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Obstetrics > Special circumstances > Flashcards

Special circumstances Flashcards

1
Q

medroxyprogesterone acetate (DMPA)

A
  • birth control
  • administered every 3 months to prevent pregnancy
  • inhibits gnrh
  • suppresses ovulation

side effects

  • menstrual irregularities
  • prolonged bleeding/spotting for 6 months
  • amenorrhea after 1 year
  • less common: weight gain, fatigue, nausea, breast tenderness
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2
Q

Fractured clavicle in baby

A
  • clavicular crepitus/bony irregularity
  • decreased more reflex due to pain on affected side
  • intact biceps and grasp reflex
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3
Q

fractured humerus in baby

A

upper arm crepitus and bony irregularity

decreased moro reflex due to pain on affected side

intact biceps and grasp reflexes

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4
Q

erb-duchenne palsy

A

decreased more and bicep refelexes

waiters tip

  • extended elbow
  • pronated forearm
  • flexed wrist and fingers

intact grasp reflex

C5, C6

shoulder dystocia

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5
Q

Klumpke palsy

A

claw hand

  • extended wrist
  • hyperextened metacarpophalangeal joints
  • flexed interphalangeal joints
  • absent grasp reflex

horner syndrome (ptosis, miosis)

C8 and T1

shoulder distocia

intact more and bicep reflexes

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6
Q

Normal postpartum findings and care

A

FINDINGS

  • transient rigors/chills
  • peripheral edema
  • lochia rubra
  • uterine contractions and involution
  • breast engorgement

CARE

  • rooming in
  • lactation support
  • serial examination for uterine bleedy or atony
  • perineal care
  • voiding trial
  • pain management
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7
Q

post partum hormones

A

INCREASED OXYTOCIN

  • uterine contractions
  • protects against hemorrhage
  • involution with lochia

INCREASED PROLACTIN
-stimulate breast milk excretion and let down

DECREASED ESTROGEN AND PROGESTERONE

  • chills and shivering
  • mild hyperthermia or low grade fevers in first 24 hours
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8
Q

Oxytocin

A

INDICATIONS

  • induction or augmentation of labor
  • prevention and management of post partum hemorrhage

ADVERSE EFFECTS

  • hyponatremia (water intoxication due to ADH action– can lead to seizure)
  • hypotension
  • tachysystole
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9
Q

Hyponatremia

A
  • headaches
  • abdominal pain
  • nausea
  • vomiting
  • lethargy
  • tonic clonic seizure

treat with gradula administration of hypertonic salline

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10
Q

rectus abdominis diastasis

A

DEFINITION
-weakening of linea alba

RISK

  • chronic abdominal stretching (pregnancy)
  • surgical weakening
  • increased abdominal pressure

CLINICAL

  • nontender midline mass
  • no associated fascial defect
  • no pain, no GI symptoms, no risk of strangulation or incarceration

MANAGE

  • observation and reassurance
  • typically resolves post partum
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11
Q

Twin-twin transfusion syndrome

A
  • monochorionic diamniotic twins
  • one placenta and thin intertwin membrane that meets placenta at 90 degree angle (T sign)
  • donor twin: anemia, renal failure, oliogohydramnions, low output HF, fetal growth restriction
  • recipient twin: polycythemia, polyhydramnios, cardiomegaly, high output heart failure, hydrops fetalis
  • Both twins are at risk of intrauterine and neonatal death
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12
Q

Early decels

A
  • symmetric to contraction
  • nadir of deceleration corresponds to peak of contraction
  • more than 30 seconds to nadir
  • caused by fetal head compression
  • can be normal fetal tracing
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13
Q

late decels

A
  • delayed compared to contraction
  • nadir of deceleration occurs after peak of contraction
  • more than 30 seconds to nadir

-caused by uteroplacental insufficiency

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14
Q

variable decels

A
  • can be but not necessarily associated with contraction
  • abrupt, takes less than 30 seconds to nadir
  • decrease ober 15 mins for more than 15 secs but less than 2 mins
  • caused by cord compression, oligohydramnios, cord prolapse
  • manage by first maternal repositioning, then maybe amnioinfusion
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15
Q

Hydatidiform mole

A

CLINICAL

  • abnormal vaginal bleeding
  • uterine enlargement greater than gestational age
  • abnormally high beta hcg
  • theca lutein ovarian cysts
  • hyperemisis
  • preeclampsia with severe features
  • hyperthyroidism –> hyperreflexia and clonus

RISK

  • extremes of maternal age
  • history of mole

DIAGNOSIS

  • snowstorm on US
  • quantititative beta hcg
  • histologic eval of uterine contents

