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Flashcards in Ob/Gyn Deck (125):
0

Compare and contrast myomectomy to fibroid embolization

Uterine fibroid embolization requires a shorterhospitalization and less time off work. General anesthesia is not required, and a blood transfusion is unlikely to be needed. Myomectomy is recommended over fibroid embolization for patients who wish to become pregnant in the future. Uterine fibroids can occur or develop after either Myomectomy or embolization.

1

Which of the following drugs is contraindicated in the second and third trimester of pregnancy: amoxicillin, azithromycin, ceftriaxone, ciprofloxacin, or doxycycline?

Doxycycline due to the risk of permanent discoloration of tooth enamel

2

SSRIs in pregnancy

Generally safe except for paroxetine, which may cause congenital cardiac malformations with first trimester use, and is pregnancy category D

3

Benzodiazepines in pregnancy

Controversial due to a possible association with cleft lip/palate

4

Bupropion in pregnancy

Not well studied, but may cause increased risk of SAB.

5

When is maternal sero-positivity to CMV virus a contraindication to breast-feeding?

When it is of recent onset, or in mothers of low birth weight infants.

6

What is appropriate follow-up for a patient whose Pap smear indicates the presence of atypical squamous cells of undetermined significance, (ASC – US).

There are three appropriate follow-up options. Best is reflex testing for HPV. Another option is to repeat ttwp cytological exams performed at six-month intervals. The final option is a single colposcopy exam.

If the HPV test is negative, the Pap smear should be repeated at one year.

7

What is the first step in the evaluation of a woman over 35 with abnormal vaginal bleeding?

Endometrial biopsy

8

At what estimated fetal weight does ACOG recommend consideration of cesarean delivery without a trial of labor?

When the estimated fetal weight is 4500 g in a mother with diabetes, or 5000 g in the absence of diabetes.

9

What laboratory test should be done in a pregnant woman who has symptoms of flu and has been exposed to H1N1?

Real-time reverse transcript days PCR. Pregnant women are at greater risk for severe disease and complications from H1N1. Real-time PCR is the most definitive method to identify H1N1. Routine testing for H1N1 using rapid test is not recommended by the CDC because the sensitivities of the currently available rapid tests are quite poor.

10

What is the most common cause of abnormal vaginal discharge in a sexually active woman?

Bacterial vaginosis. It accounts for up to 50% of cases in some populations it is more common than either Candida albicans or trichomonas vaginalis infections.

11

What measurements are used to estimate just stational age during the first second and third trimester is a pregnancy?

Crown to rump length is the most accurate measurement of gestational age and is done at 7 to 14 weeks. After that other measurements are more reliable. In the second trimester, biparietal diameter and femur length are used. During the third trimester, biparietal diameter, abdominal circumference, and femur length are best for estimating gestational age.

12

What are the various types of decelerations seen on fetal monitoring and what do they represent?

Early deceleration's are thought to result from vagus nerve response to fetal head compression, and are not associated with increased fetal mortality or morbidity. Variable decelerations are thought to be due to acute intermittent compression of the umbilical cord between fetal parts and the contracting uterus. Late decelerations are thought to be associated with uteroplacental insufficiency and fetal hypoxia due to decreased blood flow in the placenta this pattern is a warning sign and is associated with increasing fetal compromise, worsening fetal acidosis, fetal central nervous system depression, and or direct myocardial hypoxia.

13

What are the signs of uterine rupture during labor?

The only reliable sign is fetal distress. That classic signs of uterine rupture such as sudden, tearing uterine pain, vaginal hemorrhage, and loss of uterine tone or cessation of uterine contractions are not reliable and are often absent. Pain and bleeding occur in as few as 10% of cases.

14

How can serum progesterone levels be used to evaluate viability or status of a pregnancy?

A single serum level of 25 ng/mL or higher indicates a healthy pregnancy and excludes ectopic pregnancy with a sensitivity of 98%. If the level is less than 5 ng per milliliter the pregnancy is nonviable. Assessment of fetal well-being is difficult if levels are in the intermediate range of 5 to 25 ng/mL.

15

What are the criteria for diagnosis of bacterial vaginosis?

Patients must have three of the four Amsel criteria to be diagnosed with bacterial vaginosis. These include a pH of greater than 4.5, which is the most sensitive; clue cells greater than 20%, which is the most specific; a homogeneous discharge, and a positive with test.

