Obstetrics Flashcards
1
Q
What should always be suspected in a female patient who has not experienced menopause, presenting with amenorrhea, enlarged uterus, or +urinary BHCG?
A
Pregnancy
2
Q
What tests are used to confirm pregnancy?
A
Transvaginal Sonogram: See gestational sac (bHCG at least 1500)
Abdominal U/S: Fetal Heart motion at 5-6wks
Doppler: Fetal Heart sound around 8-10 wks
Physical Exam: Fetal movement after 20 wks
3
Q
What tests must be included in routine prenatal screening in first trimester or at initial visit?
A
CBC Type and Screen (Rh Ag) Direct and Indirect Coomb's Rubella-Ab HBsAg Urinalysis Urine Culture Gonorrhea/Chlamydia Nucleic Acid Amplification VDRL/RPR HIV (ELISA-only with pt. consent) Pap Smear
4
Q
What tests must be included in routine third trimester screening?
A
Oral Glucose Tolerance Test: (Fasting 1hr) (24-28 wks)
GBS: vaginal and rectal (35-37 wks)
CBC (24-28wks)
Indirect Coombs Test (for atypical Ab, anti-D)
5
Q
When is anemia in pregnancy significant?
A
Hb
6
Q
What is the most reliable indicator for anemia in pregnancy?
A
Low MCV
7
Q
What is the most common cause of anemia in pregnancy?
A
Iron deficiency (d/t increased hepcidin, which decreases iron absorption and release. Hepcidin is made/secreted by liver)
8
Q
When is an elevated serum WBC ct significant in pregnancy?
A
WBC >16000/mm3
9
Q
What is the next step in management for a pregnant woman found to have low Hb and low MCV on routine screening?
A
Iron Supplementation (PO Fe2SO4)
10
Q
What is the next step in management if a pregnant woman whose anemia is not reversed with iron supplementation?
A
Test for Thalassemia:
Peripheral Smear and RBC Electrophoresis
11
Q
What is the next step in management for a pregnant pt who has low Hb, high MCV, and high RDW on routine screening?
A
Folate Supplementation
12
Q
What is the next step in management for a pregnant pt found to have platelets
A
Work up for ITP or HELLP according to presentation
13
Q
When should Rh- mother’s receive RhoGAM ?
A
At 28 wks after routine re-screening and if it is Negative for anti-D Abs Within 72 hrs After delivery Following miscarriage/abortion During CVS or Amniocentesis With heavy vaginal bleeding in pregnancy
14
Q
What is the next step in management for a G2P1 pregnant pt who is Rh- who will have her 28 wk routine prenatal visit?
A
Re-screen for anti-D Ab with Indirect Coomb’s test.
Give RhoGAM only if Indirect Coombs is NEGATIVE for Ab.
15
Q
What is the cut off for using Nitrofurantoin to treat Asymptomatic bacturia in pregnancy?
A
Cannot give if pt is >30wks
16
Q
What is the next step in management for a pregnant woman with a negative Rubella-Ab titer who has had exposure to someone with Rubella infection?
A
Expectant management and vaccinate Mother AFTER delivery
[There is no post-exposure prophylaxis for Rubella]
17
Q
What is the next step in management for a pregnant pt with +HBsAg on routine screening?
A
Order HBeAg (if elevated, pt is highly infectious)
18
Q
What is the next step in management for a pregnant pt with –HBsAg ?
A
HBV vaccination (active immunization) during pregnancy
19
Q
What is the next step in management for a pregnant pt with –HBsAg and was recently exposed to the blood of a someone with HBV?
A
HBIG (passive imm) + HBV vaccine (active imm)
20
Q
What is the treatment for an infant born to a mother with HbsAg+, HbeAg+ in the third trimester?
A
HBIG and HBV vaccine within 12-24 hrs after birth
21
Q
What is the treatment for Chronic HBV infection during pregnancy?
A
Interferon or Lamivudine
22
Q
What is the next step in management for a pregnant woman with +VDRL or RPR on routine prenatal screen?
A
Confirm with FTA-ABS or MHATP (treponema-specific)
23
Q
What is the next step in management for a pt with + Darkfield microscopy, +FTA-ABS or +MHATP?
A
IM Benzathine Penicillin (1x)
Penicillin Allergic: Desensitize then give IM Benzathine Penicillin (1x) [have epinephrine handy during desensitization]
24
Q
What is required to obtain an HIV test from a pregnant patient for routine screening?
A
Consent prior to testing
25
What is the next step in management for a pregnant patient with a +ELISA test for HIV?
Confirm with Western Blot (for HIV core/envelope Ag)
26
What is the next step in management for a pregnant pt who has a +HIV core Ag test?
Start triple therapy antiretrovirals
27
What medication must be included in the retroviral cocktail for HIV + pregnant women?
Zidovudine
28
T/F: A newborn with a +HIV-Ab test has HIV infection?
False: HIV-Ab crosses the placenta, ALL newborns of HIV+ women will have positive screening test initially.
29
What is the next step in management for a pregnant woman with a +Chlamydia/Gonorrhea test?
PO Azithromycin + IM Ceftriaxone (1x) for mother and partner
30
What is the next step in management for a pregnant woman who presents with sx of foul smelling greenish watery discharge with vaginal discomfort?
KOH prep of discharge and microscopy
Clue Cells: Metronidazole (PO or gel) or Clyndamicin (suppository or cream)
Trichomonads: Metronidazole (PO)or
31
What is a complication of Trichomoniasis in pregnancy?
Preterm labor
32
What additional tests should be done in the first trimester for initial pregnancy screening?
PPD (high risk mothers)
| Induration (not redness) = POSITIVE
33
What is the next best step in management for a pregnant woman found to have a +PPD?
CXR (to r/o active disesae)
34
What treatment should a pregnant woman with +PPD receive?
+PPD/-CXR: INH and Pyridoxime (B6) for 9 mos
+PPD/+CXR==>Sputum Cx, if +Sputum: Triple antiTb med regimen (No streptomycin--ototoxicity)
35
When should Trisomy 21 testing be offered to pregnant women?
Offer bhcg, PAPP-A, Nuchal translucency to high risk mothers (AMA at delivery, h/o previous trisomy 21 fetus/child)
Can confirm with CVS at 10-12 wks
36
What second trimester test is optional but should be offered to all women, especially those of AMA?
Trisomy Triple Marker/Quad Screen at 15-20 wks
| MSAFP, bHCG, Estriol, Inhibin-A
37
What is the next step in management for a pregnant pt with an abnormal MSAFP?
U/S to check/verify dates (if error, repeat MSAFP
38
What is the next step in management for a pregnant pt with elevated repeat MSAFP following date verification?
Amniocentesis (for Amniotic AFP) and Acetylcholinesteras
39
What does an elevated Acetylcholinesterase indicate in pregnancy?
