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325 Cards in this Set

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Mastitis - Women who are allergic to penicillin may be given
erythromycin
If the mastitis infection is caused by resistant, penicillinase-producing staphylococci, an antibiotic such as ________ or ______ should be given and continued until 2 days after the infection subsides, a minimum of 10 –14 days.
vancomycin or cefotetan
Advise
Provide clear, strong advice to quit with personalized messages
Assess the willingness of the patient to attempt to quit within ___ days.
30
Nicotine gum and patches should be considered for use during pregnancy only when
nonpharmacologic treatments (eg, counseling) have failed
Colostrum, the fluid secreted immediately following the infant's birth, conveys a high level of immune protection, particularly
secretory immunoglobulin A (IgA).
Human milk alone, however, may not provide adequate ____ for premature newborns, infants whose mothers have low iron stores, and infants older than 6 months.
iron
_______ are rare but generally preclude nursing
True inverted nipples
Lactation is not possible for women who have had breast surgery involving the
complete severing of the lactiferous ducts.
Who Should Not Breastfeed
• Take street drugs or do not control alcohol use
• Have an infant with galactosemia
• Are infected with the human immunodeficiency virus (HIV)
• Have active, untreated tuberculosis
• Take certain medications
• Are undergoing treatment for breast cancer
Therefore the woman should neither breastfeed nor bottle feed her newborn until she has been appropriately treated for TB for at least ______ and is otherwise considered to be noncontagious.
2 weeks
if a woman has varicella, she should be isolated from the infant and neither breastfeed nor bottle feed while she is clinically infectious.
Once the infant has received ________ the woman can provide expressed breast milk for the infant if there are no skin lesions on the breasts.
varicella-zoster immune globulin
Can An IMMUNOCOMPETENT woman who develops herpes zoster infection (shingles) continue breastfeeding?
Yes.
If lesions are covered and are not on the breast. Maternal antibodies delivered through the placenta and breast milk will prevent the disease or diminish its severity.

An infant may be given varicella-zoster immune globulin in these circumstances as an added precaution
breastfeeding is contraindicated for women taking these three agents
antineoplastic, thyrotoxic, and immunosuppressive
nonbreastfeeding women, the average time to first ovulation is
45 days
Exclusive breastfeeding helps prevent pregnancy for the first ______ after delivery
6 months
Meeting lactational amenorrhea method criteria

every 4 hours during day
every 6 hours during night
Most authorities recommend introduction of long-acting progestin-only injectables or implants ____ weeks after delivery for breastfeeding women
6
with regard to progestin-only methods are based on the conservative timing outlined in labeling. Exceptions may be considered for earlier use on an ______ basis.
individual
• Combined estrogen–progestin contraceptives, if prescribed, should not be started before ____ postpartum, and only when lactation is well established and the infant's nutritional status well-monitored
6 weeks
• Progestin-only oral contraceptives prescribed or dispensed at discharge from the hospital to be started _____ weeks postpartum (eg, the first Sunday after the newborn is 2 weeks old)
2–3
Depot medroxyprogesterone acetate initiated at ______ postpartum*
6 weeks
Mastitis differential diagnosis includes
clogged milk duct

marked engorgement

inflammatory breast carcinoma
Breast Abscess is diagnosed by a palpable mass or
Failure to DEFERVESCE within 48–72 hours of antibiotic therapy.
Recently, what method was shown to be successful in treating abscesses
ultrasonographically guided needle aspiration
ACOG recommends that exclusive breastfeeding be continued until the infant is about
6 months old
Psychosocial Screening issues to discuss with patient
safety.smoke,stress
barriers - car, (day) care, language
Drugs, DV
food, moves
unintended pregnancy
2/3 of all trauma during pregnancy results from
motor vehicle crashes.
What is a complication in 40-50% of pregnant women who sustain severe trauma,
Abruptio placentae
direct injury to the uterus and fetus prior to ___ weeks of gestation is extremely unlikely because they are protected by the bony pelvis.
13
trauma in the first trimester does not cause pregnancy loss, with the exception of
profound HYPOTENSION and associated HYPOPERFUSION of the uterus and its contents.
Is Pelvic fracture is a definite contraindication for vaginal delivery?
No.
However, a severe, dislocated, or unstable fracture or a large healing callus may preclude an attempt at vaginal delivery.
In pregnancy/trauma the use of vasopressors to restore maternal blood pressure should be avoided until
appropriate volume replacement has been administered.

remember, give fluid until CVP normal, then gently squeeze flow to kidneys
CT exposes the fetus to approximately ___ rads, depending on the number and thickness of the images and the equipment used.
3.5
Fetal exposure exceeding ___ rad may be sufficient to induce adverse effects in early pregnancy.
20
Is the need to perform a laparotomy, by itself, is an indication to proceed with cesarean delivery?
No
Recommended minimum time of posttrauma monitoring includes
4 hours
Fetal Assessment
The use of electronic fetal cardiac and uterine activity monitoring in pregnant trauma victims beyond 20 weeks of gestation may be predictive of
abruptio placentae.
Post trauma monitoring should be initiated when?
as soon as the woman is stabilized.
ultrasonography following trauma during pregnancy does not appear to be as sensitive as ________ monitoring for diagnosing abruptio placentae
cardiotocographic monitoring
recommended for household contacts of Hep A and contacts in day care centers and custodial institutions.
Hepatitis A immune globulin
Hepatitis A immune globulin It should be given as soon as possible after exposure; it is ineffective if given more than how long after exposure?
2 weeks .
A vaccine is available, which may be taken during pregnancy
Hepatitis A is caused by an ___ virus
RNA
Hepatitis B is caused by a ___ virus
DNA
Hepatitis B virus contains three principal antigens.
Hepatitis B surface antigen (HBsAg) is present on the surface of the virus

Hepatitis B core antigen (HBcAg) - only in hepatocytes and does not circulate in the serum.

