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Royal College - OBGYN > Part 3 > Flashcards

Part 3 Flashcards

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1
Q

When can you defer WinRho?

A

Spotting 2 weeks after WinRho administration

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2
Q

Changes with HRT to lipids?

A
  • High triglycerides (bad)

- Increased HDL and decreased LDL (good)

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3
Q

Treatment for PMDD?

A

Mild symptoms = supportive, exercise, vitamins
Moderate sympmtoms
1. SSRI (first line if not desiring contraception)
2. OCP or GnRH agonist (may also require SSRI)

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4
Q

Medications causing galactorrhea

A

Maxeran (high risk), many antipsychotics, SSRIs, antihypertensives (methyldopa, verapamil), methadone

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5
Q

Most common cause of chromosomal abnormality of RPL?

A

Balanced/reciprocal translocation

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6
Q

Collateral blood supply to the uterus after internal iliac artery ligation

A

Lumbar artery

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7
Q

Most common bacterial cause of postpartum mastitis?

A

Staph aureus

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8
Q

Previous PPH and secondary amenorrhea - MRI finding?

A

Empty sella

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9
Q

Other name for hemabate?

A

Carboprost / 15-methyl PGF2-alpha

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10
Q

What is the mechanism of action for polyhydramnios?

A
  1. Not swallowing (neurologic or upper GI obstruction)

2. Peeing too much

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11
Q

Oomphalocele is associated with what 3 things? (if it is not an isolated finding)

A
  1. Aneuploidy
  2. Cardiac defects
  3. Increased AFP
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12
Q

Most common cardiac lesion with Turners?

A

Bicuspid aortic valve

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13
Q

Most common identifiable cause of fetal demise?

A

Abruption

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14
Q

How to deliver:
A) Brow
B) Face - mentum anterior and mantum posterior

A

A) C/S (due to risk of c-spine injury)
B) Mentum anterior - SVD
Mentum posterior - C/S (gets caught on coccyx)

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15
Q

Embryonic origin of the vagina?

A

Upper - paramesonephric ducts

Lower - urogenital sinus

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16
Q

Ducts forming embryonic structures (memory aids)

A

Mesonephric ducts = Wolfian (wolf -> men)

Paramesonephric ducts = uterus (P=pregnant -> uterus, P=pink -> girls)

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17
Q

What SSRI is teratogenic?

A

Paroxetine (P = bad in Pregnancy)

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18
Q

Work-up for POI

A
  • Adrenal antibodies
  • Thyroid
  • FSH/LH/estradiol
  • Karyotype
  • FMR-1 gene mutation
  • Imaging
  • Bone mineral density
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19
Q

Treatment for day 4 of a recurrent HSV outbreak

A

Topical lidocaine

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20
Q

Anti-epileptic medications with lowest risk of teratogenicity (2)

A

Lamotrigine + Levetiracetam (Keppra)

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21
Q

Delayed cord clamping in preterm infants prevents what?

A
  • Anemia / transfusions
  • IVH
  • NEC
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22
Q

What has the best evidence to prevent PPH after SVD (and dose)?

A

Oxytocin 10u IM

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23
Q

26 weeks with no FM after accident, first move?

A

Assess FHR

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24
Q

What decreases risk of incomplete TA at 18 weeks?

A

Dilating to 19 weeks with Hegar

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25
Q

Benefits of diagnosing vasa previa antenatally?

A
  • Decreased neonatal transfusions

- Decreased neonatal mortality

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26
Q

Cardiac arrest, when do you do a perimortem C/S?

A

At 4 minutes

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27
Q

What is the risk of stillbirth after previous stillbirth?

A

5-10x higher (OR 5.5)

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28
Q

What factor is the most predictive of successful ECV?

A 
#1 Complete vs. incomplete breech
#2 Amniotic fluid
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29
Q

What is the most important factor contributing to an AIDS defining illness?

A

CD4 Count

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30
Q

What are the risks of indomethacin?

A

> 30 weeks = premature closure of the PDA, oligohydramnios, IVH

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31
Q

Route of oxygenated blood to fetal brain

A

Umbilical vein -> ductus venosus -> foramen ovale -> brain

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32
Q

Nerve root of sensation to uterus

A

T10

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33
Q

Shunt in fetus with most oxygenated blood?

A

Ductus venosus

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34
Q

Pulmonary edema is caused by which OB drug? Why?

A

Nifedipine -> calcium channel blocker -> negative inotrope -> increased preload = pulmonary edema

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35
Q

Childhood manifestations after being an IUGR baby

A

Overweight & T2DM

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36
Q

Mode/timing of delivery for previa?