16

What are the chances of getting pregnant with intercourse in relationship to the days before or after ovulation?

There is a 30% probability of pregnancy resulting from unprotected intercourse 1 to 2 days before ovulation, 15% three days before, 12% the day of ovulation, and essentially 0% 1 to 2 days after ovulation.

17

What does the CDC recommend in terms of antenatal screening for group B streptococcal disease?

Cultures from the vaginal introitus and rectum are the most sensitive for detecting group B strep colonization. No speculum exam is necessary. The closest time to delivery that cultures can be performed and allow time for results to be available is 35 to 37 weeks gestation.

18

A strawberry cervix is a feature of what sexually-transmitted disease?

Trichomonal vaginitis

19

What is the definition of delayed or interrupted puberty in girls?

It is defined as failure to to develop any secondary sex characteristics by age 13, to have menarche by age 16, or to have menarche five or more years after the onset of pubertal development.

20

What is the most accurate test to determine whether a patient with contractions is at high risk for preterm labor?

Vaginal fetal fibronectin. In symptomatic women this is the most accurate test for predicting spontaneous preterm delivery within 7 to 10 days. It is less accurate in those who are asymptomatic. If the fetal fibronectin is negative it maybe possible to avoid interventions such as hospitalizations, tocolysis, and corticosteroid administration.

21

What is the best regimen for emergency contraception?

It is called plan B. It is a contraceptive package that contains 20.75 mg tablets of levonorgestrel to be taken 12 hours apart.

22

Which measurement by ultrasound determination during the second trimester provides the most accurate estimate of gestational age?

Biparietal diameter is the most accurate parameter during the second trimester it has a 95% confidence level of being within 5 to 10 days of the actual just additional age when used at the proper time.

23

What are the risk factors for endometrial cancer?

A history of anovulatory cycles, obesity, nulliparity, history of tamoxifen use, and diabetes mellitus.

24

What is the emergency management of dysfunctional uterine bleeding?

Intravenous conjugated estrogen – 25 mg Q4 hours until bleeding slows for 12 hours. This is believed to be a stimulus for clotting at the capillary level. It promotes rapid growth of endometrium to cover denuded endometrial surface and stop bleeding. 75% will be controlled in six hours. Another possibility is oral conjugated estrogen 10 mg per day in four divided doses.

Oral contraceptive pills or 10 days of progestin each month should be started after the bleeding stops to prevent recurrence.

25

What is the non-emergency management of dysfunctional uterine bleeding?

One combined hormonal oral contraceptive pill for seven days. If the flow stops within 12 to 24 hours, the diagnosis of dysfunctional uterine bleeding can be confidently made. The combined oral contraceptive should be stopped at seven days. Regular OCP's should be given for the next 3 to 6 months.

An alternative would be cyclic administration of progesterone for three months.

26

What patients tend to have thin endometrium?

They have heavy continuous uterine bleeding. They are often using a progestin dominant contraceptive pill, IUD, Depo-Provera, or minipill. They are excessively thin or have low body fat and may be hypoestrogenic. These include women with eating disorders and elite athletes.

27

Define menorrhagia

Cyclic prolonged and/or excessive bleeding

28

Define metrorrhagia

Bleeding at irregular and frequent intervals. This typically involves ovulatory cycles.

29

Define polymenorrhea

Menstrual cycles of less than 21 days

30

Define oligomenorrhea

Menstrual cycles of over 35 days

31

Define hypomenorrhea

Cyclic light flow

32

Define amenorrhea

Absence of menses for greater than six months

33

What needs to be excluded before you treat metrorrhagia?

Fibroids, polyps and endometrial cancer.

34

What are the possible treatments of metrorrhagia?

NSAIDs, antiestrogen such as danazol, oral contraceptive pills, continuous oral contraceptive pills, oral continuous progestins, levonorgestrel IUD, or surgical.

35

What is the surgical treatment of menorrhagia?

Hysterectomy is not used frequently anymore. What common are oblation procedures. These include first-generation procedures such as laser or rollerball resection; or second generation procedures such as cryoablation, laser intrauterine thermotherapy, radiofrequency ablation, thermal balloon ablation and microwave ablation.

36

What are the medical therapies for metrorrhagia and how much do they decrease bleeding?