Hepatitis B e antigen (HBeAg)
The presence of HBeAg indicates
High viral inoculum

Active virus replication
Hepatitis B virus is transmitted by
parenteral
sexual

At risk are receipt of blood products and household institutional contact.
In women who are seropositive for both HBsAg and HBeAg, the frequency of vertical transmission increases to approximately
90%.
Hep B; In women acutely infected in the third trimester,___% of offspring will be infected
80-90%
. Infants of women who are HBsAg positive at the time of delivery should receive both hepatitis B immune globulin (HBIG) and hepatitis B vaccine within ___ hours of birth,
12
followed by two more injections of hepatitis B vaccine in the first 6 months of life.
Hepatitis C virus is what type of virus
RNA
Many experts believe that hepatitis C virus-positive women should not breastfeed because
there is a 2-3% risk of vertical transmission.
Unlike hepatitis B, antibodies to hepatitis C are not protective.
Once cirrhosis ensues, patients demonstrate the typical signs of end-stage liver disease, such as
jaundice
muscle wasting
ascites
spider angioma
palmar erythema
ultimately, hepatic encephalopathy
Differential Diagnosis of Jaundice in Pregnancy
Viral hepatitis
AFLP
Toxic injury
ICP
Severe preeclampsia
Mononucleosis
Cytomegalovirus (CMV) hepatitis
Autoimmune hepatitis


Acetaminophen-induced hepatic failure is the second leading cause of liver transplantation.
antidote is N-acetylcysteine (NAC)
In AFLP, what are levels of transaminases like?
Minimal elevation in transaminases
Drugs causing toxic injury to liver
tetracycline,
isoniazid
erythromycin estolate
aldomet
acetominophen
MTX
AZT
Initial evaluation of the patient with suspected viral hepatitis should include tests for:
anti-HA IgM
HBsAg
HC PCR


In selected patients, additional testing can include anti-HBc IgM, HD PCR, anti-HE, and anti-HG.
In the acute stage of hepatitis B virus infection, the diagnosis is confirmed by the identification of
HepBSAg

IgM antibody to the core antigen
The time of Hep B infection can be evaluated by measuring
IgG and IgM antibodies to HBcAg. (core antigen acute and convalescent phases)


Typically, the IgG hepatitis B core antibody (HBcAb) appears 6 months or more after infection, with the IgM moiety being predominant prior to that time.

Occasionally patients with acute hepatitis B will demonstrate HBsAg only briefly and will develop anti-HBc (IgM) as their only marker of acute hepatitis B infection. Anti-HBc (IgM) may be helpful in HBsAg-negative patients in whom hepatitis B is strongly suspected
Administration of immune globulin more than ___ weeks after exposure is not effective in preventing or ameliorating the severity of hepatitis A
2
The Hep B vaccine should be administered into the _____ muscle.
deltoid


Intragluteal and intradermal injections result in lower rates of seroconversion.
What if pregnant patient is HepB SAg positive? What to do next?
Serum transaminases should be measured in seropositive women to detect biochemical evidence of chronic active hepatitis.
If the test results are abnormal or if the liver is palpable, the patient should be evaluated further to determine whether the disease is acute or chronic.
Treatment for chronic hepatitis C.
interferon alfa
Immunization against hepatitis B is protective against vertical transmission of hepatitis
D
Indications for APS antibody testing (ACA, LA)
3 or more spont losses
unexplained 2nd or 3rd trimester loss
Severe preeclampsia < 24 weeks
severe IUGR 2nd or early 3rd trimester
(Think APS & seizure PIS)

false positive RPR
Stroke in pt<55yo
autoimmune thrombocytopenia
amaurosis fugax
definition RPL
3 or more spont losses or

unexplained 2nd or 3rd trimester loss
Possible APS sequelae in pregnancy
(Like seizure disorder)

Preeclampsia
IUGR - fetal ultrasonography should be performed every 4-6 weeks starting at 18-20 weeks of gestation
Stillbirth - ANT, even as early as 24 weeks may be justified

Thrombosis or stroke
PTL
All patients with anti-phospholipid syndrome should be assessed for evidence of
(R)AT

(RPL)
anemia
thrombocytopenia
Treatment APS
if h/o and no h/o thromosis
LMWH 5000 TID if h/o thrombosis

5000 BID if no h/o thrombosis


Warfarin may be substituted for heparin during the postpartum period to limit further risk of heparin-induced osteoporosis and fracture. May continue 6-8 weeks post partum.
In an attempt to avoid severe osteoporosis, women treated with heparin should be encouraged to take
supplemental calcium (1,500 mg CAlcium CArbonate) and vitamin D daily.
In women taking warfarin, dysfunctional uterine bleeding and ovarian hemorrhage associated with ovulation pose unique and difficult problems. Suppression of ovulation may be beneficial, but hormonal formulations containing estrogen, including estrogen-progestin combination oral contraceptives, are contraindicated.
Relevant to caselist
rubella can cause multiple anatomic defects when fetal infection occurs during which trimester of pregnancy? .
first

but causes only chronic infection in the newborn when exposure occurs during the third trimester
Fetuses of women who ingest six drinks per day are at a ___% risk of developing some features of the fetal alcohol syndrome.
40
danazol before 9 weeks can affect female fetus how?
labioscrotal fusion
when would clitoromegaly occur?
anytime
anticonvulsant effects on fetus
Neural tube defects, minor craniofacial defects, fingernail hypoplasia, microcephaly,
developmental delay,
IUGR
Cocaine in pregnancy
Bowel atresias
congenital malformations of the heart, limbs, face and genitourinary tract

microcephaly;
IUGR
cerebral infarctions
Organic mercury effects
(avoid certain fish - shark, king mackerel))
Cerebral atrophy, microcephaly, mental retardation, spasticity, seizures, blindness

CP if 3rd trimester exposure
Phenytoin effects
IUGR
MR
microcephaly,
dysmorphic craniofacial features,
cardiac defects,
hypoplastic nails, and distal phalanges
The fetal effect of dilantin may depend on whether
the fetus inherits a mutant gene that decreases production of epoxide hydrolase, an enzyme necessary to decrease the teratogen phenytoin epoxide
Vitamin A and its derivatives
Increased abortion rate, microtia, central nervous system defects, thymic agenesis, cardiovascular effects, craniofacial dysmorphism, microphthalmia, cleft lip and palate, mental retardation
Cytomegalovirus
Ventriculomegaly

like Toxo

Hydrocephaly, microcephaly, chorioretinitis, cerebral calcifications, symmetric intrauterine growth restriction, microphthalmos, brain damage, mental retardation, hearing loss
Rubella
deafness
congenital heart disease
cataracts

