ACOG Summaries Flashcards
(293 cards)
1
Q
Parvovirus B19 in Pregnancy
A
- Increased activity in the USA 2. Maternal to fetal transmission in 17-33% of infected pregnancies 3. 5-10% risk of adverse fetal outcomes (fetal anemia, nonimmune hydrops, fetal loss)
2
Q
Signs of Parvovirus Infection
A
Fever, myalgia, malaise, reticular rash, arthralgia (Infectious period occurs before symptoms start)
3
Q
At what gestational ages is there an increased risk of adverse fetal outcomes with Parvovirus infection?
A
9-20 weeks
4
Q
When should pregnant individuals be screened for syphilis?
A
1st prenatal visit, 3rd trimester, and at birth
5
Q
How long does it take for POPs to become effective?
A
48 hours
6
Q
Time window of taking POPs
A
Within 3 hours of the prior 24h dose
7
Q
Fetal risks of measles infection
A
EPL, still birth, LBW, PTD
8
Q
How long do you stay isolated in case of measles
A
4 days after rash appears
9
Q
Post-exposure prophylaxis for measles
A
Pregnant: IVIG 400 mg/kg within 6 days
Non-pregnant: MMR vaccine OR IVIG within 72h
10
Q
When should RSV vaccine be given
A
Between 32w0d-36w6d through months of Sep through Jan
11
Q
New FDA approved postpartum depression treatment
A
Zuranolone: GABA A receptive positive modulator. Oral agent. Can be used if onset within 3rd trimester or within 4 weeks PP.
Brexanolone: IV treatment. 60hour in-hospital ifusion
12
Q
Zuranolone dosing
A
50mg tablet in the evening with a fatty meal for 2 weeks
Can be reduced to 40mg if CNS depressant effects occur
30mg if severe hepatic or renal impairment .
Can cause fetal harm
13
Q
Vaccines contraindicated in pregnancy
A
MMR, varicella, HPV (ok in postpartum and with nursing)
14
Q
Acceptable vaccines in pregnancy
A
Inactivated Flu, Pneumococcal, meningococcal, Tdap, HepA, HepB, COVID19
15
Q
When can Tdap be given
A
Between 27 and 36 weeks
16
Q
Risk factors associated with SCD and pulmonary arterial hypertension
A
Hx PE, Chest pain, Syncope, Hypoxia
17
Q
Ideally when should influenza vaccination be given
A
End of October - but anytime during flu season
18
Q
Treatment options for influenza in pregnancy
A
- Osteltamivir (Tamiflu) 75mg BID x 5days 2. Zanamivir (2 5mg inhalations BID x 5d) 3. Peramivir (600mg IV dose over 15-30min)
19
Q
Treatment options for COVID in pregnancy
A
Paxlovid = nirmatrelvir 300mg and ritonavir 100mg; taken BID for 5d
20
Q
Post-exposure prophylaxis for influenza
A
Consider for pregnant patients and patients up to 2 weeks postpartum: tamiflu 75mg daily for 7d within 48h of exposure
21
Q
What defines a prolonged latent phase
A
> 16 hours
22
Q
What defines a prolonged second stage
A
> 3 hours in a nulliparous woman or >2hours in a multiparous woman
23
Q
What is the most common cause of a primary CD
A
Labor dystocia
24
Q
Protracted labor can lead to…
A
CD, Chorio, PPH, fetal acidemia, NICU admission
25
A longer duration of pushing is associated with
Neonatal morbidity: mechanical ventiliation, sepsis, brachial plexus palsy, skull and clavicle fractures, seizures, HIE, death
Maternal morbidity: Triple-I, OASIS, PPH, operative, CD
26
In 2014 when ACOG recommended an additional hour of pushing for patients with an epidural, this lead to...
Decreased CD, Increased rates of neonatal acidemia, NICU admissions, OASIS
27
Most common indication for primary CS is
active phase arrest
28
Percentage of patients that have a CS after attempted operative delivery
<3%
29
What defines a late amniotomy
4 hours after the start of oxytocin
30
Delayed pushing leads to..
longer second stage, increased risk of PPH, Triple-I, fetal acidemia
31
PMS
cyclically ocurring physical, mood (or both) during the luteal phase that resolve shortly after menstruation.