NSAIDs, which work by decreasing prostacyclin and cause platelets anti-aggregating vasodilation, decrease blood flow 25 to 50%. The commonly used NSAID is Ponstel or mefenamic acid, 500 mg PO TID.

Danazol which is an entry antiestrogen drug, should be given at 200 mg every day. It decreases bloodflow by 50%, but it but side effects limit its use.

GnRH agonist and antifibrinolytic agents may both be used. Both are limited by side effects.

Levonorgestrel intrauterine systems causes an 80% decrease in blood loss and are more and more commonly used.

37

What are the steps in evaluating amenorrhea?

1. rule out pregnancy. 2. get a TSH to evaluate for hypo or hyperthyroidism, and a prolactin level to evaluate for pituitary tumor (fasting, no breast stimulation). 3. Determine the relative estrogen status. This means performing a progestin challenge test, which involves administering 5 to 10 milligrams of medroxyprogesterone acetate once a day for 10 days. ANY bleeding within 2 to 7 days is positive. A positive test means anovulation.

38

What are the risk factors of and the treatment for anovulatory amenorrhea?

These are frequently OBC women with or without PCO OS. Progesterone is not being adequately produced in the luteal phase, which gives them an apposed estrogen stimulation. This increases the risk for endometrial cancer. The treatment is progestin 10 mg every day for 7 to 10 days every month, or OCP's.

39

How should the work up continue if a woman who has amenorrhea has a negative progestin challenge?

She should be given an estrogen and progestin challenge test, which may involve simply giving oral contraceptive pills,. If there is no withdrawal bleeding, she has outflow tract obstruction (Asherman's syndrome,
mullerian agenesis).

If there was positive withdrawal bleeding following estrogen/progestin challenge then FSH and LH should be measured. If they are low an MRI should be done, which if normal makes the diagnosis hypothalamic amenorrhea. If FSH and LH are high, the diagnosis is ovarian failure.

40

How is hypothalamic amenorrhea it diagnosed? What sorts of patients have it? What are its risks? How is it treated?

It is diagnosed by low or normal FSH LA H levels within normal prolactin, low levels of endogenous estrogen, and a normal MRI of the sella. There will be positive withdrawal bleeding following estrogen progestin challenge test. It is usually diagnosed by the exclusion of pituitary lesions. Patients who have it frequently have anorexia or bulimia, bulimia Kallmann's syndrome, stress, high intensity exercise, or chronic illness.

These patients have a risk of decreased bone density of 10 to 20%. It cannot be completely overcome with supplemental calcium or weight-bearing exercise. It is unclear if calcium and a Cercis decrease the rate of fractures in in these patients. OCP's do improve lumbar and total bone mineral but again the effect on fractures is unknown. The patient should increase their BMI to greater than 20 to restore menses. They should also decrease intensive exercise.

41

What is the suggested evaluation for polycystic ovary syndrome?

1. Document biochemical hyperandrogenism me with a total testosterone and sex hormone binding globulin or bioavailable and free testosterone
2. Exclusion of other causes of hyperandrogegism. A TSH, prolactin and 17 hydroxyprogesterone should be checked. Consider screening for Cushing's syndrome and other rare disorders such as acromegaly.
3. A transvaginal pelvic ultrasound to look for polycystic ovaries.
4. Evaluate for metabolic abnormalities including a two hour glucose tolerance test and fasting lipid and lipoprotein levels.

42

What are the expected hormone levels in polycystic ovary syndrome?

FSH is normal to mildly elevated. LH is generally moderately elevated but this is dependent on timing of the sampling relationship to the last menses. Prolactin is normal to mildly elevated. Test Doster room and is normal to moderately elevated. There's a normal serum estradiol, and increased serum estrone concentrations.

43

How do you manage PCOS with oligomenorrhea or amenorrhea?

With a combination low-dose oral contraceptive pill or with monthly progesterone.

44

How is PCOS with hirsutism managed?

With combination low-dose OCP's, spironolactone or finasteride.

45

How is PCOS with insulin resistance managed?

Metformin

46

How is PCOS with infertility managed?

With clomiphene metformin and possibly pioglitazone.

47

What are the benefits and risks of post menopausal hormone replacement therapy?

The benefits include reduced risk of osteoporosis and related fractures, decreased colon cancer risk, and improvement of vasomotor symptoms.

