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235 Cards in this Set
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hCG = 1000mIU/ml, Hct 32%, TVUS shows no IUP, no adnexal mass, no free fluid. Patient stable Next step in management?
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Repeat hCG in 2 days. Inappropriate rise in hCG levels (<50% increase in 48h) or levels which don't fall with D&C is consistent w/ ectopic. Alternatively, US should show fetal pole outside uterus and should show a hCG > 2000.
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Patient w/ LLQ pain, spotting 2 days prior. Stable vitals. hCG 400mIU/ml, US negative for IUP at this time, adnexal masses or free fluid. Most likely dx?
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Unable to establish. hCG below discriminatory zone and US was negative. Could be ovarian torision, early IUP, missed abortion and ectopic pregnancy.
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17 yo G3P0 LMP 7 weeks ago hCG 2500, US adnexal mass. +CVM, hx of chlamydia x2, in 8/10 pain. Anemic. Next step in management.
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Exlap! patient has ruptured ectopic until proven otherwise. Serial examinations/ repeat hCG levels is dangerous and she could bleed out. MTX is not appropriate as she has acute abdomen.
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Healthy 19yo G2P1 LMP 6 weeks ago, hCG 48 hrs ago 1500, today 3100. Prog 26 ng/ml. No CVM tenderness or adnexal masses. TVUS should show...
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viable IUP. hcG above discriminatory zone and doubled in last 48 hrs. Progesterone > 5 (less than this is range of failing pregnancy).
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20 yo G1PO w/ LMP 6.5 weeks and +home pregnancy test. hCG 48hrs ago 750, today its 760, progesterone 3.2 ng/ml. hct 37%. TVUS shows no fetal pole or masses. Next step?
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D&C. no rise in hCG of at least 50% in 48 hrs and progesterone < 5 ng/ml indicating failing. D&C is both diagnostic and therapeutic. afterwards, hCG should be drawn and 24 hrs later. if not decreased, ectopic diagnosis.
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G3P2 w/ acute abdomen, +CVM tenderness, hx of BTL and hCG 4000mIU/ml and TVUS showing right ovarian mass and fluid in pelvis. dx?
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ectopic pregnancy diagnosis is made when either 1) fetal pole outside of uterus or 2) hCG> 2000 and no IUP on U/S or 3) hCG doesn't fall by 50% after D&C.
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MTX indications for Ectopic Pregnancy?
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hemodynamic stability, non-ruptured ectopic pregnancy (no signs and sx of acute abdomen), ectopic mass < 4cm w/o FHR.
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35 yo G5P3 hx of ectopic preg w/ peritoneal signs, hypovolemia signs and TVUS shows fetal pole outside of uterus. next step?
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laparoscopy
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19 yo G1P0 @ 6 weeks by LMP presents w/ vaginal spotting. hCG 750, prog 3.8. physical exam normal. next step?
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recheck in 48 hrs. still could be a viable pregnancy. progesterone suppositories will nto help because progesterone level is below viable level.
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19 yo G1P0 LMP 6 weeks ago c/o spotting. hCG 2000 48 hrs ago, today its 2100. TVUS shows empty uterus and thin endometrial stripe and no adnexal masses. next step?
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MTX. this is an abnormal pregnancy as shown by hCG levels. TVUS r/o IUP and a diagnosis is ectopic!!! no evidence of rupture (no peritoneal signs) thus MTX.
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Define Threatened abortion.
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vaginal bleeding before 20 weeks gestation w/o passage of POC and a closed cervix.
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Define incomplete abortion
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passing some but not all POC. complete abortion is passing all POC.
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Define missed abortion
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those who have experienced fetal demise w/o cervical dilatation or passage of POC. Recurrent abortion refers to 3 successive SAB
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What accounts for majority of first trimester spontaneous abortions?
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conceptus genetic anomalies. ~50-60% of embryos and early fetuses that are SAB contain chromosomal abnormalities.
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Which chromosomal abnormality is most often associated w/ first trimester SAB?
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autosomal trisomy (~40-50% of cases). Next is triploidy 15%, tetraploidy 5%. Monosomy X (45X, 0) is seen in 15-25% of losses.
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A women w/ hx of type I DM, Chronic HTN and prior TAB has a 1st trimester SAB. What is most likely the cause of SAB?
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DM type I. systemic diseases are associated w/ early pregnancy loss. risk appears to be 2/2 metabolic control. HTN or TAB do not increase risk of first trimester loss.
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T/F: environmental factors such as smoking, alcohol and radiation are causes of SAB.
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True.
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T/F: Hx of Pre-ecclampsia w/ previous pregnancy increases risk of SAB.
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False. Isolated hx of pre-E doesn't increase risk.
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22 G1P0 presents to ED @ 8 weeks gestation w/ heavy VB, dilated cervix, H&H of 7/21. hypotensive and tachy. Next step?
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D&C. active bleeding and anemia requires immediate treatment. She is not hemodynamically stable therefore can't use expectant management or misoprostol (+UC and dilation of cervix).
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Patient experience missed abortion @ 6 weeks. physical exam normal. She wishes to "let nature take its course." What is the best advice?
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She doesn't need any treatment of next couple of weeks. she is hemodynamically stable and expectant management is appropriate.
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29 yo G3P0 presents @ 8 weeks gestation. Prior pregnancies secondary to cerivical incompetence. sonohysterogram shows normal uterine anatomy. Game plan for patient?
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cerclage @ 14 weeks gestation. Delay cerclage till 2nd tri since 1st trimester preg not at risk w/ incompetent cervix. While prophylactic progesterone is used by some to prevent PTL, no evidence supports it use.
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32 yo G3P0 @ clinic for preconception counseling. prior 3 1st trimester losses. Which test should be ordered?
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lupus anticoagulant! r/o systemic disease in patient w/ recurrent abortions. In these cases test DM and thyroid as well as parental chromosomes.
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What is the risk of SAB in patients w/ prior history of 1 TAB in first trimester.
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Does not predispose mother to subsequent SAB.
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What complications are babies with type I DM mothers at risk for?
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Insulin-dependent diabetes have increased rates of SAB and congenital malformations. Overt type I at risk for fetal growth restriction. Others: polyhydramnious, preterm, HTN.
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of the following drugs, which is contraindicated in pregnancy: levothyroxine, labetalol, acyclovir, lisinopril, amitriptyline?
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LInsinopril. The rest are safe. ACE inhibitors use beyond 1st trimester associated w/ oligohydramnious, growth retardation, renal failure, hypotension, pulmonary hypoplasia and death.
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What management option would best decrease the risk of perinatal transmission of HIV in HIV+ mother w/ CD4 600 @ 36 weeks gestation.
