Surgery Part 3 and ObGyn Part 1 (202-233) Flashcards
Bleeding of middle meningial artery. Dx? CT?
Epidural - biconcave disk not crossing suture lines
Bleeding of cortical bridging veins. Dx? CT?
Subdural - crescenteric pattern extends across suture lines
Bleeding from Circle of Willis often at middle cerebral artery branch. Dx? Biggest cause and Sx?
Subarachnoid hemorrhage - Caused by berry aneurysm –> severe HA and CN III palsy
What does the CSF fluid of a pt with subarachnoid hemorrhage look like? Color? content?
Xanthochromia – CSF protein >150
What pharmacologic agent do you give pts with subarachnoid hemorrhage? WHy?
Nimodipine to prevent vasospasm that could result in secondary infarct.
Bleeding from basal ganglia, internal capsule and thalamus. Dx? CT/MRI shows?
Parenchymal hemorrhage - CT shows focal edema and hypodensity
What could be some causes of parenchymal bleed?
hypertension, trauama, AV malformation and coagulopathy
What is the most common temporal bone fracture?
Longitudinal fracture (80%)
After temporal bone fracture, if a CSF leak is noted, what should you do?
IV antibiotics and ear drops
If a temporal fracture affects the facial nerve, what should you do?
Facial nerve decompression
What are the 4 ( or 5) classic signs of a basilar skull fracture?
raccoon eyes, Battle’s sign, hemotypmpanum, CSF rhinorrhea and otorrhea
Dark circles (bruising) under the eyes is what?
Raccoon eyes
What is Battle’s sign?
ecchymosis over the mastoid process indicating fracture.
What is the treatment for a basilar skull fracture?
Supportive- HOB elevated, monitor ICP
Pt with increased ICP, bradycardia with hypotension, Cheyne-Stokes respirations, and papilledema. What general dx?
Tumors
Small circular lesion, often multiple at gray-white junction
metastatic
Large irregular ring enhancing lesion due to central infarction (outgrows blood supply) – most common primary CNS neoplasm
Glioblastoma multiforme
Second mC neoplasm, slow growing and bengin
Meningioma
Occurs in children (often bilateral) 60:40 sporadic:familial
Retinoblastoma
Found in cerebellum in the floor of the 4th ventricle, common in children
medullablastoma
compresses optic chiasm and hypothalamus
craniopharyngeoma
Sx: bilateral gynecomastia, amenorrhea, galactorhhea and bitemporal hemianopsia
prolactinoma
MC tumor in AIDS pt (100x incidence) – what does CT look like?
lymphoma - ring enhancing lesion
Usually affects CN VIII (acoustic neuroma)
Schwannoma
You excise all brain tumors except which two?
prolactinoma and lymphoma
Whats the tx for a prolactinoma?
Bromocriptine (D2 agonist)
Whats the tx for a lymphoma?
Radiation therapy
Dilated ventricles on CT/MRI with normal ICP. Dx?
Communicating hydrocephalus (either ex vacuo or normal pressure)
Why does hydrocephaleus ex vacuo happen? Tx?
Occurs after neuron loss - stroke, CNS dz.
No treatment
Why does normal pressure hydrocephaleus happen? Sx? Tx?
Causes: idiopathic, meningitis, cerebral hemorrhage,trauma, arthrosclerosis.
Sx: wet whacky wobbly
Tx: diuretic, repeated spinal taps and consider shunt placement.
What kind of hydrocephalus is associated with increased ICP?
Communicating or non communicating
Communicating spontaneous increased ICP commonly seen in obese young females, but can be idiopathic. Also can be caused by massive quntaties of Vitamin A. Dx? CT?
Pseudotumor cerebri
CT –> no ventricle dilation (may even be shrunken)
How to Tx pseudotumor cerebri?
acetazolamide or surgical lumboperitoneal shunt
Where is a non communicating hydrocephalus obstructed?
CSF outflow is at the 4th ventricle at the foramina
What could be the causes of noncommunicating hydrocephalus?
- Congenital (Arnold Chiari syndrome)
- tumor
- Scarring secondary to meningitis
- secondary to subarachnoid hemorrhage
Define aneurysm
Abnormal dilation of an artery to more than twice it’s normal diameter
What is the Most common cause of an aneurysm?
arthrosclerosis
What’s the difference between a true and false aneurysm?
True involves with all 3 layers of the vessel wall
False aneurysms are pulsatile hematomas covered only by a thickened fiberous capsule (adventitia)
Pt with classic abdominal pain, pulsatile abdominal mass, hypotension. Dx?
