Toy_Review_Packet

Question 1

IUGR is defined as

Answer 1

fetal weight <10th percentile for gestational age

Question 2

Whereas alcohol use has a much more nebulous connection to F.A.S., __________ is always associated with small baby size.

Answer 2

tobacco use/cigarette smoking

Question 3

In a baby with IUGR, you have two potential next steps:

Answer 3

1) delivery, if after 37 weeks gestation

2) monitor baby with BPP or Doppler studies of umbilical artery

Question 4

Severe oligohydramnios with IUGR has the highest perinatal mortality and is associated with what Doppler flow finding?

Answer 4

increased Doppler flow in umbilical arteries, which means increased resistance in the placental circulation. This can lead to absence or reversal of end diastolic flow, the two Doppler study indicatinos for delivery

Question 5

What are the two findings on Doppler umbilical artery studies that would indicate delivery?

Answer 5

absence or reversal of end diastolic flow

Question 6

What does the BPP measure?

Answer 6

Fetal movement (>2 movements of torso or limbs)
Fetal tone (at least one active bending/straightening movement)
Fetal breathing (>20s of breathing movements)
Amniotic fluid volume (at least one vertical pocket >2 cm)
Fetal Heart Rate (>2 accelerations–increase in 15 bpm for 15 sec)

Question 7

What is the recommended management based on BPP?

Answer 7

2 or less: labor induction

4: labor induction if >32 w, otherwise repeat test same day and THEN deliver if 36w, otherwise repeat test in 1 day. Deliver if 6.
8: labor induction if there is oligo

Question 8

Patient with history of diabetes and urine that “dribbles out throughout the day.” Diagnosis? Next step? Treatment?

Answer 8

1) Overflow incontinence
2) Post-void residual ~200cc
3) intermittent self catheterization (the nerves don’t grow back in this neuropathy, though in MS exacerbations things might get better…)

Question 9

What is the most common cause of ambiguous genitalia?

Answer 9

21-hydroxylase deficiency

Question 10

What is the most likely physical exam finding in a patient with 21-hydroxylase deficiency who has not had medications for 4 days? Prominent lab finding?

Answer 10

Hypotension. Prominent lab finding: Hyponatremia (salt wasting)
Also hyperkalemia, high 17-hydroxyprogesterone

Question 11

_______ is characterized by satisfying criteria with regards to somatic and mood components in the 2nd half (luteal phase) of the menstrual cycle.

Answer 11

PMDD

Question 12

What is the difference in presentation between 21- and 11-hydroxylase deficiency in CAH?

Answer 12

21 –> hypotension

11 –> hypertension (deoxycortisol is still made, which has mineralocorticoid properties)

Question 13

What is the definition of secondary amenorrhea?

Answer 13

Absence of menses for 3 months in women with previously normal menstruation and for 9 months in women with previous oligomenorrhea

Question 14

What are the four etiologies of secondary amenorrhea? Which is most common if it’s chronic? Which is most common if the patient has had regular menses up until now?

Answer 14

1. hypothalamic (prolactinoma, hypothyroid)
2. pituitary (Sheehan’s)
3. uterus (Ashermann, cervical stenosis)
4. ovary (PCOS)

chronic = PCOS
regular until now = hypothalamic

Question 15

After a pregnancy test, women with secondary oligomenorrhea should get which tests?

Answer 15

TSH, prolactin (eventually FSH, LH, estrogen)

Question 16

What is the best prevention for hydrosalpinx/tubal factor for infertility?

Answer 16

counseling about safe sex! Barrier methods of contraception. PID is not always symptomatic so it can’t always be appropriately treated!!

Question 17

If there are no endocervical cells on the Pap smear of a pregnant woman, should the Pap smear be repeated?

