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OB/GYN APGO - JD

Terms in this set (114)

Normal pregnancy, lower Hb, normal MCV, normal platelets
Relative hemodilution of pregnancy
26 weeks gestation, "Difficulty catching breath" for 2 months, normal labs
Physiologic dyspnea of pregnancy
Normal pH, low pCO2, low HCO3
Compensated respiratory alkalosis
34 weeks gestation, SOA

Increased IC, TV, minute ventilation
Decreased FRC, ERC, RV

What is best next step in evaluation?
Routine antenatal care

(These changes are normal and cause respiratory alkalosis and subjective SOA)
28 weeks gestation with difficulty breathing, cough, frothy sputum. Admitted for preterm labor 24 hours ago. Lung crackles, normal Na and K. What caused lung Sx?
Pulmonary edema due to use of tocolytics (to suppress premature labor)
Changes in pregnancy:
- CO?
- SVR?
- Heart sounds?
- Increased CO by 33% (both HR and SV)
- Decreased SVR
- Systolic murmur in 95% due to increased volume
Colicky flank pain, hydronephrosis, no calculi. This is caused by compression of ureter by what (2)? Is hydronephrosis worse in R or L side and why?
- Uterus
- Right ovarian vein

- Worse on Right side b/c dextrorotation of uterus and cushioning of left ureter by sigmoid colon
Normal TSH, Free T4, Free T3
Elevated Total T4 and Total T3

Explanation?
Increased TBG due to increased circulating Estrogen
12 weeks gestation, "fleshy" tissue protruding through os, B-hCG = 1 million, u/s shows snowstorm pattern.

Dx?
Next step?
Molar pregnancy

Chest x-ray to look for metastasis (lungs most common site)
What is appropriate total weight gain during pregnancy for each BMI range:
- < 18.5
- 18.5 - 25
- 25 - 30
- > 30
- < 18.5 = 28-40 lbs
- 18.5 - 25 = 25-35 lbs
- 25 - 30 = 15 - 25 lbs
- > 30 = 11 - 20 lbs
What is the carrier rate for sickle cell trait in African Americans?
1/10
What is the definitive and preferable preconception screening test for blood abnormalities in African Americans?
Hemoglobin electrophoresis and CBC

- This can detect sickle cell, thalassemia, and hemoglobin C
What conditions should carrier screening be done for in Ashkenazi Jews (4)?

What about Mediterranean (at least 1)?
Fanconi anemia, Tay-Sachs, Niemann-Pick, Cystic Fibrosis

Beta thalassemia
(I would think G6PD also)
The non-hispanic white population has an increased carrier frequency of what?
Cystic Fibrosis
Valproic acid increases risk of what fetal abnormality?
Neural tube defects
Poorly controlled diabetes in mother would most likely cause what structural abnormalities in fetus (2)?
- CNS (NTDs)
- Cardiovascular abn
Chorionic villus sampling is performed at what weeks gestation? What could it detect?
10-12 weeks

Chromosomal abn, biochemical or DNA based studies (CF mutation)
What screening test has highest overall detection rate for Down Syndrome?

What about only in the 2nd trimester?
Sequential screen (93%):
- 1st trimester NT and PAPP-A
- 2nd trimester quad screen

Quad screen (85%)
What are the components of the quad screen? Which ones are elevated in Down Syndrome?
- B-hCG
- inhibin A
- AFP
- Estriol

- B-hCG and inhibin A (HI!!!)
What is the risk of miscarriage with chorionic villus sampling?

How does this change with prior miscarriage history?
1%

Does not change with miscarriage history
What is the most common form of inherited mental retardation?
Fragile X syndrome
What is the most reliable method of confirming gestational age if LMP and physical exam differ?
First trimester ob exam (b/w 14-20 weeks)
What would be the best course of action in patient with 3 abnormal values from oral glucose tolerance test?
Begin a diabetic diet and blood glucose monitoring
Gestational diabetes increases risk of what (5)?

Intrauterine growth restriction is seen in patients with what?
- Shoulder dystocia
- Metabolic disturbances
- Pre-eclampsia
- Polyhydramnios
- Fetal macrosomia

- Pre-existing diabetes
What is the recommended dose of folic acid for non-high risk patients?

