PROLOG: Obstetrics Flashcards
HPV Vaccine Administration
Why is pregnancy a hypercoagulable state? (4)
- Increased venous stasis
- Decreased venous outflow
- Compression of IVC by the uterus
- Decreased mobility
Which coagulation factor is decreased in pregnancy?
Protein S
What is the most common structural malformation associated with increased nuchal translucency?
Cardiac septal defects
A fetus identified has having an increased nuchal translucency and possible cardiac defect should be assessed with 1T Doppler of the DV and 2T Echo
How to diagnose fetal hemoglobinopathies?
Genetic testing: Mutations found in the parents can be used to identify the mutation in the fetus
The DNA-based tests can be performed using chorionic villi obtained by CVS at 10-12 weeks gestation or using cultured amniotic fluid cells obatined by amniocentesis after 15 weeks
What is APA associated with?
Increased risk of having a child with a single-gene disorder (achondroplasia, Apert syndrome, Crouzon syndrome)
Increased risk mainly due to an increased incidence of gene mutations that occur with spermatogenesis as a man ages
What is the MOST common aneuploidy associated with cystic hygroma in 2T?
Turner Syndrome (45X)
Other findings: coarctation of the aorta, shield-shaped chest, short stature
What is the MOST common cause of cystic hygroma in 1T?
Down Syndrome
Noonan syndrome associated findings
Pectus excavatum, pulmonary stenosis, short limbs
Edwards syndrome associated findings
Microcephaly, micrognathia, and short, overlapping digits
What complication has amnioinfusion been shown to reduce?
Cesarean delivery
What is the most common thrombophilic gene mutation in pregnancy?
Factor V Leiden heterozygote, responsible for 40% of all VTEs during pregnancy
When should zidovudine infusion begin prior to a cesarean delivery?
3 hours preoperatively in women with viral loads at time of delivery are greater than 1,000 copies/mL
ACOG Recommendations for HIV-Positive Patients
Which of the following is MOST associated with fetal surgery for repair of myelomeningocele?
Lower rates of VP shunts (40% vs 82%)
MRI Findings after Eclampsia
Induction of Labor for Fetal Demise with Previous C/S
What is the goal of internal rotation of the fetus?
Allow turning of the fetal head so that the occiput gradually moves toward the pubic symphysis and away from a transverse axis
What is the most common cause of maternal death in the first trimester?
Ectopic pregnancy
Risk factors for ectopic pregnancy
How is diagnosis of APS made?
Presence of at least 1 clinical criterion and at least 1 antibody that is persistently elevated 12 weeks apart
Antibiotic regimen for a woman with anaphylaxis to penicillin admitted for threatened PTL with intact membranes at 34 weeks’ gestation
Vancomycin, 20 mg/kg IV every 8 hours until delivery
Antibiotic regimen for GBS ppx based on allergy status
No PCN allergy
PCN allergy wth low risk for anaphylaxis
PCN allergy with high risk for anaphylaxis
Pregnancy is within GA range of 9+0 to 13+6 weeks, the pregnancy should be redated if the discrepancy between US and LMP dating is ___.
More than 8 days
Which hormone is responsible for leukorrhea of pregnancy?
Estrogen
Leukorrhea, or vaginal discharge, in pregnancy is usually a thick white discharge that is significantly increased during pregnancy because of the elevated estrogen levels. >> stimulates cervical gland hypertrophy >> produces copious amounts of thick white discharge
Which component of the BPP is the LAST to disappear in fetal distress?
Amniotic fluid volume
The BPP evaluates the acute and chronic well-beng of the fetus, and each component, except amniotic fluid volume, is controlled by a different part of the fetal brain. All elements, except amniotic fluid, evaluate the acute status of the fetus. The amniotic fluid assessment evaluates the chronic status of a fetus, and if reduced, represents shunting of fetal blood away from the kidneys and towards vital organs (i.e. brain).
The stepwise approach in PPH due to uterine atony
Which screening test has the HIGHEST detection rate for Down Syndrome?
Noninvasive prenatal testing with cell-free fetal DNA
The test can be used starting from 9-10 weeks
The fetal component of cell-free DNA is derived from placental trophoblasts that are released into maternal circulation from cells undergoing programmed cell death. >> this component known as fetal fraction.
Fetal fraction concentration can be affected by GA, BMI, maternal medication exposure, race, single/multiple gestation, etc…
This test is the only screening test to identify fetal sex and chromosomal aneuploidies.
Characteristics, Advantages, and Disadvantages of Common Screening Tests
PKU
AR condition in which there is a decreased activity of the hepatic enzyme phenylalanine hydroxylase (PAH).
Mother with PKU and pregnancy
The fetal heart and brain are especially vulnerable to high maternal levels of phenylalanine. Fetal levels of phenylalanine are higher than would be expected based on. maternal levels because phenylalanine is actively transported across the placenta.
In patients with PAH deficiency, the goal should be to normalize blood phenylalanine levels (<6 mg/dL) for at least 3 months prior to conception and to maintain blood phenylalanine levels at 2-6 mg/dL during pregnancy in order to optimize developmental outcomes for the fetus.
Consequences of Children Born to Women with PAH Deficiency on Unrestricted Diets
Pregnant women chronically infected with HCV can have uneventful pregnancies, however they can have a 20-fold increased incidence of _________.
