Exam 4

Question 1

physiologic anemia

Answer 1

increase in plasma volume in contrast to the red cell mass results in decreased hemoglobin, hematocrit, and red cell counts during pregnancy.

Question 2

diagnosis of anemia in pregnancy

Answer 2

first - less than 11
second less than 10.5
third- less than 11

Question 3

causes of anemia

Answer 3

iron deficiency is the most common
MCV less than 80 is indicative of microcytic
MCV more than 100 is indicative of macrocytic anemia
MCH normal is 27-32
hypochromic is less than 27
serum ferritin to assess iron stores

Question 4

iron supplementation

Answer 4

30-60mg in all pregnant women

in IDA, an extra 60-120 is recommended

Question 5

iron deficiency numbers

Answer 5

MCV less than 80, but may be normal
MCH less than 27, but may be normal
Ferritin less than 12!!! (the only one with this)

Question 6

thalassemia numbers

Answer 6

MCV less than 80
MCH less than 25-27
ferritin NORMAL
thallasemia major has increased production of RBCs (only one)

Question 7

Hemoglobin S

Answer 7

sickle cell trait!!
one hemoglobin is A, one is S (AS)
maybe no symptoms.. maybe an increased risk for preclam, LBW, and PP endometritis, also more UTIs
SCD: hydrate, avoid cold, decrease stress, SCD needs 5mg folic acid

Question 8

Thalassemia

Answer 8

differential diagnosis in people with hypochromic, microcytic anemia. MCH under 25 could be intermedia or major
5mg folic acid daily

Question 9

Folate deficiency

Answer 9

folate deficiency associated with anemia, placental abruption, pregnancy loss, and neural tube defects.
look at vitamin B 12 too- similar symptoms

Question 10

vitamin B12 deficiency

Answer 10

levels decrease steadily throughout pregnancy
increased risk of birth defects such as neural tube
symptoms are a change in bowel habits, diarrhea, constipation, fatigue, SOB, and loss of appetite. red tounge or bleeding gums could also happen

MACROCYTIC anemia

Question 11

meds that cause thrombocytopenia

Answer 11

ASA, acetaminophen, indomethacin

antibiotics: ampicillin, PCN, bactrim

Question 12

gestational thrombocytopenia

Answer 12

mid second to third trimester
CBC and smear
<100 probably ITP, less than 50, definitely
if sudden in third trimester.. think PEC stuff
risk of bleeding minimal
check weekly platelets as early as 34 weeks
pp- check platelets at 1-3 months

Question 13

DVT

Answer 13

d dimer not helpful
calf swelling, pain
warfarin crosses placenta

Question 14

PEP/PUPS
polymorphic eruption of pregnancy
pruritic urticarial papule and plaques of pregnancy

Answer 14

rash along the ABDOMINAL STRIAE
HALO around the umbilicus
no specific test, clinical findings
will want to rule out PG by doing immunopathologic testing
rule out intrahepatic cholestasis by doing bile acids
no RISKS

Question 15

PP

Answer 15

eczema of pregnancy 
may be underlying, may be cholestasis 
extensor surfaces of arms, leg, abdomen. 
topical corticosteroid
NO risk

Question 16

PF

Answer 16

very rare 
rule of PG andn PEP 
papules, pustules around hair follicles, starts on trunks and extends to extremities
if no itching, no need to treat
NO risk

Question 17

PG (HG)

Answer 17

NOT herpes
severe itching, papules in periumbilical region, extremeties
usually not on face, palms, soles, MM
have tense blisters
patho: autoimmune, IgG attacks a hemidismosome transmembrane protein
BIOPSY
pre-blistering stage do steriods
prednisone
oral contraceptives can cause flare
RISK: increased risk of SGA, some newborns may have lesions
MFM collab

Question 18

ICP

intrahepatic cholestatis of pregnancy

Answer 18

bile acids build up in skin
risk: twin pregnancies, history of ICP
lots of itching, worse at night
higher bile acids
ursodeoxycholic acid not FDA approved, but use
complications: none with mom, premature birth, fetal discress, IUFD,
MFM collab

Question 19

treatments for common derm things

Answer 19

acne: topical antibiotics, peroxide, laser therapy, maybe salicylic acid
fungal: topical imidazole, not oral azole meds (associated with miscarriage)

