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Flashcards in Obstetrics Deck (123):
1

A 27-year-old woman presents with nausea and vomiting for the past 2 weeks. Symptoms are worse in the morning, but can occur at any time during the day. She has decrease in appetite. Her LMP was 6 weeks ago. Physical examination is unremarkable.

Which of the following is the best next step in the management of this patient?

a. Complete blood count
b. Beta-HCG
c. HIDA scan
d. Comprehensive metabolic panel
e. Urinalysis

B. A pregnancy test should be done first in all symptomatic women of childbearing age. Her LMP occurred 6 weeks ago and the patient is experiencing "morning sickness." Morning sickness is caused by an increase in beta-HCG produced by the placenta. This can occur until the 12th to 14th week of pregnancy. A complete blood count (CBC), comprehensive metabolic panel (CMP), and urinalysis are used to evaluate the severity of dehydration, not the etiology. A HIDA scan is done in patients with suspected cholecystitis.

2

A 20-year-old woman presents to the office because she believes that she is pregnant. Her sexual partner usually pulls out, but did not do so 2 weeks ago. She is now 4 weeks late for her menstruation.

Which of the following is one of the first signs of pregnancy found on physical exam?

a. Quickening
b. Goodell sign
c. Ladin sign
d. Linea nigra
e. Chloasma

B. One of the first signs of pregnancy that is seen on PE is the Goodell sign, softening the cervix that is felt first at 4 weeks. Quickening is the first time the mother feels fetal movement.

3

This is the softening of the cervix

Goodell sign (4 weeks, 1st trimester)

4

This is the softening of the midline of the uterus

Ladin sign (6 weeks, 1st tri)

5

There is blue discoloration of vagina and cervix

Chadwick sign (6-8 weeks, 1st tri)

6

There is small blood vessels/reddening of the palms

Telangiectasias/palmar erythema (first tri)

7

There is the "mask of pregnancy" is a hyperpigmentation of the face most commonly on forehead, nose, and cheeks; it can worsen with sun exposure

Chloasma (16 weeks, 2nd tri)

8

There is a line of hyperpigmentation that can extend from xiphoid process to pubic symphisis

Linea nigra (2nd tri)

9

What happens to cardiac output during pregnancy?

Increase

10

What happens to blood pressure during pregnancy?

Slightly lower (lowest point: 24-28 weeks)

11

What happens to the size of kidneys and ureters during pregnancy?

Increase

12

What happens to GFR during pregnancy?

Increase secondary to a 50% increase in plasma volume

13

What happens to the BUN/Creatinine ratio in pregnancy?

Decrease

14

What happens to PT, PTT, or INR in pregnancy?

None

15

What happens to fibrinogen in pregnancy?

Increase

16

How often should you see a pregnant patient in the first trimester?

every 4 to 6 weeks

17

When do you order ultrasound to confirm gestational age and check for nuchal translucency.

between 11 and 14 weeks

18

A 17-year-old woman presents for a routine prenatal checkup at 12 weeks. Which of the following is the most accurate method to establish gestational age?

a. Ultrasound
b. Beta-HCG
c. Pelvic exam
d. Fundal height
e. LMP

A. Ultrasound is the most accurate way of establishing gestational age at 11 to 14 weeks. Beta-HCG is unreliable in confirming dates, as the levels can be increased twins or decreased in early abortions. Pelvic exam and fundal height are not the most accurate methods to confirm dates because they may change with multiple gestations. A patient's account of LMPis often unreliable because histories are inaccurately remembered.

19

When should you perform a triple or a quad screen for pregnant patients?

At 15 to 20 weeks (2nd tri)

20

What are the tests included in triple screen?

MSAFP, beta-HCG, Estriol

21

What are the tests included in quad screen?

MSAFP, beta-HCG, Estriol, Inhibin A

22

What does an increase in MSAFP indicate?

Dating error, neural tube defect, or abdominal wall defect

23

What is the interval of prenatal checkup in the 3rd trimester?

every 2 to 3 weeks until 36 weeks and every week after 36 weeks

24

What should you request at 27 weeks gestation?

