Obstetrics Flashcards
(111 cards)
1
Q
Random fingerstick diagnostic of diabetes
A
200+
2
Q
Misoprostol dose
A
800 mcg buccal for pph
3
Q
Local anesthesia C-section
A
Lidocaine 0.5% with epinephrine 7 mg/k2 for 60 mL max
4
Q
Indigo carmine dosing for rom confirmation
A
1 mL in 9 mL sterile saline
5
Q
Timing of luteal-placental shift
A
Starts at 6-7 weeks, mostly done by 10 weeks, supplement to 14 weeks
6
Q
Arrest of dilation
A
6+ cm
- no change over 4 hours with adequate Montevideo units (200)
- no change over 6 hours with inadequate contractions and pitocin
7
Q
Arrest of descent
A
No descent at 2 hours for multitip, 3 hours for nullip
- add 1 hour for epidural
8
Q
Degrees of uterine inversion
A
1st: fundus within endometrial cavity
2nd: fundus through cervical os
3rd: fundus to or beyond intriotus
4th: uterus and vagina inverted
9
Q
Huntington procedure for uterine inversion
A
Clamps on round ligament to correct inversion
10
Q
Nitroglycerin dosing
A
50 mg IV every minute for 5 max doses
11
Q
Terbutaline dosing
A
0.25 or 0.5 mg IV or subcutaneous
12
Q
Transfusion reaction rate
A
20%
13
Q
Failure rate of operative delivery
A
Forceps: 9%
Vacuum: 14%
14
Q
4th degree vaginal laceration
A
Involvement of rectal mucosa in addition to external and internal anal sphincters
- Repair with subcutaneous 4-0 Vicryl
15
Q
Components of 2nd degree laceration
A
Fascia and perineal body musculature (deep and superficial transverse perineal, bulbocaverous muscles)
16
Q
Rhogam dosing
A
<12 weeks: 50 mcg
Later: 300 mcg
- Redose every 3 weeks
17
Q
TTP
A
Thrombotic thrombocytopenic purpura
- Defined by severe deficiency of ADAMTS13 (activity <10 percent)
18
Q
ITP diagnosis
A
Idiopathic thrombocytopenia purpura
- autoimmune attack on platelets
- diagnosis based on exclusion of other causes (peripheral smear, HIV, HCV, coag studies)
19
Q
Platelet transfusion timing
A
1 pack (6 units) > 30,000 units within 10 minutes - 5-10,000 units per unit
20
Q
Causes of sinusoidal fetal heart pattern
A
Medications, especially narcotics
Fetal acidemia
Fetal infection
Fetal cardiac anomalies
21
Q
Contraindications to magnesium
A
Myasthenia gravis Allergy Heart block Myocarditis Several renal dysfunction
22
Q
Diazepam dosing for seizure
A
5-10 mg
23
Q
Antidote to magnesium
A
Calcium gluconate 10% (1 gram)
Add furosemide to increase magnesium excretion
24
Q
Magnesium toxicity levels
A
Loss of reflexes: 7 mEq/L
Respiratory depression: 10 mEq/L
Cardiac arrest: 25 mEq/L
25
Differential for thrombocytopenia
```
Preeclampsia, help
ITP, TTP, gestational
Medications
Liver dysfunction
Type 2 von willebrand’s disease
```
26
Poor candidates for VBAC
Prior classical or t-uterine incision
Prior uterine rupture
Non-vertex presentation
Medical or obstetrical complications precluding vaginal delivery
> 2 c-sections
Inability to perform emergency Caesearan delivery
27
Clinical signs of uterine rupture
```
Fetal bradycardia
Recurrent decelerations
Abrupt change in contraction pattern
Loss of station of presenting part
Significant abdominal pain
Vaginal bleeding
```
28
Risks of congenital varicella syndrome
```
Greatest between 13-20 weeks
- Musculoskeletal: Skin scarring, limb hypo plasma, digital malformation
- Brain: Microcephaly
- Ocular: chorioretinitis, cataracts
Delay delivery by one week if possible!
