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EOR Exam - Women's Health > Obstetrics Part 1 > Flashcards

Obstetrics Part 1 Flashcards

1
Q

Define Chadwick Sign

A

Bluish discoloration of vagina and cervix seen in pregnancy

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2
Q

Define Goodell Sign

A

Softening and cyanosis of cervix at or after 4 weeks gestation

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3
Q

Define Ladin Sign

A

Softening of the uterus after 6 weeks gestation

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4
Q

Other than the three named signs of pregnancy, describe other signs and symptoms of pregnancy.

A

breast swelling/tenderness, linea nigra develops from umbilicus to pubis, telangiectasias (spider veins), palmar erythema, amenorrhea, N/V, quickening (fetal movement).

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5
Q

Describe cardiovascular changes seen in pregnancy.

A

30-35% inc in CO max at 20-24 weeks s/p inc in SV.
SVR and arterial BP inc s/p inc in progesterone
SBP (5-10) & DBP (10-15) dec that nadirs at 24 weeks
Inc in RBC mass and volume by 20-30%
Dec Hct s/p 50% inc in plasma volume
Hypercoagulability with no change in bleeding or clotting times
WBC inc to 20 million during labor

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6
Q

Describe gastrointestinal changes seen in pregnancy.

A

Nausea s/p inc estrogen, progesterone, and Hcg resolves by 16 weeks.
Reflux s/p delayed emptying and dec LE sphincter tone

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7
Q

Describe renal changes seen in pregnancy.

A

Inc pyelonephritis s/p inc in kidney size and dilated ureters.
GFR inc by 50%
RAAS inc with inc aldosterone but no inc in Na s/p inc in GFR.

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8
Q

Describe pulmonary changes seen in pregnancy.

A

Vt inc by 30-40%

TLC dec by 5% s/p pressure on diaphragm.

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9
Q

Describe endocrine changes seen in pregnancy.

A

Hyperestrogenic state
hCG x2 48 hours into pregnancy and peaks at 10-12 weeks then declines to steady state by week 15
Placenta produces hCG to maintain corpus luteum
CL produces progesterone to maintain endometrium
Prolactin increases
T3/T4 inc with slight early dec in TSH but overall patient remains euthyroid

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10
Q

Describe metabolic changes seen in pregnancy.

A

Caloric req inc by 300 during pregnancy
Caloric req inc by 500 during breast feeding
Patient should gain 20 - 30 pounds
Inc req for protein, iron, folate, and Ca

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11
Q

T/F: Pregnant patients see an increase incidence of carpal tunnel syndrome.

A

True –> compression on median nerve

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12
Q

Define melasma.

A

Brown or blue-gray patches (like freckles) on face during pregnancy

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13
Q

When should a patient with irregular menstrual cycles or unknown LMP be urine tested for pregnancy?

A

14 days after last intercourse to minimize possibility of false negative.

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14
Q

Why is a serum pregnancy test rarely used?

A

It is the most sensitive test but it is more expensive and results are not immediately available. A repeat urine test may substitute for serum test.

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15
Q

Define Naegle’s rule for determining due date.

A

LMP - 3 months + 7 days

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16
Q

Define gravida, parity, and TPAL.

A 
G = # total pregnancies
P = # of deliveries
TPAL = term, preterm, abortion, and live RE: P
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17
Q

Define the visit schedule for prenatal care.

A

First visit usually occurs 6-10 weeks gestation (6-8 weeks after LMP). Pt seen every 4 weeks until 32 weeks, every 2 weeks until 36 weeks, then weekly.

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18
Q

What should be included when obtaining an obstetric history of prior pregnancies from a currently pregnant patient?

A

Date, outcome (spontaneous/therapeutic abortion, ectopic, term, mode of delivery, time in labor, birth weight, any complications).

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19
Q

When is fetal movement expected to begin?

A

18-20 weeks in primigravida and 14-18 weeks in multigravida.

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20
Q

When should fundal height first be checked?

A

20 weeks - should be level of umbilicus

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21
Q

When should the clinician start assessing for cervical dilation?

A

36 weeks

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22
Q

What are the most accurate methods of estimating due date?

A

Most accurate = crown-rump length (best in 1st trimester). Transvaginal US better than abdominal US.

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23
Q

State milestones to note when assessing fetal development with sonogram?

A

Fetal yolk sac visible ~ 5 weeks then degrades by weeks 10-12
Fetal cardiac activity by week 6
2nd/3rd trimester rely on biometric markers –> biparietal diameter and head circumference.

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24
Q

List blood tests indicated during 1st trimester.

A

CBC, Hct, blood type, ab screen, RPR (syphilis), rubella ab, Hep B surface antigen, UA and culture, varicella ab, PPD.

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25
Q

Describe nuchal translucency screening.

