Toy_Review_Packet Flashcards
IUGR is defined as
fetal weight <10th percentile for gestational age
Whereas alcohol use has a much more nebulous connection to F.A.S., __________ is always associated with small baby size.
tobacco use/cigarette smoking
In a baby with IUGR, you have two potential next steps:
1) delivery, if after 37 weeks gestation
2) monitor baby with BPP or Doppler studies of umbilical artery
Severe oligohydramnios with IUGR has the highest perinatal mortality and is associated with what Doppler flow finding?
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
What are the two findings on Doppler umbilical artery studies that would indicate delivery?
absence or reversal of end diastolic flow
What does the BPP measure?
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)
What is the recommended management based on BPP?
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
Patient with history of diabetes and urine that “dribbles out throughout the day.” Diagnosis? Next step? Treatment?
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…)
What is the most common cause of ambiguous genitalia?
21-hydroxylase deficiency
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?
Hypotension. Prominent lab finding: Hyponatremia (salt wasting)
Also hyperkalemia, high 17-hydroxyprogesterone
_______ is characterized by satisfying criteria with regards to somatic and mood components in the 2nd half (luteal phase) of the menstrual cycle.
PMDD
What is the difference in presentation between 21- and 11-hydroxylase deficiency in CAH?
21 –> hypotension
11 –> hypertension (deoxycortisol is still made, which has mineralocorticoid properties)
What is the definition of secondary amenorrhea?
Absence of menses for 3 months in women with previously normal menstruation and for 9 months in women with previous oligomenorrhea
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?
- hypothalamic (prolactinoma, hypothyroid)
- pituitary (Sheehan’s)
- uterus (Ashermann, cervical stenosis)
- ovary (PCOS)
chronic = PCOS
regular until now = hypothalamic
After a pregnancy test, women with secondary oligomenorrhea should get which tests?
TSH, prolactin (eventually FSH, LH, estrogen)
What is the best prevention for hydrosalpinx/tubal factor for infertility?
counseling about safe sex! Barrier methods of contraception. PID is not always symptomatic so it can’t always be appropriately treated!!
If there are no endocervical cells on the Pap smear of a pregnant woman, should the Pap smear be repeated?
No! Not having endocervical cells is not a big deal in pregnancy because we don’t sample too vigorously
Which of the following antibodies does not cross the placenta: Lewis, Kell, Duffy
Lewis! (Lewis lives; it is IgM). Kell kills and Duffy dies (Duffy is the receptor for entry of the malaria parasite, fun fact.)
If a mother is competent and denies the C-section for fetal interest, do you perform it, anyway? Which ethical principle?
Do not perform it! Autonomy
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)?
lacerations, bruising, a cauliflower-like lesion
What is the earliest sign of chorioamnionitis?
Fetal tachycardia (even before maternal fever or uterine tenderness!).
Up to what week do you give steroids to enhance fetal lung maturity?
32 weeks! (some sources say 34 weeks)
A case where chorioamnionitis does NOT cause rupture of membranes (the exception!) is when there is infection by this organism (gram positivity? rod/cocci?).
Listeria!! Gram positive rod. Amniotic fluid is typically meconium stained. Treat with IV ampicillin.
Besides chorioamnionitis, what are other causes of PPROM?
STDs, cigarette smoking, hydramnios, abruption, multiple gestation
If meconium fluid is noted with rupture of the membranes, what do you do?
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!
Woman with twin gestation experiences moderate vaginal bleeding and twin A shows tachycardia and now sinusoidal heart tones. What do you do?
Emergent C section! sinusoidal = severe fetal acidemia
What does “minimal variablity” on the fetal heart tracing mean diagnostically?
fetoacidemia. Get the baby out or risk permanent organ injury due to hypoxemia
Lower abdominal pain, dyspareunia, throat pain, menorrhagia, and history of STDs:
gonorrhea cervicitis! Gonorrhea has pili that enable it to adhere to the back of the throat (chlamydia does not)
What is the treatment of lichen sclerosis? What is an important diagnostic step esp in a postmenopausal woman?
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
Perimenopausal years should have (increased/decreased) bleeding overall. Increasing intermenstrual bleeding indicates what next step?
should have decreased bleeding in a perimenopausal woman!
If it is increased, need endometrial biopsy to rule out endometrial cancer
Why do you see hyperemesis gravidarum in the first trimester?
HcG, which correlates with nausea/vomiting, peaks between 9 and 13 weeks.
What is the next step in a patient once hyperemesis gravidarum has been identified?
antiemetics, NPO, fluids
What hormone causes GERD in pregnancy?
Progesterone! It decreases the motility of the bowel and relaxes the lower esophageal sphincter
A female neonate having vaginal bleeding on day 2 of life is likely due to
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
In which of the etiologies of primary amenorrhea is pubic axillary hair seen: androgen insensitivity, Mullerian agenesis, gonadal dysgenesis? Breasts?
hair: Mullerian agenesis!
breasts: Mullerian agenesis and androgen insensitivity
Why is there no sensation to deep pain in necrotizing fasciitis?
loss of neurons in the subdermal layer (where the nerve endings are) because of necrosis.
What is the treatment of suspected necrotizing frasciitis, and what is it caused by?
Caused by infection with Group A Strep.
Treatment: Isotonic IV fluids (if septic hypotension), broad spectrum antibiotics (penicillin, gentamicin, metronidazole), and immediate surgical debridement.
T/F: Meperidine (demerol) is associated with hypotension.
False. But it is associated with decreased fetal heart rate variability
Why is 1 to 1.5L of “preload” fluid given to patients about to receive an epidural?
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).
How do you treat epidural-induced hypotension?
Fluids! And ephedrine.
Why is ephedrine the preferred vasopressor in epidural-induced hypotension?
It squeezes the peripheral vasculature but SPARES the uterine arteries! Maintains perfusion in the uterus.
What are the key labs/tests in suspected preeclampsia?
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)
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?
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)
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?
No! Give oxytocin (for uterine inertia) and monitor as long as everything else is stable
In patient with struma ovarii, the treatment is cystectomy or __________ (this medication) for symptoms.
Beta blockers
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?
Uterine perforation with bowel injury!
Management: surgery for bowel repair, antibiotics.
Prevention of osteoperosis includes:
1) adequate calcium and vitamin D
2) regular, weight-bearing exercise
3) avoid smoking/alcohol
When is HRT indicated?
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.
If a BBT shows temperature elevation >14d, think:
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!!)