CBC

If Hgb < 11, replace iron orally

25

What should you request at 24-28 weeks gestation?

Glucose load

If glucose > 140 at one hour, perform oral glucose tolerance test

26

What should you request at 36 weeks gestation?

- Cervical cultures for Chlamydia and Gonorrhea
- STD testing if patient was positive during pregnancy or has a risk factor
- Rectovaginal culture for group B Streptococcus

27

How would you go about the glucose load test?

Fasting or Nonfasting ingestion of 50g of glucose, and serum glucose check 1 hour later

28

How would you go about glucose tolerance test?

Fasting serum glucose, ingestion of 100g of glucose, serum glucose checks at 1, 2, and 3 hours. Elevated glucose during any two of these tests is gestational diabetes

29

When do you do Chorionic Villus Sampling?

at 10 to 13 weeks in advanced maternal age or known genetic disease in parent

30

How will you do Chorionic Villus Sampling?

catheter into intrauterine cavity to aspirate chorionic villi from placenta (can be done transabdominally or transvaginally)

31

When do you do Amniocentesis?

after 11 to 14 weeks for advanced maternal age ot known genetic disease in parent

32

How will you do Amniocentesis?

Needle transabdominally into the amniotic sac and withdraw amniotic fluid

33

A 29-year-old woman with a past medical history of chlamydia presents with left lower quadrant abdominal pain for the past eight hours. She also states that she has some abnormal vaginal bleeding. Her LMP was 6 weeks ago. On physical exam the patient's temperature is 99F, heart rate is 100 bpm, blood pressure is 130/80 mmHg, and respiratory rate is 13 per minute.

Which of the following is the most likely diagnosis?

a. Ectopic pregnancy
b. Menstrual cramps
c. Diverticulitis
d. Ovarian torsion
e. Ovarian cyst

A. Diverticulitis causes left lower quadrant abdominal pain and rectal bleeding, not vaginal bleeding. The age range of the patients has almost no overlap between ectopic pregnancy and diverticulitis. Ovarian torsion and ovarian cysts do not cause vaginal bleeding. Menstrual cramps are not associated with an altered menstrual pattern.

34

What are the risk factors of Ectopic Pregnancy?

1. Previous ectopic pregnancy (strongest risk factor)
2. Pelvic inflammatory disease (PID)
3. Intrauterine devices (IUD)

35

What diagnostic tests should you order for Ectopic Pregnancy?

Beta-HCG: to confirm pregnancy
Ultrasound: to locate the site of implantation
Laparoscopy: invasive test and treatment to visualize the ectopic pregnancy

36

After baseline exams, what should you give to patients with unruptured ectopic pregnancy?

Methotrexate

37

After giving the first methotrexate dose to patients with unruptured ectopic pregnancy, what is the next step?

Check if there is a 15% decrease in B-HCG in 4 to 7 days

38

If after 4 to 7 days, patient with unruptured ectopic pregnancy came back with persistent levels of B-HCG, what should you do?

Give a second dose of methotrexate

39

If after the second dose of methotrexate, there is no decrease of B-HCG from baseline, what should you do?

Surgery

40

What are the exclusion criteria for Methotrexate?

1. Immunodeficiency - methotrexate is an immunosuppressive drug
2. Noncompliant patients
3. Liver disease - hepatotoxicity
4. Ectopic is 3.5 cm or larger
5. Fetal heartbeat auscultated
6. Breastfeeding
7. Coexisting viable pregnancy

41

A 20-year-old woman presents to the emergency department for vaginal bleeding and lower abdominal pain for one day. She states that she is 15 weeks pregnant. Vital signs include temperature 99F, heart rate 100 bpm, blood pressure 110/75 mmHg, and respiratory rate 12 per minute. On pelvic exam, there is blood present in the vault. Ultrasound shows intrauterine bleeding, products of conception, and a dilated cervix.