A

Performed at 10-13 weeks for trisomy, 13, 18, 21, and Turner Syndrome. Measures thickness of fluid build-up at back of fetus’ neck. If wide measurement then amniocentesis or chorionic villus sampling done.

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26
Q

List three common tests performed in the second trimester of pregnancy.

A

Maternal Serum Alpha Feto-Protein (MSAFP) to test for neural tube defects and Downs
US at 18-20 weeks
Amniocentesis when prenatal Dx needed/desired

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27
Q

Differentiate tripple testing from quad testing of MSAFP.

A 
3 = B-hCG, estriol, and MSAFP
4 = B-hCG, estriol, MSAFP, ansd inhibin A
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28
Q

What second semester serum testing results indicate trisomy 21 risk? Neural tube defect risk?

A

T-21: inc inhibin A and dec unconjugated estriol, and dec AFP
NTD: inc AFP

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29
Q

What are the indications to perform an amniocentesis at 15-18 weeks gestation?

A

Adv maternal age, family Hx or previous child with chromosomal abnormality, abnormal serum screening test or US, prior loss of 2 pregnancies.

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30
Q

What is done during weekly exam visits after 36 weeks to decrease the risk of the need to induce labor?

A

Stripping and sweeping of membranes during cervix exam.

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31
Q

What tests are commonly performed during the third trimester

A

PO GLC challenge
Group B Strep
Antiviral prophylaxis at 36 weeks if latent HSV
Gonorrhea/Chlamydia vag culture repeated if high risk

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32
Q

Describe the procedure for a glucose tolerance test.

A

Fasting GLC challenge then obtain BGL 1 hour later. If > 130, then do fasting 100g challenge and obtain BGL at 1, 2, and 3 hours. Diagnosis requires more than 1 value out of range.

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33
Q

Describe parameters for monitoring fetal heart rate.

A

Non-stress test (NST) baseline HR should be 120-160. Normal is to see 2 accels 15 bpm above baseline for 15 sec. Persistent late decels defined as HR dec of 15 for more than 15 sec or delayed return to baseline.

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34
Q

What is the purpose of a biophysical profile (BPP) and what are the parameters tested?

A

Measures health of the fetus during pregnancy. Parameters tested = NST, amniotic fluid level, gross fetal movements, fetal tone, fetal breathing. Each parameter scores up to 2 points –> risk of asphyxia rises as score rises.

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35
Q

Describe how the measured height of the uterine fundus correlates to gestation.

A

pubic symphysis = 12 weeks
between symphysis and umbilicus = 14-16 weeks
umbilicus = 20 weeks
from umbilicus to xiphoid = 2 cm per week
just below xiphoid = 36 - 38 weeks
slight descend below xiphoid = 38 weeks to term

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36
Q

What is the frequency of multiple gestation?

A

1 in 80 births

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37
Q

Differentiate between monozygotic and dizygotic twins.

A

Mono: aka identical (same genetic material) –> fertilization of single egg that splits into 2 –> always same sex.
Di: aka fraternal –> fertilization of two separate eggs in same pregnancy

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38
Q

How do maternal symptoms differ in multiple gestation.

A

Symptoms are the same but more severe, typically requiring more frequent prenatal visits.

39
Q

Describe fetal transfusion syndrome and state when it most commonly occurs.

A

Occurs in monzygotic twins that share the same placenta (monochorionic). One twin may receive more blood supply than the other leading to discordant growth and problems for both twins.

40
Q

What are common maternal and fetal complications associated with monochorionic pregnancy?

A

Maternal: spontaneous abortion and preterm birth, preeclampsia, anemia
Fetal: intrauterine growth restriction, cord accidents, death of one twin, congenital anomalies, breech presentation, placental abruption or previa

41
Q

Multiple gestations, in general, are at risk for what complications?

A

preterm labor, placenta previa, postpartum

hemorrhage, pre-eclampsia, cord prolapse, malpresentation, and congenital abnormalities

42
Q

Which type of twins occurs s/p genetic predisposition and which occurs randomly?

A

Genetic: dizygotic
Random: monozygotic

43
Q

Differentiate between mo-mo, mo-di, and di-di twins.

A

mo-mo: single placenta/chorion, single amnion
mo-di: single placenta/chorion, 2 amnions
di-di: two placenta/schorions, and amnions

44
Q

What are the stages of the Quintero system for staging twin-twin transfusion syndrome (TTTS)?

A

1: oligo/poly-hydraminos, normal umbilical doppler flow, bladders visualized in both fetuses.
2: bladder of donor fetus not visualized
3: abnormal doppler flow in either fetus
4: either fetus shows signs of hydrops
5: death of one or both fetuses

45
Q

Describe the expected delivery of twins based on presentation.