Cholestasis
What is the BEST test to confirm diagnosis of pyelonephritis?
Urine Culture
Postpartum management of antibiotics in patients treated intrapartum for chorioamnionitis who undergo C/S
Receive 1 additional dose after delivery (including clindamycin) followed by discontinuation of the antibiotics
What is group prenatal care practice most associated with?
Increased rates of breastfeeding in the postpartum period
MOST common classification of neonatal herpes simplex virus infection
Infection of the skin, representing 45% of infections
Recurrent late decelerations: common causes and management
Diagnostic criteria for suspected intraamniotic infection
For patents with hyperthyroidism, when should PTU and Methimazole be used?
PTU: 1T, Methimazole: 2T
4 criteria necessary to diagnosis HIE
- Apgar score of less than 5 at 5 and 10 minutes after birth
- Fetal umbilical artery acidemia
- Multisystem organ failure
- Development of spastic quadriplegia or dyskinetic CP
Maternal and Fetal Contraindications to Tocolysis
Untreated hyperthyroidism can lead to SAB and ____.
Hydrops
PTU is linked to _______ and Methimazole is linked to ________.
- PTU: hepatotoxicity
- Methimazole: Aplasia cutus and esophageal/choanal atresia
Uncontrolled Maternal Hyperthyroidism (Fetal and Maternal Effects)
MOST likely benefit of delayed cord clamping in preterm infant?
Lower rate of necrotizing enterocolitis and IVH
What is an adequate CST?
At least 3 contractions persist for at least 40 seconds each in a 10-min period
What supplement is appropriate therapeutic adjunct to dietary restriction of foods that contain phenylalanine amoung pregnant women with PKU?
Sapropterin dihydrochloride (synthetic form of BH4)
Women with PAH deficiency are advised to achieve phenylalanine levels < 6 mg/dL for at least 3 months prior to conception and to maintain levels of 2-6 mg/dL during pregnancy.
Erb and Klumpke palsies
- Erb palsy: most common brachial plexus nerve injury (C5-C6), “waiter’s tip”
- Klumpke palsy: C8-T1
In cases of placenta previa, increasing number of prior C/S increases risk of placenta accreta as follows:
In a patient with a placenta previa and NO PRIOR cesarean sections, the risk for accreta is 3%.
Placental Abnormalities
Immediate postpartum IUD placement is contraindicated in:
A 34 yo G1 has hx of heterozygous Factor V Leiden deficiency. When is her risk for VTE greatest?
Postpartum, with the highest being the first week after delivery
At what gestational age can cell-free DNA testing be obtained?
Any time from 10 weeks until term
In which period during pregnany is a patient MOST likely to die from an amniotic fluid embolism?
During labor (70%), an additional 19% of cases occur during C/S, and 11% after vaginal delivery
How does a patient suffering from amniotic fluid embolism usually present?
Hypotension, hypoxia, coagulopathy
When mothers are using prescribed opiates for postpartum pain, what % of breastfed neonates will develop CNS depression related to this opioid use?
2-3%
Opioids are lipophilic drugs, weak bases, and have low molecular weight. These properties facilitate drug transfer into breast milk.
Among women with recurrent genital HSV, appoximately ___% can expect at least one recurrence during pregnancy
75%
Fetal blood volume at term
- Fetus Alone: 78 mL/kg
- Fetus + Placental Blood Volume: 125 mL/kg
Extra-hepatic manifestation MOST associated with chronic hepatitis C infection
Essential mixed cryoglobulinemia
Children born to women who smoke tobacco during pregnancy are at increased risk of: (5)
What are the amount of prepregnancy folic acid recommended for women at low risk and high risk for fetal neural tube defects, respectively?
400 mcg, 4 mg
Gestational Age and Radiation Dose on Radiation-Induced Teratogenesis
The rate of perinatal death is reduced by as much as 29% with interrogation of which fetal Doppler?
UA Doppler
Its use, inconjunction with standard fetal surveillance (NST, BPP) is associated with improved outcomes in fetuses in which fetal growth restriction has been diagnosed.
Increased impedance in the UA suggested that the pregnancy is c/b underlying placental insufficiency. Also, absent or reversed end-diastolic flow in the UA is associated with an increased frequency of perinatal mortality and can affect decision regarding timing of delivery in the context of fetal growth restriction.
When is the UA S/D ratio considered abnormal?
If it is >95th %ile for GA or if diastolic flow is either absent or reversed
What is MCA Doppler indicated for? Recommendations?
Fetal anemia
- Useful for detection of fetal anemia of any cause
- MCA = largest vessel of fetal cerbral circulation and carries about 80% of cerebral blood flow
- Fetal hypoxemia associated with growth restriction results in cerebral vasodilation, an early adaptive mechanism termed the brain-sparing effect
- MCA peak systolic velocity (PSV) is followed serially
- If velocity between 1.0 and 1.5 multiples of the median (MoM) and the slope is rising–such that the value is approaching 1.5 MoM–surveillance is generally increased to weekly Doppler interrogation
- If MCV PSV exceeds 1.5 MoM and GA < 34 or 35 weeks, fetal blood sampling should be considered and followed by fetal transfusion if needed
MOST common sign of uterine rupture in a patient undergoing TOLAC
FHT abnormality (acute fetal bradycardia)
What is the incidence of uterine rupture after 1 transverse C/S?
0.7%-0.9%
What is the most severe form of spina bifida?