Microcephaly
mental retardation
Syphilis
If severe-
fetal demise with hydrops;

if mild -
detectable abnormalities of skin, teeth, and bones
Toxoplasmosis
Possible effects on all systems but particularly central nervous system: microcephaly, hydrocephaly, cerebral calcifications. Chorioretinitis is most common. Severity of manifestations depends on duration of disease.
Varicella
Possible effects on all organs, including skin scarring, chorioretinitis, cataracts, microcephaly, hypoplasia of the hands and feet, and muscle atrophy
Radiation effects
Microcephaly, mental retardation
Ultrasonography may be considered confirmatory of menstrual dates if there is a gestational age agreement within _____ by crown-rump measurements obtained at 6-11 weeks of gestation or within ______ by an average of multiple measurements obtained between 12-20 weeks of gestation.
1 week

10 days
Confirmation of a mature fetal pulmonary system does not preclude consideration of the fetal risk of
intraventricular hemorrhage and necrotizing enterocolitis.
Infants delivered after attaining an L/S ratio of ____ or higher rarely develop RDS.
2.0

commonly accepted standard value indicating maturity in the fetus of a nondiabetic woman
An advantage of PG determination in assessing fetal maturity is the fact that
it is not generally affected by blood, meconium, or other contaminants

can do vaginal PG
Ethanol added to amniotic fluid, solution shaken, presence of stable bubbles at meniscus noted
Foam stability index
lung maturity test that is mature if >=55 mg/g of albumin²
Fluorescence polarization
lung maturity that shows what Spectrophotometric reading level
OD 650
Criteria to Define an Acute Intrapartum Hypoxic Event as Sufficient to Cause Cerebral Palsy

Essential criteria (must meet all four)
Evidence of a metabolic acidosis in fetal umbilical cord arterial blood obtained at delivery (pH <7 and base deficit >=12 mmol/L)

Early onset of severe or moderate neonatal encephalopathy in infants born at 34 or more weeks of gestation

Cerebral palsy of the spastic quadriplegic or dyskinetic type*

Exclusion of other identifiable etiologies, such as trauma, coagulation disorders, infectious conditions, or genetic disorders
Criteria that collectively suggest an intrapartum timing (within close proximity to labor and delivery, eg, 0–48 hours) but are nonspecific to asphyxial insults
A sentinel (signal) hypoxic event occurring immediately before or during labor
A sudden and sustained fetal bradycardia or the absence of fetal heart rate variability in the presence of persistent, late, or variable decelerations, usually after a hypoxic sentinel event when the pattern was previously normal
Apgar scores of 0–3 beyond 5 minutes
Onset of multisystem involvement within 72 hours of birth
Early imaging study showing evidence of acute nonfocal cerebral abnormality
*Spastic quadriplegia and, less commonly, dyskinetic cerebral palsy are the only types of cerebral palsy associated with acute hypoxic intrapartum events. Spastic quadriplegia is not specific to intrapartum hypoxia. Hemiparetic cerebral palsy, hemiplegic cerebral palsy, spastic diplegia, and ataxia are unlikely to result from acute intrapartum hypoxia (Nelson KB, Grether JK. Potentially asphyxiating conditions and spastic cerebral palsy in infants of normal birth weight.
Who should get CF testing/
reasonable to offer cystic fibrosis carrier screening to all pregnant patients,
The sensitivity of the CF screening test and the carrier risk vary among
different ethnic groups.
How many mutations are tested for in the CF pan-ethnic panel
panel of 25 mutations
When both partners are cystic fibrosis carriers, what next?
genetic counseling is recommended to review prenatal testing and reproductive options.

Prenatal diagnosis by chorionic villus sampling or amniocentesis, using DNA-based testing of the fetal cells, should be offered
Individuals with cystic fibrosis typically present with
cough, wheezing, failure to thrive, loose stools, abdominal pain, and, in males, infertility secondary to congenital bilateral absence of the vas deferens.
CF Treatment involves
pancreatic enzymes, proper nutrition, and respiratory therapy with aggressive treatment of infection.
When considering how to minimize multiple gestation, ___ can be viewed as the safer and more favorable approach compared with superovulation.
ART
(IVF with or without ICSI)
Anticipated outcome
medical knowledge has limitations and medical judgment is fallible
Testing for Tay Sachs in these 3 ethnic groups
Ashkenazi Jewish,
French–Canadian, or
Cajun descent
Tay Sachs
lysosomal storage disease

accumulation of these gangliosides
Tay–Sachs disease is caused by a deficiency of
Hexosaminidase A
4. If TSD biochemical screening is performed in women who are pregnant or taking oral contraceptives, ______ testing must be used.
leukocyte
Children born to mothers who smoke during pregnancy are at increased risk for
asthma
infantile colic
childhood obesity
Core preconception care considerations addressed by all include the following factors:
cats and rays
food and folate/PNV
V (vax) and DV
Dental and drugs
Salon (occupational) and smoke (environmental exposures)
safety, smoke, stress
barriers to care
drugs and DV
food and moves (frequent)
unintended pregnancy

Family history and genetic risk
Investigators have demonstrated that suture closure of the subcutaneous layer after cesarean delivery in obese patients may lead to a significant reduction in the incidence of postoperative wound disruption. What about drains?
Postoperative placement of subcutaneous draining systems, however, have not consistently been shown to be of value in reducing postcesarean delivery morbidity
Because obese patients are at increased risk for emergent cesarean delivery and anesthetic complications, anesthesiology consultation is encouraged when?
Antepartum or in early labor
Women who have undergone bariatric surgery require the following counseling before and during pregnancy:
at risk of becoming pregnant unexpectedly after weight loss following surgery
advised to delay pregnancy for 12–18 months after surgery to avoid pregnancy during the rapid weight loss phase
Women with a gastric band should be monitored by their general surgeons during pregnancy because adjustment of the band may be necessary
should be evaluated for nutritional deficiencies and vitamin supplementation where indicated.
fetal risks of obesity in pregnancy include:
prematurity
stillbirth
neural tube defect
macrosomia
counseling for women who have undergone bariatric surgery
Assessment and possible supplementation of vitamin B12, folate, iron, and calcium
Specific additional procedures that can be completed laparoscopically to facilitate the performance of vaginal hysterectomy include:
Lysis of adhesions
Treatment of endometriosis
Management of uterine leiomyomata that complicate the performance of vaginal hysterectomy
Ligation of infundibulopelvic ligaments to facilitate difficult ovary removal
Evaluation of the pelvic and abdominal cavity before hysterectomy
The benefits of LAVH must be weighed against the risk of what?
the potentially increased risk and expense of two distinct operative procedures, laparoscopy and vaginal hysterectomy, each with its own risks
Adolescents found to have endometriosis most commonly present with what type of pain?
both cyclic and acyclic pain
When evaluating an adolescent for suspected endometriosis or dysmenorrhea, the clinician should aim to rule out
a pelvic mass or
a congenital anomaly of the reproductive tract
Is a bimanual examination may necessary to evaluate pelvic pain, especially in adolescents who are virgins?
no
If a bi-manual examination cannot be performed or is declined, what may be helpful to determine if a pelvic mass or reproductive tract anomaly is present
a rectal–abdominal examination in the dorsal lithotomy position