Which of the following is the most likely diagnosis in this patient?

a. Complete abortion
b. Incomplete abortion
c. Inevitable abortion
d. Threatened abortion
e. Septic abortion

C. An inevitable abortion is characterized by intrauterine bleeding with a dilated cervix

42

Define Abortion.

Pregnancy that ends before 20 weeks gestation or a fetus less than 500 grams.

43

What is the most common cause of abortion?

Chromosomal abnormalities

44

This is a type of abortion with no products of conception found.

Complete abortion (follow-up in office)

45

This is a type of abortion with some products of conception found.

Incomplete abortion (D&C/Medical)

46

This is a type of abortion with products of conception intact, but intrauterine bleeding present and dilation of cervix.

Inevitable abortion (D&C/Medical)

47

This is a type of abortion with products of conception intact, intrauterine bleeding present, but NO dilation of cervix.

Threatened abortion (Bed rest, pelvic rest)

48

This is a type of abortion with death of fetus, but all products of conception present in the uterus

Missed abortion (D&C/Medical)

49

This is a type of abortion with infection of the uterus and the surrounding areas

Septic abortion (D&C and IV antibiotics such as levofloxacin and Metronidazole)

50

How would you define Recurrent Fetal Loss?

It is defined as 3 consecutive miscarriages that occur before 20 weeks' gestation.

51

What is the first clue to multiple gestation?

Elevated beta-HCG and MSAFP (levels higher than expected for estimated gestational age

52

Define Monozygotic Twins

1 egg and 1 sperm that splits; Identical twins: same gender, same physical characteristics, same blood type, fingerprints differ

53

Define Dizygotic Twins

2 eggs and 2 sperm; fraternal twins: different or same sex; they resemble each other, as any siblings would

54

A 28-year-old woman in her 28th week of pregnancy presents for severe lower back pain. She complains that the pain is cyclical and that it seems to be increasing in intensity. On physical examination, she seems to be in pain. Her temperature is 98.9F, HR 104bpm, BP 135/80 mmHG, RR 15 per minute. On pelvic examination, her cervix is 3 cm dilated.

Which of the following is the most likely diagnosis?

a. Premature rupture of membrane
b. Preterm labor
c. Cervical incompetence
d. Preterm contractions

B. Preterm labor is diagnosed when there is a combination of contractions with cervical dilation. A premature rupture of membranes patient would have a history of "gush of fluid" from the vagina. Patients with cervical incompetence do not have a history of contractions, but there is painless dilation of the cervix. Preterm contractions do not lead to cervical dilation.

55

Enumerate the risk factors of Preterm labor

1. PROM
2. Multiple gestation
3. Previous history of preterm labor
4. Placental abruption
5. Maternal factors: Uterine anatomical abnormalities, Infections (chorioamnionitis), preeclampsia, intraabdominal surgery

56

Enumerate the circumstances in which preterm labor should NOT be stopped with tocolytics. You should deliver pregnancy.

1. Maternal severe hypertension (preeclampsia/eclampsia)
2. Maternal cardiac disease
3. Maternal cervical dilation of more than 4 cm
4. Maternal hemorrhage (abruptio placenta, DIC)
5. Fetal death
6. Chorioamnionitis

57

If pregnancy is at 24-33 weeks with occurring preterm labor, what is the next step in the management?

Stop delivery
Give Betamethasone and Tocolytics

58

This is the most commonly used tocolytic

Magnesium Sulfate

59

This tocolytic drug should be only used to close a PDA.

Indomethacin

60

What will you expect in a sterile speculum examination of PPROM to confirm it is amniotic fluid?

-Fluid in the posterior fornix
-Fluid turns nitrazine paper blue
-When placed on slide and allowed to air dry, fluid has ferning pattern

61

Enumerate the effects of premature rupture of membranes.

-Preterm Labor
-Cord prolapse
-Placental abruption
-Chorioamnionitis

62

What should you do if there is premature rupture of membranes with presence of chorioamnionitis?

Delivery now

63

What should you do if fetus is at term and there is premature rupture of membranes and no presence of chorioamnionitis?

