General 8-23

Question 1

Rh negative and testing

Answer 1

1) Rosette: qualitative test to assess but can have false negatives
2) KB: acid elution test, with ghost cells (maternal)
3) Flow cytometry (radio labeled Ab to cells)

For increased volumes, you can give increased amount by IV, 600ug q8hours until dose is achieved.

Question 2

Thyroid nodule

Answer 2

Goal is to rule out malignancy
>/= 1cm -> FNA
Other indications for FNA (if the size is smaller than 1cm) is risks for cancer such as radiation to the neck history or family history

Radionucleotide thyroid scan- hot nodule is less likely to be malignancy

Obtain TSH

Question 3

General screening (non pregnancy) for DM

Answer 3

45 yo w/o risk factors, or 25 years old if BMI>25 with risk factors. Screen q3 years
Dx FBG >126 mg/dL
2hour 75g OGTT >= 200 mg/dL
random >/= 200 with symptoms
hub a1c >/= 6.5%

Question 4

Methimazole

Answer 4

Anti thyroid medication blocking t3 to t4 synthesis
Risks for fetus of aplasia cutis- :PTU [referred in the first trimester

Question 5

Cesarean delivery under local

Answer 5

0.5% lidocaine (4mg/kg) or with epinephritis (7mg/kg) (max 60cc) or w/o
O2 and EKG monitor with increased doses
midline vertical, minimal retraction?
skin. subcutaneous, viscera, parietal peritoneum
supportive care for lidocaine toxicity

Question 6

Chorio treatment (during and postpartum)

Answer 6

Ampgent 2g q6h and gentamicin 1.5mg/kg q8 hour OR 5-7 mg/kg q24hour

PP: gentamicin, clindamycin 900 mg q8h

Question 7

Mechanism of ursodiol

Answer 7

increases bile flow, competes for intestinal absorption

300mg q8hou

Question 8

Mechanism of glyburide

Answer 8

sulfonylurea- increase insulin sensitivity and release
max 20mg/day
1.25-2.5-5-10mg/day

Question 9

Risk of cord prolapse based on fetal presentation

Answer 9

cephalic/frank breech: 0.4-0.55
complete breech: 5%
footling breach: 15%

Question 10

Thyroid storm

Answer 10

Admit to the ICU
1) Thioamide: PTU 100mg -> 200mg
2) Iodide (lugol’s, KI)
3) Steroids, block T4-> t3
4) B-blockers: decreased sympathetic effect

Question 11

Inflixamab

Answer 11

Anti TNF alpha, monoclonal Ab, -> q8 week dosing usually

Question 12

breast candidiasis

Answer 12

Infant should be treated by peds
topical: miconazole
oral: diflucan 400mg PO x1 -> 200mg qd for 2 weeks

Question 13

KCL for cardioplegia

Answer 13

5-15cc of KCl (2meq/mL)

Question 14

Cysto procedure

Answer 14

30 or 70 degree score (esp for trigone)
5ml of indigo carmine 10-15 min prior

Insert - identify interureteric ridge, water for efflux, remove slowly to inspect uretrha

Question 15

alpha thal types

Answer 15

aa/aa normal
a-/aa asymptomatic carrier

a-/a- (African Am/African) - mild anemia
aa/– (cis) southeast asian

a-/–HbH
–/–Hb Barts hydrops. IUFD

Chromosome 16

Question 16

PPROM

Answer 16

Azithromycin 1mg PO x1
ampicillin 2g q6h -> 48 hours
amoxicillin 500mg q8h for 5 days

PCN allergic: (mild)
cefazoline 1g q8h x48 hours -0> reflex 500mg PO q6h x 5days
azithromycin 1gPO x1

PCN allergic (severe)
clindamycin 900mg q8h x 48h -> 300q8h x5da
gentamicin 7mg/kg x2 doses
azithromycin 1mg PO x1

Question 17

CMV and pregnancy:

Answer 17

0.2-2.2% of all neonates- the most common congenital infection

Question 18

HSV in pregnancy
treatment and suppression
transmission risk
neonatal HSV

Answer 18

tx valtrex 100mg BID x 10 days
suppression: valtrex 500mg BID starting at 36 weeks

transmission: 1’ near delivery 30-60%
2’ with lesions 3%, w/o 2/10K
neonatal: skin/eye/mouth, CNS, worst is disseminated CNS DIC and skin. can be trans placental but much more rare