a cotton-tipped swab can be inserted into the vagina to evaluate for the presence of a transverse vaginal septum, vaginal agenesis, or agenesis of the lower vagina.
endometriosis < 18 yo, first line treatment for endometriosis
Continuous combination hormone therapy/OCPs
NSAIDS
endometriosis > 18 yo, and had a negative assessment for an ovarian mass or tumor, first line treatment for endometriosis
empiric therapy with GnRH
typical lesions of endometriosis in adolescents, which tend to have what appearance
red, white ,or clear as opposed to the powder-burn lesions seen commonly in adults who have endometriosis.
The use of _____ in the pelvis may facilitate the identification of clear lesions, which are very common in adolescents
a liquid medium
Patients younger than 18 years with persistent pelvic pain while taking combination hormone therapy should routinely be offered what next
a laparoscopic procedure for diagnosis and surgical management of endometriosis
which osis lesions have been shown to be active producers of prostaglandins,
red

RED PROSTAGLANDINS
Proven effective in treating symptomatic endometriosis in adults, how should Danazol be given?
Doses of 400–800 mg daily for 6 months followed by continuous OCP use for maintenance suppression of the hypothalamic–pituitary ovarian axis.
to reduce the symptoms and bone loss related to a hypoestrogenic state, add-back therapy with what can help preserve bone density
norethindrone acetate (5 mg per day) or conjugated estrogens/medroxy-progesterone acetate (0.625/2.5 mg per day)
What can be considered a developmental milestone and benchmark for inclusion of adolescent endometriosis in the differential diagnosis of postpubertal girls and young women with chronic pelvic pain
thelarche and the presence of endogenous estrogen
In adolescents, standard therapy (combination hormone therapy and NSAIDs) for dysmenorrhea should be initiated, and if symptoms do not resolve after how much time, further evaluation for endometriosis is indicated?
3 months
Because there is no cure for endometriosis, long-term treatment should continue until
desired family size is reached or fertility no longer needs to be preserved.
Findings of the physical examination of adolescents may vary from the adult population because what features are found in more advanced disease and, thus, are uncommon in adolescents?
uterosacral nodularity and endometriomas
What does informed refusal mean?
possible consequences of refusal

explanation of the risks of refusing or declining the proposed intervention also must be given

The patient's reason for refusal also should be documented.
Whenever a patient refuses a medical treatment, surgical procedure, or diagnostic test, the physician should document the informed refusal in the patient's medical record and include the following information:
The patient's refusal to consent to a medical treatment, surgical procedure, or diagnostic test

Documentation that the need for the treatment, procedure, or test has been explained

The reasons stated by the patient for such refusal

A statement that the consequences of the refusal, including possible jeopardy to health or life, have been described to the patient
Which type of flu vaccine should not be given to a pregnant patient?
intranasal vaccine spray contains a live, attenuated virus and should not be used during pregnancy.
Can Amantidine and Rimantidine be given to pregnant patient?
No clinical studies have been conducted regarding their safety or efficacy during pregnancy.

These antiviral agents should be used during pregnancy only if the potential benefits justify the potential risks.

Antiviral agents should not be used as a substitute for influenza vaccination
repeat offer of HIV testing in the third trimester to women:
in areas with high HIV prevalence,
women known to be at high risk for HIV infection, and

women who declined testing earlier in pregnancy
Minors who may consent for their own health care based on their status include
those who are married, are members of the armed forces, live apart from their parents, and are parents of a child.
Which states have statutes allowing minors to receive services related to STD testing and treatment without parental consent or involvement.
All states
Gonorrhea and chlamydia
What should be considered when adolescents are reluctant to have pelvic examinations or are seen where pelvic examinations are not feasible
Urine screening
The CDC recommends that all female adolescents and women with chlamydial infections be rescreened how long after treatment is completed
3 or 4 months
What type of condoms should be promoted among those allergic to latex although data regarding the effectiveness of this type of condom at preventing STDs are sparse
Polyurethane
Screening for chlamydia is recommended during the third trimester for women younger than ____ years.
25
. Provision of emergency contraception should be considered if the sexual assault occurred within ____hours before the examination.
120
Once initiated, Pap screening should occur how often for adolescents
annually
The ACS further supports this recommendation by stating that screening LESS THAN 3 years after the onset of vaginal intercourse may result in overdiagnosis of cervical lesions, which often regress spontaneously
Hmmmm.

Inappropriate intervention may cause more harm than good.
ACOG recommends that the first visit to an obstetrician–gynecologist for health guidance, screening, and provision of preventive services should take place around what ages?
13–15 years.

This visit often does not include a pelvic examination, especially with the onset of urine-based STD screening options.

