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98 Cards in this Set

  • Front
  • Back
by what percent should B-HCG levels rise in a normal pregnancy for the first 42 days?
50%/48h

up to 100,000
progesterone level > _____ strongly suggests normal pregnancy, while a level < ______ suggests an abnormal one
a. 25
b. 5
review criteria for MTX in ectopic pregnancy
--hemodynamic stability
--nonruptured ectopic
--size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate
--normal liver enzymes and renal function
--normal white cell count
--ability of the patient to follow up rapidly (reliable transportation, etc.), if her condition changes
discriminatory B-HCG level for ectopic
2000
options x3 for pts with early pregnancy loss
expectant management
drug therapy to assist with expulsion
surgical evacuation
def:
vaginal bleeding before 20 weeks without the passage of any products
threatened abortion
def:
abortion in which some, but not all, of the products of conception have passed
incomplete abortion
def:
fetal demise without cervical dilatation or passage of products of conception
missed abortion
def:
three successive first trimester pregnancy losses
recurrent abortion

check for occult systemic disease
most common abnormal karyotype encountered in spontaneous abortuses
autosomal trisomy
the majority of first trimester spontaneous abortions are due to this type of problem
Conceptus genetic anomalies
ddx:
3T vaginal bleeding
Uterine rupture
Placenta previa
Bloody show
Abruptio placenta
Cervical trauma
EFM signs of fetal anemia
tachycardia, sinusoidal pattern
HELLP =
"hemolysis, elevated liver enzymes, low platelets”
goal of treating elevated BP in preX
reduce the diastolic blood pressure into a safe range of 90-100mm Hg to prevent maternal stroke or abruption, without compromising uterine perfusion
what SBP/DBP merit antihypertensives in preX?
SBP > 160
DBP > 100
review Mg toxicity levels/sequelae
4-7 therapeutic
7-10 loss of DTR
>12 resp depression
>15 cardiac arrest

thus the reason for "mag checks" in preX women receiving treatment
mgmt:
ecclampsia
magnesium sulfate
only definitive therapy for preeclampsia
delivery of the fetus and placenta
30 year-old G5P4 @ 24wks w/ 3x prior c/s has anterior previa -> most likely serious complication leading to obstetric hge?
placenta accreta

low-lying anterior previa suggests accreta into old C/S scar
trade name:
prostaglandin F2
hemabate
(uterotonic)
why should hemabate (PGF2) not be used in asthmatics?
PGF2 -> constriction of smooth muscle

constricts uterine vessels as well as bronchi
most common cause of PPH
uterine atony
which of the uterotonics should be avoided in women with preX?
methylergonovine (Methergine) - vasoconstrictive agent
review factors assoc w retained placenta
prior Cesarean delivery
leiomyomas
prior uterine curettage
succenturiate lobe of placenta
define PPH (vaginal and cs)
vaginal >500
CS > 1000
how should PGF2 (Hemabate) and methylergonovine (Methergine) be delivered?
IM

IV delivery leads to bronchoconstriction (PGF2) and stroke (metyhlergonovine)
describe how rhogam is used to prevent isoimmunization
-give at 28 weeks to all Rh- women with no Abs
-one ppx dose at 72h if an Rh+ baby delivered
test of fetal-maternal hge (measures #s of fRBCs in mom's circulation?)
Kleihauer Betke test
def:
collection of fluid in two or more body cavities, such as ascites, pericardial and/or pleural fluid and scalp edema
hydrops fetalis
most likely volume of feto-maternal hemorrhage that occurs in a normal pregnancy?
<0.1cc

NB: this amount can sensitize an Rh- patient with an Rh+ fetus
300 ug of RhoGAM neutralizes ___cc of fetal blood
30cc
the delta OD450 test, performed on amniotic fluid, represents what compound in the fluid?
bilirubin

abnormal test indicates presence of heme pigment, ie, severe hemolysis
(test used in ?isoimmunization)
mgmt:
severe hemolytic dz in fetus 2/2 maternal isoimmunization
Intrauterine intravascular fetal transfusion
non-invasive test to detect severe fetal anemia
MCA peak systolic velocity
24-year-old G2 P1 woman is sensitized to the D and C antigens despite receiving RhoGAM following her first delivery. What is the best explanation?
amt of fetal-maternal hge was more than estimaged

