Week 3 UWorld and Cases 9-12 Flashcards
what is a severe toxicity of oxytocin to be aware of?
hyponatremia
how does oxytocin cause hyponatremia?
can act as a vasopressin analog and stimulate the collecting ducts
of trichomonas, gardnerella and candida, which vaginosis occurs with normal pH? what is normal ph?
candida…3.8-4.5
what is difference in superficial wound dehiscence and deep wound dehiscence?
deep involves the rectus fascia and is a surgical emergency whereas superficial is just subcutaneous tissue and is managed with regular dressing changes
what is a sign for primary ovarian insufficiency?
no bleeding with progesterone withdrawal
what are some risks for primary ovarian insufficiency?
cancer drugs, radiation, Turner, fragile X carrier
what bHCG levels indicate a molar pregnancy?
greater than 100,000 IU/L
what are some risks for postpartum urinary retention?
epidural is number 1, laceration, assissted vaginal delivery, c sxn
define post partum irinary retention?
6 hrs post op no void
what is a common cause of postpartum urinary retention?
pudendal nerve injury
what determines which pill to give in hormone replacement for menopausal symptoms?
if there is a uterus or not
if menopausal woman has uterus what do you give?
estrogen and progestin
if menopausal woman doesnt have uterus what do you give?
estrogen only
at what age are endometrial cells on pap smear concerning? what is next step?
45+…need to biopsy the endometrium because there may be hyperplasia or cancer
in addition to tampon use, what is another case for females to get toxic shock syndrome from staph a?
post delivery or surgical incision repair
what is rx for toxic shock syndrome?
clindamycin and vancomycin
what are signs of toxic shock syndrome?
macular rash including hands and feet with high fever and hypotension
what are risks to fetus with chorioamnionitis?
preterm birth, pneumonia, encephalopathy
what are the signs in mom with chorioamnionitis?
fever with tachycardia or leukocytosis or purulent amniotic fluid
what is lactational mastitis? who gets it?
moms with first pregnancy over 30 yo…staph A gets into the breast
what are sx of lactational mastitis?
fever, malaise, tenderness an erythema
what is a complication of lactational mastitis?
breast abscess
how do you dx lactational mastitis and breast abscess?
US
how do you treat lactational mastitis?
dicloxacillin or cephalexin
how do you treat a breast abscess?
drainage
mom with GBS has penicillin allergy, what is option for rx?
cephazolin
are NSAIDs used in pregnancy>
typically not
what is the first stage of labor?
onset contractions until cervix fully dilated
what is full dilation of cervix?
10 cm
what are the two parts of the first stage of labor?
latent and active phase
what is the latent phase of the first stage of labor?
cervix going from 0-6cm dilation
what is the active phase of the first stage of labor?
cervix going from 6 cm to 10 cm dilated at 1cm/2hr
what is first line treatment for acute cystitis of asymptomatic bacteruria in pregnancy?
nitrofurantoin…
what should you do in follow up with patient who had either acute cystitis or asymptomatic bacteruria in pregnancy?
another urine culture in a couple weeks
where is bartholin duct cyst located?
posterior vaginal introitus, posterior to labia majora
/what are sx of bartholin duct cyst?
soft mobile non tender cystic mass
what is a complication of a bartholin duct cyst?
development of infected abscess
three conditions that increase risk for preeclampsia?
SLE, chronic HTN, diabetes and twins
what should be done at first prenatal visit with a patient at higher risk of developing preeclampsia
go ahead and get a baseline urine protein 24 hours
what is the main difference between a breast abscess and inflammatory breast cancer?
cutaneous edema and skin dimpling are seen in inflammatory breast cancer
what is active phase protraction?
when cervix is dilating less than a cm every 2 hrs btween hrs 4 and 8 of labor
what is a common cause of active phase protraction?
cephalopelvic disproportion
what is cephalopelvic disproportion?
head too big for moms pelvis
what are some other risk factors for active phase protraction?
advanced maternal age
obesity
excessive wt gain
inadequate contractions
what is vaginal hematoma? when does it occur? why?
