Obstetrics Flashcards
Role of estrogen in combined OCPs?
FSH suppression
Effect of FSH suppression by combined OCPs?
Prevents maturation of follicle
Role of progesterone in combined OCPs?
LH suppression
Effect of FSH suppression by combined OCPs?
Prevents ovulation (LH surge), Promotes cervical mucosal thickening
Shared effect of estrogen and progesterone in combined OCPs?
Thinning of endometrial lining … inhibits implantation of fertilized ovum
Which form of birth control is indicated for females immediately after delivery?
Progesterone-only OCPs
Why are Progesterone-only OCPs indicated immediately after delivery?
Progesterone cannot pass into breast milk
Why might lactation be thought to serve as contraception?
Increased prolactin inhibits release of GnRH … No ovulation with low LH/FSH
Route of contraception administered by Norplant?
Releases small amount of progestin
AE of Norplant?
Break-through pregnancy (ectopic)
Definition of melasma?
Dark pigmentation of face
Risk factors for melasma?
OCP use, Pregnancy
Recommended dose of Ca2+ for pregnant females < 19 yo?
1300 mg
Recommended dose of Ca2+ for pregnant females > 19 yo?
1000 mg
Recommended dose of Fe for pregnant females?
30 mg
Recommended dose of Folate for pregnant females?
1 mg
Recommended dose of Folate for pregnant females with HX of pregnancy with NTD?
4 mg
Average weight gain during pregnancy?
20-40 lbs
Which screening should be performed during 1st trimester for African, Asian females?
Thalassemia
Which screening should be performed during 1st trimester for AA females?
Sickle Cell
3 effect of Sickle Cell disease during pregnancy?
Increased risk of crisis … CHF, Pulmonary infarction, Pre-eclampsia
Treatment of choice for pregnant female who is HIV (+)?
IV zidovudine during delivery; Oral zidovudine to baby
How long should Zidovudine be administered to baby born to HIV (+) mother?
6 weeks
Best route of delivery for HIV (+) female?
C-section
Normal risk of vertical transmission of HIV?
25%
Risk of vertical transmission of HIV after administration of zidovudine?
8%
Should female with HIV breastfeed?
No … HIV is absolute contraindication to breastfeeding
If pregnant female is not immune to Rubella, should you give the vaccine?
No … MMR vaccine is live-attenuated
On routine GYN exam, unilateral adnexal mass is palpated in young asymptomatic female – diagnosis?
Failure of dominant follicle to rupture
Treatment for Failure of dominant follicle to rupture?
None
US of pregnant female shows corpus luteum cysts – next step in workup?
Observe … cyst will begin to shrink at 10 weeks, disappear at 16 weeks
What accounts for increased nausea/vomiting in pregnancy?
Increased estrogen, progesterone, β-HCG
Definition of Chadwick’s sign?
Blue discoloration of cervix
Definition of Goodell’s sign?
Cervical softening
At what point in pregnancy does β-HCG have 100% sensitivity?
11 days after missed period
In which condition is β-HCG very low?
Ectopic pregnancy
In which condition is β-HCG very high?
Hydatidiform mole
What is doubling time of β-HCG during normal pregnancy?
2 days
At what point in pregnancy does β-HCG level peak in pregnancy?
8-10 weeks
Most reliable method of determining gestational age?
US
How do you determine gestational age with US?
Gestational sac diameter (in mm) + 30
2 aspects of clinical presentation for molar pregnancy?
Painless vaginal bleeding; Hyperemesis
Change to uterus size in setting of molar pregnancy?
Larger than expected
Prognosis for 80% of hydatidiform moles?
Benign
During pregnancy, cardiac output increases by …
40%
Which type of murmur is always pathologic when heard during pregnancy?
Diastolic
Hematologic change seen in pregnancy?
Increased coagulability
Which type of murmur is normal when heard in pregnancy?
Systolic
Change to BUN and creatinine in pregnancy?
Increase … due to fluid expansion
Which 2 pulmonary values increase during pregnancy?