What if woman with previous pregnancy with NTD?
0.4 mg/day

4 mg/day
Increased nuchal translucency is noted, what non-invasive testing could be used to exclude other abnormalities after 1st trimester?
Detailed u/s and fetal echocardiogram at approximately 18-20 weeks gestation
Which anticoagulant is okay during pregnancy?

Which is teratogenic?
Low molecular weight heparin

Warfarin
Late in pregnancy, lower abdominal pain, irregular contractions every 2-8 minutes
Braxton-Hicks contractions
Labor warnings:
- Contractions every ___ minutes for 1 hour
- Rupture 0f ___________
- Fetal movement less than ___ per ___ hours
- Vaginal _________
- Contractions every 5 minutes for 1 hour
- Rupture of membranes
- Fetal movement less than 10 per 2 hours
- Vaginal bleeding
If a patient is unsure if their membranes have ruptured then do a _______ exam with a _______ test
Speculum, nitrazine
If obtaining fetal heart rate externally is difficult b/c patient can't lie still, what should be done?
Use fetal scalp electrode
Mother in labor, fetal scalp visible, fetal heart rate drops to 60s. What should you do?
If not delivered with 1-2 pushes then assisted operative vaginal delivery (vacuum or forceps)
If an intrauterine pressure catheter (IUPC) is placed and significant blood and amniotic fluid is lost then what should you do? Why?
Withdraw catheter, monitor fetus then replace if tracing reassuring

You must rule out placenta separation or uterine perforation that could compromise fetus
What's the difference between early, late, and variable contractions?
Early happen before peak of contraction, late happen after peak of contraction, variable are irregular jagged/dramatic dips
What is the most common cause of variable decelerations in labor?

What is associated with late decelerations?

What is associated with early decelerations?
Variable: Umbilical cord compression

Late: Uteroplacental insufficiency

Early: Head compression
Define dilation, effacement, and station
Dilation: size of opening of cervix

Effacement: stretching and thinning of cervix

Station: refers to how far down baby's head has come into pelvis
What does a station 0 mean? Negative? Positive?
0: baby is settled into pelvis, but not started descent into birth canal

Negative (-3 to -1): Baby has dropped but not yet into pelvis

Positive (+1 to +3): Baby is heading toward cervix

(numbers are measurements of cm)
During labor you palpate a 5cm long section of umbilical cord in patient's vagina. What's next step?
Elevate fetal head with vaginal hand and perform C-section
How does routine use of episiotomy affect outcomes?
Insufficient data to recommend, it increases risk of incontinence, 3rd/4th degree lacerations, and anal incontinence
Flattened nasal bridge, small rotated/cup-shaped ears, sandal gap toes, hypotonia, protruding tongue, short broad hands, Simian creases, epicanthal folds, and oblique palpebral fissures suggests what abnormality?
Down Syndrome
Wide spaced nipples and lymphedema are associated with what condition?
Turner syndrome
Maternal pre-eclampsia (HTN and proteinuria) that is treated with magnesium could cause what most likely complication in infant?
Respiratory distress
Large babies are seen with what type of maternal diabetes? What about small babies?

What about sugar levels in infant?
Large: gestational diabetes
Small: type I diabetes

All newborns of diabetic mothers should be monitored closely for hypoglycemia
Maternal fever and fetal tachycardia with minimal variability suggests what?

What would the baby look like at delivery?
- Lethargic or vigorous?
- Pink or pale?
- High or low temperature
Chorioamnionitis

Lethargic, pale, with high temperature (septic infant)
Twins where one is much larger than the other could indicate what?

This is due to what?

How are donor and recipient twins each affected in size, fluid amount, and complications?
TTTS (Twin-twin transfusion syndrome)

Imbalance of blood flow in shared placenta

Donor:
- Smaller, oligohydramnios
- Anemia

Recipient:
- Larger, polyhydramnios
- Polycythemia
- Volume overload can lead to heart failure and hydrops
Infants born to diabetic mothers are at increased risk for:
- Hypo or hyper-glycemia?
- Polycythemia or anemia?
- Hyper or hypo-bilirubinemia?
- Hyper or hypo-calcemia?
- What respiratory issue?
- Hypoglycemia
- Polycythemia
- Hyperbilirubinemia
- Hypocalcemia
- Respiratory distress
Limp unresponsive infant with no respiratory effort is born to mother who used marijuana during pregnancy. What's first step?
Give positive pressure ventilation and prepare to intubate
HIV+ mother uses antiretroviral therapy prior to and during pregnancy. What should you do once baby is born?

