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MS3 OBGYN > OB > Flashcards

OB Flashcards

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1
Q

Post partum hemorrhage definition

A

> 500 ccs if vaginal;

>1000 ccs if c-section

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2
Q

What is the Pomeroy technique?

A

Tubal ligation involving removal or a part of the uterine tube

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3
Q

What is the Parkland method?

A

The Parkland procedure involves tying two non-absorbable ligatures around the fallopian tube in its proximal to middle segment and then cutting out the tubal segment between the ligatures. The end result is similar to the Pomeroy method of tubal ligation.

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4
Q

Post partum hemorrhage and absent uterus on physical exam, dx?

A

Uterine inversion

Manage with surgery

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5
Q

Post partum hemorrhage and boggy, soft uterus on physical exam, dx?

A

Uterine atony

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6
Q

Post partum hemorrhage and firm placenta on physical exam, dx?

A

Retained placenta

Manage with surgery

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7
Q

Post partum hemorrhage and normal-feeling uterus on physical exam, dx?

A

Vaginal laceration

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8
Q

Post partum hemorrhage, never forget this dx in your differential:

A

DIC

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9
Q

What is the management for unexplained post partum hemorrhage?

A

Surgery to ligate arteries and possible TAH

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10
Q

What is the pathology behind uterine atony?

A

Uterus cannot contract down, usually a product of:
a prolonged labor,
a labor that used pitocin;
a labor that used tocolytics (anti-contraction meds)

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11
Q

What is an absolute contraindication for the use of MgSO4?

A

Myasthenia gravis bc MgSO4 is a myosin light chain inhibitor

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12
Q

What tocolytic should not be used in conjunction with MgSO4?

A

Nifedipine (Procardia, Adalat), a Ca channel blocker

Also contraindicated in cardiac disease

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13
Q

What is the management of uterine atony?

A
  1. Massage
  2. Methergen or Pitocin if massage does not work
  3. PGF-2 alpha
  4. go to surgery if bleeding does not stop
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14
Q

How is the diagnosis of uterine atony made?

A

Clinically;

Pt presents with PPH and boggy uterus on physical exam

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15
Q

What is the pathology of uterine inversion?

A

Uterus births itself and there is a defect in the myometrium, which falls into the uterine lumen, pushing the uterus into the birth canal

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16
Q

How is the diagnosis of uterine inversion made?

A

Clinically;

Speculum reveals uterus

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17
Q

What is the management of uterine inversion?

A

Transvagial surgery to tack down the fornices of the uterus;

Can give pitocin if bleeding continues

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18
Q

What conditions predispose vaginal lacerations?

A

Precipitous births;

Macrosomal births

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19
Q

What are the causes of retained placenta?

A
  1. Burrows too deeply, or
  2. Accessory lobe
    - -> placenta tears during birth
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20
Q

T/F: Placenta blood vessels never go to the surface of the placenta

A

True

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21
Q

What is the management of retained placenta?

A
  1. D&C, then
  2. TAH

Follow-up with beta-quant to rule out choriocarcinoma later

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22
Q

What is placenta accreta?

A

Retained placenta at the layer of the endometrium

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23
Q

What is placenta increta?

A

Retained placenta burrows into myometrium

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24
Q

What is placenta percreta?