bleeding from injured uterine arteries during delivery
what are the signs of vaginal hematoma?
low bp, tachy, vaginal mass, minimal bleeding
where does bleeding occur in vaginal hematoma?
paravaginal space…so it is occult bleeding
what are two risks for vaginal hematoma?
operative vaginal delivery and large baby (8.8lbs)
if patient develops significant proteinuria and elevated creatinine prior to 20 weeks gestation what is most likely underlying cause?
not preeclampsia…most likely is underlying renal pathology like diabetic nephropathy
what are two treatment options for stress urinary incontinence?
urethral sling and pelvic floor exercises
what is aromatase deficiency?
when female karyotype cannot convert testosterone into estrogen
what are signs of aromatase deficiency?
normal internal female genitalia with external virilization, normal XY karyotype, low estrogen
what are lab values of FSH/LH and estrogen in puberty with aromatase deficiency?
high FSH and LH low estrogen
what happens in pregnancy to mom with aromatase deficiency?
she can be masculinized
are vaginal petechiae a common menopausal exam finding?
yes..
what is the test to determine dose of rhogam to give mom?
Kleihauer Betke test
how do you manage delivery of fetus that is non viable? what about if pre term?
you focus on the well being of the mom…allow for delivery to occur spontaneously because this is safest to mom…even if it is preterm
what testing should be done to fetus with intrauterine fetal demise?
autopsy and genetic testing
what testing should be done to mom in intrauterine fetal demise?
Kleihauer Betke test and antiphospholipid antibody screen
other than mom and fetus, what else should be checked in intrauterine fetal demise?
placenta
what are some risks for uterine atony?
prolonged labor, assisted delivery, macrosomia, retained placenta
what are signs of uterine atony?
PPH and enlarged soft boggy uterus
what is first line rx for uterine atony
massage and oxytocin
what is second line rx for uterine atony?
trenaxemic acid
clear cervical mucus is what?
mucus associated with ovulation
what happens if epidural is accidentally put into vasculature?
get CNS overactivity…can be fatal
what are signs of epidural accidentally put into vasculature?
perioral numbness
metalic taste
tinnitus
seizures
how long after delivery must one go without voiding to have postpartum urinary retention?
6hrs
what is rx for postpartum urinary retention?
foley catheter
what is level of thrombocytopenia that is normal in pregnancy?
100-150
what level of thrombocytopenia in pregnancy is concerning for preeclampsia or HELLP?
100 or less
what is a luteoma in pregnancy?
solid mass of ovaries that is stimulated by hcg and secretes androgens
what can happen to mom and fetus with luteoma in pregnancy?
virilization
what is a theca lutein cyst in pregnancy?
uni or bilateral cyst of ovary stimulated by hcg
what can happen to mom with theca lutein cyst in pregnancy>
virilization
what is main difference between theca lutein cyst and luteoma in pregnancy?
luteoma is SOLID
what is rx for theca lutein cyst and luteoma in pregnancy?
watchful waiting
what is treatment of cornual ectopic pregnancy?
not methotrexate…need to do surgery to minimize risk of rupture
what are some contraindications to methotrextate therapy for ectopic pregnancies?
breastfeeding
anemia and immunosuppression
pulmonary disease
hepatic or renal disease that would affect clearance
what level hcg do you want to start methotrexate therapy for ectopic?
LESS than 5000
what is reversal agent of Mg?
Ca2+
what is treatment for eclampsia?
immediate Mg and c sxn
what is treatment for preeclampsia with severe features?
Mg and induced delivery
what should fibrinogen levels be in pregnancy?
elevated
what should D dimer level be in pregnancy?
elevated
what two lung volumes change in pregnancy?
increased tidal volume and decreased FRC
what is a PUBS test? what does it test for?
percutaneous umbilical blood sampling for fetal anemia
what is a TCD test ? what does it screen for?
transcranial doppler that screens for fetal anemia
what is an indication to perform either a trans cranial doppler or a PUBS?
if you think theres a chance of alloimmunization
when can CVS be performed?
10 weeks and after
when can amniocentesis be performed?