When would you do HIV testing?
Treat infant with AZT immediately after delivery

HIV testing begins at 24 hours
Positive pressure ventilation in a newborn should include:
- Adjusting head to modified flex or sniffing position?
- Compressing bag until when?
- What minimum flow rate?
- Sniffing position (tilt neonate's head back and lift chin)
- Compress just until chest rise is seen
- Oxygen flow rate at minimum 10 L/min
What does APGAR stand for?
Activity (muscle tone)
Pulse
Grimace (reflex irritability)
Appearance (skin color)
Respiration
Describe 0, 1, and 2 point values for each section of apgar score.
Activity:
0 - Absent
1 - Arms and legs flexed
2 - Active movement

Pulse:
0 - Absent
1 - Below 100 bpm
2 - Above 100 bpm

Grimace:
0 - Flaccid
1 - Some flexion of extrematies
2 - Active motion (sneeze, cough, pull away)

Appearance:
0 - Blue, pale
1 - Body pink, extremities blue (acrocyanosis)
2 - Completely pink

Respiration:
0 - Absent
1 - Slow, irregular
2 - Vigorous cry
Post partum hemorrhage is most commonly caused by what? It is defined by blood loss greater than ___ mL in vaginal births or ___ mL in C-section
Uterine atony
500
1000
Mom who suffered postpartum hemorrhage one yr ago now has fatigue, forgetfulness, depression, difficulty staying warm, no milk production, hypotension, and amenorrhea.
Sheehan syndrome (significant blood loss causing anterior pituitary infarct)
Protracted labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of placenta manually and low socioeconomic status all increase risk for what?
Endometritis
What is the most common cause of postpartum fever?
Endometritis
Postpartum endometritis will most likely show what on bacterial isolates?
Polymicrobial (aerobic and anaerobic)

Staph and strep specifically
In addition to the more common symptoms of pregnancy, patients with postpartum depression are likely to experience what (2)?
- incapability of loving her family
- ambivalence toward infant
What is the most significant risk factor for postpartum depression?
Personal history of depression
What is the best way to suppress lactation in a woman who does not want to breastfeed?
Breast binding, ice packs and analgesics

Hormonal targets can increase risk of thromboembolic events
Breastfeeding decreases the risk of what cancer?
Ovarian cancer
During breastfeeding, if mother and baby aren't belly-to-belly what could develop in mother?
Bleeding and cracked nipples from poor positioning
What hormone is responsible for milk production?

After delivery, the inhibitory action of which hormones is lifted?
Prolactin

Estrogen and Progesterone
During breastfeeding, mom gets fever and red tender wedge-shaped area on outer quadrant of left breast.

Dx?
Treatment?
Mastitis (strep or staph)

Antibiotics, and if persistent then incision and drainage
Hospital policies that promote breast feeding are getting the baby on the breast within ___________ of delivery and providing ___________ access of mother to baby.
Half an hour