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IV Zidovudine (AZT) at time of delivery always offered regardless of CD4/HIV RNA. Best protocol: start at 14 weeks thru delivery and treatment of neonate. CS also recommeneded.
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MCC of sepsis in pregnancy?
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acute pyeloneprhitis. However, pneumonia and chorioamnionitis should be in differential?
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T/F: DKA is a usual complication of uncontrolled gestational DM.
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False.
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24 yo G2P1 @ 18 weeks w/ hix of asthma presents w/ worsening of asthma sx and use of albuterol. afebrile, NAD, Pulm: good air movement mild wheezing, no rales. Next step?
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inhaled corticosteroids. Patient has worsening asthma in pregnancy. (40% of asthmatics during pregnancy). If short acting beta agonists use > 2x/week, move to inhaled corticosteroids or cromolyn sodium.
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34 yo G4P3 @ 19 weeks presents to ED in thyroid storm (maternal mortality > 25%). What therapy is contraindicated at this time?
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131I: concentrates in the fetal thyroid causing congenital hypothyroid. PTU, propranolol, NaI, and dexamethasone can be used.
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18 yo G1P0 presents for PNC @ 16 weeks gestation. +FTA and allergic to penicillin. correct treatment?
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Desensitization and Penicillin!. Syphilis transmission rates 50-80% and no alternatives to pencillin. Confirm anaphylaxis risk w/ skin testing. Erythromycin has 11% failure rate and Doxycycline in contraindicated.
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Describe White's classification of diabetes
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Class A(1 or 2): Gestational diabetes, during pregnancy only. Class B: diagnosed at age over 20 yo, diagnosed <10 years. Class C: diagnosed at age before 20yo, carried diagnoses more than 10 y. Class D: had disease over 20 years and diagnosed under age of 20. Class F: nephropathy, diagnosed any age.
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Most appropriate management in patient diagnosed w/ gardenella type bacterial vaginosis. Patient's partner?
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Not known, but oral flagyle probably equally as effective. Treat ASAP to reduce incidence of PTL. No treatment for partner recommended
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What is the concern for 33 you G2P1 diagnosed with pulmonary HTN?
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Mortality rate > 25%. decreased venous return --> decreased RV filling.
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19 yo G1P0 @ 18 weeks gestations c/o 3 mo h/o palpatations and intermittent chest pain. she has 2/6 systolic ejection murmur. ECG normal. ECHO pending. Best treatment?
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beta blockers. Patient may have MVP or stenosis. use beta blockers do decrease risk of arrhythmias. If asx + systolic murmur 2/6 = no treatment if ECG is normal.
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Besides cough, pleuritic chest pain and fever, what is essential for diagnosis of pneumonia in a 27 yo G1P0 @ 32 weeks?
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CXR. (does not accurately predict etiology of PNA)
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18 yo nulliparious black woman is suffering from renal infection (US: calculi obstruction in right ureteral) refractory to broad spectrum abx x 4 days. Next step?
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pass a double J ureteral stent. If hydration and abx don't work after 72 hrs, place a stent. if that doesn't work, percutaneous nephrostomy.
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5'4'' 220lbs @ 12 weeks gestation and nullparious wants to know how her size may effect pregnancy. MC problem...
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HTN. Increased maternal morbidity results from obesity and includes HTN, Gestational DM, pre-E, macrosomia and high rates of post partum complications. w/ BMI of 38 she is @ increaesd risk of Pre-E and HTN.
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16 yo G1P0 black woman @ 8 weeks gestation presents for PNC. hgb 8 and microcytic. Most likely diagnosis?
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Anemia during pregnancy and in puerperium (time after delivery) MCC are iron deficiency and acute blood loss.
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27 yo G1P0 @ 22 weeks h/o SLE c/o malaise, joint aches and fever. What is first line therapy for severe manifestation of SLE in prego?
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steroids. Lupus has variable presentation. If arthralgia and serositis only, can use NSAIDs, otherwise steroids.
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What is NOT a recommended therapy for breast adenocarcinoma during pregnancy?
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Radiation. If young, can present w/ more advanced aggressive cancer (usually mets if diagnosed during prego). surgery + chemotherapy recommended.
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Which of the following psych meds is contraindicated: paroxetine, sertraline, fluoxetine, nortyptyline, bupropion.
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paroxetine (paxil). MC used antidepressants are SSRIs but paxil has increased risk of fetal cardiac malformation and pulm HTN. Older SSRI okay. TCA and wellbutrin okay also.
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Patient presents w/ severe itching and slightly yellow skin @ 32 weeks gestation. Best treatment?
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antihistamines. patient has pruitus gravidarum (mild variant of intrahepatic cholestasis of pregnancy). Cholestyramine causes decrease in fat soluble vitamins absorption and limited effectiveness. Ursodeoxycholic acid is not first line.
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27 yo G2P1 presents to ED w/ f/n/v and abdominal pain. decreased BS and ride ab tenderness. best next step?
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Graded compression ultrasound (not abdominal or pelvic u/s). A large uterus shifts appendix upward and outward toward the flank so pain may not be RLQ. CT is high rads exp.
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17 yo prmigravida presents @ 37 weeks w/ no complaints. BO 138/89 and 144/91 on repeat. UA negative and CBC and CMP normal. dx?
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Gestation HTN. she lacks other defining criteria for preecclampsia. 25% of women w/ gHTN develop pre-E
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17 yo @ 34 weeks has bp 155/99, 440mg/dl/24hrs protein and swelling in hands and face. Dx? If 39 weeks, what would treatment be?
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Mild pre-E. >300mg/dL/24 hrs + BP b/w 140-160/90-100. If @ 39 weeks, deliver is treatment. Mag sulfate during labor and 24 hrs post partum is indicated to lower seizure threshold.
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40 yo G1P0 @ 34w3d has grand mal seizure and dx of pre-E. ABCs secure. next best step in treatment?
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Mag sulfate. treatment of choice for ecclampsia. second line agents include valium hydantoin and phenobarbital.
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which of the following IS NOT associated w/ increased risk of preeclampsia: 1. hx of pre-E 2. chronic HTN 3. multfetal pregnancy 4. age 5. previous SAB
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previous SAB. other risk factors: molar pregnancy, systemic diseases, triploidy in mom.
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22 yo G1P1 undergoing treatment for severe Pre-E. hx of previous CS 2/2 NRFHRT. oliguric, lethargic, no DTR b/l. mag 11mq/L. What condition can magnesium tox result in?
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Respiratory depression. A therapeutic mag level is b/w 4-7 mEq/L. Respiratory depression occur above 12. Cardiac arrest above 15.
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What are contraindications for expectant management of severe preeeclampsia remote from term (<32w)?