Myelomeningocele, affects approximately 1 in 3,000 live births in the U.S.
Both the meninges and the spinal cord herniate through a defect in the spinal column and skin
The higher the lesion, the more nerves are affected and the poorer the prognosis
How long should therapeutic dose of LMWH be held before regional anesthesia is administered?
24 h
1 in 18,000 risk of spinal hematoma
How long should prophylactic dose of LMWH be held before regional anesthesia is administered?
12 h
A 28 yo G1 woman is started on a twice-daily therapeutic dose of LMWH during her pregnancy. What is the best target anti-Xa level when titrating the therapeutic dosage of LMWH in pregnancy?
0.6-1.0 units/mL measured 4 h after dosing
What is the BEST way to prevent wound infection in an obese patient (presents for R C/S)?
Antibiotics prior to skin incision
2 g cefazolin within an hour prior to incision; if she is > 120 kg, should receive 3 g cefazolin
The risk of surgical site infection after C/S delivery is 18%. Obese women have increased risk of wound infections due to (4):
- Increased inflammation
- Excess adipose tissue that is poorly oxygenated which extends wound healing
- Increased dead space
- Additionally, there are often larger incisions, prolonged operative times, and high blood losses in surgery with obese patients > increased risk of wound infection
Home Birth vs Hospital Birth
Home birth is associated with lower rates of maternal intervention but increased risks of perinatal death and neonatal neurological dysfunction
Absolute contraindications to home birth (3)
Malpresentation
Multiple gestation
Prior cesarean delivery
How does Roux-en-Y (RNY) gastric bypass cause nutritional deficiency?
RNY creates a small stomach pouch (restrictive) tha tconnects to the jejunum (malabsorption). This bypasses the duodenum and decreases the time that nutrients can be absorbed, which causes nutritional deficiencies.
Most common nutritional deficiencies after RNY
Protein
Iron
B12 (Cobalamin)
B9 (Folate)
Vitamin D
Calcium
During a C/S, an injury to the base of the bladder is made, immediately adjacent to the right ureteral orifice. What is the next best step?
Retrograde stent placement
The bladder should be repaired once the obstetrical portion of the procedure is complete. Bladder injuries should be repaired in a two-layer closure (if at the dome).
This injury is at the base. When immediately next to a ureteral orifice, place retrograde stent prior to closure. Will prevent kinking or occlusion of the ureter’s base during closure and the healing process.
Current guidelines recommend proceeding with perimortem C/S delivery after ____ minutes of CPR has failed to achieve spontaneous return of circulation, with a goal being a delivery by 5 minutes.
4
Maternal outcomes are not thought to be worsened following perimortem cesarean, and may be improved as evacuation of the gravid uterus can improve venous return to the heart.
Patients with GDM should check fasting and either 1or 2 hour postprandial blood glucose levels.
Goal
Causes of PPH and % cases of PPH (approximate)
What are the serum lab test components in a FTS for fetal chromosomal abnormalities?
PAPP-A, free or total bHCG
What is the first-trimester screen?
2-part screening test, which involves maternal serum labs and U/S to assess nuchal translucency
FTS has 82-87% detection rate for T21
The labs for FTS are PAPP-A and free or total bHCG
What are the maternal serum labs tested in a quad screen?
MSAFP, hCG, unconjugated estriol, and inhibin A
Performed during 2T, between 15 to 22 weeks, and has detection rate of 81% for T21
Rubin maneuver
- McRoberts
- Suprapubic
- Delivery of posterior arm
- Rubin maneuver: Place a hand in the vagina and on the back surface of the posterior fetal shoulder, then rotate the shoulder anteriorly towards the fetal face. This may be used instead of delivery of the posterior arm or after failure to delivery the posterior arm
What is the approximate risk of uterine rupture in women with one previous low-transverse cesarean delivery who are undergoing IOL using prostaglandins?
Up to 2.2%
Criteria for outlet forceps (5)
Criteria for Low Forceps
Who should get CL screening?
Women who have a current singleton pregnancy and a history of preterm birth
Which hemoglobin is deficient in a patient with beta-thalassemia?
Hemoglobin A (2 alpha-globin chains and 2 beta-globin chains)
Gestational thrombocytopenia is a benign condition that occurs in almost 12% of pregnancies.
Definition
Recommended Classification of Deliveries from 37 weeks of gestation
Post-term pregnancies are associated with:
- Incresaed risk of neonatal convulsions
- Meconium aspiration syndrome
- 5-minute Apgar scores < 4
- Oligohydramnios
- Stillbirth
- Postmaturity syndrome (complicates 10-20% of postterm pregnancies
Maternal and Fetal Risk Factors for Postterm Delivery
Type of Breech Presentation
Risks of PROM (3)
- Intraamniotic infection (Incidence: 15-35%)
- Postpartum infection (Incidence: 15-25%)
- Placental abruption (Incidence: 2-5%)
Risks of cHTN in pregnancy
Rate of stillbirth in the US
0.4% (1 in 160 deliveries)
Recurrence rate in subsequent pregnancies is 2.5%
Definition of stillbirth
Fetal death at 20 weeks or greater of gestation (if the GA is unknown) or a weight greater than or equal to 350 g (“ “)
350 g is the 50th %ile for weight at 20 weeks of gestation
What is the most sensitive test to diagnosis chorioamnionitis?
