Exam #4 Flashcards
1
Q
What supplementations should a pregnant patient be taking daily?
A
- Folic acid (4 mg/day)
- Calcium
- Iron
2
Q
At ________ weeks, an U/S can detect fetal age up to +/- 7 days
A
6-11 weeks
3
Q
At ________ weeks, an U/S can detect fetal age up to +/- 10 days
A
12-20 weeks
4
Q
At ________ weeks, an U/S can detect fetal age up to +/- 14-20 days
A
20+ weeks
5
Q
Important maternal history dz to look out for (6):
A
- DM
- HTN
- CVD
- Renal dz
- Pulmonary dz
- Autoimmune
6
Q
Important family history dz to look out for (6):
A
- DM
- HTN
- CVD
- Anemia
- CA
- Blood clotting d/o
7
Q
Labs for the Initial PN visit
A
Blood type Anemia Syphilis (Rapid Plasma Reagin / VDRL) Kidney Dz (UA) Cervical Dysplasia (Pap Smear) Chlamydia DM (glucose) Hep B/Hep C/HIV
8
Q
When should a pregnant patient be screened early for gestational DM?
A
Fam hx of DM High BMI (Obesity > 30)
Should be screened early, and then again at 28 wks
9
Q
TORCH Titer
A
Toxoplasmosis Rubella CMV / HSV / HIV / EBV Syphilis Hepatitis B Parvovirus B19
10
Q
Category X Medications
A
Warfarin
Chemo (antineoplastic agents)
Retinoids
DES (diethylstilbestrol)
11
Q
Category C Medications
A
SSRIs
12
Q
Craniofacial findings for Fetal Alcohol Spectrum D/O
A
Small Eye Openings
Smooth philtrum
Thin upper lip
13
Q
Risky seizure medications during pregnancy
A
Phenytoin
Valproic Acid
Carbamazepine
Phenobarbital
14
Q
What can happen to the fetus/mother if the mother has a seizure during pregnancy?
A
Trauma from fall
Hypoxia
Decreased heart rate
Premature labor, miscarriage
15
Q
Live attenuated immunizations, such as Rubella, MMR, and Varicella, must be given during which time frame?
A
> 3 months before/after pregnancy
16
Q
Which immunizations can be given during pregnancy?
A
Recombinant Immunizations Influenza Gardasil Hep B Tetanus
17
Q
What can cause a blueberry muffin baby?
A
Rubella Toxoplasmosis Syphilis Hep B CMV EBV
18
Q
Fetal heart can be heard around _____ weeks
Normal rate?
A
12 weeks
120-160
19
Q
Symptoms of pregnancy
A
N/V HA Acne Varicose Veins Hemorrhoids Leg Cramps Heartburn Backache
20
Q
When does N/V of pregnancy start? How long can it continue to?
A
Starts around 4-6 weeks
Usually resolves by 16 weeks
21
Q
Tx for N/V of pregnancy
A
Rest BRAT diet Sea bands Ginger Several small meals Carbohydrate snacks before bedtime
22
Q
Signs/Symptoms of hyperemesis gravidarum
A
Persistent vomiting / inability to tolerate PO
Weight loss > 5% of pre-pregnancy weight
Dehydration (ketones, orthostasis)
Electrolyte abnormalities
23
Q
Tx of hyperemesis gravidarum
A
- IV hydration
- Antiemetics (Phenergan, Zofran)
- GI motility drugs (Reglan)
- Goal is toleration of po liquids
24
Q
If a patient with hyperemesis gravidarum is admitted, what should be done?
A
U/S to rule out multiple gestations, molar pregnancy
Thyroid panel to r/o Graves
25
Urinary frequency of pregnancy improves after _____ weeks when the uterus rises in the abdomen, but worsens again in the third trimester. Tx includes:
12 weeks
Kegel exercises, frequent urination
Make sure to watch for sx of UTI
26
Management of heartburn in pregnant patient
Avoid lying flat
Sleep with more pillows, lay on right side
Small frequent meals, avoid late night snacks
Antacids
27
Management of varicosities in pregnant patient
Elevate feet, pump leg muscles
28
Management of constipation in pregnant patient
Fruits and vegetables, drink lots of water
Exercise and walking
Stool softeners, laxatives prn
29
Patients > 35 years old are at increased risk for:
Trisomy 18, 13, and 21
30
```
Risk of Trisomy 21:
_______ at age 35
_______ at age 39
_______ at age 45
_______ at age 49
```
1/800
1/300
1/80
1/20
31
Tests used to detect chromosomal abnormalities in first trimester
U/S: nasal bone absence and nuchal translucency
| Serum: bHCG and PAPPA
32
When should fundal height measurement start?
