Gynecology Flashcards

Question

types of decidua?

Answer 1

Decidua basilaris: Basal plate of placenta at implantation site Decidua capsulris: overlying the developing embryo Decidua vera: remaining lining of uterine cavity

Answer 2

Syncythiotrophoblast cytotrophoblast extraembryonic mesoderm these three layers are also called chorion

Answer 3

connecting stalk - provide CT for the umbilical cord

Answer 4

The embryonic disc, which diff into: Epiblast Hypoblast

Answer 5

Syncytiotrophoblast invades the endometric tissue around day 9, resulting in rupture of maternal capillaries, and thus establishing an interface between maternal blood and embryonic extracellular fluid.

Answer 6

end of week 2

Answer 7

1. synsythiotrophoblast invades endometrium 2. cytotrophoblast invades synsytio 3. primary chorionic villi is formed 4. extraembryonic mesoderm invades villi 5. core of loose CT is formed 6. secondary villi is formed 7. 3rd week blood vessels form in villi 8. tertiary villi is formed 9. by day 17 maternal fetal circulation is formed

Answer 8

1. Evaluate the vulva 2. use speculum to see vagnal walls 3. Colposcope to look for abnormal tissue 4. Pap smear 5. Extended colposcope with acetic acid and iodine solution 6. Bimanual pelvic exam

Answer 9

Apply acetic acid solution and iodine solution to the surface to better visualize possible precancerous or cancerous lesions.

Answer 10

Acetic acid areas of whiteness correlate with higher nuclear density. The areas that appear white are considered for biopsy.

Answer 11

The squamocolumnar junction is a

Answer 12

To determine the size and nature of the uterus and the presence or absence of adnexal masses

Answer 13

Every 4th week until week 28 Every 2nd week from week 28-35 Every 1 week from week 35 and to birth If high risk every 1-2 week intervals

Answer 14

Full medical history Estimation of due date Physical examination Laboratory tests Patient education

Answer 15

A standard way of calculating the due date for a pregnancy: First day of last menstrual period – 3 months + 7 days (add 1 year) The result is approximately 280 days (40 weeks) from the start of the last menstrual period

Answer 16

First: 1-12 weeks Second: 13-27 weeks Third: 28- 40 weeks

Answer 17

# gravidities GTPAL # Gravidity numbers: total number of pregnancies # Term births # Preterm births # Abortions # Live children

Answer 18

8-9 days post conception in blood 28 days in urine 1st day of LMP (last mensens)

Answer 19

Double every 2nd day until week 10

Answer 20

Ectopic pregnancy Abortion Inaccurate dates

Answer 21

Multiple gestations Molar pregnancy Trisomy 21 Inaccurate dates

Answer 22

hCG hPL (human placental lactogen) CRH (corticotropin-release hormone) Prolactin Relaxin

Answer 23

Progesterone Estrogen Oxytocin

Answer 24

1. Increase from day 8-9 - peak at day 60-80 2. Secreted by trophoblastic cells of placenta 3. in beginning it maintain CL ensuring progesteron release until placeta takes over release

Answer 25

hCG producing tumors: - Hydatidiform mole - Choriocarcinoma - Embryonal carcinoma

Answer 26

No, due to the lack of the enzyme 17-a-hydroxylase, must use androgens as its source of precursor for estrogen production

Answer 27

Antagonizs the cellular action of insulin and decrease maternal glucose utilization, which increase glucose availability to the fetus. Low values are found with threatened abortion and IUGR

Answer 28

Made by the placenta, goes into fetal circulation at 12w stimulating ACTH which stimulates fetal adrenals to secrete DHEA's precursor to estrogen.

Answer 29

The main function of prolactin is stimulation of postpartum milk production

Answer 30

Associated with softening of the cervix, however, its primary function appears to be in promoting implantation of the embryo

Answer 31

In the luteal phase: Changes in the endometrium preparing it for egg implantation. In pregnancy: Higher levels induce decidual changes. It has a smooth muscle relaxant effect inhibiting early contractions of the myometrium

Answer 32

Up to 6th or 7th week of pregnancy: corpus luteum Thereafter the placenta begins to play the major role

Answer 33

1. Increase uterine blood flow 2. prepare breast tissue for lactation 3. stimulate production of hormone binding globulin in liver

Answer 34

causes uterine contractions, can be administered to induce or augment labor

Answer 35

the action of giving birth

Answer 36

can be divided into 4 phases

Answer 37

QUIESCENSE (inactivity): Myometrial activity is inhibited through pregnancy where progesteron plays a big role Braxton hicks contractions might happen

Answer 38

ACTIVATION - Last 6-8 weeks - Fetal maturity - fetal hypothalamus secretes CRH increasing ACTH and subsequent cortisol + androgen - Cortisol stimulate surfactant release - major lung surfactant protein (SP-A) into amniotic fluid stimulates labor

Answer 39

STIMULATION - Uterine contraction - Cervical ripening - Decidual/fetal membrane activation - drop in progesteron/rise in estrogen enhance expression of contraction ass proteins (CAP)

Answer 40

Connexin-43 (gap junctions - more contractions) Oxytocin receptors Prostaglandin receptors

Answer 41

enhances contractions

Answer 42

INVOLUTIN (puerperium) During expulsion of the fetus there is a dramatic increase in the release of maternal oxytocin which facilitates the initiation of the final phase of labor ▪ There is placental separation and continued uterine contractions

Answer 43

- Mother and child are immunologic aware of each other - Cytotoxic adaptive immune response is inactive

Answer 44

HLA IDO (indoleamine 2,3-dioxygenase)

Answer 45

Progesterone: high concentrations suppress maternal immune response by altering Th1/Th2 balance and inhibits production of TNF-a Prostaglandin E2: makes lymphocytes proliferate poorly

Answer 46

The extravillous trophoblasts migrate into the decidua do not express HLA-A or HLA-B class Ia antigens that are primary stimulators of classical graft rejection Instead display HLA-E, HLA-F and HLA-G HLA-E and HLA-G may dampen immune response by interacting with receptors on uterine NK-cells. HLA-G is also thought to promote release of anti-inflammatory cytokines such as IL-10, has a role in maintaining pregnancy

Answer 47

Promoting catabolism of tryptophan which is required for T cell function

Answer 48

Both the decidua and the placenta produce the active form of vitamin D, providing the fetus with a natural mechanism of immune surveillance

Answer 49

o Viruses: hepatitis, influenza, varicella, CMV, polio o Bacteria: listeria, streptococcus, gonorrhea, slamonella o Parasites: malaria, coccidioidomycosis

Answer 50

1. Increased metabolic demands 2. Expansion of vascular channels 3. Increase in steroid hormones

Answer 51

Increase in sodium and water retention resulting in an increase of TBW from 6 to 8L: 2/3 in the extravascular space. The plasma volume rises as early as week 5 and reaches a plateau around 32-34 weeks’ gestation

Answer 52

starts to increase at the beginning of 2nd trimester and continues to rise until delivery

Answer 53

Dilutional anemia results due to the increased in intravascular volume. Elevated EPO levels lead to a compensatory increase in total RBC mass, but never fully correct the anemia

Answer 54

Hb: non-pregnant: 12–14 g/L, pregnant: 10–14 g/L Hematocrit: non-pregnant: 36 – 46%, pregnant: 32 – 39%

Answer 55

Due to bone marrow hyperplasia (normally 10.000 leu, in pregnancy 12.000)

Answer 56

Fibrinogen is increased from 300 – 500/600 mg/dl Increase in factor VII, IX, X

Answer 57

Protects the mother from excessive blood loss at delivery but also predispose to thromboembolism

Answer 58

1. The heart is rotated anterior, upwards and left, 2. It is enlarged due to muscle hypertrophy 3. A soft systolic murmur may be heard (S3) 4. The pulse rate is increased 5. Blood pressure should not normally increase

Answer 59

Cardiac output rises by the 10th week of gestation Reaching about 40% above nonpregnant levels by 20-24 weeks

Answer 60

Early in pregnancy progesterone decrease SVR → decreased BP → increased CO (compensation) It is primarily due to increase in SV and to a lesser extent, heart rate CO = HR x SV

Answer 61

Blood flow to most regions of the body increase, while the 2 organs with the highest increase are the kidney and the skin (due to increased need for waste elimination)

Answer 62

The nonpregnant uterus usually receive around 2% of CO while the uterus at term receives as much as 17%

Answer 63

1. The mechanical effects of the enlarging uterus 2. The increased total body O2 consumption 3. The respiratory stimulant effects of progesterone (increase)

Answer 64

1. Diaphragm at rest rises 4cm above usual resting position 2. The ribs flare outwards enlarging the chest by 2cm This results in less negative intrathoracic pressure and a decrease in resting lung volume (decreased FRC) There is no change in diaphragmatic muscle motion so the vital capacity remains unchanged No change is RF but there is increased tidal volume resulting in a rise in minute ventilation

Answer 65

analogous to changes seen in pneumoperitoneum

Answer 66

Total body O2 increases by 15-20% in pregnancy CO2 decreased to 27-32 mmHg (normal 35-40mmHg)

Answer 67

Undergoes marked dilation in the 1st trimester and may persist until the 12th postpartum week. Obstruction by the pregnant uterus may result in hydronephrosis

Answer 68

Progesterone appears to produce smooth muscle relaxation in various organs, including the ureters

Answer 69

RBF and GFR increase early in pregnancy and reaches a maximum plateau level of at least 40-50% above normal by mid-gestation

Answer 70

The elevated GFR is reflected in lower serum levels of creatinine and urea nitrogen

Answer 71

Glycosuria can be normal due to the increased GFR resulting in decreased resorption of glucose, but the patient should be tested for gestational diabetes

Answer 72

Increase in bladder capacity from 400ml – 1500ml Frequent urination is common due to compression The bladder is pulled up in the abdomen and caution is important during a C-section

Answer 73

There is an elevated renin concentration, which is produced by the kidneys, uterus and placenta leading to a 40% increase in blood volume.

Answer 74

Thyroid binding globulin increase + slight thyroid enlargement and an overall increase in hormone production but free T3 and T4 remains the same

Answer 75

Serum calcium decrease leading to an increase in PTH Causing conversion of cholecalciferol (vitamin D3) to its active metabolite increasing intestinal absorption of calcium

Answer 76

The pituitary grows in size and demand, this increase the risk for Sheehan’s syndrome (ischemic necrosis due to blood loss and hypovolemic shock during and after childbirth)

Answer 77

Chronic hypertension Gestational hypertension Preeclampsia Eclampsia

Answer 78

1. Systolic BP ≥ 140 OR diastolic BP ≥ 90 on 2 separate measurements at least 4 hours apart 2. Diagnosed post 20w' gestation, no prior history of HTN 3. Does not persist longer than 12 weeks postpartum.