Rupture of AAA
What is the rate of rupture for a 5cm AAA rupture?
6% per year
What is the rate of rupture for a 6cm AAA rupture?
10% per year
What is the most difinitive diagnosis of a AAA?
Aortogram
Why are CTs done for AAA?
to determine the size of the aneurysm in a stable pt
When is surgical intervention for a stable AAA recommended?
infrarenal and juxtrarenal aneurysms >5.5
What complication can be seen in patients who have had synthetic grafts placed for AAA disease who have GI bleeding?
formation of a aortoduodenal fistula
Where is the most common peripheral aneurysm?
popliteal artery
What percent of the peripheral aneurysms are bilateral?
50%
with 33% of pts with popliteal aneurysms have a AAA
Where is a type A dissection located?
ascending aorta
Where is a type B dissection located?
both ascending and descending aorta
Pt presents with classic severe tearing (ripping) chest pain in hypertensive pts that radiates toward the back
Aortic dissection
Why does peripheral vascular dz happen?
arthrosclerosis dz in the lower extremeties
What are the factors associated with peripheral vascular disease?
smoking
increased homocystiene
elevated levels of C-reactive protein
What happens when cellulitis superimposes active infection to necrotic tissue?
wet gangrene
What is Leriche Syndrome?
Aortoiliac disease that causes claudication in hip and gluteal muscles, impotence
What is the ankle brachial index?
Ratio of BP in the ankle to the BP in the arm.
What is a normal ABI?
Greater than 1
What is an ABI with severe occlusive disease?
What is an ABI in a pt with claudication?
What is a normal waveform in an artery?
triphasic
Moderate occlusive disease waveform?
biphasic
severe disease waveform?
monophasic
What kind of lifestyle modifications can be suggested to pt with PVD?
smoking cessation and increase exercise
What is the pharmacologic intervention for PVD? (first and second line)
Cilostazol (vasodilator and platelet inhibitory properties)- first
Pentoxifyllin - second
What is minimally invasive therapy for PVD?
percutaneous balloon angioplasty and/or arthrectomy + endoluminal stents
What are indications for PVD surgery?
rest pain, tissue necrosis, non healing infection and intractable claudication
Dilated prominent tortuous superficial veins in the lower limbs
varicose veins
What kinds of people get varicose veins? (2) Why?
- pregnancy (progesterone causes dilation of veins)
- prolonged standing professions
- possible inheritance
Why do venous ulcers occur?
Seconday to venous hypertension, DVT, varicose veins –> usually located on the medial calf or ankle
Are venous ulcers painful or painless?
painless?
What is phelgmasia alba dolens?Tx?
milk leg –> venous thrombosis usually occuring in post partum women
Tx: heparin and elevation
What is phlegmasia cerula dolens? Tx?
venous gangrene –> venous thrombosis with complete obstruction of arterial inflow
Tx: heparin, elevation and venous thrombectomy if unresolved
What are unna’s boots?
zinc oxide paste impregnated bandage used to reduce swelling
Why do arterial ulcers occur?
secondary to occlusive arterial disease
Are arterial ulcers painful or painless
painful in contrast to venous ulcers
Where are arthrosclerotic plaques most often seen in carotids?
most commonly the carotid bifurcation
What is the indication for carotid endarterectomy in symptomatic patients?
stenosis > 70%
multiple TIAs
Pts with Hx of CVA, amenable to surgery
What is the indication for carotid endarterectomy in asymptomatic patients?
carotid steonosis >75%
What dz is caused by an occlusive lesion in subclavian arteria or innominate artery that causes decreased blood flow distal to the obstruction?
Subclavian steal syndrome
Where does subclavian artery “steal” blood from?
vertebral artery via retrograde flow
What is the tx for subclavian steal syndrome?
Carotid-subclavian bypass
What causes renovascular hypertension?
Renal artery stenosis and subsequent activation of the renin-angiotensin pathway
What causes renal artery stenosis to begin with?
Arthrosclerotic lesions… but can be secondary to fibromuscular dysplasia, subintimal dissections and hypoplasia of the renal artery
What’s the initial test you would do to test for renal artery stenosis? Gold standard?
renal duplex ultrasound and gold standard is angiography
Can also do renin:vein renin ratio (captopril test)
Define chronic intestinal ischemia
secondary to arthrosclerotic lesions of atleast 2 of the 3 major vessels supplying the bowel.