MANAGE

  • D and C
  • serial beta hcg after evacuation
  • contraception for 6 months
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16
Q

Fetal growth restriction

A

Definition
-weight less than the 10 percentile for gestational age

RISK

  • maternal hypertension
  • pregestational DM
  • genetic abnormalities
  • congenital infection

APPEARANCE

  • large anterior fontanel
  • thin umbilical cord
  • loose, peeling skin
  • minimal subcu fat

EVAL

  • placenta histopathology
  • consider karyotype, urine tox, serology

NEONATAL COMPLICATIONS

  • polycythemia
  • hypoglycemia
  • hypocalcemia
  • poor thermoregulation
17
Q

Short inter pregnancy interval

A

Definition
-less than 6-18 months from delivery to next pregnancy

COMPLICATIONS

  • maternal anemia
  • PPROM
  • preterm delivery
  • low birth weight
18
Q

malignant hyperthermia

A

EPI

  • genetic mutation alters control of intracellular Ca
  • triggered by volatile anesthetics, succinlycholine, excessive heat

MANIFESTATIONS

  • masseter or generalized rigidity
  • sinus tachy
  • hypercarbia resistant to minute vent
  • rhabdomyolysis
  • hyperkalemia
  • hyperthermia

TREATMENT

  • respiratory/ventilatory support
  • immediate cessation of causative anesthetic
  • dantrolene
19
Q

Magnesium toxicity

A

CLINICAL

  • mild: nausea, flushing, headache, hyporeflexia
  • moderate: areflexia, hypcalcemia, somnolence
  • severe: respiratory paralysis, cardiac arrest

TREATMENT

  • stop mg
  • give IV calcium gluconate
20
Q

Post partum urinary retention

A

DEF

  • inability to void after 6 hours post partum
  • overflow incontinence due to overflowing bladder

RISK

  • primiparity
  • regional neuraxial anesthesia
  • operative vaginal delivery
  • perineal injury
  • c section

CLINICAL

  • small volume voids or inability to void
  • incomplete bladder emptying
  • dribbling of urine

PATHOPHYS

  • prolonged second stage of labor
  • pudendal nerve injury
  • neuraxial anesthesia suppression of micturition reflex
  • bladder atony

MANAGE

  • self limited
  • intermittent catheterization
21
Q

Postdural puncture headache

A

PATHOPHYS
-unintentional dural puncture leading to CSF fluid leakage
-low pressure, slight herniation
CLINICAL
-after lumbar puncture or neuraxial anesthesia
-positional (worse when upright, improves when supine)
-photophobia, diplopia
-hearing loss, tinnitus

MANAGEMENT

  • typically self limited
  • epidural blood patch
22
Q

Contraindications to breast feeding

A

MATERNAL

  • active untreated TB
  • HIV ***
  • Herpetic breast lesions
  • active varicella
  • chemotherapy or radiation therapy
  • active substance use

INFANT

  • Galactosemia
  • PKU
23
Q

theca lutein cysts

A

PRESENTATION

  • multilocular
  • bilateral enlarged ovaries
  • enlarged uterus
  • elevated beta hCG

PATHOGEN

  • ovarian hyperstimulation due to
  • gestational trophoblastic disease
  • multifetal gestation
  • infertility treatment

CLINICAL COURSE
-resolve with decreasing beta hCG levels

24
Q

Ovarian hyperstimulation syndrome

A

PATHOPHYS

  • risk with ovulation induction
  • increased hCG ehances vascular permeability
  • acute fluid shift to extravascular space

CLINICAL

  • ascites
  • respiratory distress
  • hemoconcentration
  • hypercoagulability
  • electrolyte imbalances
  • multi organ failure
  • DIC
  • bilateral ovarian cysts

EVALUATION

  • fluid balance monitoring
  • serial CBC, electrolytes
  • serum hCG
  • pelvic U/S
  • CXR
  • Echo

MANAGEMENT

  • correct electrolyte imbalances
  • paracentesis and thoracentesis
  • thromboembolism prophylaxis
25
Q

Causes of hyperandrogenism in pregnancy

A

placental aromatase deficiency

luteoma

theca lutein cyst

sertoli-leydig tumor

26
Q

placental aromatase def

A

no ovarian mass

high maternal and fetal virilization risk

resolution of maternal symptoms after deliver

27
Q

luteoma

A

solid, unilateral/bilateral ovarian masses

moderate maternal virilization risk

high fetal virilization risk

spontaneous regression of masses after delivery

28
Q

sertoli-leydig tumor

A

solid unilateral ovarian mass

high maternal and fetal virilization

surgery required (2nd trimester or postpartum)

