Obstetrics Flashcards

Question

Oligohydraminous DDx

Answer 1

Kidney issues (Potter's sydrome, posterior urethral valves) Meds: NSAIDs IUGR: Placental Insufficiency Ruptured membranes Late pregnancy (Fluid peaks 33 wks) ( Induce Term + 10: legality, amniotic fluid becomes thick which baby may aspirate )

Answer 2

COX inhibitors (indomethacin) CCB (nifedipine) Oxytocin antagonist (atosiban) Ritodrine (B2-agoinst)

Answer 3

No contraindication to the drug No contraindication for prolonging the pregnancy Fetus is currently healthy Clear diagnosis of preterm labour Cervix \< 4cm dilated Gestational age between 24-34 weeks

Answer 4

Severe hemorrhage Abruption Severe preeclampsia Eclampsia Intrauterine fetal death Severe intrauterine growth restriction Pulmonary hypertension Known intolerance to tocolytics Fetal maturity Lethal fetal anomaly Chorioamnionitis

Answer 5

FBC and urineanalysis Evaluate for maternal infection Amniocentesis Assess fetal lung maturity Ultrasound Assess AFI Gestational age and EFW Transvaginal scan for cervical length Cervicovaginal swab for FfN test

Answer 6

Prenatal Previous GBS infected baby GBS bacteriuria during current pregnancy Intrapartum Maternal temprerature more than 38 degree C Gestational age \< 37 weeks Ruptured membranes \>18 hours Rx penicillin 1st line (benzylpenicillin 3g IV stat dose; followed 1.5 g IV q 4 hours until baby born), ampicillin 2nd line (cefazolin if penicillin allergic)

Answer 7

Benzylpenicillin 3g iv stat dose Followed by 1.5g iv every 4 hours until baby born If allergy to penicillin Clindamycin 900 mg iv every 8 hours until delivery

Answer 8

Ovulatory (30-40%) BBT, Mid-luteal Progesterone, LH,FSH ``` Uterine Hysterosalpinogram (first-line - done days 6-10) ``` Tubal Male factor Peritoneal factor (endometriosis)

Answer 9

1. Wrong Dates 2. Small normal baby 3. Congenital defects 4. IUGR

Answer 10

- Pre-eclampsia - Smoker - Isolated IUGR - Maternal disease ## Footnote Placental insuffiency

Answer 11

**Symmetric** = fetal causes (irreversible) TORCH infections & congenital anomalies (Turner`s, T21, T18, T13) **Asymmetrical** = mother causes (reversibe) after 28 wks Smoking, drug use, alcohol, Maternal disease (SLE, APS, DM 1), Previous IUGR, pre-eclampsia, Chronic HTN (most common cause IUGR)

Answer 12

Serial U/S: twice wkly Umbilical Doppler U/S: \< 3 ratio & +ve EDV MCA Doppler: fetal anemia

Answer 13

**Prolonged second stage:** This includes nulliparous woman with failure to deliver after 2 hours without, and 3 hours with, conduction anesthesia. It also includes multiparous woman with failure to deliver after 1 hour without, and 2 hours with, conduction anesthesia . Suspicion of immediate or potential fetal compromise in the second stage of labor.

Answer 14

ASCUS: 3 consecutive ASCUS -\> refer to colposcopy Ascus + LSIL -\> refer to colposcopy LSIL (= CIN I): 2 consecutive LSIL -\> refer to colposcopy Must have 3 consecutive normal smears at 6 month intervals to go back to routine PAPs schedule (every 3 years under 45 and every 5 years 45-60)

Answer 15

- If 1 abnormal smear of AGUS or HSIL (= CIN II, CIN III, or CIS), you must refer to colposcopy!! - must have 2 consecutive normal smears at 6 month intervals, then annual smears for 9 years before going back to routine PAPs schedule. - treatment options include **ablation** (ie. cold coagulation) or **excision** (ie. conization or LETTZ); the latter being able to take biopsy samples for histology. ***Therefore only use ablation when you are sure there is no risk of invasive carcinoma.*** - CIN I and CIN II 4, 4, 2 rule for regress, stay the same, progress - CIN III 1,6,3 for regress, stay the same, progress

