Women's Health

Front 1

Indentical and feternal

Back 1

• indentical= splittin of the embryo= monozygotic
• fraternal= fertilization of more then 1 egg= dizygotic (more common) and safer

Front 2

risks, and splitting times with monozygotic twins

Back 2

• the earlier the split the more separate the membranes will be, the safer
• within 72 hrs of fertilization--> 2 of each dichorionic --> two seperate sacs for the babies
• between 4-8 days the chorion has already formed--> monochronic, diamniotic (2 sacs)
• after 8 days--> monochorionic, monoamniotic (most hazardous)

Front 3

Twin twin transfusion

Back 3

• occurs in about 10% of monozygotic twins. typically the donor twin is about 35% smaller then the recipient twin
• both babies have their own cord it is just one babie is geetine way too much blood
• usually the larger baby is the one that dies

Front 4

Breach presentations

Back 4

• Frank- feet up
• Complete- butt comong out (more like indian style
• footling--> foot coming out head is not going to fit
• most dangrous is footling b/c head can get trapped

Front 5

External cephalic version

Back 5

• after 37 weeks and before labor beings if baby is breach
• must be performed in a hospital under US guidance
• may abrupt the placent or may be breech b/c of the cord being twisted
• dont' attempt before 35 weeks b/c baby may flip on its own --> also don't want to delvier it that early if a problem occurs

Front 6

face presentation

Back 6

• 1 in 500 deliveries
• common in anencephalics (absence of part of brain and skull)
• Can be delivered vaginally if the obstetrican is expereiences otherwise cesarean is safer

Front 7

causes of pregnancy related dealths during live births

Back 7

• embolism, hypertensive disorders/hemorrhage
• infections
• cardiomyopathy

Front 8

hypertensive disorder of pregnancy

Back 8

• the most common medical problems occuring during pregnancy
• one of the top three causes of maternal dealth along with infection and hemorrhage
• Bp 160/110 call for help b/c increased risk for seizure, placenta abruption

Front 9

preeclampsia

Back 9

• new onset of hypertensive and proteinuria after 20 weeks gestation, systolic BP >140 OR diastolic BP >90, proteinuria of 0.3 or greater
• before 20 weeks think molar preganancy
• mild deliver before 37 weeks, severe ASAP

Front 10

presentation of a preeclampsia PT

Back 10

• <18 or >35--> so yonger and older
• black (higher risk of HTN)
• first pregnancy with a specific partner
• prior preeclampsia

Front 11

presentation of preeeclampsia

Back 11

• rare before the 3rd trimester
• rapidly increased edemia, especially in the face/ hands
• brisk reflexes, visual distrubances, new onset of a HA --> anyone with visual distrubances and HA get admitted
• constant epigastric pain due to hepatic sweeling and inflammation

Front 12

severe preeclampsia

Back 12

• deleivery ASAP for these PT regarless of fetal maturity
• Sx of CNS dysfunction--> blurred vision, scotomata, severe HA
• sx of liver distention- RUQ or epigastric pain
• Systolic BP > 160 diastolic >110 on more then two occasions
• proteinuria= 5 or more grams in 24hrs

Front 13

prevention of eclampsia

Back 13

• MgSO4 --> if pt is seizing and they are pregent us this
• caution with toxicity, patella deep tendon reflex

Front 14

Eclampsia

Back 14

• occurrence of generalized convulsion and or coma in the setting of preeclampsia with no other neurological conditions
• frequently preceeded by hyperreflexia
• warrants head CT or MRO to exclude cerebral hemorrhage and R/O mass lesions or other causes

Front 15

management of preeclampsia

Back 15

• Delivery, if the pt has sever preeclamia or eclampsia she is stabalized and then delievered
• MGSO4 to prevent eclampsia
• if PT is mild, and gestation too early for delivery, stabilize the PT, give steroids to advance fetal lung maturity and deliver when maturation achieved, as long as mom is stable

Front 16

antihypertensives used during pregnancy for chronic HTN

Back 16

• methyldopa--> can casue folmant liver cancer so not used as much
• labetalol(#1)
• CCB
• No ACE or ARB

Front 17

laboring with preeclampsia

Back 17

• Seizure prophylaxis- magnesium sulfate during labor and 24 hrs postpartum
• control HTN--> 130/80 is goal--> hydralazine or labetalol

Front 18

daily exam of the hospitalized PT with preeclampsia

Back 18

• fundoscopic exam for retinal spasm or edemia
• lung auscultations to r/o pulm. edema
• cardic exam for gallop rhythms S4= LVH
• abd exam for hepatic tenderness
• neurological exams for clonus