Thereafter, annual preventive health care visits to a gynecologist are strongly recommended
when multiple diagnostic X-rays are performed on a pregnant patient, what should you do?
Consultation with an expert in dosimetry calculation may be helpful in calculating estimated fetal dose
Radiopaque and paramagnetic contrast agents - are they ok in pregnancy?
Radiopaque and paramagnetic contrast agents are unlikely to cause harm and may be of diagnostic benefit, but these agents should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
The use of radioactive isotopes of iodine is contraindicated for therapeutic use during pregnancy.
Hmmmmm.
familial dysautonomia gene,
IKBKAP

Think AUTONOMIC!

abnormal sweating, pain and temperature insensitivity, labile blood pressure levels, absent tearing, and scoliosis
First-trimester screening using nuchal translucency, free ß-hCG, and pregnancy-associated plasma protein-A has comparable detection rates and positive screening rates for Down syndrome as second-trimester screening using 4 serum markers (alpha-fetoprotein, ß-HCG, unconjugated estriol, and inhibin-A).
Hmmmm.
UAE complications include

Embolic microspheres have been documented histologically in the ovarian arterial vasculature in patients undergoing the procedure
infection,
abscess,
sepsis,
hysterectomy,
permanent amenorrhea,
labial abd bladder necrosis,
vesicouterine fistula uterine wall defects,
groin hematoma, pulmonary emboli, and, rarely, death
undiagnosed leiomyosarcoma
loss of ovarian function
Anticipated outcome of UAE
short-term relief of bulk-related symptoms and

reduction of menstrual flow.
What to tell patient who wants UAE but still desires future fertility:
the procedure should be considered investigational or relatively contraindicated in women wishing to retain fertility.

The use of uterine artery embolization in postmenopausal women is rarely, if ever, indicated.
Two things to d/w patients about UAE
Potential complications
Fertility/reproductive wishes
Preventive care:

glucose
TSH
lipid testing
Fasting glucose testing
(every 3 years after age 45 years)
TSH
screening (every 5 years beginning
at age 50 years)
Lipid profile assessment (every 5 years
beginning at age 45 years)
In the absence of new risk factors, subsequent bone density screening should not be performed more frequently than every __ years.
2
Who should get fasting glucose testing before usual age 45?
Overweight (body mass index >=25 kg/m2)
FH of DM
habitual physical inactivity

high-risk race/ethnicity (African American, Hispanic, Native American, Asian, Pacific Islander

have given birth to a newborn >9 lb
history GDM

HTN
HDL <=35 mg/dL;
TG >=250 mg/dL;
history of impaired glucose tolerance or impaired fasting glucose

PCO

history of vascular disease
Who should get Colorectal cancer screening before age 50?
Colorectal cancer or adenomatous polyps in first-degree relative younger than 60 years or in 2 or more first-degree relatives of any ages

FH of familial adenomatous polyposis

FH HNPCC

history of colorectal cancer

adenomatous polyps

IBD
Who should get Lipid profile assessment before age 45?
Think of CHD and equivalents
Think of Risks besides increased LDL


Family history suggestive of familial hyperlipidemia; family history of premature (age <50 years for men, age <60 years for women) cardiovascular disease; diabetes mellitus; multiple coronary heart disease risk factors (eg, tobacco use, hypertension)
Who should get Thyroid-stimulating hormone testing before age 50?
Strong family history of thyroid disease
autoimmune disease

***evidence of subclinical hypothyroidism may be related to unfavorable lipid profiles

Too little thyroid hormone = lipid
Too much thyroid hormone = osteoporosis
progesterone supplementation reduces preterm birth in a select group of women
those with a prior spontaneous birth at <37 weeks of gestation

ideal progesterone formulation is unknown
When progesterone is used, it is important to restrict its use to only women with
a documented history of a previous spontaneous birth at less than 37 weeks of gestation because unresolved issues remain, such as optimal route of drug delivery and long-term safety of the drug.

supplemental vaginal progesterone (100 mg daily)
Newborn screening: These two screening tests are the only tests that are performed in all 50 states and the District of Columbia.
Phenylketonuria and congenital hypothyroidism
Newborn screening: Forty-nine states screen for
galactosemia
it appears that the best way to detect early ovarian cancer is:
for both the patient and her clinician to have a high index of suspicion of the diagnosis in the symptomatic woman.
symptoms commonly associated with ovarian cancer
Persistent symptoms such as an increase in abdominal size, abdominal bloating, fatigue, abdominal pain, indigestion, inability to eat normally, urinary frequency, pelvic pain, constipation, back pain, urinary incontinence of recent onset, or unexplained weight loss should be evaluated with ovarian cancer being included in the differential diagnosis.
Does a normal CA 125 measurement alone rule out ovarian cancer?
No.
Up to 50% of early-stage cancers and 20–25% of advanced cancers are associated with normal values
PREmenopausal women who have a pelvic mass that is suspicious for a malignant ovarian neoplasm, as suggested by a very elevated CA 125 level, such as this cutoff can be used:
>200 U/mL
add to SAC BAGS
a family history of one or more first-degree relatives with ovarian or breast cancer
At the time of surgery for a pelvic mass, what should always be done immediately upon entering the abdomen?
samples for peritoneal cytology should be obtained when the abdomen is entered.
What to examine when intraop for pelvic mass? What's the ex lap part inspected and palpated?
the liver
spleen
all peritoneal surfaces
both hemidiaphragms
What is defined as the staging procedure?
a bilateral pelvic and paraaortic lymphadenectomy is performed along with an omentectomy, peritoneal biopsies, removal of the uterus and adnexa, and biopsies or removal of any suspicious lesions.
germline mutation of BRCA1 or BRCA2. Is there a way to screen for ovarian cancer?
no data demonstrating that screening improves early detection of ovarian cancer in this population.
Invasive GBS disease in the newborn is characterized primarily by
sepsis, pneumonia, or meningitis.
Late-onset GBS disease in the newborn may be the result of
vertical transmission or of nosocomial or community-acquired infection.
early-onset GBS infection occurs when?
sepsis, or, rarely, meningitis during the first week of life.
Intrapartum administration of antibiotics to the women (during labor or after rupture of membranes, but before delivery) has been demonstrated to reduce which type of GBS disease, early-onset or late-onset?
EARLY-onset neonatal GBS disease
risk of fatal anaphylaxis has been estimated at
1 per 100,000
Should you strip or not strip membranes if GBS pos?
risks of membrane stripping in GBS-colonized women have not been investigated in well-designed prospective studies
What to do when find a patient with false pos HCG/Heterophile antibodies
Patients with evidence of hCG assay interference should be notified that they are at risk for recurrent false-positive hCG assay results. Tell future caregivers.
Lovenox Injection is not recommended for thromboprophylaxis in patients with
prosthetic heart valves

reports of valvular thrombosis in patients who were apparently adequately anticoagulated
is the most significant medical complication seen in women with spinal cord injuries.
Autonomic dysreflexia

85% of patients with lesions above T5 through T6 level
Common complications affecting women with spinal cord injuries include:
urinary tract infections
decubital ulcers
impaired pulmonary function
autonomic dysreflexia.
DVT/PE
unattended delivery
Why do they get UTI?
Incomplete bladder emptying
neurogenic bladder
urinary diversions
indwelling

Frequent urine cultures or antibiotic suppression are indicated.
Describe Autonomic dysreflexia
resultant catecholamine release and vasoconstriction
hypertension associated with headache
bradycardia
tachycardia
cardiac arrhythmia
sweating
flushing
tingling
nasal congestion
respiratory distress

Uteroplacental vasoconstriction may result in fetal hypoxemia
It is important to avoid stimuli that can lead to autonomic dysreflexia, such as
distension or manipulation of the vagina, bladder, urethra, or bowel.