Wait 6 to 12 hours for spontaneous delivery. If there is no spontaneous delivery, then induce labor

64

What is the treatment for preterm fetuses without chorioamnionitis without chorioamnionitis?

Betamethasone, Tocolytics, 1 dose of Azithromycin

If penicillin allergic with low risk for anaphylaxis, use Cefazolin and 1 dose of Azithromycin

If high risk of Anaphylaxis, use clindamycin and 1 dose of Azithromycin

65

What are the risk factors of Chorioamnionitis?

-Prolonged labor
-Prolonged rupture of membranes
-Multiple digital vaginal exams
-Cervical insufficiency
-Invasive testing
-Internal fetal monitoring
-STDs

66

Patient has maternal fever, high WBC count, maternal and fetal tachycardia, and uterine tenderness. What is the most likely diagnosis?

Chorioamnionitis

67

How would you treat Chorioamnionitis?

Delivery of the baby. Give ampicillin and gentamicin for a vaginal delivery. If delivery is by C-section, add clindamycin for anaerobic coverage.

68

This is an abnormal implantation of the placenta over the internal cervical os.

Placenta Previa

69

Enumerate the risk factors for Placenta Previa.

-Previous CS
-Previous Uterine Surgery
-Multiple gestations
-Previous placenta previa

70

A 24-year-old woman in her 32nd week of pregnancy presents to the emergency department. She states that she woke up in her bed in a pool of blood. She has had no contractions or pain. Her heart rate is 105 bpm and blood pressure is 110/70 mmHg.

Which of the following is the best next step in the management of this patient?

a. Digital vaginal exam
b. Transabdominal ultrasound
c. Immediate vaginal delivery
d. Immediate cesarean delivery
e. Transvaginal ultrasound

B. Transabdominal ultrasound is done before a digital vaginal exam in all third-trimester bleeding. This patient has painless vaginal bleeding, which may be indicative of placenta previa. If a digital vaginal exam is done, it can result in increased separation of the placenta and the uterus, leading to an increase in bleeding. Delivery is premature at this point. Do an ultrasound to distinguish between cesarean and vaginal delivery modes should it become necessary.

71

Patient presents with painless vaginal bleeding. It may be detected on routine ultrasound before 28 weeks, but usually does not cause bleeding until after 28 weeks. What is the most likely diagnosis?

Placenta Previa

72

This a type of placenta previa with complete covering of the internal cervical os

Complete Placenta Previa

73

This is a type of partial covering of the internal cervical os.

Partial Placenta Previa

74

This is a type of placenta previa where placenta is adjacent to the internal os (often touching the edge of os)

Marginal Placenta Previa

75

This a type of placenta previa where fetal vessel is present over the cervical os

Vasa previa

76

This is a type of placenta previa that is implanted in the lower segments of the uterus but not covering the internal cervical os (more than 0 cm but less than 2 cm away)

Low-lying placenta

77

This is a type of placental invasion that abnormally adheres to the superficial uterine wall

Placenta accreta

78

This is a type of placental invasion that attaches to the myometrium

Placenta increta

79

This is a type of placental invasion that invades into the uterine serosa, bladder wall, or rectal wall

Placenta percreta

80

This is the premature separation of the placenta from the uterus and presents with painful vaginal bleeding.

Placenta abruption

81

Enumerate the risk factors of Placental Abruption

-Maternal hypertension
-Prior placental abruption
-Maternal cocaine use
-Maternal external trauma
-Maternal smoking during pregnancy

82

Enumerate risk factors for Uterine Rupture

-Increased risk with previous cesarean deliveries (both types)
- Trauma
- Uterine myomectomy
- Uterine overdistention (Polyhyramnios, Multiple gestation)
- Placenta percreta

83

How would you treat Uterine Rupture?

Immediate laparotomy with delivery of the fetus

84

This occurs when the mother is Rh negative and the baby is Rh positive

Rh incompatibility

85

This is a type of IUGR with brain in proportion with the rest of the body and occurs before 20 weeks gestation

Symmetric IUGR

86

This is a type of IUGR with no decrease in brain weight, abdomen is smaller than the head and occurs after 20 weeks

Asymmetric IUGR

87

What is the best initial therapy for hyperemesis gravidarum?

