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OB GYN MB > OB > Flashcards

OB Flashcards

1
Q

What is the most common sign of uterine rupture?

Are IUPC’s useful for this DX?

A

fetal heart tracing abnormalities (can you name them?):

  • fetal bradycardia
  • late decal’s
  • deep variables

NO IUPC’s have not been shown to be helpful. They may CONFUSE the picture: if you see any of the above FHT abnormalities, cut!!!

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2
Q

You’ve just given a woman misoprostol for cervical ripening. About 2 hours later, you see a prolonged deceleration on the FHM. What is the most likely etiology?

A 
Uterine hyperstimulation (>5 contractions in 10 minutes)
-Most commonly happens with misoprostol, although it can happen with any of the prostaglandin ripening agents (including cervidil, aka dinoprostone)
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3
Q

Name some maneuvers that improve fetal oxygenation during labor (5)

A
  1. lateral decubitus position
  2. fluid bolus
  3. 100% O2 mask
  4. stop oxytocin (oxytocin causes uterine contractions as well as vessel compression)
  5. push IV ephedrine (epidural causes maternal hypotension)
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4
Q

Name the steps in assessment of fetal bradycardia.

What causes it?

A
  1. differentiate mom’s pulse from what you’re seeing on the FHT monitor!!!
  2. fetal scalp pH; *requires at least 4cm dilation
  3. Poor fetal oxygenation!!!
  4. umbilical cord prolapse
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5
Q

How does one fix poor fetal oxygenation during labor?

A
  • lateral decubitus position
  • 100% O2 mask
  • IV fluid bolus
  • stop the pit
  • terbutaline to relax the uterus
  • apply pressure to the presenting part to relieve cord compression
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6
Q

What are the causes of non reassuring FHT abnormalities? (3)

Can you name their fixes?

A
  1. maternal hypotension (IV fluids, position change, IV ephedrine)
  2. uterine hyperstimulation (stop pit, IV terbutaline)
  3. umbilical cord prolapse (manual pressure and emergent CS)
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7
Q

name the treatment options for postpartum hemorrhage (PPH)

A
  1. IV pit
  2. uterine massage and compression
  3. hemabate (prostaglandin F2, don’t use in asthmatics)
  4. methergine (NOT for use in HTN)
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8
Q

definitive amount of blood loss for PPH in vaginal vs CS

A
  1. vaginal>500mL

2. CS>1000mL

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9
Q

risk factors for uterine atony (7)

A
  1. Mag
  2. oxytocin during labor
  3. rapid labor/delivery
  4. overdistension of the uterus
  5. chorioamnionitis
  6. prolonged labor
  7. high parity
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10
Q

causes of PPH with a firm uterus (4)

A
  1. genital tract lacerations
  2. uterine inversion
  3. placental accreta or retention
  4. coagulopathy (suspect with abruptions!)
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11
Q

Surgical management of uterine atony

A

ligating the blood supply
placing compression stitches
hysterectomy

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12
Q

Name a procedure to prevent preterm labor in a woman with cervical insufficiency

A

cervical cerclage

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13
Q

Which arteries can you ligate in PPH (3)?

A
  1. ascending branch of uterine
  2. internal iliac (hypogastric)
  3. utero-ovarian ligaments (ONLY IF you already ligated the uterine aa)
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14
Q

Woman on post partum day 10 comes in with 2 days of bright red bleeding. How you gonna treat her?

A
  • Methergine if she’s not HTN
  • Misoprostol if she’s not asthmatic
  • Crap, what if she’s got both??? give IV pit and crystalloids
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15
Q

First trimester screening:

  • When?
  • Which serum markers (2) and imaging technique (1)
A

10-13 weeks

PAPP-A, beta-HCG, NT US

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16
Q

What does increased nuchal thickness imply risk of?

A

Down syndrome and trisomy 18

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17
Q

Causes of elevated maternal serum AFP (msAFP) (9, sorry)

A 
underestimated GA
multiple gestations
NTDs
abdominal wall defects
cystic hygroma
skin defects
sacrococcygealteratoma
decreased maternal weight
oligo
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18
Q

decreased msAFP

A 
overestimated GA
trisomies
molar
fetal death
increased maternal weight
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19
Q

unexplained elevated msAFP, what’s the risk?

A

stillbirth
growth restriction
preeclampsia
placental abruption

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20
Q

Trisomy 21 serum analytes

A

AFP low, uE3 low, hCG high, inhibit A high, PAPP-A high,

You only need to know 2 analytes for down syndrome

AED for down syndrome
AFP is down
E3 is down

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21
Q

trisomy 18 analytes

A

AFP low, uE3 low, hCG low, PAPP-A low

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22
Q

What is the most common mechanism of vertical transmission of HSV?