Answer 79

Hypertension diagnosed before pregnancy or in the first 20 weeks of pregnancy

Answer 80

Systolic BP > 160 OR diastolic BP > 110 that persists for ≥ 15 min

Answer 81

1. New-onset gestational HTN with proteinuria or end-organ dysfunction 2. Preeclampsia that occurs in a patient with chronic hypertension

Answer 82

A life-threatening form of preeclampsia characterized by: Hemolysis Elevated Liver enzymes Low Platelets

Answer 83

Gestational trophoblastic disease

Answer 84

New-onset seizures (tonic-clonic, focal, or multifocal) in the absence of other causes; a convulsive manifestation of hypertensive pregnancy disorders

Answer 85

- Hypertension that persists after delivery - Generally resolves within 12 weeks. - If it lasts > 12 w pp, 2nd cause should be considered.

Answer 86

Thrombophilia < 20 or > 35 years of age Black individuals Diabetes mellitus or gestational diabetes Chronic hypertension Chronic renal disease Obesity (BMI ≥ 30) Previous preeclampsia Nulliparity Multiple gestation (twins)

Answer 87

Uterine spiral arteries normally develop into high-capacity blood vessels. This process is defective in patients with preeclampsia, Arterial hypertension with systemic vasoconstriction causes placental hypoperfusion → release of vasoactive substances → ↑ maternal blood pressure to ensure sufficient blood supply of the fetus

Answer 88

Preeclampsia: multiorgan involvement (primarily renal) Eclampsia: predominantly cerebral involvement HELLP syndrome: severe systemic inflammation with multiorgan hemorrhage and necrosis (thrombotic microangiopathy of liver)

Answer 89

Mild: BP > 140/90 + proteinuria > 300mg/day after 20th week Severe: BP > 160/110 + proteinuria > 5g/day after 20th week - Thrombocytopenia (platelets < 100,000 cells) - Serum creatinine > 1.1 mg/dL OR double of serum creatinine - Liver tests x2 times the ULN of transaminases

Answer 90

Deterioration with headaches, RUQ pain, hyperreflexia, and visual changes

Answer 91

Asymptomatic hypertension Nonspecific symptoms (morning headaches, fatigue, dizziness)

Answer 92

Preeclampsia without severe features - Usually asymptomatic Severe preeclampsia: - Severe hypertension - Proteinuria, oliguria - Headache - Visual disturbances (blurred vision, scotoma) - RUQ or epigastric pain - Pulmonary edema - Cerebral symptoms (altered mental status)

Answer 93

Preeclampsia usually present (∼ 85%) Nonspecific symptoms: nausea, vomiting, diarrhea RUQ pain (liver capsule pain; liver hematoma) Rapid clinical deterioration (DIC, pulmonary edema, acute renal failure, stroke, abruptio placentae)

Answer 94

Onset: The majority of cases occur intrapartum and postpartum. Most often associated with severe preeclampsia Eclamptic seizures: generalized tonic-clonic seizures (usually self-limited)

Answer 95

H = Hemolysis (↓ Hb, ↓ haptoglobin, ↑ LDH, and ↑ in-bilirubin) EL = Elevated Liver enzymes (↑ AST, ↑ ALT) LP = Low Platelets (< 100,000 cells/mm3)

Answer 96

Renal function: RBF and GFR are significantly lower due to constriction of afferent arteriole system (may result in damage to the glomerular membrane → proteinuria)

Answer 97

only treatment is delivery If > 37weeks → IV Mg sulfate (seizure prophylaxis) and deliver If < 37 weeks: weigh risk: benefit; if no signs of fetal compromise and the disease is not severe → wait with close monitoring until 37w

Answer 98

▪ Are the features of the disease process severe? ▪ Is there evidence of fetal compromise (IUGR, oligohydramnios, HR abnormalities) Is the fetus mature for uncomplicated course after delivery

Answer 99

1. Cardiotocography (CTG): monitor fetal HR and uterine contractions 2. Ultrasound

Answer 100

1. Place patient in the left lateral decubitus position to prevent placental hypoperfusion due to IVC compression 2. Start anticonvulsive therapy: first line: Mg-sulfate 3. Start antihypertensives for urgent blood pressure control 4. Indication for acute delivery regardless of gestational age

Answer 101

1. Administer blood products (platelets, PRBCs, FFP) as needed 2. Initiate anti HTN for urgent blood pressure control 3. Administer magnesium sulfate for seizure prophylaxis. 4. Delivery is indicated for all patients regardless ≥ 34 weeks' gestation: Deliver immediately. 24–34 weeks' gestation: Administer corticosteroids for lung maturity. Delivery may be delayed until 24–48 hours after administration if maternal and fetal status remains stable.

Answer 102

Parenteral labetalol Nifedipine (immediate release) Parenteral hydralazine

Answer 103

Avoid ACE inhibitors and angiotensin receptor blockers during pregnancy (especially during the 1st trimester) because of their teratogenic effect.

Answer 104

“Hypertensive Moms Need Love”: Hydralazine, Methyldopa, Nifedipine, or Labetalol

Answer 105

All patients receiving magnesium need close monitoring (including continuous telemetry) for signs of hypermagnesemia.

Answer 106

Aspirin for preeclampsia prophylaxis ≥ 1 high-risk or ≥ 2 moderate-risk factors for preeclampsia. Initiate low-dose aspirin between 12–20 weeks' gestation

Answer 107

Placental abruption DIC Cerebral hemorrhage, ischemic stroke Acute respiratory distress syndrome (ARDS) Acute renal failure

Answer 108

Occur due to insufficient placental perfusion Fetal growth restriction Preterm birth Seizure-induced fetal hypoxia Fetal death

Answer 109

Presumptive signs Probable signs Positive signs First signs Later phases complaints and signs

Answer 110

1. Chadwick’s sign: bluish discoloration of the cervix and vagina due to pelvic vasculature engorgement (6th week) 2. Pigmentation of the skin and abdomen o Most common sites for pigmentation are the midline of the lower abdomen (linea nigra), over the bridge of the nose, and under the eyes (chloasma)

Answer 111

Those mainly related to changes in the uterus - Piskacek sign: soft prominence over the site of implantation- - Goodell’s sign: softening of the cervix (4-6 weeks) - Hegar’s sign: softening of the cervical isthmus (6-8 weeks) - Positive home urine pregnancy test

Answer 112

- Detection of a fetal heartbeat o Endovaginal US is capable of detecting fetal cardiac activity as early as 6 weeks o Doppler techniques can detect fetal heart beat between 9-12 weeks o Fetal heart tones can be detected with a stethoscope between 16-20 weeks - Recognition of fetal movement o Endovaginal US is capable of detecting fetal movement from about 7-8 weeks’ gestation o The multiparous woman generally recognize fetal movement between 15-17 weeks o The primipara women usually does not recognize fetal movements until week 18-20

Answer 113

Endovaginal US: as early as 6 weeks Doppler techniques: 9-12 weeks Fetal heart tones can be detected with a stethoscope 16-20w

Answer 114

1. Cessation of menstruation 2. Nausea, vomiting 3. Breast tenderness (mastodynia) and enlargement 4. Frequent urination 5. Weakness and fatigue 6. Changes in eating habits: eating a lot is ok but healthy 7. Changes in sensation: common to be sensitive to smell

Answer 115

Due to a combination of relaxing effect of progesterone on the bladder and pressure exerted on the bladder by the enlarged uterus

Answer 116

When lying in the supine position the uterus compress the IVC In most women there will be a compensatory rice in peripheral resistance to minimize the pressure fall In around 10% a significant fall occur leading to nausea, dizziness and discomfort for the mother ▪ The syndrome is relieved by changing position to the left side (greater VR)

Answer 117

1. Difficulty sleeping 2. Inferior vena cava syndrome 3. Hemorrhoids 4. Predisposition to thrombosis 5. Edema 6. Poseiro effect 7. Frequent urination due to compression on bladder 8. Fetal heart sound 9. Fetal movement: after 18-20th gestational week 10. Palpable fetal body parts 11. Constipation 12. Tachypnoe 13. Galactorrhea 14. Weight gain

Answer 118

Late in the pregnancy the uterus may compress the aorta and its branches resulting in lower pressure in the femoral artery compared with the brachial artery. The compression may cause fetal distress when supine

Answer 119

Normal weight gain is 9-14 kg skinny mom: SMA Obese mom: LGA

Answer 120

Edema might be the first sign of preeclampsia and must be taken very seriously. It can occur fast (within 5-10days) and it may increase the mothers weight with 4-5kg

Answer 121

Naegele rule First-trimester US: estimation is based on crown-rump length Second-trimester US: estimation based on fetal biometric parameters

Answer 122

12th Just above the symphysis 16th Between the symphysis and navel 20– 24th Navel 32nd Between the navel and xiphoid 36th Peak: at the costal arch 40th Two finger widths below the costal arch

Answer 123

Measured from top of pubic symphysis to top of the uterus. Fundal height can be used to monitor fetal growth or to roughly estimate gestational age in an emergency. Screen all patients > 24 weeks' gestation for fetal growth abnormalities using symphysis fundal height. From 20 weeks, fundal height in centimeters should roughly approximate the week of gestation

Answer 124

1. First-trimester US is performed to estimate gestational age and assess for complications 2. Second-trimester US is recommended between 18–22 weeks to assess fetal anatomy. 3. Additional US may be performed for further evaluation of potential pregnancy complications,

Answer 125

Trisomy 21: Downs Trisomy 18: Edwards Trisomy 13: Patau

Answer 126

Ischemic heart disease Cardiac arrhythmias Rheumatic heart disease Congenital heart disease

Answer 127

Impaired glucose tolerance diagnosed during pregnancy Associated with an increased risk of maternal and fetal morbidity Usually in the second and third trimesters

Answer 128

The insulin requirement varies during pregnancy. In the first trimester, insulin sensitivity increases and there is a tendency towards hypoglycemia. In the second and third trimesters, hormonal changes trigger progressive insulin resistance that results in hyperglycemia, particularly after mealtimes.