20 weeks
| Within +/- 3cm of gestational age
33
Fetal movement is first noted in the patient around ________ weeks in the first pregnancy, but the examiner cannot typically feel until _________ weeks
18-22 weeks
| 20-24 weeks
34
One in ______ pregnancies have recognizable chromosomal abnormalities. _____% are trisomy 21, 18, 13, or changes in X and Y
300
| 95%
35
Pregnancy Check Up Timings
Every 4 weeks until 28 wks
Every 2 weeks until 36 wks
Every week until 40 wks
2x a week after 40 wks
36
Worrisome in 3rd trimester:
```
Vaginal bleeding (including spotting)
Persistent abdominal pain
Severe / persistent vomiting
Absence or decreased fetal movement
Severe HA
Edema of hands, face, legs, and feet
Fever above 100F
Dizziness, blurred vision, double vision, spots
Painful urination
```
37
>____% of structural and chromosomal fetal abnormalities are born to low risk women
90%
38
When can a nuchal translucency test be performed to be valid?
First trimester
| 11 weeks to 13 weeks and 6 days
39
What is involved in the integrated prenatal screening (IPS)?
1st TM: NT and serum PAPPA
| 2nd TM: serum AFP, uE3 (estriol), hCG
40
Why is the integrated prenatal screening controversial?
Doesn't calculate risk until 2nd trimester, so technically withholding information from the parents until. Also has high false positive rates due to wrong gestational dates and undiagnosed multifetal pregnancies.
41
What is involved in the serum integrated prenatal screening (SIPS)? It is the best option if ______ is not available.
1st TM: PAPPA
2nd TM: AFP, uE3, HCG, inhibin-A
Best option if NT is not available.
42
What do you do if one of the prenatal chromosomal screenings is positive?!
Offer CVS or amniocentesis
43
Timing for CVS?
| Timing for amniocentesis?
10-13 weeks
| 15-22 weeks
44
Miscarriage risk for CVS?
| Miscarriage risk for amniocentesis?
1/100-1/200
| 1/200-1/500
45
Where is the moderator band located?
Right ventricle
46
What's a lemon sign?
Arnold Chiari II malformation
47
Leopold maneuvers are especially important after ______ weeks
34 weeks
| Help determine the position of the fetus inside the uterus!
48
Breech presentation is in ____-____% of fetuses at 24-28 weeks, and ____% at 36 weeks
30-40% at 24-28 weeks
| 5% at 36 weeks
49
What's the fetal kick count?
Patient sits quietly, observes fetal movement after 30 wks
| Should report 10+ movements in 2 hours
50
Absence of fetal movement usually precedes IU fetal death by _______
48 hours
51
Loss of amniotic fluid prior to labor onset
PROM
52
Loss of amniotic fluid prior to 36 weeks
PPROM
53
Backaches during pregnancy may be due to increased __________. What's the tx?
Lordosis
| Exercise, sit with knee slightly higher than hips
54
Complications of fetus from gestational DM:
1. Macrosomia
2. Shoulder dystocia (increased rate of C/S)
3. Hypoglycemia
4. Hyperbilirubinemia
55
What is the initial GDM test?
50g glucose test
| After 1 hour, positive if > 140
56
What's the next step if the first GDM test if positive?
3 hour glucose tolerance test
| + if 2/4 are elevated or if FBS is high
57
What is associated with Group B strep in an infant delivery?
Sepsis
PNA
Death
58
When is a vaginal swab for Group B strep performed?
36 weeks
| If present, give ABX in labor!
59
Braxton-Hicks contractions is "false labor," where contractions are irregular, and ______ per 10 minutes. They serve to ______ / _______ the cervix in anticipation of delivery
< 3 per 10 minutes
| Soften / efface the cervix
60
A score of < ____ is an unfavorable cervix, while a score of > ____ is a favorable cervix
< 5
| > 7
61
When is stripping the membranes performed?