29
Q

physiologic hydronephrosis of pregnancy

A
  • urinary frequency, nocturia, back pain, round ligament pain
  • bilateral enlarged kidneys, enlargement and dilation of renal pelvices and proximal ureters
  • right is usually more pronounced
  • no additional management needed
30
Q

Delivery planning for a non viable fetus

A

DIAGNOSIS

  • acardia
  • anecephaly
  • bilateral renal agenesis
  • holoprosencephaly
  • intrauterine fetal demise
  • pulmonary hypoplasia
  • thanatophoric dwarfism

Obstetric management

  • vaginal delivery
  • no fetal monitoring

Neonatal management
-palliative care if not stillborn

31
Q

Sheehan syndrome

A

PATHOGEN

  • obstetric hemorrhage complicated by hypotension
  • post partum pituitary infarction

CLINICAL

  • lactation failure (low prolactin)
  • amenorrhea, hot flashes, vaginal atrophy (low FSH and LH)
  • fatigue, bradycardia (low TSH)
  • anorexia, weight loss, hypotension (low ACTH)
  • decreased lean body mass (low growth hormone)
32
Q

Management of shoulder dystocia

A
  • Breath do not push
  • elevate legs and flex hips and thighs against abdomen (mcroberts)
  • call for help
  • apply suprapubic pressure
  • enlarge vaginal opening with episiotomy

MANEUVERS

  • deliver posterior arm
  • rotate posterior shoulder (wood screw)
  • adduct posterior fetal shoulder (Rubin)
  • mother on hands and knees (Gaskin)
  • replace fetal head into pelvic for C section (Zavanelli)
33
Q

Type II osteogenesis imperfecta

A

PATHOPHYS

  • AD
  • Type I collagen defect

US findings

  • multiple fractures
  • short femur
  • hypoplastic thoracic cavity
  • fetal growth restriction
  • intrauterine demise

PROGNOSIS
-lethal

34
Q

post partum thyroiditis

A
  • occurs in 7-8% of women
  • usually in first 6 months post partum
  • brief hyper followed by hypo thyroid
  • anxiety, palpatations
  • fatigue, weight gain, constipation

EXAM

  • nontender goiter
  • bradycardia
  • diastolic HTN
  • LE edema

LAB

  • hypercholesterolemia
  • hyponatremia
35
Q

melasma

A

PATHO

  • acquired hyperpigmentation
  • occurs on sun exposed areas of the face
  • uv light radiation triggers melanocyte production

RISK

  • reproductive age
  • pregnancy: estrogen and progesterone stimulate melanocyte proliferation
  • thyroid dysfunction

CLINICAL

  • irregularly shaped, hyperpigmented macules of varying color
  • malar distribution

MANAGE

  • no further evaluation
  • minimize sun exposure
  • typically resolves post partum
36
Q

ABO hemolytic disease

A

RISK
-infants with blood types A or B born to a mother with O

CLINICAL

  • jaundice within 24 hours of birth
  • anemia
  • increased reticulocyte count
  • hyperbili
  • positive combs

MANAGE

  • serial bili levels, oral hydration and phototherapy
  • exchange transfusion for sever anemia/hyperbili
37
Q

Indications for prophylactic administration of anti-D immune globulin for RH negative patients?

A
  • at 28-32 weeks gestation
  • less than 72 hours after delivering a positive infant
  • less than 72 hours after a SAB
  • ectopic pregnancy
  • threatened abortion
  • hydatididifiom mole
  • chorionic villus sampling, amniocentesis
  • abdominal trauma
  • second and third trimester bleeding
  • external cephalic version
38
Q

twin pregnancy

A

MATERNAL COMPLICATIONS

  • hyperemesis
  • preeclampsia
  • gestation DM
  • iron deficiency anemia
  • uterine crowding
  • uterine overdistension –> increased prostaglandins and oxytocin receptors and contractility within uterus

FETAL COMPLICATIONS

  • congenital anomalies
  • fetal growth restriction
  • preterm delivery
  • malpresentation
  • monochorionic twins: TTTS
  • monoamniotic twins: conjoined, cord entanglement
39
Q

pseudocyesis

A

PATHO

  • somatization of stress
  • affects HPO axis

CLINICAL

  • amenorrhea
  • breast fullness
  • morning sickness
  • abdominal distention
  • believes self to be pregnant
  • negative pregnancy test

RISK

  • history of infertility
  • prior pregnancy loss

MANAGE
-psych eval and treatment

Obstetrics (5 decks)

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