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79 Cards in this Set
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18 yo white G1P0 @ 28 weeks presents for routine PNC. Hgb 10.6 MCV 88.2. No PNV use. Anemia etiology?
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relative hemodilution of pregnancy. 36% increase in blood volume (peak @ 34 weeks) Plasma peaks @ 47% and RBC mass 17%.
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34 yo G3P1 @26 weeks c/o dyspnea after exertion x 2 months. PE: II/VI systolic murmur. Hgb 9.9. Etiology?
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Psyiologic dyspnea of pregnancy present in up to 75% of women by 3rd trimester.
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24 yo G4P2 @ 34 weeks w/ viral URT symptoms/signs. pH 7.44, PO2 normal, PCO2 slightly low, HCO3 slightly low. CXR normal. Interpretation of ABG?
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compensated respiratory alkalosis. increased minute ventilation during pregnancy causes compensated respiratory alkalosis. Breath out more CO2, body responds w/ decreased HCO3.
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T/F: minute ventilation is increased in pregnancy 2/2 increased RR.
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False. RR unchanged, TV increased which increases minute ventilation --> respiratory alkalosis.
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24 yo G1P0 @ 30 weeks c/o dyspnea and frothy sputum. Admitted for PTL, now receiving terbutaline. PE dx. Most likely cause of PE in patient?
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tocolysis w/ terbutaline (B2 ag) esp w/ use of isotonic fluids. plasma osmolaity is dec --> inc susceptibility to PE.
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Pregnant patient in septic shock develops PE? most likely cause?
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chorioamnionitis
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T/F diastolic murmur is pregnancy can be normal.
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diastolic murmurs are never normal.
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T/F maternal SVR is decreased .95% of women will have a systolic murmur due to...
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True. murmur d/t increased volume
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maternal CO increased due to...
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increased HR and SV. it increases 33% by 12 week.
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etiology of Right-sided hydronephrosis and + right CVA tenderness in pregnant woman w/o calculi, or evidence of infection.
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compression by the uterus and right ovarian vein (dextroverted uterus) as well as smooth muscle relaxation 2/2 inc progresterone can cause urinary system dilatation.
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In a 34 yo G4P2 @ 18 wks c/o n/v/wt loss w/ +FHx of Graves and low TSH but asx, what would you expect to find w/ total thyroxine and TBG?
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TBG increased 2/2 increased estrogens and increased total. free thyroxine remains constant.
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Next step in management of patient diagnosed w/ Gestational trophoblastic disease (HCG, CBC, U/S, T4 already obtained).
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Get a CXR. lungs are most common site of mets in patient w/ GTD suspicious of neoplasia.
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T/F: Chorionic somatomammotropin (hPL) induces insulin resistance.
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True. look for a patient w/ genetic predispositions, previous macrosomic infants, age and obesity. All RFs for Type II and GDM.
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T/F: Glycosuria is always an abnormal finding in pregnancy
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False. Glycosuria during can be due to increased GFR and increased filtering but impaired reabsorption. Does not always mean hyperglycemia.
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Mom: Brother is a carrier of sickle cell. Dad: African American. Carrier rate in blacks 1/10. Odds child will have SCA.
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2/3 x 1/10 x 1/4 = 1/60. SCA is autosomal recessive. explain the math to yourself.
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Black couple w/o significant FHx of disease wants to start a family. What blood test should you order tos creen for Hgb abnormalities?
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Hgb electrophoresis and CBC. electrophoresis is preferred over SC preparations because other hemoglobinopathies can be detected including Hgb C trait (defect in beta chain) and thalassemia minor (inc HbA2)
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Name 4 AR conditions which are increased in Askenazi Jews.
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Fanconi, Tay-sachs, CF and Niemann-Pick Dz.
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What is th emost common recessive genetic disease among individuals of Eastern European Jewish Decent?
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Tay-Sachs disease, a lysomal storage disease (Defective Hexosamidindase A) occurs in 1/3000.