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thrombocytopenia (under 100k), HTN refractory to max doses of 2 antihypertensives, NRFHRT, LFTs elevated x 2, eclampsia (seizure!).
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T/F: severe preecclampsia remote from term mother is being treated w/ expectant management. at f/u visit her labs are normal except for elevated uric acid and hct. Its safe to deliver now.
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False. hemoconcentration and uric acid are markers of pre-E but not indications to deviate from expectant management if all other labs/vitals are normal
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T/F: it is possible to have HELLP syndrome w/o RUQ pain, hemolysis (bilirubin and anemia).
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True. especially if diagnosis is made early!. HELLP is a severe manifestation of severe pre-ecclampsia
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T/F: acute fatty liver almost always manifests late in pregnancy
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True. Sx develop over days to weeks: malaise, anorexia, n/v/epigastric pain and jaundice. there is usually severe liver dysfunction (albumin, cholesterol, increased coags) and marked hypoglycemia.
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36 yo G5P4 w/o PNC presents in active labor. BP 170/105 w/ 3+ proteinuria. FHT 170s/dec variability/sinusoidal pattern. BRB per vaginal x 1hr. eitiology of VB?
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Abruptio placenta. look for tachysytole on tocometer and evidence of fetal anemia (tachycardia and sinusoidal heart pattern) on HRT. HTN and pre-E are risk factors for abruption.
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27 yo P1 @ 36 weeks w/ severe pre-E. BP 200/105. what diastolic BP are you aiming for w/ antihypertensive rx?
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90-100. atnihypertensive treatment is indicated if >160/>105. first line agents hydralazine or labetalol. Goal is not normal BP but reduce diastolic BP into safe range to prevent stroke or abruption.
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28 yo G2P1 presents @ 20w0d w/ anti D titer 1:64. Normal amniocentesis. Previous C/S 2/2 abruption. Mom is Rh negative. Source of Rh senstization.
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Placental abruption caused transplacental hemorrhage of fetal rh+ RBC into mom. other ways this can happen, amniocentesis, CVS, ectopic, pre=E, antepartum hemorrhage, C/S.
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What is the most likely volume of feto-maternal hemorrhage that occurs during a rh sensitization pregnancy.
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<0.1cc is all it takes!. 75% of gravidas have evidence of transplacental hemorrhage.
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Name a non-invasive test used to detect severe fetal anemia.
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middle cerebral artery peak systolic velocity (doppler).
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anti-D antibodies detected in G2P1 mom @ 10w gestation. What ultrasound findings would be most explained by presence of Rh disease?
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Fetal hydrops is easily diagnosed via US. It develops in presence of decreased hepatic protein production. Defined as collection of fluid in +2 body cavities (ascites, pericardal effusion and/or pleural fluid and scalp edema).
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what amount of fetal blood is neutralized by 300mcg of RhoGAM?
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30 cc of fetal blood is neutralized by 30 mcg of RhoGAM. This is equivalent to 15cc of fetal RBC. At 28 weeks this dose is routinely adminstered after testing for sensitization w/ an indirect Coomb's test (mother's serum). Administration is given following amniocentesis at any gestational age.
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What is the current recommendation for preventing Rh isoimmunization?
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Administration for Rh-negative patients w/ no Rh antibodies at 28 weeks. RhoGAM (anti-D Ig) prevents isoimmunization.
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What is recommendation for RhoGAM?
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@ 28 weeks in Rh negative patients w/o Rh antibodies @ 28 weeks. w/in 27 hrs of delivery of Rh +, following SAB/TAB, antepartum hemorrhage, amniocentesis or CVS.
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How can one accurately and immediately estimate the decree of fetal-maternal hemorrhage?
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Kleihauer-Betke test is an acid elution test. using acid elution, mother's RBC become pale while fetal cells (different Hgb) remain stained.
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Amniotic fluid gathered from amniocentesis for fetus that is affected by Rh disease, is sent for OD450 measurement. What does this value represent in amniotic fluid.
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Bilirubin. amniotic fluid in presence of eryhtroblastotic fetus will be yellow.
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At 30 weeks gestation, the delta OD450 results plot on the liley curve in zone 3. What is the most appropriate next step in management?
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Intrauterine IV fetal transfusion. zone 3 = severe hemolytic disease w/ hydrops and death in 7-10 days. @ 30 weeks, try to give more time in utero. If transfusion not possible, maternal plasmapheresis can be attempted.
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24 yo G2P1 is sensitized to D and C antigens despite RhoGAM her first delivery. What best explains these findings?
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Rh negative woman will be sensitized despite prophylaxis on rare occasions. The amount of feto-maternal hemorrhage was more than previously estimated (1 dose for 30 cc fRBCs), sensitization to non-D ag, or if not receiving RhoGAM after procedure. RhoGAM only confers protection against D ag.
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25 yo G2P1 @ 16w3d by 1st tri U/S has 22cm fundal height and MSAFP is elevated. Most likely cause of abnormal result?
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Twin Gestation. AFP are elevated and should be ~2x v singleton. Additional clue: FH > GA (weeks).
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Besides twins, what other things should be considered in woman w/ elevated AFP and FH>GA?
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other causes of elevated MSAFP are errors in dating, NT defects, pilonidal cysts, cystic hygroma, teratoma, fetal abdominal wall defects and death.
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What ultrasound marker is suggestive of dizygotic (fraternal twins)?
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Two separate placentas (anterior and posterior), dividing membrane > 2mm, twin peak (lambda). Dizygotic conceptions ALWAYS have dichorionic placentas.
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What is the variable which decides whether monozyotic conceptions may have monochorionic or dichorionic placentation?
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Time of division of zygote.
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What time frame of division will produce diamniotic-dichorionic? Di-mono? Mono-mono- Conjoined twins?
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di-di: prior to morula state (3> days post fertilization). di mono: 4-8d; mono-mono: 8-12d; conjoined twins: after day 13 post fertilization.
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T/F: twin infant death rate is 5x higher than that of singleton.
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True. Important information in couples using ART. Risk of CP in twins 5X greater, higher incidence of IUGR. 85% of twins deliver prematurely (~35w)
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T/F: Congenital anomalies are increased in twins.
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True. particularly in monzygotic twins.
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What intervention can be recommended to reduce risk of preterm, low-birthweight infant in mother w/ di-di gestation?
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early, good weight gain. adequate weight gain in the first 20-24w is important to reduce risk of PTL and low BW babies. Aids in development. 24lbs by 24 weeks is recommended.
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What kind of twins are required in TTTS?
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monochorionic, monozygotic. (can be mono or di amniotic). U/S look for different size twins and/or differences in AFI. after establishing monochorionic monozygotic.