Unlimited (baby in mom's room)
What does mom produce for first 1-2 days after delivery? What does this contain? What happens after this period?
Colostrum
Protein and nutrients
Normal breast milk production (prolactin w/o E and P to inhibit)
Mom who is breastfeeding develops very sensitive sore nipples with burning pain in breasts that is worse when feeding. Tips of nipples are pink and shiny with peeling at periphery. What organism probably causes this?
Candida
(this is not classic mastitis)
What is a common side effect of depot medroxyprogesterone?
Weight gain
What type of birth control should you offer to someone who is breastfeeding?
One that doesn't contain Estrogen b/c it can decrease milk production. IUD's such as Mirena are progesterone only and are safe.
Signs that baby is getting sufficient milk include:
- ___ stools in 24 hours
- ___ wet diapers in 24 hours
- Weight gain
- Sounds of _____
- 3-4 stools
- 6 wet diapers
- Weight gain
- Sounds of swallowing
Engorgement can occur when milk comes in. Strategies that help are:
- (More/less) frequent nursing
- Applying (warm/cold) item
- (Massaging/resting) the breast
- Hand expressing some milk
- (Wearing/not wearing) a bra
- Taking _____ 20 minute before feeding
- More frequent nursing
- Applying warm compress or warm shower to enhance milk flow
- Massaging breast
- Hand expressing some milk
- Wearing a good support bra
- Taking an analgesic 20 minutes before feeding
Suckling stimulates what hormone? This is responsible for what?
Oxytocin
Milk ejection
Patient cramping and spotting, Hx of chlamydia, LMP 8 weeks ago, elevated B-hCG, no intrauterine pregnancy. What is next step?
Repeat B-hCG in 48 hours
How high should B-hCG be to see an early intrauterine pregnancy on ultrasound? What is this called?
2000 mIU/mL
Discriminatory zone
(shouldn't Dx ectopic pregnancy until B-hCG above this to r/o intrauterine pregnancy)
In normal pregnancy, B-hCG increases by _________ in 48 hours until pregnancy is ___ days old. Also, progesterone level is ______.
> 50%
42 days old
> 25
What is the MOA of mifepristone?
Progestin receptor antagonist
In ectopic pregnancy, B-hCG increases by ______ every 48 hours
less than 50%
What are the 3 criteria for ectopic pregnancy diagnosis? (only need 1 to diagnose)
1. Fetal pole outside uterus on u/s
2. B-hCG > 2000 but no intrauterine pregnancy seen on u/s
3. B-hCG increases by < 50% each 48 hours
Methotrexate can be used for Tx of ectopic pregnancy if following are true:
- _________ stability
- Non-_______ ectopic pregnancy
- Size < __ cm w/o fetal heart rate or < __ cm w/fetal heart rate
- Normal _______ enzymes and _____ function
- Normal _______ count
- Ability to ______ __ rapidly
- Hemodynamic
- Non-ruptured
- < 4 cm , < 3.5 cm
- Liver, renal
- WBC
- Follow up (reliable transportation)
What 3 things lead to Dx of ruptured ectopic pregnancy and therefore rapid treatment?
1. Hypovolemia (tachycardia, hypoTN)
2. Peritoneal signs (rebound, guarding, severe abd tenderness)
3. Positive pregnancy test
Severe Lupus in pregnancy is treated with what? What is used to treat associated arthralgia and serositis? What about to control skin manifestations?
Steroids
NSAIDs
Hydroxychlorquine
Breech presentation is a/w:
- (pre or post) term birth
- (first or multiple) gestation
- Genetic disorders
- (poly or oligo) hydramnios
- Hydrocephaly
- Anencephaly
- Placenta (previa or accreta)
- Uterine anomalies including _______
- Preterm birth
- Multiple gestations
- Genetic disorders
- Polyhydramnios
- Hydrocephaly
- Anencephaly
- Placenta previa
- Fibroids
Pregnant patient develops intense itching of arms, legs, feet. Also slightly yellow skin. Dx? Tx?
Cholestasis of pregnancy
Ursodeoxycholic acid
Premature ROM at 36 weeks, what is next step?
Augmentation of labor (high risk of chorioamnionitis if expectant management)
Rh(-) mother received RhoGAM last pregnancy, but now during second pregnancy she's discovered to be sensitive to the D antigen. What could be cause?
The amount of fetal maternal hemorrhage was more than previously estimated (normal dose only protects exposure to 30 cc blood)
C-section under general anesthesia secondary to cord prolapse. Next day develops fever, chills, with normal physical exam and u/a. What is next step? Why?
Chest x-ray
Lungs are most common source of fever on first postpartum day (atelectasis, aspiration pneumonia)
Postterm pregnancies are a/w:
- Placental _______ deficiency
- Fetal adrenal ___-plasia
- __-encephaly
- Inaccurate dating
- Placental sulfatase deficiency
- Fetal adrenal hypoplasia
- Anencephaly
- Inaccurate dating
What tocolytics are contraindicated in patients with diabetes (2)?
Contra in myasthenia gravis?
Contra late in pregnancy such as 33 weeks?
Contra in cardiac disease?
Terbutaline, ritodrine
Magnesium sulfate
Indomethacin (premature ductus arteriosus closure)
Nifedipine
What treatment for breast cancer should NOT be given to pregnant patients?
Radiotherapy
MOA of magnesium sulfate (tocolytic)
Competes with Ca for entry into muscle cells (blocks actin/myosin interaction)
MOA of terbutaline (tocolytic)
Increase cAMP in cell -> decreases free Ca
MOA of indomethacin (tocolytic)
PG synthetase inhibitor
MOA of nifedipine (tocolytic)
Calcium channel blocker -> prevent Ca entry into muscle cells
Why is C-section rate in US higher (3)?
- Less VBACs
- Fewer ob's willing to perform vaginal breech deliveries
- Many ob's don't use forceps or vacuum
Fetus at 35 weeks is < 10th percentile and biometry shows 30 week. The fetus is at increase for what (4)? What is it not at increased risk of (1)?
- Cardiovascular disease
- Chronic HTN
- COPD
- Diabetes