Front 19

HELLP syndrome

Back 19

• a cariant of severe preeclampsia with high morbidity
• microangiopathic Hemolysis, elevated liver enzymes and thrombocytopenia (low platelets)
• b/c of precipitous drop in platelet count these PT can exsanguinate rapidly
• liver may be enlarged and is usually tender
• malaise, RUQ pain, N/V, and HA
• many not present until 48 hrs postpartum

Front 20

Gestational Hypertentsion

who, what, treatment, long term consequences

Back 20

• HTN w/o proteinuria or other signs of preeclampsia, develops after 20 weeks gestation and resloves 12 wks pospartum
• can progress to preeclampsia
• be careful with treating b/c BP goes down in 2nd trimester

Front 21

Rh background

Back 21

• if the baby is Rh positive and te mother is Rh negative, the transfer of etal RBC's into mother's circulation will cause the production of Ab to the Rh antigenof rare consequence of the pregnancy, the antibodies will corss teh placenta in subsequent pregnancy attackign the fetal RBC's and causing erythroblastosis fetalsis
• therefore rhogam at 28 weks of pregancy and after the "end" of pregnancy (delivery, AB, ectopic)

Front 22

kleihauer betke test

Back 22

• used to determine how much fetal cells and mother cells are together after a major truma like a MVA
• and the tells you what dose or rhogam to use
• blood test used to measure the amt of fetal Hb transferred from a fetus to a mother's bloodstream

Front 23

two ways to predict fetal anemia due to incompatibility(Rh)

Back 23

• OD 450
• middle cerbral artery blood flow

Front 24

indirect Coomb's titer

Back 24

• Measures ab free in the serum and is used to monitor maternal serum
• measure ab attached to the RBC and is more typically done on the neborn
• will be able to determine if true ab or Rhogam

Front 25

Delta OD 450

Back 25

• measures the level of bilirubin and predicts severity of hemolytic disease afte 27 weeks --> excellent correlation betweent he level of amniotic fluid bilirubin and fetal hematocrit begining at 27 weeks
• not accurate in the presence of fetal hydrops, meconium, or blood stained amniotic fluid

Front 26

middle cerebral artery blood flow

Back 26

• evaluates the velocity of blood flwo throught the MCA via doppler studies at the circle of willis. The velocity of blood flow is increased in anemia b/c of increased CO, basdilation in the brain, decreased blood viscosity

Front 27

Screening test for gestational diabetes

Back 27

• all are screened at 24-28 weeks with a 50g oral glucse tolerance test (1 h post 50gm glucola... normal <130) if abnormal 100g 3 hr test
• high risk PT or those that have glucosuria are screen earlier
• 1st prenatal visit get a baseline A1C
• mom's glucose will cross the placenta but her insulin will not

Front 28

risk factors for gestational diabetes

Back 28

• advance maternal age
• previous hx
• pervious macrosomic infant--> Fat baby
• pervious unexplained fetal demise
• Fx of DM
• obesity
• PCOD

Front 29

pregestational DM

Back 29

• increased risk of birth defects and SAB, especially if A1C is >8%, should be 6 before conception
• insulin has been the rx during pregnancy

Front 30

Graves disease in pregnancy

presentation outcome treatment

Back 30

• hyperthyrodism--> autoimmune TSH receptros antbody which mimics TSH increased TH production, inc. free T4 and dec. TSH
• untreated--> CHF, preeclampsia, thyroid storm, SAB, sx may be masked by pregnancy

Front 31

Thyroid storm in pregnancy

Back 31

• can be confused with sx of preeclampsia but no proteinuria present
• hyperthermia, tachycaridia, cardiac arrhythmia, change in mental status/seizures, excessive seating. voming
• treatment it PTU

Front 32

most common cause of hypothyroidism in preganancy

Back 32

• Hashimoto's disease (autoimmune disease--> Ab that attack the thyroid--> low thyroid hormone production) TSH is elevated
• untreated--> CHF, preeclampsia, anemia, SAB, IUGR
• Tx--> levothroxine --> as pregancy progresses adjust dose (increase)
• vitamins contain iron which impair the absorption of levothyroxine so should be taken at different times of day

Front 33

cardic disease in pregnancy which are contraindicated

Back 33

• Blue(cyanotic heart disease are a major concern
• the increased CO requirements of pregnancy can worse cardic disease sx--> nearlly all women with A fib will devlop CHF
• PT with primary pulmonary HTN or cyanotic heart disease will fair the worse. considered contraindications of pregnancy--> maternal mortatlity as high as 90%