During labor, the symptoms of autonomic dysreflexia are commonly synchronous with uterine contractions.
Spinal or epidural anesthesia extending to the ___ level is the most reliable method of preventing autonomic dysreflexia by blocking stimuli that arise from pelvic organs.
T10
umbilicus
10er outie
Congenital absence of uterus and vagina (MRKH) - what should be the first-line approach.
Nonsurgical creation of the neovagina
If surgery is preferred, a number of approaches are available; the most common is
the Abbe-McIndoe operation.
imperforate hymen and transverse vaginal septum. Patients with these latter conditions will have a normal cervix and fundus, both of which are palpable on
rectal examination.
What to examine when intraop for pelvic mass? What's the ex lap part?
the liver, spleen, and all peritoneal surfaces, including both hemidiaphragms, are inspected and palpated,
What is defined as the staging procedure?
a bilateral pelvic and paraaortic lymphadenectomy is performed along with an omentectomy, peritoneal biopsies, removal of the uterus and adnexa, and biopsies or removal of any suspicious lesions.
germline mutation of BRCA1 or BRCA2. Is there a way to screen for ovarian cancer?
no data demonstrating that screening improves early detection of ovarian cancer in this population.
Invasive GBS disease in the newborn is characterized primarily by
sepsis, pneumonia, or meningitis.
Late-onset GBS disease in the newborn may be the result of
vertical transmission or of nosocomial or community-acquired infection.
early-onset GBS infection occurs when?
sepsis, or, rarely, meningitis during the first week of life.
Intrapartum administration of antibiotics to the women (during labor or after rupture of membranes, but before delivery) has been demonstrated to reduce which type og GBS disease, early or late?
EARLY-onset neonatal GBS disease
Laparoscopy is seldom required to make the diagnosis, but may be appropriate in the rare patient presenting with cyclic pelvic pain
cyclic pelvic pain in patient with mullerian anomaly
may have remnant structure
first-line approach of MRKH treatment
Nonsurgical creation of the neovagina

initial surgery has the greatest chance for success
Abbe-McIndoe operation.
dissection of a space between the rectum and bladder

placement of a mold covered with a split thickness skin graft into the space

diligent use of vaginal dilation postoperatively.


This surgery is inappropriate if the patient rejects the nonsurgical technique because she has concerns about or objections to dilation
Although laparoscopy is not necessary to diagnose müllerian aplasia, it may be useful in the evaluation of patients with cyclic abdominal pain to exclude the possibility of endometrial activity in müllerian structures
cyclic abdominal pain to exclude the possibility of endometrial activity in müllerian structures
imperforate hymen and transverse vaginal septum. Patients with these latter conditions will have a normal cervix and fundus, both of which are palpable on
rectal examination
single course of corticosteroids to all pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within
7 days
multiple courses of steroids have been associated with
fetal adrenal suppression
In the absence of a medical contraindication, what reason is a sufficient medical indication for pain relief during labor
maternal request
Anthrax is an infection caused by Bacillus anthracis, an aerobic, gram-positive, spore-forming, nonmotile bacillus species. There are three primary clinical manifestations of the disease:
cutaneous,

inhalational,

gastrointestinal.
Risk factors for placenta accreta include
placenta previa with or without previous uterine surgery
prior myomectomy,
prior cesarean delivery
Asherman's syndrome
submucous leiomyomata
maternal age older than 35 years
who have had two or more cesarean deliveries with ANTERIOR or CENTRAL placenta previa have nearly a __% risk of developing placenta accreta.
40%
Profuse hemorrhage after vaginal delivery also may be due to placenta accreta. In this instance, what may be an alternative to hysterectomy, or this procedure may decrease blood loss before or after hysterectomy
selective pelvic vessel embolization
why not deliver vaginal breech?
perinatal mortality, neonatal mortality, and serious neonatal morbidity were significantly lower among the planned cesarean group compared with planned vaginal birth group
The success rate for versions average
58%
The diagnostic value of FHR monitoring is limited. When the FHR tracing is reassuring, it has a predictive value of what % for fetal well-being?
99%
an abnormal FHR tracing has a positive predictive value of only what % for fetal compromise?
50%
When stillbirth or neonatal death occurs, the obstetric history including exposures (eg, medications, viral infections), and family history, including a
three-generation pedigree if possible, should be reviewed
credentialing for cosmetic procedures should be based on
education, training, experience, and demonstrated competence.
Add grandmultiparity to STRIP CAMPS
Uterine rupture
Misoprostol Doses for cervical ripening should not be administered more frequently than every
3–6 hours.
There is insufficient clinical evidence to address the safety or efficacy of misoprostol in patients with multifetal gestations or suspected fetal macrosomia.
Hmmmm.
Current recommendations for adults indicate that plasma HIV viral load should be determined at baseline and then every __ months or following changes in therapy
3

The patient's most recently determined viral load should be used to direct counseling regarding mode of delivery.
viral load units
copies per ml
Tamoxifen use should be limited to __ years' duration because a benefit beyond this time has not been documented
5
If a patient is on Tamoxifen and atypical endometrial hyperplasia develops, appropriate gynecologic management should be instituted, and the use of tamoxifen should be reassessed. If tamoxifen therapy must be continued, What should be considered in women with atypical endometrial hyperplasia?
hysterectomy