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T/F: neurologic sequelae increased in the donor twin (TTTS) versus recipient twin.
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False. in any surviving infants. increased rates of CP.
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Name some complications of the donor twin in TTTS.
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anemia, hypovolemia and subsequent growth retardation. Either twin can develophydrops. The donor twin has anemia and high output failure and becomes hydroptic
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Name some complications of the recipient twin in TTTS.
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excessive volume can lead to cardiomegaly, Tricuspid regurgitation, ventricular hypertrophy and hydrops. This twin becomes pleothroic (red), hypervolemic and macrosomic.
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What is the most concerning complication for a multiple gestation?
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Preterm delivery! it increases risk of M&M, increasing w/ higher orders of multiples. 50% twins, 90% in triplets. PTD is associated w/ RDS, incracranial hemorrhage, CP, low birth weight.
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T/F: IUGR, IU Demise, miscarriage and congenital anomalies are all more common w/ multiple gestations as are complications of pre-E, DM and placental anomalies.
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True.
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Twin A breech (2800g) and twin B vertex (3200g). Appropriate delivery option for mother?
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Elective Cesarean Section. When A is in breech, same problems can occur as in singletons (cord prolapse, head entrapment).
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Twin A vertex, Twin B breech. Best mode of delivery.
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Controversial.
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What is the single most likely cause for increase in number of multiple gestations in recent years?
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Assisted reproductive technologies (ART). However, its all about the quality of eggs (younger > older).
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What is the most likely karyotype found in spontaneous abortions in 1st trimester? Most common chromosomal aneuploidy?
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Autosomal trisomy. Trisomy 16.
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At what gestational age would the fetus be most susceptible to developing mental retardation w/ sufficient doses of radiation?
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The risk of developing microcephaly and severe MR is greatest 8-15 weeks. No risk of MR has been documented w/ doses of 50 rads @ less than 8 weeks or >25 weeks. X-ray is about 5 rads. However, this doesn't include malformation (organogenesis) or growth restriction.
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What is the MC inherited thrombophilic disorder affecting white women in USA? obstetric complications
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FVL. AD associated w/ stillbirth, preeclampsia, placental abruption and IUGR. Look for young patient w/ hx of DVT w/ or w/o OCP use.
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Name the MC birth defects associated w/ uncontrolled DM during organogenesis.
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NT defects (spine) and heart defects. exposure to high glucose levels have increased growth and polyuria --> polyhydramnious.
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20 yo G1P0 @ 26w by 1st trimester U/S has FH 20cm. Normal pregnancy to date w/ PNC. w/o LOF/VB Most likely diagnosis?
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Fetal demise. FH <GA is a sign of demise if no PPROM. If patient has PNC and U/S regularly, wrong dating is less likely.
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26 yo G1 w/ LMP 10 wk ago presents for 1st PNV. +VB x 2d. U/S c/w IUP @ 9wks and no cardiac activity. Next lab value to check?
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Maternal blood type. ALWAYS check on women w/ vaginal bleeding during pregnancy unless documented previously. If Rh(-), RhoGAM would be indicated @ this time.
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27 G1 has fetal demise @ 34 wks. No PNC, Vitals normal, not in labor. No VB or ROM. What untreated condition is most likely cause?
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Diabetes. Type I: FD and FGR (and macrosomnia). Other risks: polydramnious, malformations, PT delivery, HTN.
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After a fetal demise a couple typically shows coping responses. After denial, what is expected?
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Denial --> Angerl --> Bargaining --> Depression --> Acceptance
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During D&C, "fatty tissue" is noted to be coming through the curette. Next best step in management?
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Laparoscopy! Most likely omental tissue and may include bowel. Turn off suction and convert. COnsider laprotomy. Don't Delay is the main idea.
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33 yo G2P1 w/ twin gestation presents @ 24 weeks c/o nosebleed x2d. U/S shows demise of one twin @ 21 weeks. Next step?
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Maternal Fibrinogen level. If dead fetus in utero 3-4 weeks, fibrinogen levels may decrease leading to coagulopathy. Must r/o . Consider monitoring but may be induced after BMTZ.
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What is spalding's sign"
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Abdominal X-ray which shows overlapping of fetal skull bones suggesting fetal demise. Usually U/S can confirm w/o this.
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major causes of higher Cesarean delivery rates?
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VBAC rates decreased due to studies that showed increased risk of uterine rupture. Other causes: fewer docs willing to perform vaginal breech deliveries and reluctance to use instrumental deliveries.
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15 yo G1P0 at 40w is in latent phase of stage I for 6hrs with contractions q5-6minutes. Next step?
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Begin Pitocin to increase frequency and strength of contractions. If not cervical change afterwards, do an IUPC.
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does ambulation facilitate delivery?
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Nope.
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G2P1 @ 40 weeks w/ hx of NSVD wants induction because her back hurts. SVE 0/20%/-2. Next step?
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Adminster Cytotec. Uncomfortable and in pain @ term with unfavorable cervix. Cytotec (misoprostol) adminstration is appropriate before pitocin indiction. Cannot AROM or foley bulb w/ a closed cervix!
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Labor indications for misoprostol?
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Women scheduled for induction w/ a non-favorable cervix. PGE1 (cytotec) is recommended for ripening. Side effects: uterine tachysystole and FHR changes
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Associated with breech presentation?
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Prematurity, multiple pregnancy, genetic disorders, polyhydramnious, hydrocephaly, anencephaly, placenta previa, uterine anomalies and fibroids (this was the choice).
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Define prolonged latent phase. Treatment?
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>20 hours nulliparas and > 14 hours for multiparas. Although tedious, recommend counseling and rest if not beyond time frame. Afterwards, treat w/ augmentation of labor.
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Greatest risk factor for shoulder dystocia?
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Gestational diabetes. Fetal macrosomia, maternal obesity, post-term, prior dystocia delivery and prolonged 2nd stage.
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25 yo G1 @ 41w c/o painful contractions q4min. SVE 5/90/not vertex. Body part palpable on cervical exam. What's most likely palpated?
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buttocks. Frank breech is most common in breech presentation.
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30yo G2P1 @ 38w in active phase for past 4 hrs and unchanged SVE for past 2 (7/100/0). FHTR. Next step?
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Amniotomy as patient has secondary arrest of dilation (no cervical change after 2 hrs, should move 1.5cm/hr in multiparous). If no adequate contractions are AROM, try pitocin.
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>2hrs second stage in 25 G2P1. FHTR and patient feels strong contractions q3min. Next step?
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continued monitoring as long as CPD or macrosomia not suspected.
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T/F: increased # of previous C/S is inversely proportionate to success of VBAC.