Specific for NEURAL TUBE DEFECTs
40
What is the next step in management for a pregnant pt with a decreased MSAFP?
Karyotype Analysis
41
What is the most likely diagnosis consistent with low MSAFO, Low Estriol, High Bhcg, High Inhibin-A
Trisomy 21, Down'S Syndrome
42
What is the most likely diagnosis consistent with low MSAFP, low Estriol, and low bHCG?
Trisomy 18, Edward's Syndrome
43
What value is considered abnormal for MSAFP?
Value >2.5 MoM (multiples of the median)
[Normal:
44
What is the next step in management for a pregnant pt with a screening (fasting) OGGT >140mg/dL?
Fasting 3 hr OGTT (100g) confirmatory test
45
What are abnormal values for 3hr OGTT in pregnancy and how is Gestational Diabetes diagnosed?
Abnormal values: >180 @1hr, >155@2hrs, >140@3hrs
1 abnormal value= Impaired Glc tolerance
2 abnormal values= Gestational Diabetes
46
What test should be done prior to 3hr OGTT?
Plasma glucose (fasting) should be drawn prior to administering testing solution to r/o underlying Diabetes Mellitus
47
What are safe antiemetic options during first trimester of pregnancy
Doxylamine (H1-antihistamine/anticholinergic)
Metoclopromide(pro-motility, dopamine antagonist)
Ondansetron (antiserotonin, 5HT3 antagonist)
Promethazine (H1 antihistamine/anticholinergic)
Pyridoxine (B6)
48
What is the first step in management for a pt presenting with vaginal bleeding in third trimester of pregnancy?
Get pt History, vitals
Place external fetal monitor
Start fluids
49
Following initial management in third trimester bleed, what is the next step in workup?
Transvaginal sono to assess for previa (before speculum/manual exam)
CBC (pay attention to Hb, Hct, platelets)
PT/PTT
D-dimer
Fribinogen
Type and cross-match (in preparation of transfusion)
50
What is the most likely dx in a pregnant pt presenting with sudden onset vaginal bleeding and severe, constant pelvic pain with a h/o HTN or abdominal trauma?
Abruptio Placenta
[the hemotoma may be concealed, in this case the presentation would be scant vaginal bleeding with severe constant pain]
51
What is a hematologic complication of Placental Abruption?
DIC (d/t exposure of thromboplastin (TF, Factor III)--> Factor VII activation-->Factor X, IX activation)
52
What is the most likely diagnosis in a pregnant pt. presenting with sudden onset vaginal bleeding with NO pain with/without a h/o intercourse, vaginal exam, or trauma prior to bleeding onset?
Placenta Previa (marginal, incomplete, complete)
53
What is a complication of placental villous invasion of the uterine wall?
Hysterectomy (Cesarean) d/t intractable bleeding subsequent to
Placenta Accreta: into Endometrium
Placenta Increta: into Myometrium
Placenta Percreta: into Serosa
54
What is the most likely diagnosis in a pregnant woman who presents with sudden painless vaginal bleeding with fetal bradycardia/distress following artificial rupture of membranes (amniotomy)?
Vasa Previa (Velamentous cord insertion with umbilical vessels coursing throughout fetal membranes and passing over internal os)
55
What is the next step in management for vasa previa?
Immediate C-Section
56
What is a complication of Vasa Previa?
fetal Exsanguination
57
What is the most likely diagnosis in a pregnant pt with a h/o uterine scar now presenting with sudden onset abdominal pain and vaginal bleeding associated with loss of fetal hrt rate, contractions, recession of fetal presenting part, abnormal abdominal contours?
Uterine Rupture
58
What is the management for a pt dx'd with Uterine Rupture?
Immediate deliver and surgery for uterine wall repair
59
What is a maternal complication of uterine rupture?
Hysterectomy
60
What is the next step in management for a pt dx'd with placenta previa but NOT currently bleeding?
Admit pt, observe. Maintain stable maternal/fetal vitals.
| Give Betamethasone series if
61
What is the next step in management if pt dx'd with placenta previa presents with continued bleeding w/w/o maternal/fetal deterioration?
Emergency C-section
62
What is the next step in management for a pregnant pt. presenting in labor at > 35 wks GA who has a h/o infant with GBS sepsis but has a negative GBS screen for this pregnancy?
Administer GBS prophylaxis (Intrapartum IV penicillin, cefazolin, clindamycin, eythromycin if allergic)
63
What are high risk indications for GBS Ab administration intrapartum?
Maternal Fever
Ruptured Membranes>18 hrs
Preterm delivery
Previous baby with GBS sepsis/infection
64
When should a pregnant woman with GBS+ culture NOT receive Ab's?
Planned C-section w/o membrane rupture
| GBS cx+ in previous pregnancy (but no neonatal manifestations) and GBS Cx- in current pregnancy
65
What are the complications of vertical GBS transmission?
Neonatal Pneumonia and Sepsis (w/in hrs to days after birth)
[Note: Neonatal GBS Meningitis is d/t hospital acquired GBS, not intrapartum and occurs after first week of life]
66
What is the most likely diagnosis for a pregnant pt presenting with exposure to cat feces/litter box, raw goat milk, or raw meat with mild mono-like syndrome, chorioretinitis, intracranial calcifications, and hydrocephalus?
Toxoplasmosis
67
What is the management for a pregnant pt in first trimester with dx of primary Toxoplasmosis?
Pyrimethamine +sulfadiazine IV for serologically confirmed fetal/neonate infection via amniocentesis
Advise to avoid handling kit litter boxes, ingesting raw/undercooked meat, or raw goat's milk
68
When is the risk of vertical transmissionof varicella greatest to fetus?
When maternal rash develops between 5 dys antepartum and 2 days postpartum.
69
What is the most likely dx in a neonate presenting with "zigzag" skin rash, limb hypoplasia, microcephaly, microphthalmia, chorioretinitis, and cataracts?
Varicella infection
70
What is the treatment for uncomplicated maternal Varicella infection?
PO acyclovir + VariVZIG to mother and neonate
71
What is the treatment for congenital varicella infection?
VariVZIG + IV acyclovir to neonate
72
What are the best preventative measures for pregnant women and their fetuses against primary Varicella infection?
Vaccination (before pregnancy, CANNOT give accine in pregnancy)
Postexposure Prohylaxis: VariZIG within 10 dys of exposure (attenuate effects but will not prevent infection)
73
In what nervous system region does Varicella remain dormant post primary infection?
Dorsal Root Ganglia
74
What is the most likely intrauterine exposure in a neonate presenting with congenital DEAFNESS, CATARACTS, heart disease (PDA), mental retardation, HEPATOSPLENOMEGALY, THROMBOCYTOPENIA, and BLUEBERRY MUFFIN rash?
Rubella (German Measles)
75
What is the most sommon sequelae associated with congenital Rubella?