A

both vertex - deliver vaginally
vertex/non-vertex - vaginal delivery possible
both non-vertex - C-section required
mo/mo - C-section required

46
Q

Define hydrops fetalis.

A

Excess buildup of fluid in 2 or more fetal body areas.

47
Q

When and how is TTTS managed?

A

Managed at stages 2-4 by fetoscopic laser ablation of placental anastomoses.

48
Q

What recommendations for mother’s of twins during pregnancy differ from a single fetus pregnancy?

A

Weight gain of 37 - 54 pounds
Take 1 prenatal vitamin with iron in 1st trimester
Take 2 prenatal vitamins with iron in 2nd and 3rd tri’s
Exercise as tolerated
Supplement with 1mg of folate and 1g of vitamin D
More frequent US
Sleep on left side in 2nd and 3rd tri’s

49
Q

T/F: Pregnant patients should be encouraged to take laxatives to manage constipation.

A

False –> laxatives can induce labor in 3rd trimester

50
Q

State 5 risk factors for spontaneous abortion.

A

smoking, infection, maternal systemic disease, immunologic parameters, drug use

51
Q

Compare findings for threatened, inevitable, incomplete, complete, and septic abortion.

A

Threat: vag bleeding, cervix closed, no tissue passage
Inev: vag bleeding, cervix open, no tissue passage
Inc: vag bleeding, cervix open, some tissue passed
Comp: vag bleeding, cervix closed, all tissue passed
Septic: Open cervix with purulent discharge, no or incomplete passage of tissue

52
Q

Describe the pathophysiology and management of Rh incompatability.

A

Rh negative mom becomes sensitized and produces Rh antibodies then becomes pregnant with an Rh positive fetus. Can cause hemolytic disease of the neonate. Managed by prevention - RhoGAM administered to Rh negative mother to prevent sensitization to to Rh antigen.

53
Q

Define ectopic pregnancy and state the most common cause.

A

Implantation of pregnancy anywhere but endometrium - fallopian tube most common (95%). Most common cause is occlusion of tube s/p adhesions.

54
Q

State five risk factors for extopic pregnancy.

A

Previous ectopic, salpingitis (s/p PID), abdominal or tubal surgery, IUD use, assisted reproduction.

55
Q

Define salpingitis.

A

Inflammation of the fallopian tubes

56
Q

State the common S/S of ectopic pregnancy.

A

unilateral adnexal (pelvic) pain, amenorrhea, spotting, tenderness or mass on pelvic exam, syncope, dizziness, GI distress. If ruptured –> severe LQ abdominal pain or shoulder pain, peritonitis, tachycardia, orthostatic HypoTN

57
Q

How is ectopic pregnancy diagnosed?

A

Serial increases in hCG less than expected - > 1500 should show intrauterine gestation on US. Transvaginal US is > 90% sensitive for diagnosis.

58
Q

How is ectopic pregnancy managed?

A

Methotrexate if stable and no contraindications
Surgery if emergent or methotrexate C/I
Follow up testing is crucial

59
Q

What is the MOA of methotrexate?

A

Folic acid antagonist that inhibits DNA replication - inhibits cell growth and terminates pregnancy.

60
Q

What are the indications for use of methotrexate in ectopic pregnancy?

A

hemodynamically stable, hCG < 5000, mass < 3.5cm, no fetal cardiac activity, able to compy with post-treatment follow-up

61
Q

What are the contraindications to methotrexate in ectopic pregnancy?

A

Breastfeeding, active pulmonary disease, immunodeficiency, hypersensitivity

62
Q

Define and state the disease states in the category of Gestational Trophoblastic Disease and state the risk factors.

A

Def: abnormal chorionic villi proliferation
Hydatidiform moles, placental-site invasive moles, trophoblastic tumors, choriocarcinomas.
R/F = advanced maternal age, previous mole

63
Q

What are the S/S of a complete and partial molar pregnancy?

A

Comp: no viable fetus, abnormal vag bleeding, uterine size > gestational age, hyperemesis gravidarum, HTN in first 20 weeks, snowstorm pattern/vesicles on US
Part: fetus is present but non-viable

64
Q

How is a molar pregnancy diagnosed?

A

hCG > 100,000 and persistently elevated, snowstorm vesicles on US s/p swelling of chorionic villi.

65
Q

Describe the treatment of molar pregnancy.

A

benign/low-risk: chemotherapy
high-risk: chemo with radiation or surgery
surgery involves suction curettage if desired to preserve fertility or hysterectomy if not.
Monitor with serial hCG to assure return to baseline
Contraception recommended for 6-12 months

66
Q

What non-obstetric test should be done following diagnosis and treatment of molar pregnancy?

A

CXR - trophoblastic tumors metastasize to lung, liver, and brain

67
Q

What is the best method to monitor for recurrent gestational trophoblastic disease (GTD)?