Answer 129

Mothers usually asymptomatic or may present with edema. Warning signs include: Polyhydramnios Large-for-gestational age infants (> 90thpercentile)

Answer 130

1. Dietary modifications and regular exercise (walking) 2. Strict blood glucose monitoring (4x daily) 3. Insulin therapy if glycemic control is insufficient with diet 4. Regular ultrasound to evaluate fetal development 5. Consider inducing delivery at week 39–40, if glycemic control is poor or if complications occur

Answer 131

Metformin and glyburide

Answer 132

Early pregnancy loss and perinatal death Transposition of the great vessels Ventricular septal defect Truncus arteriosus Coarctation of the aorta Patent ductus arteriosus Spina bifida Renal agenesis Anorectal malformations

Answer 133

Human placental lactogen Progesterone Prolactin Cortisol

Answer 134

Step 1: universal screening between 24-28 weeks’ gestation with a 50g OGCT (measure after 1h) In women with risk factors screening at 1st prenatal visit If there are symptomsfasting glucose should be checked first If a 1st trimester screen is done and found to be negative, it should be repeated at 24-28 weeks

Answer 135

Performing a diagnostic 3-hour 100g OGTT Fasting glucose is checked after overnight fast Then the patient consume 100g glucose drink Levels are checked hourly for 3h If x2 abnormal values the patient is diagnosed with GDM

Answer 136

o Patients < 80% of ideal body weight: 35-40kcal/kg o Patients 80-120% of ideal body weight: 30kcal/kg o Patients > 120-150% of ideal body weight: 24 kcal/kg o Diet composed of 45-50% carb, 20-25% protein, 20-25% fat o 20% breakfast, 30% lunch, 30% dinner, 20% bedtime snack

Answer 137

Insulin is the best of choice, does not cross the placenta A combination of rapid- or short-acting (lispro or regular) and intermediate-acting (NPH) insulin is usually given

Answer 138

o Detailed obstetric US study, fetal echocardiogram, and maternal serum a-FP should be obtained in the 2nd trimester to check for congenital malformations o Maternal renal, cardiac, and ocular function must be closely monitored o Glycosylated hemoglobin should be measured every trimester o Antenatal testing with the following should be done weekly from 32 weeks to delivery: nonstress tests, biophysical profiles and kick counts

Answer 139

C-section may be elected for large fetuses (>4500g)

Answer 140

Euglycemia is necessary during labor and plasma glucose levels are measured frequently, and if elevated, a continuous infusion of regular insulin is given and dose is adjusted as needed to maintain levels between 4.4 – 6.7 mmol/l

Answer 141

1. Glucose crosses the placenta causing fetal hyperglycemia result in fetal hyperinsulinemia 2. Major congenital malformations and spontaneous abortion 3. Fetal macrosomia, preeclampsia, spontaneous abortion, shoulder dystocia, arrested labor. 4. Hypoglycemia: after delivery IV glucagon must be given

Answer 142

Pregnancy not often worsen renal disorders, it seems to only exacerbate noninfectious renal disorders when uncontrolled hypertension coexists

Answer 143

the kidney has been in place for > 2years, normal renal function, no episodes of rejection, normal BP

Answer 144

Women with severe renal insufficiency may require hospitalization after 28 weeks’ gestation for bed rest, BP control, and close fetal monitoring. Cesarean delivery is very common, although vaginal delivery is possible

Answer 145

UTI, mostly asymptomatic bacteriuria, so must be screened. Due to increased urinary stasis from mechanical and hormonal (progesterone) factors Organisms include GBS as well as those that occur in non-pregnant women

Answer 146

Yes, due to increased risk of pyelonephritis and preterm laboure

Answer 147

First line: amoxicillin - alternatives: nitrofurantoin or cephalosporins. If pyelonephritis hospitalization and IV antibiotics

Answer 148

Increased risk of preterm labor and premature rupture of membranes with UTIs and asymptomatic bacteriuriaGI

Answer 149

Hyperemesis gravidarum GERD (gastroesophageal reflux disease) Acid aspiration syndrome (Mendelson syndrome) IBD (Crohns disease and ulcerative colitis) Acute fatty liver of pregnancy

Answer 150

Severe, persistent nausea and vomiting associated with a > 5% loss of prepregnancy weight and ketonuria with no other identifiable cause. The overall incidence is about 1-2%

Answer 151

Multiple gestation Hydatidiform mole Nulliparity Migraine headaches GERD

Answer 152

Pyridoxine (vitamin B6) and/or doxylamine Refractory symptoms, add Diphenhydramine For refractory symptoms despite combination therapy add Metoclopramide

Answer 153

Progesterone has an smooth muscle relaxant effect resulting in decreased sphincter tone + increased residual volume in the stomach (due to increased emptying time)

Answer 154

Sucralfate is useful in pregnancy: no apparent fetal toxicity If no respons give PPI omeprazole)

Answer 155

Labor increase risk of regurgitation and acid aspiration of gastric content due to delayed gastric emptying and increased intraabdominal and intragastric pressures

Answer 156

Damage to the pulmonary tissue (which may cause ARDS) is greatest when the pH of aspiration fluid is < 2.5 or the volume of aspiration is >25ml

Answer 157

Preventive efforts include nothing-by-mouth during labor and no food intake for at least 6h before elective c-section

Answer 158

Anemia of pregnancy Thromboembolic disorders Gestational thrombocytopenia (rare)

Answer 159

Hb < 10g/dl and Hct < 30%

Answer 160

Microscytic IDA Responsible for 80% of non-physiologic anemia Varies from 0.5-25% depending on region, population, and diet

Answer 161

Prevention (non-anemic): 30 mg elemental iron/d (met by most prenatal vitamins) Treatment (anemic): 30-120 mg elemental iron/d OR Iron dextran 100mg IM every other day 10x over 3w 325 mg ferrous fumarate = 106 mg elemental Fe

Answer 162

Prevention: 0.4-1 mg folic acid PO daily for 1-3 mo preconceptually and throughout first trimester Treat with folate 1mg po twice/day

Answer 163

Hypercoagulability Stasis Endothelial damage during delivery

Answer 164

Increased risk of VTE throughout pregnancy with highest risk of DVT in T3 and post-partum period; highest risk of PE post-partum (First 6 weeks)

Answer 165

LMWH preferred: should be stopped 24 h prior to delivery Warfarin is CI in pregnancy due to potential teratogenic effects

Answer 166

Spontaneous loss: of pregnancy < 24 weeks' gestation Early pregnancy loss: spontaneous loss before 13 weeks' Recurrent pregnancy loss: two or more losses before 20w

Answer 167

Abnormalities of the reproductive organs Septate uterus Uterine leiomyomas Uterine adhesions Cervical incompetence

Answer 168

Diabetes mellitus Hyperthyroidism/hypothyroidism Infections Hypercoagulability (antiphospholipid syndrome, which is associated with recurrent miscarriages)

Answer 169

Chromosomal abnormalities account for 50% of abortions. Congenital anomalies Anembryonic pregnancy

Answer 170

20-30% of women with confirmed pregnancies bleed during the first 20 weeks, and half of these women spontaneously abort, thus incidence of spontaneous abortions is about 10-15% of confirmed pregnancies

Answer 171

1. Speculum exam - Assess for cervical dilatation and retained POC. - Confirm that the source of bleeding is uterine. 2. Transvaginal ultrasound - Absence of fetal heart sounds 3. Laboratory studies - Serial serum β-hCG: Downtrending levels

Answer 172

Expectant management: Symptoms will resolve or progress to inevitable, incomplete, or complete abortion. Advise the patient to avoid strenuous physical activity. Repeat pelvic ultrasound in one week.

Answer 173

1. Expectant management 2. Medical evacuation Misoprostol is used to induce cervical ripening and expulsion of the products of conception. 3. Surgical evacuation Indicated for septic abortion, heavy bleeding, or if there are maternal comorbidities

Answer 174

vaginal bleeding occurring < 20week gestation without cervical dilation, usually no pain, indicating that spontaneous abortion may occur, do US to confirm everything is ok

Answer 175

vaginal bleeding or rupture of the membranes accompanied by dilation of the cervix, emergency aspiration must be done

Answer 176

Septic abortion: serious infection (most commonly S,aureus, E.coli and bacteroids) of the uterine contents during or shortly before or after an abortion, give antibiotics and evacuate

Answer 177

Live birth between 20 weeks' and 36 weeks gestation Extremely preterm < 28 weeks Very preterm 28 to 32 weeks Moderate to late preterm 32 to 37 weeks

Answer 178

Complications of preterm birth are the leading cause of death in children < 5 years of age worldwide.

Answer 179

History of preterm birth (greatest risk factor) Cervical insufficiency Short cervical length Multiple gestations Polyhydramnios Preterm premature rupture of membranes (PPROM) Antepartum hemorrhage

Answer 180

Maternal and fetal conditions Infections (urinary tract infections, STIs, vaginal infections) Hypertensive pregnancy disorders (preeclampsia, HELLP) Diabetes mellitus, gestational diabetes Lifestyle and environmental factors: Smoking Substance use (heavy alcohol use, heroin, cocaine) Maternal or fetal stress Maternal age (≤ 18 years, > 35 years) Low maternal prepregnancy weight Short interval between pregnancies (< 18 months)

Answer 181

Transvaginal ultrasound: Cervical length > 3 cm indicates a low likelihood of delivery within 14 days Cervicovaginal fetal fibronectin (fFN) test: Elevated levels in cervical secretions associated with increased risk of preterm delivery. Clinically based on preterm contractions and cervical changes.

Answer 182

Documented uterine contractions (4/20min or 8/60min) Documented cervical change (cervical effacement of 80% or cervical dilation of > 2cm)

Answer 183

34 -36 weeks' gestation: Proceed with normal delivery. < 34 weeks' gestation: consider tocolysis to inhibit uterine contractions and administer steroids for induction of fetal lung maturity. Administer antibiotic prophylaxis for PPROM. < 32 weeks' gestation: Consider magnesium sulfate for fetal neuroprotection.

Answer 184

To inhibit uterine contractions and prolong pregnancy to allow for induction of fetal lung maturity and/or transfer to another medical center, if necessary. Duration: up to 48 hours

Answer 185

Nifedipine (CCB, No known adverse effects on fetus) Indomethacin (NSAID) Terbutaline (beta-2 adrenergic agonist)

Answer 186

Administration of antenatal steroids to promote the production of surfactant and thereby improve neonatal survival and fetal lung maturity

Answer 187

Betamethasone Dexamethasone

Answer 188

administration of antenatal magnesium sulfate to reduce the risk and severity of neurological disorders (e.g., cerebral palsy) Indication: preterm labor at < 32 weeks' gestation

Answer 189

GBS prophylaxis PPROM antibiotic prophylaxis

Answer 190

low birth weight (<2500g), IRDS, necrotizing enterocolitis, intraventricular hemorrhage, and sepsis

Answer 191

At the 18-20 week checkup, the length of the cervix should be checked, and women with shortened cervix (10-20mm) should receive vaginal progesterone 200mg daily from 19-20 weeks until 36 weeks

Answer 192

CBC, random blood glucose levels, serum electrolyte levels, urinalysis and urine culture - Anovaginal cultures for group B streptococci and prophylaxis initiated if necessary - Cervical cultures to check STDs if suggested by clinical findings - US should be done to assess fetal weight, presentation, assess cervical length and rule out the presence of any accompanying congenital malformations

Answer 193

o Penicillin G or ampicillin IV o Clindamycin or erythromycin if penicillin allergy

Answer 194

Lower than normal fetal growth characterized by an estimated fetal weight below the 10th percentile for a given gestational age.

