OBGYN Precision & Pearls #3

Question 1

name and describe the four stages of labor

Answer 1

Stage 1: onset of labor to full dilation of cervix
–Latent Phase: onset to 4-6 cm
–Active Phase: rapid dilation to completion
Stage 2: 10 cm to delivery of baby
–Passive: dilation to active efforts
–Active: active effort to delivery
Stage 3: Postpartum to delivery of placenta
–0-30 minutes usually
–examine for three vessels and make sure intact
Stage 4: 1-2 hours after delivery

Question 2

What testing is done in the first trimester (weeks 1-12)

Answer 2

Biochemical screening - free beta-HcG, PAPP-A
Antibody titers (HepB, HIV, sickle cell, rubella, CF)
Nuchal translucency US (for Trisomy 13, 18, 21)
Chorionic villous sampling

Others:
-Fetal heart tones by doppler at 10-12 weeks
-Transvaginal US heart tones by 5-6 weeks
-PAPP-A low in Down Syndrome
-STI testing

Question 3

What testing is done in the second trimester (weeks 13-27)

Answer 3

-Gestational DM screen (24-28 weeks)
-Amniocentesis at 15 weeks if high risk
-Triple Screening (a-fp, beta HcG, and unconjugated estriol, inhibin A if Quad Screen)

Question 4

What is quickening and when is it seen?

Answer 4

Moving of the fetus at 18 weeks

Question 5

at 20 weeks, where is the fundus of the baby?

Answer 5

At the level of the umbilicus

Question 6

Regarding the Quad Screen, explain what is seen in Trisomy 18

Answer 6

All low

Question 7

Regarding the Quad Screen, explain what is seen in Down Syndrome (Trisomy 21)

Answer 7

High inhibin A & BhCG
Low Estriol and AfP

2 high, 2 low

Question 8

If Afp is high on Quad Screen, what should you suspect?

Answer 8

Neural Tube Defect (spina bifida or anencephaly)

Question 9

What testing is done in the third trimester (weeks 28-birth)

Answer 9

-DM screening at 24-28 weeks
-Group B Strep Screen at 36-37 weeks (retrovaginal culture) –> give IV Pen G during labor
-Antibody titers
-Biophysical profile (2 pts each for fetal tones, breathing, movements, etc.)
-Nonstress testing
-Contraction stress testing
-Counseling

Question 10

What counseling is given to mothers during the third trimester?

Answer 10

No airline travel > 35 weeks
Postpartum birth control
Birth plan discussion

Question 11

Explain what is seen on a non stress test and what does each option mean?

Answer 11

Baseline fetal HR is 120-160 bpm

Reactive (fetal well being): > 2 accelerations, rate >15 from baseline

Nonreactive (sleeping or immature fetus): no accelerations or < 15 from baseline

Question 12

What is premature labor defined as?

Answer 12

Regular contractions (>4-6/hr), progressive cervical dilation and effacement < 37 weeks

Question 13

Premature labor is the #1 cause of fetal morbidity and mortality. What is the definition (dilation and effacement).

Answer 13

Dilation of 3 cm or greater

80% effacement or greater

Question 14

What are some diagnostics that are highly suggestive of preterm labor?

Answer 14

Nitrazine paper test: turns blue (suggestive of amniotic fluid because pH > 6.5)

Presence of fetal fibronectin between 20-34 weeks

L:S ratio < 2:1 = fetal lung immaturity

Question 15

Treatment for preterm labor

Answer 15

-< 34 weeks: Delay delivery with tocolytics (Mag Sulfate, Indomethacin, Nifedipine) and give Dexamethasone to improve lung maturity

->34 weeks: admit for delivery

Question 16

How does Plan B work.

Answer 16

Emergency Contraception pill - Uses protesting to stop ovaries from releasing an egg. Most effective if taken within 72 hours after unprotected sex

Question 17

Explain how combination OCPs work

Answer 17

Prevent ovulation by inhibiting mid-cycle LH surge, thicken cervical mucosa and thins endometrial lining.

Question 18

Combination (estrogen + progesterone) OCPs protect against 5 things, name them.

What are some contraindications to using combo OCPs?