The risks include increased risk of breast cancer, CVA, myocardial infarction, and venous thromboembolic events.

48

What are the contraindications to hormone replacement therapy?

The only absolute contraindication is a previous thromboembolic event. Heart disease, breast cancer and endometrial cancer are relative contraindications.

49

What are the most effective therapies for hot flashes?

Gabapentin 100 mg per day, clonidine 0.1 mg per day and venlafaxine 37.5 to 75 mg per day. All of these provide a significant reduction in hot flashes. There is some reduction in hot flashes with methyldopa at the expense of frequent side effects.

50

In what patients are combined oral contraceptives contraindicated?

Patients over age 35 who smoke or are obese, patients over 35 who have hypertension with vascular disease, patients who have lupus with vascular disease or nephritis, patients who have migraines with focal aura, patients who currently have or who have a history of venous thromboembolism associated with pregnancy or estrogen unless on anticoagulation, patients with coronary artery or cerebrovascular disease.

51

What are the risks and benefits of Dep oh progesterone contraception?

It is a good choice for chronic medical problems. It decreases crisis and sickle cell disease, it has no effect on blood pressure on the risk of venous thromboembolism on CVA or MRI. Side effects include waking amenorrhea hair loss and bone loss. It should be used therefore only for two years and continued over two years only of other methods are inadequate.

52

Who are candidates for Depo-Provera use?

Women who are postpartum, smokers over 35, women who are lactating, and women who can tolerate a period of infertility after the Depo is discontinued. Of note 70% of these women conceive by 12 months and by 24 months the rates are similar to other methods.

53

What drugs are likely to lead to contraceptive failure when given with combined hormonal contraception?

Only one antibiotic: rifampin. All anticonvulsants have a significant effect except valproic acid. Antifungals such as griseofulvin. HIV medications.

54

What are the contraindications to IUD insertion?

Current sexually-transmitted disease or PID, undiagnosed abnormal vaginal bleeding, malignancy of the genital tract. The uterus must sound to 6 cm, otherwise there is high-risk for expulsion. Therefore any uterine anomaly or fibroids distorting the cavity in a way incompatible with IUD insertion is a contraindication. Allergy to any compounded of the IUD or Wilson's disease. (for copper containing IUDs)

55

Who should be screened in pregnancy for asymptomatic bacteriurianp and how often?

All women should be screened at presentation for pregnancy care. Women with sickle cell trait or disease should be screened at presentation and every trimester.

56

What antibiotic should be used for the empiric treatment of asymptomatic bacteriuria in pregnant women?

Cephalexin QID. The most common organism for this condition is E. coli, and it has high rates of resistance to ampicillin, which therefore should not be used.

57

What antibiotics are typically considered safe in pregnancy?

Amoxicillin, ampicillin, clindamycin, erythromycin, penicillin, and cephalosporins.

58

What antibiotics should typically be avoided in pregnancy?

Tetracyclines, nitrofurantoin, and sulfonamides.

59

When and how is HIV testing done in pregnancy?

It should be offered at the first visit and again in the third trimester. Rapid testing must be available during labor in every state if the mother has undocumented HIV status. If that test is positive antiretroviral prophylaxis (with consent$ should be initiated without waiting for confirmatory test. If the mother refuses the test during labor, the baby is tested postpartum.

60

And couples who are considering pregnancy or who are pregnant, which should be offered screening for cystic fibrosis and when?

CF carrier screening should be offered before conception or early in pregnancy if both partners are of Caucasian, European, or Ashkenazi Jewish ethnicity.

61

What are the problems with parvovirus B 19 and pregnancy?

It is embryo toxic, not teratogenic. An infection in the first trimester causes miscarriage. It peaks early in the second trimester, and causes fetal anemia, hydrops fetalis, and stillbirth. The fetus is at greatest risk 3 to 6 weeks after a maternal infection. The screening is done via maternal IgG and IgM levels.If the woman has a positive IgG level for parvovirus B 19 there's essentially no risk to the fetus. For those with positive IgM titers fetal monitoring is done weekly with ultrasound and middle cerebral artery Doppler. If hydrops and anemia are present red blood cell transfusion may be needed.

62

If a patient has active recurrent genital herpes during pregnancy, what should be done?