Question 19

LSIL in pregnancy

Answer 19

Preferential: colposcopy in pregnancy (mostly to rule out high grade lesions or cancer)
can defer colposcopy for 6 wks PP

Question 20

types of cerclages

Answer 20

history: prior cerclage, cervical insufficiency, >/= 2 trimester losses
US: <25mm at 24 weeks (with prior history)
exam: <10mm OR cervical dilations- usually with no history of PTB
C

Question 21

Classical CD indications

Answer 21

preterm- can be up to 32 weeks if the LUS is not developed (such as FGR)
dense, extensive adhesions
Fibroids
+/- transverse with back down
post-mortem c/s (for maternal death)
3-7% rupture in the next pregnancy (possibly even up to 10%)

Question 22

Posplacental IUD

Answer 22

Ideally within 10 minutes of delivery of the placenta
20-35ry% of expulsions
Contraindications: endometritis, PAS

Question 23

Therapeutic anticoagulation
- dose antepartum
- intrapartum management

Answer 23

Lovenox 1mg/kg q12H
heparin: goal aPTT 1.5 2.5 (q12h dosing)
consider UFH at 36-37 weeks
- Lovenox d/c i 24 hours and then plan for delivery
if high risk (prosthetic heart valve, fib, PE), consider IV UFH in labor -< stopped for epidural (4-6) and before delivery

In labor:
24 hours stop Lovenox before epidural
UFH: 12 hours stopped before an epidural

Postpartum:
Resuming Lovenox dose:
4-6-12 VD
6-12 CD
Resuming UFD dose:
4-6-12 VD
12-24 CD

Question 24

Home birth

Answer 24

2-3x increased risk of neonatal death
no recommended by ACOG

Question 25

Respiratory disease: Flu TB CPAP (PNA) Asthma

Answer 25

Flu: PCR testing and treatment with oseltamivir (neuramidase inhibitor) in 48 hours within for symptoms 75mg PO for 5 days TB: LTBI for 3-4 months, postpartum treatment if the CXR is negative CPAP/PNA: S. pneumo, viruses, PO2>70, IV abx with ceftriaxone, aziithromycin- avoid fluroquinolones Asthma: acute keep O2>95%, if <90%, get an ABG albuterol q20minjutes and IV methyprednisone Long term meds: Budesonide: ICS Fluticason: ICS Advairr: fluticasone + salmeterol Symbicord: budesonide + formetrol

Question 26

cervical pregnancy or corneal pregnancy

Answer 26

cervical: asymmetrical distention of the cervix, US will show hourglass shaped uterus and ballooning of the cervical canal Treatment: excision of the mass, possible hysterectomy, placement of sutures, packing, UAE +/- med management but if medical management ,then needs to be managed inpatient for high risk of bleeding CORNUAL - XLAP, excision and uterine reconstruction (possible laparoscopically but will need a specialist) - NO ROOM FOR MED MANAGEMENT

Question 27

Gardasil vaccine

Answer 27

Covers HPV 6, 11, 16, 18, 31, 33 45, 52, 58 (9 subtypes) Ages 9-26(female) and males 13-21) - although ages have been now extended 3 months (0, 2, 6 months) 14-16 years old- only need 2 doses 0, 6, months Covers 10% HPV related cancers, 15% of cervical cancers does NOT cover condylomata - should be treated with TCA, imiquimod

Question 28

Molar pregnancy Imaging High risk factors for poor prognosis

Answer 28

Additional imaging: CT chest, pelvis, head Poor prognosis risk factors: HCG >40K before treatment >4 months from last pregnancy last pregnancy full term brain/liver mets prior chemo treatment for molar pregnancy TREATMENT a) no mets: Hysterectomy if childbearing is complete or MTX IM weekly until there are 2 negative readings b) Low risk mets: hysterectomy, single MTX +/- actinomycin c) High risk: EMA/CO treatment chemo

Question 29

FGR delivery timing

Answer 29

FGR 39 weeks Severe FGR: 37 FGR with elevated UAD 37 weeks sFGR with elevated UAD 36 weeks FGR absent 33-34 FGR reversed 30-32