16 weeks and after
when can PUBS be performed?
between 20 and 34 weeks
what is the rule with ultrasound dating in each trimester?
1st tri +- 1 week
2nd tri +- 2 weeks
3rd tri +- 3 weeks
what is preventative med used for migraines in prgenancy?
propanolol
are triptans or ergotamine used for migraine abortion in pregnancy?
NO
what is reason for increased migraines in pregnancy>
increases stressors and changes to daily routines
what is reason for increased migraines in childbearing age but nor pregnant?>
estrogen and progesterone cycling
what two hormones are elevated in PCOS?
estrogen and testosterone
what does estrogen elevation in PCOS put patients at risk for?
endometrial hyperplasia and cancer
what is percentile cutoff for fetal growth restriction?
less then 10% for gestational age
what is growth restriction in first trimester called?
symmetric growth restriction
what is growth restriction in second or third trimester called?
asymmetric growth restriction
what are common causes of symmetric growth restriction in 1st tri?
infections and aneuploidy
what are common causes of asymmetric growth restriction in 2nd and 3rd tri?
placental insuff like HTN and diabetes
and
maternal malnutrition
what test is done to confirm a vesicovaginal fistula?
bladder dye testing
high prolactin levels during breatfeeding do what to levels of FSH and LH?
cause them to decrease because prolactin inhibits release of GnRH
low levels of FSH and LH during breastfeeding can cause what with women?
low estrogen so menopausal symptoms
what is issue in nonclassic congenital adrenal hyperplasia?
decreased actvity of 21-hydroxylase but not entirely absent
when does nonclassic congenital adrenal hyperplasia present?
usually in adolescence
what builds up on nonclassic congenital adrenal hyperplasia?
17-hydroxyporogesterone and androgens
what are signs ofn nonclassic congenital adrenal hyperplasia?
early pubic hair, bad acne, amenorrhea or oligomenorrhea in females
what four things in the quad screen for aneuploidies?
inhibin A, estriol AFP and hCG
what are levels of Inhibin A, AFP, hCG and estriol in downs?
inhibin A and hCG up
AFP and estriol down
what are levels of Inhibin A, AFP, hCG and estriol in T18/Edwards?
all down
what is rx for asymptomatic bacteruria in pregnancy?
amoxicillin
what is rx for asymptomatic bacteruria in pregnancy if mom is allergic to amoxicillin??
nitrofurantoin
what is rx for pyelonephritis in pregnancy?
ceftriaxone
what is management of pyelonephritis in pregnancy?
admit and give ceftriaxone then reasses
if mom has pyelonephritis and it isnt responding well to ceftriaxone, what should you look for? how?
look for an abscess with an ultrasound
what drug is used to treat hyperthyroid in pregnancy?
PTU
what drugs can be used to treat seizures in pregnancy?
lamotrigine and leviteracetam
what is BP goal in pregnancy?
140/80 or lower
what should you do with insulin after baby is delivered?
drop dose!!
what issue is associated with high blood glucose in first trimester?
transposition of the great vessels
what is Hbg cutoff for anemia in pregnancy?
10
what is hct cutoff for anemia in pregnancy?
30
if you are worried about alloimmunization, what test do you run?
transcranial doppler
what is fasting glucose goal in 3 hr GTT?
90
what is 1 hr glucose goal in 3 hr GTT?
180
what is 2 hr glucose goal in 3 hr GTT?
155
what is 3 hr glucose goal in 3 hr GTT?
140
what is rule about diagnosing gestational diabetes with the 3hr GTT?
3 or more values elevated means you have it
if twin fertilization occurs in 0-3 days what is result?
monozygotic, dichorionic and diamniotic
if twin fertilization occurs between 4-8 days what is result?
monozygotic, monochorionic, and diamniotic
what are monochorionic, diamniotic twins at risk for?