RhoGAM works in a dose-dependent fashion
review US markers suggestive of dizygotic (fraternal) twins
dividing membrane thickness greater than 2 mm
twin peak (lambda) sign
different fetal genders
two separate placentas (anterior and posterior)
most important intervention to reduce risk of a preterm LBW infant in a multifetal gestation?
early good weight gain

these pregnancies deliver early, so must give more nutrients early
twin-twin transfusion occurs in this type of twin pair
monochorionic, monoamniotic

this setup allows for formation of vascular anastomoses
two factors that have increased the # of twin gestation
-advanced maternal age
-ART
optimal mode of delivery for twins in which the first twin is in the breech presentation
csxn
2x major problems with breech vaginal delivery
head entrapment
umbilical cord prolapse
twin infant death rate is ____x higher than that of singletons
5x higher than singletons
BMZ given to premature fetuses to increase pulm maturity, reduce incidence of RDS. It is also assoc with decr incidence of these two dz of premature infants?
-intracerebral hge
-NEC
which tocolytic works by the mechanism below?

Increases cAMP in the cell, which decreases free calcium
B-adrenergic agonist (terbutaline)
which tocolytic works by the mechanism below?

Decreases prostaglandin (PG) production by blocking conversion of free arachidonic acid to PG
PG synthetase inhibitor
which tocolytic works by the mechanism below?

Inhibits calcium transport -> calcium can't enter muscle cells
calcium channel blocker
which tocolytic works by the mechanism below?

Competes with calcium for entry into cells
MGSO4
fetal fibronectin ...

a. what is it used for?
b. what is its most valuable use?
a. PTL - found in disrupted cervical secretions near time of delivery; indicates disruption in materno-fetal interface

b. if it is ABSENT, the patient is VERY unlikely to delivery in next 14d
most common etiology of PTL
idiopathic
____% of patients with preterm contractions have spontaneous resolution of abnormal uterine activity
50%

NB: preterm contractions not the same as PTL (ie, they aren't leading to cervical change)
adverse fetal effect associated with indomethacin tocolytic treatment for PTL?
premature closure of ductus arteriosus
Fetal hypoxia and decreased uteroplacental blood flow have been associated with the use of this tocolytic
CCB (nifedipine)
mgmt:
20yo G2P1 @32.0 p/w ctx q4mins. Exam benign, 2/50/-1. FHT 140s, reassuring. WBC 18000.
amniocentesis to rule out intra-amniotic infection

BMZ is another important step here, but must r/o infxn before giving steroids
3 tests needed if IUGR diagnosed on screening pregnancy US
-amniotic fluid volume
-UA doppler systolic:diastolic ratio
-NST
_____ percent of patients with oligohydramnios delivered growth restricted infants
90%
IUGR:
incr UA doppler systolic:diastolic ratio indicates what?
increased vascular resistance
review the components of a biophysical profile
ultrasound evaluation of fetal movement, fetal tone, amniotic fluid and breathing
a fetus with IUGR will be monitored once or twice weekly with these 2x tests
-NST
-biophysical profile (US eval of fetal mvmt/tone, amn fluid, breathing)
the crown-rump length on US can reliably date a fetus to within ___to____days
5 to 7 days
symmetric growth restriction more likely to be due to events ____in pregnancy

review causes on reverse of card
early in pregnancy

organ system anomaly
aneuploidy
chronic intrauterine infection
symmetric growth restriction more likely to be due to events ____in pregnancy
late

usually re/fr uteroplacental insufficiency
the _______(test) is a rough estimate of the amount of amniotic fluid
amniotic fluid index

normal 8-18
oligohydramnios <6
polyhydramnios >20
normal range for AFI
normal 8-18

oligohydramnios <6
polyhydramnios >20
mgmt:
33 yo G2P1 @ 36 weeks with IUGR and non-reassuring tests of fetal wellbeing
induction of labor
2x common side effects of SSRI
sleep disturbance
sexual dysfunction (decr libido, anorgasmia)
what neonatal condition is associated with using fluoxetine (Prozac)
fetal cardiac defects
Mgmt:
22-yo F with regular periods reports tension, depressed mood and decreased productivity towards the end of each cycle. She is otherwise healthy and maintains a high-profile job.
ascertain timing of sx each month
consider dx of premenstrual dysphoric disorder
dx:
28 yo G1P1 3d post-delivery reports insomnia, easy crying, depression, poor concentration, irritability or labile affect and anxiety
"postpartum blues" - likely related to biochemical changes of puerperium

depressive sx are more pronounced
def:
the period between childbirth and the return of the uterus to its normal size
puerperium