Deafness
76
What is the next step in management for a pregnant woman found to be seronegative on routine Rubella titer screening?
Advise to avoid infected people
Post partum rubella vaccination
[Note: no post-exposure prophylaxis for Rubella]
77
What is the most common congential viral syndrome in US?
CMV syndrome
78
What is the most common cause of sensorineural deafness in children?
CMV
79
What are the intrauterine manifestation of congenital CMV infection?
```
Periventricular Intracranial Calcifications*
IUGR
Chorioretinitis
Prematurity
Microcephaly
Jaundice
Hepatosplenomegaly
Petechiae
Pneumonitis
```
[Note: most mothers are asymptomatic or develop mild mono-like symptoms]
80
What are the diagnostic tests used in working up a pregnant pt suspected of CMV infection?
Maternal Serum CMV IgM and IgG
[+IgM w/ -IgG, or +IgG ==> recent infection: treat)
-IgM w/ +IgG==> past exposure/Immunity conferred, no fetal risk]
81
What is the treament for CMV infection in pregnancy?
Ganciclovir (or Foscarnet)
[Note: these meds prevent viral shedding /sensorineural hearing loss but does NOT cure CMV]
CMV hyperimmune globulin may reduce risk of congenital CMV in women with primary infection
82
What preventative measures should be taken against CMV infection in pregnancy?
Universal Precautions with all body fluids
| Avoid transfusion with CMV-pos blood
83
What is the next step in management for a pregnant pt. who presents in late third trimester with pain, pruritis, and found to have a localized painful, ulcerated lesion on vaginal mucosa?
Schedule C-section (most common cause of vertical transmission is contact with maternal vaginal secretions during active outbreak)
84
Transplacental HSV infection is one method of acquiring congenital HSV?
True
85
What viral infection is associated with maternal fever, malaise, and diffuse vesicular genital legions?
HSV
86
What are some neonatal complications associated with Congenital HSV?
```
Meningoencephalitis
Mental Retardation
Pneumonia
Hepatosplenomegaly
Jaundice
Petechiae
```
87
How is HSV diagnosed in pregnancy?
Culture (vesicle/ulcer )
| HSV PCR
88
What preventative measures are available for pregnant pts against HSV infection?
C-section for pt suspected of active HSV genital lesions
No fetal scalp electrode
Standard Precautions (esp with ppl w/ active oral/genital lesions)
89
What is the treatment for maternal HSV infection?
Acyclovir during pregnancy
90
What is the most effective recommendation for decreasing risk of vertical transmission of HIV?
Triple AntiretroviralTherapy immediately and throughout pregnancy, and after (independent of viral load/CD4 count)
91
What additional recommendations should be followed to decrease risk of vertical HIV transmission to 1%?
Avoid breastfeeding
C-section delivery at 38 wks (if viral load >/= 1000 at time of delivery)
Intrapartum IV-Zidovudine for mothers with high viral load at delivery
Avoid artificial Rupture of membranes/fetal scalp electrode (invasive procedures)
Continue Combination therapy in mother for at least 6 wks post partum
Zidovudine to neonate for 6 wks post pirth prophylaxis
92
T/F: ALL neonates of HIV + mothers will have HIV Ab screening test?
True: Maternal anti-HIV IgG crosses placenta
93
What stage of Syphilis has the highest risk of vertical transmission?
Primary and Secondary Syphilis
| Lowest risk is Tertiary or latent Syphilis
94
What is the most likely dx in a neonate presenting with nonimmune Hydrops Fetalis (swollen), Maculopap/vesicular PERIPHERAL rash, anemia, thrombocytopenia, hepatosplenomegaly, and LARGE EDEMATOUS PLACENTA?
Congential Syphilis (first trimester/early acquired)
95
What is the most likely dx in a child >2yo, presenting with saber shins (anterior bowing of tibia), Hutchinson teeth, mulberry molars, saddle nose, and deafness (CN8 palsy)?
Congenital Syphilis (late acquired)
96
What additional test should be ordered for any pregnant woman who tests positive for any STD?
HIV test, but only with her consent
97
Is C-section delivery a good preventative measure against vertical transmission of Syphilis?
NO, syphilis Ag crosses placenta!
98
What is the next step in management for a pregnant woman presenting with painless ulcerative vaginal legion?
Darkfield Microscopy ( VDRL/RPR can be false + in Primary Syphilis)
99
What treatment should be used for Primary and secondary Syphilis in a pregnant pt with Penicillin allergy?
Desensitization (with epinephrine on hand)then
| IM Benzathine Penicillin x1
100
During what stage of pregnancy will HBV transmission occur?
```
Third trimester (primary infection) or
Delivery (Ingest infected vaginal secretions)
```
101
The presence of which HBV marker in addition to HBsAg and IgM anti-HBcAb indicates the highest risk of vertical transmission?
+HBeAg
102
What preventative measures should be taken against HBV vertical transmission?
Avoid invasive procedures during pregnancy (Amnio)
Immunizations:
HBV vaccine to non-immune -HBsAg mom during
pregnancy.
HBIG +HBV vaccine to mothers for Post Exposure
Prophylaxis
103
What treatment is given to neonate of mother with HBV infection?
HBIG and HBV vaccine (within 12-24 hrs of life)
| Note, breastfeeding is ok once neonate receives HBIG and HBV vaccine
104
How is chronic HBV treated in pregnancy?
Interferon (IFN) or Lamivudine
105
What are some complications associated with sustained HTN in pregnancy?
Pre-eclampsia/Eclampsia
Placental Abruption
IUGR
Hypoxia (Poor placental Oxygen Exchange)
106
What condition is most likely to be diagnosed in a pregnant pt with a BP >140/90 before 20wks gestation or before pregnancy?
Chronic HTN
107
What condition is most likely to be diagnosed in a pregnant pt with a BP >140/90 after 20wks gestation and returns to normal baseline by 6 wks post partum?
Gestational HTN
108
What condition is most likely to be diagnosed in a pregnant pt with a sustained BP >140/90 and proteinuria of >300mg/24 hr (1-2+ on dipstick) without any other symptoms?
Mild Preeclampsia
109
What condition is most likely to be diagnosed in a pregnant pt with any of the following: sustained BP >160/110, proteinuria of >5g/24 hr (3-4+on dipstick), epigastric/RUQ pain, vision changes, pulmonary edema, oliguria, thrombocytopenia, or elevated liver enzymes?
Severe Pre-Eclampsia
| Note: Eclampsia is severe Preeclampsia + seizure
110
Who is at highest risk of developing Pre-eclampsia?
Primiparas
(Note: Multiple gestation, Molar pregnancy, DM, Age extremes, Chronic HTN, and Chronic renal disease are all risk factors too!)
111
What is the next step in management for a pregnant pt who presents at > 20wks to routine exam with trace pedal edema, BP >140/90 initial and repeated at 10 min, and trace pedal edema?