TTTS
if twin fertilization occurs at 9-12 days, what is result?
monozygotic, monochorionic, monoamniotic
what are monochorionic monoamniotic twins at risk for?
all baseline risks plus TTTS, cord entanglement and conjoined
if twin fertilization occurs 12+ days what is result
conjoined twins
if twins are different genders, what do we know we must have in terms of placenta and sac?
dichorionic and diamniotic…also dizygotic
what are the baseline risks of multiple gestations, no matter the sac and placenta status?
preterm birth, malpresentation and increased risk of PPH
3 risks of GBS in mom for delivery?
PPROM, preterm, and chorioamnionitis
when is first GBS screen in pregnancy?
week 10
if mom is GBS + in week 10 what does this mean?
no matter status at delivery you treat
what is first line rx for GBS?
ampicillin
if mom - at week 10 for GBs, when do you screen again?
36 week s
if moms GBS status is unknown at delivery, what do you do?
treat
what are three indications for GBS treatment in delivery aside from moms GBS status being positive or unknown?
prolonged rupture of membranes, intrapartum fever, previous pregnancy with GBS
what do you give for GBS if mom allergic to amoxicillin?
cefazolin
if cefazolin is contraindicated and amoxicillin, what can you give for GBS?
clindamycin or vancomycin
if mom hep B positive during pregnancy, how is delivery managed?
cxsn
what do we give baby if mom is hep B positive?
ivig and hep b vaccine
if HIV status is unknown at delivery, what do you do?
give AZT
if mom has HIV with low viral load and on meds, how do you deliver?
vaginally
if mom has high HIV load and not on meds, how do you deliver?
csxn
what two NRTIs are used in pregnancy?
tenofivir and emtricitabine
in addition to two NRTIs, what else should HIV + mom be on during pregnancy?
either a PI or NNRTI
what NNRTI is used in pregnancy?
neviparine
what PI is used in pregnancy for HIV?
atazanavir
3 things to look for in baby with toxo?
calcification,s ventriculomegaly and seizures
if mom does not have toxo ab on screening, what should she avoid?
cat feces and undercooked meat
what happens if syphilis passed in first tri?
dead baby
what happens to baby if syphilis passed later on in pregnancy?
snuffles, saber shins, hutchinson incisors, saddle nose
what is rx for tertiary syphilis in pregnancy?
IV penicillin for 7-10 days q
what are four signs of rubella in baby?
blueberry rash
cataracts
cardiac defects
deafness
what does mom look like with toxo and cmv infxn?
flu like illness
if baby gets HSV in pregnancy, what can happen?
IUGR, blindness
what is type of incisions for elective c sxn?
transverse under bikini line
what is type of incision for emergent c sxn?
vertical
what signifies a low risk for vaginal birth after c sxn?
less than 2 transverse c sxns prior
what signifies high risk for vaginal birth after c sxn?
2 or more c sxns prior or an emergent vertical c xsn
if mom is high risk for vaginal birth after c sxn what should be done?
planned c sxn
if mom is low risk for vaginal birth after c sxn, what should be done?
trial of labor
what are two indications for epiostomy?
big bby with small mom and preventing shoulder dystocia
what are the two types of epiostomies/
medial and medial lateral cuts
what is risk with medial epiostomy that medial lateral does not have?
further laceration into rectum
when do you put in cerclage? when do you remove it?
week 14 insertion week 36 removal
what type of anesthesia can you give during dilation?
paracervical block
a paracervical block during dilation can cause what in baby?
bradycardia
what can you give during stage II of labor for anesthesia?
pudendal nerve block
what is a common cause of cord compression?
rupture of membranes so cord gets pressed on
what is FHR tracing with cord compressions?
variable decels
if variable decels are occuring with more than 50% of contractions, what should be done?
reposition mom to try and alleviate the compression
what are the signs of false labor in a pregnant woman?
irregular contractions with no cervical change
what are signs of true labor in a pregnant woman?
regular painful contractions with cervical change
what are false labor contractions called?
braxton hicks contractions
what is a risk for chemical pneumonitis seen in L&D?
anesthesia for c sxn
what are signs of chemical pneumonitis?
low grade fever, hypoxia, pulmonary edema, and diffuse crackles
what is management of chemical pneumonitis?
supportive care…no abx indicated
what is aspirated in chemical pneumonitis?
gastric acid
what are some risk factors for amniotic fluid embolism?
advanced maternal age, gravida over 5, preeclampsia, placenta previa, c sxn
what are clinical signs of amniotic fluid embolism?
cardiogenic shock, respiratory failure, DIC, coma and seizures
what is rx for amniotic fluid embolism?
intubate and ventilate
what is initial evaluation of adnexal mass in premenopausal woman?
pregnancy test and ultrasound
what do you ultrasound an adnexal mass in a premenopausal woman in which the mass is likely physiologic?
because you need to rule out malignancy
what are the diagnostic criteria for cervical insufficiecny?