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which anti-epileptic drug is assoicated w/ increased risk of NT defects, hydrocephalus and craniofacial malformation.
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valproic acid
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T/F: women w/ poorly controlled diabetes immediately prior to conecption and during organogenesis have an incresed risk of structural anomalies.
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True.
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Majority of lesions associated w/ poorly controlled DM during conception and organogeneis are involved in what organ systems?
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CNS and cardiovascular
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Chorionic villus sampling is generally performed @ ____ weeks gestation. What is analyzed? What can't it detect.
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10-12 weeks. analyzed for fetal chromosomal anomalies, biochemical and DNA-based studies. Can't detect NT defects (do u/s and blood work)
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What's are the analytes of the Quadruple Screen? When is it performed?
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AFP, hCG, uE3, Inhibin A. Performed b/w 15-20 weeks
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NT and adbominal wall defects will show an elevated _______ on quad screen.
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AFP
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Screening results for Trisomy 21
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low AFP, inc hCG, dec uE3, inc inhibin A (more sensitive for Down's)
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Screening results for Trisomy 18
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low AFP, inc hCG, dec uE3, normal inhibin A
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Risk of miscarriage associated w/ CVS?
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~1%
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MCC of inherited mental retardation?
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Fragile X (CGC repeats - anticipation). 2nd most CC of MR behind trisomy 21
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Most reliable method of confirming gestational age?
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Obstetrical Ultrasound. bHCG will not be reliable to predict age.
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Most effective screen for Down's in 2nd trimester?
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Quad test. addition of inhibin A achieves a detection rate of 80-85%.
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Describe 1st trimester for Down's.
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nuchal translucency measurement + maternal PAPP-A and free b-hCG (cominined test). 85% detection @ 5% FP rate.
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Describe cutoffs for normal results of 3h OGTT, initial management of GDM
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FBS < 95, 1h < 180, 2h < 155, 3h < 140. 2+ abnormal diagnosis for GDM. start diet and BG monitoring
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risk factors for gestational diabetes
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hx abnormal intolerance, previous large baby (> 9lbs), obese, mexican or native american.
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T/F: 29 yo G2P1 @ 36 weeks & GDM requiring insulin is at for IUGR.
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False. IUGR is seen in women w/ pre-existing DM. GDM places risks of dystocia, pre-E, polyhydramnios & macrosomia
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woman w/ Past OBHx of anecephaly requires what dose of folic acid?
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4 mg daily before conception and throughout 1st trimester.
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what is the most comon anomaly assoicated w/ prenatal exposure to valproic acid?
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NT defects. 1.2% incidence, specifically lumbar. get a fetal u/s @ 16-18 weeks to detect. can also cause cardiac, facial clefts and radial limb aplasia.
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recommendation for weight gain in pregnancy for women w/ BMI > 30
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11-20lbs. majority of weight gained in 2nd half of pregnancy
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Patient taking labetalol, phenobarbital and citalopram @ 10 weeks gestation. If she stops now does she decrease her risk?
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No. organogenesis is during the first 8 mentrual weeks. baby already effected. cannot decrease risk. risk of teratogenesis not present for entire pregnancy. phenobarbital is associated w/ defects.
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of the following which does not pose a risk to pregnancy: warfarin, methyldopa, retinoic acid, phenytoin, enalapril.
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methyldopa. sympathoplegic used for pregnancy induced HTN.
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23 G1P0 @ 38w0d c/o lower abdominal pain and mild nausea. +irregular contractions 2-8 minutes, cervix closed long and high. Vital signs normal.
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Braxton Hicks contractions. shorter in duratino, less intense than true labor w/ discomfort in lower abdomen.
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routine antepartum care counseling is to return to the hospital for suspected labor if any of the following occur...
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UC's q5minutes for 1 hr, rupture of membranes, FM less than 10 per 2 hours or VB.
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if FHR externally cannot be achieved, what is the next step in management?