Answer 18

Osteoporosis, cervical cancer, ovarian cancer, ovarian cysts, ectopic pregnancy

History of breast cancer, smoking, >35 years old, DVT/PE, severe HTN.

Question 19

What are some Progestin-only OCP’s?

Answer 19

Depo = increases risk of osteoporosis
Nexplanon = increases risk of HA, menstrual irregularities

IUD (Mirena = 5 years, Kyleena = 5 years, Skyla = 3 years). Risk of perforation and ectopic pregnancy, PID

Copper IUD = Paragard (10 years). Increased risk of PID

Question 20

What is the most effective Progestin only OCP besides abstinence

Answer 20

IUD = however, there is an increased risk of PID

Question 21

True or False: Progestin only OCPs are safe during lactation?

Answer 21

True

Question 22

Ovarian torsion is ________ and some symptoms include what?

Answer 22

compromised ovarian blood flow

-Sudden onset of acute, unilateral pelvic pain.
-Nausea, vomiting
-Abdominal tenderness or adnexal mass

Question 23

Diagnostics done for ovarian torsion

Answer 23

-US with Doppler: shows decreased ovarian blood flow

-Surgical exploration = definitive diagnostic

Question 24

Treatment for ovarian torsion

Answer 24

-Laparoscopy with detorsion

Question 25

What is the pathophysiologic triad for polycystic ovarian syndrome (PCOS)? There are actually four things...

Answer 25

-Bilateral cystic ovaries + oligo/anovulation + hyperandrogenism + insulin resistance

Question 26

Symptoms of PCOS

Answer 26

-Menstrual dysfunction -Hirsuitism (from high androgen) -DM, obesity, HTN -Bilateral, smooth, enlarged ovaries -Acanthosis nigricans

Question 27

Labs for PCOS shows

Answer 27

-Increased testosterone (DHEA) -Increased LH:FSH ration

Question 28

What diagnostic is done for PCOS?

Answer 28

Pelvic US: multiple ovarian cysts with a "string of pearls" appearance

Question 29

Treatment for PCOS

Answer 29

-Lifestyle modifications (for insulin resistance) -Combo OCP's (Mainstay) -Spironolactone (blocks testosterone)

Question 30

What are two risks of PCOS?

Answer 30

Increases risk of infertility and endometrial cancer

Question 31

Atrophic vaginitis occurs MC in postmenopausal women. What is it?

Answer 31

Drying due to decreased estrogen

Question 32

What are some symptoms of atrophic vaginitis?

Answer 32

Dryness, dyspareunia, pruritus, bleeding due to irritation

Question 33

Treatment for atrophic vaginitis

Answer 33

-Topical vaginal estrogen -Moisturizers -Alcohol free products

Question 34

What is Fitz-Hugh Syndrome?

Answer 34

Perihepatitis in RUQ with pelvic inflammatory disease

Question 35

Symptoms of Fitz-Hugh Syndrome

Answer 35

RUQ pain (may radiate to shoulder)

Question 36

What diagnostic should be done if you suspect Fitz-Hugh Syndrome?

Answer 36

Laparoscopy: violin string adhesions on liver

Question 37

Toxic Shock Syndrome occurs due to a ________. What is the pathophysiology of this condition?

Answer 37

Staph Aureus toxin -Superantigen that releases inflammatory mediators --> multi organ failure

Question 38

What is the MC risk factor for Toxic Shock Syndrome?

Answer 38

Tampon Use (Infrequent removal)

Question 39

Symptoms of Toxic Shock Syndrome

Answer 39

-Abrupt onset of high fever -Erythroderma (diffuse erythematous rash) resembling sunburn -Hypotension, headache, myalgias, n/v, diarrhea (symptoms of shock)

Question 40

Treatment for toxic shock syndrome

Answer 40

-Hospital admission -IV rehydration -ABX (Clinda + Vanco or Linezolid)

Question 41

What is congestive mastitis?

Answer 41

Bilateral breast enlargement 2-3 days postpartum due to milk stasis.

Question 42

What is the treatment of congestive mastitis?

Answer 42

Breast drainage (manual or pump)

Question 43

What is polyhydramnios?