```
29
Coverage of triple antibiotics
Ampicillin: gram positive cocci
Gentamicin: gram negative rods
Clindamycin: anaerobes
30
Reasons for elevated MS-AFP
False positive
Maternal tumor (endodermal sinus tumor, liver cancer)
Anatomical anomalies (abdominal wall defects)
Renal or liver anomies
IUGR
31
Risk of elevated MS-AFP with no anatomic anomalies
Stillbirth
IUGR
Preterm delivery
SIDS
32
Sensitivity of prenatal genetic screening other than cell-free
80-90%
33
Methergine dosing
0.2 mg, every 2-4 hours
34
Hemabate dosing
0.25 mg, every 15 minutes up to max of 2 mg (8 doses)
35
Risk of accreta with placenta previa
No prior c-section: 5%
1: 15%
2: 25-30%
3+: 50-60%
Compared to <5% risk with 5 c-sections and no previa
36
Length GBS valid
5 weeks
37
Abnormal for GTT
1-hour: >=140
| 3-hour: 105/190/165/145
38
Normal values for gestational diabetes
Fasting 95
1-hour postprandial: 140
2-hour postprandial: 120
39
Daily suppression for UTIs
After pyelonephritis or 2 UTIs
40
Cardiac changes in pregnancy
Increased heart rate
Increased plasma volume
Increased cardiac output
41
Cardiac conditions that decompensate in pregnancy
```
Mitral stenosis
Aortic stenosis
Eisenmenger syndrome (VSD+)
Pulmonary hypertension
Congestive heart disease
```
42
Timing of ocp restart postpartum
No one <21 days
| Can start 21-45 days if no other risk factors
43
Why is OP position more difficult delivery than OA position?
With OA delivery, head extends under pubic symphysis
| With OP, fetus has to descend lower before head extension or deliver without head extension.
44
Which type of transverse lie requires classical or low-vertical C-section?
Back down (unable to access fetal parts otherwise)
45
Management of category 3 tracing
```
Halt uterotonics
Intrauterine resuscitation
- lateral position
- IV fluid bolus
- maternal oxygen
Tocolytic
Move toward delivery if no resolution
```
46
Posterior division of hypogastric artery
Lateral sacral
Iliolumbar
Superior gluteal
47
Anterior division of hypogastric artery
```
Umbilical/Superior vesicle
Obturator
Uterine
Vaginal
Internal pudendal
Inferior gluteal
```
48
HSV treatment in pregnancy
Episodic: Valacyclovir 1000 mg BID 5 days
Suppression: Valacyclovir 1000 mg daily
49
Twining by post-conception day
<4: di-di
4-8: di-amniotic, mono-chorionic
8-12: Mono-amniotic, mono-chorionic
>12: conjoined
50
Delivery for placenta previa
Bleeding after 34 weeks
| Otherwise 36-37 weeks
51
Delivery for absent end-diastolic flow
34 weeks
52
Delivery for reversed end-diastolic flow
32 weeks
53
How do rotational maneuvers help shoulder dystocia?
Pushing posteriorly on fetal shoulder to rotate shoulder under pubic symphysis > decreased A/P diameter
54
Risk of recurrent shoulder dystocia
10-20%
55
Time benefit of magnesium for fetal neuroprotection
>2 hours from presentation to deliver
| Re-evaluate after 12 hours
56
Syphillis treatment monitoring
- 4-fold decline in RPR consistent with response
Repeat titers every 4 weeks
Fluorescent treponemal antibody absorption (FTA-ABS) will stay positive forever
57
Folic acid supplementation with seizure disorder
4 mg folic acid
58
Bile acid threshold for 36 week delivery
Total bile acids > 100 umol/L
59
Hepatitis screening in pregnancy
Anti-HCV antibody
| Hepatitis B surface antigen
60
Positive after Hepatitis B vaccination
Anti-HBs positive (hepatitis B surface antibody)
61
Risk of perinatal Hepatitis B and C transmission
Hepatitis B 20-50%
- 90% if hepatitis b envelope antigen positive
Hepatitis C 5%
- 20% if HIV positive
HIV 2% if controlled, 25% if not and no c-section
62
Abdominal wall defects
Gastroschisis: no genetic abnormalities, not midline
Omphalocele: midline, chromosomal abnormalities
63
2nd trimester genetic screening
Triple: HCG, AFP, estriol
Quadruple: plus inhibin A
Only 1st trimester screening has PAPP-A.