Tidal volume, O2 consumption
Which 2 pulmonary values decrease during pregnancy?
Residual volume, FRC
Which molecule is responsible for insulin resistance in pregnancy?
HPL (Human Placental Lactogen)
What accounts for improvement in PUD during pregnancy?
Increased prostaglandin production
Which 2 neurologic conditions might improve during pregnancy?
MS, Migraines
Which endocrine condition might improve during pregnancy?
Graves disease
2 contraindications to use of IUD?
Vaginal/cervical infection; HX of infertility
What size of uterus is contraindicated in IUD use?
Depth of uterus <6 cm
Contraindication to use of Diaphragm as birth control?
Latex allergy of patient or partner
2 AEs of Diaphragm as birth control?
UTI, Toxic shock syndrome
Which pathogen is associated with IUD placement?
Actinomyces israelii
Role of estrogen in combined OCPs?
FSH suppression
Effect of FSH suppression by combined OCPs?
Prevents maturation of follicle
Role of progesterone in combined OCPs?
LH suppression
Effect of FSH suppression by combined OCPs?
Prevents ovulation (LH surge), Promotes cervical mucosal thickening
Shared effect of estrogen and progesterone in combined OCPs?
Thinning of endometrial lining … inhibits implantation of fertilized ovum
Which form of birth control is indicated for females immediately after delivery?
Progesterone-only OCPs
Why are Progesterone-only OCPs indicated immediately after delivery?
Progesterone cannot pass into breast milk
Why might lactation be thought to serve as contraception?
Increased prolactin inhibits release of GnRH … No ovulation with low LH/FSH
On 2nd trimester US, thickened nuchal translucency is associated with …
Down Syndrome
Which NTD screening should be provided to females < 35 yo?
AFP
Change to serum AFP in NTD?
High
3 other etiologies of high serum AFP?
Multiple gestation, Duodenal atresia, Gestational age error
Change to serum AFP in Down Syndrome?
Low
Which NTD screening should be provided to females > 35 yo?
Triple marker … AFP, Estriol, β-HCG
4 components of Quad Screen for NTD?
AFP, Estriol, β-HCG, Inhibin A
5 screenings that should be performed during 3rd trimester?
Gestational DM, GBS, Chlamydia/gonorrhea, RH blood type, HSV
At what stage in gestation should female be evaluated for gestational DM?
Between 24-28
Treatment for vaginal birth if 3rd trimester GBS screening is (+)?
Intrapartum IV penicillin
In addition to Down Syndrome, what is another complication of pregnancy > 35 yo?
Multiple fetal losses
Renal abnormality associated with Turner’s Syndrome?
Horseshoe kidney
35 yo female presents at 15 weeks; Triple marker screen shows increased AFP – what is next step in management?
Amniocentesis
Role of amniocentesis in female >35 yo with increased AFP?
Determine fetal karyotype
Best method of determining fetal RH isoimmunization and fetal CBC?
Percutaneous umbilical cord sample
Complication of amniocentesis?
Amniotic fluid embolus
Clinical presentation of Amniotic fluid embolus?
Pregnant female with hypotension, tachycardia, bronchospasm, cyanosis
Hematologic complication of Amniotic fluid embolus?
DIC
Treatment for Amniotic fluid embolus?
Intubation
Role of Chorionic villi sampling during pregnancy?
Best diagnostic way to detect fetal chromosomal abnormalities
Indication for testing fetal lung maturity?
If premature delivery is necessary
Normal L:S ratio in fetal lung maturity testing?
> 2:1
L:S ratio during fetal lung maturity testing stands for …
Lecithin : Sphingomyelinase
Which substance increases lecithin and surfactant during pregnancy?
Corticosteroids
2 complications of gestational DM?
Shoulder dystocia, Uterine atony
In setting of shoulder dystocia, fetal anterior shoulder will impact …
Maternal symphysis
DOC for diabetic nephropathy?