"pure-peer-ee-yum"
most likely complication of PPTL?
future pregnancy
what is the main advantage of CVS over amniocentesis?
CVS performed earlier

CVS 10-12 wks
amnio >15 weeks
fetus at highest risk of MR 2/2 radiation exposure from ____ to ____ weeks
8 to 15 weeks
dx:
21yo G1 @39wks pmhx of vte on OCP p/w decr fetal mvmt x2d -> US w/ asymmetric IUGR and IUFD
FVL
what lab most important?
21yo G1 p/w vaginal spotting and has US showing IUFD at 9 weeks
maternal blood type
want to give RhoGAM to prevent sensitization if necessary
mgmt:
mom with a dead fetus in utero for an unknown duration
check maternal fibrinogen levels

after >4 weeks of IUFD with retained fetus, can re/in severe maternal coagulopathy
what is a Spalding sign on fetal xray?
overlapping skull bones suggesting IUFD
mechanism:
coagulopathy after >4wks retained IUFD
release of tissue factor from placenta into maternal circulation -> consumption of clotting factors -> coagulopathy if bleeding occurs
mgmt:
18yo G0 w/ LMP 14d ago presents with unprotected intercourse 12h ago, has taken OCPs in past and asks if she can just re-start them
provide emergency contraception
restart OCP immediately
how long does unpredictable bleeding usually last with progesterone contraception?
2-3 mos
50% of DP pts amennorheic at 1y
review contraindications to estrogen-containing OCP x4
history of thromboembolic disease
women who are lactating
women over age 35 who smoke
women who develop severe nausea with combined OCP
what components of the clotting cascade are found in FFP? (x3)
fibrinoge
factor V, factor VIII
what components of the clotting cascade are found in cryoprecipitate? (x3)
fibrinogen
VIII
vWF
dx:
32yo G3P2 woman at 40.1 presents in spontaneous labor and with painless vaginal bleeding; SVE reveals 5.0/100/-1 friable cervix that bleeds easily with intact membranes
bloody show

occurs due to bleeding from highly vascularized cervix near the time of delivery
The time from premature rupture of membranes to labor is inversely related to ________________________.
gestational age
2x methods to confirm rupture of membranes
-ferning vaginal fluid
-nitrazine testing
primary risk factor for PPROM
genital tract infxn (esp BV)
recurrence rate of pprom
~30%
what is the role of tocolysis in pprom (say, in a 31 weeker?)
delay delivery long enough for steroids to be on board for 48h
this drug class prolongs latency in pprom by 5-7d
antibiotics

also decr rate of maternal amnionitis and neonatal sepsis
what is the cause of fever in this pt?

23yo G1P1 PDD#2 after NSVD now with T=100.4, no complaints, normal exam except for firm and tender breasts without erythema
breast engorgement

-milk letdown can cause fever if baby is not feeding well
-lactating women can feed often and use breast pump to prevent this
postpartum fever: ddx (x3
-endometritis
-cystitis
-mastitis
mgmt:
32yo g2p1 @41 weeks with an unfavorable cervix and who strongly desires NOT to have induction of labor
"modified BPP"
NST/AFI twice weekly with IOL for nonreactive NST or oligohydramnios
in order to accurately date a pregnancy, ultrasound should be obtained prior to ___ weeks
20 weeks
def:
procedure in whcih normal saline is infused into intrauterine cavity
amnioinfusion
indication for amnioinfusion?
repetitive variable decelerations
def:
infant with EGA > 43 weeks who "looks like an old man" and has peeling skin, meconium staining, long nails, and appears frail
dysmaturity
most commonly used cervical ripening agent
misoprostol (local PGE1 analogue)