A
  1. Previa
    a) risk factors - 36+0 to 36+6
    b) no risk factors - 37+0 to 37+6
  2. Low-lying placenta
    a) placental edge <1cm from os
    i. risk factors - CS at 37+0 to 37+6
    ii. no risk factors - CS at 38+0 to 38+6
    b) placental edge >1cm from os
    - trial of labour
    - CS at 39+0 to 40+6 per maternal request
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37
Q

Management of vasa previa

A
  • serial TVUS (15% will regress)
  • goal of pre-labour pre-ROM CS
  • if PVB/ROM -> to BU for EFM, +/- test for fetal blood -> CS if abnormal
  • hospitalization (consider at 30-32 weeks)
  • steroids (at 28-32 weeks for all)
  • place of delivery (chart note, have O- irradiated blood ready for baby)
  • timing: 35-36 weeks
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38
Q

What is the cutoff value of CPR and why is it significant?

A
  • CPR <1
  • late onset IUGR (>34wks)
  • increased risk of IUFD
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39
Q

When to deliver based on Dopplers?

A

AEDF = 34 weeks
REDF = 30 weeks
Reversed a wave = 26 weeks

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40
Q

Risk factors for PAS disorders? (8)

A
  • Age >35
  • IVF
  • Previa
  • Prior C/S
  • Previous uterine surgery (hysteroscopy, D&C)
  • Myomectomy
  • Fibroid embolization
  • Intrauterine adhesions
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41
Q

Who gets ASA?

A 
one of:
- hx PET
- twins 
- chronic HTN
- renal disease 
- SLE, APLAS
- DM1 or 2
2 of: nulliparity, obesity, low SES, age >35, fam hx PET, personal hx RF (prev SGA, adverse outcome, pregnancy interval >10yrs)
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42
Q

Risk factors for placenta previa? (9)

A
  • AMA
  • Multiparity
  • Previous CS
  • Previous placenta previa
  • Chronic HTN
  • DM
  • Smoking / cocaine
  • Multiple gestation
  • ART
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43
Q

Risk factors for vasa previa? (9)

A
  • Velementous cord insertion (pre-req)
  • Bilobed placenta
  • Succenturiate lobe
  • IVF
  • T2 placenta previa
  • Anomalies
  • Prematurity
  • APH
  • IUGR
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44
Q

Timing of delivery with PAS disorder?

A
  • 34-36 weeks
  • want controlled elective surgery
  • remember steroids if <34+6
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45
Q

Risk of recurrence of PAS?

A

Overall 17-29%

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46
Q

Risk of PAS if previa & __ CS (1-4)

A 
1 CS - 11%
2 CS - 40%
3 CS - 61%
4 CS - 67%
5+ CS - 67%

Elective CS guideline table

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47
Q

Risk of leaving placenta in situ and PAS

A

Infection (50%)
Emergency hysterectomy (50%)
Bleeding
Coagulopathy

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48
Q

What is the progression of least bad to worst fetal findings for IUFD?

A 
Low growth
Early redistribution
Minimal growth
Abnormal umbilical artery doppler
Low AFI
Abnormal venous doppler
Abnormal FHR
IUFD
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49
Q

Management of early CS ectopic (i.e. early PAS)

A

Type 1 can be managed expectantly KCl into embryo
IM methotrexate = wait 2-3 days
Hysteroscopic resection +/- laparoscopy

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50
Q

Definition of placenta previa and low-lying placenta

A 
Previa = placenta lies directly over cervix
Low-lying = placenta is within 2cm of cervical os
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51
Q

What type/location of placenta previa is most likely to resolve?

A

Anterior

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52
Q

What percent of previa will resolve by term if diagnosed in T2?

A

90-98%

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53
Q

How to confirm previa diagnosis

A

Ultrasound >32 weeks

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54
Q

When to hospitalize a placenta previa

A

Risk factors or remote location / lack of access

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55
Q

When to give steroids with a previa

A

Only if risk of delivery within 7 days (1 of 8 risk factors at <34+6)

56
Q

When to make final diagnosis of placenta previa

A

If no risk factors and degree of cervical overlap minimal -> wait until repeat US at 36 weeks

57
Q

Risk factors in the presence of a previa for APH? (6)

A
  • History of APH (first episode <29 weeks, recurrent 3+)
  • Thick placenta edge (>1cm)
  • Marginal sinus
  • Short cervical length (<3cm with previa, <2cm if low-lying)
  • Previous CS
  • Evidence of invasive placentation
58
Q

HIV drugs teratogenic or contraindicated?