Symptoms: irritability, bloating, mood swings, breast tenderness, lethargy, anxiety and tension, feelings of rejection. Occurs in 20-30% of women
32
PMDD
Type of depressive disorder. Cyclic recurrence of severe, sometimes disabling changes. Includes mood lability, irritability, dysphoria, anxiety. Occurs in 2-5% of women
33
Pathophysiology of PMS/PMDD
heightened sensitivity to fluctuations in estrogen and progesterone // dysfunction of serotonin and GABA neurotransmitter systems
34
Diagnosis of PMS/PMDD
Symptom diary - present for prior year and 2 months of prospective symptom recording
3 month trial of gnRH agonist may help confirm diagnosis
35
Management of PMDD
1. SSRI: sertraline, paroxetine, fluoxetine (can reduce symptoms within days)
2. COCs: 20mcg EE and 3 mg DRSP in 24d regimen
3. Severe: GnRH agonists with add-back therapy
4. CBT
5. Routine exercise- regulates endorphins, cortisol, and ovarian hormone levels
6. Calcium supplementation (1000-1200mg/day)
7. Acupuncture
8. Chasteberry (may stimulate dopamine receptors)
9. NSAIDs: reduce physical symptoms
10. Last last - Bilateral oopherectomy
36
What is treatment for HepC?
12-24 week course of Ribavirin
36
Which pregnant patient needs triple panel HepB screening? (HgsAg, anti-HBs, total anti-HBc)
1. Pregnant women without a documented negative triple screen after age 18
2. Have not completed Hep B vaccine series
3.Ongoing known risk for Hep B infection
37
How long after HepC treatment should you wait to conceive
6 months due to teratogenic effect
38
Risks associated with HepC+ pregnant patients
Increased risk of FGR, PTB, ICP
39
Treatment of Hep B in pregnancy
Use antivirals (tenofovir) during 3rd trimester if HBV DNA viral load is >200,000 IUto reduce perinatal transmission
40
Treatment of neonates born to HepB+ Moms
Receive both HBIG and Hep B virus vaccine within 12h of birth
41
Who should be vaccinated against HepA in pregnancy
international travelers, illegal drug use, occupational risk exposure, homelessness, close contact with internatinal adoptee
High risk: chronic liver disease, HIV+, or patient request
42
Acute viral hepatitis symptoms
anorexia, malaise, fatigue, nausea, vomiting, diarrhea, RUQ or epigastric pain
43
Hep A
small RNA virus, replicates in liver and excreted in bile, fecal/oral transmission from contaminated food/water, no chronic infection state. 10-15% have prolonged or relapsing disease that can last 6 months
44
Hep B
small DNA virus, transmitted through IV or sexual contact, 85-90% have complete resolution of infection and develop protective Ab
45
What percentage of patients that contract Hep B develop chronic infection
10-15%
46
What percent of people with chronic Hep B develop cirrhosis
15-30%
47
Where is HbsAg present
Serum
48
Where is HBcAg present
In hepatocytes only
49
What does HBeAg indicate
Extremely high viral inoculum and active virus replication
50
What is present in serum of individual vaccinated against Hep B
Anti-HBs antibody
51
What is present in individual who is chronic carrier of Hep B
+HBsAg
52
Transmission rate of HepB without maternal treatment or neonatal ppx
up to 90%
53
Hep C
small RNA virus with multiple genotypes
54
Percentage of Hep C infections that are asymptomatic
75%
55
What percentage of those with Hep C become chronic
> 50%
56
What percentage of chronic HepC infections lead to cirhosis
> 20%
57
what is the most common bloodborne infection in the USA
Hep C
58
How is Hep C transmitted
IV drug use, sexual contact (low with vaginal-penile intercourse)
59
What is the risk of developing Hep C in patient that has HIV
Co-infection accelerates progression and severity of hepatic injury
60
Hep D
incomplete viral particle that only causes infection if Hep B present
61
Percentage of people that develop cirrhosis after Hep D infection
70-80%
62
Hep E
incomplete RNA virus, transmitted fecal/oral route
63
Vertical transmission with Hep E
50%
64
Mortality associated with Hep E infection
20-35%
65
what percentage of women have a perinatal mental health condition
20%
66
Risk of BPD relapse in PP period
66% for those not on medications and 23% for those on medications
67
What are pregnant people who have an anxiety disorder at risk for
PTD, low birth weight, increased suicidality, increased PP depression, behavioral changes in offspring