Answer 43

>25cm fluid around the baby

Question 44

What are two symptoms of polyhydramnios?

Answer 44

-Uterine size large for dates -Low fetal activity

Question 45

Polyhydramnios is associated with what conditions?

Answer 45

Maternal DM, multiple gestations, fetal issues with breathing or chromosome abnormalities

Question 46

On the contrary, what is oligohydramnios?

Answer 46

<5 cm of fluid around the baby

Question 47

Symptoms of oligohydramnios?

Answer 47

-Uterus size small for date -Low fetal activity

Question 48

Explain what macrosomia is, what a common cause is, and what two risks associated with this condition are.

Answer 48

Macrosomia: birth weight > 95%ile Common cause: Maternal DM Risks: Shoulder dystocia & maternal trauma

Question 49

Treatment for macrosomia

Answer 49

-Plan C-section if estimated weight >5,000g without DM and >4,5000g with DM

Question 50

What is an APGAR score, what is normal, when is it done, and what are the components?

Answer 50

Done at 1 and 5 minutes 7 or above is normal Appearance (Pink normal) Pulse (>100 normal) Grimace (cry is normal) Activity (movement of all limbs normal) Respiration (strong cry normal)

Question 51

A spontaneous abortion is ____________. 80% of these occur in which trimester? What is the only type of spontaneous abortion that is potentially viable?

Answer 51

Loss of pregnancy < 20 weeks First trimester Threatened is the only potentially viable one

Question 52

Explain a threatened abortion

Answer 52

-Cervical OS closed -POC intact -Supportive tx

Question 53

MCC of spontaneous abortion

Answer 53

-Chromosomal abnormalities

Question 54

Explain an inevitable abortion

Answer 54

-Os DILATED -POC intact -D&C or Misoprostol evacuation

Question 55

Explain an incomplete abortion

Answer 55

-OS dilated -Some POC expelled -D&C or Misoprostol

Question 56

Explain a complete abortion

Answer 56

-Os closed -All POC expelled -Supportive, RhoGAM given

Question 57

Explain a missed abortion

Answer 57

-OS closed -POC intact, non viable fetus -D&C, Misoprostol

Question 58

Explain a septic abortion

Answer 58

-OS closed, Cervical motion tenderness -POC retained, foul brown discharge -D&C And ABX (Levo + Metro)

Question 59

What is vasa previa?

Answer 59

Complication of placenta previa -Fetal vessels crossing over the os

Question 60

Symptoms of vasa previa

Answer 60

-painless vaginal bleeding + fetal distress (bradycardia) + rupture of membranes

Question 61

What should be done if you suspect vasa previa?

Answer 61

Deliver the baby

Question 62

MCC of postpartum hemorrhage

Answer 62

Uterine atony

Question 63

Symptoms of postpartum hemorrhage (what does the patient look like?)

Answer 63

-Soft, flaccid boggy uterus with dilated cervix -Bleeding with hypovolemic shock

Question 64

Treatment for postpartum hemorrhage

Answer 64

-Bimanual uterine massage and compression (1st line) -IV Oxytocin -Artery embolization if ineffective

Question 65

Prelabor Rupture of Membranes (PROM) is? It occurs prior to when? Symptoms of this condition.

Answer 65

PROM: rupture of amniotic membranes prior to onset of labor Occurs after to 37 weeks Gush of fluid or persistent leakage

Question 66

What are some diagnostics that can be done for PROM?

Answer 66

-Nitrazine paper test: turns blue if pH > 6.5 (amniotic fluid) -Fern test: amniotic fluid dries in a fern pattern -NO DIGITAL EXAM!

Question 67

Treatment for PROM

Answer 67

-Admit and await spontaneous labor -Induce labor with Oxytocin or Prostaglandin gel is no labor within 18 hours

Question 68

If under 34 weeks and you are dealing with PPROM, what should you do?

Answer 68

Give Betamethasone to improve fetal lung maturity -Delivery if signs of maternal or fetus distress/infection

Question 69

What is Preterm Prelabor Rupture of Membranes?

Answer 69

occurs prior to 37 weeks