Labetolol … (ACEIs = teratogenic)
What type of Ig does RH (-) mother produce against RH (+) fetus?
IgG
What IgG titer in mother is significant?
1:16
When should RhoGAM by administered?
28 weeks AND within 72 hours of delivery
Alternate name for RhoGAM?
IgG anti-D
What is does of RhoGAM that is administered both antepartum and postpartum?
1500 IU IV/IM
During an acute HTN episode, what is the target BP for pregnant female?
Drop BP to mild-moderate level … (don’t normalized completely to <120/80)
2 DOCs for HTN crisis in pregnant females?
Labetalol, Hydralazine
1 DOC for mild-moderate HTN during pregnancy?
Methyldopa
3 complications of tobacco use during pregnancy?
Placental abruption, Placenta previa, IUGR
Fetal Hydantoin Syndrome is associated with increased risk of …
Neuroblastoma
Change to eyes in setting of Fetal Hydantoin Syndrome?
Coloboma
Best management of asymptomatic pregnant female who presents on initial visit, found to have bacteriuria?
Treat with ampicillin, cefalexin, nitrofurantoin
34 yo female G3P2A0 presents with recurrent cystitis – what is best management?
Treat with nitrofurantoin for ENTIRE pregnancy
Best management for pregnant female who presents with pyelonephritis?
Admission, IV ABX
Best management for pregnant female who is concerned that she may have been exposed to chickenpox?
If mother is NOT immunized … Check varicella titer, give IgG within 72 hours
Best management of fetus born to mother with possible chickenpox exposure?
Give infant IgG if mother was exposed within 3-5 days before/after delivery
DOC for Toxoplasmosis during 1st trimester pregnancy?
Spiramycin
DOC for Toxoplasmosis during 2nd/3rd trimester pregnancy?
Pyrimethamine, Sulfadiazine
When during gestation is travelling outside of country considered to be safe?
18-32 weeks
Are inhaled and systemic steroids safe to use during pregnancy in patients with asthma?
Yes
28 yo female G2P1A0 presents with non-tender LLE swelling after sitting in car for 3 hours; What is best management?
Perform venous Doppler, Administer IV heparin
What accounts for hypercoagulability during NML pregnancy?
Increased levels of coagulation factors – fibrinogen, VWF, Factor VIII
How long should anti-coagulation meds be continued in pregnant female after delivery?
Until 6 weeks post-partum
Change to spine during 3rd trimester pregnancy?
Increased lumbar lordosis
What accounts for low back pain during 3rd trimester pregnancy?
Relaxion of pelvic girdle ligaments
2 most common pathogens responsible for PID?
Chlamydia, Gonorrhea
Best Outpatient treatment for PID?
Ampicillin + Sulbactam + Doxycycline
Best Inpatient treatment for PID?
Cefotetan + Doxycycline
3 circumstances in which patients should be admitted for PID?
PID during pregnancy; PID with underlying HIV; PID with ovarian abscess
Change to β-HCG for gestational age in setting of ectopic pregnancy?
Low
Which type of imaging is most sensitive for detection of ectopic pregnancy?
Transvaginal US
Procedure used during treatment of ectopic pregnancy?
Exploratory laparotomy
DOC for treatment of ectopic pregnancy?
Methotrexate
Pattern of β-HCG trends in setting of ectopic pregnancy that is responsive to methotrexate treatment?
β-HCG = high on 4th day; β-HCG = drops by 15% on 7th day
Alternate name for pseudocyesis?
Pseudo-pregnancy
Best management of pseudocyesis?
Referral to psychiatry
Exercise recommendation during pregnancy?
Exercise = beneficial; Should be continued throughout pregnancy
State of cervix in setting of threatened abortion?
Closed
2 steps of workup for threatened abortion?
Check β-HCG level; Check fetal cardiac activity
State of cervix in setting of inevitable abortion?
Open
First step of workup for inevitable abortion with protrusion of products of conception through cervix?
Send fetal tissue for chromosomal analysis
Most common cause of abortion during 1st trimester?