  • primary infection during labor
  • nonprimary first episode at time of labor
  • recurrent infection at time of labor
  • asymptomatic shedding in a pt with no history of HSV
A

-Asymptomatic shedding in a patient without a history of HSV:75% of situations involving neonatal HSV are due to this method, making prevention really tricky.

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23
Q

How does a baby get infected by HSV in utero?

A

If it’s the mother’s primary infection

-more widespread, more likely to access placenta

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24
Q

Risk factors for placenta previa (5)

A
  1. multiparty
  2. prior c/s
  3. prior uterine curettage
  4. previous placenta prevue
  5. multiple gestation (larger placental surface area increases odds of covering the cervical os)
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25
Q

which is painful? placenta previa or abruption?

A

abruption is painful! due to uterine contractions!

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26
Q

Which of the following is a typical feature of placenta previa?

  • painful bleeding
  • commonly associated with coagulopathy
  • first episode of bleeding is usually profuse
  • associated with postcoital spotting
A

post-coital spotting is the answer!
-the placenta is close enough to the cervix to get irritated by sex–>spotting

The rest of the answer choices are associated with placental abruption

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27
Q

A mother at 37 weeks has serious bleeding. US shows placenta previa. what do you do?

  • expectant mgmt
  • induce labor
  • suppress labor
  • c/s
A

Give her a c/s.
-She’s at greater than 37 weeks, so the baby’s lungs are fully mature. c/s is the safest way to deliver a woman with placenta previa.

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28
Q

Woman at 34 weeks comes in with moderate bleeding. I In what order do you do the following exams?

  • digital
  • speculum
  • US
A
  1. US (always visualize the placenta FIRST)
  2. speculum (look for cervical lacerations)
  3. digital (assess for dilation/effacement/station)
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29
Q

Woman in second trimester has placenta previa on US. Is it too late for the placenta to change positions?

A

No. The woman has until the early third trimester to change placental positions.

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30
Q

risk factors for placental abruption (9)

A
  1. previous abruption
  2. cocaine
  3. short umbilical cord
  4. trauma
  5. uteroplacental insufficiency
  6. submucosal leiomyomata
  7. sudden uterine decompression
  8. cigarette smoking
  9. PPROM
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31
Q

Vocab question: what is bleeding into the myometrium of the uterus, giving it a discolored appearance?

A

couvelaire uterus

*not important, whatsoever lol

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32
Q

what’s a concealed abruption?

A

bleeding is retained behind the placenta so that non of it flows through the genital tract.
-This is bad news: the woman is actively losing blood, mixing with baby’s blood, and has no external clue.

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33
Q

Can you DX abruption using US?

A

NO!!!!

  • Blood pours out from behind the placenta, and when visualized on US it has the same sonographic consistency as the placenta itself.
  • Use your clinical suspicion!
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34
Q

Prior c/s is a risk factor for which of the following? (more than one is correct):

  • placenta previa
  • placenta accreta
  • placental abruption
A

c/s is a risk factor for previa and accreta
-the scar tissue makes it hard for the placenta to migrate to its proper position, causing either previa or accreta

c/s does NOT increase risk for abruption!

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35
Q

What’s the difference in mgmt if a woman is abrupting significantly at 37 wks and:

  1. US confirms fetal demise
  2. US confirms fetal stress, but still alive
A
  1. if there is fetal demise: induce labor and prep for a vaginal delivery. Less blood loss, puts mom under less physiologic stress.
  2. if there is fetal life: prep for c/s and get that baby out while you still can!

*In case of DIC, you better give mom FFP, platelets, and packed RBCs

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36
Q

Define: when the placenta implants into the myometrium

A

Placenta increta

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37
Q

Risk factors for placenta accreta (12)

A
  1. placenta previa or low lying
  2. price c/s or other INTRA-uterine scar
  3. prior uterine curettage
  4. AMA
  5. IVF pregnancy
  6. Multifetal pregnancy
  7. Multiple c/s and placenta previa
  8. Prior Asherman
  9. Prior endometrial ablation
  10. Uterine leiomyomata
  11. Prior pelvic irradiation
  12. smoking
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38
Q

Which is worse for placenta accreta? anterior or posterior placenta?

A

Anterior placenta has a higher risk

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39
Q

What can you do for a woman with placenta accreta who strongly wishes to have more children?