Answer 195

Substance use (alcohol, cigarettes, cocaine, heroin) Teratogenic drugs: ACEi, carbamazepine, phenytoin, warfarin Maternal phenylketonuria

Answer 196

Placental insufficiency (most common cause in the US) Placenta previa Multiple gestations Placental abruption Umbilical artery thrombosis/extensive infarction Uterine malformations (e.g., fibroids)

Answer 197

Fetal factors Genetic abnormalities in the fetus (e.g., aneuploidy) Cyanotic congenital heart defects Early intrauterine infections (TORCH)

Answer 198

Asymmetrical IUGR: most common IUGR (∼ 70%) - Weight, length and head circumference all < 10th percentile - Caused by extrinsic factors - Late onset, usually due to maternal systemic disease (hypertension) that results in placental insufficiency. Symmetrical IUGR is less common (∼ 30%) - Weight < 10th perc, head circumference and length preserved - Caused by intrinsic factors - Early onset, usually due to a genetic disorder (aneuploidy), congenital heart disease, or early intrauterine TORCH infection

Answer 199

Serial ultrasonography: - Decreased fetal growth, weight below the 10thpercentile - Oligohydramnios Doppler velocimetry of the umbilical artery: - Reduced or reversed diastolic flow; ↑ systolic/diastolic ratio Nonstress test: - Late decelerations of the fetal heartbeat, bradycardia

Answer 200

1. Treatment of the underlying condition 2. Close monitoring of fetal status and placental development 3. If non-reassuring fetal status induce labor or cesarean 4. If the infant is < 34 weeks gestation and close to delivery, administer steroids 48 hours before inducing labor.

Answer 201

Serial uterine fundal height measurements serves as primary screening, if the height lags >3cm behind expectations, US should be done.

Answer 202

Irregular, uncoordinated uterine contractions of moderate intensity (helps with fetal positioning) Frequency: typically ≤ 2 times/hour Duration: ≤ 1 minute Do not increase in frequency, intensity, or duration Cervical changes are absent.

Answer 203

Thinning of the cervix that occurs during labor; usually reported in percentages Cervix effaces and shortens → cervical dilation Bloody show: A blood-tinged mucous plug may be discharged when the cervix shortens and dilates. Spontaneous ROM Delayed ROM

Answer 204

as a result of increased water content and collagen lysis

Answer 205

1st stage - Latent stage: onset of labor til 6 cm dilation - Active stage: from 6cm til 10 cm 2nd stage: completey dilated cervix and ends with the birth 3rd stage: until complete expulsion of the placenta 4th stage: the 1–2 hour postpartum period

Answer 206

Alvarez-waves Braxton Hicks contractions (false labor) Prelabor contractions Stage 1: cervical dilation and effacement Stage 2: fetal expulsion Stage 3: placental expulsion or afterbirth Afterpains

Answer 207

physiological after week 20 Low intensity, high frequency

Answer 208

Irregular contractions of high intensity, which occur every 5–10 min shortly before phase 1 begins. They are responsible for correctly positioning the fetal head in the pelvis.

Answer 209

Coordinated, regular, rhythmic contractions of high intensity Occur approximately every 10 minutes. Shortly before stage 2 they occur every 2–3 min. These contractions are responsible for cervical dilation.

Answer 210

Coordinated and regular contractions of high intensity; occur approximately every 4–10 min and are responsible for fetal expulsion. Towards the end of the stage, they occur very often (every 2–3 minutes) and are of higher intensity (≥ 200 Montevideo units).

Answer 211

Irregular contractions of very low intensity, which force the placenta through the vaginal canal within 30 min after fetal expulsion

Answer 212

Active phase disorders Second stage disorders

Answer 213

Divided into either a slower-than normal progress (protraction disorder), or a complete cessation of progress (arrest disorder) Active-phase arrest is defined as no dilation for 2h and is most commonly due to inadequate uterine contractions o Protraction disorders are less well described, and the diagnosis is often made in retrospect

Answer 214

Disproportion of the fetus and pelvis frequently becomes apparent during the 2nd stage o Maternal pushing efforts may also be reduced due to analgesia or exhaustion

Answer 215

Hypotonic uterine dysfunction (more common): Hypertonic contractions

Answer 216

o Contractions have normal gradient pattern, but the pressure during a contraction is insufficient to cause cervical dilation o Treatment: amniotomy, augmentation with oxytocin, assisted vaginal delivery or section

Answer 217

o The contractions are irregular and painful o High uterine P, may result in maternal and/or fetal distress o Treatment: analgesics (morphine/epidural), nifedipine, move o Colicky uterus with uncoordinated contractions o Hyperactive lower segment (abnormal gradient pattern)

Answer 218

A significantly larger-than-average fetus, defined as birth weight > 90th percentile or > 4,000 g

Answer 219

Expected patterns of descent of the presenting part and cervical dilatation fail to occur in the appropriate time frame. * During active phase: > 4 h of < 0.5 cm/h * During 2nd stage: > 1 h with no descent during active pushing

Answer 220

the 4 P's 1. Power: contractions (hypotonic, uncoordinated) * Passenger: fetal position, size, anomalies (hydrocephalus) * Passage: pelvic structure, tumours, full bladder or rectum * Psyche: hormones released in response to stress

Answer 221

cephalic, vertex, occipitoanterior

Answer 222

1. Any presentation or lie that is not the cephalic presentation 2. Fetal position where fetus is in cephalic presentation but not oriented anteriorly

Answer 223

Frank breech Complete breech Single footling breech Double footling breech

Answer 224

Both hips and knees are flexed with the feet close to the buttocks.

Answer 225

This malpresentation is characterized by flexed hips and extended knees. The buttocks of the baby are directed towards the birth canal.

Answer 226

one foot/leg is stretched to be delivered first.

Answer 227

both feet/legs are stretched to be delivered first.

Answer 228

Occiput posterior position Occiput transverse position

Answer 229

Fetal lie: long axis of the fetus related to long axis of the uterus Fetal presentation: fetal part presenting at pelvic inlet Fetal position: position of presenting part relative to pelvis

Answer 230

Occipitoanterior (OA): normal (left more common than right) Occipitoposterior: most rotate spontaneously to OA Occipitotransverse: leads to arrest of dilation

Answer 231

o Vertex (flexed): normal o Brow: head partially extended o Face: head fully extended

Answer 232

5-15% present in OP presentation, however, it is the most common abnormal presentation Tends to prolong 2ns stage and is more painfull A wide mediolateral episiotomy may be required

Answer 233

< 37 weeks: no intervention necessary, as most fetuses spontaneously convert to cephalic presentation closer to term ≥ 37 weeks: Consider external cephalic version. A planned cesarean delivery may be necessary if external cephalic version not performed, unsuccessful, or CI

Answer 234

Indications for cesarean delivery Placental abruption Nonreassuring fetal status Active labor or ruptured membranes Oligohydramnios

Answer 235

Birth asphyxia Infection (intrauterine and neonatal) Intracranial hemorrhage Birth injuries Perinatal death

Answer 236

An obstetric emergency in which the anterior shoulder of the fetus becomes impacted behind the maternal pubic symphysis during vaginal delivery

Answer 237

History of shoulder dystocia Fetal macrosomia Maternal diabetes mellitus or gestational diabetes Maternal obesity Prolonged second stage of labor

Answer 238

Inability to deliver shoulder with downward traction on the fetus Turtle sign: retraction of the partially delivered fetal head

Answer 239

1. McRoberts maneuver (mother hip rotation) Then: 2. Rubin II maneuver 3. Woods corkscrew maneuver 4. Zavanelli maneuver: head is pushed back into pelvis for a section to be done OR last resort intentional clavicular fracture

Answer 240

Diabetes mellitus in pregnancy Previous macrosomic fetus Multiparity Maternal obesity Excessive gestational weight gain Maternal birth weight (> 4,000 g) Postterm pregnancy

Answer 241

Birth injuries (shoulder dystocia, brachial plexus injury) Acute respiratory distress, transient tachypnea of the newborn Neonatal hyperbilirubinemia Neonatal polycythemia Neonatal hypoglycemia

Answer 242

Brachial plexus palsy (most commonly Erb palsy, less commonly Klumpes palsy), Clavicle fracture

Answer 243

Gynecoid Anthropoid Android Plateylpelloid

Answer 244

The fetal size is disproportionately large for the maternal pelvis. Can result in a prolonged second stage of labor

Answer 245

Because of its spacious inlet, large interspinous diameter, and wide subpubic arch, the gynecoid pelvis is the most suitable for vaginal birth. In general, the gynecoid and anthropoid pelvises are acceptably favorable; however, the android and platypelloid are known to be suboptimal.

Answer 246

Spontaneous ROM: usually occurs at the onset of labor and is unprovoked by health practitioners Artificial ROM (amniotomy): A procedure in which the amniotic sac is ruptured in order to release amniotic fluid. Delayed ROM: that occurs during fetal expulsion, after cervical dilation and effacement

Answer 247

the rupture of the amniotic sac followed by the release of amniotic fluid

Answer 248

Premature rupture of membranes: before contractions Preterm premature ROM: before contractions and < 37w Prolonged rupture of membranes:

Answer 249

Occurs during onset of labor and ends at 6 cm of cervical dilation Characterized by mild, infrequent, irregular contractions with a gradual change in cervical dilation (< 1 cm / hour) Nulla: < 20 h Multi: < 14 h

Answer 250

Occurs after the latent phase at ≥ 6 cm of cervical dilation and ends with complete 10 cm cervical dilation Characterized by increased rate of dilation (1–4 cm/hour) Nulla: 4-6h 1.2 cm/h Multi: 2-3h 1.5 cm/h

Answer 251

A stage of labor that begins once the cervix is completely dilated and ends with the birth of the infant Regular contractions increasing in frequency and intensity Crowning: the appearance of the fetus's head at the vaginal Nulla < 2h Multi < 1h

Answer 252

1. Analgesia upon request 2. Fetal heart rate monitoring 3. Determine fetal position 4. Regular assessment of dilation and descent of the head

Answer 253

Help the mother to find comfortable and safe positions. Guide the delivery of the fetus through the vaginal canal Clamp the umbilical cord after no less than 30–60 seconds

Answer 254

A stage of labor that begins with the birth of the infant and lasts until the complete expulsion of the placenta 30 minutes

Answer 255

Cord lengthening Gush of vaginal blood (usually accompanied by a blood loss of 300 mL) Uterine fundal rebound (the uterus becomes less elongated and more spherical)

Answer 256

Administer a uterotonic drug, usually methergine or ergometrine soon after delivery of the anterior shoulder and/or oxytocin 5-10 IU IV within 1min of the birth of the baby

Answer 257

o Monitor vital signs and bleeding o Repair lacerations with absorbable sutures size 00 o Do a rectal examination to ensure that the sutures have not inadvertently transected the rectal mucosa o Ensure uterus is contracted (palpate uterus and monitor uterine bleeding) o Inspect placenta for completeness and umbilical cord for presence of 2 arteries and 1vein

Answer 258

o T10 – L1 supply innervation to the uterus o L1-L4 supply pain pathways to the vagina and deep pelvis o S2 - S4 supply nerve fibers to the pudendal nerve