Answer 16

Advantages: - Useful when patient has conditions predisposing to clots (previous DVT, diabetes, SLE, smoking above 35), and can take if hx of migraine +- aura - 3rd generation (desorgestral) work mainly by preventing anovulation (90%, compared to 50% in traditional ), whereas tradition work by thickening cervical mucus - as efficacious as COC when used correctly (99%) - immediate return to fertility - can be used immediately post-partum Disadvantages: - irregular bleeding (4, 4, 2 have none), weight gain, acne, mood change, bloating - change in bleeding should b investigated for STI - need to take it within a 12 hour window for 3rd generation, can't miss a pill or need contraception for 48 hours and NO PILL FREE INTERVAL - affected by liver-inducing agents

Answer 17

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides psychiatric drugs: lithium, benzodiazepines aspirin carbimazole sulphonylureas cytotoxic drugs amiodarone

Answer 18

DDx Approach 1. Failure to ovulate - excessive exercise, underweight, PCOS, hyperprolactinemia 2. Fallopian tube not patient - endometrosis, infection, adhesions 3. Failure of sperm production: testicular radiotherapy and infection Ix - LH/FSH/estradiol - day 2-6 - Progesterone - day 21 or 7 days before menses - Transvaginal ultrasound - fibroids or PCOS - Blood: TSH, prolactin, testosterone ## Footnote Semen sample: 2-3 days abstience and repeat after 6 weeks.

Answer 19

**Coagulopathies** von Willebrand's disease Thrombocytopenia (due to idiopathic thrombocytopenic purpura, hypersplenism, chronic renal failure) Acute leukemia Anticoagulants Advanced liver disease **Neoplasm** Endometrial adenocarcinoma Uterine sarcoma **Structural lesions** Leiomyomata uteri (fibroids) Adenomyosis Polyps **Other** Endometritis Hypothyroidism Intrauterine device Hyperestrogenism Endometriosis

Answer 20

**Fetal ** Intrauterine growth restriction Oligohydramnios Abnormal Doppler velocimetry Preterm labour Multiple pregnancy Breech presentation Rhesus iso-immunisation **Maternal** Previous Caesarean section Pre-eclampsia Pregnancy \>42 weeks Prolonged ROM \>24 hours Diabetes Antepartum haemorrhage Significant medical condition – eg cardiac

Answer 21

Differential diagnoses include adhesions, chronic pelvic inflammatory disease, irritable bowel syndrome, musculoskeletal pain, and neuralgia.

Answer 22

**Maternal ** Gestational HTN Gestational Diabetes Hyperemesis gravidarum Anemia C-section **Placental (P's)** Incr. PROM Polyhydraminous PPH Placenta Previa Placenta Abruptio Cord Prolapse **Fetal** Prematurity (most common) IUGR Malpresentation Congenital abnormalities Twin-to-Twin Incr. mortality and morbidity Single fetal demise

Answer 23

Multiple Gestations Inaccurate menstrual hx polyhydraminous hydatiform mole adnexal mass uterine myoma dystended bladder pushing up uterus fetal macrosomia

Answer 24

**Demographic** More common in women \< 20 years of age and \>35 years of age _Nulliparity (8x risk)_ **Obstetric** History of previous preeclampsia Positive family history Multiple gestations Blacks Thrombocytosis obesity Molar pregnancy (can develop pre-eclampsia before 20 wks) **Medical** DM Chronic HTN Renal Disease SLE

Answer 25

**_Pre-elampsia_** **Maternal monitoring** - Admit - 4 hourly BP - Regular blood tests - 24 hour urine collection ○ Urine input/ouput - Daily medical review * *Fetal Monitoring** - Fetal movement - Daily CTG - USS **Mom** - FBC (anemia), BUN, Cr, AST/ALT, LDH, uric acid - LFTs, platelets (think HELLP) Fetal: - U/S - look of IUGR - Look at lycor volume - Doppler through umbilical artery (incr. resistance will bounce blood off placenta) **_Eclampsia _** **Management (worry about mom not baby)** - ABC (establish 2 large bore cannulas) ○ Pulse oximeter, O2 - Restrict IV fluid to 80 ml/hr (can cause pulmonary edeam), like to see 30 ml output/ hr - monitor input and output - Place mom in LL position - Prevention: MgSO4 4g over 15 minutes (IV load) then 1-3 g/hr for next 24 hour (prophylactic \>160/110 or symptoms of pre-eclampsia then start) ○ Therapeutic range: 2-4 mmol/L (check reflexes) § 1 g IV slow (over 3 min) infusion Ca gluconate if too high - BP: goal 90-110 maternal diastolic ○ If BP 160/110: IV labetalol or IV hydralazine Post-partum management - Generally improvement after 24 hrs - Risk of seizures greatest first 24 hrs - therefore continue MgSO4 for 1 day