Urinalysis (check dipstick protein to r/o preeclampsia)
112
What is the most likely diagnosis in a pregnant pt with a h/o chronic HTN prior to pregnancy now having increasing BP, proteinuria, or warning signs?
Chronic HTN with Superimposed Preeclampsia
113
What should be included in the diagnostic workup for a pt thought to hv preeclampsia?
CBC
Chem-12 (Liver enz, BUN, Cr)
Coagulation panel (PT,PTT)
Urinlaysis with Urine protein
114
What will labs for a pt with Preeclampsia show?
Hemoconcentration (Elevated Hb, HCT, BUN, Cr, Uric Acid)
Proteinuria
Elevated Liver Enzymes (severe)
+/- DIC (severe)
115
What is the management for a pt with HTN in pregnancy?
Diet/Lifestyle only if BP less than (160/110)
116
What HTN medications are used in pregnancy for mild preeclampsia?
Only give if BP sustained at >160/110
First Line: Methyldopa or Labetalol (alpha and beta blocker- preserves placental flow)
Alternative: Nifedipine (CCB)
117
What BP meds are used in acute elevation of BP or severe preeclampsia?
IV Hydralazine or Labetalol
118
What is the treatment for Eclampsia?
Airway protection
IV Magnesium Sulfate (neural protection) bolus and infusion
IV Hydralazine or Labetalol
Serial BP checks and Urine protein
Aggressive, prompt delivery (of all POC) at any gestational age (w/ intrapartum IV Magsulfate, Hydralazine/Labetalol)
119
What is the most likely dx in a pt who is 2 days post partum with BP>160/100, labs showing elevated LDH, Total bilirubin, AST, ALT, and Thrombocytopenia?
HELLP Syndrome
| most commonly presents in third tremester to 2 days post partum
120
How is HELLP syndrome treated in the pregnant pt?
1) Immediate delivery at any gestational age
| 2) Dexamethasone if Plt
121
When should steroids be stopped in pt with HELLP syndrome in labor?
Discontiune steroids when plt ct>100,000 and liver enzymes normalize
122
What is the recommendation for labor in a pt with mild preeclampsia?
Induction (oxytocin infusion) if >/= 36wks-vaginal delivery if fetus and mother are stable
(Note: consider Betamethasone series if fetus is 24-34 wks)
123
When is C-section indicated in Preeclampsia/Eclampsia/ HELLPsyndrome
When mother and/or fetus are in distress/unstable
124
What are some complications of HELLP syndrome?
```
DIC
Ascites
Abruptio Placenta
Fetal Demise
Hepatic Rupture
```
125
What is the most common cause of thrombocytopenia in pregnancy?
Gestational Thrombocytopenia
| Third trimester, no other abnormalities/symptoms, Plt cts not lower than 70,000
126
Women with which cardiopulmonary conditions should be advised against becoming pregnant due to risk of sudden death?
Pulmonary Hypertension
H/o post-partum Cardiomyopathy
Severe Valvulopathy
Eisenmenger Syndrome
127
At what gestational age do the hemodynamic changes associated with normal pregnancy typically peak?
28-34wks gestational age
128
During what period of time can a pregnant woman develop Peripartum Cardiomyopathy?
Last month of pregnancy up to 5 mos post-partum
129
What are the risk factors associated with Peripartum Cardiomyopathy?
AMA
Multiparity
Multiple Gestations
Preeclampsia
130
What is the management for Heart Failure in pregnancy?
Loop Diuretics
Nitrates
BBlockers
Digoxin (only improves symptoms, no improved outcome)
131
What is management for arrhythmia in pregnancy?
Continue rate control medications (same as non-pregnant)
NO amiodarone or warfarin in pregnancy
132
What is appropriate Endocarditis prophylaxis in pregnancy?
Daily prophylaxis to pts with rheumatic heart disease
NO prophylaxis for uncomplicated vaginal/cesarean deliveries in pt with valvular disease/ prosthetic valves
Follow Endocarditis prophylactic guidelines for non-pregnant pt.
133
Which valvular diseases do NOT require therapy in pregnancy?
Regurgitant Valve Lesions
134
Which valvular lesions can worsen in pregnancy?
Stenotic Valve Lesions (esp Mitral Stenosis --> increased risk of pulmonary edema and A-Fib)
135
How is gestational age determined?
Crown-Rump length at 10-13 wks
136
When is high resolution ultrasound indicated for fetal evaluation?
FHx of congenital malformation or
| Abnormal maternal serum markers
137
During what gestational period can CVS be done?
10-12 wks
138
What is an indication for CVS
AMA, previous child with chromosomal abnormality
139
During what gestational period can an Amniocentesis be performed?
Any time >15 wks (w/U/s guidance)
140
What are some indications/uses for Amniocentesis?
```
Maternal Screen (when serum levels abnormal)
Karyotype Analysis
```
141
When can Percutaneous Umbilical Blood sample be collected and what can it be used for?
After 20wks gestation
Dx: bld gases, karyotype, IgG, IgM
Tx: Intrauterine transfusion for fetal anemia
142
When can Fetoscopy be performed and what are its indications/uses?
After 20 wks gestation with anesthesia
Intrauterine surgery
Fetal scalp bx (icthyosis)
143
What is the diagnosis when a pregnant pt presents with fluid leakage/passage without cervical changes?
Premature Rupture of Membranes (PROM)
144
What is the most common risk factor for PROM?
Ascending lower genital tract infection
145
What is the next step in management when PROM is suspected in a stable patient?
External Fetal Monitoring/ Maternal Vitals
Sterile Speculum exam:
Pooling (posterior fornix, can ask pt to valsalva/cough)
Nitrazine Test of fluid
Microscopy of Smear of vaginal fluid swab
U/S: Oligohydramnios
146
What is a significant/feared complication of PROM?
Chorioamnionitis
147
What is the typical presentation associated with Chorioamnionitis?
Maternal Fever with Uterine tenderness
Confirmed PROM
Absence of URI/UTI
148
What is the next step in management for a pregnant pt who presents with uterine contractions, PROM, and fever?
CULTURES/SMEAR and Antibiotics!!!!!:
Cervical cultures (chlamydia/gonorrhea)
Anovaginal culture ( GBS)
KOH prep for Bacterial Vaginosis, Trichomonas, Yeast
IV Ab x7dys (ampicillin + erythromycin)
149
When should tocolytics be given to a woman with PROM?
Only if she is Extremely Premature to allow time for transport to tertiary facility and/or to give steroids for fetal lung maturity. (no more than 48 hrs)
150
What are the contraindications for tocolytic use in PROM?
```
Chorioamnionitis
Nonreassuring fetal status
Severe preeclampsia/Eclampsia
Fetal Demise
Fetal Maturity
Maternal hemodynamic Instability
```
151
If a pt with PROM is also having contractions, should tocolytics be administered?
