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Step 2 CK > Obstetrics > Flashcards

Obstetrics Flashcards

1
Q

Nagele Rule

A

Estimation of delivery date

LMP - 3 months + 7 days

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2
Q

At what gestational age do you consider resuscitation?

Pre-term
Early Term
Full Term
Late Term
Post-Term
A

No resuscitation if < 22 wks, case by for 23-25 wks, always resuscitate if 25+ wks

Pre-term 25 - 37 wks

Early Term 37 to 38 and 6 days
Full Term 39 to 40 and 6 days
Late Term 41 wks to 41 wks and 6 days

Post-Term 42 wks +

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3
Q

Goodell Sign

Ladin Sign

Chadwick Sign

A

Goodell - FIRST (approx 4 wks), softening of cervix

Ladin - softening of midline uterus

Chadwick - blue discoloration of cervix and vagina

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4
Q

When should a gestational sac appear on US?

A

4-6 wks

or beta-hCG of 1500 +

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5
Q

Physiologic Changes in Pregnancy

A

Inc HR, inc plasma volume, dec peripheral resistance

Dec residual volume, normal FEV1/FVC

Inc tidal volume but normal RR, inc minute ventilation –> respiratory alkalosis

Inc GFR

Hydronephrosis 2/2 ureter compression and progesterone decreasing ureter peristalsis

Inc neutrophils, sometimes dec platelets (tests if < 80,000)

Anemia (dilutional)

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6
Q

Testing by Trimester

A

1st - blood tests, pap smear, gonorrhea and chlamydia, may do US to confirm gestation age, FIRST screen (US, beta hcg and PAPP-A)

2nd - triple or quad screen w/ AFP, anatomy US at 20 wks

3rd - CBC (for anemia), 1 hr glucose test, repeat cervical cx for chlamydia and gonorrhea, group B strep swab

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7
Q

Timing of Chorionic Villous Sampling v. Amniocentesis

A

CVS - 10 to 13 wks with catheter

Amnio - 15 to 17 wks with needle

BOTH YIELD KARYOTYPE

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8
Q

Biophysical Profile

A

NST - 2 accelerations in 30 min

1 episode of fetal breathing > 30 sec in 30 min

3 movements in 30 min

1 flexion/extension episode in 30 min

Amniotic fluid index - no vertical pocket > 2 cm

**2 pts per category, BPP of 4 or less may mean fetal compromise

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9
Q

Acceleration

Early Deceleration

Late Deceleration

Variable Deceleration

A

Acceleration - inc by 15 BPM for 15-20 seconds

Early Decel - mirrors contractions, due to head compression

Late Decel - BAD, dec in HR after contraction has started, decreased placental perfusion –> fetal hypoxia

Variable Decel - no relationship to contractions, due to umbilical cord compression which inc peripheral resistance

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10
Q

Stages of Labor

A

Stage 1 - onset to full cervical dilation

  • Latent - up to 6 cm (6 hrs prime, 4 hrs)
  • Active 6 to 10 cm (1.2 cm/hr prime or 1.5 cm/hr)

Stage 2 - delivery of baby (up to 3 hrs prime, 30 min in multipara)

Stage 3 - delivery of placenta (30 min)

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11
Q

Signs of Placental Separation

A

umbilical cord lengthening

uterine fundus lowering/anterior

uterus becomes firm

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12
Q

Mgt of Ectopic Pregnancy

A

Dx - beta HCG and US

If unstable … surgery (try for salpingotomy - just hole)

If stable … CBC, type and screen, LFTs

Methotrexate - check for 15% dec in beta HCG at 4-7 wks, if less than 15% do second dose, if 2 doses still inadequate –> surgery (cont to check weekly until beta hCG is 0)

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13
Q

Contraindications to Methotrexate for Ectopic

A

Immunodeficiency

Non-compliant

Liver disease

Ectopic > 3.5 cm

If fetus has heartbeat

Co-existing viable pregnancy

Breastfeeding

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14
Q

Abortion Types (6) + Tx of Each

A

Complete - no products, os closed, outpatient follow-up

Incomplete - retained products, os open, D&C or miso

Inevitable - products intact, bleeding, dilated, D&C or miso

Threatened - products intact, bleeding, NOT dilated, BED REST

Missed - all products but not viable, os closed, D&C or miso

Septic - infection of uterus, D&C and IV abx (cefoxitin and doxy or gentamicin and clinda)