Answer 259

o Emotional support, back massage, hydrotherapy, transcutaneous electrical nerve stimulation, acupuncture

Answer 260

Lumbar epidural injection: ▪ The most commonly used method with an increase in use ▪ It is used during 1st and 2nd stage of labor ▪ E.g. Bupivacaine ▪ Adverse effects: hypotension and nausea from sympathetic block (give ephedrine)

Answer 261

Spinal injection: ▪ Inserted into the paraspinal subarachnoid space ▪ Not used much for vaginal deliveries due to short duration of action and has a small risk of spinal headache afterwards ▪ Vital signs checked every 5min to detect hypotension

Answer 262

Pudendal block Paracervical block Not really used anymore

Answer 263

Nitrous oxide 40% with O2 may be used during vaginal delivery as long as verbal contact with the woman is maintained. Thiopental (sedative-hypnotic) is commonly given IV for induction of general anesthesia during c-section It is mandatory during emergency c-section

Answer 264

▪ All opioids readily cross the placental barrier and may cause neonatal respiratory depression (antidote: naloxone) ▪ Fentanyl and nalbuphine are the most commonly used and have short neonatal half-lives

Answer 265

Post-term pregnancy (≥ 42 weeks of pregnancy or gestation) PPROM after 34 weeks PROM at term Hypertension during pregnancy, preeclampsia, eclampsia, HELLP syndrome Maternal diabetes to avoid post-term pregnancy (risk of macrosomia) Maternal request at term Intrauterine fetal demise

Answer 266

History of uterine rupture Complete placenta previa Vasa previa Transverse fetal lie Cord prolapse Active maternal genital herpes Nonreassuring fetal heart rate

Answer 267

Bishop score Bishop score ≥ 8: favorable cervix (ready for vaginal delivery) Bishop score ≤ 6: unfavorable cervix (not ready for vaginal delivery)

Answer 268

Membrane sweeping (shortens time to onset of labor) If cervix is still unfavorable: cervical ripening with PG E1 or E2 Maternal oxytocin infusion Consider amniotomy (only if the cervix is partially dilated and completely effaced, and the fetal head is well applied) Administer under fetal heart rate monitoring.

Answer 269

o Capability of c-section if necessary o Determination of gestation o Short, thin, soft, anterior cervix with open os (“ripe”) o Fetal: normal heart tracing, cephalic presentation, adequate fetal monitoring available

Answer 270

The process of softening and widening the cervix in preparation for childbirth. If Bishop score is <6 ripening is necessary

Answer 271

A 30-mL to 50-mL Foley catheter filled with saline is placed in the uterus, and the balloon is filled. Direct pressure is then applied to the lower segment of the uterus and the cervix

Answer 272

Uterine tachysystole (excessive uterine contractions): ▪ >5 contractions in 10min ▪ Can lead to fetal hypoxia and uterine rupture ▪ Treatment: remove prostaglandin tablet and IV oxytocin, if no good response, give terbutaline (tocolytics) o Uterine muscle fatigue, uterine atony o Vasopressin-like action causing anti-diuresis (brain edema)

Answer 273

Promote adequate contractions when spontaneous contractions are inadequate and cervical dilation or descent of fetus fails to occur Done by using oxytocin

Answer 274

If its shortest AP diameter is <10cm or if the greatest transverse diameter is < 12cm

Answer 275

Before labor the fetal biparietal diameter has been shown to average from 9.5-9.8 cm, it might be difficult or even impossible for a fetus to pass through a pelvic inlet with AP diameter < 10cm

Answer 276

Early spontaneous rupture of membrane Delayed labor Abnormal presentation

Answer 277

Contracted midpelvis, because the capacity of the midpelvis is smaller than that of the inlet - It frequently causes transverse arrest of the fetal head, which can lead to a difficult midforceps operation or to c-section

Answer 278

Prematurity is the major factor predisposing to breech, and 20-30% of all breeches are of low birth weight (<2500g)

Answer 279

Leopold maneuver Vaginal examination US Doppler

Answer 280

Only for Frank or complete breech Estimated fetal weight: 2500 – 3500g No hyperextension of the fetal head Capacity for emergent C-section, experienced operator Adequate progress in labor Absence of “fetal distress”, preferably Multiparous woman (“proven pelvis”)

Answer 281

Spontaneous breech delivery Assisted breech delivery Total breech extraction

Answer 282

The abdomen is much smaller than the head and in breech delivery it might deliver through an incompletely dilated cervix o This might result in the head getting stuck, which may result in fetal asphyxia and birth trauma

Answer 283

The infant is allowed to spontaneously deliver up to the umbilicus, and then certain maneuvers are initiated by the clinician to aid the delivery

Answer 284

Fetal feet are grasped and entire fetus is extracted by clinician Should only be used for a noncephalic second twin Should not be used for singleton fetuses because the cervix may not be adequately dilated to allow passage of the fetal head

Answer 285

Breech + any of the following: ▪ Preterm ▪ 1st delivery ▪ PROM ▪ Incomplete breech ▪ Twins ▪ Large fetus

Answer 286

Normal rupture of membranes is spontaneous rupture within 1h of labor onset

Answer 287

Prolonged ROM >18h from rupture to onset of delivery

Answer 288

o At term, >90% of women with PROM begin labor within 24h o At 32-34 weeks, mean latency period is about 4 days

Answer 289

do not insert you hand into the vagina, use speculum to avoid infection risk

Answer 290

Assess cervical dilation and length If preterm obtain cervical cultures and amniotic fluid for pulmo maturation tests

Answer 291

Pool of water in posterior vaginal fornix Valsalva maneuver or slight fundal P may expel fluid from the cervical os US will show oligohydramnios (as expected) Nitrazine paper test: turn blue if AF

Answer 292

Amniotic fluid index measures the amniotic fluid present in 4 quadrants, and a value < 5 is considered abnormal (delivery is indicated)

Answer 293

Management is largely dictated by gestational age at the time of membrane rupture Risk/benefit for preterm Risks are chorioamnionitis and failed induction in the mother Signs of fetal compromise or infection

Answer 294

Induce labor 6-12h after rupture if no spontaneous contractions occur If unfavorable cervical conditions with no evidence of infection, induction can delay for 24h to decrease the risk of failed induction

Answer 295

The goal is to continue the pregnancy until the lung profile is mature Careful surveillance for chorioamnionitis BP, HR and temperature should be measured > 3x/day Activity should be limited to modified bed rest In pregnancies < 34 weeks give corticosteroids IV MgS should be given in pregnancies < 32w

Answer 296

o AB only delayed only until appropriate cultures taken o Ampicillin + gentamycin drug of choice o Once AB started, labor should be induced

Answer 297

Presence of the placenta in the lower uterine segment, which can lead to partial or full obstruction of the internal os; high risk of hemorrhage and birth complications

Answer 298

Maternal age > 35 years Multiparity with short intervals between pregnancies Previous curettage or cesarean delivery Previous placenta previa, previous/recurrent abortions

Answer 299

Sudden, painless, bright red vaginal bleeding Usually occurs during the 3rd trimester (before ROM) Initial bleeding episodes are often self-limited Soft, nontender uterus Usually no fetal distress

Answer 300

Routine prenatal care: transvaginal or transabdominal ultrasound to assess placental position

Answer 301

Placenta previa detected on routine ultrasound during Monitor placental placement If placenta previa persists at ∼ 32 weeks: Repeat US at 36w Schedule cesarean, ideally 36 and 37 weeks' gestation. If placenta previa is complicated by placenta accreta: Schedule delivery between 34 and 35 weeks' gestation.

Answer 302

Fetal malpresentation: transverse lie is common because the placenta is covering the pelvic inlet so the fetus cannot assume normal position Other: PPROM, IUGR, vasa previa

Answer 303

Delayed delivery of the placenta (>30min after fetus) with profuse bleeding during manual separation

Answer 304

When accreta is suspected, laparotomy with preparation for large-volume hemorrhage is required, an scheduled cesarean hysterectomy is done at 34 weeks (the placenta is left in situ while hysterectomy is done)

Answer 305

Pregnancy with two or more fetuses. Twin pregnancies can be differentiated into monozygotic and dizygotic pregnancies

Answer 306

Monozygotic twin pregnancies result from the division of the fertilized oocyte into two embryonic layers Dizygotic twin pregnancies arise from the fertilization of two oocytes with two spermatozoa.

Answer 307

Dichorionic-diamniotic Monochorionic-diamniotic Monochorionic-monoamniotic

Answer 308

The twins have separate chorionic sacs (separate placentas) and separate amniotic sacs.

Answer 309

The twins share a single chorionic sac (the twins share a placenta) but have a separate, individual amniotic sac.

Answer 310

The twins share a single chorionic sac (the twins share a placenta) and a single amniotic sac.

Answer 311

Dichorionic twins: lambda sign on US

Answer 312

Monochorionic twins: T-sign

Answer 313

Preterm labor and birth (most common complication) Hyperemesis gravidarum Gestational diabetes Preeclampsia, eclampsia, pregnancy-induced hypertension Cervical incompetence, premature rupture of membranes Placental insufficiency, hypotrophy, and intrauterine malnutrition of at least one fetus Uterine atony

Answer 314

Twin-to-twin transfusion syndrome

Answer 315

Affects 10–15% of monochorionic twin pregnancies (share the placenta) Blood is continuously shunted from one twin to the other through vascular anastomoses on the shared placenta, risk for both fetus

Answer 316

Recipient twin - Polycythemia - Hypervolemia - Polyhydramnios in diamniotic pregnancies

Answer 317

Donor twin - Anemia - Growth retardation - Hypovolemia, dehydration - Oligohydramnios in diamniotic pregnancies

Answer 318

Monochorionic-monoamniotic twin pregnancies between 32–34 weeks' gestation

Answer 319

Monozygotic twins arise from a single fertilized egg at various stages during embryogenesis, and therefore the arrangement of the fetal membranes and placenta depend on the time at which the embryo split

Answer 320

Division within 72h of fert: diamniotic, dichorionic Division after 4-8 days: monochorionic, diamniotic Division after 8-13 days: monochorionic, monoamniotic Division after 13-15 days: conjoined twins

Answer 321

Demise before 12 weeks, the dead fetus will be reabsorbed If retained > 3 w after 20 week gestation, it may result in DIC

Answer 322

The partial or complete separation of the placenta from the uterus prior to delivery; subsequent hemorrhage occurs from both maternal and fetal vessels.

Answer 323

Hypertension (most common cause) Preeclampsia/eclampsia (Abdominal) trauma: car accidents, falls Twin pregnancy Sudden decrease in intrauterine pressure Previous abruption, chorioamnionitis Short umbilical cord Maternal age: < 20 years and > 35 years Alcohol and cigarette consumption, cocaine use

Answer 324

Maternal symptoms - Sudden onset of continuous vaginal bleeding - In 20% of cases, the hemorrhage is mainly retroplacental and vaginal bleeding does not occur - Sudden onset of abdominal pain or back pain - Uterine tenderness - Hypertonic contractions (rigid uterus), premature labor Fetal symptoms - Fetal distress (60% of cases) - Possible diminished or absent fetal movement - Decelerations on fetal heart monitor

Answer 325

patients may present with signs of hypovolemic shock without evident vaginal bleeding!