No
152
How is PROM managed in a pt that is
Bed rest at home
153
How is PROM managed in a pt presenting between 24-33 wks?
```
Hospitalization
Betamethasone series (if
```
154
What is the management for a pt with PROM presenting at >34 wks?
Initiate delivery (in stable mom and baby - vaginal delivery)
155
In what stage of labor is a woman with uterine contractions that have been occurring between 14-20 hrs and cervical dilation to about 4cm at a rate
Stage 1-Latent Phase
156
In what stage of labor is a woman with regular uterine contractions and rapid cervical dilation at a rate of appx >1.2(primipara) - >1.5 (mutipara)cm/hr?
Stage 1-Active Phase
157
What is the definition of Arrest of labor in stage 1 active phase?
When there is no change in cervix in 2+ hours of Active phase Stage 1 labor
158
What are some common causes associated with arrest of labor?
Passenger: fetal size/presentation
Passage: Cephalopelvic disproportion
Power: Inadequate/dysfunctional contractions
159
How is arrest of stage 1 labor managed?
If inadequate/hypotonic contractions --> IV Oxytocin
If Hypertonic contractions --> Give morphine sedation
If contractions are adequate --> Emergency C-Section
160
What is the definition for prolonged latent phase of stage 1 labor?
Cervix dilates>/=3cm and no change in 14-20 hrs
161
What is the most common cause of prolongation of Latent phase of labor?
Medications (analgesics)
162
What is the management for prolonged latent phase of labor?
Rest and sedation
163
What denotes the end of Stage 1 labor?
Complete cervical dilation
164
What stage of labor is a pt in when they are fully dilated/effaced?
Stage 2-Descent (ends with fetus delivered)
165
What is considered Stage-2 arrest of labor?
Failure to deliver fetus within:
3hrs (primipara w/ Epidural)
2hrs (primipara w/o epidural; Multipara w/Epidural)
1hr (multipara w/o epidural)
166
What are some common causes of Stage 2 arrest of labor?
Abnormal passenger, passage, power
167
What is the management for arrest of stage-2 labor?
Fetal Head not engaged --> Emergency C-Section
| Fetal Head engaged--> Try Forceps or vacuum extraction
168
What occurs during stage 3 of labor?
Expulsion of placenta
169
What should be considered in a pt presenting with prolonged Stage 3 of labor?
Placenta Accreta, Increta, Percreta (if it takes longer than 30 min)
170
What is the management for Prolonged stage 3 of labor?
Uterine Massage
IV oxytocin
If oxytocin fails--> manual removal
Hysterectomy if all else fails
171
What are possible clues to prolapsed cord during labor/delivery?
Sudden fetal bradycardia or Severe Variable Decelerations (indications of possible hypoxemia)
172
What is the next step in management for a female in labor who now has a prolapsed cord?
Put pt in Knee-to-Chest position
Elevate presenting fetal part
Terbutaline (b2-agonist)decrease force of contractions
Immediate C-Section
NOTE: DO NOT try to replace cord
173
What is the concern regarding umbilical cord prolapse?
Decreased fetal oxygenation --> hypoxemia
174
How does Terbutaline aid in the management of umbilical cord prolapse?
B2 agonist-->increases Adenylyl Cyclase-->increase cAMP--> inhibits MLCK phosphorylating activity --> decreased contractile force -->Smooth muscle relaxation
This pthwy is mediated by Gs protein
175
What is a possible fetal response to maternal terbutaline administration?
Tachycardia
176
A fetal heart tracing showing a baseline hr of 110-160bpm, accelerations, no late or variable decelerations, beat-to-beat variability is considered to be what kind of tracing?
Reassuring
177
What components of a fetal heart tracing would indicate a non-reassuring tracing?
Baseline tachy/bradycardia
Absent accelerations
Repeated variable and/or late decels
No beat-to-beat variability
178
What is usually the underlying cause for early decelerations on fetal heart tracing?
Head Compression (with contractions)
179
What is an underlying cause for variable decelerations on fetal heart tracing?
Cord Compression
180
What is an underlying cause of late decelerations on fetal heart tracing?
Uteroplacental insufficiency
181
What is the normal fetal heart rate range?
110-160 bpm
182
What are some common causes of fetal tachycardia/bradycardia?
Medications :
Tachycardia--> B-agonists (terbutaline/ritodrine)
Bradycardia--> B-blockers, local anesthetics
183
What possible condition could the presence of sinusoidal fetal heart tracing pattern indicate?
Fetal Acidosis
184
What possible condition could the presence of severe variable fetal heart tracing pattern indicate?
Fetal Hypoxia
185
What is the next step in management for a pt at term in active labor who is receiving oxytocin, morphine for pain, whose cervix is not fully dilated but 100% effaced, membranes intact, no vaginal bleeding, and fetal heart tracing showing fetal tachycardia, with minimal variability, and repetitive late decelerations?
1)Evaluate Strip for nonreassuring patterns
2)Identify non-hypoxic causes (meds)
3)Start Intrauterine resuscitation:
Discontinue oxytocin (or other inciting meds)
IV Fluids (normal saline)
High Flow Oxygen
Change maternal position (to left lateral)
Vaginal Exam (r/o cord prolapse)
Scalp stimulation (ck strip for accelerations)
4)Prepare for delivery if strip doesn't improve
5)Fetal scalp pH (nml >7.20) if strip is equivocal and cervix is dilated and membranes ruptured
186
When is Vacuum or Forceps delivery indicated?
Prolonged Stage 2(most common)
Nonreassuring tracing without contraindications
To avoid maternal pushing in cases of cardiopulmonary conditions with increased risk of sudden death
187
What are the indications for Cesarean delivery?
Cephalopelvic Disproportion (with failure of progression or arrest)
Fetal malpresentation
Nonreassuring Strip
Placenta/Vasa Previa
Infection (Herpes lesions present, HIV)
Uterine Scar (myomectomy, h/o classical uterine incision)
188
When should forceps/vacuum NOT be used in delivery?
```
When fetal head is not clearly visible/accessible
If membranes Not ruptures
Fetal head not engaged
Head orientation not certain
Small pelvis
Cervix NOT fully dilated
```
189
What are the contraindications for a VBAC?
H/o Classical uterine incision
Infection (Active vaginal herpes)
Uterine scar
190
What is the next step in management for a pregnant pt at routine follow-up visit at 37 weeks with a fetus that is in breech/transverse position?
Offer External Cephalic Version and discuss possibility of Cesarean delivery
191
What is the most common cause of excessive post partum bleeding?
Uterine Atony
192
When should post- partum hemorrhage be suspected?
Rapid/Protracted Labor
Chorioamnionitis
Medications (MgSO4, Halothane)
Overdistended uterus (grand multiples)
193
What is the next step when a woman is having persistent post-partum bleeding following placental delivery?
Uterine massage and Uterotonic medications
194
What are some medications that can be used to manage excessive post-partum bleeding?