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yup! also indications for previous C/S may affect VBAC. previa and breech have better VBAC success v CPD's VBAC.
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19 yo G1 @ 25w c/o of VB x 1hr. Recent intercourse, +FM. Uncomplicated pregnancy so far. FHT 150s. Abd/uterus nontender. Next step? What should you r/o?
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Pelvic ultrasound. r/o abnormal placentation. A placenta previa must be r/o before vaginal exam because risk of injury to placenta. previa is often w/o warning or pain!
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23 yo G2P1 @ 36w p/w 2nd episode of heavy VB. Known placenta previa. No pain, no contractions. S=D, FHTR. U/S: cephalic presentation. Next step?
|
Cesarean section. catastrophic bleeding can occur 2/2 disruption of blood vessels as cervix dilates in a NSVD. Kids close to term. do it!
|
|
|
38 yo G5P4 @ 36w p/w VB x 1 hr. Hx of 4 C/S and a current low anterior placenta. No other abnormalities on H&P. She is at greatest risk for what complication?
|
Placeta accreta. the scar tissue from previous surgery prevents proper implantation of the placenta. In accreta, placenta grows into myometrium.
|
|
|
In a patient w/ 1500ml loss in postpartum. Team decides on FFP. Why?
|
FFP contains fibrinogen as well as clotting factors V and VIII. Cryoprecipitate contains fibrinogen, factor VIII and vWF.
|
|
|
18 yo G1 @32 c/o abd pian and VB. +TOB/+cocaine. Uterus tender, U/S: fundal placenta, cephalic. FHRT: 160s/poor variability/+decels. Dx?
|
Placental abruptions: abd pain, bleeding, uterine hypertonus. Risk factors: TOB, Cocaine, HTN, trauma and prolonged PROM. Rx: CS
|
|
|
Next step in patient w/ suspected abruption w/ NR FHRT.
|
CS. Mother at risk for hemorrhage, DC and hysterectomy. Fetal risks neuro injury from anoxia.
|
|
|
What's a double set-up examination?
|
Trial of Vaginal delivery w/ C/S team scrubbed and ready just in case.
|
|
|
Smoking increases the risk of what obstetric complications?
|
placenta abruption, previa, growth restriction, pre-ecclampsia and infection.
|
|
|
32 yo G3P2 @ 40w1d p/w regular contractions q5min. Bright, red bloody discharge for past 30 min. Funda placenta/ cephalic presentation. no ROM. cervix 5cm dilated, is friable and bleeds easy. Source of blood?
|
Blood show. cervix is extremely vascular and bleeding occurs w/ dilation. need to r/o abruption and previa though.
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|
|
17 yo G1P0 at 24w p/w VB. Denies pain/dysuria. Intercourse 3 weeks ago. VSSAF. U/S fundal placenta and viable. Cervix closed but is friable with blood in vault. cause of bleeding?
|
cervicitis caused by C&G or trich can p/w VB. r/o other previa, abruption w/ U/S. No bloody show as cervix is NOT dilated.
|
|
|
When does threatened abortion occur?
|
first trimester
|
|
|
45 yo G4P3 p/w VB. +urine pregnancy test. +TOB x 20 y. Vaginal exam: 3cm posterior lip lesion on cervix. Bleeds and hard. Cause?
|
cervical cancer. r/o abortion, infection and trauma.
|
|
|
Most frequent cause of PTL?
|
Idiopathic. Dehydration and uterine distortion (2/2 to fibroids or structural malformations) are associated.
|
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|
20 yo G1 @ 32w c/o contractions q4min. cervix long, closed and posterior. Not dehydrated. UA normal. Next step?
|
observe. 50% of PT contractions resolve spontaneously. No tocolysis (CCB, indomethacin, terbutaline, Mg sulfate) since no preterm labor (no cervical change)
|
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|
20 yo G2P1 @ 32w p/w contractions q4min. T 38.1 HR 120. SVE 2/50%. FHTR, WBC 18000. Next step?
|
aminiocentesis to r/o intraamniotic infection, which is on DDx if unexplained fever and leukocytosis in prego.
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|
|
Most appropriate tocolytic in 26yo G2P1 in PTL @ 33w? (Hx of PTL, IDDM and myasthenia gravis, BP 140/90) Why?
|
CCB. Terbutaline and ritodrine (B-agonist) are C/I in DM, Mag C/I in myasthenia gravis and indomethacin is C/I @ 33w d/t risk for premature PDA closure (via constriction)
|
|
|
By what mechanism of action does Magnesium sulfate work as a tocolytic?
|
Competes w/ calcium for entry into cells (thats why Mag toxicity resembles hypocalcemia i.e. loss of DTR, AND RESPIRATORY DESPRESSION)
|
|
|
By what mechanism does indomethacin work as a tocolytic?
|
PG syntetase inhibitor --> decrease PG --> decrease contractions
|
|
|
How do CCB work as tocolytics?
|
block calcium entry into muscle cells by inhibiting transport
|
|
|
Side effects of terbutaline?
|
Beta-2 adrenergic agents cause tachycardia, hypotension (reflex), anxiety.
|
|
|
What usually develops before cardiac and respiratory depression in magnesium toxicity?
|
loss of deep tendon reflexes
|
|
|
At what GA does indomethacin exposure pose a serious risk?
|
After 34w.
|
|
|
Possible fetaleffect of betamethasone therapy?
|
Decreased incidence of intercerebral hemorrhage and necrotizing enterocolitis in newborn (in addition to preventing RDS)
|
|
|
What is the strength of using a fetal fibronectin test in patients w/ preterm contractions? (statistics)
|
NPV 99.2%. fFN is an ECM protein thought to act as an adhesive b/w fetal membranes and deciduus. Used in women w/ sx of PTL 24-35w or asx b/w 22-30w.
|
|
|
29 G1P0 @ 31 GA p/w LOF x several hours. Uncomplicated PN course. VSSAF. Next step?
|
PTL test: pooling, nitrazine test of vaginal fluid (posterior fornix) and evaluation of ferning.
|
|
|
What is the role of tocolysis in a 29yo G1P0 @ 31w p/w PPROM?
|
To attempt to delay delivery in order to administer steroids. (its role is controversial)
|
|
|
What is the primary risk factor for preterm rupture of membranes?
|
genital tract infection, especially BV. Other risk factors: short cervical length, oligohydramnious, smoking and prior hx of PPROM.
|
|
|
How is GA related to PROM?
|
the time from PROM to labor is inversely related to GA.
|
|
|
What medication will prolong the latency period by ~7days in woman w/ PPROM?
|
Antibiotic therapy. Corticosteroids and toclytics can prlong pregnancy, but not 7days.