Answer 326

Hemo unstable or moderate-severe bleeding: acute sectio Hemo stable with mild bleeding: reassuring fetal status < 34 weeks: expectant management, aim normal delivery. 34–36 weeks + active uterine contractions: vaginal delivery > 36 weeks: deliver the fetus

Answer 327

Intrauterine fetal death Maternal DIC and hypovolemic shock Uterine rupture|

Answer 328

into the decidua basalis with formation of a decidual hematoma

Answer 329

The risk of recurrent abruption is 10% after one abruption and 25% after 2

Answer 330

Diabetes mellitus Rh incompatibility (hemolytic disease of the newborn)

Answer 331

GI: (esophageal or duodenal atresia and stenosis): reduced swallowing and absorption of amniotic fluid CNS: anencephaly (impaired swallowing, leakage of CSF) Pulmonary: cystic lung malformations Multiple pregnancy: twin-to-twin transfusion syndrome Fetal anemia Chromosomal aberrations Intrauterine infections (congenital TORCH infections)

Answer 332

Physical examination: abdominal girth and uterine size LGA Ultrasound: AFI ≥ 25 cm Assess for fetal anomalies Rh screen

Answer 333

Amnioreduction: drainage of excess amniotic fluid Indications: severe abdominal discomfort, uterine irritability, severe shortness of breath Complications: preterm labor, premature rupture of membranes

Answer 334

Fetal anomalies - Urethral obstruction (e.g., posterior urethral valves) . Bilateral renal agenesis Maternal conditions - Placental insufficiency - Late or postterm pregnancies (> 42 weeks of gestation) - Premature rupture of membranes

Answer 335

Small abdominal girth and uterine size SGA US: Amniotic fluid index (AFI) < 5

Answer 336

normal range: 8–18 cm

Answer 337

Amnioinfusion: into the amniotic cavity through amniocentesis Treat underlying cause Delivery is advised if the fetus is close to term.

Answer 338

Increases in volume from 30ml at 10w to 200ml by 16w Reaches 800ml by the mid-3rd trimester

Answer 339

Creates a physical space for fetal movement Fetal swallowing essential for GI and lung development Guards against umbilical cord compression Protects the fetus from trauma

Answer 340

Fetal urinary production (can produce 1L/day) Fetal swallowing (750ml/day) Fetal lung secretion (350ml/day), half of which is swallowed Intramembranous fluid transfer across and into fetal vessels 400ml

Answer 341

Blood loss of > 500ml during or immediately after the 3rd stage of labor in vaginal delivery or > 1000ml in a cesarean delivery

Answer 342

occurs when your uterus doesn't contract (or tighten) properly during or after childbirth. It's a serious complication that can cause life-threatening blood loss.

Answer 343

Most common cause: uterine atony (75-80%) Vaginal or cervical laceration (2nd most common) Uterine inversion Retained placenta DIC

Answer 344

Uterine overdistention: twins, polyhydramnios, macrosomia Prolonged labor Relaxant anesthetics (halothane) or tocolytics Rapid labor Chorioamnionitis Manangement: uterine massage, uterotonics (oxytocin)

Answer 345

▪ Uncontrolled: fast delivery, too early pushing ▪ Traumatic: shoulder dystocia, macrosomia ▪ Operative: episiotomy, forceps, vacuum

Answer 346

ABCs Start 2 large bore IVs and crystalloids CBC, coagulation profile 4 units of RBCs Treat the underlying cause

Answer 347

Rare medical emergency in which the corpus turns inside out and protrudes into the vagina - It occurs most commonly when too much traction is applied to the umbilical cord in an attempt to deliver the placenta

Answer 348

Manual reduction by pushing up on the fundus until the uterus is returned to its normal position (do this before removing the placenta if it is still attached) o IV analgesics and sedatives or general anesthetic as needed o Once the uterus is in place, start an oxytocin infusion

Answer 349

Vulvovaginal lacerations Cervical lacerations Lacerations of the perineum Uterine rupture

Answer 350

Relatively common Often superficial Little or no bleeding Repair is usually not indicated

Answer 351

Superficial lacerations can be seen in >50% Most of them are < 0.5cm Rarely, the cervix may be entirely or partially avulsed from the vagina (colporrhexis) Injuries sometimes follow forceps delivery More severe lacerations may involve the uterine artery Treatment: sutures

Answer 352

Tear of the perineal area due to significant or rapid stretching forces during labor and delivery Risk factors Macrosomia Forceps delivery No previous delivery Prolonged second stage of labor

Answer 353

Class I-IV

Answer 354

I or II degree: Minor tears (superficial, hemostatic lacerations) Left to the clinician to determine if suturing is required. Conservative: NSAIDs, sitz baths Third and fourth degree Regional or general anesthesia may be used. Reconstructive surgery to repair the anal sphincters and mucosa Reconstruction of the distal rectovaginal septum and the perineal body

Answer 355

Spontaneous tearing of the uterus that may result in the fetus being expelled into the peritoneal cavity (high morbidity and mortality). Rare, occurs most commonly (40%) along healed scar lines in women who have had prior c-section

Answer 356

Clinical presentation: fetal bradycardia, variable decelerations, evidence of hypovolemia, loss of fetal station, severe or constant abdominal pain Treatment: immediate laparotomy with cesarean delivery and, if necessary, hysterectomy

Answer 357

Toxoplasmosis Others (syphilis, varicella, parvovirus B19 infection, listeriosis) Rubella Cytomegaly (CMV) Herpes simplex virus (HSV) infection

Answer 358

Petechiae and purpura (blueberry muffin rash) Chorioretinitis (a form of posterior uveitis) Diffuse intracranial calcifications Hydrocephalus Epilepsy Intellectual disability Visual disabilities Sensorineural hearing loss

Answer 359

Increased risk of premature birth and spontaneous abortion Early-onset syndrome: granulomatosis infantiseptica Severe systemic infection characterized by disseminated abscesses (may develop in any organ system) Most common findings: respiratory distress and skin lesions Late-onset syndrome (1 to 3 weeks after birth): Listeria meningitis/encephalitis

Answer 360

Aplastic anemia Fetal hydrops

Answer 361

Early congenital syphilis (onset < 2 years) - Jaundice and hepatosplenomegaly - Lymphadenopathy - Nasal discharge (sniffles) - Maculopapular rash - Skeletal abnormalities Late congenital syphilis (onset > 2 years) - Frontal bossing, rhagades - Hutchinson teeth - Interstitial keratitis - Sensorineural deafness - Saber shins

Answer 362

IUGR, premature birth Chorioretinitis, cataract Encephalitis Pneumonia CNS abnormalities Hypoplastic limbs

Answer 363

IUGR Sensorineural deafness Cataracts Heart defects (PDA, pulmonary artery stenosis) CNS abnormalities Petechiae and purpura (blueberry muffin rash)

Answer 364

Jaundice, hepatosplenomegaly IUGR Chorioretinitis Sensorineural deafness Periventricular calcifications Petechiae and purpura (blueberry muffin rash) Microcephaly Seizures

Answer 365

Premature birth, IUGR Skin, eyes, and mouth involvement: vesicular lesions, keratoconjunctivitis Localized CNS involvement: meningoencephalitis Multiple organ involvement, sepsis

Answer 366

Congenital TORCH infections are vertically transmitted infections (acquired directly from the mother and transmitted to the embryo, fetus, or newborn through the placenta or birth canal) that are capable of significantly influencing fetal and neonatal morbidity and mortality

Answer 367

Associated with transmission during passage in birth canal Chlamydia Neisseria gonorrhea Streptococcus agalactiae (group B streptococci)

Answer 368

Fetal complications: pneumonia, neonatal conjunctivitis o Diagnosis: screen with NAAT early in pregnancy o Treatment: ▪ Fetus: silver nitrate eye drops ▪ Mother: azithromycin

Answer 369

o Pregnancy complications: chorioamnionitis, PROM o Fetal: neonatal conjunctivitis (purulent) sepsis, meningitis, arthritis o Diagnosis: screen with vaginal smear and culture early in pregnancy o Treatment: ▪ Fetus: silver nitrate eye drops ▪ Mother: ceftriaxone

Answer 370

o Diagnosis: screening (vaginal culture) at 35-38 weeks o Fetal complications: sepsis (12h postpartum), pneumonia, meningitis (most common cause in newborns) o Treat with IV penicillin, ampicillin to prevent preterm labor o Prophylactic treatment is indicated in the following conditions: GBS bacteriuria in current pregnancy, prolonged PROM, 3rd trimester culture positive for GBS, previous neonatal sepsis due to GBS, preterm labor

Answer 371

spontaneous loss of pregnancy before 20 weeks' gestation

Answer 372

o Intrauterine fetal demise (IUFD) is fetal death after 20 weeks’ but before the onset of labor o It complicates about 1% of pregnancies

Answer 373

Fetal-maternal hemorrhage (FMH) Diabetes mellitus Hypertensive pregnancy disorders (especially if complicated by placental insufficiency or placental abruption) Uterine rupture Advanced age Heavy smoking

Answer 374

IUGR (which is most commonly due to placental insufficiency) Placental abnormalities (placental abruption) Infection (especially following PROM) Chromosomal abnormalities Congenital malformations Umbilical cord complications (knot leading to fetal vascular compromise) Fetal hydrops

Answer 375

Absence of movements, particularly if the uterus is small Placenta may continue to produce bhCG so a positive pregnancy test does not exclude IUFD Real-time US will confirm the lack of fetal movement and absence of fetal cardiac activity Determination of cause: fetal karyotype on autopsy, maternal CBC, screening for hereditary and acquired thrombotic disorders, TORCH test, DM testing, examination of the placenta

Answer 376

Spontaneous labor usually begins within 2 weeks Vaginal (misoprostol or oxytocin infusion) safer than cesarean Express empathy and acknowledge patient grief. Provide privacy and emotional support. Offer contact between parents and the stillborn baby after delivery.

Answer 377

persist beyond 42 weeks from the onset of LMP

Answer 378

Week 41 expectant management with surveillance every 3d Perform induction of labor by 42 0/6 weeks' gestation Induction unsuccessful: Perform C-section.

Answer 379

Oligohydramnios Increased birth weight and macrosomia Stillbirth Low Apgar scores ( ≤ 4 points) Meconium aspiration syndrome Neonatal seizures Admission to the NICU Cerebral palsy Postmaturity syndrome

Answer 380

Changes in appearance: Weight loss Subcutaneous wasting Dry, peeling skin Possibly cause: placental insufficiency and oligohydramnios

Answer 381

Maternal self-assessment of fetal wellbeing Non-stress test assessment (NST) Biophysical profile US assessment Contraction stress test

Answer 382

Noninvasive test that measures how fetal heart rate (FHR) Mother report movement, and effects of the fetal movements on the HR is determined Responds to fetal movements; a rise in fetal HR is expected

Answer 383

Perform electronic fetal HR monitoring over a mi of 20min Review the FHR tracing for FHR accelerations + decelerations If no FHR accelerations are observed within the first 20min Perform vibroacoustic stimulation. Continue with the NST for another 20–40 minutes.