Dietary modification, avoidance of triggers, and nonpharmacological treatments such as acupuncture, ginger, or vitamin B6

88

In women with severe symptoms of hyperemesis gravidarum, what should you give?

Diphenhydramine

89

After giving antihistamine to patients with hyperemesis gravidarum and still with no improvement, what is the next step in management?

Dopamine antagonists such as Metoclopramide

90

This is the final choice you can give a patient with hyperemesis gravidarum when all others didn't work.

Serotonin antagonists such as Ondansetron

91

What is the empiric treatment for asymptomatic bacteriuria in pregnant patients?

Nitrofurantoin, Amoxicillin, and Cephalexin

92

What is the empiric therapy for Acute Cystitis?

Nitrofurantoin or Penicillin until the results of sensitivity return.

93

What is the treatment for Acute Pyelonephritis in pregnant patients?

Admit and give IV Ceftriaxone

Nitrofurantoin or Cephalexin for the remainder of the pregnancy to prevent recurrence

94

What is the best initial test for PE in pregnancy?

V/Q scan --> CT pulmonary angiogram if V/Q scan is indeterminate

95

What is the treatment for PE/DVT in pregnancy?

Low-molecular-weight (LMW) heparin

Warfarin, Direct thrombin inhibitors, and Factor Xa inhibitors are contraindicated in pregnancy

96

What are the things you should consider when giving LMW heparin to pregnant patients?

It should be stopped 24 hours before delivery (if set time for delivery is known), resume 12 hours after C-section and 6 hours after vaginal delivery, and continue for 6 weeks postpartum

97

A 29-year-old woman G2P1 in her 30th week of pregnancy presents for a routine prenatal visit. She says she has no real complaints except that her wedding ring is getting too tight. On physical exam, her blood pressure is 150/100 mmHg, heart rate is 92 bpm, respiratory rate is 12, and temperature is 99F. Urine dipstick done in the office reveals 1+ protein.

Which of the following is the most likely diagnosis?

a. Chronic hypertension
b. Gestational hypertension
c. HELLP syndrome
d. Preeclampsia
e. Eclampsia

D. Preeclampsia is characterized by hypertension, edema, and proteinuria. Eclampsia is preeclampsia with seizures. HELLP syndrome is a complication of preeclampsia with with elevated liver enzymes and low platelets. Chronic hypertension is increased blood pressure that was present before the patient became pregnant. Gestational hypertension begins during pregnancy but has no edema or proteinuria.

98

Define Chronic Hypertension

BP above 140/90 before the patient became pregnant or before 20 weeks of gestation.

99

How would you treat Chronic Hypertension

Methyldopa, Labetalol, or Nifedipine

100

These are anti-hypertensive drugs that should not be used during pregnancy.

ACEi and ARBs

101

Define Gestational Hypertension

BP above 140/90 that starts after 20 weeks gestation. There is no proteinuria and edema

102

This is the only definitive treatment in preeclampsia

Delivery

103

A 28-year-old woman in her 27th week of gestation presents for a routine prenatal visit. She doesn't have any complaints. On physical examination her temperature is 99F, blood pressure is 120/80 mmHg, and heart rate is 87 bpm. The patient is asked to ingest 50 mg of glucose and have her blood glucose checked in one hour; it returns as 145 mg/dL.

Which of the following is the best next step in the management of this patient?

a. Treat with insulin
b. Treat with sulfonylurea
c. Do a fasting blood glucose level
d. Perform oral glucose tolerance test

D. An oral glucose tolerance test should be done after a positive glucose load test (described in the question). Two fasting blood glucose levels above 126 mg/dL is the diagnostic test for overt diabetes. Treatment with insulin is premature without a diagnosis of gestational diabetes. Sulfonylurea has been used but it does not have better pregnancy outcomes than insulin.