A

Ribavirin
Efavirenz (NTD in T1)
Nevirapine (SJS and hepatotoxicity)
*Don’t stop drugs if patient is stable on them

59
Q

Treatment for toxoplasmosis?

  • If in mom / placenta only
  • If confirmed in fetus
A

Mom / placenta: spiramycin 1g q8h PO (for duration of pregnancy)

Fetus: Pyrimethamin PO daily + sulfadiazine 75mg/kg PO then 50mg/kg PO q12h + folinic acid

60
Q

Percent of women with parvovirus who will have an infected fetus

A

30%

61
Q

Percent of fetuses with parvovirus that will develop anemia

A

1%

62
Q

When to test for Zika?

A

2-3 weeks after last exposure (including unprotected intercourse)

63
Q

Toxoplasmosis IgG+ and IgM+ next step?

A
  • Repeat testing in 2-3 weeks to confirm or rule out false +

- Diagnosis confirmed if 4-fold increase in titre (IgG)

64
Q

When you repeat a toxoplasmosis serology you send it to who? What result confirms infection?

A
  • Send to reference lab

- 4 fold increase in titre

65
Q

GBS prophylaxis treatment? Penicillin allergy?

A
  • Pen G 5 million units IV, then 2.5 million units IV q4
  • Allergy non-anaphylactic: Ancef 2g IV x1, then 1g q8h
  • Anaphylactic: susceptibilities! Either clinda 900mg IV q8h or vanco 1g IV q12h
66
Q

Risk of vertical transmission for Hep C is directly related to what? Other risks?

A

Related to viral load

Other risk is co-HIV infection

67
Q

Risk of vertical transmission of HIV

a) baseline
b) with PNC and ART
c) in Canada with at least 4 weeks of ART
d) overall with ART and no breastfeeding

A

a) 25%
b) <2%
c) 0.4%
d) <1%

68
Q

What percent of maternal infection of CMV transfer to the baby?

A

30-40%

69
Q

What percent of babies infected with CMV develop sequelae?

A

25%

70
Q

What percent of babies infected with CMV will have US findings?

A

25%

71
Q

Contraindications to vaccines (3)

A
  1. Anaphylaxis to vaccine or components
  2. Severe uncontrolled asthma
  3. Hx of Guillan-Barre within 6 months of getting the vaccine previously
72
Q

How long after acute toxoplasmosis infection should you wait to conceive?

A

6 months

73
Q

Risk of Hep B vertical transmission with amniocentesis

with and without Hep e antigen

A

1.4% without e antigen

Up to 16% with e antigen

74
Q

When and what Hep B prophylaxis is used in pregnancy

A

If HBV DNA >10^6 copies or 200,000 IU/ml start at 26-32 weeks
Tenofovir 300mg PO daily

75
Q

Diffuse red raised patching rash on pregnant woman

A

Rubella

76
Q

What is the treatment for syphilis?

A

Benzathine penicillin G

77
Q

What reaction can pregnant women get with syphilis treatment?

A

Jarisch-Herxsheimer (causes contractions and fever)

78
Q

When to do an amniocentesis for rubella

A

At least 6 weeks post-infection and after 20 weeks gestation

79
Q

When to do an amniocentesis for CMV

A

7 weeks post infection and 21 weeks

7x3 = 21, 3 letters in CMV

80
Q

CMV ultrasound findings

A
  • IUGR
  • Microcephaly
  • Intracranial calcifications
  • Hydrops
  • Echogenic bowel
  • Placentamegaly
  • IUFD
  • Hepatic calcifications
81
Q

What do you do about varicella exposure in pregnancy?

A

VZIG!

  • within 96 hours
  • 125u/10kg IM
  • need to get consent
82
Q

Neonatal findings of CMV?

A
  • IUGR
  • Microcephaly
  • Hepatosplenomegaly
  • Petechiae
  • Jaundice
  • Anemia
  • Sensorineural hearing loss*
  • Visual impairment
  • Developmental delay
83
Q

When do you give GBS prophylaxis (7)

A
  • GBS+
  • Previous infant affected by GBS sepsis
  • Current pregnancy GBS+ in urine (regardless of CFU)
  • <37 weeks in labour (unless known GBS-)
  • <37 weeks PPROM (at least 48hrs unless known GBS-)
  • Intrapartum fever/chorio (regardless of GBS status)
  • > 37 weeks with ROM >18hrs and GBS unknown
84
Q

Neonatal sequelae of rubella (6)

A
  • IUGR
  • Microcephaly
  • Sensorineural hearing loss
  • Eye abnormalities (cataracts, glaucoma)
  • Cardiac abnormalities (PDA/PS)
  • Neurologic sequelae (developmental delay)
85
Q

Ddx for echogenic bowel

A
  • Normal variant
  • Aneuploidy
  • IUGR
  • APH
  • CF
  • Bowel obstruction
  • CMV or toxoplasmosis
86
Q

Treatment for listeria in pregnancy

A
  • Culture (if fever)

- IV ampicillin (erythromycin or vancomycin if allergy)

87
Q

Sources of listeria in pregnancy?