She should be offered viral therapy at or beyond a 36 weeks of gestation, which will decrease the risk of recurrent genital herpes at delivery by 75%. The regimens recommended are 400 mg of acyclovir here TID daily or 500 mg of valacyclovir here b.i.d. daily. Both are given from 36 weeks until delivery.

63

If a patient has an abnormal one hour glucose test at 24 to 28 weeks, what should be done next?

A three hour glucose a test.

64

Who should not be screened for diabetes during pregnancy?

Low risk women. These women must meet all of the following criteria: age less than 25 years, Caucasian, weight normal before pregnancy i.e. a BMI of 19.8 2to 25, no history of abnormal glucose tolerance, no history of poor obstetric outcome, and no known diabetes and a first degree relative.

65

When would a pregnant woman with a positive one hour glucose tolerance test the presumed to have a diabetes and therefore not receive a three hour test?

If the one hour test has a result of 190 or higher.

66

When should maternal serum alpha-fetoprotein and quad screens be done during pregnancy? Describe the possible abnormal outcomes for maternal serum alpha-fetoprotein during pregnancy. What do they mean?

Screening is most accurate when performed between 16 and 18 weeks EGA. A high level of AFP means probable open neural tube defect. A low level means either trisomy 21 or trisomy 18. To distinguish between the results of low-level AFP, a quad screen is done. A low AFP with a high hCG, low estriol, and high DIA means trisomy 21. Low levels of all four analytes means trisomy 18.

67

What is trisomy 18 and what are its manifestations?

It is called Edwards syndrome. It is a genetic disorder caused by the presence of all or part part of a next or 18th chromosome. It is the second most common autosomal trisomy after down syndrome, that carries to term it occurs in about one in 6000 life birth and around 80% of those affected are female. The majority of fetuses with the syndrome die before birth. The incidence increases as the mothers age increases. The syndrome has a very low rate of survival, resulting from heart abnormalities, kidney abnormalities, and other internal organ disorders.

68

What is the most common reason for an abnormal AFP or quad screen result?

The lab has been given the wrong gestational age.

69

Which pregnant women should be on folic acid? How much should date be on and what kind?

All women of childbearing age who are attempting pregnancy should be on a 0.4 mg per day of full like acid through the the first three months of pregnancy. If the woman has a history of a delivery with a neural tube defect she should take 4 mg per day 1 to 3 months before and continuing through the first three months of pregnancy.

The folic acid should be synthetic because the synthetic form is apparently more bioavailable than the natural form.

Note that these recommendations are by the CDC. The Institute of medicine recommends somewhat higher doses of 600 µg per day for women over 19 and 800 µg per day for adolescents 14 to 18.

70

A pregnant woman on antiepileptic drugs should be on how much Folic acid per day?

If she is taking valproate or carbamazepine, she should be on 4 mg per day. If she is taking any other anti epileptic drug she should be on 800 µg per day. The folate should start 1 to 3 months prior to conception and continued through the first trimester.

Note that it is not conclusively determined that folic acid supplementation prevents neural tube defects in women on antiepileptic drugs. However low serum folate levels in women with epilepsy is an independent risk factor for major fetal malformations.

71

What is the definition of a screening ultrasound for pregnancy?

Sonographic assessment of the pregnant abdomen between 16 and 20 weeks EGA (second trimester) in the absence of specific indications for a second trimester ultrasound.

72

What pregnant women should be screened for GBS and when?

All women should get a GBS culture at 35 -37 week.

There are two groups of women who do not get screened. These are women who have had a previous pregnancy where the infant was born infected with GBS, or women who had a positive GBS culture at any time during the pregnancy.

73

What are the alternatives to penicillin or ampicillin prophylaxis in pregnant women who are allergic to penicillin?

If they are at low risk for anaphylaxis they should be given cefazolin. If there at high-risk for anaphylaxis the choice is clindamycin and and erythromycin-- Clinda 900 mg IV every eight with erythromycin 500 mg IV every six hours both until delivery.

If the woman has GBS that is resistant to Clinda and erythromycin or if the susceptibility of the GBS is unknown then she should be placed on vancomycin 1 g IV every 12 hours until delivery.

74

What are the risk factors for ectopic pregnancy?

Number one is a previous ectopic pregnancy. Also in utero DES exposure, history of genital infections or infertility, and current smoking.p

75

At what hCG level should a gestational sack be visible within the uterus?

1800 for a transvaginal ultrasound, and 3500 for trans abdominal ultrasound.