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fetal scalp electrode. do this especially to document FHT in patient request epidural.
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+10/100%/+2 w/ FHR in 60s and scalp @ introitus. Next most appropriate step?
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Assisted operative vaginal delivery (forceps or vacuum-assisted delivery). Do not confirm FHR w/ electrode or repeat US, wasting time!
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uterine perforation may occur w/ placement of intrauterine pressure catheter. Next step in managment?
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perforation indicated by blood and amniotic fluid, if patient in active labor, withdraw IUPC monitor fetus and replace if tracing reassuring.
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MCC of variable decelerations?
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umbilical cord compression. oligohydramnios increases risk of compression.
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>10cm/100%/+3 station w/ decelerations AFTER onset of contractions. Etiology?
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uterplacental insufficiency (late decelerations). station and dilation are distractors.
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T/F: episiotomy enlarges the vaginal outlet
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True. midline increases risk of 3/4 degree lacs. Prophylactic episiotomy are debatable.
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Define 4th stage of labor.
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immediate postpartum period of 2 hrs after delivery of placenta. 1st stage, onset till full cervical dilation. 2nd stage: dilation --> delivery of infant. 3rd stage: after delivery --> delivery of placenta.
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Infant delivered w/ flat nasal bridge and small rotated ears. Mother had scant prenatal care. Next step in management?
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Further examine infant for sandal gap toes & hypotonia. Along w/ protruding tongue, short borad hands, simian creases, epicanthic folds and olique palprebal fissures, these are associated w/ Down's.
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Mom diagnosed w/ preeclampsia and is treated with MgSO4 x 40 hrs. What is most likely complication to be encountered in infant?
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Respiratory distress 2/2 use of magnesium. However, w/o Rx, baby most likely at risk for complications 2/2 hypoperfusion
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T/F: Large hyperglycemic babies are assoicated w/ mothers w/ type I diabetes.
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False. small and hypoglycemic babies are more common in type I DM v gestational. Macrosomic infants are associated w/ gestational diabetes.
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While in labor, 24 yo G1P0 spikes a fever + tachy. GBS unknown, during delivery, foul smell. What is appearance of baby?
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Lethargic, pale w/ high temp. Chrioamnionitis and foul smell upon delivery is a sign of sepsis.
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In TTTS, twin A is large and pleothoric and B is small and pale. Diagnosis and next appropriate step?
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TTTS. Polycythemia is common complication for plethoric large twin as well as polyhydramnios --> HF and hydrops, anemia for small twin and thus IUGR. TTTS is complication of monochorionic pregancies, charaterized by blood flow imablace.
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Name infant risks associated w/ gestational diabetic mothers.
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PCV, RDS, thrombocytopenia, hyperbilirubinemia. These kids are born puffy, ruddy and jittery.
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Infant born unresponsive, HR>100 bpm, no respiratory effort. Mother incomplete history, +marijuana use, during labor treated w/ demerol (opioid anagesic).Next step?
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give PPV and prepare to give naloxone. Naloxone (narcan) may be negated if mom has hx of narcotic use as baby can go into life threatening w/drawal. Suction will not necessitate respiratory effort.
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Infant born to 32 yo G3P2 @ 36 weeks w/ hx of HIV+. Apgar scores 9,9, most appropriate next step?
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treat neonate w/ AZT immediately after delivery. Testing begins @ 24 hrs post. No breast feeding
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T/F: adjusting head position to modified flex position will NOT improve PPV in a newborn.
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True. This position is typically used in adult CPR. Correct position is sniff position. secure mask to face and observe chest rise. Recommended rate is 10L/min
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@ 1 min, HR > 100, crying, acrocynaosis, gags when suctioned and moves all 4 extremities. APGAR
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9. gets 1 point for acrocyanosis
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28 yo G3P3 delivers 4150g baby w/ NSVD. OBHx previous LSTCS 2/2 to tranverse lie. immediately post placental, rapid vaginal bleeding 700cc. Most likely cause?