IL-6
What is the MOST common congenital infection?
CMV
However, 90% of maternal infections are asymptomatic. 12-18% of CMV infected newborns may show signs of hepatosplenomegaly, jaundice, petechiae, thrombocytopenia, or hearing loss at birth.
What suture is used for B-Lynch suture?
Number 1 chromic suture
Large suture and less likely to break in addition to being rapidly absorbed, which decreases the risk of bowel herniation through a loop of suture after uterine involution
Define PPROM
Preterm premature rupture of membranes (PPROM) is ROM prior to 37 weeks’ gestation
What is the optimal abx regimen for PPROM?
7-day total course of combination IV ampicillin and erythromycin followed by oral amoxicillin and erythromycin
Why is amoxicillin-clavulanic acid (Augmentin) not recommended for PPROM abx?
Increased rates of necrotizing enterocolitis
OCPs are contraindicated in which of the following conditions (8 h + 2 b)
Risk factors for chorioamnionitis
- Prolonged rupture of membranes
- Prolonged labor
- Mec
- GBS
- Genital tract infections
- Multiple digital exams
How is anema in pregnancy defined?
Diagnostic test with best sensitivity and specificity for IDA
Hgb < 11 in 1T and 3T
Hgb < 10.5 in 2T
Ferritin level
Optimal timing of delivery for history of previous classical cesarean delivery
36 or 37 weeks
A 32-year-old woman, gravida 2, para 1, is sent to the labor and delivery unit at 32 weeks of gestation with a persistent blood pressure of 200/120 mm Hg. She has a known history of asthma requiring daily medication and chronic hypertension, which has been treated with methyldopa. The most appropriate intravenous (IV) medication to control her blood pressure is:
(A) hydralazine
(B) labetalol
(C) magnesium sulfate
(D) nifedipine
(E) sodium nitroprusside
(A) Hydralazine
Intravenous labetalol and hydralazine are considered first-line medications for the management of acute-onset, severe hypertension in pregnant and postpartum patients. No significant changes in umbilical blood flow have been reported with the use of either labetalol or hydralazine, and maternal and perinatal outcomes are similar for both drugs.
Parenteral labetalol may cause neonatal bradycardia and should be avoided in women with asthma, heart disease, or congestive heart failure (Box 7-1).
Parenteral hydralazine may increase the risk of maternal hypotension and tachycardia.
Despite these possible adverse effects, the described patient’s clinically significant asthma makes hydralazine the preferred IV medication (Box 7-2).
A 24-year-old patient, gravida 1, presents at 26 weeks of gestation to your office reporting swelling in her neck, tachycardia, palpitations, and heat intolerance. She has no personal or family history of thyroid disease. Her blood pressure is 140/90 mm Hg, and her heart rate is 104 beats per minute. Examination does not demonstrate ophthalmopathy, but you notice some fullness of her thyroid gland on the right. Her thyroid-stimulating hormone is less than 0.02 mIU/L and her free thyroxine (T4) is high at 5.0 ng/dL. Her only medication is prenatal vitamins, and she has no other contributory medical history. The best next step in treatment for this patient is administration of
(A) desiccated thyroid
(B) levothyroxine
(C) methimazole
(D) propranolol
(C) methimazole
To balance the rare risks of hepatotoxicity (associated with PTU) and embryopathy (methimazole associated aplasia cutis and esophageal or choanal atresia), the American Thyroid Association and the American Association of Clinical Endocrinologists recommend treating hyperthyroidism with PTU in the first trimester and switching to methimazole in the second trimester.
Although β-blockers such as propranolol, can some- times be used for treatment of tachycardia for heart rate control, treating the patient’s underlying etiology is the first step in her management. Her HR of 104 beats per minute is not high enough to warrant its use.
A 36-year-old woman, gravida 2, para 1, with monochorionic, diamniotic twins at 20 weeks of gestation presents to your office for an ultrasonography that shows appropriately and concordantly grown twins, each with a normal fetal anatomical survey. Her medical history is significant for a spontaneous preterm delivery at 35 weeks of gestation. The most appropriate management for this patient is to have her return every 2 weeks for ultrasonographic evaluation of
(A) cervical length
(B) fetal growth
(C) amniotic fluid volume
(D) umbilical artery Doppler velocimetry
(E) middle cerebral artery Doppler velocimetry
C) Amniotic fluid volume
Compared with dichorionic twins, monochorionic twins have higher rates of complications, mortality, and morbidity, including twin–twin transfusion syndrome (TTTS), twin anemia polycythemia sequence, congeni- tal anomalies, and growth restriction. Therefore, it is of utmost importance to determine chorionicity. Typically, chorionicity is best assessed in the first trimester.