39 wks
| Can speed up onset of labor within next 48hours
62
____% of transgender people have attempted suicide
41%
63
____% of transgender people have experienced family rejection
57%
64
Transgender populations have higher rates of: (4)
1. HIV (4x)
2. EtOH use
3. Smoking
4. Drug use
65
It is important patient information to relay that hormone treatment may decrease _________
Fertility
| Consider sperm bank for MTF patient
66
How often do you routinely follow up with a transgender patient?
Every 4 weeks
| Can taper this as the patient progresses/stabilizes
67
Screening for TransMen patients:
1. Osteoporosis risk (consider VitD / Ca) - bone density screening 5-10 years after starting T
2. May need to add progesterone if menses continue > 3 months
3. Check T level every 6 mo
4. Annual mammogram starting 40-50 y/o
5. Bimanual pelvic exam every 1-2 years
6. Pap smear every 2-3 years
68
Baseline Labs for TransWomen:
```
Annual fasting lipid profile
K and Cr if on spironolactone
LFTs periodically
Monitor BP q 1-3 mo
Annual FPG
```
69
Screening for TransWomen patients:
1. Annual mammogram starting at 40-50 y/o
| 2. Annual rectal exam w/ PSA at 50 y/o
70
Baseline Labs for TransMen:
1. Hemoglobin
2. Testosterone
3. Lipids
4. LFTs
71
Goals to prevent CVD in transmen planning to start masculinizing hormones within 1-3 yrs
SBP < 130, DBP < 90
| LDL < 135 mg/dL
72
What should you advise your transmen patients taking testosterone to avoid tendon rupture?
Increase weight load gradually
Emphasize repetitions over weight
Emphasize stretching
73
________ is a good adjunct tx for hair loss in transwomen
Finasteride
| Also topical minoxidil
74
What can you give a transmale patient with decreased libido?
Low-dose SSRI
75
It is recommended that a transmale patient wait ________ before surgery to remove breast tissue
6 mo
| Wait to see how much effects the hormones themselves will have
76
It can take up to ________ for the transmale body hair pattern to finalize
5 years
77
Clinical Prophylaxis for Rh Isoimmunization
1. If Mom is Rh-, check for Rh antibodies
2. If Mom has Rh antibodies, REFER
3. If no Rh antibodies, find out father's blood type
4. If Dad Rh-, no action needed
5. If Dad Rh+, patient needs Rhogam
78
When is Rhogam given?
24 weeks or when any bleeding during pregnancy is noted
| Repeat Rhogam at time of delivery OR 12 weeks after prior dose (if given early)
79
1st TM Complications
1. Hyperemesis gravidarum
2. Bleeding
3. Pregnancy Loss
4. Molar Pregnancy
80
Spectrum of trophoblastic dzs, which are HCG +, which have the ability to convert to malignancies if their tissue is not removed
Molar Pregnancy
| Gestational Trophoblastic Neoplasia
81
Which molar pregnancies result in malignancies that need chemo?
Choriocarcinoma
| Placental site trophoblastic tumor
82
Presenting symptoms of a molar pregnancy
1. Hyperemesis
2. Bilaterally enlarged theca lutein cysts
3. Vaginal bleeding (bundle of bloody grapes)
4. Uterine enlargement > expected for GA
5. Pregnancy induced HTN
Sx are due to large hydropic growths of the placenta and large amounts of HCG production
83
2nd TM Complications
1. Abnormal Prenatal diagnostics
2. Second trimester loss
3. Bleeding
4. Placenta Previa
5. Cervical Insufficiency (incompetent cervix)
84
You should suspect ____________ whenever painless vaginal bleeding occurs in the second trimester
Placenta Previa
85
Risks if placenta previa found in 3rd TM:
Vaginal bleeding
Placental abruption
IUGR (intrauterine growth restriction)
86
If placenta previa found in 3rd TM:
Avoid labor!