Oxytocin
Methylergonovine
Carboprost
195
What are the main differences between Carboprost and Misoprostol?
Carboprost: PGF2-alpha analog, CANNOT be used in pt w/ HTN
Misoprostol: PGE1 agonist, can use in pt with HTN
196
Which uterotonic medications can be used in pts with HTN?
Misoprostol
197
What is the most likely diagnosis in a woman who just delivered and has completed stage 3 of labor but upon examination of the pacenta, some of the cotyledons are missing?
Retained placenta
198
What is the management for retained placenta?
Manual removal or U/s guided curettage
| Hysterectomy if accreta/increta/percreta present and/or cannot control bleeding
199
When should DIC be suspected in a post-partum pt?
Oozing-type bleeding from IV sites/lacerations with a contracted uterus
200
What hematologic condition are Abruptio Placenta, Severe Preeclampsia, Amniotic Fluid Emboli, or Prolonged retained Fetus associated with?
Disseminated Intravascular Coagulation (DIC)
201
What is the next step in management for a woman who just delivered her placenta and upon examination, the uterus cannot be palpated and a beefy-appearing, bleeding mass is visible within the vagina?
Uterine Inversion
202
What are the next steps in management for a post partum woman who presents with Urinary Retention with a residual volume of >250ml?
Give Bethanechol, if this fails--> Catheter (2-3 dys max)
203
What are absolute contraindications to breastfeeding?
HIV
HTLV-1
HSV lesions on breast
Active Tb
Drug/Medication use/abuse (not alcohol or cigarettes)
Cytotoxic medications (MTX, cyclosporine)
Galactosemia
204
When can an IUD/Diaphragm be placed for contraception following delivery?
Not before 6 wks post partum
205
Which contraceptive option(s) can be used while breastfeeding?
Progestin-only methods
206
When can combined E-P contraceptive methods be used relative to delivery?
Not before 3wks post partum if not breast feeding
207
What is the mechanism by which Progestin-only contraceptives prevent pregnancy?
Ingibit GnRH (mid cylce)--> Decreased FSH/LH --> Anovulation
208
What is the next step in management for a pt who delivered about 6 hours ago by Cesarean Section with general anesthesia now complaining of incisional pain, and on exam has mild fever, few scattered rales bilaterally, and cannot take deep breath due to pain?
Incentive Spirometry and Ambulation
209
What are 2 risk factors associated with post partum atelectasis?
General anesthesia use and inadequately controlled incisional pain
Cigarette Smoking
210
What is the next step in management for a woman on post-partum day 1 with high fever, CVA tenderness who has had multiple vaginal exams and urethral catheterizations.
```
Urinalysis/Urine Cx
IV antibiotics (Single Agent, nitrofurantoin or ciprofloxacin)
```
211
What is the most likely dx in a woman on post partum day 2-3 who had a c-section following hospitalization for PROM and now has fever, uterine tenderness, but no peritoneal signs?
Endometritis
212
What is the next step in management for a post partum pt with endometritis?
IV antibiotics (multi-agent, Gentamicin + Chlindamycin)
213
What is the most likely diagnosis in a pt who keeps spiking fevers despite antibiotics and on exam has erythema, fluctuance, or drainage associated with her c-section incision on postpartum day 4-5?
Wound infection
214
What is the management for wound infection in post partum pt?
IV Antibiotics
Wet-to-Dry dressing
Closure by secondary intention (ex packing, wound vac)
215
What are the history and clinical findings associated with septic thrombophlebitis?
Prolonged labor
| Persistent wide range fevers (on broad spectrum antibiotics) on postpartum day 5-6
216
What is the management for post partum septic thrombophlebitis?
IV heparin 7-10 days
217
What is the most likely diagnosis in a woman who is breast feeding and presents 1-3 weeks post partum with unilateral erythematous, swollen, tender breast with cracked nipple?
Mastitis
218
What is the most likely organism associated with mastitis?
S.aureus
219
What is the treatment for mastitis?
Nafcillin (PO)
| Continue bilateral breast feeding
220
What antihypertensive medications should never be given/started during pregnancy?
ACEi/ARBs
Renin Inhibitors
Thiazide Diuretics
221
What is the leading cause of MATERNAL death in the US?
Pulmonary Embolism
222
When should Anticoagulation be given?
DVT or PE in pregnancy
Afib with underlying heart disease
Antiphospholipid Ab Syndrome
Severe Heart Disease (EF
223
What is the anticoagulant of choice in pregnancy and why?
Low Molecular Weight Heparin
| It does NOT cross placenta
224
Which anticoagulant should not be given during pregnancy?
Warfarin (crosses placenta)
225
Which anticoagnulant is associated with orthopenia?
Unfractionated Heparin
226
How are pt with a h/o DVT/PE in prior pregnancy or h/o underlying thrombophilia managed during pregnancy?
LMW Heparin prophylactically throughout pregnancy
Unfractionated Heparin during Labor/delivery
Warfarin for 6 wks Post-partum
227
What are the most common underlying thrombophilias?
```
Factor V Leiden (resistant to Protein C)
Prothrombin gene mutation
Antiphospholipid Antibody Syndrome
Hyperhomocysteinemia (MTHFR)
Antithrombin III Deficiency
```
228
What are 2 fetal complications associated with HYPERthyroidism in pregnancy
Growth Restriction
| Stillbirth
229
What are 2 complications associated with HYPOthyroidism in pregnancy?
Intellectual deficits
| Miscarriage
230
What are effects of pregnancy on Thyroid hormones?
Increased Total T3 and T4 d/t estrogen effects on liver-->
Increased TBG release
231
What adjustment should be done to pt on Thyroid replacement medication during pregnancy?
Increase dose of Levothyroxine by 25-30%
232
What is the only Thyroid replacement drug of choice in pregnancy?
Levothyroxine
233
What is the drug of choice for symptomatic HYPERthyroidism in pregnancy?
B-Blockers (Propranolol)
234
What is the drug of choice for treating HYPERthryoidism during pregnancy?
Propylthyouracil (PTU) for First Trimester
| Methimazole for Second and Third Trimesters
235
What are the fetal side effects of PTU use?
It crosses placenta and can cause:
| Goiter and Hypothyroidism
236
When does Congenital Grave's disease typically become apparent in neonate?
7-10 days after delivery (when medications effect subside)
237
What Thyroid-related Ab's cross the placenta?
Thyroid-Stimulating Immunglobulins
and
Thyroid-Blocking Immunglobulins
238
What are some clinical findings in fetus associated with exposure to Thyroid Immunglobulins in utero? (3)
Goiter
Fetal Tachycardia
Growth Restriction
239
What are the target values for blood sugar in a pregnant pt?
>90 and
240
What is the initial management for a pregnant woman dx with Gestational Diabetes (GDM)?