Does this alternative have any associated risks?

A

IV MTX therapy.

-Risks: hemorrhage and infection due to necroses placental tissue

40
Q

Let’s say you perform a myomectomy on a subserosal fibroid. Would that increase your risk for placenta accreta?

A

NOPE. Subserosal procedure–>subserosal scar.

41
Q

Usual mgmt of placenta accreta

A

Prelabor cesarean hysterectomy

  • 34-35 weeks
  • after betamethsaone administration
42
Q

Patient presents at 11 wks GA with RLQ pain, n/v, fever.

  • Dx?
  • Tx?
A
  • Acute appendicitis

- surgery

43
Q

Patients presents at 16 wks GA with RUQ pain, n/v, fever.

  • Dx?
  • Tx?
A
  • cholecystitis

- surgery

44
Q

Pt at 16 wks GA has colicky pain in the RLQ, n/v

  • Dx?
  • Tx?
A
  • ovarian torsion due to absence of fever

- surgery

45
Q

Pt at 20 wks GA has epigastric pain radiating to her back. She also has n/v, and complains the pain is burning through her.

  • Dx?
  • Tx?
A
  • pancreatitis

- NPO, ERCP if suspected blockage

46
Q

Pt presents with progressive pelvic pain, n/v, and spotting that started 1 day ago.

  • Dx?
  • Tx?
A
  • ectopic pregnancy

- med/surge

47
Q

pt at 8 wks GA presents with sharp pain in her lower abdomen that started an hour ago. It was so severe that she passed out. She is afebrile and denies n/v. US shows free fluid in the peritoneum

  • Dx?
  • Tx?
A
  • rupture corpus lute

- laparoscopy: first ligate the blood supply, then if needed perform cystectomy

48
Q

you’ve just appropriately treated a woman at 9 wks GA for ruptured corpus luteum.

  • what do you need to supplement now?
  • what if it were later on in the pregnancy?
A
  • give supplemental progesterone!

- after 10-12 weeks GA, no supplemental progesterone is necessary

49
Q

What is the most common cause of pancreatitis in pregnancy?

-what do you do to search for this cause?

A

gallstones

-US, if + prep for surgery when they’re stable

50
Q

When would you do an ERCP for a stone obstruction causing pancreatitis?

A

when the common bile duct is obstructed.

51
Q

what kind of pain is associated with ovarian torsion

A

COLICKY

52
Q

woman presents at 38 wks GA with clusters of vesicles that itch on her abdomen. She’s in labor, her cvx is 5/90/0.

  • what do you do?
  • will this affect the baby?
A

This is herpes gestationalis because of the unique abdominal distribution.

  • you simply observe the labor as if it were normal. this condition does not cause any complications of labor.
  • this can caused neonatal lesions, due to IgG crossing the placenta. They always resolve. not to worry, not caused by HSV
53
Q

woman at 32 wks GA has RUQ pain, n/v, and jaundice. which of the following can also result from this condition? (more than one)

  • acute renal failure
  • hypoglycemia
  • coagulopathy
  • liver failure
A

ALL OF THEM. this is acute fatty liver of pregnancy. It’s caused by mitochondrial mismanaging of fatty acid chains–>microsteathosis in the liver. the downstream effects involve most of the liver’s functions.

  • acute renal failure
  • hypoglycemia due to low glycogen stores
  • coagulopathy due to liver failure
54
Q

what do you do if a woman scores 8/10 on her BPP, but her amniotic fluid is less than appropriate?

A

You deliver her if her GA is high enough. oligohydramnios is highly predictive of fetal demise, so you’ve gotta get that baby out ASAP

55
Q

what’s a normal amniotic fluid index?

normal deepest pocket of amniotic fluid?

A

> 5cm

deepest vertical pocket of at least 2x2cm

56
Q 
19 yo G1 with severe SOB at 29 wks GA
RR is 44, O2 sat is 90%, BP is 160/114
PC ratio is 0.6, AST is 84, ALT is 90
-Prioritize the steps to stabilize this patient
-how do you stabilize the fetal status?
A
  1. O2 mask to increase sat >94%
  2. IV antihypertensives (lab, hydra)
  3. start a Mag drip for seizure PPx
  • pt is <37 wks, so you should give betamethasone for lung development since you will have to deliver her.
  • also give PCN due to GBS unknown
57
Q

if you have a pt with suspected pre-e, what are the first labs you should order?

A

-CBC with pl8lets, LFTs, serum creatinine

58
Q

What are the two criteria for pre-e?