|
|
|
What are indications for delivery in a 24yo G1P0 @ 32w p/w PPROM but no contractions?
|
maternal signs of chorioamnionitis or evidence of intra-amniotic infection. signs include tender uterus
|
|
|
PPROM @ 20w, which is before viability (24w), is at greatest risk for what neonatal complication?
|
pulmonary hypoplasia
|
|
|
What amniotic fluid test result is indicative of intraamniotic infection?
|
Amniotic glucose < 20mg/dL. Other findings: elevated IL-6.6Presence of leukocytes has low predictive value for infection.
|
|
|
What is the recurrent risk of PPROM in a 22 yo G2P1 w/ hx of PPROM @ 28w?
|
30%
|
|
|
G2P1 @ 36w w/ PROM. No complications. EFW 2700g. Next step?
|
induction of labor. after 34w, risks (infection) of expectant management w/ PROM is outweighed by benefit of delivery after lung maturity.
|
|
|
29 G1P0 @ 41w for PNC. +TOB, +chlaymydia culture (treated) and pap LGSIL. BP 128/76; afebrile. SVE 1/50/-2. Next step?
|
NST.
|
|
|
When is a vibroacoustic stimulation test indicated?
|
when NST is non-reactive.
|
|
|
What does a contraction stress test assess?
|
uteroplacental insufficiency and identifies persistent late decelerations after contractions (3/10min).
|
|
|
19yo G3P0020 w/ SROM. 102F, FHRT 180/poor variablity. regular contractions. Most likely cause of fetal tachy?
|
chorioamnionitis. fever, Regular contractions and fetal tachy in presence of ROM are most likely 2/2
|
|
|
Define variable decelerations.
|
an acute fall in FHR, w/ a rapid down slope and a variable recovery phase.No consistent relationship to a contraction
|
|
|
Define etiology of variable deccelerations.
|
reflex mediated (baroreceptor) usually associated w/ umbilical cord compression as a result of cord wrapped around parts or oligohydramnious.
|
|
|
What kind of deccerlations are defined by symmetric fall in FHR, beginning at or after the peak of contraction and returning to baseline only after contraction ended.
|
Late deccels. associated w/ uteroplacental insufficiency.
|
|
|
Name causes for uteroplacental insufficiency.
|
decreased uterine perfusion or placental function leading to fetal hypoxia and acidemia.
|
|
|
What effect does uterine hyperstimulation have on the fetal heart?
|
prolonged bradycardia
|
|
|
29 yo @ 42w p/w intermittent contractions. uncomplicated pregnancy. BP 140/96 EFW 2900g. Cervix 0/25%/-2. FHRT shows decels. Next step?
|
Initial measures to evaluate and treat fetal hypoperfusion: LL position, oxygen mask, STOP PITOCIN, consider IU resuscitation w/ tocolytics and fetal scalp pH. consider aminoinfusion. DO NOT DIRECTLY PROCEED TO CS.
|
|
|
29 G1P0 @ 41w for PNC. +TOB, +chlaymydia culture (treated) and pap LGSIL. BP 128/76; afebrile. SVE 1/50/-2. Next step?
|
NST.
|
|
|
When is a vibroacoustic stimulation test indicated?
|
when NST is non-reactive.
|
|
|
What does a contraction stress test assess?
|
uteroplacental insufficiency and identifies persistent late decelerations after contractions (3/10min).
|
|
|
19yo G3P0020 w/ SROM. 102F, FHRT 180/poor variablity. regular contractions. Most likely cause of fetal tachy?
|
chorioamnionitis. fever, Regular contractions and fetal tachy in presence of ROM are most likely 2/2
|
|
|
Define variable decelerations.
|
an acute fall in FHR, w/ a rapid down slope and a variable recovery phase.No consistent relationship to a contraction
|
|
|
Define etiology of variable deccelerations.
|
reflex mediated (baroreceptor) usually associated w/ umbilical cord compression as a result of cord wrapped around parts or oligohydramnious.
|
|
|
What kind of deccerlations are defined by symmetric fall in FHR, beginning at or after the peak of contraction and returning to baseline only after contraction ended.
|
Late deccels. associated w/ uteroplacental insufficiency.
|
|
|
Name causes for uteroplacental insufficiency.
|
decreased uterine perfusion or placental function leading to fetal hypoxia and acidemia.
|
|
|
What effect does uterine hyperstimulation have on the fetal heart?
|
prolonged bradycardia
|
|
|
29 yo @ 42w p/w intermittent contractions. uncomplicated pregnancy. BP 140/96 EFW 2900g. Cervix 0/25%/-2. FHRT shows decels. Next step?
|
Initial measures to evaluate and treat fetal hypoperfusion: LL position, oxygen mask, STOP PITOCIN, consider IU resuscitation w/ tocolytics and fetal scalp pH. consider aminoinfusion. DO NOT DIRECTLY PROCEED TO CS.
|
|
|
What is the MCC of postpartum hemorrhage?
|
Uterine atony!
|
|
|
precipitous labor, multiparity, general anesthesia, oxytocin use in labor, prolonged labor (hint), macrosomia, hydramnious and chorioamnionitis are risk factors for what?
|
Uterine atony
|
|
|
When is Methylergonovine, a uterotonic agent, contraindicated in women?
|
It is an ergot alkaloid which is used for smooth muscle constrictions, however, because of its vasoconstrictive properties it should be avoided in women w/ pre-ecclampsia or hypertension.
|
|
|
What uterotonic agent should be avoided in post-partum hemorrhaging patient w/ steroid-dependent asthma and with VSSAF?
|
Prostaglinadin F2. It is a smooth muscle constrictor however it also has bronchio-constrictive effect.
|
|
|
29 yo G2P1 p/w ROM and delivers in 35 min (2650g male). A pale mass appears at the introitus when delivering the placenta. Etiology?
|
uterine inversion (uncommon etiology of post-partum hemorrhage).
|
|
|
MCC risk factor for uterine inversion
|
excessive traction (iatrogenic) on umbilical cord during 3rd stage of delivery.
|
|
|
How is postpartum hemorrhage defined?
|
> 500 cc after vaginal delivery or in excess of 1000 cc after a Cesarean delivery.
|
|
|
37 yo w/ poorly controlled HTN presents @ term. delivers 3500g males s/p oxytocin induction. postpartum develops massive bleeding. BP 130/84, P 84, afebrile. placenta intact, uterus firm. next step?
|
exploration for lacerations.
|
|
|
ensuring a well contracted uterus, making sure there is no retained placental tissue and looking for lacerations are all part of the first management of what?