104

Define a reactive NST.

detection of two fetal movements, acceleration of fetal heart rate greater than 15 bpm lasting to 15 to 20 seconds over a 20-minute period

105

Enumerate the components of BPP

NST
Fetal chest expansions
Fetal movement
Fetal muscle tone
Amniotic fluid index

106

What is the normal BPP

8-10

107

What is an abnormal BPP

below 4

108

A 22-year-old primipara in her 39th week of pregnancy presents with intense abdominal pain that is intermittent. She claims that she felt a gush of fluid from her vagina almost 3 hours ago. On physical exam her cervix is 3 cm dilated and 50% effaced, and the fetus's head is felt at the -2 station. For the next 3 hours she continues to progress so that her cervix is 5 cm dilated, 60% effaced, and fetal head is felt at -1 station. Six hours after presentation, her cervix is 5 cm dilated.

Which of the following is the most likely diagnosis?

a. Prolonged latent stage
b. Protracted cervical dilation
c. Arrest of descent
d. Arrest of cervical dilation

D. Arrest of cervical dilation is when there is no dilation of the cervix for more than 2 hours. Patients who are more than 6 cm dilated are considered to be in active stage 1 labor. Patients with prolonged latent stage take more than 20 hours (in primipara) to reach 6 cm of dilation. Protracted cervical dilation occurs when the primipara's cervix does not dilate more than 1.2 cm in one hour. It is dilating slowly, but still not dilating. Arrest of descent is when the fetal head does not move into the canal.

109

How long should the latent phase last in primipara and multipara to be called Prolonged Latent Stage

>20 hours, primipara ; >14 hours, multipara

110

Treatment for Prolonged Latent Stage of labor

Rest and hydration

Most will convert to spontaneous delivery in 6 to 12 hours

111

What are the parameters to diagnose protracted cervical dilation?

Slow dilation during the active phase of stage 1 labor, less than 1.2 cm per hour in primipara, and less than 1.5 cm per hour in multipara

112

Treatment for Protracted Cervical Dilation

CPD - Cesarean delivery. Give Oxytocin if uterine contractions are weak

113

What is the parameter for arrest in cervical dilation?

No cervical dilation for 2hours

114

What is the parameter for arrest in fetal descent?

No fetal descent for 1 hour

115

A 25-year-old woman in her 35th week of gestation presents for a routine prenatal check up. She has no complaints. On physical examination her temperature is 98F, blood pressure 130/90 mmHg, heart rate 87 bpm, and respiratory rate 12 per minute. Her abdomen is gravid. On palpation of the abdomen, a hard circular surface is felt in the proximal part of the uterus.

Which of the following is the next step in management of this patient?

a. External cephalic version
b. Ultrasound
c. CT scan
d. X-ray

B. This patient is showing signs of a possible breech presentation on physical exam (the hard circular surface is the fetal head). Breech presentation should be confirmed via ultrasound before therapeutic measures such as external cephalic version are implemented. X-ray and CT scan are avoided during pregnancy secondary to the radiation exposure.

116

When can you do External Cephalic Version?

after 36 weeks gestation

117

This is the first-line treatment for shoulder dystocia; maternal flexion of knees into abdomen with suprapubic pressure

McRoberts Maneuver

118

This is a maneuver where rotation of the fetus's shoulders is performed by pushing the posterior shoulder towards the fetal head

Rubin Maneuver

119

This is a maneuver where rotation of the fetus's shoulders is performed by pushing the posterior shoulder towards the fetal back

Woods Manuever

120

This is the last maneuver you can try for shoulder dystocia wherein you push fetal head back into the uterus and perform CS

Zavanelli maneuver

121

How would you treat Lactational Mastitis?

Dicloxacillin or Cephalexin, Anti-inflammatory medications, and cold compress

122

How would you define Postpartum Hemorrhage?

It is defined as bleeding more than 500 mL after delivery

123

Enumerate the risk factors for Uterine Atony

- Anesthesia
- Uterine overdistention (such as in twins and polyhydramnios)
- Prolonged labor
- Laceration
- Retained placenta (can occur with placenta accreta)
- Coagulopathy