Monitor closely
Schedule C/S
87
Risk of placenta previa goes up with each _______
C/S
88
Weakness of the cervix that results in cervical dilation/effacement in the 2nd TM in the absence of contractions. Often enough to cause early pregnancy loss (2nd or 3rd TM)
Cervical Insufficiency (Incompetent Cervix)
89
Cervical insufficiency should be suspected in patient's with prior _________ _________
Cervical surgeries
90
Tx for cervical insufficiency
Cervical cerclage
Purse-string type suture placed in cervix to add strength to cervical tissue
Suture are removed if labor ensues or pt has reached near-term gestation
91
Tx for cervical insufficiency in the NEXT pregnancy
Cervical cerclage in 2nd TM if needed
| Progesterone supplementation starting at 18-20 weeks
92
3rd TM Complications:
1. Preeclampsia
2. Preterm Labor
3. Gestational Diabetes
93
Triad of preeclampsia
1. Edema
2. Proteinuria
3. HTN
94
Preeclampsia does NOT happen before _____ weeks
20
95
Placenta and preeclampsia seems to correlate with (3):
Placental Pressure
Umbilical blood flow
Spasms of spiral arterioles
96
Who is the problem child in preeclampsia?
The placenta!
| Placental thromboplastins probably cause the materanl vasospasm associated with it
97
Sx of preeclampsia
HA, edema (sudden weight gain), N/V
Blurred vision, seeing spots, or scotomata
Decreased urine output
98
When is there evidence of HELLP?
HTN
Platelets < 100K and/or
AST/ALT elevated and/or
Pulmonary edema
99
Tx for preeclampsia (when becoming severe)
```
MgSO4 infusion (should be continued for 24 hrs)
Best tx is delivery
```
100
What's post-partum preeclampsia?
Typically happens w/n 24 hrs of delivery
Sometimes as late as 3-4 days after delivery
Same tx - MgSO4
101
Contractions with cervical change at 24-36 wks gestation
Preterm labor
102
Fetal risk of preterm labor
```
Brain: intraventricular hemorrhage, hypoxic injury
Lungs: pulmonary insufficiency
GI: necrotizing enterocolitis
Retina: O2 toxicity
Immune: infxn risk
Neuro-Respiratory: apnea
```
103
At 24 weeks, the average fetus is _________ and morbidity is _____%
1 lb 6 oz
| 90%
104
At 32 weeks, the average fetus is ________ and there's a _______% the lungs are mature enough to fxn on RA
4 lbs
| 50%
105
What disposes to preterm labor?
```
Cervicitis
Proximate infxns like UTIs
Drug use (cocaine, alcohol)
Dehydration
Polyhydramnios
Multiple gestation
```
106
A cervical length of > ______ on U/S correlates well with NOT delivery the baby in the next 1-2 weeks
3.5 cm
107
Tx options for preterm labor
```
Betamethasone (surfactant) - 12 mg IM, repeat in 24 hrs
Bedrest
Oral nifedipine (allows more time)
Terbutaline
Indomethacin
IV MgSO4
```
108
ADRs associated with terbutaline
Pulmonary edema
Tachycardia
Increased BF
109
ADRs of MgSO4
Flushing
Nausea
Hyporeflexia
Toxicity is possible (watch levels)
110
If a patient has a hx of preterm labor, they will receive this during their next pregnancy
Progesterone supplementation
Vaginal gel or IM injection
Start around 18 wks then weekly to 34-36 wks
111
Three tissue types that exist in the breasts
1. Fat
2. Glandular epithelium
3. Fibrous stroma
112
Arterial supply to the breasts comes from
Internal mammary artery (60%)
| Lateral thoracic artery (30%)
113
Venous return from the breasts comes from
```
Axillary vein (primary)
Internal mammary vein, intercostal vein
```
114
Lymphatic drainage from the breasts comes from
75% to the axillary nodes
115
Nontender, slow growing breast mass, no nipple discharge. Proliferative process in a single lobule.