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uterine atony. postpartum hemorrhage is emergency (> 500 cc after vaginal birth, > 1000 after CS). Uterine atony is MCC
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At post-partum f/u patient who suffered PPH w/ IVVR has slurred speech, moderate, non-pitting edema, breast atrophy and amenorrhea. diagnosis?
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sheehan syndrome. hypovolemia results in anterior pituitary necrosis --> decrease in gonadotropin, TSH and ACTH.
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Most important risk factor for development of postpartum enometritis?
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cesarean delivery. Other factors related to increased rate of infection: prolonged labor, prolonged ROP, internal fetal monitoring, manual removal of placenta & low socioeconomic status
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MCC of postpartum fever?
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endometritis. DDx: UTI, LTI, wound infxn, pulm infxn, thrombophlebitis, and mastitis.
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bacterial isolates related to postpartum endometritis are typically...
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aerobic and anaerobic. Most causative agents are s aureus and streptococcus
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Signs and Symptoms of depression < 2 weeks postpartum.
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Postpartum blues. self-limited. If beyond 2 weeks, PP depression.
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Patient presents 10 days postpartum. c/o depression, delusions (false beliefs), hallucinations and thought disorganization.
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postpartum psychosis
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What symptom of postpartum depression is useful for distinguishing it from PP blues?
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Ambivalence toward the newborn.
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T/F: A complicated labor and delivery is NOT a risk factor for postpartum depression.
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True. Risk factors: hx of depression, marital/mother conflict, lack of social support, stress, uterine irritability.
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What is the safest method of lactation suppression in this patient?
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breast binding, ice packs and analegesics. Hormonal interventions (OCPs, depo) increase risk of thromboembolisms and rebound engorgement. Bromocpritine was assoicated w/ HTN, stroke and seizures.
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Physicians should enourage breast feeding at least for the first 6 months after birth. T/F
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True. benefits: increased uterine contraction 2/2 oxytocin, major source of IgA to baby (prevents GI infxns). Note: breast milk i slow in iron and majority of drugs will enter breast milk
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T/F: poor positioning of infant can be a cause for bleeding cracked nipples.
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True. Belly-to-belly is important for good latching.
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T/F: both oxytocin and parlodel (bromocriptine) are not responsible for synthesis of milk.
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False. Progesterone, estrogen, hPl, prolactin, cortisol and insulin act to + G&D of mammary gland. Prolactin is inhibited by elevated E&P. Bromocriptine IS NOT involved.
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Most appropriate treatment of mastitis? specific name of treatment...
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antibiotics. usually staph, so if CAO use penicillin or cephalosporin. If persists, I&D.
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What hospital policy should be included for women who want to exclusively breastfeed their baby?
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Unlimited access of mom to baby
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What the are the 2 hormones that decrease after delivery. How does this effect milk production/letdown.
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Progesterone and estrogen. Progesterone has inhibitory effect on a-lacalbumin and prolactin. Resultant increase in prolactin and lack of prog causes the increased a-lactalbumin stimulates milk lactose.
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Breastfeeding mom has sore, sensitive buring nipples which is worse when feeding. pink and shiny w/ peeling at periphery. Diagnosis.
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candidiasis. Next step: inspect baby's oral cavity
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Best BCM for mother who wants to breastfeed and is unsure if she wants any more children.
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IUD. estrogen may have negative impact on quality of milk and progesterone may have inhibitory effect on prolactin.
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What signs that baby is getting sufficient milk?
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3-4 stools/24hrs. 6 wet diapers in 24 hrs, weight gain and sounds of swallowing
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List strategies that may help with breast engorgement in mothers who wish to breastfeed.
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nurse q1.5-3hrs. warm shower/compress to enhance flow, massaging the breast and wearing good bra support and analgesic use 20 minutes before feeding.
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suckling stimulates what hormone?
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oxytocin which helps with milk ejection.
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