A

Retained placenta burrows to serosa

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25
What is the pathology of DIC-PPH?
Placental contents get into blood stream --> fibrin clots consume platelets and clotting factors
26
How does a patient with PPH-DIC present?
PPH that won't stop, no other cause found, plus oozing from IV sites
27
What is the management of PPH-DIC?
1. Get a DIC panel - -Plts low - -clotting factors low - -PT/PTT high - -fibrinogen low - -shistocytes on smear 2. Give FFP, transfuse platelets and blood
28
What is the pathology behind gestational diabetes?
Insulin insensitivity
29
What are the risk factors for gestational diabetes?
1. Preconception obesity 2. >1lb/wk weight gain 3. Advanced maternal age
30
How do you diagnose gestational diabetes?
Asymptomatic screen with 1 hr glucose tolerance test; | confirm with 3 hour gTT
31
How does the gTT work?
``` Give non-fasting patient 50g glucose load: + if >/= 140 If +, give fasting patient 100g glucose load and check fasting, 1h, 2h and 3h: + if: fasting >/= 125 1h >/= 180 2h >/= 155 3h >/= 140 ``` Gestational diabetes is any two + tests from the above
32
What is the management of gestational diabetes?
Basal-bolus insulin
33
When in pregnancy does hemoglobin reach a nadir?
28-30 weeks because of gain of fluid volume
34
What is the definition of third trimester anemia?
Asymptomatic screen CBC that shows H/H
35
What is the pathology behind isoimmunization?
Isoimmunization - when Rh (-) mom has Rh (+) kid. Aka, mom has no Rh antigen. Blood mixes during delivery or procedure, and mom makes antibodies to baby. IgM cant cross placenta, but IgG can, which can cause anemia or fetal death
36
How is Rh status evaluated and managed?
1. Asymptomatic screen in beginning of pregnancy to find out if mom if Rh + or - 2. If mom is Rh -, does she have antibodies to Rh? 3. If she is Rh (-) with no Ab --> give Rhogam at 28 weeks and then within 72 hrs of delivery or procedure 4. If she is Rh (-) with Ab --> too late --> get transcranial Doppler to evaluate risk for fetal anemia
37
What are the Rh subtypes?
Lewis - won't kill baby Duffy - will kill baby Kal - will kill baby Titers >1:8 sufficient
38
What is the management of fetal anemia?
If > 34 weeks, deliver; | If
39
How is fetal anemia diagnosed?
1. Transcranial Doppler; then | 2. PUBS (needle into umbilical vein), if Hct
40
When can mom's and baby's blood mix?
1. D&C 2. PPH 3. Normal vaginal delivery 4. Third trimester bleeding
41
What is a reactive NST?
2 or more accelerations in 20 minutes, each lasting at least 15 seconds
42
How high is the beta-quant if a fetus can be seen on u/s?
At least 1500
43
What is the effect of pregnancy on the renal system?
GFR increases, +50% by week 24
44
What are the cardiovascular effects of pregnancy?
HR up BP down (vasodilated bc of increased estrogen) CO up up up
45
What are the pulmonary effects of pregnancy?
TV up | Minute volume up
46
What is the effect of pregnancy on albumin?
Down bc of increased plasma volume
47
What are the effects of pregnancy on the thyroid?
thyroid-binding protein up; | effective circulating T4 down
48
What labs are drawn at the first OB visit?
``` CBC Rh factor type and screen U/A and culture RPR/VDRL Heb B Ag HIV GC/chlam cervical swab pap smear ```
49
What is a normal Hgb at the start of pregnancy?
13-15
50
What is a normal Hgb at 28 weeks?
10
51
What are the test results for trisomy 18?
low MSAFP; low estriol; low inhibin A; low b-hCG
52
What are the test results with trisomy 21?
low MSAFP; low estriol; high inhibin A; high b-hCG
53
What is the treatment for asymptomatic bacteriuria?
Nitrofurantoin (same for cystitis)
54
What is the treatment for pyelonephritis?
IV ceftriaxone; | if no improvement, u/s
55
What are the acceptable treatments for chronic HTN in pregnancy?
Alpha-methyldopa; Hydralazine; Metoprolol
56
What is the management of hyperthyroidism in pregnancy?
PTU; surgery if 2nd semester
57
What is the management of hypothyroidism in pregnancy?
give thyroid
58
What is the latent phase of stage I labor?
Beginning of contractions to 4 cm 20 hrs for first time delivery 14 for multip
59
What is the active stage of stage I labor?
4cm - fully dilated or 10; about 4 hours; 1.2 cm/hr for primi; 1.5 cm/hr for multi
60
What is stage II labor?
10cm --> delivery
61
What is stage III labor?
delivery fetus --> delivery placenta
62
What are the cervical changes in labor?
1. Dilation 2. Effacement 3. Softening 4. Position * *breakages of disulfide bonds and collagen mediated by prostaglandin E2, stimulated by engagement of fetal head or balloon**
63
What is station -2?
Fetal head has engaged the cervix
64
What is station -1?
Fetus has entered the vagina
65