|
postpartum hemorrhage
|
|
|
30 yo G5P4 @ 24w p/w anterior placenta w/ a previa and hx of 3 prior CS. Most serious complication that can lead to obstetric hemorrhage?
|
placenta accreta.It is a abnormally firm attachment of the palcenta to uterine wall. in the presence of low lying anterior placenta always keep in DDx. incidence increasing w/ more CS. Treatment: hysterectomy 2/2 to intractable bleeding
|
|
|
28 G2P1 delivers at term, a 3500g male after oxytocin augmentation. 30 min later, placenta not delivered. PMHx: leiomyoma uteri and male factor infertility. Most likely risk for retained placenta.
|
leiomyoma. other risks: prior CS, uterine curettage hx, and succesturiate lobe of placenta.
|
|
|
37 yo G4P3 delivers normally after oxytocin augmentation. postpartum, 2000cc blood loss. No lacs and uterus is floppy. Next step?
|
PG F2 IM or directly into uterine.
|
|
|
which uterotonics should never be adminstered intravenously? Why?
|
PGF2 and methylergonovine can lead to bronchoconstriction and stroke respectively.
|
|
|
In a women w/ intractable bleeding post partum, you proceed w/ ex lap, what is the most appropriate next step?
|
hypogastric artery ligation (internal iliac artery). If this fails, proceed w/ hysterectomy.
|
|
|
20 yo G1P1 delivered 24 hrs ago. Epidural placed at labor. c/o ha/ photophobia and nausea. denies bleeding. tachy, febrile. Pain w/ neck movement. uterus nontender. No extremity edema. next step?
|
lumbar puncture.
|
|
|
In addition to ampicillin, what would be another antibiotic of choice for endomyometritis?
|
Gentamycin to cover for gram negative since the infection is polymycrobial.
|
|
|
What organism is most likely to cause acute cystitis?
|
E coli!. Others, K pneumoniae, P mirabilis, S faecalis and S agalactiae.
|
|
|
In a women 2 days postpartum w/ fever, w/o any clinical signs of infection other firm and tender breasts (no erythema), what is the most likely cause
|
Breast engorgement. It is an exaggerated response to lymphatic and venous congestion associated w/ lactation. If baby is not feeding well after milk let down, it can cause low grade fever. Rx: use breast pump!
|
|
|
In addition to breast engorgement, what else is on the DDx for postpartum fever?
|
endometritis, cystitis and mastitis.
|
|
|
In a Pfannenstiel incision w/ erythema and purulent, bloody drainage, what is the next step in management?
|
open drainage of wound. mixed bacteria originating from the skin, uterus and vagina cause wound infections after CS. Rx: check for dehicscence and drainage. Pack until healed from bottom up. Start abx.
|
|
|
32 yo G2P2 delivered 5 days ago uncomplicated. Woke up middle of last night w/ RUQ pain and chills. Febrile. Elevated LFTs. eitiology?
|
cholecystitis. pregnancy puts women at risk for cholithiasis. sx n/v/dyspepsia and UQ pain after fatty foods.
|
|
|
22 yo s/p CS 5 days ago. fever refractory to broad specturm abx. No clinical signs or symptoms. Most likely cause of fever?
|
septic pelvic thrombophlebitis. thrombosis of venous system of pelvis. Diagnosis of exclusion. Sometimes a CT can help. Rx: anticoagulations + abx.
|
|
|
Rx for septic thrombophlebitis?
|
short-term anticoagulation and antibiotics.
|
|
|
4th degree laceration + fever. laceration site repaired after delivery 2 days ago: perineum erythematous, swollen and the laceration edges grey. lac site is nontender and w/o feeling. tenderness of surrounding tissue. etiology of fever?
|
necrotizing fasicitis. caused by gas formers (clostridium) which cause sepsis. look for fever, pain and induration wound. Rx? abx and debridement of necrotic tissue.
|
|
|
28 yo G1P1 delivered 4w ago c/o difficulty sleeping, anxiety and thoughts of suicide. Dx?
|
Postpartum depression, more pronounced than "blues" (sx > 2w). No evidence of visual or auditory hallucinations to indicate psychosis
|
|
|
23yo G1P1 diagnosed with postpartum depression (including suicidal ideation) x 3mo. Next step in management?
|
Inpatient psychiatric admission. suicidal ideation makes inpatient best idea.
|
|
|
What FDA category is sertraline (zoloft) in?
|
Categroy C drug. animal studies showing adverse effect but not well-controlled studies in humans.
|
|
|
Category __ Drugs have well-controlled studies in pregnant women and have not shown an increased risk of fetal abnormalities to the fetus in any trimester.
|
A
|
|
|
Category __ Drugs have well-controlled studies in animals that no evidence of harm to fetus. adequate well controlled studies in pregnant women have failed to show increased risk to the fetus in any trimester.
|
B
|
|
|
Category ___ drugs have well-controlled or observational studies in pregnant women and are known risks to fetus.
|
D
|
|
|
Category __ drugs should not be used in pregnancy because adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities. or risk
|
X
|
|
|
In a women w/ hx of psychiatric disorder, what is she at most increased risk for in postpartum period?
|
PP depression
|
|
|
23 yo G1P0 @ 24w treted for pression. No other complications. Begins fluoxetine. Most common side effects of drug?
|
SSRI is an antidepressant whose most common side effect is insomnia. Others: sexual dysfunction
|
|
|
Postpartum taking sertraline (zoloft), an SSRI, wants to breastfeed. Next step in management?
|
Continue meds. SSRIs are safe during lactation.
|
|
|
When are anti-depressants appropriate in pregnant or postpartum women?
|
when it begins to interfere with patient's ability to function. Before this, establish a good support system.
|
|
|
27 yo w/ no significant PMHx c/o low energy, anhedonia, early awakening and difficulty concentrating. Next best step?
|
ask about suicidal ideation. Most depressed patients are relieved to be asked about it.
|
|
|
22yo patient w/ regular menses c/o tension, depression and decreased productivity at end of cycle. No PMHx or FMHx. No drugs. Next best step?
|
get more details on timing of symptoms each month. Premenstrual dysphoric disorder occur in the luteal phase and are absent in the beginning of the follicular phase.
|
|
|
28 yo G1P1 delivered 4 days ago and c/o crying, trouble sleeping, anxiety and irritability. She feels better today. Dx?
|
PP Blues. Affects 50% of women 3-6d postpartum. Insomnia, crying, depression, poor concentration, labile affect and anxiety. last a few hours/day. less pronounced than PP depression.
|
|
|
what GA would define postterm pregnancy?
|
any pregnancy that has progressed past 42w or 294d.
|
|
|
29yo G1 @ 42w. what factor is most liekly to be associated w/ postterm pregnancy?