Ultrasonographic Features of Twin–Twin Transfusion Syndrome
- Presence of single placenta
- Gender concordance
- Significant growth discordance (usually greater than 20%)
- Discrepancy in amniotic fluid volume
- Thin membrane and absence of twin peak sign
- Presence of fetal hydrops or cardiac dysfunction
- Abnormal umbilical artery Doppler findings, such as absent end diastolic flow in donor fetus
A 34-year-old woman at 37 weeks of gestation presents to the labor and delivery unit reporting severe uterine contractions and decreased fetal movement for the past 48 hours. She admits to using cocaine within the past 72 hours. Her blood pressure is 136/85 mm Hg and her temperature is 37.2°C (99.0°F). Her uterus is firm and moderately tender. Ultrasonography demonstrates absent fetal car- diac activity with a fundal placenta and a large retroplacental heterogeneous collection. Admission laboratory data demonstrate white blood count of 11,000/mm3, hemoglobin of 10 g/dL, platelet count of 50,000/mm3, fibrinogen of 180 mg/dL, aspartate aminotransferase of 18 international units/L, alanine aminotransferase of 24 international units/L, prothrombin time of 22 seconds, and activated partial thromboplastin time of 50 seconds. The most likely cause of her thrombocytopenia is
(A) disseminated intravascular coagulation
(B) gestational thrombocytopenia
(C) hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome
(D) idiopathic thrombocytopenic purpura
(E) sepsis
A) DIC
Placental abruption occurs when maternal blood vessels in the decidua basalis rupture and cause separation of the placenta from the uterine lining. Placental abruption com- plicates approximately 1% of all pregnancies and has been identified in 10–20% of preterm labor cases. The present- ing symptoms of vaginal bleeding, uterine contractions, and abdominal pain may vary in intensity according to the severity of the placental abruption.
Placental abruption >> DIC, a bleeding disorder that first is characterized by the formation of diffuse thrombi in the vasculature. > Uncontrolled bleeding may develop with the progressive consumption of clotting factors and platelets. > Trophoblastic cells of the placenta are normally rich in TF. During placental abruption, when the placenta is sheared from the underlying myome- trium, an excess amount of tissue factor is released into the maternal circulation, and DIC is initiated. Tissue factor activates factor X to factor Xa, ultimately leading to excess production of thrombin and fibrin clots. Concentrations of coagulation inhibitors, such as antithrombin III, protein C, and tissue factor pathway inhibitor, are significantly decreased in disseminated intravascular coagulation. Likewise, hypo- fibrinogenemia is commonly associated with acute dis- seminated intravascular coagulation. Excessive thrombin levels lead to the conversion of plasiminogen to plasmin. Plasmin stimulates fibrinolysis, thereby increasing the production of fibrinogen degradation products. The anticoagulation effects of fibrinogen degradation products contribute to uncontrolled bleeding.
A 30-year-old woman, gravida 2, para 1, undergoes first-trimester screening which shows an abnormal risk of trisomy 18 (1:42). Her nuchal translucency measured 2.3 mm, β-human chorionic gonadotropin (β-hCG) is 1.8 multiples of the median (MoM), and pregnancy-associated plasma protein A (PAPP-A) is 0.25 MoM (ie, less than the first percentile). She is referred for genetic counseling and undergoes a chorionic villus sample which returns normal, 46,XX. The most likely pregnancy complication associated with these analyte findings is
(A) preterm prelabor rupture of membranes
(B) preeclampsia
(C) preterm labor
(D) fetal growth restriction
(E) stillbirth
(D) fetal growth restriction
A low PAPP-A value has a positive predictive value for a SGA fetus.
A 35-year-old woman, gravida 3, para 2, presents for her first prenatal visit at 14 weeks of gesta- tion. She has a history of rhesus alloimmunization, which was diagnosed during her last pregnancy. She gave birth to a term neonate who required phototherapy for hyperbilirubinemia as well as a blood transfusion. Her current pregnancy resulted from a different father than her two previous pregnancies, and she has no contact with him. The most reasonable next step in management is to assess
(A) fetal hemoglobin level
(B) fetal rhesus type by noninvasive prenatal testing
(C) maternal anti-D titer
(D) middle cerebral artery (MCA) peak systolic velocity (E) paternal rhesus D antigen status
(B) fetal rhesus type by noninvasive prenatal testing
A 28-year-old primigravida at 32 weeks of gestation reports severe pruritus of her palms and soles. On examination, you note excoriations but no other dermatologic lesions. Laboratory evaluation reveals a serum aspartate aminotransferase of 60 units/L, alanine aminotransferase of 42 units/L, total bilirubin of 1.1 mg/dL, and total bile acids of 40 micromol/L. Her risk of intrauterine fetal demise is most significantly associated with her
(A) alkaline phosphatase level
(B) bile acid level
(C) bilirubin level
(D) gestational age of onset
(E) severity of symptoms
B) bile acid level
Intrahepatic cholestasis of pregnancy (ICP) classically presents in the third trimester with pruritus, most notably on the palms of the hands and soles of the feet and without overt dermatologic lesions. In some cases, women may additionally present with jaundice, dark urine, and pale stools.
Intrahepatic cholestasis of pregnancy is reported to complicate 0.2–6% of pregnancies, and the incidence varies by maternal ethnicity and geographic location. Other maternal characteristics associated with a higher risk of ICP include multiple gestation, in vitro fertiliza- tion treatment, hepatitis C positive status, and advanced maternal age.
What % of women with elevated MSAFP level are actually carrying a child with neural tube defect?
2%
What is the most commonly isolated organism in chorioamnionitis?
Genital mycoplasmas (ureaplasma, mycoplasma)
How does aspirin work (starting at 12 weeks) re: PEC?
It inhibits TXA2 (vasoconstrictor)
When should monitoring for TTTS for mono-di twins start?
16 weeks, every 2 weeks
Arrest of labor in the first stage
Treatment of postpartum thyroiditis
Beta blockers (propranolol)
Thioamides (methimazole and PTU) will not help as the release of TH is from destruction of thyroid tissue and is not from overproduction of thyroid hormones.