What is station +2?
Fetal head is at opening of vagina
66
What are the two ways of assessing fetal position?
1. u/s, or | 2. Leopold maneuver
67
What is frank breech?
Knees are extended, butt facing down
68
What is complete breech?
Baby indian style, butt facing down
69
What is incomplete breech?
Baby's knees partially extended, butt facing down
70
What is footling breech?
One leg extended, baby is feet first
71
What is transverse lie?
Baby's back is pointing down, perpendicular to mom
72
What is the management for breech?
Can try external version
73
What are the cardinal movements of labor?
``` Engagement - at cervix Descent Flexion - upper 2/3 vagina Internal Rotation - upper 2/3 vagina Extension External Rotation Expulsion ```
74
What does the Bishop score measure?
How favorable vaginal delivery is, and how soon it will come
75
What is a common cause for prolonged labor?
Giving analgesics too soon | Manage by waiting out the effect of the analgesic
76
What is the initial management for prolonged latent labor?
``` Measure uterine contractions (IUPC) They should be > 3/30 min and > 40 mmHG ...can then insert balloon ...if balloon fails, c-section can always augment with pitocin ```
77
What is the management of arrested active phase labor?
Pitocin, give it 2 hrs, then c-section
78
What is prolonged second stage labor?
> 3 hrs epidural or > 2 hours no epidural
79
In what station can vacuum or forceps be used?
Station 1 or 2 | If 0 --> go to c-section
80
What is the only reason for prolonged third stage labor?
Power (contractions) | Manage with massage, or pitocin, or manual manipulation
81
How do you manage transient HTN?
>140/>90 before 20 weeks. Nothing seen on u/a because no time to damage kidneys, keep a log
82
How do you manage chronic HTN?
>140/90 before 20 weeks: alpha-methyldopa; hydralazine; metoprolol
83
What is the pathology of pre-eclampsia?
Placental contents released into blood stream, causing vasoconstriction
84
What is mild pre-eclampsia?
u/a has 140/>90;
85
What is severe pre-eclampsia?
Sustained >160/>90 after 20 weeks; >5g/dL protein - full on nephrotic symptoms; 1+ alarm symptoms
86
How is mild pre-eclampsia managed?
If >36 weeks, Mag and deliver; | If baby shows any signs of clinical worsening, and is
87
How is severe pre-eclampsia managed?
Mag and deliver via c/s
88
What is eclampsia?
If mom has a seizure during pregnancy with no hx of seizures; BP and u/a don't matter,
89
What is HELLP syndrome?
Hemolysis Elevated Liver enzymes Low Platelets
90
How is HELLP syndrome managed?
Mag and deliver
91
What are the alarm symptoms of pre-eclampsia?
Hemoconcentration especially in the presence of edema (third spacing) - patient is losing protein in urine --> Hgb appears higher; Epigastric abdominal pain - swelling of the liver - Gleason's capsule stretching; Headaches, vision changes - sign of vasospasm; Gets labs - CBC, LFT, U/A
92
What is the goal of u/s?
Assess IUP, fetal age, fetal well-being
93
What is the goal of transcranial Doppler?
Generally used after 20 weeks, used to assess fetal anemia (can measure increased flow through the cranium, which is a compensatory mechanism for anemia)
94
What is the goal of amniocentesis?
Can only be done in 2nd trimester and later (>16 weeks); AFP, genetic material, risk of loss is 1:200; If in beginning of 2nd trim - for genetic material; If >36 weeks, can assess lecithin:sphingomyelin ratio
95
What is the goal of chorionic villous sampling?
6-12 weeks, risk of loss is 1/150; | can do genetic screens and karyotypes
96
What is the goal of PUBS?
Percutanous Umbilical Blood Sampling >20 weeks; only done later on to test for fetal anemia if transfusion is needed; Risk of loss is 1:30
97
What anti-emetics do you prescribe for hyperemesis gravidarium?
Doxylamine Promethazine Metaclopromide Ondansetron
98
What is the pathology behind the premature rupture of membranes?
Ascending infection
99
What is the risk of prolonged ROM?
Group B strep infection --> prophylaxis with amoxicillin
100
What is the risk with a post-date baby?
Macrosomia --> shoulder distocia
101
What is included in the BPP?
NST + AFI with U/S
102
What is the management of a non-reactive NST?
vibroacoustic stimulation, repeat NST
103
What is the next step in management of babies that failed repeat NST after vibroacoustic stimulation?
BPP reassuring 8-10 score; if 0-2, fetal demise imminent or occurred --> deliver; If >36 weeks and iffy, deliver (pitocin or c/s);
104
What is the management of a
Contraction stress test = give pitocin, watch for DECELERATIONS; if late decels or bradycardia --> deliver; If reassuring --> grow baby, admit mom, +/1 steroids

MS3 OBGYN (2 decks)

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