68
Postpartum psychosis
Occurs 1-2/1000 pregnancies
Increased risk of suicide and infanticide
Inpatient hospitilization usually required
69
When does postpartum psychosis occur
Often acute in onset beginning 3-10 days PP but can occur > 4 weeks PP
Often occurs in those with Bipolar 1
70
What medication is shown to be most effective in preventing postpartum psychosis
Initiation of high dose lithium immediately after delivery. Full remission can be achieved within 2 months
71
Pharmacotherapy for anxiety disorders
SSRIs are first line and should be started at half the lowest recommended dose to avoid agitation or insomnia
72
What mood stabilizer should be avoided in pregnancy
Valproic acid - leads to NRD, craniofacial anomalies, limb malformations, CV anomalies) can also lead to neurodevelopment disorders such as autism, cognitive impairment.
FGR, hepatotoxicity, coagulopathy, withdrawal symptoms and hypoglycemia have also been noted
73
Risks associated with untreated bipolar disorder
FGR, PTD, adverse neurodevlopmental outcomes
74
What are antipsychotics associated with
metabolic side effects, weight gain, insulin resistance
75
What anomaly is lithium associated with
Ebstein anomaly (tricuspid valve displaced downward into ventricle)
76
Therapeutic window of lithium
0.6-1.0 mEq
77
At what dose does lithium toxicity occur
1.5 mEq (renally metabolized)
78
Symptoms of lithium toxicity
nausea, vomiting, lethargy, tremor, fatigue, confusion, agitation, seizures, hypothermia
79
High neonatal lithium drug levels associated with
hypotonia, lethargy, respiratory difficulties
80
Acute treatment options for PP psychosis
Olanzapine or haloperidol
Also use benadryl if high dose haldol is being used to prevent EPS
81
Side effects of SSRIs
Nausea, dry mouth, insomnia, diarrhea, headache, dizziness, agitation/anxiety, drowsiness, sexual dysfunction
82
Abrupt discontinuation of SSRI/SNRI can lead to...
GI upset, dizziness, fatigue, headache, sleep disruption, agitation, anxiety, myalgia, tremors, electric-like shock
83
Rare fetal risk associated with SSRI/SNRI use
persistent pulmonary hypertension of the newborn . 10-20% mortality rate; serotonin exposure can cause vasoconsctriction and smooth muscle proliferation in fetal lung
84
Neonatal adaptation syndrome
Symptoms include irritability, restlessness, sleep disruptions, hypothermia, poor feeding.
Resolves within 2 weeks
10-30% incidence
Seen with fluoxetine and paroxetine use
85
Mortality associated with perinatal mental heath disorders
23% - suicide, overdose, poisoning
86
Tools used to screen for depression and anxiety
EPDS, PHQ-9, GAD-7
87
How often should perinatal mood screening be done
Initial visit, later in pregnancy, postpartum
88
Tools used to screen for bipolar disorder
MDQ (7+ is positive screen), CIDI ( 3 questions)
89
Risk factors for perinatal depression
Race (as a social construct), psychological IPV, sexual IPV
FH and personal history of depression
Young age
Veteran
Unemployment
lack of support
incarceration
insomnia and other sleep problems
90
Risk factors for perinatal anxiety and PTSD
prior loss, ectopic pregnancy, unplanned or unwanted pregnancy, medical complications, childhood abuse, IPV, sleep disorders, neonatal complications and NICU admissions
91
Percentage of women that self-harm prior to suicide
25% in preceding 3 months
92
Prophylactic postpartum sertraline
PPD1: 25mg x 4d then 50mg x4w then 75mg from week 5-17 then taper over 3w and stop at 20w postpartum
**PPD reduced to 7% vs 50% with placebo
93
what are the 3 headache types
1. Migraine (with and without aura)
2. Tension-type headaches
3. Cluster headaches
94
Those with migraines are at increased risk for
HDP
95
Tension type headaches
Bilateral, lasts 30 minutes to 7d, typically respond to OTC meds
96
Treatment options for migranes
1. 1000mg tylenol + caffeine (200mg MAX)
2. NSAIDs in 2nd trimester only
3. IV reglan (10mg) with or without benadryl (25mg)
97
Epidural puncture headache
epidural blood patch (typically within 48h of epidural placement)
98
CVST
Treatment with LMWH; if diagnosed then women should have thrombophilia work-up
99
PRES
Posterior reversible encephalopathy syndrome-- MRI will show cerebral edema in occiptal lobes.