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15
Q

When should you deliver in pre-term labor? (6)

A

severe HTN (160/110)

maternal cardiac disease

cervical dilation > 4 cm

maternal hemorrhage (DIC, placental abruption)

fetal death

chorioamnionitis (even if fetus will not survive)

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16
Q

How do you delay pre-term labor?

A

Betamethasone - inc surfactant, lung maturity (peaks at 48 hrs)

Tocolytics - CA CHANNEL BLOCKERS, dec uterine contractions (alternative - terbutaline)

**add ampicillin and 1 dose azithromycin if premature rupture of membranes (to prevent chorio)

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17
Q

Tx of Intrauterine Infection

A

Amp + gentamicin

Add clindamycin if C section

18
Q

Placenta Previa v. Placental Abruption (presentation, risk factors, tx)

A

Both present with bleeding, do abdominal US first (abruption may not be seen but rules out previa)

Previa - painLESS bleeding, risk factors include prior uterine surgeries/ C sections

  • Tx is pelvic rest and no sex
  • Plan for C section at 36-37 wks if persists
  • Immediate C section if hemorrhage, 4 cm dil, fetal distress

Abruption - painFUL bleeding and contractions, can be severe (hypovolemia, DIC), risk factors include HTN, cocaine, tobacco, trauma
- C section if uncontrolled, expanding hemorrhage, fetal distress, rapid placental separation … otherwise vaginal okay

19
Q

Indications for C section based on gestational wt

A

> 4500 g in diabetic mothers

> 5000 g in non-diabetic mothers

20
Q

When should Rho-gam be given?

A

Anytime unsensitized RH neg mom (no titers yet) has exposure to fetal blood cells that may cross placenta

  • abortion
  • amniocentesis
  • vaginal bleeding
  • placental abruption
  • delivery

Also given to unsensitized mom’s at 28 wks –> again at delivery

**Check Rh status at first pre-natal visit, if Rh neg get titers

21
Q

Definition, RF and Tx of Hyperemesis Gravidarum

A

6 lb wt loss or 5% body weight loss

Tx = diet modification to avoid triggers, acupuncture, ginger, vit B6

Antihistamines (benadryl) if severe

Metoclopramide if persists

ondansetron (last resort)

RF = twins, hydatiform mole, previous hx

22
Q

Wt Gain Recs in Pregnancy

A

If BMI < 18 … 28-40 lb

If BMI 18-24.9 (normal) … 25-35 lb

If BMI 25 - 29.9 … 15-25 lb

If BMI > 30 … 11-20 lb

23
Q

Screening and Mgt if Asymptomatic Bacteriuria

A

Screen at 12-16 wks w/ UA and culture

TREAT - nitro, amoxicillin, cephalexin

24
Q

Pyelonephritis Tx in Pregnancy

A

IV ceftriaxone (aztreonam if allergy) inpatient

Evaluate urine cultures monthly for recurrent bacteriuria

25
Q

Tx of PE/DVT in Pregnancy

A

LMWH

Stop 24 hrs before delivery

Resume 12 hrs after C sect and 6 hrs after vaginal

Cont 6 wks post-partum

26
Q

How do you differentiate acute fatty liver of pregnancy from pre-E?