A
  • Deli meats
  • Unpasteurized cheese/dairy
  • Pate
  • Undercooked meat
88
Q

HSV treatment (2 options for each)

a) Initial episode
b) Recurrent
c) Suppressive

A

a) Acyclovir 400mg TID x10d OR Valacyclovir 1g BID x10d
b) Acyclovir 800mg TID x2d OR Valacyclovir 1g daily x3d
c) Acyclovir 400mg TID OR Valacyclovir 500mg BID from 36 weeks until delivery

89
Q

Treatment of known or suspected influenza in pregnancy

A

Tamiflu 75mg PO BID (ideally within 72hrs of symptom onset)

90
Q

Screening and diagnostic testing for syphilis

A 
Screening = VDRL (non-treponemal)
Diagnostic = Treponemal or dark field microscopy direct visualization
91
Q

Symptoms of primary, secondary, early and late latent syphilis

A

Primary = chancre, papule, lymphadenopathy
Secondary = 6wks to 6 months, flu-like symptoms, rash on palms/soles, condylomata lata
Early latent = asymptomatic
Late latent = neuro, cardiac, or skin (gumma)

92
Q

Findings of congenital syphilis

A
  • IUFD
  • IUGR
  • Snuffles (rhinitis)
  • Mulberry molars
  • Hutchinson’s teeth
  • Saber shins (bowing of tibia)
93
Q

Neonatal sequelae of listeria

A
  • IUFD
  • PPROM
  • TPTL
  • Abnormal FHR
94
Q

Neonatal mortality (%) and morbidity with HSV infection

A

Mortality 60%

Morbidity = microcephaly, microopthalmia, intracranial calcifications, chorioretinitis

95
Q

What should you avoid in labour for a patient with HIV?

A
  • FSE
  • IUPC
  • Scalp lactates/pH
  • Prolonged ARM/SRM
  • Operative delivery
  • Episiotomy
  • Ergot (worsens vasoconstriction with protease inhibitors)
96
Q

HIV prophylaxis in labour? When do you start?

A

Zidovudine 2mg/kg/hr bolus, then 1mg/kg/hr until delivery
If no cART, can use nevirapine 200mg POx1

Start if…active labour, SRM, 2-3hrs pre-C/S

97
Q

Mode of delivery with HIV?

A 
Trial of VD if viral load <1000 within 4 weeks of delivery
C/S at 38-39 weeks if...
> no cART
> monotherapy with zidovudine 
> viral load >1000
> unknown viral load
98
Q

Antenatal risks of HIV (3)

A
  • IUGR/SGA
  • Oligohydramnios
  • Preterm birth
99
Q

Antenatal care for HIV in the first trimester

A
  • Dating US
  • MSS + NT (less risk for invasive testing)
  • 1mg folic acid
  • Labs: toxo, CMV, syphilis, Hep A/B/C, rubella, varicella
  • Aggressive management of N/V
  • Harm reduction
100
Q

Antenatal care for HIV in the second trimester

A
  • Part 2 MSS
  • Routine anatomy US
  • NIPT preferred over invasive testing
  • CD4, viral load, LFTs, renal function
  • Labs q4-8 weeks and 6 weeks PP
101
Q

Antenatal care for HIV in the third trimester

A
  • US q4wks for fluid/growth
  • Risk of PTB (consider early GBS and HSV prophylaxis)
  • Make formula feeding plan
102
Q

Nausea/vomiting with HIV cART

A
  • STOP all cART at once

- Resume all at once once N/V resolved

103
Q

Blueberry muffin baby?

A

Rubella

104
Q

Congenital cataracts?

A

Rubella

105
Q

Infectious causes of microcephaly (6)

A
  • Zika
  • CMV
  • Toxoplasmosis
  • Rubella
  • HSV
  • HIV
106
Q

Avoid pregnancy for how many weeks post Zika-related travel? Protected intercourse for how many weeks?