Symptoms: HA, vomiting, AMS, blurred vision, seizures
100
RCVS
Reversible encephalopathy vasoconstriction syndrome
Will have abnormal cerebral angiography with diffuse segmental constriction of cerebral arteries
Symptoms: sudden headache, transient blindess, confusion
101
How to diagnose osteoporosis
1. T score on DEXA <2.5
2. Fragility fracture (fracture from falling less than standing height)
3. T score between -1 and -2.5 by FRAX
102
Rate of osteoporotic fractures in postmenopausal women
1 in 2 women >50y will have fracture in their lifetime
103
Treatment of osteoporosis
Bisphosphonates with treatment holiday after 5y of oral therapy OR
3y with IV zoledronic acid
104
Risks associated with bisphosphanates
May increase risk of femoral head fracture and mandible osteonecrosis
105
Denosumab
Treatment option for osteoporosis for those that prefer q6month subQ injection
106
Treatment option for osteoporosis with those that have increased risk of breast cancer and low DVT risk
Raloxifene
107
What do you recommend if someone has a high risk fracture while on treatment
2 year course of PTH analogs (teriparatide or abaloparatide)
108
Surveillance while undergoing treatment for osteoporosis
Ongoing 1-3 year yearly DEXA scans until bone density is stable
109
How should bisphosphonates be taken
Early in the morning, on an empty stomach, with 8oz water, wait 30-60min before eating and remain upright
110
Contraindications to oral bisphosphonates
Esophageal disorders, GI malabsorption, renal failure, reduced kidney function
111
Nutritional recommendations for bone health
Dietary calcium: 1000mg/day and 1200mg over age 50
Vit D: 600 IU/day up to age 70 then 800 IU/day
112
Diagnosis of Triple-I
When maternal temp is over 39C or fever with 1 additional risk factor present
113
How do you confirm diagnosis of Tripe-I
Positive amniotic fluid test or placental pathology
114
Biomarker that predicts risk of PreEwSF
Ratio of sFlt-1:PIGF >40 predicts progression of PreE within 2 weeks with 94% sensitivity
115
Which patients are excluded from PIGF biomarker testing
Non-hospitalized patients <23 weeks or > 35 weeks
Postpartum patients
<18 years old
Multiple gestation
Those receiving IV heparin
116
When does ACOG recommend screening for GDM
Between 24-28 weeks and NOT before 24w
117
Who should be screened for pregestational diabetes
Those with BMI >25 +
1. 1st degree relative with DM
2. Minority population
3. History of CVD
4. HTN
5. HLD
6. PCOS patients
7. Physical inacitivity
8. previous GDM
9. 35+ age
10. HIV+
118
When should postpartum DM screening be done for those with GDM
Immediate PP while hospitalized or 4-12weeks PP -- This is 75g OGTT
119
Diagnostic criteria for DM
A1c > 6.5
Fasting glucose >126
2hr glucose level >200 during 75g OGTT
Random glucose > 200
120
At what gestational age is routine Rh testing and RhIg prophylaxis recommended for pregnancy loss
At 12 weeks or greater
121
When should average risk individuals initiate screening mammograms
at 40 years old with 1-2 year intervals
122
Percentage of people that use some form of cannabis
Over 25% use it for pain, depression, anxiety
123
Side effects associated with cannabis use
transient cognitive impairment, vomiting, drowsiness, nausea, dizziness and sedation
124
What are the FDA approved bioidentical hormones for treatment of menopause
Micronized progesterone, estradiol, DHEA
125
Testosterone treatment for menopausal symptoms
Short term use of transdermal testosterone can be used for those with sexual interest and arousal disorders (shared decision making). ACOG recommends against pellet therapy
126
Side effects of testosterone use
Hirsutism, acne, virilization
127
Target range of estradiol level for relief of menopausal symptoms
40-100 pg/mL
128
Target range of testosterone level for menopausal treatment
20-80 ng/dL
129
FDA approved combination therapy for menopause treatment
Oral estradiol 1 mg + micronized progesterone 100mg
130
Percentage of patients that have endometrial cancer on specimen with EIN
30-50%
131
Gold standard sampling for EIN
Hysteroscopy D&C vs EMB
132
How often should sampling be performed for patients with EIN taking progesterone
3-6 months
133
UTIs affect ___ % of pregnancies
8%!