Drugs used in hyperthyroidism (MOA, Side Effects, Use)
The heterozygous factor V Leiden mutation accounts for about ___% of VTE cases during pregnancy. Interestingly, women with this mutation and history of VTE have only a ____% risk of develping VTE during pregnancy.
40%
0.5%-1.2%
Which fetal tachyarrythmia pattern has the worst long-term neonatal prognosis?
Atrial flutter
One of the more rare causes of tachycardia but can often lead to a fetal HR >300 bpm due to varying degrees of block at the AV node.
Difficult to treat in utero and often requires multiple antiarrhythmic medications to help prevent fetal hydrops. Even if no hydrops develops in utero, once delivered, most of these infants will have relapse of the AF requiring medications throughout their first few years of life.
Primary PPH is defined as…
- EBL > 1000 mL within 24 h after delivery, applicable to both vaginal and cesarean deliveries
- Presence of signs or symptoms of hypovolemia (regardless of amount of blood loss) within 24 h after birth process
MOA of Metformin
Biguanide that stimulates glucose uptake in peripheral tissues and inhibits gluconeogenesis and glucose absorption
Recommended weight gain for BMI
Recommended first-line pharmacologic treatment of nausea and vomiting of pregnancy
Vitamin B6 (pyridoxine) + doxylamine
cryoprecipitate
made from FFP and contains factor VIII, XIII, fibrinogen, and VWF
Coagulation pathway
EDD dating
Definition of prolonged latent phase?
>20 h in nulliparous women and >14 h in multiparous women
this is NOT an indication for C/S
Possible adverse effect of an oxytocin bolus?
High-dose oxytocin may cause profound hypotension.
Cephalohematoma vs caput succedaneum
Cephalohematoma: collection of blood beneath the periosteum and does NOT cross suture lines. More common with vacuum deliveries
Caput succedaneum: above periosteum and crosses suture lines… it is an edematous swelling that can sometimes be hemorrhagic. It is self-limited and resolves within a few days.
Management of amniotic fluid embolism
Obstetric emergency
Diagnosis is clinical, with many patients losing consciousness and requiring CPR.
There are two phases, the early phase characterized by RV failure, and the second phase, characterized by LV failure. Hallmarks of management are high-quality CPR, supportive measures, and correction of coagulopathy.
LIMIT excessive fluid rseuscitation, as patients can become easily fluid overloaded and develop pulmonary edema
Rhogam administration
Earliest GA in which vacuum-assisted vaginal delivery is appropriate
34 weeks
Indications for cerclage placement
In a pregnant patient with a history of HIT, which AC should be used?
Fondaparinux (binds to ATIII and accelerates the inhibition of factor Xa)
The routine use of external fetal monitoring in labor has reduced ______?
Neonatal seizure risk
Factors associated with failure of ECV
How long after delivery should a postpartum patient wait before starting an estrogen-containing contraceptive method?
3 weeks
What fetal heart tracing is most representative of fetal anemia?
Sinusoidal pattern
Placenta Accreta Spectrum
When is repeat dosing of prophylactic antibiotics indicated at the time of cesarean delivery?
When surgery exceeds more than two drug half-lives of the antibiotic (measured from time of administration) or estimated blood loss is > 1500 mL.
Why do you see a decrease in TSH during the first trimester of pregnancy?
The glycoproteins that makes up human chorionic gonadotropin (hCG) and thyroid-stimulating hormone (TSH) have a common alpha subunit and a unique beta subunit.
However, there is considerable homology between the beta subunits of hCG and TSH. As a result, hCG has weak thyroid-stimulating activity.
Decrease in thyroid-stimulating hormone (TSH) occurs during the first 12 weeks of gestation due to weak stimulation of TSH receptors as result of the high levels of human chorionic gonadotropin (hCG) in the first trimester. Thyroid hormone secretion is stimulated, and the resultant increased serum thyroxine suppresses hypothalamic thyrotropin-releasing hormone, which then limits pituitary TSH secretion.
What changes in thyroid functions tests are often seen in women with hyperemesis gravidarum?
Elevation of serum free thyroxine and decrease in TSH.
You are performing a detailed fetal echocardiogram at 22 weeks gestation for a suspected fetal congenital cardiac anomaly. You discover that the fetus has pulmonic stenosis and a ventricular septal defect with an overriding aorta. Which of the following is most likely responsible for these findings?
Acute appendicitis: landmark and signs
How is the diagnosis of appendicitis made?
- Diagnosis is made by CT (adults)
- Ultrasound (pediatric or pregnant patients)
- MRI (pregnant patients with nondiagnostic ultrasound)
Bishop score
A score of 7 or greater is considered favorable, while a Bishop score of 6 or less is considered unfavorable and indicates a need for cervical ripening.
Gentamicin: MOA
What is the preferred dosing regimen for gentamicin?
Inhibits 30s ribosomal subunit / NEPHROTOXIC
5 mg/kg daily
Types of SAB
What dose of anti-D immune globulin is indicated for an Rh-negative patient at less than 12 weeks gestational age?
50 micrograms
What is the recommended ratio of packed red blood cells to fresh frozen plasma to be transfused in trauma situations of massive hemorrhage?
1:1
At what gestational sac size should you see a yolk sac?
10 mm
Where should suction cup of vacuum be applied?