Tamoxifen use may be reinstituted following hysterectomy for endometrial carcinoma in consultation with the physician responsible for the woman's breast care.
Phenylketonuria is caused by a deficiency of the enzyme
phenylalanine hydroxylase
Why are fetuses of mothers with PKU at risk, even if the fetuses themselves do not have the disease but are just carriers?
these metabolically normal fetuses of women with PKU who are on an unrestricted diet may develop microcephaly, low birth weight, heart defects, and mental retardation due to maternal hyperphenylalaninemia.
Women with PKU should begin dietary phenylalanine restriction when?
prior to conception
uterine tachysystole is
(six or more uterine contractions in 10 minutes in CONSECUTIVE 10-minute intervals)
When given in doses of __ mcg or more, misoprostol use has been associated with an increased rate of uterine tachysystole
50
clinical features of Canavan disease usually appear after the first few months of life and include
developmental delay
MACROcephaly
hypotonia
poor head control.

chromosome 17

LARGE/MACRO Caravan
Because the incidence of breast cancer is extremely low in patients younger than ___years of age, patients in this age group who have solid masses that appear to be benign when examined by ultrasonography can be monitored without biopsy at the discretion of the physician.
20

These guidelines apply both to pregnant and to nonpregnant women.
An Apgar score of ___at 5 minutes is associated with an increased risk of cerebral palsy in term infants,
0-3

scores alone should not be considered evidence of or a consequence of substantial asphyxia
A neonate who has had "asphyxia" proximate to delivery that is severe enough to result in acute neurologic injury should demonstrate all of the following:
Profound metabolic or mixed acidemia (pH < 7.00) on an umbilical cord arterial blood sample, if obtained

An Apgar score of 0-3 for longer than 5 minutes

Neonatal neurologic manifestations (eg, seizures, coma, or hypotonia)

Multisystem organ dysfunction (eg, cardiovascular, gastrointestinal, hematologic, pulmonary, or renal system)
What is the only neurologic deficit clearly linked to perinatal asphyxia.
Cerebral palsy
Apgar scores alone should not be used as evidence that neurologic damage was caused by hypoxia that results in neurologic damage or by inappropriate intrapartum management
Hmmmm.
is the most common inherited form of mental retardation,
Fragile X syndrome
Hypoxia as a cause of acute neurologic injury and adverse neurologic outcome occurs in infants who demonstrate the four perinatal findings
In the absence of such evidence, subsequent neurologic deficiencies cannot be ascribed to perinatal asphyxia or hypoxia
Fragile X features
autistic behaviors
macroorchidism in adult males
characteristic narrow face with a large jaw
speech and language problems.
Transmission of a Fragile X disease-producing mutation to a fetus depends upon
the sex of the parent and

the number of cytosine-guanine-guanine repeats present in the parental gene.

CGG CGG CGG
placental path finding:
microabscesses of
listeriosis
placental path finding:
amnion nodosum suggesting
long-standing oligo
There are no pathognomonic signs, symptoms, or diagnostic tests for ITP; it is a diagnosis of exclusion. However, four findings have been traditionally associated with the condition:
Platelet count <100,000/µL with or without accompanying megathrombocytes on the peripheral smear


normal or increased numbers of megakaryocytes determined from bone marrow


exclusion of other systemic disorders or drugs that are known to be associated with thrombocytopenia


absence of splenomegaly.
A woman can use LAM if all three of these conditions exist:
No menses since delivery

breastfeeding exclusively

q4 hours during the day
q6 hours during the night

baby is less than 6 months old
Question How effective is LAM?
98%

protection from pregnancy in the first six months
Ortho Evra dose
0.75 mg ethinyl estradiol

6.0 mg norelgestromin
Endometritis and toxic shock syndrome associated with what pathogen after medical abortion?
Clostridium sordellii

can occur within one week after medical abortion
Clinical findings Clostridium Sordelli include:
absence of fever

profound leukocytosis

tachycardia

hypotension

edema

hemoconcentration
Treat septic abortion with .
PCN G.
When should a hysterectomy be performed?
If evidence of gas gangrene,
Premenstrual syndrome can be diagnosed if the patient reports at least one of the following affective and somatic symptoms during the 5 days before menses in each of the three prior menstrual cycles*:
Affective
Depression
Angry outbursts
Irritability
Anxiety
Social withdrawal

Somatic
Breast tenderness
Abdominal bloating
Headache
Swelling of extremities
treatment PMS
Support
NSAIDS
progesterone - breast tend, bloating, worrying
OCP - physical sxs
GnRH
BSO (if GnRH successful x 3 months)
Menorrhagia is defined as
the loss of 80 mL or more of blood per menstrual cycle

bleeding that lasts for more than 7 days
What cause may enhance blood loss in women with chronic anovulation
abnormal/decreased vasoconstriction produced by altered endometrial prostaglandins
lower concentrations of _____ have been found in the endometrium of women with anovulatory bleeding as compared with women with ovulatory menstrual cycles
PGF2a
anovulator y bleeding v ovulatory cycles

anovulatory bleeding has what endometrial finding causing increased menstrual blood loss?
endometrial PGF2a/PGE2 ratio
GDM, when the estimated weight is 4,000–4,500 g, additional factors such as what factors may be helpful to consider in determining mode of delivery.
PAST
PELVIMETRY
PROGRESS
jehovahs witness
Conservation techniques may include
erythropoietin (takes 3-4 days)

iron supplementation

autologous donation preoperatively 72 hours, preferably 2 weeks before

blood salvage (cell saver)

acute normovolemic hemodilution - intraoperatively (50% dlution of blood)

muscle paralysis/sedation (less meabolism)
What is Erythropoietin?
glycoprotein hormone

regulator of
erythropoiesis

formed in the
peritubular interstitial cells of the kidney parenchyma
accreta
The outcome when the placenta is left in place after methotrexate administration varies widely; it ranges from expulsion in ____ to progressive resorption in roughly ______.
7 days

6 months
Risk of leaving placenta in:
bleeding

infection
Many conservative treatments of placenta accreta have been previously reported including
medical management with methotrexate,

angiographic-directed embolization

surgical wedge resection
laparoscopic insufflator—instead of the hysteroinsufflator—was used to distend the uterus?
Cardiac arrest occurred "during the insufflation of the uterus." Most likely, the arrest was caused by either air embolism or CO2 gas embolization.
The laparoscopic insufflator flows at ___L/minute;
1-15 Liters!
the hysteroscopic insufflator will maximally distend the uterus with ___mL/minute.
100 milliliters!
difference between LS and HS insufflators?
LS Liters/min