Answer 384

Nonreactive: abnormal NST shows < 2 FHR accelerations Reactive: a normal NST that shows ≥ 2 FHR accelerations Normal respons are acceleration in fetal HR of >15 BPM above the baseline for at least 15seconds

Answer 385

Fetal sleep (most common) Hypoxemia or acidemia Neurologic or cardiac abnormalities Fetal immaturity Maternal drug use

Answer 386

110-160BPM (bradycardia < 110, tachycardia > 160)

Answer 387

o Oligohydramnios can be defined as AFI < 5cm o Polyhydramnios can be defined as AFI > 23cm

Answer 388

High systolic/diastolic ratio suggest abnormal flow due to increased vascular resistance within fetal/placental circulation o When the flow becomes very abnormal, diastolic flow ceases and there can be reversal of flow from placenta to the fetus o If this occurs an emergency c-section is usually indicated

Answer 389

Noninvasive test with US of 4 specified parameters + NST: 1. Fetal movement 2. Fetal tone 3. Fetal breathing 4. Amniotic fluid volume (AFI) NST is performed if any US parameter is abnormal Each parameter of the US examination and the NST is given a score of either 0 (abnormal) or 2 (normal)

Answer 390

A normal profile = 10 points if NST, 8 points if no NST o 8-10 points: Reassuring o 3-7 points: do contraction stress-test ▪ If > 36weeks, CST is not necessary, delivery is indicated o 0-2 points: deliver by emergency c-sectio

Answer 391

Offer all patients genetic carrier screening and testing for chromosomal abnormalities. Screening should preferably be offered at the initial prenatal visit. Provide counseling prior to prenatal genetic testing to all patients.

Answer 392

Noninvasive aneuploidy screening of maternal serum biomarkers and US markers, or cell-free fetal DNA testing Invasive genetic testing with amniocentesis or chorionic villus sampling

Answer 393

o Advanced maternal age >35 o Positive fam history: chromosomal aberration, monogenic disorders (AR, AD) NT defect ++ o Abnormalities suspected in pregnancy o Other high-risk factors (maternal disease, obstetric history)

Answer 394

6.5% of all birth defects are attributed to teratogens A teratogen is a chemical, physical or biological agent capable of interfering with the development of a fetus, causing birth defects

Answer 395

1. The pharmacological properties and dose 2. Stage of pregnancy in which exposure occurs

Answer 396

0–15 days after fertilization: early embryonic period Toxicity to the developing embryo can cause spontaneous abortion (all-or-nothing effect). First trimester Corresponds to the period of organogenesis Most significant period for teratogenic birth defects Second and third trimesters Period of fetal growth and maturation Can lead to deficits in organ function, intellect, behavior, or minor structural malformations

Answer 397

Syndactyly: fusion of two or more fingers or toes Polymelia/polydactyly: supernumerary limbs, fingers, or toes Oligodactyly, adactyly: absence of one or more fingers or toes Ectromelia: collective term for hypoplasia and/or aplasia of one or more long bones, resulting in limb deformity Peromelia: amputation-like stump of a limb, finger, or toe

Answer 398

Diabetes mellitus: Diabetic embryopathy/Diabetic fetopathy Obesity: a lot Graves disease: Neonatal hyperthyroidism Hypothyroidism: Congenital hypothyroidism Phenylketonuria (maternal PKU): a lot

Answer 399

Cigarette smoking Alcohol Caffeine Aspartame Vitamin A

Answer 400

Drugs can affect the fetus directly (cross the placenta) or indirectly (constrict placental vessels, produce uterine hypertonia, cause maternal hypotension etc.) o The effect is largely determined by fetal age at onset

Answer 401

Came in 2015 an replaces the drug categories A-X All labeling of drugs should have a detailed subsection including summary of risks using the drug in 3 different categories (pregnancy, lactation, reproductive potential)

Answer 402

Cocaine: Bath salts: designer drugs made from amphetamine-like Hallucinogens: MDMA, ketamine, methamphetamines, LSD Opioids: withdrawal symptoms at birth Increased risk of: spontaneous abortion, fetal growth restriction, preterm birth, stillbirth, placental abruption, congenital malformations

Answer 403

Leopold maneuver Uterine fundal height Cervical cerclage

Answer 404

1st: height of fundus, which fetal pole occupies the fundus 2nd: fetal lie and position 3rd: fetal presenting part and its relation to the pelvic inlet 4th: presenting part, engagement, descensus of the head 5th (Zangemeister maneuver): cephalopelvic disproportion (the head lies at the same level as or even projects above the symphysis)

Answer 405

- 20 weeks: 2 fingers widths below umbilicus - 24 weeks: at umbilicus - 28 weeks: 2 fingers width above umbilicus - 32 weeks: 4 fingers width above umbilicus - 35 weeks: between umbilicus and xyphoid process - 36 weeks: 4 fingers with below xyphoid process (xy/4) - 37 weeks: xy/3 - 38 weeks: xy/2 - 39 weeks: xy/3 - 40 weeks: xy/4

Answer 406

Placement of a supportive suture in the cervicovaginal junction to prevent early pregnancy loss or preterm birth McDonald cerclage: a removable suture in the cervix that allows vaginal delivery; Removal is indicated between 36–37 weeks' gestation, before the onset of spontaneous labor. Shirodkar cerclage: a permanent suture that is placed in the cervical submucosal tissue; Cesarean delivery is necessary.

Answer 407

11th – 13th week of gestation Transvaginal (first) and transabdominal ultrasound Determination number of fetuses. Evaluation of the embryo or fetus, including: - Cardiac activity (from week 6) - Crown-rump length for estimating gestational age - Nuchal translucency: patients that want aneuploidy screening - Nasal bone - Ductus venosus flow Evaluation of maternal pelvic anatomy

Answer 408

18th – 20th week of gestation Transabdominal, transvaginal if abdominal is suboptimal Fetal biometric parameters: - Biparietal diameter - Fetal femoral length - Abdominal circumference Evaluation of amniotic fluid volume and placenta Congenital malformations: Duodenal atresia, omphalocele, renal dysplasia, congenital pulmonary airway malformation

Answer 409

▪ Assesses subcutaneous fluid at the level of the fetal neck ▪ >3mm can be sign of chromosomal/structural abnormalities

Answer 410

TAS 30th – 31st week of gestation (“fetal size screening”) - Important to compare the measurements with previous screening to differentiate possible SGA from IUGR - Aim: to recognize high-risk population for follow up Check for intra uterine growth restriction (IUGR) Check amniotic fluid, the placental location and blood supply Check late onset congenital malformations (corpus callosum)

Answer 411

4th US screening TAS during the 36th – 37th week of gestation Aim: to recognize the high-risk population Gain information for delivery

Answer 412

The postpartum period refers to the six-to-eight-week period after the birth of a baby in which the body recovers from the changes caused by pregnancy and birth.

Answer 413

Low‑grade fever, shivering, and leukocytosis are common Uterine involution: first small then large, then small Locha: women pass discharge for about 4 weeks after delivery

Answer 414

Lochia rubra: blood red; approx. the first 4 days after birth Lochia serosa: brown red; watery, lasts approx. 2–3 weeks Lochia alba: yellow white; lasts approx. 1–2 weeks

Answer 415

Aafter delivery of baby, amniotic fluid, placenta: approx. 6 kg Additional due to lochia and uterine involution: approx. 2–7 kg

Answer 416

1000g at delivery to normal weight of 50-100g 6 weeks postpartum

Answer 417

Eschar from placental site sloughs off and bleeding occurs Total blood loss is about 250ml

Answer 418

The perineum Abdominal wall Urinary tract changes The vagina Cardiovascular system

Answer 419

Increased capacity and insensitivity to intravesical fluid P Overdistension, incomplete emptying are common The dilated ureters and renal pelvis return to prepregnant state over the course of 2-6 weeks after delivery

Answer 420

Immediat increase in PVS due to removal of low-pressure uteroplacental circulatory shunt CO and plasma volume gradually return to normal during the first 2 weeks Leukocytosis and thrombocytosis occur during and after labor During first few days postpartum, hb and hematocrit fluctuate

Answer 421

Diastasis recti Pelvic atrophy Hemorrhoids Endometritis Urinary retention Wound infection Puerperal sepsis PP blues or depression Postpartum sexual dysfunction Septic pelvic thrombophlebitis

Answer 422

Inflammation of the endometrium, possibly also including the myometrium and parametrium: Risk factors: Cesarean delivery Prolonged labor Multiple cervical examinations Retained products after delivery, miscarriage, or abortion

Answer 423

Antibiotic treatment: IV clindamycin and gentamicin Uterine curettage to remove retained products of conception.

Answer 424

maternal sepsis that develops in the timeframe between birth and 6 weeks postpartum: Fever Pelvic pain Abnormal vaginal discharge Abnormal smell/foul odor discharge Delay in uterine involution

Answer 425

Genital tract, most common (endometritis) Urinary tract (acute pyelonephritis) Respiratory tract (severe pneumonia) Breast (mastitis) Skin/soft-tissue infections (episiotomy wound, IV, catheters) Group A beta-hemolytic streptococcal infection (S. pyogenes) Gastrointestinal tract

Answer 426

Diagnosis: clinical + find source!! Treatment: ABC resuscitation if necessary Give IV clindamycin + piperacillin within 1h

Answer 427

Wipe the newborn's mouth and nose to clear airway secretions Dry and stimulate the newborn. Provide warmth. Skin-to-skin contact with mother and initiation of breastfeeding Clamp and cut the umbilical cord. Apgar score assessment at 1 and 5 minutes after birth Begin resuscitation if no resp within 30–60 seconds

Answer 428

Standard clinical assessment at 1 and 5 minutes after birth Reassuring: 7–10 Moderately abnormal: 4–6 Low: 0–3 Score <7, assessment performed 5–minute intervals for 20 min

Answer 429

o Normal weight: 2500 – 4290g o Normal length: 44 – 54cm o Normal head circumference: 32 – 38cm o Normal abdominal circumference: 17 – 24cm

Answer 430

Ophthalmic AB: to prevent gonococcal conjunctivitis (erythromycin ophthalmic ointment) Vitamin K: to prevent vitamin K deficiency bleeding of the newborn (VKDB)

Answer 431

Rh-negative mother and Rh-positive newborn: Maternal exposure to fetal blood → production of maternal IgM antibodies against the Rh antigen → over time, seroconversion to Rh-IgG (able to cross the placenta) In a subsequent pregnancy with an Rh-positive newborn: rapid production of maternal IgG anti-D antibodies to fetal RhD antigens → Rh-IgG agglutination of fetal RBCs with hemolytic anemia → risk of Hemolytic disease of the newborn with possible hydrops fetalis