Answer 17

No! Not having endocervical cells is not a big deal in pregnancy because we don’t sample too vigorously

Question 18

Which of the following antibodies does not cross the placenta: Lewis, Kell, Duffy

Answer 18

Lewis! (Lewis lives; it is IgM). Kell kills and Duffy dies (Duffy is the receptor for entry of the malaria parasite, fun fact.)

Question 19

If a mother is competent and denies the C-section for fetal interest, do you perform it, anyway? Which ethical principle?

Answer 19

Do not perform it! Autonomy

Question 20

Though foreign body may be the most likely cause of vaginal bleeding and malodorous discharge in a toddler, what might make you think of sexual abuse (the 2nd most common)?

Answer 20

lacerations, bruising, a cauliflower-like lesion

Question 21

What is the earliest sign of chorioamnionitis?

Answer 21

Fetal tachycardia (even before maternal fever or uterine tenderness!).

Question 22

Up to what week do you give steroids to enhance fetal lung maturity?

Answer 22

32 weeks! (some sources say 34 weeks)

Question 23

A case where chorioamnionitis does NOT cause rupture of membranes (the exception!) is when there is infection by this organism (gram positivity? rod/cocci?).

Answer 23

Listeria!! Gram positive rod. Amniotic fluid is typically meconium stained. Treat with IV ampicillin.

Question 24

Besides chorioamnionitis, what are other causes of PPROM?

Answer 24

STDs, cigarette smoking, hydramnios, abruption, multiple gestation

Question 25

If meconium fluid is noted with rupture of the membranes, what do you do?

Answer 25

Use pitocin to speed up the process and monitor for even occasional decels. Hypoxemia/acidosis leads the baby to gasp, which causes aspiration. Monitor with a fetal scalp electrode! If there is evidence of even mild hypoxemia, deliver by Cesarean!

Question 26

Woman with twin gestation experiences moderate vaginal bleeding and twin A shows tachycardia and now sinusoidal heart tones. What do you do?

Answer 26

Emergent C section! sinusoidal = severe fetal acidemia

Question 27

What does “minimal variablity” on the fetal heart tracing mean diagnostically?

Answer 27

fetoacidemia. Get the baby out or risk permanent organ injury due to hypoxemia

Question 28

Lower abdominal pain, dyspareunia, throat pain, menorrhagia, and history of STDs:

Answer 28

gonorrhea cervicitis! Gonorrhea has pili that enable it to adhere to the back of the throat (chlamydia does not)

Question 29

What is the treatment of lichen sclerosis? What is an important diagnostic step esp in a postmenopausal woman?

Answer 29

topical steroids (clobetasol) for treatment with annual monitoring (lichen sclerosis is a risk factor for squamous cell cancer).

Next diagnostic step is a biopsy of the affected area

Question 30

Perimenopausal years should have (increased/decreased) bleeding overall. Increasing intermenstrual bleeding indicates what next step?

Answer 30

should have decreased bleeding in a perimenopausal woman!

If it is increased, need endometrial biopsy to rule out endometrial cancer

Question 31

Why do you see hyperemesis gravidarum in the first trimester?

Answer 31

HcG, which correlates with nausea/vomiting, peaks between 9 and 13 weeks.

Question 32

What is the next step in a patient once hyperemesis gravidarum has been identified?

Answer 32

antiemetics, NPO, fluids

Question 33

What hormone causes GERD in pregnancy?

Answer 33

Progesterone! It decreases the motility of the bowel and relaxes the lower esophageal sphincter

Question 34

A female neonate having vaginal bleeding on day 2 of life is likely due to

Answer 34

withdrawal of maternal estrogen. Estrogen in utero may cause the proliferation of the baby’s endometrium, which then sheds as “pseudomenstruation.” Breast swelling with fluid leaking (witch’s milk) may also be seen, as well as acne

Question 35

In which of the etiologies of primary amenorrhea is pubic axillary hair seen: androgen insensitivity, Mullerian agenesis, gonadal dysgenesis? Breasts?