76

What are the criteria for expectant management of an ectopic pregnancy?

Minimal pain or bleeding, reliable follow-up, no evidence of tubal rupture, Beta hCG less than 1000 and falling, adnexal mass less than 3 cm or not detected, and no embryonic heartbeat.

77

What pregnant women should get RhoGAM and when?

I'm desensitized and D negative patients should get routine RhoGAM at 28 weeks. It should also be performed if she has a condition or procedure which causes risk of fetal to maternal bleed. These would include ectopic pregnancies, abortion either threatened spontaneous or induced, chorionic villus sampling or amniocentesis, abdominal trauma, external cephalic version, abruptio placentae, or delivery of a D positive baby.

Note that a woman who got RhoGAM at 28 weeks and delivers a D positive baby should get it again at delivery.

78

What pre-existing diagnoses are associated with an increased risk of preeclampsia?

Age less than 20 or or over 35, family history of preeclampsia, nulliparity, preeclampsia in a previous pregnancy, black race. Medical conditions include diabetes of either type 1 or geststational, chronic hypertension, renal disease and thrombophilias.

79

What is the most common cause of intrauterine growth restriction?

Chronic hypertension

80

what treatments may decrease the risk of preeclampsia and in whom should they be administered?

There is no supplementation that decreases the risk of preeclampsia and low risk patients. And high-risk patients low-dose aspirin and calcium supplementation may decrease the risk

81

What immediately treatment should be given to a woman who presents with extremely high blood pressure, seizures, and a very low fetal heart rate at delivery?

Magnesium sulfate for grandma loading dose IV followed by a trip at 2 g per hour. A vaginal delivery should be performed if possible, because this woman is at high risk for DIC.

82

At what blood pressure level is hypertension treated intrapartum? And what is commonly given?

It is treated when there is a persistent elevation of diastolic blood pressure over 105-110.

Labetalol is the most commonly given drug

83

Which patients who have hypertension during pregnancy are at highest risk for postpartum hypertension?

Women who have antenatal preeclampsia, especially if it involves high urinary protein, serum uric acid, and BUN.

84

What sort of follow-up should a woman get who has hypertension during pregnancy, and her prepregnancy blood pressure was normal or unknown?

Oral medication should be stopped after 3 to 4 weeks postpartum. She should be observed with weekly blood pressures every 1 to 2 weeks for a month, then every 3 to 6 months for one year. If the hypertension recurs it should be treated, because it is most likely chronic.

85

Define fetal macrosomia.

Birth weight of more than 4500 g.

86

What abnormalities associated with high or low lab values are common in babies born to diabetic mothers?

Hypoglycemia, hypocalcemia, hyperbilirubinemia, and polycythemia.

87

What is the most common cause of the individual death in children of mothers known to have diabetes before pregnancy?

Congenital abnormalities

88

Gestational diabetics should check their blood sugars how often? What are the goals? When should insulin be started?

Human insulin therapy should be begun if on more than three occasions there is a fasting whole blood glucose of over 95 or a two hour postprandial whole blood glucose of more than 120. Once they have begun insulin they should monitor sugars daily.

89

Which oral medications may possibly be safe in pregnancy? Do they cross the placenta?

Glyburide, which does not cross the placenta and metformin which does.

Incidentally, insulin does not cross the placenta.

90

What are the types of diabetes in pregnancy?

A1: these women develop diabetes during pregnancy and are not on insulin

A2: these women develop diabetes during pregnancy and are on insulin

B: these women have a pre-existing diabetes

91

What should be the timing for delivery in pregnant women with the various types of diabetes?

A ones should be managed expectantly as long as the glucose values remain normal. A 2/Bs should be delivered by 40 weeks with twice-weekly monitoring if beyond 38 weeks. If there is going to be an intervention in terms of hastening delivery, the fetal lung maturity should be documented. If there is poor diabetes control or complications, lung maturity should be documented and delivery should be induced at 38 weeks.

92

Women with intrahepatic cholestasis a pregnancy should be screened for what condition?

Hepatitis C. More than 20% of women known to be infected with hepatitis C will develop ICP.

93

What is the treatment for intrahepatic cholestasis of pregnancy?

Ursodeoxycholic acid, 10 mg per kilogram per day. Cholestyramine may be effective in mild or moderate intrahepatic cholestasis, but it's less effective and safe than ursodiol.