Answer 26

**BRADYCARDIA\<110** Gestation \> 40 weeks Cord compression Congenital heart malformations Congenital heart block (including SLE) Drugs eg.benzodiazepines

Answer 27

**TACHYCARDIA\>160** Excessive fetal movement Maternal anxiety Gestation \<32 weeks Maternal pyrexia Fetal infection Chronic hypoxia

Answer 28

Maternal position change, Oxygen and iv fluid Change method of monitoring Reassess maternal vital signs Assess cervix for dilation or prolapse Stop oxytocin if in use Fetal blood sampling Tocolysis Amnioinfusion Acoustic or scalp stimulation Plan immediate delivery

Answer 29

Above 7.25 Repeat pH in 1 hour if tracing non reassuring ## Footnote Between 7.20 to 7.25 Repeat pH in 30 minutes if tracing not improved Below 7.20 Deliver immediately

Answer 30

** Maternal complications** • polyhydramnios - 25%, possibly due to fetal polyuria • preterm labour - 15%, associated with polyhydramnios • Diabetes may develop at a later date (\>50% of cases) **Neonatal complications** • macrosomia (although diabetes may also cause small for gestational age babies) • hypoglycaemia • respiratory distress syndrome: surfactant production is delayed • polycythaemia: therefore more neonatal jaundice • If pre-gestational diabetic: malformation rates increase 3-4 fold e.g. sacral agenesis, CNS and CVS malformations (hypertrophic cardiomyopathy) • stillbirth • hypomagnesaemia • hypocalcaemia

Answer 31

Advancing material age Multiparity Multiple gestations Smoking Prior caesarian section (10%)

Answer 32

- More globular uterus - Lengthening of cord - Gush of blood

Answer 33

Hypertension (greatest risk factor; 40-50% of cases) Smoking cigarettes Cocaine addiction; advanced maternal age Trauma; chorioamnionitis Premature rupture of membranes Previous abruptio placentae

Answer 34

antiphospholipid syndrome endocrine disorders: poorly controlled diabetes mellitus/thyroid disorders. Polycystic ovarian syndrome uterine abnormality: e.g. uterine septum parental chromosomal abnormalities smoking

Answer 35

Simple 1% Complex 3% Simple with atypia 8% Complex with atypia 29%

Answer 36

**_Endometrioid 80- 85%_** Generally resembles normal proliferation Adeno-squamous Papillary Serous 10% Clear cell 4%

Answer 37

Endometrial ca. Endometrial/cervical polyps Endometrial hyperplasia Other gynecological cancers Exogenous estrogen use (tamoxifen) Atrophic endometritis/vaginitis

Answer 38

HSV-1 HSV-2 • Trigeminal ganglia • Lumbo-sacral ganglia • Can be latent many years • Can be latent many years • Cold sores • Genital ulcers • Typically 1/3 of new cases • Typically 2/3 of new genital cases genital cases. • 5% genital recurrences • 95% genital recurrences • Causes ocular herpes, • Causes encephalitis encephalitis, whitlow. • Does not protect against • Protects against HSV-1 HSV-2

Answer 39

1. - Early pregnancy - change endothelial lining to make it more favourable for implantation ## Footnote - Late pregnancy - stabilizes myometrium to prevent preterm labor 2. \<5ng/ml - poor outcome; \>25 ng/ml viable IUP

Answer 40

Identifiable sac and placental tissue, with no embryo

Answer 41

Major genetic anomaly Internal environmental factors - Uterine (anomalies, leiomyomata, incompetent cervix), maternal DES exposure, luteal phase defect, immunologic factors External environmental factors - Substance use (tobacco, EtOH, cocaine), irradiation, infection, occupational chemical exposure Advanced maternal age

Answer 42

Failure of bHCG to double in 48-72 hrs Low serum progesterone U/S - transvaginal - gestational sac outside of uterus Laparascopy - gold standard Extrauterine signs of EP inlcude - no mass or free fluid, any free fluid, echogenic mass

Answer 43

Bleeding Perforation Infection Incomplete evacuation Late sequelae : Intrauterine synchaie(asherman's syndrome), depression/guilt