A

AFLP - signs of hepatic insufficiency (hypoglycemia, encephalopathy) and coagulation abnormalities
-IMMEDIATE DELIVERY

Pre-E - just elevated LFTs

27
Q

Chronic HTN

Gestational HTN

Pre-E

Pre-E w/ severe features

HELLP

Eclampsia

A

Chronic HTN - prior to 20 wks, no protein in urine (labetolol, nifedipine, hydralazine)

Gestation - after 20 wks, no protein in urine (“severe gestational HTN” if > 160/110 but still no protein in urine)

Pre - E BP 140-160/90-110 and protein in urine (induce if at term, if not steroids and Mg)

Severe Features - BP > 160/110, mental status changes, vision changes, RUQ pain (swelling of Glisson capsule)
- Tx = steroids, Mg sulfate, hydralazine

HELLP - hemolysis, elevated LFTs, low platelets
- same treatment

Eclampsia - pre -E + seizure
- same treatment

28
Q

What additional tests do you do in pregnant woman w/ pre-gestational DM?

A

EKG

Baseline 24 hr urine - for protein and creatinine clearance

HgbA1c

Baseline retina exam (retinal exam every trimester)

29
Q

Eval for Gestational DM and Tx

A

24-28 wks

1 - 1 hr glucose load (50g) if > 130-140 positive do next test

2 - fasting glucose tolerance test
- meas fasting glucose
- 100 g load
- measure at 1 hr, 2 hr and 3 hr 
POS if 2/4

Tx = diet and exercise first, insulin is gold std (can also use metformin and glyburide)

30
Q

In thyroid disease, what can and cannot cross placenta?

A

Can cross - TRH, TSH receptor antibodies

CANNOT cross - TSH, T4

31
Q

How does beta-hcg affect thyroid disease?

A

Stimulates TSH receptor because share same alpha unit - inc thyroid hormone (why hydatiform mole often presents with hyperthyroid sx)

32
Q

Tx of Hyperthyroid in Pregnancy

A

PTU 1st trimester

Methimazole 2-3rd (can cause cutis aplasia)

33
Q

Definition and Mgt of Prolonged Latent Stage

A

> 20 hrs in prime
14 hrs multiparous

Rest and hydration

34
Q

Definition, Causes, Tx of Protracted Cervical Dilation

Vs. Active Phase Arrest

A

SLOW DILATION

< 1.2 cm/ hr in prime
< 1.5 cm /hr in multiparous

Causes = 3 P’s (passenger, power, pelvis)

  • if contractions too weak or too far apart –> oxytocin
  • if cephalopelvic disproportion –> C section

Arrest = no change in 4 hrs if adequate contractions (200+ montevideo units) OR no change in 6 hrs if inadequate contractions

35
Q

Presentation and Mgt of Uterine Inversion

A

Smooth round mass protruding

Esp if fast delivery, placenta accreta, uterine abnormalities, macrosomia, short cord

Tx = STOP uterotonics (relax for repositioning), manual repositioning, may need nitroglycerin/terbutaline/mg to further relax

Laparotomy as last resort

36
Q

Definition of Postpartum Hemorrhage, 4 Main Causes, Mgt

A

> 1000 mL blood loss

early if < 24 hrs

1 - TONE (atony) #1 reason
2 - Tissue (retained placenta)
3 - Trauma (laceration)
4 - Thrombin (coagulopathy)

Mgt - bimanual exam (r/o rupture or retained placenta), uterine massage, may need oxytocin (constriction)

37
Q

Tx of Vasa Previa, Umbilical Cord Prolapse & Uterine Rupture

A

Vasa Previa - torn umbilical vessels over os –> emergency C section

Umbilical cord prolapse - sudden fetal bradycardia or variable decelerations with palpable cord on vaginal exam –> elevate fetus to avoid cord compression and emergency C section

Uterine rupture - sudden loss of fetal station and bump in abdomen –> laparotomy because fetus in abdomen

38
Q

If woman has prior uterine rupture what do you do in future pregnancies?

A

Planned C section at 36 wks

39
Q

How do you distinguish between 3 types of twins and specific complications of each?

A

Monochorionic, monoamniotic - no thin membrane between, risk of cord entanglement and conjoined twins

Monochorionic, diamniotic - T sign, risk twin-twin transfusion syndrome

Di, di - lambda sign

40
Q

HSV Mgt in Pregnancy

A

If prior HSV - acyclovir from 36 wks to delivery

If active disease in GU lesions or prodrome - C section

If no active disease - vaginal delivery okay

Step 2 CK (28 decks)

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