Question 30

Maternal cardiac disease management - ante/intra/post

Answer 30

Ante: ECHO, WHO category, consultations Intra: strict I/O monitoring, L Lateral positioning, early epidural to prevent catecholamine surge with pain, +/- operative delivery, +/- telemetry Postpartum: telemetry, +/- diuresis

Question 31

Vesicovaginal fistula- non surgical initial managemen t

Answer 31

Foley catheter to decompress the bladder first If there is a small or high fistulae, this may spontaneously heal with a cathether keep the catheter in for 4-6 weeks If still draining despite conservative management -> give it a longer time to 12 weeks (to wait for all suture material to dissolve) and go for OR management with 3 layer closure technique: 1) excise the fistula 2) bladder submucosa 3) bladder muscularis 4) vaginal mucosa

Question 32

Lidocaine doses and side effects

Answer 32

LEEP: <10cc with 1% lidocaine c/s: 30cc of 1% w/o epi 60cc of 1% w/ api or double if 0.5% lidocaine 7mg/kg is the rough estimate side effects: metallic taste, oral numbness, tinnitus, speech changes, vision changes, AMS, seizures, arrhythmia, cardiac arrest

Question 33

Respiratory parameters intubation in the ICU(for asthma and other respiratory conditions)

Answer 33

PO2 <50 Pco2 >45 Ph <7.35 maternal exhaustion altered mental status

Question 34

steroids for mag neuroprotection

Answer 34

steroids: increase surfactant production max effect 2-7 days after BMZ BMZ more definitive effect on IVH improves: mortality, RDS, IVH, necrotizing enterocolitis Mag: stablizes blood pressure in the fetus and cerebral blood flow stabilized neuronal membranes 6-12 hours before birth improves: mortality, cerebral palsy

Question 35

twin breech extraction- inclusion criteria

Answer 35

Twin A must be cephalic 32 -39 weeks (or 28 weeks, pending 1500g cutoff) SVD does not have higher composite risk of adverse neonatal outcomes <20% weight discordance between the twins (namely, Twin B being larger than twin 1) at least 1500mg/28 weeks Give nitro 50-200mcg for uterine relaxation for breech extraction

Question 36

post term pregnancy

Answer 36

definition: >/= 42 weeks, 0.25% of pregnancy morbidity/mortalitiy - macrosomia risk - risk of dysmaturity and uteroplacental insufficiency - risk of meconium - seizures, CP, hypoglycemia mortality rate is increased by 2x

Question 37

Fetal OP and manual rotation

Answer 37

AP diameter occiput to town: 9.5 (ideal) occiput to front (11.5) occiput to mentum (13.5) -> OP Occurs 25% of the time in labor, of these 80-90% will spontaneously become OA 5-12% will be born OP without any intervention (and persistence) Management: Stage 2: Nullip: 1.5-2 hours multiple: 1 hours

Question 38

Fetal T21 and tests sen for NIPT

Answer 38

Extra chromosome 21 cfDNA sens 99.3%, spec 99.8% PPV: age 25: 33%, age 40 87% dysmorphia features, developmental delay findings: nuchal thickening, bowel, short humerus/femur, pyelectasis, duodenal atresia

Question 39

IV iron dosing

Answer 39

10-20cc/100mL NS -> do EFM for risk of anaphylaxis 20mg Fe/ML Required iron dose (mg) = (2.4 × (target Hb-actual Hb) × pre-pregnancy weight (kg)) + 1000 mg for replenishment of stores Equations : Total body iron deficit (mg) = body weight (kg) x (target Hb – actual Hb in g/dL) x 2.4 + iron depot (mg)** [1, 2] Iron depot: 15 mg/kg for body weight less than 35 kg 500 mg for those with a body weight greater than or equal to 35 kg Ideal Body Weight (kg) =45.5 +2.3 * (height inches - 60 inches) [3]

Question 40

SCD risks and treatment for SC crisis

Answer 40

Risks: PTL, PPROM, FGR, IUFD, infections, crisis, folate deficiency Crisis treatment: O2 sat >95%, IVF, pain medication (will need opioids), Hgb >10, HgA>40%, may need exchange transfusion

Question 41

Nephrotic syndrome and pregnancy and AC

Answer 41

Definition: >300mg protein/day (increased dues to increased FGR) glomerular dz treatment: - immunosuppression +/- - start LDA - limit Na intake 1.5g/day - +/- AC due to low albumin Risks: PEC, thrombosis in pregnancy or postpartum