Chromosomal abnormalities
Important step of treatment for mothers after inevitable abortion?
Treat RH- mothers with RH Ig to suppress immune response (in preparation for subsequent pregnancies)
During monitoring of β-HCG after complete abortion, levels do not return to zero – diagnosis?
Incomplete abortion
State of cervix in missed abortion?
Closed
State of cervix in complete abortion?
Closed
Appearance of intrauterine cavity in setting of missed abortion?
Nonviable fetus
Appearance of intrauterine cavity in setting of complete abortion?
Empty
Complication of missed abortion?
DIC
2 aspects of treatment for septic abortion?
D&C, ABX
2 ABX of choice used during treatment of septic abortion?
Levofloxacin, Metronidazole
Diagnostic test for Asherman Syndrome?
Hysteroscopy
Change to LH in setting of Asherman Syndrome?
NML
Change to FSH in setting of Asherman Syndrome?
NML
What is next best step of workup for mother who has not felt fetal movement for 8+ hours?
Real-time US
Most common cause of early recurrent abortion?
Chromosomal abnormality
Most common cause of late recurrent abortion?
Incompetent cervix
Treatment for incompetent cervix?
Cerclage
Important step of treatment to perform for incompetent cervix, before placement of cerclage?
Culture cervix for gonorrhea/chlamydia/streptococcus
Risk factor for placenta previa?
Prior c-section
Clinical presentation of placenta previa?
Painless vaginal bleeding
Ideal delivery of female with placenta previa?
C-section
Clinical presentation of placenta abruption?
Painful vaginal bleeding
3 risk factors for placenta abruption?
Cocaine use, Injury, Smoking
4 DOC for treatment of thyroid storm during pregnancy?
β-blockers, PTU, Corticosteroids, Iodine
β-blockers, PTU, Corticosteroids, Iodine Appearance of blood smear in setting of HELLP Syndrome?
Schistocytes
What is most effective treatment for HELLP Syndrome?
Delivery of fetus
Metabolic change associated with Acute Fatty Liver of Pregnancy?
Hypoglycemia
Complication of Acute Fatty Liver of Pregnancy?
DIC
Best recommendation about pregnancy for females with Acute Fatty Liver of Pregnancy?
Patient should be advised against pregnancy
21 yo female presents at 35 weeks gestation for intense pruritis and dark urine – diagnosis?
Intrahepatic cholestasis of pregnancy
Hallmark lab value seen in setting of intrahepatic cholestasis of pregnancy?
Increased bile acids
Where is pruritis most intense during intrahepatic cholestasis of pregnancy?
Palms, Soles
Classic triad of symptoms seen in Pre-eclampsia?
HTN, Proteinuria, Edema
Ocular symptom seen in severe pre-eclampsia?
Retinal hemorrhage
How long should IV MgSO4 be administered to patient with severe pre-eclampsia?
24 hours after delivery
Definition of eclampsia?
Pre-eclampsia with seizure OR coma
Treatment of eclampsia during pregnancy is contraindicated in patients with which condition?
Graves disease
2 DOCs for eclampsia that is non-responsive to MgSO4?
Diazepam, Phenytoin
Why is BP control important during treatment of eclampsia?
Hemorrhagic CVA is common cause of death in setting of eclampsia
Definitive treatment of eclampsia?
Delivery of fetus
Clinical presentation of patient with magnesium toxicity after being treated for eclampsia with MgSO4?
Hyporeflexia
DOC for treatment of magnesium toxicity?
IV calcium gluconate
Risk factor for development of chorioamnionitis?
Prolonged rupture of membranes
Classic triad of maternal clinical symptoms associated with chorioamnionitis?
Maternal tachycardia, leukocytosis, uterine TTP
Fetal clinical presentation of chorioamnionitis?
Tachycardia
Treatment of chorioamnionitis?
ABX + Delivery
Normal fetal HR?
110-160 BPM
Take immediate action if fetal HR is less than …
90 BPM
2 methods of prenatal assessment?