The suction cup must be placed on the flexion point, which is along the sagittal suture, approximately 3 cm in front of the posterior fontanelle.
What is the antidote to magnesium toxicity?
10% solution of calcium gluconate 15–30 mL IV over two to five minutes.
According to the American College of Obstetrics and Gynecology, when is it recommended to deliver patients whose pregnancy is complicated by placenta accreta?
34 weeks 0 days to 35 weeks 6 day
Management of hyperemesis gravidarum in pregnancy
Methylprednisolone use before 10 weeks gestation is associated with which congenital birth defect?
Oral clefts
A 21-year-old G1 woman at 28 weeks gestation presents to the office with a rash and severe pruritus. Medical history is significant for type 1 diabetes mellitus and multiple sclerosis. Physical exam reveals plaques covering her abdomen and bullae over her wrist and forearm. Skin biopsy with direct immunofluorescence demonstrates linear deposit of complement C3 at the basement membrane. What is the first-line medical treatment for this condition?
Which dermatologic condition of pregnancy can mimic pemphigoid gestationis but typically begins in abdominal striae?
Polymorphic eruption of pregnancy.
Which postpartum complication is associated with polyhydramnios?
Uterine atony
What are the components of FFP?
All coagulation factors and soluble proteins present in the original unit of blood.
What medications can cause a pseudosinusoidal fetal heart tracing?
Meperidine, morphine, and butorphanol.
What is the standard dosage of oseltamivir for post-exposure prophylaxis in pregnancy?
Oral 75 mg once daily for 7 days.
How is pubic symphysis diastasis diagnosed?
Radiograph
Pubic symphysis diastasis is diagnosed by a standard anterior-posterior pelvic radiograph showing pubic symphysis separation > 1 cm.
The pelvis should return to normal by 4 to 12 weeks postpartum, with pain resolution at 1 month but can be prolonged (over 2 years). Management begins with conservative measures, such as mild analgesics, physical therapy, and pelvic girdle support.
What are the 4 types of cephalic malpresentation?
Cephalic malpresentations include face, brow, and occiput posterior and transverse presentation. Face and brow presentations both result from a deflexed neck, which increases the head diameter, leading to protracted and arrested labor.
Face presentations are diagnosed on vaginal exam.
First line treatment for lactational mastitis?
Dicloxicillin 500 mg QID 5-7 days
What is the cause of a “shoulder” observed with a variable deceleration?
Baroreceptor-mediated reflex inducing a rise in fetal heart rate due to compression of the umbilical vein and consequent decrease in fetal venous return
Types of perineal lacerations
Contraindications to breastfeeding in the U.S.
Benefits of delayed cord clamping in term vs. preterm infants
What is the definition of a protracted active phase?
Active labor in which dilation is occurring at a rate less than 1–2 cm/hour.
What is the rate of expulsion of immediately placed postpartum intrauterine devices?
10-27%
Indications for amniocentesis
What are the risks of performing amniocentesis before 15 weeks gestation?
Fetal loss and inadequate cell yield
What branch of the internal iliac artery supplies the upper vaginal wall?
The vaginal artery, a branch of the anterior division of the internal iliac artery.
Interpretations and Outcomes of Various Antenatal Fetal Testing Methods
Blood supply for:
Vulvar hematoma
Vaginal hematoma
Vulvar: Branches of the pudendal artery
Vaginal: Descending branches of uterine artery
What are the branches of the posterior division of the internal iliac artery?
Iliolumbar, lateral sacral, superior gluteal.
Confirmation of term gestation
Choosing the route of delivery for di-di twins
Which bacteria is often associated with a pH of 8.0 in urinary tract infection?
Proteus.
Von Willebrand Disease
What is the approximate therapeutic range of magnesium sulfate?
5–9 mg/dL (4–7 mEq/L).
Teratogenic drugs
Which types of abnormal cervical cytology during pregnancy require colposcopy NOW?
ASCUS, HSIL, AGUS
When does alloimmunization occur?
Alloimmunization occurs when a patient is exposed to an erythrocyte antigen that is not present on the patient’s blood cells, causing the patient to mount an immune response
This may occur during a blood transfusion, but may also happen during pregnancy if a mother is exposed to fetal erythrocyte antigens
How does the K-antigen cause fetal anemia?
The K antigen is a minor antigen of the Kell blood group system.
If a mother has anti-K antibodies, they can bind to fetal erythrocyte precursors in the bone marrow. This can cause fetal anemia due to decreased production of erythrocytes.
What are the five major antigens of the Rh blood group system?
C, c, D, E, e.
Which three recommended vaccines should be given to most susceptible women before or after pregnancy, but should not be given during pregnancy?
Varicella, MMR, and HPV.
Regimens for second trimester medical abortions
Management of short cervical length in 2T found on U/S
What is the most common chromosomal anomaly in products of conception in a first trimester spontaneous abortion?
Trisomy 16
75 g two-hour oral glucose tolerance test
Fasting: 92
1 h: 180
2h: 153
Diagnosis, ONE abnormal result
Renal physiological changes in pregnancy
The renal collecting system dilates in response to progesterone, peaking by the 20th week of gestation.
This dilation + progesterone-induced decreased ureteral tone and compression of the ureters along the pelvic brim by a growing uterus, –> hydronephrosis, worse on the right compared to the left.