94

What are the fetal and maternal risks of intrahepatic cholestasis of pregnancy?

There are generally no risks for the mother except for discomfort. Fetal risks include risk for preterm labor and preterm delivery, risk for fetal compromise and increased need for cesarean delivery, meconium stained amniotic fluid, and intrauterine fetal demise.

95

What factors place a woman at risk for placenta previa?

Advanced maternal age, prior cesarean delivery, cocaine and tobacco use.

96

What is the relationship of placenta previa and malpresentation?

Malpresentation is the result rather than the cause of previa.

97

What is the recurrence risk and subsequent pregnancy for placenta previous?

6 to 12 times.

98

When is a placenta previa likely to clear the os by term, and when is it unlikely to do so?

90% of placentas which appear to be close to the os before 24 weeks will have moved away from the os at term. If the bulk of the placenta is over the os after 24 weeks it is less likely to be clear of the os at term.

99

What are the etiologies of placental abruption?

Trauma, cocaine abuse, acute decompression of amniotic fluid, preterm rupture, hypertensive disorders, tobacco. Diabetes is not a risk factor.

100

What is the risk of recurrence of placental abruption in subsequent pregnancies?

20 to 30 times.

101

How is placental abruption managed?

If there is fetal demise there is usually placental detachment of more than 50%. The fetus should be delivered and you should be prepared to transfuse the mother.

If there is a live fetus and a rigid uterus, again there is likely to be over 50% detachment. A C-section should be performed immediately. Without it there's a 90% incidence of fetal demise.

If there is a live fetus and a soft uterus, labor may be induced. This is likely to be a small abruption.

102

Compare and contrast placenta previa to placenta abruptio.

In placenta previa there is minimal pain, absent or mild contractions, bright red blood, normal coagulation, and almost never a concealed hemorrhage.

In abruptio, there is severe pain, hard rapid and tetanic contractions, port wine colored blood, abnormal coagulation, and concealed hemorrhage more than 20% of the time.

103

Define premature onset of labor.

Occurs in a gestation of more than 20 weeks and less than 37 weeks. There must be contractions and cervical change.

104

What are the greatest risk factors for premature onset of labor?

Prior preterm birth, concurrent STD, African-American race, prepregnancy weight of less than 50 kg, and bleeding.

105

When and at what dose are corticosteroids given to promote fetal lung maturation?

At 24 to 34 weeks EGA. Betamethasone 12 mg IM every 24 hours times two doses.

106

How do you manage preterm labor?

It is symptomatic management only with the goal of allowing time for fetal lung maturation. Tocolytics are given such as magnesium sulfate for 24 hours. Two doses of betamethasone 12 mg IM are given 24 hours apart. If there is rupture of membranes, broad-spectrum antibiotics are given. If there is no rupture of membranes, GBS prophylaxis is given as indicated.

107

Define postpartum hemorrhage

It is a 10% change in the hematocrit between admission and postpartum period or a need for erythrocyte transfusion.

Early occurs in the first 24 hours after delivery, and late after 24 hours and before six weeks after delivery.

108

What are the causes of early postpartum hemorrhage?

The four tees: tone, tissue, trauma, and thrombin.

Tone refers to uterine atony, with uterine overdistention. Causes include hydramnios, multiple gestation, and fetal macrosomia. Also oxytocin use, high parity, rapid or prolonged labor, intra-amniotic infection, and halogenated anesthetics.

Tissue refers to retained placental fragments including abnormal placentation such as accreta, increta and percreta.

Trauma refers to lacerations of vagina and cervix, uterine rupture or uterine inversion. It may be caused by forceps, fetal macrosomia, precipitous labor and delivery, or episiotomy.

Thrombin refers to coagulopathy. It may be hereditary, or caused by DIC with sepsis or abruption or HELLP syndrome.

109

Define placenta accreta, placenta increta, and placenta percreta

They're all conditions in which the placenta attaches abnormally to the uterine wall. In placenta accreta the placenta attaches too deep in the uterine wall but does not penetrate uterine muscle. Placenta accreta accounts for 75% of cases of abnormal uterine attachment. In placenta increta the placenta attaches even deeper and it does penetrate the uterine muscle. This accounts for 15% of cases. In placenta percreta the placenta penetrates through the entire uterine wall and attaches to another organ such as the bladder. It is the least common of these and occurs in approximately 5% of all cases of abnormal attachment.

