q

Acute cervicitis presents with mucopurulent discharge, and a friable cervix. In pregnancy, it can cause what symptom not associated with the fetus?

A

postcoital bleeding

Empirically treat with ceftriaxone and azithromycin

To cover Chlamydia trachomatis & Neisseria gonorrhoeae.
FYI: threatened abortion has bleeding originating from the uterus (bleeding from the endocervical canal on examination) not cervix.

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5
Q

Diagnosis

Presents with painful vaginal bleeding, cramping, and a dilated cervix, often with products of conception visualized at the os.

A

inevitable abortion

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6
Q

Pregnant patients with von Willebrand disease (vWD) are at increased risk for what?

A

postpartum hemorrhage

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7
Q

Maternal sickle cell disease can cause uteroplacental insufficiency which may present with
* decreased fetal movement
* oligohydramnios (ie, amniotic fluid index ≤5 cm)
* Fetal
* Preterm birth
* Spontaneous abortion
* Abruptio placentae

s/t vasoocclusion that can result in placental infarction and ischemia

A

Fetal growth restriction

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8
Q

Diagnosis

Present with:
* decreased fetal movement
* oligohydramnios
* abnormal anatomical ultrasound findings (hydrops fetalis, microcephaly)

A

Fetal congenital infections

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9
Q

Diagnosis

Increases the risk of obstetric complications such as,
* gestational diabetes
* fetal macrosomia
* uterine size-greater-than-dates discrepancy

A

Maternal obesity

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10
Q

What type of diabetes mellitus can cause uteroplacental insufficiency, fetal growth restriction, and oligohydramnios?

A

Prepregnancy

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11
Q

Diagnosis

Can cause fetal macrosomia and polyhydramnios (ie, amniotic fluid index ≥24 cm).

A

Gestational diabetes mellitus

However,** pregnancy-induced hyperglycemia** (an** abnormal glucose challenge test** + a normal glucose tolerance test) does not cause significant changes.

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12
Q

In Rh(D)-negative women (aka no + sign in blood type) with a negative coombs test require a anti-D immunoglobulin at 28-32 weeks gestation.

Other indications include (4–8):

Antepartum prophylaxis is not indicated if the father is Rh(D) negative.

A

Ectopic Pregnancy
Threatened abortion
<72 hours after delivery of Rh(D)-positive infant
<72 hours after spontaneous abortion
Hydatidiform mole
Chorionic villus sampling, amniocentesis
Abdominal trauma
2nd- & 3rd-trimester bleeding

Because Fetomaternal blood mixing and maternal anti-D antibody production can cause Rh(D) alloimmunization

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13
Q

Intramuscular ____ is used for medical treatment of some ectopic pregnancies (no fetal cardiac motion, small size).

A

methotrexate

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14
Q

What procedure is indicated for patients with acute cervical insufficiency?

(ie, painless cervical dilation at <24 weeks gestation)

A

Cervical cerclage

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15
Q

What medication is used for fetal neuroprotection (ie, cerebral palsy risk reduction) for fetuses at risk for preterm birth at <32 weeks gestation?

A

Magnesium sulfate

Also used for seizure prophylaxis/treatment for patients with preeclampsia/eclampsia.

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16
Q

Patients with systemic lupus erythematosus have an increased risk of passive placental transfer of maternal anti-SSA (Ro) and anti-SSB (La) antibodies to fetus resulting in what fetal complication?

A

Fetal atrioventricular block (persistent bradycardia, decreased fetal movement) → Cardiomyopathy →Hydropsfetalis

Neonatal lupus

Pts with decreased fetal movement requires additional testing (eg, biophysical profile, fetal growth ultrasound) and possible delivery

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17
Q

A fetal sleep cycle can present with minimal or absent variability and decreased frequency of accelerations; however, what remains normal?