Answer 44

**Antenatal** Macrosomia, maternal DM, maternal obesity, excessive weight gain in pregnancy (\>20 kg gain), short pelvic structure, previous shoulder dystocia or big bag **Labour** Oxytocin augmentation, slow progress through first stage of labor, secondary arrest after 8cm/2nd stage, midcavity arrest, need for midcavity assisted delivery **Delivery** Head delivering at the end of contraction, difficulty with delivery of head and chin, retraction of head between contractions

Answer 45

**Non-androgenic causes** Chronic skin irritation and excess hair growth Acromegaly Iatrogenic(drug-induced)hirsutism **Androgenic hirsutism** Polycystic ovarian syndrome Hyperandrogenic insulin-resistant acanthosis nigricans syndrome Non-classical congenital adrenal hyperplasia Cushing’s syndrome Androgen-secreting tumours **Idiopathic hirsutism** Hirsutism in the presence of normal androgens and ovulatory cycles

Answer 46

Infertility - Infertility after a single episode is 15% but after 3 episodes increases to 75% Chronic pelvic pain Risk of EP - 7 x greater Chronic tubo-ovarian abscess

Answer 47

Umbilical cord pH falls by 0.04 unit/minute. Delivery should be done within 5 minutes Permanent injury is progressively more likely with delays above 10 minutes.

Answer 48

EP Multiple gestations Ovarian hyperstimulation syndrome (resence of multiple luteinized cysts within the ovaries leading to ovarian enlargement and secondary complications incl nausea, bloating, etc) Infection and/or hemmorhage No response to treatment

Answer 49

Uterine hyperstimulation hypoxia of intervillus space fetal compromise abruption uterine rupture water toxicity in high doses

Answer 50

Management depends on whether urge or stress UI is the predominant picture. If urge incontinence is predominant: bladder retraining (lasts for a minimum of 6 weeks, the idea is to gradually increase the intervals between voiding) bladder stabilising drugs: immediate release oxybutynin (an antimuscarinic) is first-line surgical management: e.g. sacral nerve stimulation ## Footnote If stress incontinence is predominant: pelvic floor muscle training (for a minimum of 3 months) surgical procedures: e.g. retropubic mid-urethral tape procedures

Answer 51

Anti-D immunoglobulin should be given as soon as possible (but always within 72 hours) in the following situations: delivery of a Rh +ve infant, whether live or stillborn any termination of pregnancy miscarriage if gestation is \> 12 weeks ectopic pregnancy external cephalic version antepartum haemorrhage amniocentesis, chorionic villus sampling, fetal blood sampling

Answer 52

Affected fetus oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls) jaundice, anaemia, hepatosplenomegaly heart failure kernicterus treatment: transfusions, UV phototherapy

Answer 53

Examples of UKMEC 3 (disadvantages generally outweigh the advantages) conditions include more than 35 years old and smoking less than 15 cigarettes/day BMI \> 35 kg/m^2\* migraine without aura and more than 35 years old family history of thromboembolic disease in first degree relatives \< 45 years controlled hypertension immobility e.g. wheel chair use breast feeding 6 weeks - 6 months postpartum ## Footnote Examples of UKMEC 4 (represents an unacceptable health risk) conditions include more than 35 years old and smoking more than 15 cigarettes/day migraine with aura history of thromboembolic disease or thrombogenic mutation history of stroke or ischaemic heart disease breast feeding \< 6 weeks post-partum uncontrolled hypertension breast cancer major surgery with prolonged immobilisation

Answer 54

25-49 years: 3-yearly screening 50-64 years: 5-yearly screening

Answer 55

Smoking Nulliparity Medically treated depression Toxic chemical exposure Treatment of childhood cancer with abdominal-pelvic radiation and alkylating agents ## Footnote Premature, or early, menopause (age \< 40 years) has been linked to both familial and non-familial X-chromosome abnormalities.

Answer 56

Vertebral fractures

Answer 57

**E deficiency results in:** Thin and paler vaginal mucosa. Moisture content is low. pH increases (usually pH \> 5). Inflammation and small petechiae. Loss in superficial cells and an increase of basal and parabasal cells. UTI (eg, coliform bacteria), as a result of the reduced acidity. Decrease in lactobacilli, yeast.

Answer 58

**Obstetrics** Severe abruption Ruptured membranes Chorioamnionitis **Fetal** Lethal anomaly Fetal demise Fetal jeopardy **Maternal** Eclampsia Severe pre-eclampsia Advanced dilation