A
  1. HTN (>140/90) 2x 6hrs apart

2. Proteinuria (>300 in 24 or P/C>0.3)

59
Q

Which findings can replace proteinuria in the dx of pre-e? (6)

A
  1. thrombocytopenia
  2. impaired LFTs
  3. renal insufficiency
  4. pulmonary edema
  5. cerebral disturbances
  6. visual impairment
60
Q

How is posterior reversible encephalopathy syndrome dx/d?

A

MRI: shows enhancement of the posterior parietal lobes

61
Q

Labs in pre-e (not including BP and proteinuria) (3)

A
  1. thrombocytopenia (<100,000)
  2. impaired LFT (2x normal)
  3. renal insufficiency (Cr<1.1)
62
Q

Minimum isolated BP for a dx of severe pre-e

A

> 160/>110

63
Q

in which scenarios of pre-e would you deliver regardless of GA? (6)

A
  1. uncontrollable severe HTN
  2. eclampsia
  3. pulmonary edema
  4. abruption
  5. DIC/marked thrombocytopenia
  6. non reassuring fetal status
64
Q

What’s the magic number of GA that allows you to deliver in the presence of severe features?

A

34 weeks

65
Q

A G1 at 28 wks GA is admitted with pre-e. On HD 7 her status changes and you decide to deliver her. Which of the following could have prompted this decision?

  • elevated uric acid
  • platelets =110,000
  • PT 1.9 PTT 50
A

-PT and PTT elevated. Indicates DIC could happen.

66
Q

which of the following require antihypertensive mgmt?

  1. chronic HTN
  2. pt at 31 wks GA with BP 150/90 and platelets 90,000
  3. pt at 32 wks GA with BP 160/90
A
  1. chronic HTN always gets controlled
  2. severe pressures need controlled
  3. does not need meds; regular pre-e does not need controlled
67
Q

how long does HTN have to last postpartum to be considered chronic??

A

12 weeks, beeyotch.

68
Q

woman at 29 weeks presents with sharp pain in her belly and back. denies leakage of fluids. her vitals and the baby’s vitals are stable. what methods can you use to rule out preterm labor?

A
  1. fetal fibronectin: if positive she’s likely in labor, if negative she has at least a week, on average
  2. transvaginal US cervical length
  3. ultrasound measurements of cervical stiffness
69
Q

you check a G1P0 at 28 wk GA woman’s cervix to r/o labor. you find that its 1/80/-3. is she in preterm labor?

A

no. you need to have at least 2/80 to dx preterm labor with a cervix check.

70
Q

name the most commonly used agents for tocolysis (4)

A
  1. indomethacin
  2. nifedipine
  3. terbutaline
  4. ritodrine
71
Q

is mag sulfate a useful tocoloytic agent?

A

no! trick question though.

it’s been found to help prevent CP in births less than 32 wks GA.

72
Q

you should give antenatal steroids at less than what GA?

A

34 wks.

baby’s lungs are mature at 34 wks. steroids speed it along before that.

73
Q

alright. here’s a 25y G2P1001 at 30wks with contractions. no fluids. you just did a cervix exam, and kick yourself because now your fetal fibronectin assay results would be worthless. besides, she says that she had intercourse last night (so it’s not completely your fault, results would still be worthless). you remember that you can do a transvag US to check for cervical length. turns out, the cervix is 20 mm in length in this patient.
- is she at increased risk for preterm delivery?
- what’s the usual cutoff?

A
  • she’s at increased risk, but the PPV of this test is poor so we’re not really sure
  • if the cervical length is <25mm, you have a positive test result that indicates increased risk of preterm labor.
74
Q

what’s the date range for late preterm gestation?

A

between 34 +0/7 and 36 +6/7 wks

75
Q

there are three infectious etiologies that increase risk for preterm delivery. what are they?

only two of them, when treated, decrease risk. which?

A
  • pyelonephritis
  • gonorrhea
  • BV

treating pyelo and gonorrhea actually decreases risk.

BV does increase risk, but treating it has not shown to decrease risk of preterm delivery

76
Q

review the risk factors for preterm labor (11)

A
  1. PPROM
  2. multiple gestations
  3. previous preterm labor/birth
  4. hydramnios
  5. uterine anomaly
  6. h/o cervical/cone bx
  7. cocaine
  8. black
  9. trauma to the belly
  10. pyelo
  11. abd. surg in pregnancy
77
Q

so you’re working a woman up for preterm labor. she doesn’t have any risk factors for it. now you wanna do a physical exam. what should you do?