Question 20

early pregnancy loss

Answer 20

80% in first trimester
considered less than 20 weeks or when fetus is less than 500g
Rhogam 48-72 hours after onset of bleeding whether pregnancy continues or not
less than 12 weeks, give 50. more than that give 300

Question 21

late pregnancy loss

Answer 21

greater than 20 weeks, less than 400g
birth defects, placental problems, growth restriction, infection
misoprostol before 28 weeks, pit after
evaluation: autopsy, placental pathology, fetal karyotype, KB test on mother, coombs test,
perinatal death- early, late, or neonatal death

Question 22

Recurrent pregnancy loss

Answer 22

greater than 3 losses before 20 weeks

Question 23

hypothalmic- pituitary- thyroid network

Answer 23

negative feedback
hypothalamus responds to circulating levels of t3 and t4
if levels are rising, it signals to decrease TSH
if t3 and t4 are decreasing, it will make TRH, which will increase amount of TSH

Question 24

TSH values

Answer 24

first 0.1-2.5
second 0.3-3.0
third- 0.3-3.0

Question 25

hypothyroidism symptoms

Answer 25

weight gain 
cold intolerance
fatigue 
depression 
constipation 
dry skin, thin hair 
\+++ when well-managed, maternal and neonatal outcomes are the same was without thyroid disease

Question 26

hypothyroid labs

Answer 26

TSH will be elevated (between 2.5 and 10) and t4 will be decreased
antithyroid antibodies

Question 27

hypothyroid surveillance

Answer 27

no need for antenatal surveillance when hypothyroidism is being treated and is well-controlled
TSH rechecked every 4-6 weeks during the first 20 weeks of gestation, again between 26 and 32 weeks
return to pre-pregnancy dose of levo post-partum and have level rechecked at 6 weeks

Question 28

treatment

Answer 28

treated when between 2.5-10
levothyroxine started at 25-50
might need higher doses in pregnancy because of increased metabolic demand

Question 29

subclinical hypothyroidism

Answer 29

elevated TSH without elevated t4… make sure it does not progres to overt, draw labs..

Question 30

Screen if..

Answer 30

history of thyroid dysfunciton 
older than 30 
morbidly obese 
miscarriage or preterm birth 
diabetes 1 or autoimmune disorder 
head or neck radiation 
family history 
infertility 
area without iodine

Question 31

hyperthyroid in pregnancy

Answer 31

suppression of TSH, elevation of T4
(conception is very hard!)
higher rate of SAB, LBW, stillbirth, neonatal mortality
enlarged thyroid is almost always present

Question 32

hyperthyroid labs

Answer 32

TSH very low (maybe undetectable), T4 is very elevated

Question 33

Hyperthyroid treatment

Answer 33

propylthiouracil and methimazole, PTU in first trimester (bad effect on liver) and MMI in second trimester

Question 34

hyperthyroid surveillance

Answer 34

fetus should be monitored for thyroid dysfunction by periodic US to determine if there is evidence of thyroid enlargement, growth restriction, hydrops, tachycardia, or heart failure

Question 35

postpartum thyroididitis

Answer 35

no signs or symptoms prior to pregnancy

hyperthyroid, then hypo

Question 36

anemia again..

Answer 36

Microcytic: Iron deficiency, thalassemias
Macrocytic: folate and B12
MCH isues: thallesemias
ferritin: only iron deficiency is an issue.. will be less than 12!!!
thalassemia major is the only one with increased production of RBCs

Question 37

antibiotics not for pregnancy

Answer 37

no fluroquinolones no doxycycline

Question 38

respiratory changes in pregnancy

Answer 38

increased gas exchange
respiratory rate remains the same
increase in tidal volume and resting minute ventilation
decreased functional residual capacity
progesterone stimulates respiratory drive
compensated respiratory alkalosis

Question 39

meds causing asthma exacerbation

Answer 39

aspirin, NSAIDS, beta blockers

Question 40

meds not safe in pregnancy

Answer 40

motrin
ACE/ARB
Benzos
miso
carbamazepine, phenytoin, dilantin, valproic acid, lithium 
retinoids
tetracyclines (doxy) 
thalimdomide
coumadin
folic acid agonist: aminopterin/methotrexate
aminogylcocides (gent) 
amnidarone
anticonvulsants
dilantin
tamoxifen
vit a
lithium, lindane
methylprednisone
diazepam

Question 41

big issues with early loss

Answer 41

thrombophilias

immune endocrine