Question 42

Vasa previa - types - % resolution - fetal blood volume - admission and delivery

Answer 42

Admission +/- 30 weeks Delivery at 34-35 weeks Types: I: velamentous II: bilobed III: branded out and returns (most rare) 15% may resolve by the 3TM there can be up to 60% perinatal mortality due to hemorrhage if undiagnosed Fetal blood volume: <100cc/kg clues on ultrasound: multi lobed, succenturiate, velamentous placental TVUS: FHR/doppler

Question 43

IgA nephropathy

Answer 43

most common cause of primary/idiopathic/ glomerulonephritis slow progression to ESRD Risks in pregnancy: HTN, age, proteinuria, race, ACEi Tx: optimized supportive care, HTN control, RAAS.ACEI , may. need immunosuppression with high risk Types: IgA with minimal change -> usually goes into remission IgA with AKI IgA with rapidly progressive glomerulonephritis Pregnancy: usually well tolerated if not rapidly progressing

Question 44

Rheumatic heart disease Mitral valve (bio prosthetic)

Answer 44

RHD - fever with group A strep (usually highest risk ages 5-15) - Sx present as JONES (2 major and 1 minor): joints, cardiac, nodules, erythema marginatum, syndeham chorea (hypotonia and movement) - cardiditis with MV damage, 10-20 years after and turns into MV stenosis - presenting symptoms: dyspnea, fib (causing thrombosis), WHO Class IV, can turn into increased L atrial pressure, dyspnea, pulmonary edema ***50% in pregnancy will progress to pulmonary edema and heart failure Tx: beta blockers diuretics AC (fib, thrombosis, prosthetic valve) Lovenox (mitral) Xa 1.0-1.2 Lovenox (aortic) Xa 0.8-1.0 UFH: 2-2.5 PTT

Question 45

Non-OB surgery in pregnancy

Answer 45

optimize for 2nd trimester <24 weeks needs FHR before and after >24 hours, EFM during surgery LSC consideration Fundal height, alternative port placement, LL til, 10-15mm Hg for abdominal pressure, +/- BMZ depending on the sickness of the patient and surgery needs

Question 46

Chronic hepatitis B

Answer 46

sAg +, hepbcag +, E ab (if positive- then high risk of transmission) Plan: - check VL, LFTs, GI and other hepatitis - check HIV - tenofovir 300mg -> 2x10^5 Vl copies - increased fetal risk of FGR, PtD, IUFD - Ensure there is no cirrhosis or varicose - okay for breastfeeding - HBIg +N vaccine for the newborn

Question 47

Maternal hydrocephalus - causes management and delivery

Answer 47

NPH: normal pressure hydrocephalus- increased ventricular size can affect dementia, gait, incontinence and may need a VP shunt Shunt complications: 25-50% (shunt occlusion) -> enlarging uterus -> increased ICP VD +/- shorten second stage with operative delivery consult neurology

Question 48

cardinal movements of labor

Answer 48

Engagement Descent Flexion Internal rotation Extension External rotation restitution expulsion

Question 49

hidradenitis suppurativa

Answer 49

it is a chronic inflammatory disease of apocrine glands (pelvic, axillary) - can have a secondary bacterial infection: S aureus, s pyrogens, gram negatives - can cause extensive scarring and formation of draining sinus Treatment: Clindamycin, orał micocyclie, tetracycline steroids (intralesional) Retinoinds cyclosporine Surgical: wide local excision

Question 50

Toxo

Answer 50

Toxoplasmosis - parasite from raw meat and cat feces - 1TM 10-15% transmission - 2TM 25% - 3TM: 60% or more Dx IgG /IgM Amnio PCR TX: spiramycin findings: ventriculomegaly, microcephaly, calcifications, hepatomeglaly, FGR

Question 51

CMV

Answer 51

30-40% with increased tramission in the 3TM IgG/M with PCR Findings of microcephaly, chorioretinitis

Question 52

VZV

Answer 52

treatment with Vz/ig FEtal findings of FGR, hydros, echogenic bowel, microcephaly

Question 53

Fetal weights 24 28 32 36 weeks

Answer 53

24 - 670g 28- 1210g 32 2000g 36 2800 40 3600