A

Avoid pregnancy >3 months

Protected intercourse for duration of pregnancy

107
Q

Exposures for toxoplasmosis (4)

A
  • Raw meat
  • Water
  • Animals (cats)
  • Northern communities
108
Q

Lots of black holes in head on US?

A

Toxoplasmosis

109
Q

U/S findings with toxoplasmosis (6)

A
  • Intracranial calcifications
  • Ventriculomegaly
  • Microcephaly
  • IUGR
  • IUFD
  • Abnormal placenta
110
Q

When do you give Tdap?

A

All pregnancies, ideally 21-32 weeks

111
Q

Which infections require avidity testing? What does it mean?

A
  • Toxo, CMV, Rubella
  • Low avidity = more recent infection <3 months
  • High avidity = more remote infection >5 months
112
Q

Slap check / erythema infectiosum / fifths disease

A

Parvovirus B19

113
Q

Fetal consequences of Parvovirus? How do you monitor?

A

Anemia - need MCA dopplers for 12 weeks

114
Q

TORCH in general: early infection vs late infection risks

A 
Early = lower vertical transmission but worse consequences
Late = higher vertical transmission but lower consequences
115
Q

a) IgM - and IgG -
b) IgM - and IgG +
c) IgM + and IgG +
d) IgM + and IgG -

A

a) no evidence of infection, susceptible
b) past infection or immunization
c) possible primary infection
d) possible primary infection or false positive

116
Q

How long to wait post-live vaccine to get pregnant

A

4 weeks (28 days)

117
Q

What do you give a baby with a Hep B+ mom?

A

HBIG 0.5ml x3 doses (passive immunity)
Hep B vaccine (active immunity)
- Give within 12 hours, then complete vaccine series

118
Q

Listeria symptoms

A

Nausea, vomiting, diarrhea, fever, myalgias

119
Q

Treatment of CMV

A

No treatment

120
Q

Investigations for echogenic bowel?

A
  • MSS
  • Genetic sonogram
  • Amnio -> RAD
  • NIPT
  • CF testing
  • TORCH screen
121
Q

What infection is associated with Hutchinson’s teeth and Mulberry molars?

A

Congenital syphilis

122
Q

What is the risk of HSV transmission

a) Primary infection
b) Recurrent infection
c) Asymptomatic with positive history

A

a) 30-40%
b) 3-4%
c) 0.03-0.04%

“HSV is rules of 3”

123
Q

Most common congenital infection?

A

CMV

124
Q

Symptoms of CMV

A

Mono-like symptoms (fever, myalgias)

Most commonly asymptomatic

125
Q

Maternal risks of varicella

A

Pneumonia, death

126
Q

What percent of congenitally infected infants with CMV will have symptoms at birth?

A

10-15%

127
Q

What percent of infants infected with CMV who are asymptomatic at birth will develop symptoms? What will these symptoms be?

A

5-15%

Deafness, psychomotor delay, blindness

128
Q

What is the rate of asymptomatic shedding with HSV?

A

3% in the first year, 1% in the next 2 years

129
Q

Mode of delivery for active HSV?

A

C/S if…
> Within 4 hours of ROM
> No benefit if imminent delivery
> Protective effect lost if prolonged ROM

If PPROM, suppression until delivery

130
Q

When do you treat asymptomatic bacteruria in pregnancy?

A

If >100,000 CFU/hpf of any bacteria

131
Q

What are maternal and perinatal risks of bacteriuria in pregnancy?

A
  • Pyelonephritis
  • LBW
  • PTB
  • Chorioamnionitis (GBS)
132
Q

Treating asymptomatic bacteruria in pregnant woman decreases the risk of what?

A

Pyelonephritis and LBW

133
Q

When do you do an amniocentesis for toxoplasmosis?

A

4 weeks post-infection and at least 18 weeks GA

4 letters in toxo = 4 weeks, 8 looks like two 0’s and two 0’s in toxo

134
Q

In general terms, what drugs do you use to treat HIV?

A

Dual nucleoside reverse transcriptase inhibitors (NRTI) + protease inhibitors

135
Q

What are the neonatal risks of varicella?

A
  • Chorioretinitis
  • Cerebral cortical atrophy
  • Cutaneous scarring (cicatrial)
  • Bony defects
  • IUGR
136
Q

When is the highest risk time for neonatal varicella?

A

2% risk in second trimester (of congenital varicella)

Increased risk 5d prior and 2d postpartum (of neonatal varicella)

137
Q

Rubella findings?

A
  • Head, heart, eyes, ears
  • Congenital cataracts
  • Blueberry muffin

Royal College - OBGYN (3 decks)

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