64
Components of 1st trimester screening
US: Nuchal thickness testing
Lab: HCG, PAPP A
Does not detect open neural tube defects
65
Insulin dosing
0. 7-1.0 IU/kg
- 2/3 AM and 1/3 PM
- AM: 2/3 immediate acting and 1/3 long acting
- PM: 1/2 immediate, 1/2 long acting
66
Face presentation that requires c-section
Mentum posterior
67
Prerequisites for operative vaginal delivery
```
Fully dilated, ruptured membranes
Engaged fetal head (2+)
Known position
Adequate pelvis
Adequate analgesia
Empty bladder and rectum
Facilities to perform emergency c-section
Gestational age <34 weeks
No evidence of fetal bleeding disorder or bone demineralization
```
68
Maylard incision
2-3 cm above pubic symphysis
Ligate inferior epigastric vessels
Split rectus muscles
69
How to reduce nuchal arm
Rotate fetus toward impacted arm
70
Pregnancy weight gain recommendations
Underweight: 28-40 pounds
Normal weight: 25-35 pounds
Overweight: 15-25 pounds
Obese: 11-20 pounds
71
Category 3 tracing
```
Sinusoidal pattern
Absent FHR variability with:
- Recurrent late decelerations
- Recurrent variable decelerations
- Bradycardia
```
72
Bishop score
Dilation, cervix position, effacement, station and consistency
0: closed cervix, posterior cervix, 0-30% effacement, -3 station, firm cervix
1: 1-2 cm cervix, mid position cervix, 40-50% effacement, -2 station, medium consistency
2: 3-4 cm cervix, anterior position, 60-70% effacement, -1 to 0 position, soft cervix
3: 5-6 cm cervix, 80% effaced, +1-+2
73
Tachysystole
More than 5 contractions in 10 minutes averaged over a 30 minute period
74
Confirmation of term gestation
Ultrasound less than 20 weeks
36 weeks since positive pregnancy test
Fetal heart tones present for 30 weeks
75
Moderate fetal heart rate variability
6-25 beats per minute
76
Normal fetal heart rate baseline
110-160 bpm
77
Indications for cerclage
History
- Prior Exam or US indicated cerclage
- 1 or more second trimester losses from painless cervical dilation (no labor or abruption)
Physical exam
- Painless cervical dilation in second trimester
Ultrasound
- Cervical length < 25 mm before 24 weeks and history of prior preterm birth
- Cervical length < 10 mm with no previous preterm births
78
Ultrasound redating criteria
1st trimester: 5-7 day discrepancy
2nd trimester: 7-14 day discrepancy
3rd trimester: 21+ day discrepancy
79
Oxytocin dosing for PPH
IM: 10 units
IV: 40 units per 1000 mL as continuous infusion
80
How much to fill a Bakri balloon
300-500 mL normal saline
81
Diclegis dosing
Max vitamin B6 (pyridoxine): 40 mg
Max doxylamine: 40 mg
- Add antihistamines, prochlorperazine, or promethazine next
82
Typical starting dose of insulin
0.7-1 units/kg
83
Postpartum diabetes diagnosis
Fasting glucose >125 mg/dL
| 2-hour glucose > 199 mg/dL
84
Coagulation changes in pregnancy
Increased: Fibrinogen, factor VII, factor VIII, factor X, von willebrand factor
Deceased: Free protein S
Others no change
This means you can test for factor V Leiden, prothrombin mutation, protein c deficiency and antithrombin deficiency in pregnancy.