A

Serial hCG testing - 20% of patients retain trophoblastic tissue even after dilation and curettage

68
Q

Describe placental site trophoblastic tumors.

A

Malignant tumors that typically occur after a non-molar abortion or pregnancy.

69
Q

What are characteristic S/S of placental site trophoblastic tumors?

A

very low, but persistent levels of hCG. Dx months to years after pregnancy. Present with abnormal uterine bleeding and pelvic pressure. Pelvic US shows intrauterine mass that may invade myometrium.

70
Q

What is the treatment for placental site trophoblastic tumors?

A

Hysterectomy if fertility preservation is not desired

Tumors generally resistant to chemotherapy

71
Q

Define the various types of placenta previa.

A

Complete: placenta completely covers internal os
Partial: placenta covers part of internal os
Marginal: edge of placenta reaches margin of os
Low–lying: in close proximity but not extending to os
Vasa-previa: fetal vessel may lie over cervix

72
Q

Describe the pathophysiology of placenta previa.

A

Small disruptions in placental attachment cause bleeding in 3rd trimester. May stimulate further uterine contractions leading to further placental separation and bleeding.

73
Q

Define and describe placenta accreta.

A

Superficial attachment of placenta to uterine myometrium. Causes profuse hemorrhage s/p inability of placenta properly separate from uterine wall after delivery.

74
Q

What is the major complication associated with placenta accreta.

A

3-5 L blood loss –> 2/3 women require hysterectomy at time of delivery, esp s/p uterine atony.

75
Q

Define placenta increta and percreta.

A

Increta: placenta invades myometrium
Percreta: placenta invades through myometrium to uterine serosa

76
Q

What fetal complications are associated with placenta previa?

A

Preterm delivery, PROM, intrauterine growth restriction, malpresentation, vasa previa, congenital abnormalities

77
Q

What is the cardinal sign of placenta previa?

A

Painless vaginal bleeding after 28 weeks gestation.

78
Q

What are the S/S of accreta and increta?

A

Usually asymptomatic

79
Q

What are the risk factors for placenta previa?

A

prior C-section, multiple gestations, multiple induced abortions, advanced maternal age

80
Q

What testing is contraindicated in the presence of placenta previa?

A

digital exam –> can cause further separation

81
Q

How is placenta previa diagnosed?

A

US - transvaginal preferred over abdominal

May give false positive s/p full bladder

82
Q

What tretament is recommended for placenta previa?

A 
Pelvic rest (no intercourse) and modified bed rest
Type and screen (may req transfusion)
C-section is preferred delivery
RhoGAM if mother is Rh negative
Delivery at 34-37 weeks may be optimal
83
Q

What is the treatment for increta, accreta, and percreta?

A

C-section scheduled 34-37 weeks with planned simultaneous total hysterectomy.

84
Q

What are the most common complications associated with placenta previa?

A

hemorrhage, preterm labor with rupture of membranes, and fetal malpresentation

85
Q

What is the most common cause of 3rd trimester bleeding?

A

Placental abruption

86
Q

Define placental abruption and state when it most commonly occurs.

A

Premature separation of placenta from uterine wall after 20th week resulting in hemorrhage between uterine wall and placenta. Half occur between 30th week and onset of labor.

87
Q

List 6 risk factors for placental abruption.

A

hypertension, cocaine use, trauma, multiparity, smoking, history of abruption.

88
Q

What are the S/S of placental abruption?

A

30% are asymptomatic –> 3rd trimester bleeding with severe abdominal pain and/or frequent, strong contractions, increased uterine tone, fetal distress.

89
Q

Define couvelaire uterus.

A

Life threatening condition in which bleeding s/p abruption infiltrates the myometrium and penetrates into the peritoneal cavity. Uterus will demonstrate a bluish-purple tone on C-section.

90
Q

Describe the use of US in diagnosing placental abruption.

A

Dx is clinical –> negative findings on US do not rule out abruption. Diagnosis is confirmed upon inspection of placenta after delivery.

91
Q

Describe the treatment of placental abruption.

A

Stabilize hemodynamics –> fluids/blood products

Prepare for preterm delivery –> emergent if bleeding is life threatening or fetal testing is concerning.

92
Q

Describe the pathophysiology of the most severe maternal complication of placental abruption.

A

Severe hemorrhage leading to DIC. Abruption results in intravascular and retroplacental coagulation resulting in depleted platelets, fibrinogen, and clotting factors. This results in thrombocytopenia and hypofibrinogenemia along with increased INR and PTT.

93
Q

What indicates the need for blood products in resuscitation of lacental abruption?

A

Obtain labs early - thrombocytes, fibrinogen, INR, PTT. Abnormalities should be replaced via transfusion with platelets and fresh frozen plasma.

EOR Exam - Women's Health (7 decks)

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