Answer 432

The placental barrier normally separate the fetal and maternal circulation so only small amounts of fetomaternal blood mixing occurs Sensitization occurs when the barrier is broken, and there is more severe fetomaternal hemorrhage

Answer 433

Fetomaternal hemorrhage: ▪ 90% occur during delivery ▪ 3rd trimester bleeding, postpartum hemorrhage, ectopic pregnancy, gestational trophoblastic disease o Rh + transfusion

Answer 434

o Always determine Rh status and titers of AB during the first prenatal visit o If the mother is Rh-negative or sensitized, paternal Rh genotyping should be done o If father is neg, the bay will be neg, no risk of anemia o If father is pos, fetal genotyping should be done (cell-free fetal DNA or amniocentesis)

Answer 435

Rh-negative mother not sensitized: - Give RhoGAM at week 28 and 72h before delivery or any procedures (amniocentesis) if the baby is Rh-positive Mother is sensitized, but the baby is not anemic and AB low: - Close monitoring of the mother and baby every 2-4 weeks - RhoGAM at 28 weeks

Answer 436

Hemolytic anemia, hyperbilirubinemia (kernicterus), jaundice, hepatosplenomegaly, portal hypertension, hypoalbuminemia Fetal hydrops: accumulation of fluid in > 2 compartments (subcutis, pleura, peritoneum, pericardium)

Answer 437

If MCA blood flow show anemic fetus further management depend on gestation: ▪ > 34 weeks: delivery ▪ < 34 weeks: PUBS transfusion to replace fetal hemolysis every 1-2 weeks until fetal maturity

Answer 438

Percutaneous Umbilical Blood Sampling

Answer 439

Transient tachypnea (RR > 60): follows short labor/c-section Aspiration syndrome: Meconium in amniotic fluid Congenital pneumonia: Idiopathic respiratory distress syndrome: pulmonary surfactant deficiency

Answer 440

Preductal pulse oximetry PPV at rate of 40–60/minute if inadequate respiratory HR < 100 Ventilation should be provided with room air for infants ≥ 35 Premature infants < 35 weeks: FiO2 21– 30%, titrated to SpO2 Chest compression indicated if HR is < 60 bpm despite adequate ventilation for 30 seconds IV epinephrine if heart rate < 60 bpm despite adequate ventilation and chest compressions for at least 30–60 seconds If there is no evidence of ROSC within 20 minutes, consider termination of resuscitation.

Answer 441

Heart defects, cleft lip/palate, Down syndrome and spina bifida

Answer 442

1. Left to right shunts: - Patent ductus arteriosus (PDA) - Ventricular septal defect (VSD)(most common with 25%) - Atrial septal defect (ASD) 2. Right-to-left shunts: - Tetralogy of Fallot - Transposition of the great arteries - Tricuspid atresia

Answer 443

Acyanotic diseases include left-to-right shunts resulting in increased pulmonary blood flow and obstructive lesions, which usually have normal pulmonary blood flow Cyanotic disease includes the 5 Ts: Tetralogy of Fallot, transposition of the great arteries, tricuspid atresia, truncus arteriosus

Answer 444

Part of chromosomal abnormalities: - Pierre Robin sequence - Patau syndrome (trisomy 13) - Edwards syndrome (trisomy 18) Environmental factors: exposure to teratogenic substances Nicotine and/or alcohol Drugs: antiepileptics

Answer 445

Cleft lip Partial or total failure of primary palate formation during the 6–7th week of development Failed fusion of the maxillary prominences and medial nasal prominences at the midline

Answer 446

Failed formation of the secondary palate during the 8–12th week of development Failed fusion of either the lateral palatine processes (palatine shelves) or of the palatine shelves with the nasal septum and/or primary palate

Answer 447

Proper feeding techniques: feeding in upright position to prevent nasal regurgitation Nasoalveolar molding: Use of a custom made orthodontic prosthesis to bridge and reduce the palatal gap Nasal stent: to lift the drooping nostril and shape the nose Lip taping: use of adhesive tape to reduce the defect; makes definitive surgery easier Lip adhesion: suturing the edges of the cleft lip

Answer 448

Cleft lip: 3 months Cleft palate: 6–9 months

Answer 449

Defective closure of the vertebral column due to a neural tube defect (folate deficiency)

Answer 450

The physical effects of teratogens are widely varied: VACTERL associations Vertebral Anal Cardiac Tracheoesophageal fistula Renal abnormalities Limb abnormalities Due to defect development of embryonic mesoderm

Answer 451

Episiotomy Cesarean delivery Operative vaginal delivery: assisted

Answer 452

Consists of a perineum incision (midline or mediolateral) to enlarge the vaginal opening during delivery No longer routinely recommended. Can be considered if vaginal delivery needs to be expedited and maternal perineal tissue is thought to pose a significant obstacle: - Shoulder dystocia - Inability to insert instrument for assisted vaginal delivery - Vaginal breech delivery Repair the incision with lidocaine and sutures after delivery

Answer 453

Forceps are instruments designed to provide traction and/or rotation of the fetal head when the expulsive efforts of the mother are insufficient There are 2 classes of forceps: classic and specialized

Answer 454

Prolonged 2nd stage of labor Suspicion of immediate or impending fetal compromise To stabilize the after-coming head during a breech delivery To shorten the 2nd stage of labor for maternal benefit

Answer 455

Vacuum extractor is a metal or plastic cup, attached to the fetal head with a suction device, that enables traction of the fetal head during vaginal delivery

Answer 456

Prolonged second stage of labor Nonreassuring fetal heart rate

Answer 457

Maternal: suction of soft tissue: hematomas/lacerations Fetal: cephalohematoma , scalp lacerations, life-threatening head injury (intracranial hemorrhage or subgaleal hematoma)

Answer 458

Primary cesarean delivery Placenta praevia totalis Refractory HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count), severe preeclampsia Severe uterine abnormalities (e.g., myoma) of the mother Maternal skeletal deformities

Answer 459

Immediate threat to life of mother Severe vaginal bleeding of unknown etiology (suspected placental separation) Suspected uterine rupture

Answer 460

Primary cesarean delivery Fetal growth retardation with circulatory depression Premature birth, if further risk factors are present, e.g., infection Fetal malformations that hinder a natural birth

Answer 461

Skin incision above the pubic symphysis. Largely blunt penetration through the abdominal muscles, fascia, and peritoneum Hysterotomy Fetal extraction, cord clamping, and manual placental removal Wound closure

Answer 462

The umbilical cord contains 3 allantois-derived blood vessels The normal umbilical cords are 40-70cm long Cords are helical in nature, and can have as many as 380 helices 2 umbilical arteries: branches from the internal iliac arteries that carry deoxygenated blood from the fetus to the placenta 1 umbilical vein: supplies oxygenated, nutrient-rich blood from the placenta to the fetus (merges into the inferior vena cava via the ductus venosus)

Answer 463

A single umbilical artery is a sign of chromosomal disease and congenital anomalies.

Answer 464

Condition in which the fetal vessels are located in the membranes near the internal os of the cervix, putting them at risk of injury if the membranes rupture

Answer 465

Short cords Long cord Cord knots Nuchal cord (neck) Cord prolapse Single umbilical artery Vasa previa

Answer 466

Number of infant deaths during the first 28 days of life)/ (total number of live births) × 1,000 Late neonatal mortality rate (number of infant deaths during postnatal days 7–28)/ (total number of live births) × 1,000 Early neonatal mortality rate (number of infant deaths during first week after birth)/ (total number of live births) × 1,000

Answer 467

When the fetal head align with the ischial spines,b baby is in station 0

Answer 468

Descent Flexion Internal rotation, Extension External rotation Expulsion

Answer 469

Recommended that infants exclusively breastfed up of 6m On-demand feeds are recommended. Plays an important role in mother-child bonding. Initiated within 30min after birth Newborn infant nurses minimum 8-10x/day)

Answer 470

The process of mammary epithelial cell differentiation and milk production in the mammary gland that begins mid pregnancy as a result of increased estrogen and progesterone levels Lactation is initiated by the delivery of the placenta → abrupt ↓ progesterone levels → ↑ prolactin → stimulation of milk secretion

Answer 471

Requires suckling, which stimulates secretion of: Prolactin from the anterior pituitary: leads to stimulation of continued lactogenesis (milk production) and disruption of pulsatile GnRH secretion (causing lactational amenorrhea) Oxytocin from the posterior pituitary: leads to stimulation of milk ejection (letdown) and uterine contractions

Answer 472

Breast milk contains all the required nutrients (except vitamin D and vitamin K) for infants up to 6 months of age

Answer 473

Colostrum: the first milk produced during late pregnancy until 3–4 days postpartum; rich in proteins and immunoglobulins Mature milk is composed of: Proteins, lactose and oligosaccharides, fats, minerals, trace elements, and vitamins Proteins and cells that provide passive immunity in neonates Immunoglobulins (secretory IgA), lactoferrin, lysozymes Lymphocytes, macrophages

Answer 474

Decreased risk of middle-ear, respiratory, gastrointestinal, UTI Breast milk Ig (especially IgA) and WBC provide passive immunity Better gastrointestinal function and motility Lower risk of asthma, allergies, obesity, and diabetes mellitus

Answer 475

Faster uterine involution and post-partum weight loss Lower risk of ovarian and breast cancers Postpartum contraception (lactational amenorrhea) Improved bonding with the infant Reduced costs

Answer 476

Maternal factors: HIV infection (regardless of viral load or treatment) Infant factors: galactosemia

Answer 477

Inadequate milk production or intake Breastfeeding jaundice Breast milk jaundice Mastitis Galactocele Nipple injury

Answer 478

Elective surgery should be avoided in pregnancy If a must, but not emergently, 2nd trimester is the safest

Answer 479

During this period the risk of teratogenesis and miscarriage is much lower than in the first trimester and the risk of preterm labor is lower than in the 3rd trimester

Answer 480

Regional analgesia preferred: ass with lower mortality, morbidity All pregnant women should be treated as they have full stomach Premedicated with citrate and H2-receptor blockers

Answer 481

apendecitis

Answer 482

Symptoms can be similar to pregnancy, although right lower abdominal pain is still the most common presentation Leukocytosis and diminished tendency to develop hypotension and tachycardia add complexity to the diagnosis Due to delayed diagnosis there is an increased rate of rupture

Answer 483

cholelithiasis

Answer 484

Increase serum cholesterol and lipid levels, along with biliary stasis, leads to higher incidence of cholelithiasis, biliary obstruction and cholecystitis

Answer 485

Usually associated with postoperative adhesions, although volvullus and intussusception are rare cause It generally occur in late pregnancy and is associated with traction on adhesions as the uterus enlarges

Gynecology Flashcards

(523 cards)