110

What is active management of the third stage of labor?

It has been shown to reduce the risk of postpartum hemorrhage. With the delivery of the shoulder the oxytocin is opened up. As soon as the baby is delivered to the cord is clamped and cut. When the oxytocin hits, which is about 90 seconds after it is opened up, you put controlled traction on the cord and deliver the placenta with the first contraction.

111

When should induction be performed for post dates pregnancies?

Level A evidence

Postterm pregnancies with unfavorable cervix can undergo induction or expectant management. Prostaglandins can be used to promote cervical ripening and induce labor. Delivery should be effected if there is evidence of fetal compromise or oligohydramnios,

Level C evidence

It is reasonable to initiate kill monitoring between 41 and 42 weeks, which many practitioners do twice-weekly. An NST and AFI should be adequate. Many recommend induction or prompt delivery in patients with a favorable cervix and no other complications.

112

What is the definition of menopause?

No menstrual bleeding for at least 12 months.

113

At what age should abnormal vaginal bleeding prompt an endometrial biopsy?

Any age over 35

114

At what estimated fetal weight does ACOG recommend consideration of cesarean section?

4500 g in a mother with diabetes, or 5000 g in the absence of diabetes. However even at that size there is not adequate data to show that cesarean section is preferable to a trial of labor.

115

What is the usual cause of bilateral nipple pain with and between feedings after the initial soreness has resolved?

Candida.

116

What would be the most appropriate first step for evaluating a 32-year-old female who has increasing hair growth on her chin and chest, acne, and itregular menstrual periods?

Laboratory testing including: early-morning total testosterone, pregnancy test if the patient is amenorrhea, serum prolactin level, DHE – S and early morning 17-hydroxyprogesterone. These last two tests exclude hyperandrogenism and congenital adrenal hyperplasia. Assessment for Cushing's syndrome, thyroid disease, or acromegaly is appropriate if associated signs or symptoms are present.

117

What treatments are recommended for mother and baby when varicella is contracted during pregnancy?

Maternal varicella infection is particularly problematic during weeks 13 to 20 of pregnancy, which results in a 2% risk of congenital varicella in the newborn, and when the onset of maternal symptoms occurs from five days before until two days after delivery. Administration of varicella immune globulin to the mother has not been shown to benefit the fetus or infan. But because pregnancy can cause increased risk of serious complications in the mother, administration of varicella immune globulin to the mother should be considered. It is also recommended that term infants born within the seven day window as above, as well as all preterm infants, receive varicella immunoglobulin, and that those who develop any signs of varicella infection also be given intravenous acyclovir.

118

What is the preferred treatment for DVT during pregnancy?

Low molecular weight heparin. I'm fractionated heparin requires more frequent monitoring and is associated with heparin induced thrombocytopenia. Warfarin is contraindicated during pregnancy but may be used during lactation.

119

If a pregnancy occurs with an IUD in place, when should the IUD be removed?

It should be gently removed as soon as possible. This reduces the risk of spontaneous abortion, Preterm labor and sepsis.

120

What hormonal contraceptives are most effective in obese women?

The Nuvaring combination contraceptive vaginal ring, or depot medroxyprogesterone acetate.

121

What drug is first-line therapy for hypertension in pregnancy?

What drugs should be avoided?

Labetolol is first-line therapy.

Metoprolol has been associated with fetal growth restriction and is generally avoided. Both ACEs and ARB's are contraindicated in pregnancy because of the risk of birth defects and fetall or neonatal renal failure. immediate release nifedipine is not recommended due to the risk of hypotension.

122

What drugs are indicated for the initial choice in the management of severe hypertension during pregnancy?

Intravenous hydralazine, intravenous labetalol or oral nifedipine.

123

What are the criteria for severe preeclampsia?

Blood-pressure of 160/110 or higher on two occasions, six hours apart. Proteinuria above 5 g per 24 hours, thrombocytopenia with a platelet count count of less than 100,000, liver enzyme abnormalities, epigastric or right upper quadrant pain, and alteration of mental status.

124

What is the antidote for magnesium toxicity in the treatment of severe preeclampsia?

Calcium is the antidote. Calcium gluconate should be used if it is administered through a peripheral line. Calcium chloride can be used if a central line has been established.