Fibroadenoma Tumor
116
15-35 y/o and a painless lump
Fibroadenoma Tumor
117
Dx for fibroadenoma tumor
PE: rubbery, mobile, painless mass
US: circumscribed solid mass
FNAC/CNB
118
Rapid growth, large, leaf-like projections in a 40-50 y/o
Phyllodes tumor
119
Smooth, multinodular, well-defined, mobile and painless firm mass
Phyllodes tumor
120
Tx for phyllodes tumor
Wide local excision with follow-up
Simple mastectomy
Have to tx aggressively because only 60% are benign
121
30-50 y/o with smooth, firm, discrete, often tender mass
Cyst
122
Tx for breast cyst
Aspiration (multiple if needed)
| Excision if multiple recurrences
123
History of trauma (seatbelt, other blunt trauma, surgery). Will present with pain and lump in breast.
Traumatic fat necrosis (TFN)
| DDX: carcinoma
124
Tx of traumatic fat necrosis
Excision vs. follow
| No increased risk of malignancy
125
____% of women report > 5 days per month of mastalgia
30%
126
Cyclic mastalgia usually onsets in the late ______ _______, and dissipates with the onset of menses
Late luteal phase
127
Tx for cyclic mastalgia
```
Diet, breast support (good bra 24/7)
NSAIDs/Acetaminophen, evening oil of primrose
Vitamin E
Danazol
Tamoxifen
Bromocriptine
Topical NSAID
```
128
Most frequent breast lesion, common in women 30-50 y/o
Fibrocystic breast changes
129
Bilateral tender breast lumps and bilateral nipple discharge
Fibrocystic breast changes
130
Tx for fibrocystic breast changes
```
Symptomatic relief (same as mastalgia)
If dominant mass --> have to r/o CA (mammogram, US, cytology)
```
131
Bloody nipple discharge, usually unilateral, may have associated mass
Tx?
```
Intraductal Papilloma (IDP)
Tx: Remove!
```
132
Often asymptomatic, can cause green/black discharge. May have mass, inflammation of nipple/surrounding tissue
Tx?
Duct Ectasia
| Symptomatic, ABX, excision
133
Purulent discharge
Subareolar abscess
134
Milk discharge in a non-lactating breast?
Prolactin secreting pituitary adenoma
Hypothyroidism
Medications (dopamine antagonists)
135
Lactating female with throbbing pain in unilateral breast plus a fever
Mastitis
136
Localized inflammation of the breast associated with fever, myalgias, breast pain, and redness
Mastitis
137
Onset of mastitis? Etiologies? Tx?
First 2-4 weeks postpartum
Staph aureus, staph epidermidis, candida albicans, strep
Fluids, ice, NSAID, handwashing, regular emptying of breast by pumping or nursing
ABX: dicloxacillin or cephalosporin x 10-14 days
138
If no response to ABX for mastitis in 3 days? Etiology? Dx? Tx?
Breast abscess
Often MRSA
Confirm with breast US
Tx: Needle aspiration or surgical drainage
139
Breast CA is the ___ most common CA in women
2nd
| Skin = 1st
140
Breast CA is the ____ leading cause of CA death in women
2nd
| Lung = 1st
141
5-year survival for stage 0-1 breast CA is _____%
| 5-year survival for stage 4 breast CA is _____%1
100%
| 20%
142
Unalterable RF for breast CA
Female, age
| Fam hx, personal hx, race, diethylstilbestrol, radiation, genetic, menstrual hx
143
Controllable RF for breast CA
Obesity, diet, exercise, breastfeeding, EtOH, HRT, OCP,
144
Risk calculation for breast CA
Gail-NCI Model
145
Associated risk for breast CA with BRCA-1
| Other CA associated?
50-85%
Second primary breast CA
Ovarian CA
Prostate, Colon
146
Associated risk for breast CA with BRCA-2?
| Other CA associated?
50-85%
Ovarian
Prostate, laryngeal, pancreatic, melanoma
147
When is the best time to do a self-breast examination?
