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Risk of shoulder dystocia with macrosomia
15%
definition macrosomia
4000g
Why isn't macrosomia an indication for induction?
No reduction in shoulder dystocia

CD rate rises
Misoprostol broken down in:
lung
Pulmonary edema

physiology
physical finding
lung exam
CXR finding
management
increased oncotic pressure

pink frothy sputum

auscultation rales

patchy infiltrates

sit pt upright
lasix up to 100mg
Clotting time
red top tube
should clot in 10 minutes
Nitro given how for uterine inversion?
IV or sublingual
seatbelt
how to wear in pregnancy
should strap b/w breasts
lap belt under protuberance and on ASIS b/l
High Brow presentation can deliver how?

diagnose brow how?
Possibly vaginally, will see how comes down.
Low brow must CD

feel anterior fontanelle and orbital bridge
PPH, Don't forget to examine placenta!
PPH, Don't forget to examine placenta!
after 6 units prbc, give
1 amp Calcium gluconate
after 4 units prbc, give
FFP if not in DIC
If in DIC give FFP until >100 or nl PT
treatment hypovolemia, don't forget can try as last resort
MAST Suit
Severe oliguria, must do this
CVP by PAC
Pulmonary artery catheter
Severe oliguria, don't forget meds!
Also give ephedrine and Dopamine.
renal dose/cardiac dose
vasopressors to gently squeeze flow to kidney.
Why fracture clavicle?
creates new bisacromial diameter
Try all maneuvers again.
# cervical vertebrae
# cranial nerves
7 vertebrae
8 cranial nerves
Complications of fracturing clavical
pneumothorax
hemothorax
subclavian vessel injury
A possible laparaomy last ditch in shoulder dystocia to:
give suprapubic pressure directly intraop
ECV contraindications
Multiple geststion
IUGR
Previa/abruption
maternal cardiac disease
Gest HTN
Uterine malformations
large submucosal fibroid
Marked oligo
PROM
Unexplained uterine bleeding
Prerequisites ECV
37 weeks
L&D, weekday
NPO since MN
notify anesthesia
T&S
informed consent
NST
u/s DVT PE PACU
SQT for which ECV candidates?
Nulliparous
What is only force to be give to breech?
Rotational force to keep sacrum anterior
head entrapped breech? What to do?
u/s, needle decompression if hydrocephaleus
Still entrapped?
symphysiotomy
Going to OR for vag breech, call for:
u/s
Deliver breech head by
Suprapubic pressure
Mariceau-Smellie-Veit
Pipers
Duhurssens
c/s under local, call for:
EKG
need continuous monitoring
CPR for mother, how much time to deliver fetus?
4 minutes
Postmortem?
17 minutes (20 minutes)
undocumented scar, mode of delivery
VD.
No increased rupture risk.
VBAC twins?
YES!
No increased rupture risk.
ECV if prior CD?
Yes, unless classical was prior.

Also, only if 1 prior c/s.
Gestational HTN - BP PP?
Normal BP
AFLP lab findings
low glucose
elevated serum ammonia
coagulopathy- hypofibrinogenemia
LFTs elevated

give D50
Superimposing?
Symptomatic OVER HIT
new onset proteinuria
worsening proteinuria
abrupt change BP
HELLP
Secondary causes HTN
Cushings
Pheo
Renal artery stenosis
Coarctation aorta
What to do with severe remote from term preeclampsia?
Transfer to tertiary care center. Needs delivery if term.
Mg toxic range based on symptoms:
increments of 6

reflex 10
cardiac arrest 22

repsiratory in between at 16
Seizure in Myasthenia? What to give?
Phenoarbital 250mg

Dilantin
valium
Dilantin needs what?
EKG
Valium needs what?
Bag mask
Pregestational DM without preexisting retinopathy needs how many exams?
One ophtho exam

preexisting needs q trimester
how to treat hypoglycemic episode
glucagon
milk
Creatnine level in ESRD
Creatnine > 1.5
Preconceptional DM counseling
D Document and classify/Whites
E Evaluate end organ ophtho, renal, cardiac
A Autoimmune/TSH and Adverse outcomes maternal/fetal
R Reinforce tight control/meds/diet/exercise/folate
insulin used for pump?
Glargine
24 hour duration
No peak, all basal
Pederson's Poor Prognostic signs.
An indication to regard DM pregnancy to be high risk
HTN/Preeclampsia
Pyelo
DKA
Self neglect
recurrence DM next preg?
50%
Which DM to deliver early
Poor control
Nephropathy
Vasculopathy
Prior Stillbirth
No need for 3 hour if GTT is:
185
u/s efw off either way by what %
15%
Which stage labor most risky time for cardiac patients?
Third stage
increased blood infused from retracted uterus
Besides TSH, how can PTU be monitored?
pulse rate
What happens to Total and free T3 T4 in pregnancy, and why?
Estrogen increases TBG, so increase in total T3 and T4