- NOT osteoporosis
Mother with preeclamsia, fetal heart tones 170s and sinusoidal pattern, bright red vaginal bleeding for last hour. What likely caused the bleeding?
Abruptio placenta
- Fetal anemia and mom w/preeclampsia
Macrosomia of diabetic mothers increases risk for:
- Birth ____ including shoulder _____ and _____ ____ injury
- (hypo/hyper) glycemia
- (hypo/hyper) bilirubinemia
- Birth trauma including shoulder dystocia and brachial plexus injury
- Hypoglycemia
- Hyperbilirubinemia
What are the 5 stages of grief (usually seen after fetal death)?
Denial
Anger
Bargaining
Depression
Acceptance

(DABDA)
Mother at 39 weeks with contractions every 4 minutes for 4 hours without change, what is next step?
Place an intrauterine pressure catheter (not clear if contractions are adequate)
Treatment with an anti-hypertensive is indicated for blood pressures persistently greater than __/__?
160/110
Severe pre-eclampsia treated with anti-hypertensive Rx tries to get diastolic pressure into what range?
90-100 mmHg
(to prevent maternal stroke or abruption w/o compromising uterine perfusion)
Fresh frozen plasma contains what (3)?

What is found in cyoprecipitate that is not in FFP?
Fibrinogen
Factor V
Factor VIII

vWF
Anterior placenta previa and Hx of 3 prior C-sections. What is most likely serious complication that can lead to obstetric hemorrhage in this woman?
Placenta accreta
Amniocentesis to Dx intra-amniotic infection, Dx is supported by:
- (Inc/Dec) IL-6
- (High/low) glucose

What other marker has the lowest predictive value?
- Increased IL-6
- Low glucose

- Amniotic leukocyte presence has lowest predictive value
What is most frequent cause of preterm labor? Name 2 other causes.
Idiopathic

- Dehydration
- Uterine distortion (fibroids, structural malformations)
What anti-HTN medication is contraindicated in pregnancy?
ACE-inhibitors
What anti-thyroid Tx is contraindicated in pregnancy?
Radioactive iodine
Post-op day 2 from C-section, develops fever for 3 days, IV Abx don't help, normal physical and u/a. What is next step? What is this to treat?
Heparin anticoagulation
Septic thrombophebitis
Ibuprofen is safe until what week of pregnancy? Then what does it increase risk of?
Week 32
Premature closure of ductus arteriosus
Smoking increases risk of:
- Placental _______
- Placenta ______
- Fetal _____ restriction
- ___-eclampsia
- Infection
- Placental abruption
- Placenta previa
- Fetal growth restriction
- Pre-eclampsia
- Infection
What is most reliable measurement of gestational age in first trimester?
Crown-rump length on ultrasound
What intervention early in pregnancy can reduce risk of preterm delivery of twins of low-birthweight?
Early, good weight gain
To stop post-partum bleeding, what drug can be given:
- IM?
- Rapid infusion of dilute solution?
- Orally or rectally?
- Prostaglandin F2-alpha (Dinoprost)
- Oxytocin (Pitocin)
- Misoprostol (Cytotec)
3 cm lesion on posterior lip of cervix, bleeds with palpation and hard in consistency. What is most likely Dx?
Cervical cancer
Tx for syphillis in pregnancy
Penicillin G
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