Front 34

Cholestatis of preganacy

Back 34

• intense pruritis in the second half of pregnancy
• tends to be wores on palms and soles which stops 48hrs of delivery
• increased risk of meconium stained amniotic fluid and fetal demise, as well as maternal pp hemorrhage
• usually gets worse with each pregnancy
• Tx: ursodeoxycholic acid (UDCA) biweekly antenatal testing for baby, and delivery by 38wks

Front 35

Acute fatty liver of pregnancy

Back 35

• life threatening
• occurs in the 3rd trimest or pospartum peroid, and leads to hepatic coma and renal failure
• Sx: N/V anorexia, abd pain,
• tx: deliveyr w/n 24 hrs of diagnosis, can try induction but if too slow go to cesarean
• dx: liver biopsy: rarely used

Front 36

thrombotic disease in pregnancy

Back 36

• pregnancy is a 5 to 10 fold increase risk of DVT which is further increased during last 3 months
• inc. susceptibilit during pregnacy--> virchow's triad: venous stasis, hypercoagulability, damage to the vessel wall

Front 37

DVT

Back 37

• most common postpartum than antepartum, 50% asymptomaic
• signs and symtoms: positive homan's sign ( pain on dorsiflexion of the foot) dull ache, pain in calf
• Tx: IV heparin for 5-7 days follwe by subq heparin until 6weeks antipartum low molecular weight is safer (lovenox)

Front 38

superficial thrombophlebitis

Back 38

• usually limited to calf or vulvar regions w/ localized edema and tenderness
• Rx: bedrest, heat, support hose and pain meds
• no increased risk of pulmonary embolism

Front 39

pulmonary embolism

Back 39

• maternal mortality <1% if tx early >80 if not
• most common sx sudden onset of dyspnea and tachypnea sx may not be present in 70% of pt
• tx same as DVT --> lovenox 1mg/kg if you are tx q12hrs and 40mg prophylaxisis

Front 40

Amniotic fluid embolism

Back 40

• anaphylactic syndrome of pregnancy--> maternal mortatlity 86%, 50% die w/n 1 hr
• unknown why it occurs may be an anaphylactic reaction to fetal antigens usually seen right before or right after L&D

Front 41

risk factors for amniotic fluid embolism

Back 41

• oxytocin induced labor, grand multiparity, operative delivery, placental abruption

Front 42

stages of amnitoc fluid embolism

Back 42

• Stage one--> pulmonary artery vasopasms w/ pulmonary HTN and elevated right ventricular pressure
• stage two--> hemorrhagic phase characterized by massive hemorrhage with uterine atony and DIC

Front 43

indications for amniocentesis

Back 43

• the most common invasive dx procedure of pregnancy
• indications--> genetic dx at 16-20 wks, AFP level, assess fetal lung maturity
• follow delta OD 450 for Rh disease

Front 44

most preferred types of US

Back 44

• before 16 weeks do a transvaginal to date, implantation site, fetal number, nucal transucency for down's, structural abnormalities, cervical lengh
• after 16 weeks you do a transabdominal looking for structural abnormalities, fetal growth, fetal well being, amniotic fluid level

Front 45

indications for CVS

Back 45

chrion eventually forms the fetal side of the placenta, since the cells are of fetal origin they can be obtained and examined for genetic makeup (genetic testing)

benifits of amnio--> done earlier, at 8 to 10 wks

Front 46

aids to assist a prolonged second stage of delivery

Back 46

• forceps delivery--> used to assist the fetal delivery in an instance where pushing efforts are ineffective, also used to hasten delivery due to fetal compromise
• Vacuum extraction delivery--> done for the same indication of forceps delivery, maternal morbidity is higher with forcepts and fetal morbidity is higher with vacuum

Front 47

most preferred type of C/S

Back 47

low cervical transverse cesarean section preferred (LCTCS) over the classical

Front 48

leading casue of infant mortality

Back 48

• prematurity
• premature brith is the leading cause of neonatal mortality in the US
• responsible for 75-95% of neonatal mortality and 50% of longer term neurolgoic impairment in children
• IUGR is second

Front 49

risks of preterm delivery

Back 49

• #1 risk if pervous preterm delviery
• multiple gestations, premature preterm rupture of membranes, maternal HTN, incompetent cervix

Front 50

the most common causes of pretern labor

Back 50

• ascending infections
• hypoxic ischemic damage to the uteroplacental unit
• chronic stress
• fetal and uterine developmental malformations