A
  1. FFA swab (before sticking anything weird in there)
  2. speculum exam to assess ruptured membranes (ferning/pooling)
  3. serial digital cvx exams
78
Q

you know that a couple risk factors for preterm labor include pyelo, drug abuse, and infections that cause cervical insufficiency. based on that info, what labs should your order?

A
  1. UA and culture, sensitivity
  2. UDS
  3. G and C
79
Q

oh god. this G1 is here and she’ s in labor. she’s only at 32 wks. what IV drugs are you gonna start immediately?
do you give mag?

A
  1. antenatal steroids
  2. PCN for GBS ppx

no mag, she’s at 32.

80
Q

why can’t you use indomethacin in the third trimester?

A

it closes the fetal ductus arteriosus

not good! this can lead to pulm HTN

81
Q

i just gave a G1 at 36 wks mag for seizure ppx. now she’s breathing rapidly. RR is 42. i can barely hear any breath sounds on both sides. why???

A

she’s now got pulmonary edema thanks to the mag.

we just caused a L sided heart failure significant enough to cause pulmonary edema. way to go, intern. this is why we do mag checks.

82
Q

what are the contraindications to terbutaline and ritodrine (they’re both beta agonists)

A
  1. arrhythmias (let’s not fire up a crappy heart)
  2. hypertension (pumping more blood into a high pressure circuit is a bad idea, this includes pre-e)
  3. seizure disorders (beta agonists are insulin antagonists. that means lots of sugar and little potassium in the blood. low potassium plus seizures equals more seizures)
83
Q

what is 17-alpha-hydroxyprogesterone’s MOA as a tocolytic?

A

it’s a synthetic progesterone. it inhibits release of gonadotropins to maintain pregnancy.

it’s given as injections from 16 to 36 wks to decrease risk by 1/3.

84
Q

a 35 y G1 at 32 wks has confirmed preterm labor for AFA. her cvx dilates to 3 and 90. you give her a tocolytic agent. the monitor shows numerous variable decels. which could cause that?

  • nifedipine
  • indomethacin
  • mag
  • terbutaline
A

variable decels are due to cord compression and oligo (due to less buffering of compression).

therefore, indo could have caused this. indo leads to oligo

85
Q

woman at 33 wks GA has leakage of fluid. You test the fluid and determine that there is phosphatidylglycerol present. what should you do?

  • corticosteroids
  • antibiotics
  • induce labor
A

-induce labor. the kids lungs are mature, as demonstrated by the PG in the fluid. there’s no point in giving abx and waiting till 34.

86
Q

which IgG and IgM status would prompt you to re-test that patient’s Ig levels in 4 weeks?

A

IgM negative, IgG negative

-There could be an acute infection, but the body may not have had enough opportunity to form abs

87
Q

hey this lady has parvo B19. you check FHT and see a sinusoidal wave pattern. what caused that?

A

sinusoidal wave patterns indicate severe fetal anemia!!!

88
Q

how do you treat chlamydial cervicitis in pregnancy?

A
  1. erythromycin
  2. azithromycin
  3. amoxicillin
89
Q

ophthalmic antibiotics prevents which of the following:

  • gonococcal conjunctivitis
  • chlamydial conjuncitivitis
A

-only gonococcal

90
Q

can a woman with HIV breastfeed?

A

nope.

91
Q

what are the best means of preventing vertical transmission of HIV? (3)

A
  • HAART
  • c/s if viral load is high
  • zidovudine syrup to the infant
  • avoid breast feeding
92
Q

what about a woman with Hep C? can she deliver vaginally and breast feed?

A

yes she can!

93
Q

do you have to do a c/s on a woman with Hep B?

A

nope. just antiviral therapy.

- also: make sure you avoid invasive procedures so mom’s blood doesn’t mix with baby’s too much

94
Q

how can you treat the baby of a hep B + mother in the neonatal period?

A

hep B ig and and vaccine!

95
Q

24 y F delivered vaginally 2 months ago. how she has nervousness, tremulousness, and palpitations. Her TSH is 0.01 (nl is 0.5-5). what’s the most likely etiology?

A

postpartum destructive thyroiditis. usually occurs 1-4 months after pregnancy. may result in hypothyroidism then euthyroid.

during pregnancy, corticosteroids are really high, which suppresses the immune system. there’s a parabolic increase in immune activity postpartum.

next, the body forms antimicrosomal and antiperoxidase antibodies. not good.

OB GYN MB (2 decks)

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