A

Baseline fetal heart rate remains normal

(110-160/min)

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18
Q

Diagnosis

Presents with fever, uterine tenderness, and fetal tachycardia (on fetal heart rate tracing)

A

Intraamniotic infection

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19
Q

Diagnosis:

Morbidly adherent placental attachment to the myometrium rather than decidua basalis
ultrasound revealing a low-lying placenta, myometrial thinning, and numerous placental lacunae

A

Placenta Accreta

Management planned cesarean hysterectomy/ emergency hysterectomy

Postpartum diagnosis: adherent placenta, postpartum hemorrhage

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20
Q

Fetal hydantoin syndrome presents with
* microcephaly
* wide anterior fontanelle
* cleft lip and palate
* distal phalange hypoplasia
It results from in utero exposure to what medication?

A

Antiepileptics
(phenytoin, carbamazepine)

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21
Q

What teratogen causes
* fetal renal failure
* oligohydramnios
* pulmonary hypoplasia
* growth restriction
* limb defects (ie, Potter sequence)

A

lisinopril (and other angiotensin-converting enzyme inhibitors)

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22
Q

Diagnosis

It’s use causes microcephaly and midfacial hypoplasia

A

Fetal alcohol syndrome

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23
Q

Routine prenatal laboratory tests for
24-28 weeks gestation?

2

A

Indirect Coombs (if Rh– for Rhogam)
1-hr 50-g Glucose Tolerance Test

if 1hr GTT abn do 3hr test

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24
Q

Routine prenatal laboratory test for
36-38 weeks gestation?

A

Group B Streptococcus rectovaginal culture

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25
Q

Initial prenatal visit laboratory test:
* Rh(D) type & antibody screen (indirect coombs)
* Urine culture
* Urine dipstick for protein
* Rubella & varicella immunity
* HIV, VDRL/RPR, HBsAg, anti-HCV Ab
* Chlamydia PCR (if risk factors are present)
* (if screening indicated) _____

  • Hemoglobin/hematocrit, MCV, ferritin
A

Pap test

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26
Q

Nerves affected?

Delivery c/b shoulder Dystocia
“Claw Hand”
Absent Grasp Reflex

A

C8-T1
Klumpke palsy

Hold the eight’s (ape’s) claw

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27
Q

Nerves affect?

“waiter’s tip” posture
Intact grasp reflex

Moro reflexes: decr/absent

A

C5-C6
(5, 6 give a tip)

Erb-Duchenne palsy (mcc)

unlike Klumpke palsy which has absent grasp reflex

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28
Q

Preterm Prelabor ROM
management at <34 weeks

without infection or fetal/maternal compromise

5

A

betamethasone (corticosteroid)
Ampicillin + Azithro
Fetal monitoring
Expectant management

Magnesium (if <32w)

no Nifedipine bc ROM has occurred already

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29
Q

Preterm Prelabor ROM
management at <34 weeks

with Infection or fetal/maternal compromise

4

A

Delivery
Betamethasone
Ampicillin + Gentamicin

Magnesium (if <32w)

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30
Q

Diagnosis

Nitrazine-positive fluid and a closed cervix (ie, prior to labor onset) at <37 weeks

A

preterm prelabor rupture of membranes (PPROM)

31
Q

prolonged or excessive ____ administration can cause severe hyponatremia, cerebral edema, and generalized tonic-clonic seizures.

A

oxytocin

32
Q

Diagnosis

presents with:
* RUQ pain, N/V
* HTN
* Anemia
* Elevated liver enzymes
* Thrombocytopenia
* ± Proteinuria

A

HELLP Syndrome
(Hemolysis, Elevated LFTs, Low Platelets)

Tx: Delivery, Magnesium (seizure ppx), Hydralazine (antihypertensive)

Complications: Abruptio placentae, Subcapsular liver hematoma/distention (ie, blood pooling beneath the hepatic capsule), Acute renal failure, Pulmonary edema, DIC

33
Q

Symptoms of what toxicity?

neuromuscular depression
* decreased respiratory effort/apnea
* Decreased deep tendon reflexes
* muscle paralysis
* somnolence.