Answer 35

hair: Mullerian agenesis!
breasts: Mullerian agenesis and androgen insensitivity

Question 36

Why is there no sensation to deep pain in necrotizing fasciitis?

Answer 36

loss of neurons in the subdermal layer (where the nerve endings are) because of necrosis.

Question 37

What is the treatment of suspected necrotizing frasciitis, and what is it caused by?

Answer 37

Caused by infection with Group A Strep.
Treatment: Isotonic IV fluids (if septic hypotension), broad spectrum antibiotics (penicillin, gentamicin, metronidazole), and immediate surgical debridement.

Question 38

T/F: Meperidine (demerol) is associated with hypotension.

Answer 38

False. But it is associated with decreased fetal heart rate variability

Question 39

Why is 1 to 1.5L of “preload” fluid given to patients about to receive an epidural?

Answer 39

The epidural leads to vasodilation due to a sympathetic blockade. If not adequately preloaded, this causes decreased placental perfusion, leading to late decelerations (fetal hypoxia).

Question 40

How do you treat epidural-induced hypotension?

Answer 40

Fluids! And ephedrine.

Question 41

Why is ephedrine the preferred vasopressor in epidural-induced hypotension?

Answer 41

It squeezes the peripheral vasculature but SPARES the uterine arteries! Maintains perfusion in the uterus.

Question 42

What are the key labs/tests in suspected preeclampsia?

Answer 42

1) CBC (platelets, hemoconcentration)
2) CMP (liver enzymes, BUN/Cr)
3) LDH (evidence of hemolysis)
4) uric acid (increased with preeclampsia)
5) BPP (to evaluate uteroplacental insufficiency)
6) maybe UA/urine collection (but proteinuria has NOT been shown to correlate with outcome of fetus or mom)

Question 43

Dyspnea, orthopnea in pregnant woman/postpartum woman with CXR showing bilateral pulmonary infiltrates and an enlarged cardiac silhouette. What is the most likely diagnosis and what is the therapy?

Answer 43

Diagnosis (in absence of preexisting heart condition) = peripartum cardiomyopathy, a 4 chambered dilated cardiomyopathy. Treat with oxygen, diuretics, ACEIs and ARBs, spironolactone, B blockers, anticoagulation, digoxin

if pregnant, treat with digoxin, B-blockers, loop diuretics, and drugs reducing afterload (hydralazine, nitrates)

Question 44

In delivery of twin gestation, if first twin delivers sopntaneously and second twin is undelivered for 60min but heart tones in the 150s, do you do C section?

Answer 44

No! Give oxytocin (for uterine inertia) and monitor as long as everything else is stable

Question 45

In patient with struma ovarii, the treatment is cystectomy or __________ (this medication) for symptoms.

Answer 45

Beta blockers

Question 46

Patient underwent suction D&C for embryonic demise 8 hours previously and now has severe abdominal pain, n/v, and chills with fever, hypotension, tachycardia. Clear lungs. Distended abdomen with decreased bowel sounds; tender abdomen with rebound. Diagnosis?

Answer 46

Uterine perforation with bowel injury!

Management: surgery for bowel repair, antibiotics.

Question 47

Prevention of osteoperosis includes:

Answer 47

1) adequate calcium and vitamin D
2) regular, weight-bearing exercise
3) avoid smoking/alcohol

Question 48

When is HRT indicated?

Answer 48

To treat vasomotor symptoms! Its many risks (breast cancer, cardiovascular disease, stroke, pulmonary embolism) all contraindicate it for osteoperosis prevention, but it is the most effective vasomotor symptom treatment.

Question 49

If a BBT shows temperature elevation >14d, think:

Answer 49

pregnancy! Usually the corpus luteum (which is making the progesterone responsible for the temperature surge) becomes atretic after 14 days, unless the patient is pregnant!! HcG has then taken over the role of LH in maintaining the corpus luteum (which continues to make progesterone until the 12th week, when the placenta takes over!!)