2 2nd tri losses that were painless
or short cervix with history of preterm
or cervical dilation in 2nd tri that is painless
how does uteroplacental insufficiency cause oligohydramnios?
lack of renal perfusion leads to decreased fetal urination
what is initial treatment of pyelonephritis in pregnancy?
IV broad spectrum abx
if patient improves on Iv broad abx with pyelonephritis, what are your next abx options?
can switch to whatever culture shows sensitivity to
what abx are safest in pregnancy for oral rx of improved pyelonephritis?
cephalosporins, penicillins and nitrofurantoins
what is therapy for dysfunctional uterine bleeding from anovulation that occurs intermestrual?
medroxyprogesterone or OCP tape or TXA
what is the main SE of medroxyprogesterone at high dose to treat AUB
depresssion
what is initial treatment of menorrhagia from fibroids? why does this work?
NSAIDs…prevent prostaglandin synthesis
how long can latent stage of labor last in nulligravid womam?
20 hrs
how long can latent stage of labor last in multigravid womam?
14 hours
how long can stage 2 of labor last in nullugravid woman?
3 hrs
how long can stage 2 of labor last in multigravic woman?
2 hrs
what is stage 3 of labor?
fetus out to placenta out
what is chemical change that leads to cervical dilation?
breaking of disulfide bonds
when is the active phase of stage 2 of labor considered arrested?
no change in cervix for four hours or takes longer than 5 hours
if you have issue with stage 3 of labor, what do you try first? then what?
massage then oxytocin then manual removal
if stage 2 is arrested of labor and baby in negative position what do you do?
csxn
if stage 2 is arrested of labor and baby in positive position what do you do?
forceps or vacuum
what are four options to help if latent phase of stage 1 is arrested?
balloon, amniotomy, misoprostol and oxytocin
what is PROM
premature ROM so rupture but no contractions
what is PPROM?
preterm premature ROM, no contractions
what is usual cause of PROM?
infection
what is usual cause of PPROM?
usually infection too
define prolonged ROM
18 hours or more from ROM to baby
what is risk with prolonged ROM?
infection into mom..chorioamnionitis and endometritis
what is rx for endometritis and chorioamnionitis?
ampicillin gentamycin and clindamycin
what should you not do for mom with endometritis?
culture vagina
PPH with absent uterus means what path?
uterine inversion
PPH with boggy uterus means what path?
atony
PPH with firm uterus means what path?
retained placenta
PPH with normal uterus means what path?
vaginal laceratoion
what should you do if PPH is unexplained and interventions arent working?
2 large bore IVs
in surgery for PPH, what are three rx options?
uterine artery ligation or embolization, hyst
what is rx for uterine inversion?
manual repositioning
if manual repositioning doesnt work in uterine inversion what do you do?
tocolytics then oxytocin
how do you diagnose retained placenta?
look at placenta and see if vessels run to edge…if they do then some is left in the uterus
what is risk of hydatiform mole?
gestational trophoblastic neoplasia
what is immediate rx for hydatiform mole?
D and C
what do you need to do after D and C for molar pregnancy?
follow hcg weekly until undetectable then follow monthly for 6 months
during 6 months of following hcg after a molar pregnancy, what should be given?
contraception
why give contraception after molar pregnancy?
so new conception doesnt interfere with the hcg monitoring
what is bloody show?
blood in active stage of labor that is from rapid cervical dilation
how to remove vaginal foreign body in prepubertal girl?
local anesthetic and warm irrigation