A

Magnesium

34
Q

diagnosis

A polymicrobial infection characterized by fever >24 hours postpartum, purulent lochia, and uterine tenderness.

A

Postpartum endometritis

Tx: clindamycin + gentamicin

Risk factors: prolonged rupture of membranes, operative vaginal delivery, prolonged labor, & cesarean delivery.

35
Q

The treatment of choice for pyelonephritis during pregnancy?

A

Ceftriaxone (must be IV)

a third-generation cephalosporin that covers the most common cause of pyelonephritis, gram-negative E coli.

36
Q

A dual-therapy regimen that covers the most common bacterial causes of acute cervicitis, Neisseria gonorrhoeae (gram-negative cocci) and Chlamydia trachomatis (atypical organism).

A

Ceftriaxone + doxycycline

37
Q

Diagnosis

Head sparing growth lag
s/t Uteroplacental insufficiency or Maternal malnutrition

A

Assymetric Fetal Growth Restriction

37
Q

Diagnosis

Head sparing growth lag
s/t Uteroplacental insufficiency or Maternal malnutrition

UP Insufficiency s/t maternal HTN, sickle cell, etc.

A

Assymetric Fetal Growth Restriction

Fetal growth restriction (FGR) is characterized by estimated fetal weight <10th percentile or birth weight <3rd percentile

38
Q

Global growth lag
s/t Chromosomal abnormalities or Congenital infection

A

Stmetric Fetal Growth Restriction

FGR is characterized by estimated fetal weight <10th percentile or birth weight <3rd percentile

39
Q

DIagnosis

Presents with generalized pruritus, hyperbilirubinemia, and elevated transaminases due to impaired bile acid flow.

A

Intrahepatic cholestasis of pregnancy

Tx: ursodeoxycholic acid

40
Q

In Pre-Eclampsia w/ severe features, severe HTN increases maternal risk of stroke, pulmonary edema, and MI;
fetal risks include abruptio placentae & IUFD.
Acute antihypertensive therapy with one of what 3 meds is required?

A

hydralazine, labetalol, or nifedipine

41
Q

Inadequate maternal folate intake is a major risk factor for fetal neural tube defects like what?

A

Anencephaly

Diagnosed by fetal u/s, shows absent cerebrum, a calvarial defect, an abnormal cerebellum or brainstem, and polyhydramnios

42
Q

The following are complications of what maternal illness?

  • Fetal growth restriction ± oligohydramnios
  • Preterm delivery
  • Intrauterine fetal demise
  • Perinatal mortality
A

Obstetric HTN

Chronic hypertension is prepregnancy hypertension **or **hypertension recognized at <20 weeks gestation

43
Q

Common causes of uterine size–dates discrepancies:
* Incorrect pregnancy dating
* large uterine leiomyoma (ie, fibroid)
* Multiple Gestations
* Rh alloimmunization can cause hydrops fetalis

Name 4 other causes

A
  • Polyhydraminos (GI atresias/anencephaly/infection)
  • Molar Pregnancy
  • gestational diabetes mellitus
  • Macrosomia
44
Q

causes of Polyhydramnios (AFI ≥24 cm)

  • Multiple gestation
  • Diabetes mellitus
  • Idiopathic (mcc)

List 4 more

Polyhydramnios: amniotic fluid index ≥24 cm or a deepest vertical pocket of ≥8 cm
s/t an imbalance of fluid production (fetal urination) and removal (fetal swallowing).