Diet and Light Exercise
241
What is the treatment of choice in pregnancy of diet and exercise fail to meet target values?
Insulin
242
How is insulin managed during pregnancy?
Must increase dose as pregnancy progresses (increased hPL production)
Must stop insulin infusion after delivery (bc requirement falls drastically following delivery of placenta)
243
What type of hypoglycemic medication should be avoided while breastfeeding and why?
Oral Hypoglycemics
| -they can transfer to breastmilk and cause hypoglycemia
244
What is done for routine monitoring of diabetic pt in pregnancy?
HBA1c each trimester
Triple Marker Screen (16-18 wks)-ck NTD
Monthly Sono-Ck for IUGR/macrosomia
Monthly BBP
Weekly NST and AFI at 32wks (if on insulin, macrosomia, h/o stillbirth,or HTN)
Start NST and AFI at 26 wks (if pt has small vessel disease or poor glycemic control)
245
What should be done for the management of pt with Gestational Diabetes Mellitus (GDM)?
2-hr 75g OGTT @ 6-12 wks Post-partum (to ck for resolution of DM)
246
What is a rare but significant anatomic abnormality that can be associated with overt DM?
Caudal Regression Syndrome
247
What tends to be associated with a HBA1c >8.5 in a pregnant pt with preexisting DM?
Congenital Malformations (esp NTD)
248
Are congenital malformations associated with Gestational Diabetes or underlying Diabetes Mellitus?
Underlying DM
| GDM does not become problematic until second trimester and congenital malformations occur mainly in first trimester
249
How is labor managed in a pt with DM?
1)Delivery target: 40 wks GA
2)Induction: 39-40wks GA or earlier if 2.5; phosphatidyl glycerol presence =lung maturity)
3)Schedule C-section if >4500 g (risk of shoulder
dystocia)
4)D5W and Insulin Drip to (maintain maternal blood
glucose b/w 80 and 100 mg/dL)
5) Stop insulin drip immediately after placental delivery
6) Maintain glucose with Sliding Scale
250
What is the most likely diagnosis in a pregnant pt at 20 wks with dizygotic twins who is of Swedish descent with intense itching, especially at night, involving her palms and soles. There is a positive FHx and no rash on physical exam but c/o dark colored urine.
Intrahepatic Cholestasis of Pregnancy
251
What are some risk factors associated with intrahepatic cholestasis of pregnancy?
European heritage
| Multiple Pregnancies
252
What tests should be done to dx Intrahepatic Cholestasis of Pregnancy?
Serum Bile Acids (10-100 fold increase)
253
What is the treatment for Intrahepatic Cholestasis of Pregnancy?
```
Ursodeoxycholic Acid (decreases cholesterol absorption, dissolves gallstones- only while taking the medication)
(Antihistamines and cholestyramine may help symptoms)
```
254
What is the treatment for asymptomatic Bacteruria in pregnancy?
Outpt: Nitrofurantoin; Alt- Cephalexin or Amoxicillin
255
What is the most likely dx in a pregnant woman presenting with urgency, frequency, or burning and found to have a positive Urine Culture?
Acute Cystitis
256
What is the treatment for Acute Acystitis?
Outpt: Nitrofurantoin; Alt- Cephalexin or Amoxicillin
257
What is a complication of untreated asymptomatic bacteruria or acute systitis?
Pyelonephritis
258
What is the most likely dx in a pregnant woman who presents with urgency, frequency, or burning, fever and CVA tenderness and found to have a positive Urine Culture?
Pyelonephritis
259
What is the treatment for Pyelonephritis?
1) Admit to Hospital
2) IV Hydration and Ab (IV Cephalosporin or Gentamicin)
3) IV Tocolysis
260
What are some complication of Pyelonephritis?(4)
```
Preterm Labor/Delivery
Severe cases:
-Sepsis
-Anemia
-Pulmonary Dysfunction
```
261
What are the options for first trimester elective Abortion?
Dilation & Curettage (D&C)-before 13wks, most common
Medical Abortion: w/in 63 days (~9wks) of amenorrhea
-Mifepristone-(Progesterone antagonist) and
-Misoprostol-(PGE1 agonist)
262
What medications need to be given when a pt is having D&C for abortion?(3)
Prophylactic Abs
Conscious Sedation
Paravertebral Block (local)
263
What are some rare complications of D&C abortion and how are they managed?
Endometritis (PO Ab's)
| Retained Products of conception (repeat curettage)
264
What are two rare complications of medical abortion and how are they managed?
```
Retained POC (D&C)
Sepsis (Clostridium sordellii-IV antibiotics)
```
265
What is the definition of Spontaneous Abortion?
Expulsion of embryo/fetus
266
What is the most common initial presentation of Spontaneous Abortion?
Uterine Pain/Cramping
| Vaginal Bleeding
267
What is the definition for Fetal Demise?
In utero death of fetus >20wks GA
268
What is the most common symptom pts will report associated with fetal demise?
Loss of fetal movement
269
What is the most likely dx for a pt who presents with a h/o recent vaginal bleeding and passage of clots but on exam her cervix is closed and u/s shows no product of conception?
Complete Spontaneous Abortion
270
What is the management for a Complete SAB?
Follow-up BhCG
271
What is the most likely dx for a pt who presents with a recent h/o vaginal bleeding and passage of clots, on exam her cervix is closed and u/s shows some products of conception?
Incomplete SAB
272
What is the management for an Incomplete SAB?
D&C
273
What is the most likely dx for a pt who presents with vaginal bleeding, passage of clots and on exam her cervix is dilated and u/s shows products of conception present?
Inevitable SAB
274
What is the management for Inevitable SAB?
Medical Induction or D&C
275
What is the most likely dx for a pt who presents with vaginal bleeding but on exam her cervix is closed and u/s shows products of conception present and fetal heart motion/beat identified?
Threatened Abortion
276
What is the management for a pt with Threatened Abortion?
Bed Rest
277
What is the most likely dx for a pt whose u/s shows a dead fetus and products of conception?
Missed Abortion
278
What is the most likely dx for a pt who presents with a h/o recent vaginal bleeding and passage of clots no fetal heartbeat detected and pt has fever, positive cx?
Septic Abortion
279
What is the management for Missed Abortion?
Medical Induction or D&C
280
What is the management for a pt with a Septic Abortion?
D&C
| IV Levofloxacin + Metronidazole
281
What is the most common cause of Spontaneous Abortion?
Chromosomal Abnormalities
282
What are risk factors associated with SAB?
AMA
H/o previous SAB
Maternal SMoking
283
What is the most common cause of Fetal Demise?
Unknown--> Idiopathic
284
What risk factors are associated with Fetal Demise?(5)
```
Antiphospholipid Ab Syndrome
Overt MAternal DM
Maternal Trauma
Severe Maternal Isoimmunization
Fetal Infection
```
285
What are the steps to working up a SAB in the first trimester ?