134
Most common pathogens found in UTIs in pregnancy
1. E.Coli
2. Proteus
3. Klebsiella
135
UTIs are associated with these adverse outcomes
PTD, low birth weight, maternal anemia, sepsis, DIC, ARDS
136
Asymptomatic bacteriuria with colony counts over ___ should be treated
100K
137
What two tests on UA are likely to indicate UTI if positive
Leukocyte esterase and nitrites
138
Recurrent UTIs occur in __% of pregnancies
4-5%
139
Common suppressive regimens for UTI in pregnancy
Macrobid 100mg daily or cephalexin 250-500mg daily
140
Which antibiotics should not be used for pyelo treatment
Macrobid and fosfomycin
141
How long should suppression antibiotics be taken
After treatment and up to 4-6 weeks postpartum
142
Antibiotics for treatment of pyelo
Amp+Gent
CTX
Cefepime
Aztreonam (PCN allergy)
143
Can testosterone be used to achieve amenorrhea in transgender individuals
Yes!
144
Incidence of breakthrough bleeding
50%
145
Length of time BTB lasts when starting new regimen
3-6 months
146
Treating BTB with IUD in place
NSAIDs, doxycycline, POP, cOCP
147
Breastfeeding with Hep B
Individuals can breastfeed if the infant has received immonoprophylaxis
Do not feed from any cracked/bleeding nipple
148
Hep B treatment in pregnancy
If viral load >200,000 then tenofovir should be given in 3rd trimester (28-32 weeks) to reduce transmission rates
For maternal benefit treatment should be initiated if viral load >20,000 if e AG positive and level >2000 if e Ag negative
149
When should Hep B ppx be given to neonate
Within 12 hours of birth
150
Who can receive the Hep B vaccine
All adults aged 19-59
151
Assessment of infertility in women
1 year for those under 35
6 months for those over 35
Immediately for those over 40 and with those that have a condition known to cause infertility
152
Initial infertility evaluation
Up to date on screening, genetic screening, evaluation of ovulatory status, structure and patency of female reproductive tract, semen analysis
153
What D21 progesterone level confirms ovulation
>3 ng/mL
154
Evaluation of ovarian reserve
Basal FSH/estradiol on D2-4
AMH anytime
TVUS for antral follicle count
155
Ovulatory dysfunction rates that contribute to infertility
15% of infertile couples, 40% of infertile women
156
Most common causes of ovulatory dysfunction
PCOS, obesity, perimenopause, weight gain/loss, excessive exercise, thyroid dysfunction, hyperPRL
157
Percentage of women that are ovulatory with regular menses and no hirsutism
99.5%
158
Percentage of women that have regular menses and have hirsutism
60% - will need D21 luteal progesterone
159
What do OPKs test
Urinary LH (reflects midcycle LH surge that proceeds ovulation by 1-2 days)
**Pts with PCOS can have tonic elevation of LH
160
If FSH is high and E2 is low then
ovarian insufficiency
161
If FSH is low and E2 is low then
hypothalamic dysfunction
162
If FSH and E2 are normal then
Eval for PCOS with testosterone and 17OHP
163
Uterine abnormalities occur in __% of infertile women
16%
164
Morbidity and survival in delivery <23 weeks
5-6% survival rate
Morbidity is 98-100%
165
When can antibiotics be offered in setting of previable PPROM
Can be considered as early as 20w
166
Most common complications associated with expectant management in case of previable PPROM
Triple-I and hemorrhage
167
Outcomes after expectant management of PPROM <24 weeks
Neonatal survival: 39%
Maternal morbidity: 60%
168
Neonatal complications associated with PPROM