A

Esophageal/duodenal atresia
TE Fisula
Anencephaly
Congenital infection

45
Q

Complications of Polyhydraminos

Preterm labor
Preterm prelabor ROM

List 3 more

A

Fetal malpresentation (eg, breech)
Umbilical cord prolapse
postpartum uterine atony

46
Q

Causes of Oligohydramnios (AFI <5 cm)

  • Preeclampsia
  • Abruptio placentae
  • NSAIDs

List 2 more

A

Uteroplacental insufficiency
Renal anomalies

47
Q

Complications of Oligohydraminos

Preterm delivery

List 2 more

A

Meconium aspiration
Umbilical cord compression

48
Q

Management of Polyhydraminos

Most patients are asymptomatic.
Management is based on severity, maternal symptoms, and gestational age

A

Severe/Symptomatic polyhydramnios at preterm gestation →
amnioreduction (ie, amniotic fluid removal by amniocentesis)

Mild/Asymptomatic polyhydramnios at term gestation → expectant management

After 20 weeks gestation, fundal height in centimeters should directly correlate to gestational age in weeks with a small variation (eg, ±2-3 cm)

49
Q

A uterine size–dates discrepancy requires further evaluation with what to measure fetal growth and amniotic fluid volume?

A

ultrasound

50
Q

Diagnosis

Second-trimester quadruple screening
MSAFP: ↓
β-hCG: ↓
Estriol: ↓
Inhibin A: normal

MSAFP = maternal serum α-fetoprotein

A

Trisomy 18 (Edward’s syndrome)

diaphragmatic hernia, rocker-bottom feet ± clenched hands with overlapping fingers
small jaw (micrognathia), low set ears, heart disease, omphalocele, myeloiningocele

51
Q

Diagnosis

Second-trimester quadruple screening
MSAFP: ↓
β-hCG: ↑
Estriol: ↓
Inhibin A: ↑

A

Trisomy 21 (Down Syndrome)

advanced maternal age is a risk factor
Risk ↑ for alzheimers, AML/ALL

flat facies, single palmar crease, epicanthal folds, thickened nuchal fold
ASD/VSD, duodenal atresia, esophageal atresia
Hirschsprung (missing nerve cells in colon – delayed passage of meconium)

52
Q

Diagnosis

Second-trimester quadruple screening
MSAFP: ↑
β-hCG: normal
Estriol: normal
Inhibin A: normal

A

Neural tube or abdominal wall defect

Multiple-gestation pregnancies are associated with isolated elevated AFP

53
Q

The quadruple marker test (Quad screen) is performed in the second trimester (13 – 26 weeks gestation).
It screens for congenital defects and what else?

A positive screening results require confirmation via what?

A

Fetal aneuploidy (chromosome abnormalities)

Confirmed via amniocentesis for karyotyping.

A fetal anatomy ultrasound also done to screen for fetal anomalies

54
Q

Diagnosis

Normal Quad Screen
* Microcephaly
* Holoprocephaly (one central eye)
* cleft lip/palate (medial)
* Polydactyly
* Cutis Aplasia (focal or widespread absence of the skin)
* Heart/Kidney disease

A

Trisomy 13 (Patau syndrome)

IUFD or death by 1 year

55
Q

Myelomeningocele (ie, spina bifida) is a neural tube defect (NTD) due to what deficiency

A

folate

56
Q

Prolonged and early-onset oligohydramnios’ most significant sequela is what?

A

Pulmonary hypoplasia (ie, neonatal respiratory syndrome)

Additional complications include flat facies and limb deformities (Potter sequence)

amniotic fluid is required for fetal lung development

57
Q

Describe the pathophysiology of the Potter Sequence

A

Urinary tract anomaly (ex: renal agenesis) or PPROM <26 weeks → severe olygohydraminos → Fetal Compression → Potter Sequence (Flat Face, Lung Hypoplasia, Limb deformities)

58
Q

Duodenal atresia is commonly associated with what 2 syndromes?

Bc these syndrome present w/ multiple congenital anomalies, the presence of duodenal atresia requires evaluation for other malformations.