HS Milliters/min
Another cause of cardiac arrest during HS could be:
air remaining in the hysteroscopic tubing

if it had not been purged prior to attaching it to the patient.
AFter HS procedure, the operative note should reflect
which instruments and equipment were used.
CNS Lidocaine toxicity is
biphasic:

excitatory
depression
CNS Lidocaine toxicity

initial manifestations are
excitatory

tingling

numbness

mental status changes

seizures
Subsequent manifestations of lidocaine toxicity include
CNS depression

cessation of convulsions

unconsciousness

respiratory depression
This biphasic effect occurs because local anesthetics
first block inhibitory CNS pathways (resulting in stimulation) and then

eventually block both inhibitory and excitatory pathways (resulting in overall CNS inhibition).
Local anesthetics MOA
block sodium channels

affects impulse conduction through the heart and nerve tissue
Lidocaine is commonly associated with what benign effect?
sinus tachycardia,
Management of lidocaine toxicity?
Stop injection
ABC – IV, bag mask. intubate
Drugs
What drugs?
Anticonvulsants
Specifically which anticonvulsants?
Benzodiazepines barbiturates

diazepam 5-10 mg
thiopental 50-100 mg
Anesthesia can also administer which drug?
succinylcholine
Ventricular arrhythmias are best treated with
bretylium
Lidocaine toxicity effects in order of severity?
Tinnitus
Agitation
Metallic taste
Tachypnea,
Tonic/clonic seizures.
Respiratory depression/arrest
cardiovascular depression/arrest
Severe hypokalemia is defined as a level less than
2.5 mEq/L.
Severe hypokalemia may result from
renal or GI losses

inadequate diet

transcellular shift (movement from serum into cells)

medications
Severe hypokalemia causes:
Renal losses
Hyperaldosteronism
Vomiting
NGT
Diarrhea
Malnutrition or decreased dietary intake, parenteral nutrition
What meds cause hypokalemia?
Enemas or laxative use
Diuretics (most common cause)

Beta-adrenergic agonists

Steroids

Theophylline

Aminoglycosides

Insulin
hypokalemia studies
BUN/Cr
Glucose
Ca, Mg, Phos

digoxin level

ABG: Alkalosis



EKG
Management if severe hypokalemia
ABC
Cardiac monitor
Direct potassium replacement therapy by
symptomatology

potassium level
potassium level is less than 2.5 mEq/L, what K should be given?
IV potassium should be given
KCl replacement therapy takes how long?
more than a few hours
Serum potassium is difficult to replenish if serum ______ is also low. Look to replace both.
magnesium
Consultations for hypokalemia:
An internist or a nephrologist
severe hypokalemia and are symptomatic,
IV and oral replacement
patients should receive no more than ___mEq/h IV to avoid potential deleterious effects on the cardiac conduction system.
20 Meq/hr
KCl infusion rules:
never IV push

should be dilute solution.
Higher concentrations of IV potassium are damaging to
the smaller peripheral veins.
high plasma concentrations of potassium may cause
death due to cardiac depression

arrhythmias

arrest
Monitor KCl infusions with:
continuous or serial EKGs
What are the most common causes of hypokalemia in elderly patients
diarrhea

chronic laxative abuse
In patients with hypokalemia and diabetic ketoacidosis, part of the serum potassium should be administered as
potassium phosphate
Beneficence is defined as
unconditional goodwill and compassion
Jehovah's witness first prenatal visit, she should be started on
iron and folic acid supplementation
The goal should be to maintain the patient’s hematocrit above
40%.
The eating of foods high in heme content, such as
meat, poultry, and fish
Vitamin __ enhances the absorption of iron in the gastrointestinal tract.
C
Erythropoietin for which JW patients?
hematocrit of less than 40% who has not responded to iron supplementation
Not all Jehovah’s Witnesses will accept erythropoietin because the drug is packaged with
albumin
Erythropoietin stimulates the bone marrow to
maximize red blood cell production.
JW counseling
Iron/folate/stool softeners
Vit C
discussion of all blood products
discussion of albumin in erythropoietin
Discussion of autologous blood donation
autologous donation ideally when?
ideally 2 weeks before elective CD or EDD
The latest autologous donation can be done?
72 hours preop
ACOG advocates the use of ______ during cesarean delivery for placenta accreta.
cell salvage systems
Using a cell saver during a cesarean delivery carries the potential risk that
fetal cells may enter the maternal circulation if they are not properly filtered

could result in an amniotic fluid embolism
Explain "Cell saver" systems
allow for free blood in the abdomen to be aspirated, filtered, and then reinfused into the patient perioperatively.
Intraoperative techniques involved in the abatement of a massive hemorrhage include:
Normovolemic hemodilution


Controlled hypotensive anesthesia – MAP 50 mmHg


Sedation


Muscle paralysis
Normovolemic hemodilution involves
removing whole blood in the immediate preoperative period and replacing it with crystalloid or colloid.
Normovolemic hemodilution MOA
decrease in the viscosity of blood

allowing for better tissue perfusion.


optimizes the oxygen-carrying capacity of the red cells.
Controlled hypotensive anesthesia involves reducing the MAP to
50 mm Hg
What is significant about MAP 50mmHg?
This is the minimum requirement for tissue perfusion

allows for minimization of blood loss in the setting of substantial intraoperative hemorrhage.
Sedation and muscular paralysis have also been used both peri- and postoperatively to
decrease oxygen consumption.
Preo op for JW
possibility of preplacement of an embolization catheter or vascular balloons.

Erythropoetin
Erythropoetin can be given, preferably at least how long prior to anticipated delivery.
2 weeks
iron supplementation can also be given how?
Parenteral iron supplementation
When a family member refuses transfusion for an unconscious patient whose wishes are not known, what should be done?
a court order should be sought to clarify the situation
strong evidence that an acute intrapartum hypoxic event did not occur.
Cord gases with normal pH, pO2, pCO2, and base excess
An infant with elevated pCO2 who responds quickly to simple resuscitation efforts also helps to differentiate a benign transient acute respiratory acidosis from
a metabolic acidosis related to a chronic or preexisting condition.
a metabolic acidosis with a base excess of
–10.0 or greater is more likely to be associated with
neurologic injury