Pt with weight loss, post prandial pain and abdominal bruit. dx?
chronic intestinal ischemia
Define Acute intestinal ischemia
acute thrombosis of a mesenteric vessel secondary to arthrosclerotic changes or emboli from the heart
How do you confirm or rule out diagnosis of acute intestinal ischemia?
Angiogram
At how many weeks is a term delivery?
37 weeks
How many weeks is a premature delivery
between 20-37 weeks
What is Chadwick’s sign?
blue-ish discoloration of the vagina due to vascular congestion
What is Hegar’s sign?
softening of the cervix
What hormone do pregnancy tests detect?
hCG or it’s Beta subunit
At what age is a gestational sac identified?
5wks
At what age is a fetal image detected?
6-7weeks
At what age is cardiac activity first noted?
8 weeks
What is Nagele’s rule?
LMP+7 days - 3 months +1 year = estimated due date
During first visit, what tests do you do on mom?
CPE Pap smear cultures for GC CBC Blood type with Rh RPR Rubella TB Skin testing Offer HIV antibody test
Teratogen effect of lithium
Ebstein’s anomoly
Teratogen effect of Carbamazepine or valproate
Neural tube defects
Teratogen effect of Retinoic acid
CNS defects, craniofacial defects, cardiovascular defects
Teratogen effect of ACEi
Renal failure in neonates, renal tubule agenesis, decreased skull ossification
Teratogen effect of Oral hypoglycemic
neonatal hypoglycemia
Teratogen effect of warfarin
skeletal and CNS defects
Teratogen effect of NSAIDs
Constriction of ductus arteriosus, necrotizing enterocolitis
Teratogen effect of thalidomide
phocomelia (underdevelopment of limbs and face)
Medication has not shown increased risk for birth defects in human studies. Category?
A
Medications are associated with birth defects in humans; however potential benefits in rare cases may outweigh their known risks. Category?
D
Animal studies show adverse effects, but no studies available in humans. Category?
C
Medications are contraindicated in human pregnancy bc of known fetal abnormalities that have been demonstrated in both human and animal studies. Category?
X
Animal studies have not demonstrated a risk and no adequate studies in humans OR animal studies = risk, but human studies = no risk
B
If a pregnant pt is not immune to rubella, what should you do?
DO NOT VACCINATE. – Rubella vaccine is a live virus
How much weight gain is recommended during pregnancy?
25-35 lbs
In the first trimester, how often should a woman visit the obgyn?
every 4 weeks
Why is trace glucosuria seen in normal pregnancy?
increase in GFR.. but anything more than trace protein should be evaluated
At what weeks are the following uterine landmarks?
- Pubic symphysis
- midway from symphysis to umbilicus
- at umbilicus
- Correlates with wk of gestation
- Pubic symphysis 12 weeks
- midway from symphysis to umbilicus 16 weeks
- at umbilicus 20 weeks
- Correlates with wk of gestation 20-36 weeks
All pregnant women should undergo what testing in first trimester?
Down’s syndrome
What is the ultrasound test to look for down’s syndrome?
Nuchal translucency
What are the blood work results (AFP, Estriol, HcG, Inhibin A) for Down’s syndrome?
AFP and Estriol down
HcG and Inhibin A is HIgh (in down’s ironically)
What are the blood work results (AFP, Estriol, HcG, Inhibin A) for Turner’s syndrome
AFP and Estrio is down
HcG and Inhibin A are VERY HIgh
What are the blood work results (AFP, Estriol, HcG, Inhibin A) for Edward’s syndrome?
Estriol and HcG is low. (HE is low)
What are the blood work results (AFP, Estriol, HcG, Inhibin A) for Pateu syndrome?
AFP is high
Adding what test to the quad screen increased the detection to >85%?
PAPP-A
When is quickening seen in the fetus?
17-19 weeks
At what week should glucose screening be done?
24 weeks (1 hr glucola)
At how many weeks should you start going to the obgyn more frequently?
Every 4 weeks til 32 weeks, Every 2 weeks from 32-36 weeks and every week til delivery
What should you ask when concerned about preterm labor?
Are you having any vaginal bleeding, contractions or rupture of membranes
At how many weeks do you screen for GBS?
35-37 weeks
If mother is Rh - , at how many weeks is Rhogam administered?
28-30 weeks
Why is pregnancy a hypercoagulable state?
increased clotting factors
venous stasis due to uterine pressure on lower extremity great veins
Why is there a relative anemia seen in pregnancy?
Plasma volume increases by about 50% and red cell mass increases later on so relative anemia of 15% seen
What happens to cardiac output in pregnancy?
increases by 50%
What kind of murmurs are normal in pregnancy?
systolic ejection murmur
What murmurs are not normal in pregnancy?