A

Down syndrome (VSD/ASD, Hirschsprung’s, single palmar crease, duodenal atresia)
&
VACTERL (vertebral defects, anal/duodenal atresia, cardiac defects, tracheo-esophageal fistula, renal anomalies, and limb abnormalities)

59
Q

Patients at high risk for preeclampsia (ex: multiple gestations) are prescribed what prophylaxis at 12-28 weeks gestation (but optimally before 16 weeks) for prevention?

A

low-dose aspirin

60
Q

What is the most common cause of postpartum hemorrhage (PPH) within 24 hours of delivery?

PPH: estimated blood loss ≥1,000 mL or bleeding with signs/symptoms of hypovolemia.

A

uterine atony

patient w/ heavy bleeding & blood clots in the lower uterine segment

presents as Enlarged, soft, boggy, poorly contracted uterus

61
Q

Diagnosis

Presents w/ severe abdominal pain, a smooth mass protruding from the cervix or vagina, and no palpable uterine fundus.

A

Uterine inversion

can occur due to excessive traction on the umbilical cord with an adherent placenta, causing the uterine fundus to invert and prolapse.

62
Q

Diagnosis

Trauma due to operative vaginal delivery, particularly forceps-assisted vaginal delivery. Resulting in bleeding/PPH immediate after fetal delivery.

A

Cervical lacerations

63
Q

Management of PPH s/t Uterine Atony

6 steps

A
  1. Bimanual Massage
  2. High-dose oxytocin (first-line uterotonic agent)
  3. If persists, tranexamic acid (antifibrinolytic agent that stops breakdown of blood clots to achieve hemostasis) reduces maternal mortality
  4. If STILL persists, give second-line uterotonic medications
  5. If still persists, use intrauterine balloon tamponade

Finally, patients with PPH refractory to medical and minimally invasive techniques require either:
1. uterine artery embolization or
2. Laparotomy (and possible hysterectomy)

2nd line meds: carboprost tromethamine, methylergonovine & misoprostol

Carboprost tromethamine is contraindicated in patients with asthma
Methylergonovine is contraindicated in patients with hypertension (regardless of the pt’s’s current BP)

64
Q

Dilation and curettage may be indicated for PPH due to what?

A

retained products of conception

(eg, placenta, membranes)

65
Q

Due to the high risk for severe complications (eg, maternal sepsis, preterm delivery),
management of Acute Pyelonephritis in Pregnancy is with
hospitalization and which empiric intravenous antibiotic?

A

Ceftriaxone

66
Q

Gestational diabetes mellitus
Fetal macrosomia
Cesarean delivery
are complications for ____ in pregnancy?

A

Excessive weight gain

67
Q

Fetal growth restriction
Preterm delivery
are complications for ____ in pregnancy?

A

Inadequate weight gain

68
Q

Risk factors for a cause of painless second-trimester pregnancy loss include,
- inherited collagen defects (Ehlers-Danlos syndrome)
- prior cervical surgery (cervical conization)

A

cervical insufficiency

because these conditions cause structural weakness of the cervix.

69
Q

Typically occurs due to fetal red blood cell destruction (hemolysis).
Risk factors include Rh alloimmunization and intra-utero infection (ex:Parvovirus B19)

A

fetal anemia

70
Q

Umbilical cord prolapse is typically associated with an abrupt, prolonged decelerations or ____ as the umbilical cord is compressed with no subsequent decompression

A

bradycardia

71
Q

umbilical cord compression s/t transient occlusion of the umbilical vessels, particularly during contractions. FHT would reveal what?

versus umbilical cord prolapse where the umbilical cord is compressed with no subsequent decompression

A

Variable decelerations

can be, but NOT always, associated w/ contractions

Oxytocin augmentation worsens umbilical cord compression

72
Q

Next best step in management

In patients with absent variability and recurrent variable decelerations on FHT

A

cesarean delivery

73
Q

Fetal head compression causes what on FHT?
They have a slow onset and occur symmetrically with contractions.

A

early decelerations

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