Front 51

late preterm birth and early preterm birth

Back 51

• late preterm birth 34-37 weeks
• early preterm birth <34 weeks

Front 52

preterm labor

Back 52

• the presence of uterine contractions of sufficient frequency and intensity to effect progresive effacement and dilation of the cervix prior to term gestation
• aftter 20 weeks and before 37 weeks
• most critical times is between 24 and 33 wks

Front 53

the 2 best and most widely accepted methods of identifying women at high risk for PTB is

Back 53

• fetal fibronectin
• cervical lengh measurements

Front 54

fFN

Back 54

• protein that acts as a glud attaching the fetal sac to the uterine lining should not be measureable from 24 weks to 24 weeks if negative fewer then 5% delevier within next 2 weeks but + test doesn't tell you anything
• due this before digital exam, rotate swab across posterior fornix

Front 55

Cervical lenght measurements

Back 55

• transvaginal cervical lenght measuremens <25 mm between 22 and 24 weeks--> risk of spontaneous PTB is higher in both CL and fFN are abnormal than if only on is abnormal
• if <20 mm before 24 weeks, mom is treated with vaginal progesterone, if mom has had a PTB she is maintatined on 17OHPC 16-36 weeks, regarless of cervical lenght

Front 56

treatment of preterm labor

Back 56

• proven insufficeint cervix--> cerclage around 15 wks
• use progesterone 17OHPC if hx of previous preterm births
• no previous prenancies/ preterm births use vaginal progesterone

Front 57

Dx of preterm labor

Back 57

• uterine contactions >4/20mins.. not very predictable therefore called "preterm contractions" unless there is cervical change
• cervical change >80% effacement of >2cm dilation... much higher predictive value

Front 58

tocolysis

Back 58

• MgSO4 in hospital only IV buy 48 hrs of time for the administration of glucocorticoids (bethamethasone or dexamethasone) to advnace fetal lung maturity and decrease the incidence of intraventricular hemorrhage)
• indications--> spontaneous premature contractions, painful, palpable contractions that last longer then 30 sec

Front 59

PROM vs PPROM

type of exam, management

Back 59

• spontanous rupture of the membranes before the onset of labor (PROM) if the PT is preterm (PPROM), sterile speculum exam no digital exam
• nitrazine paper turns blud due to basic nature of amniotic fluid
• Managment if >36 weeks, induce contractions after 12 hrs, if <36 wks, asses amniotic fluid for fetal lung maturity if mature induce, if not hospitalize and begin antibiotis (ampicillin or erythromycin)

Front 60

what if chorioamnionitis occurs

Back 60

change abx to gentamycin and ampicillin and induce labor

Front 61

lab values to asses lung maturity

Back 61

• LBC(lamellar body count): directly measurment of surfactant
• L/S= lecithin/ sphingomyelin
• mature= L/S >2 with PG present, LBC hight
• even if L/S is <2, if PG is present, less then 5% of infants will have problems with RDS
• LBC less then 15K associated w/ pulmonary maturity

Front 62

RDS

Back 62

• respiratory distress syndrome which is caused by a lack of surfactant which is made up of PT+ phosphatidylglycerl, L/S, surfactatn begins to be made at 25 weks

Front 63

IUGR

Back 63

• the fetus is unable to achieve its genentically determined size, birth weight is frequently <10thpercentile
• more at risk for maconium aspirations, asphyxia (involving multiple organ systems is on of the most significant problems of IUGR), polycythemia
• funal height lags behing EGA by 3-4 cm

Front 64

long term sequelae of IUGR

Back 64

• some long term consequeces of IUGR last well into adulthood w/ a greater predisposition to develop a metabolic syndrome later in live manifesting as obesity, HTN, hypercholesterolemia, CVD

Front 65

Significants of asymmetrical IUGR

Back 65

• symmeetric IUGR body that is entire, proportionately small
• Asymmetric growth restriction--> undernourished fetus wiath an abdominal circumference lagging behind at a relatively greater rate then that of the head
• fetus is directing its diminished energy to supply brain and heart and not liver, muscle and fat,
• these seem to fair worse

Front 66

Postterm pregnancy when it is common, and how is it assessed and treated

Back 66

• beyond 42 weeks gestation
• aging and infarction of teh placenta--> poor perfusion--> increased featl and perinatal morbidity and mortality, common in anencephalic infants
• biophysical profile should be started by 41 weeks and performed every week
• induce labor (need to ripen cervix first)

Front 67

in utero fetal demise

Back 67

• Death in utero afte 20 weeks, but before onset of labor
• associated meternal etiological factors: DM, HTN, infection, autoimmune disease
• associated fetal factors: erythro. fetalis, umbilical cord acident
• confirmed by lack of fetal cardiac activity on US