Diastolic murmur
Why is there decreased peripheral vascular resistance?
Progesterone mediated smooth muscle relaxation
Why is there increased nasal stuffiness and increased nasal secretions in pregnancy?
Increased hyperemia (more vessels growing) = increased congestion
What happens to GI motility, esophageal sphincter tone in pregnancy?
decreased –> constipation results in hemorrhoids
What happens to bladder tone? Why might this be a problem?
decreased tone, predisposed to UTIs
What happens to serum creatinine and BUN?
decreases because increased GFR by 50% which means more gets filtered out
What happens to fasting blood glucose? Why?
decreases because of fetal utilization
What week does the fetus start making it’s own insulin?
9-11 weeks
why does hyperpigmentation occur?
Increased estrogen and melanocyte stimulating hormone affects umbilicus, perineum, face (cholasma) and linea nigra
What is the #1 medical complication of pregnancy occuring in 2% of pregnancies?
gestational diabetes mellitus
What are some risk factors of GDM risk factors
- hx of previous GDM
- maternal age >30
- obesity
- FHx of DM
- previous infant weighing more than 4000 g at birth
- unexplained still births
- repeated spontaneous abortions
Why is GDM caused in pregnancy?
Human placental lactogen antagonizes insulin which causes hyperglycemia so fetus can get more.
What fetal weight is considered macrosomia?
greater than 4500 g
What are 2 complications to mom during pregnancy because of GDM? Why?
Abruption and pre-term labor bc of increased uterine size and post partum uterine atony
What is the screening test and diagnostic test for GDM?
1 hour glucola test screens at 24-28 weeks
3hr GTT confims
Why are oral hypoglycemics contraindicated in GDM?
they can cross the placenta and result in retal and neonatal hypoglycemia
What is White’s classification?
Class A1 = GDM diet controlled
Class A2 = GDM insulin controlled
When is thromboembolic disease in pregnancy most likely to happen?
During pregnancy 1-2%, post partum 80 %
What is the first line for diagnosing thromboembolic disease?
dopplar ultrasound
What is the gold standard for thromboembolic disease/?
venography
Tx for superficial thrombophlebitis
leg elevation, rest, heat and NSAIDs
What do you treat DVT with?
heparin to maintain PTT at 1.5-2.5 times the baseline
Why is warfarin contraindicated in pregnancy?
It crosses the placenta – > teratogenic (bone deformities, abortion, opthomalogic abnormalities) early and causes bleeding later
What percentage of DVTs untreated progress to PE?
25%
What are some risk factors of pregnancy induced hypertension?
nulliparity age >40 FHx of PIH chronic HTN chronic renal dz diabetes twin gestation
What happens to reflexes in pts with pre-eclampsia?
hyperreflexia and clonus
Cure for PIH?
delivery of baby
What are the 3 criteria for pre-eclampsia?
> 140/90 of increased SBP >30 or DBP>15 compared to previous
new onset proteinuria/edema
Generally occuring at >20wks
What additional symptoms must be seen to classify as severe pre-eclampsia?
SBP >160 OR DBP > 110
Marked proteinuria (>1g/24h or >11 dip)/ increased creatinine
CNS disturbances
pulmonary edema/cyanosis
epigastric/RUQ pain or hepatic dysfunction
What is the hallmark sx of Eclampsia?
convulsions
When should you start MgSO4?
in severe pre-eclampsia
When should you treat the blood pressure of eclampsia?
to maintain
What is a complication of severe PIH?
Hemolysis
Elevated Liver enzymes
Llow Platelets
What is the treatment for HELLP?
delivery, transfuse bloos, platelets and fresh frozen plasma as needed, IV fluids, pressors as needed to maintain BP
What is peripartum cardiomyopathy?
A type of dilated cardiomyopathy that decreases ejection fraction
When does peripartum cardiomyopathy occur?
Last month of preg or first 6 months post partum
What are some risk factors to peripartum cardiomyopathy?
African american multiparious age >30 twin gestation Pre-eclampsia
What is the treatment for peripartum cardiomyopathy?
bed rest, digoxin and diuretics along with possible anticoagulation
When is intrapartum prophylaxis for GBS indicated?
- PTL or prolonged ROM or fever in labor
- GBS + at 36 wks
- GBS bacteruria or previous baby with GBS
What is the drug of choice to treat GBS if pt is allergic to penicillin?