Pulmonary hypoplasia, bronchopulmonary dysplasia, RDS (50-80%)
169
Patient assessment for outpatient monitoring of previable PPROM
Daily temperature checks
Monitor for VB, CTX, abd pain, malodorus vag discharge
Weekly FHR, vitals, possible CBC
170
First trimester is defined as
<13w6d
171
GS typically appears at __
5w
172
Yolk sac typically appears at __
5.5 weeks
173
Embryo usually appears at __
6w
174
Embryo is defined as
<10w6d
175
Fetus is defined as
>11w
176
What is the "normal" location of a pregnancy
within the decidualized endometrium in the upper 2/3 of the uterine cavity
177
Most IUPs will be seen when hCG is___
>3000
178
Pneumococcal conjugate vaccine should be given
Adults 50y and older (one dose sufficent)
179
RSV vaccine should be given (in adults)
Individuals over 75y or age 60-74 if at risk for severe RSV disease
180
RSV vaccine (in pregnancy)
32w-36w6f during Sep through Jan
1 dose of Abrysvo
**Additional doses not recommended in subsequent pregnancies
181
Meningococcal vaccines
2 doses given 6mo apart to healthy adolescents
OR
3 doses for those at high risk
182
Sepsis is responsible for __% of pregnancy related deaths
14%
183
SOFA score evaluates 3 criteria; what are they?
Systolic BP <100
RR> 22
AMS
184
What is the first line vasopressor during pregnancy for septic shock
Norepinephrine
185
What can be given when pregnant patients are requiring vasopressors
IV corticosteroids and VTE ppx
186
At what glucose level should insulin be initiated for those with sepsis
Glucose > 180
187
Most frequently encountered organisms in cases of sepsis
E. Coli
GAS
GBS
188
Antibiotic regimen for treatment of GAS or Clostridium
Pen G + clindamycin
189
Sepsis and septic shock are associated with increased risk of...
PTD, prolonged recovery, stillbirth, maternal death
190
What marker is SPECIFIC for SLE
Anti-dsDNA antibodies
191
What markers are indicative of a SLE flare
decrease in complement levels (C3 and C4) and elevations in double-stranded DNA levels
192
Common complications of SLE
Nephritis, thrombocytopenia, neurologic abnormalities
193
Common symptoms of SLE flare
fatigue, fever, arthralgias, myalgias, weight loss, rash
194
Adverse pregnancy outcomes associated with SLE
placental insufficiency, PreE, FGR, neonatal lupus
195
Which patients are at an increased risk of developing a fetus with neonatal lupus
Those with anti-SSA and anti-SSB antibodies
196
Risk of heart block with anti-SSA and anti-SSB antibodies
2%
197
When would fetal heart block typically develop in those with SSA and SSB antibodies
Between 18-25 weeks
198
How should fetal heart block be managed if diagnsoed
Weekly US to evaluate for hydrops
199
What agents should be discontinued in those with SLE desiring pregnancy
Methotrexate and mycophenolate 6 weeks before attempting conception
200
Patients with APLS and no prior thrombotic event should receive
PPx heparin or LMW heparin + ASA
201
Patients with APLS and prior thrombotic event should receive
Therapeutic UF or LMWH
202
What are the most common arrhythmias seen in pregnant patients
Sinus arrhythmia, SVT, premature beats (all benign)
203
What is the most common newly diagnosed arrhythmia in pregnancy
AFib
204
What does the left lateral tilt achieve
When > 30 degrees, this position increases the IVC volume and cardiac output
205
Most common cause of syncope in pregnancy
Vasovagal mediated
206
What beta blocker should be avoided in lactation
NadololUn
207
Untreated maternal thyroid disease can lead to...