Pelvic/Speculum Exam (ck for bleeding and dilation)
| Ultrasound (ck fetal cardiac activity +/-, POC)
286
What is the most feared complication when a pregnant woman presents with fetal demise >2wks?
DIC (d/t Tissue Thromboplastin elevation from dying fetal organs)
287
WHat should be ordered on CCS for a pt in whom coagulopathy is suspected?
CBC-platelet Count
PTT/PT
D-dimer
Fibrinogen
288
What is the next step in management for a pt presenting with fetal demise and DIC is confirmed
Immediate delivery of fetus
289
What is the most likely dx in a 24 yo pt who comes to clinic w/ left side abdominal and flank pain, LMP 7 wks ago, and denies n/v or fever with an IUD and pelvic exam showing slightly enlarged uterus, closed cervix, tenderness on bimanual exam but no palpable adnexal mass and serum bhCG is 2650mIU?
Ectopic Pregnancy (Amenorrhea, Vaginal Bleeding, Unilateral Abdominal Pain)
290
What is the most likely dx in a 24 yo pt who comes to clinic w/ left side abdominal and flank pain w/ rebound and guarding and rigidity, hypotension, tachycardia LMP 7 wks ago, and denies n/v or fever with an IUD and pelvic exam showing slightly enlarged uterus, closed cervix, tenderness on bimanual exam but no palpable adnexal mass and serum bhCG is 2650mIU
Ruptured Ectopic Pregnancy
- Hemodynamic Instability
- Peritoneal Signs present on Exam
291
What is the treatment for a Ruptured Ectopic Pregnancy?
1) Immediate Laparotomy/slpingectomy
2) RhoGAM is RH- mother
3) Follow-up with bhCG to ensure complete removal
292
What is the workup for an ectopic pregnancy?
1) bhCG >1500mIU
2) U/s- not intrauterine pregnancy seen
Note: absence of adnexal mass on exam does NOT r/o ectopic pregnancy
293
What are some common risk factors for ectopic pregnancy and which is most common?
1) H/o previous ectopic pregnancy
2) Any other cause of tubal scarring/adhesions:
- Infection: PID (most common) and IUD
- Surgical Hx:Tubal ligation/ surgery
3) Congenital: DES exposure in utero
294
What bhCG value corresponds to visible intrauterine pregnancy on vaginal U/s?
bhCG >1500 mIU (5wks)
295
What bhCG value corresponds to visible intrauterine pregnancy on abdominal U/s?
bhCG >6500 mIU (6wks)
296
What is the next step in management for a pt who presents with amenorrhea for several weeks and endorses sexual activity but her serum bhCG is
Repeat BhCG followed by repeat Sono when quantified BhCG is >1500mIU.
297
What is the treatment for an ectoic pregnancy that has not ruptured?
1) Methotrexate or Laparascopy w/ Salpingostomy
2) RhoGAM to RH- moms
3) F/u bhCG
298
What are the indications for Methotrexate use to manage abortion or ectopic pregnancy? (4)
Pregnancy mass
299
What is the next step in management for a pregnant woman presenting at 19 wks in the ED with lower pelvic pressure, no contractions, fetal membranes bulging from vagina cervix cannot be palpated?
R/o Chorioamnionitis
300
What is the most likely dx in a pregnant woman presenting at 19 wks in the ED with lower pelvic pressure, no contractions, fetal membranes bulging from vagina cervix cannot be palpated?
Cervical Insufficiency
301
What are risk factors for cervical insufficiency?
Second trimester Abortion
Cervical Laceration During Delivery
Deep Cervical Conization
DES exposure
302
When should elective Cerclage be performed in a pt with cervical insufficiency?
13-16 wks GA with >/= 3 unexplained midtrimester pregnancy losses
303
What must be done prior to urgent Cerclage being placed in a pt with cervical insufficiency?
R/o labor and r/o chorioamnionitis
304
When should cerclage be removed?
36-37 wks (after fetal lung maturity)
305
What is the next step in management for a woman who has no symptoms and no prior h/o preterm labor but has short cervix on routine transvaginal sono b/f 16-20 wks?
Transvaginal Cervical Surveillence --> repeat after 20 wks if short cervix persists
(Note: only perform cerclage if evidence of cervical dilation and chorioamnionitis and labor are r/o)
306
What is the definition of IUGR?
EFW
307
What is required prior to dx'ing a fetus with IUGR?
Must have accurate dates.
308
What is the next step in management for a pregnancy for which accurate GA/EDC is unknown?
Early Sonogram (16-20wks)
[Note: NEVER use late sonogram to adjust dates in pregnancy]
309
What are the conditions associated with Symmetric IUGR?
Fetal Causes (Intrinsic Causes-genetic/fetal infection):
- Aneuploidy
- Infection (eg TORCH)
- Structural Anomalies (CHD, NTD, Ventral Wall Defect)
310
What are the U/S findings for Symmetric IUGR?
All fetal measurements are small
311
What is the next step in management for a pregnancy that has a report of symmetric IUGR?
Detailed Sonogram
Karyotype
Fetal Infections Screening
312
What are the conditions associated with Asymmetric IUGR for Maternal Causes?
Extrinsic Factors ( Low Oxygen and nutrient transfer from placenta--> fetal hypoxia----> hypoglycemia and Polycythemia (decreased glycogen/fat stores and increased Erythropoietin)
- Hypertension
- Small Vessel Disease (ex SLE)
- Malnutrition
- Tobacco, Alcohol, Drugs
313
What are the conditions associated with Asymmetric IUGR for Placental Causes?
Infarction
Abruption
Twin-twin transfusion
Velamentous Cord Insertion
314
What might the U/s show for a pt with Asymmetric IUGR?
Decreased Abdomen Measurements
| Normal Head Measurements
315
What is the next step in management for a pt dx'd with Asymmetric IUGR?
1)Serial Sonograms: to monitor
2)Nonstress Test
3)Amniotic Fluid Index (decreased, esp w/ severe
uteroplacental insufficiency
4)BBP
5)Umbilical Artery Doppler
316
Waht is the definition of fetal Macrosomia?
EFW >90-95% for GA or birth wt of 4000-4500b
317
What are the risk factors associated with Fetal Macrosomia?(7)
```
GDM
Overt DM
Prolonged Gestation
Obesity
Excessive Wt Gain in pregnancy
Multiparity
Male Fetus
```
318
What are some maternal complications of fetal Macrosomia?
Injury during delivery
Post-partum Hemorrhage
Emergency C-Section
319
What are some fetal complications of Macrosomia?(3)
Shoulder Dystocia
Injury during birth
Asphyxia
320
What are some neonatal complications of fetal Macrosomia?
Hypoglycemia
| Erb Palsy
321
What is the management for fetal Macrosomia?
Elective C-section if:
-EFW >4500g in diabetic mother
OR
-EFW >5000g in non-diabetic mother