|
placental sulfatase deficiency (X-linked ichthyosis) - absence or reduction in production of unconjugated estrogens. Other risks: fetal adrenal hypoplasia, anenecephaly, inaccurate dates.
|
|
|
20 yo G2P1 @ 41w. PNC uncomplicated. what complications is most likely to occur?
|
Macrosomnia. Other associations w/ postpartum pregnancy: oligo, meconium aspiration, uteroplacental insufficiency and dysmaturity.
|
|
|
32 yo G@P1 @41w odes not report contractions but good FM. desires NSVD. Next step?
|
perform NST and AFI q2/week with induction for labor for a NRNST or oligohydramnious
|
|
|
T/F: ~50% of patients w/ a history of postterm pregnancy will experience prolonged pregnancy with next gestation.
|
True. Diagnosis of PTP is based on accurate GA dating.
|
|
|
24 yo G2P1 @ 42w in early labor. At amniotomy, there is thick meconium. What FHRT is indication?
|
repetitive variable deccelerations (indicative of uterine cord compression)
|
|
|
Etiology of meconium staining in postterm pregnancy?
|
3-4x more common due to 1) greater amt of time in utero to activate mature vagal system (increased passage fecally) and 2) fetal hypoxia.
|
|
|
32yo G2P1 @ 42w. cervix 4cm/100%. No contractions, +FM. Next step?
|
induction! because her cervix is favorable (unfavorable cervix and induction increase risk for CS).
|
|
|
22 yo G1P1 w/o PNC delivered 2100g "old man baby." GA estimated at 43w. List findings associated w/ dysmature postdate infant.
|
Peeling skin, meconium stained, long nails and fragile. These infants are at great risk for stillbirth.
|
|
|
Best inducer to ripen cervix in 22yo G1 @ 42w.
|
PGE1. PG applied locally are the most commonly used cervical ripening agent.
|
|
|
In a 36yo G1 @ 33w w/ PMHx HTN, Class F diabetic (nephropathy) w/ reveals limited fetal growth over past 3 weeks, EFW 1900g (10th percentile), what is most likely etiology of IUGR.
|
uteroplacental insufficiency 2/2 to systemic vascular diseases (HTN and DM) --> decreased substrate to fetus.
|
|
|
36yo G1 @ 35w w/ PMHx HTN and DM type 2 w/ limited fetal growth over past 3 w (10th percentile). next most appropriate step?
|
AFI, Doppler of umbilical artery, NST.AFI - to search for oligohydramnious. doppler to assess vascular resistance (increased S/D ratio and common in IUGR).
|
|
|
36 yo G1 w/ type I DM diagnosed w/ IUGR @ 33w. Next step?
|
Antenatal testing. fetus needs to be evaluated periodically for evidence of well-being. 1-2 weekly NST and BPP.
|
|
|
Most reliable method of confirming GA at term?
|
1 of the following: FHT documented x 20w, 36w since +hCG. Then either an crown-rump length b/w 6-12w SUPPORTS GA >39w and U/S b/w 13-20w CONFIRMS GA > 39w.
|
|
|
34yo Chronic HTN G1 @ 34w p/w S<D. Biparietal consistent w/ 34w but abdominal circumference of 28w & EFW < 10 percentile. Most likely cause of IUGR?
|
uteroplacental insufficiency can lead to asymmetric growth pattern seen in 3rd tri.
|
|
|
IUGR is associated with...
|
oligohydramnious, fetal demise, perinatal demise, meconium aspirations and PCV.
|
|
|
T/F: Fetus w/ IUGR is at risk for CVD, HTN, COPD, DM and Osteoporosis as an adult.
|
False. Osteoporosis is not increased.
|
|
|
Between a type 2 DM mom w/ benign retinopathy and mom w/ gestational diabetes wich is more likely to deliver a macrosomic infant?
|
GDM! a diabetic patient w/ nephropathy or retiniopathy is more likley to have IUGR 2/2 to uteroplacental insufficiency.
|
|
|
a fetus w/ marcosomia (> 90 precentile) is at greatest risk for what complications during birth?
|
birth trauma (including shoulder dystocia and brachial plexus injury)
|
|
|
28 yo G1 presents for PNC. Menses irregular. Uterus is 10w size and no adnexal masses. Best way to date pregnancy?
|
ultrasound - crown rump length b/w 6-12w. considered most reliable (+/- 5d) in first tri.
|
|
|
laceration involves rectal sphincter and rectal mucosa
|
4th degree
|
|
|
laceration involving only vaginal mucosa
|
1st degree
|
|
|
laceration involving vaginal fascia and perineum
|
2nd degree
|
|
|
laceration involves the rectal partial or complete transection of rectal sphincter
|
3rd degree.
|
|
|
What structure does a mediolateral episiotomy avoids?
|
external anal sphincter
|
|
|
T/F: uterine fibroid in the lower segment may obstruct labor and is an indication for CS
|
True.
|
|
|
Define macrosomia
|
> 4000g in a diabetic and 4500 in non-diabetic
|
|
|
22yo G1 @ 28w is in active labor. fetus @ +4 station. Epidural in and pushing effectively x 3 hrs. Exhausted. Next step?
|
Forceps/vacuum assist.
|
|
|
What the requirements for a instrument assisted vaginal delivery?
|
complete dilation, head engagement, vertex presentation, clinical assessment of fetal size and maternal pelvis, known position of fetal head, adequate pain control and ROM
|
|
|
what is less likely to occur w/ vacuum assist versus forceps assist?
|
maternal lacerations
|
|
|
complications of vacuum assist?
|
lacerations at edges of vacuum cup which can lead to cephalohematoma and place fetus at risk for jaundice.
|
|
|
19yo G1 @ 41w p/w f/SROM/no contractions. Febrile, tachy. U/S shows oligohydramnious and placeta previa. Why perform C/S
|
Patient has chorioamnionitis (delivery indicated if @ term), but cannot be induced 2/2 previa.
|
|
|
left sacrum anterior is code for what position?
|
breech. therefore perform a c-section
|
|
|
symmetric fetal growth restriction in the presence of polyhydramnious is associated with ________. Next step.
|
trisomy 18. get amniocentesis to get fetal karyotype, can allow for FISH (aneuploid conditions) --> trisomy 13, 18 and 21.
|
|
|
When would a therapeutic amniocentesis be indicated.
|
for respiratory compromise or preterm labor (both caused by polydramnios)
|
|
|
What two tests are useful for assessing abruption?
|
maternal fibrinogen level and Kleihauer-Betke levels.
|
|
|
CVS v amniocentesis
|
CVS - detect genetic and chromosomal abnormalities. Loss rate 0.5-3%. performed b/w 10-12 w.
|