Clindamycin or erythromycin
What antibiotics should be used if pt is dx with chorioamnionitis?
broad spectrum *Look up later
What is the definition of hyperemesis gravidum?
N/V past 16 weeks of pregnancy
What are the causes of hyperemesis gravidum?
increased HcG levels, thyroid or other GI hormones
If there is more than a 2cm deviation from expected fundal height during 18-36 weeks, what should you do?
repeat measurement or do ultrasound
What is the most reliable tool for assessing fetal growth?
ultrasound
What is measured in early pregnancy to obtain gestational age?
crown rump length
To get gestational age later in pregnancy, what 4 measurements are done?
biparietal diameter of skull
abdominal circumference
femur length
cerebellar diameter
How many fetal movements per hour indicate fetal well being?
4 per hour
How many accelerations in a NST are considered normal?
2 within 20 minutes
What are the 5 components of a biophysical profile? Scoring?
Fetal breathing Gross body movements Fetal tone Qualitative amniotic fluid volume Reactive FHR
Each rated on scale of 0-2. 8-10 is normal, 6 equivocal and
What do you test for fetal lung maturity?
Lecithin:sphingomyelin ratio >2
and phosphatidylglycerol
What is lecithin?
a phospholipid found in surfactant and increases as lungs mature
What is sphingomyelin?
An agent that remains constant throughout pregnancy
What is phosphotidylglycerol?
Marker that appears late in pregnancy, indicates lung maturity
After how many weeks are fetal lungs generally mature?
after 34 weeks, but highly variable
How are the phospholipids for lung maturity measured?
by amniocentesis because they enter the amniotic fluid from fetal breathing
What is normal fetal heart rate?
120-160bpm
What’s VEAL CHOP
Variable - Cord compression
Early deceleration - Head compression
Accelerations - OK
Late decelerations - Placental insufficiency
What is the MCC for fetal tachycardia?
maternal fever
Why does head compression cause early decelerations?
Because the vagus nerve stimulated reflex response to release acetylcholine at the fetal SA node
Development of maternal immunoglobulin antibodies following RBC exposure is called..
Isoimmunization
Why is isoimmunization dangerous to subsequent pregnancies?
cross the placenta, attach to fetal RBCs and hemolyze them causing fetal anemia
What is the worst case scenario to isoimmunization and why does it occur?
Hydrops fetalis – occurs bc significant Abs across placenta causes fetal anemia.. The liver attempts to make new RBCs (fetal hematopoiesis occurs in liver and bone) at the expense of other proteins –> decreased oncotic pressure –> fetal ascities and edema
What 2 times during pregnancy is Rhogam given to mother to prevent isoimmunization if she is Rh negative and father is Rh + or unknown
28 weeks and 72 hours after pregnancy
Define braxton hicks contractions
False labor = uterine contractions without effacement and dilation of the cervix
All lactating women have approximately ____ greater energy requirement than the average pregnant woman.
2/3
At what point in gestation does an Rh- mother with Anti-Rh IgG titers greater than 1:16 whos pregnant with Rh+ fetus begin amniocentesis?
16-20 weeks to track amniotic fluid bilirubin levels (which depicts level of fetal hemolysis level)
What are the cardinal movements?
Engagement Descent Flexion Internal rotation Extension External rotation (restitution) Delivery.
Hypergonadotrophic hypogonadism is classic of what genetic condition?
Turner’s syndrome. nonfunctional gonads so negative feedback doesn’t work so increased levels of FSH and LH
What are the top 3 DDx to abnormal mid cycle bleeding?
Pregnancy
Hypothyroid
OCP mis-use
What is the definition of pre-term labor?
regular contractions at intervals of 10 minutes or less lasting > or = to 30 seconds, occuring between weeks 20-36. Eventual cervical dilation and effacement will occur
What time period does missed abortion occur?
What are 3 tests done to test for rupture of membranes?
- Pool (speculum exam shoes a pool of fluid in vagina)
- Nitrazine test (fluid is placed onto nitrazine paper, positive if blue-alkaline-aka amniotic fluid)
- Fern = slide shows ferning pattern
Untreated hydatidiiform moles become what?
choriocarcinoma
What is the most common cause of 1st trimester abortion?
Chromosomal abnormalities?
What is the MCC for 2nd trimester abortion?
Cervical incompetence is #1 but other causes include: fetotoxic agents such as warfarin, enalapril, isotretinoin, cocaine
What is LGA?
Large for gestational age >90th percentile
What is SGA?
small for gestational age
What is Beckwith-Wiedemann syndrome?
Pancreatic cell hyperplasia –> risk for LGA