It can precipitate fetal arrhythmias
208
Which patients should be offered a transabdominal cerclage
1. Prior TVS cerclage and subsequent delivery before 28w
2. Anatomic reasons for short cervix
3. Congenitally extremely short cervix
209
Transabdominal cerclage can be considered until ___ weeks
22 weeks
210
When should delivery be done for those with an abdominal cerclage
Between 37 and 39w
211
Describe Shirodkar cerclage placement
Dissection of the vesico-cervical mucosa to place nonabsorbable suture as close to internal os as possible
212
Describe McDonald cerclage placement
Placing non absorbable suture at the cervicovaginal junction
213
Where should an abdominal cerclage be placed
At the cervico-isthmic junction
214
Pregnancy rates in women who used cryopreserved oocytes vs fresh occytes
Similar pregnancy rates
Similar neonatal outcomes
215
When can ECC be omitted
Pregnancy
Planned subsequent excisional procedure
Nullips younger than 30 with ASCUS or LSIL
216
Recommendations for management of CS scar ectopic pregnancy
1. Surgical management (not sharp curettage)
2. Intragestational MTX or other agent
217
Delivery timing for CS scar ectopic that chooses expectant management
34w-35w6d
218
Rate of transient brachial plexus palsies during a shoulder dystocia
10%
219
Rate of permanent brachial palsy injury after shoulder dystocia
1%
220
Rate of death due to shoulder dystocia
.04 in 1000 deliveries
221
If head to body delivery in a shoulder dystocia is over __ minutes, there is a __% chance of permanent brain damage
1. >7 minutes
2. 67% chance
222
Incidence of AMA pregnancies
20%
223
AMA is associated with an increased risk of
Chromosomal anomalies, congenital anomalies, medical co-morbidities, PPH, CS, GDM, PreE. multiple gestation (from ovulation induction)
224
Patients 40 years and older need a 3rd trimester growth scan due to increased risk of
LGA and SGA
225
Stillbirth occurrence rate
1 in 160 deliveries
226
Fetal death is defined if...
>20wk GA or >350gm
227
Potential causes of stillbirth
FGR, abruption, chromosomal and genetic abnormalities, infection, umbilical cord events
228
What is most useful in the evaluation of a stillbirth
Examination of placenta, umbilical cord, and fetal membranes -- provides information in 30% of cases
229
In genetic analysis of a stillbirth, abnormalities were found __% of the time
8%
230
Maternal testing recommendations for stillbirth evaluation
KB test, APLS, RPR, Indirect Coombs, A1C, Toxicology
231
What is the overall rate of VBAC with an attempted TOLAC
60-80%
232
What is the optimal start time for baby AS for PreE prevention
At 12 weeks, preferable before 16 but can start as late as 28w
233
High risk factors for PreE that warrant ASA
Hx PreE, CHTN, Multigestation, T1DM ot T2DM, Renal disease, SLE/APLS
234
Moderate risk factors for PreE and ASA ppx
Nulliparity, obesity, FH of PreE, Black, low income, AMA, IVF, Prior SGA
235
Pathophysiology of osteoporosis
Decline in estrogen levels leads to increased bone resorption by osteoclasts which exceeds bone formation by osteoblasts
236
How is bone density assessed
DEXA scam of the hip and lumbar spine
237
Diagnostic criteria for osteoporosis
T-Score > -2.5
Hx fragility fracture
T score between -1 and -2.5 with increased FRAX
238
Definition of low bone mass (osteopenia)
T score between -1 and -2.5
239
What is a Z score
Used to determine premenopausal women at risk for secondary osteoporosis
240
What is an abnormal Z score
-2 or greater
241
What height change should make you worry about osteoporosis risk
Loss of 2cm in <3 years or loss of 4cm from peak height
242
What is the incidence of preterm birth
10%
243
At what cervical length is US indicated cerclage done