85
Anemia definitions
Hb < 11 g/dL in 1st and 3rd trimester
| Hb < 10.5 g/dL in 2nd trimester
86
Placement of vacuum
2 cm anterior to posterior fontanelle
87
NPH pharmokinetics
Onset of action: 1-3 hours
Peak of action: 5-7 hours
Duration of action: 13-18 hours
88
Oral nifedipine dosing and timing
10 mg > repeat BP in 20 minutes > 20 mg > repeat BP in 20 minutes > 20 mg > repeat BP in 20 minutes > switch to labetalol 20 mg
89
IV hydralazine severe hypertension regiment
5-10 mg > repeat BP in 20 minutes > 10 mg > repeat BP in 20 minutes > switch to labetalol 20 mg
90
IV labetalol severe hypertension guidelines
Labetalol 20 mg > repeat BP in 10 minutes > 40 mg > repeat BP in 10 minutes > 80 mg > repeat BP in 10 minutes > switch to hydralazine 10 mg
91
Valacyclovir dosing
Treatment: 1 gram daily or twice daily for 5-10 days
Suppression: 500 mg BID from 36 weeks
92
Severe preeclampsia criteria
```
BP 160/110 4 hours apart or requiring treatment
Platelets <100
Twice normal LFTs
RUQ or epigastric pain unresponsive to medication
Cr > 1.1 or doubling baseline
Pulmonary edema
Headache unresponsive to medications
Visual disturbances
```
93
Chronic hypertension treatment options
Labetalol 200-2400 daily divided into 2-3 doses (100 mg BID to 800 mg TID)
Nifedipine 30-120 mg daily
Methyldopa 500-3000 mg daily divided into 2-3 doses
94
Thyroid testing in pregnancy
Estrogen increases thryoid binding globulin > increased total T3 and T4
- no change in free T3 or free T4
- TSH varies by trimester
95
Mechanism of heparin
Binds to antithrombin 3 > inhibits thrombin
96
Mechanism of low-molecular heparin
Inhibits factor Xa
97
Placental causes of IUGR
```
Cirmcumvallate placenta
Velamentous cord insertion
Marginal cord insertion
Chronic abruption
Single umbilical artery
- Start antenatal surveillance at 36 weeks
```
98
Biophysical profile
Fetal breathing: 1 or more episodes of 30+ seconds
Fetal movement: 3 or more discrete body or limb movements
Fetal tone: 1 or more extension/flexion or opening or closing of a hand
Amniotic fluid volume: MVP 2+ cm
NPV for stillbirth within 1 week: 99.9%
99
Twin peak sign (lambda or delta sign)
Triangular projection of tissue that extends beyond the placenta > di-di pregnancy
- Visible after 9-10 weeks
100
Apgar score
```
Heart rate
Respiratory rate
Muscle tone
Reflex irritability (grimace, cry)
Color
```
101
Clinical pelvimetry
```
Inlet = diagonal conjugate
- symphysis to sacral promontory
- obstetrical conjugate = above - 2 cm
Mid-pelvis
- sacral promontory to sacral hollow
Interspinous diameter
```
Goal: 10+ cm for each
102
Branchial nerve palsy
Erb’s palsy = C5-C6
- waiters tip (arm medially rotated)
Klumpke’s palsy = C8-T1
- hand and wrist paralysis, arm hangs at side
103
Proteinuria criteria for pre-eclampsia
2+ urine dip
P/c ratio >= 0.3
Proteinuria > 300 mg/24 hours
104
TORCH fetal consequences
```
Chorioretinitis
Intracranial calcifications
Hydrocephalus
Hearing loss
Mental retardation
Hepatosplenomegaly
```
105
Low vs outlet
Outlet: vertex evident at intriotus between contractions
Low: fetal skull at +2 station or lower
106
Cardinal movements of labor
```
Engagement
Descent
Flexion
Internal rotation
Extension
External rotation
Expulsion
```
107
Findings of ARRIVE trial
Decreased c-section rate with 39 week induction
Lower hypertension rates
No difference in perinatal outcomes
108
HELLP criteria
LDH > 600
LFTs 2X normal
Platelets < 100
109
MOM cutoffs for second trimester screening (hCG, estriol, inhibin, afp)
0.5-2.5 MOM
110
Delivery timing for isolated oligohydramnios
36-37 weeks
| - if IUGR, 34-37 weeks
111
Chlymadia treatment in pregnancy
Azithromycin 1 gram once
| Amoxicillin 500 mg tid for 7 days