Patients are also at increased risk for pyelonephritis in the setting of asymptomatic bacteriuria.
With decreased systemic vascular resistance in pregnancy, renal vasodilation leads to increased tubular filtration of glucose, proteins, and uric acid. While hyperfiltration of protein and increased protein excretion is common in pregnancy, proteinuria exceeding 300 mg in 24 hours is considered abnormal.
How many colony-forming units are required for treatment in the setting of asymptomatic bacteriuria of pregnancy due to Group B Streptococcus?
105,000 or more colony-forming units
Trisomies are a result of chromosomal nondisjunction during meiosis I or meiosis II.
How often is hypertension absent in eclampsia?
In up to 20% of patients, particularly if eclampsia occurs postpartum.
You perform a cesarean section at term in a woman with no known drug allergies. For which indication would you consider adding azithromycin, in addition to cefazolin, for antibiotic prophylaxis?
Non-elective C/S
Azithromycin is an extended-spectrum antibiotic that is suggested as an adjunct to cefazolin. Benefits of this addition have been shown primarily in the setting of non-elective cesarean delivery:
significant reduction in endometritis, SSI, and other infections.
Treatment for postdural headache
NSAIDs, supine position, caffeine, epidural blood patch
Most common abnormal ultrasound finding on Doppler examination in cases of placenta accreta spectrum
Turbulent lacunar blood flow
The integrity of which structure differentiates a uterine dehiscence from uterine rupture?
Uterine serosa
What are the most common locations for an obstetric hematoma?
Vulva, vagina/paravaginal area, and retroperitoneum.
Which suture is the best for repairing a cervical laceration?
Repair of vaginal and cervical lacerations should be done with a running locked absorbable suture such as polyglactin 910 (chromic catgut).
A 32-year-old G3P0202 woman at 24 weeks gestation is admitted to the ICU in hypertensive crisis. She has a history of severe pre-eclampsia in both of her prior pregnancies and is in need of accurate and tight blood pressure control. What is the best management strategy to monitor her blood pressure?
Intra-arterial blood pressure monitoring is the radial artery
How are Montevideo units calculated?
The total pressure generated by each contraction in 10 minutes is summed together.
Procedure for B-Lynch Suture
What are the first-line medications for treatment of purulent postcesarean cellulitis?
Purulent cellulitis after cesarean section could be due to methicillin-resistant staph aureus (MRSA); appropriate first-line antibiotics include clindamycin, bactrim, or doxycycline.
You are called to evaluate a 28-year-old woman, six hours after delivery. She had an uncomplicated primary cesarean section for arrest of descent and delivered a 4650 g infant. Prenatal course was uncomplicated. Vital signs reveal a pulse of 110 beats per minute, blood pressure of 110/70 mm Hg, and a temperature of 100.6°F. Point of care hemoglobin result is 7.6 g/dL and lower than anticipated based on intraoperative blood loss. Physical exam is unremarkable and fundus is firm to palpation with minimal lochia. Which of the following is the best next step in diagnosis?
CT A/P to assess for retroperitoneal hematoma
Retroperitoneal hematomas result from injury to branches of the hypogastric artery, like the uterine artery, or from an extension of a vaginal hematoma.
A 32-year-old G2P1001 woman has just delivered vaginally. She suddenly experiences cardiovascular collapse. Which of the following presentations is most consistent with an etiology attributable to activation of an immunological response resulting in pulmonary hypertension?
Abrupt onset 30 min
In amniotic fluid embolism, it is postulated that amniotic fluid and debris in the maternal circulation causes an acute immunological response, leading to severe pulmonary hypertension and disseminated intravascular coagulation (DIC).
What is the primary source of estrogen during pregnancy?
Placenta
What ovarian cancer histology is most frequently encountered in patients with a BRCA mutation?
High grade serous carcinoma
What type of forceps is recommended for rotation of the fetal head from occiput posterior to occiput anterior position?
Kielland forceps
What is the false-positive rate for electronic fetal monitoring to detect cerebral palsy?
>99%
What is the most likely impact that tubal sterilization will have on a woman’s menstrual cycle?
No change.
In which conditions is IV magnesium contraindicated for the treatment of an eclamptic seizure?
- Myasthenia gravis
- Hypocalcemia
- Moderate to severe renal failure
- Cardiac ischemia
- Heart block, and
- Myocarditis.
qSOFA score
What is the definition of septic shock?
Septic shock: sepsis + persisting hypotension requiring vasopressors to maintain MAP ≥ 65 mg Hg and having serum lactate level > 2 mmol/L (18 mg/dL) despite adequate volume resuscitation
placental alpha microglobulin-1 protein
This is a protein that is released from uterine decidua, and the presence of this protein suggests rupture of membranes.
What is the name of the syndrome of chronic growth insufficiency seen in postterm fetuses?
Fetal dysmaturity syndrome
What is the term for severe abruptions in which blood extravasates into the myometrium?
Couvelaire uterus.
A 37-year-old woman is undergoing in vitro fertilization with preimplantation genetic testing for aneuploidy. She expresses she has always wanted to have twins. Which of the following is the recommended limit of the number of embryos to transfer?
One euploid blastocyst
At what stage of development do transferred embryos have the highest rate of pregnancy and life birth?
Blastocyst
How to diagnose maternal and fetal parvovirus B19?
Maternal infection: IgG, IgM
Fetal infection: PCR of amniotic fluid