<10mm
244
What medication is given for those with short cervix
VagP - 200mg daily
245
What is the Hct/Hgb cut-off for anemia
1st tri: 33%, <11
2nd tri: 32%, <10.5
3rd tri: 33%, <11
246
How many mg of Fe is needed to support the pregnancy
1000mg
247
Daily iron recommended in pregnancy
27mg
248
Foods that decrease iron absorption
Dairy, soy, spinach, coffee, tea
249
Folate requirements in pregnancy
400mcg/d
250
Treatment for B12 deficiency
1mg B12 IM monthly
251
Treatment for folate deficiency
1mg folate/day
252
What is the risk of VTE after benign Gyn surgery
15-40%
253
How long should VTE ppx be continued for those undergoing surgery for cancer
28 days
254
Risk of TTTS in monochorionic pregnancies
15%
255
Monochorionic pregnancies are at increased risk for what type of anomalie
Cardiac - fetal echo warranted at 18-22wk
256
When is multifetal reduction typically done
10-12 weeks
257
What complications do steroids reduce
Neonatal death, RDS, IVH, NEC
258
What is discordance in twin gestation
20% or greater
259
Rate of spontaneous 1st trimester fetal reduction
33% in twins
50% in triplets
66% in quads
260
What is the percentage of overweight or obese pregnant women
>50%
261
Appropriate weight gain in pregnancy
25-35 for those with normal BMI
15-25 lbs for those overweight
11-20 lbs for those that are obese
262
Incidence of fibroids
70% by menopause
25% are symptomatic
263
How soon does regrowth of fibroids occur after stopping GnRH agonist
3-9 months
264
What are forms of GnRH antagonist therapy
Elagolix/Orlissa (300mg BID)
265
Add back therapy for Orlissa
Estradiol 1mg and Norethindrone 0.5mg
Can be used for a max of 24 months
266
UAE decreases volume and bleeding from fibroids for up to __
5 years
267
Risk of recurrence with FGR if prior pregnancy complicated by FGR
20%
268
Incidence of T21 per live birth
1 in 700
269
Incidence of T18 per live birth
1 in 3000
270
Incidence of T13 per live birth
1 in 6000
271
Turners Syndrome incidence
1 in 2500
272
When can NIPT testing be done
As early as 9w but best at 10w and beyond
273
What is an abnormal NT
>3mm
274
Increased NT is associated with
Cardiac anomalies, abdominal wall defects, diaphragmatic hernias, and aneuploidy
275
1st trimester PAPP-A results below the 5th percentile is associated with...
SAB, IUFD, FGR, PreE, placental abruption, PTD
276
Elevated 2nd trimester analytes are associated with
Increased risk of fetal death, FGR, PreE
277
What percentage of abortions are performed prior to 10 weeks
60%
278
What percentage of abortions are medication abortions
40%
279
If mife is not used for medication abortion, how should miso be dosed
800mcg q3hrs for max of 3 doses
280
Contraindications to medication abortion
Ectopic, IUD in place, long term systemic steroid therapy, coagulopathy or anticoagulant use, inherited porphyria, chronic adrenal failure
281
In failed medical abortions, miso can lead to...
Congenital anomalies - primarily limb defects
282
A serum decrease of __% or greater after __ days indicates succesful med abortion
80%, 7 days
283
Which form of contraception can decrease the efficacy of medical abortion
Depo
284
What is the risk of underlying carcinoma in those with lichen sclerosis
2-5%
Squamous cell
285
Therapeutic range for Mag
4.8-9.6
286
If Mg level is too high and needs to be stopped, at what level can it be restarted again
When <8.4
287
Treatment for Mg toxicity
10% Calcium gluconate 10cc over 3 minutes with lasix
288
The goal of treating severe HTN is to prevent
CHF, MI, renal failure, stroke
289
Recurrence rate of HSV1 in 12 months
55%
290
Recurrence rate of HSV2 in 12 months
80%
291
Where does the herpes virus lay dormant
Dorsal root ganglia of S2-S4
292