Non-stress test, Biophysical profile
What is considered to be a Normal fetal NST?
2 accelerations of 15 BPM, lasting 15 seconds … within 20 minutes
Next step of workup if fetal NST is non-reactive?
Perform BPP
5 components of BPP?
NST, Amniotic fluid, Breathing, Movement, Tone
Normal BPP score?
8-10
BPP score that suggests immediate delivery?
0-2
Purpose of Contraction Stress Test?
Determine effect of uterine contractions on fetal HR
3 types of fetal HR decelerations?
Early, Late, Variable
Description of early deceleration?
Nadir of deceleration occurs at same time at peak of contraction
Description of late deceleration?
Deceleration begins at peak of contraction
Description of variable deceleration?
Decelerations don’t always occur with contractions; Shoulders
Etiology of early deceleration?
Head compression
Prognosis for early deceleration?
NML
Etiology of late deceleration?
Uteroplacental insufficiency
Prognosis for late deceleration?
Serious … Immediate C-section
Etiology of variable deceleration?
Cord compression
Prognosis for variable deceleration?
Change position of mother
Definition of normal labor?
Uterine contractions that induce dilation and effacement of cervix
___ refers to progressive thinning/shortening of the cervix during labor
Effacement
___ refers to failed progression of labor after cervix has dilated to 6 cm
Prolonged active phase labor
Management of prolonged active phase labor in female with hypotonic uterine contractions?
IV oxytocin
Management of prolonged active phase labor in female with hypertonic uterine contractions?
Morphine
___ refers to failed progression of labor after full dilation of cervix to 10 cm
Prolonged 2nd stage labor
At what point is delivery of placenta considered to be abnormal?
30+ minutes after fetus delivery
First procedure that is used during delivery of baby with shoulder dystocia?
McRoberts maneuver
Description of McRoberts maneuver?
Flex mother’s hip as far back as possible; Exert downward traction on fetus’ head
Procedure that is used during delivery of baby with shoulder dystocia, if McRoberts maneuver is unsuccessful?
Zavanelli maneuver
Description of Zavanelli maneuver?
Push baby’s head up through vagina; Deliver baby via C-Section
Best management of prolapsed umbilical cord?
OB emergency; Immediate C-section delivery is indicated
Best management of fetus who presents in Breech position <37 weeks gestation?
Observation
___ refers to subcutaneous extraperiosteal fluid collection with ill-defined margins, caused by pressure of dilated cervix on presenting part of scalp
Caput Succedaneum
(Caput crosses; Subgalleal crosses)
Characteristic of fluid collection seen in Caput Succedaneum?
Extends across suture lines
Best management of Caput Succedaneum?
Observation … Fluid collection will resolve spontaneously
___ refers to subperiosteal bleeding caused by prolonged 2nd stage labor
Cephalhematoma
(Cephalhematoma does not cross)
Characteristic of fluid collection seen in Cephalhematoma?
Does NOT extend across suture lines
Best initial management of premature labor?
Bed rest; Hydration
2nd step of premature labor management?
Tocolytic drugs + Corticosteroids + ABX (GBS)
3 examples of tocolytic drugs used during management of premature labor?
MgSO4, Terbutaline, Nifedipine
Where is pain felt during Braxton Hicks contractions?
Only felt in front of abdomen
Where is pain felt during true contractions?
Begin in lower back; Move to front of abdomen
Most common cause of postpartum hemorrhage?
Uterine atony
Initial treatment of uterine atony causing postpartum hemorrhage?
Uterine massage + Oxytocin
2nd most common cause of postpartum hemorrhage?
Trauma to uterus/cervix/vagina … macrosomia, operative delivery
Best management of postpartum psychosis?
Psychiatric evaluation
Which medication is NOT recommended in setting of lactation suppression?
Bromocriptine
Effect of breast implants on autoimmune disorders (RA, SLE)?
None
Effect of breast implants on increased risk of CA?
None
When should females with breast implants begin mammograms?
Continue mammogram plan as usual