7-8 days post menses
148
Clinical breast exams should be performed every 1-3 years ages ____ - _____, and annually after age _____
20-39 y/o
| 40 y/o +
149
Mammograms should be started at age ____ and done annually until age ______
40 y/o
| 75 y/o
150
Enhanced screening in BRCA mutations
Self-exams beginning at 18 y/o
Semiannual clinical breast exams beginning at 25 y/o
Annual mammography and breast MRI beginning at 25 y/o or earlier
151
Chemoprevention of Breast CA
Tamoxifen
Raloxifene
Aromatase Inhibitors
152
ADRs of Tamoxifen
```
Increased risk of endometrial CA
Increased risk of DVT
Cataracts
Depression
Vasomotor Sx
Vaginal dryness/discharge
```
153
ADRs of Raloxifene
TE events
Cataracts
Better bone density
Decreased Uterine CA
154
ADRs of aromatase inhibitors
Osteoporosis
Vasomotor Sx
Joint pain
Depression
155
___% of the presenting complaint is a painless breast lump for breast CA
70%
156
The ____ _____ quadrant is the location of 60% of breast CA
Upper outer quadrant
157
85% of breast CA are ______, not lobular
Ductal
158
After breast CA:
```
Need for close f/u
Lymphedema of upper extremity
"Chemo-brain"
Menopausal sx
Osteoporosis, CV issues
```
159
Itch/burn/superficial erosion of nipple. May not have mass. Dx often missed or delayed tx for dermatitis or infxn
Paget carcinoma
160
Most malignant form of breast CA
Inflammatory carcinoma
161
Red hot breast
Inflammatory carcinoma
162
Inflammatory carcinoma is often mistaken for:
Mastitis
| Refer for bxx if no response to ABX
163
Contractions of labor come in a regular pattern, ____-____ minutes apart, each lasting ____-____ seconds
3-5 minutes apart
| Last 30-60 seconds
164
Thinning of the cervix and cervical softening is due to: (2)
Increased water content
| Collagen lysis
165
Mucous plug often comes out as a result of _________ (bloody show)
Effacement
166
The fetus will usually start with ______ position, and will follow with the cardinal movements (7)
Left Occiput Anterior
| Engagement, descent, flexion, internal rotation, extension, external rotation, expulsion
167
Stages of Labor
1. Dilation/effacement
2. Pushing/Delivery
3. Placental Delivery
168
2 phases of the first stage of labor (dilation/effacement):
1. Latent phase: early effacement and dilation from 0-4 cm
2. Active phase: rapid effacement, most dilation occurs 6-fully dilated
As one goes into active phase, transitioning often occurs
169
What's involved in the second stage? (pushing/delivery)
Full dilation to delivery of the fetus
Pressure and desire to bear down
Molding of the fetal head
Cardinal movements
170
What's involved in the third stage? (placental delivery)
Separation of the placenta from the uterine wall begins
Usually takes 2-10 minutes
Gush of blood, lengthening of the umbilical cord, uterus becomes firm, very gentle traction on the cord, almost none
171
Failure of the myometrium to contract, leading to hemorrhage
Uterine Atony
172
Tx of uterine atony
Bimanual uterine massage
Uterine packing
Pitocin and Prostaglandins
Hysterectomy (last resort)
173
It is an absolute indication for a C/S if the uterine incision from a prior C/S is ____________________
Above the lower uterine segment
174
Procedure in which caregivers attempt to externally manipulate a fetus from breech to vertex. The father in gestation, the less likely to flip
External Cephalic Version
175
Methods of induction of labor
Membrane stripping
Amniotomy
Pitocin
Vaginal prostaglandins
176
Inflammation of the fetal membranes (amnion and chorion) due to a bacterial infxn. Most often associated with prolonged labor.
Chorioamnionitis
177
Chorioamnionitis is suspected when at least 2 of the following are present:
Fever
Fetal tachycardia
Uterine tenderness
Foul-smelling amniotic fluid
178
Tx of chorioamnionitis
```
IV ABX (continue for 24 hr after delivery)
Monitor fetus
Prompt delivery
```
179
Blood loss > 500 mL in the first 24 hours after vaginal delivery or > 1000 mL after a C/S
Early Postpartum Hemorrhage
180
Hemorrhage that occurs after the first 24 hours of delivery
Late Postpartum Hemorrhage
181
Causes of early postpartum hemorrhage:
```
Uterine Atony
Retained Placental Fragments
Placenta Accreta
Cervical or Uterine Lacerations
Inversion of the Uterus
Vulvar or Vaginal Hematomas
```
182
Postpartum hemorrhage due to a laceration from delivery - what's the action?
Get blood typed and crossmatched early in the process
Inspect entire lower birth canal
Suture any bleeders
Vaginal pack: remove and assess bleeding after 24-48 hrs
Blood replacement as needed