TSH, Free T3 and T4 stay same
(except for early pregnancy HCG effect)
Why do seizure med levels go up or down in pregnancy?
Decreased albumin - free drug up
increased RPF and GFR - total levels down
Not usual pharmacokinetics
Newborns of mothers on anticonvulsants should get what?
Vitamin K
Fetal Hydantoin syndrome:
Phalangeal hypoplasia
neonatal coagulopathy

microcephaly
MR
IUGR (sIp)
Management seizure disorder/meds in pregnancy
control - preconception
convert - to single agent
content - rest/sleep
adjust - levels
assess - NTD, IUGR
APS diagnosis
RAT and
LA/ACA

RPL
Autoimmune thrombocytopenia
Thrombosis
and
LA or ACA
This antibody if present will have a prolonged PTT
anti La (SSA)

La La La La prolonged...
This antibody predisposes to congenital lupus
anti Ro (SSB)
This antibody predisposes to fetal wastage
anti La

To live and die in La
heart block for lupus
La (SSA)

Jenny from La block.
APS like seizure disorder risk how?
SIP

watch for preeclampsia/Gest HTN

Also IUGR and Stillbirth

aPS-I like SIP
Treat APS?
Low dose ASA
Heparin 5000 BID
Congenital lupus
cutaneous - temporary
anti- Ro
also partial heartblock
definition gestational thrombocytopenia in pregnancy:

Likely ITP if what platelet level?
<150,000

No strict clinical definition of gestational thrombocytopenia

ITP if < 70,000
ddx thrombocytopenia
ITP
FAIT
Gestational thromocytopenia
HELLP/Severe Preclampsia
Heparin/AZT/MTX
SLE/APS
DIC
Treatment ITP
Prednisone
Treatment FAIT
IVIG
Splenectomy
platelet transfusion if having surgery
Mode delivery ITP, FAIT?
obstetric principles
Intrapartum fetal platelet estimation helpful?
No
What is FAIT?
Platelet equivalent Rh disease.
What is mosaic
Two different cell lines with different karyotypes
More common twinning?
Dizygotic
Family history?
Dizygotic
AMA cutoff for twins
32 years old
Definition discordance

Usually in which type twins?
20%

Dizygotic
Diagnosis of discordance?
May have discordance in retrospect
difficulty with inaccuracy of u/s (15%)
What to look for in u/s twins?
intervening membrane
placentae
fluid
anomalies
cervical length/funneling shortening
Deliver twins when?
Deliver at 40, can aim for 38 if concerns/maternal symptoms.
TTT look at
bladders
fetal survival 24 weeks (viability)
15%
fetal survival 28 weeks
82%
When ANT per ACOG?
41 weeks
Hep A vax and IG okay in pregnancy?
yes
Hep B vax and IG okay in pregnancy?
Yes
Parvo findings in fetus
hydrops
anemia
heart failure

SAB first trimester
(TORCH IUFD)
Think of parvo as
Hydrops

mother makes antibodies to fetal rbcs and precursors.

virus replicates in bone marrow
What is treatment Parvo?
PUBS - blood transfusion
needs rbcs, and precursors were knocked out!
Parvo transmission?
30%
Mother presents with Parvo:
lacelike rash
flu
polyarthralgias peripheral - joint pain in adults
parvo dx:
Elisa/Western
Fetal survival with transfusion?
80%

(100-80 = 20%) without
Vertical transmission CMV?
30%
same as Parvo
What % fetuses die?
30%
Recurrent CMV disease?
negligible
Clinical features CMV?
Like Toxo

Chorioretinitis
Hydrops
HSM
IUGR
VENTRICULOMEGALY

Blueberry muffin rash/petechie from thrombocytopenia
MR
Most severe trimester for CMV?
First

Like toxo
Most common CMV trimester vertical transmission?
Third

Like toxo!

90/10 rule!
HIV, when should viral load be checked to determine mode delivery?
36 weeks
% transmission if HIV VL< 1000?
1%
When before c/s should ZDV be given?
3 hours prior
check HIV VL when?
36 weeks
risk transmission HIV if VL < 1000?
1%
ROM before c/s, what to do?
c/s within 4 hours.
increase transmission rate 2%/hr.
Give ZDV how long prior to scheduled c/s?
3 hours prior
Advanced HIV disease, increased risk transmission , what lab findings?
low CD4
high VL
p24 antigenemia on Western
side effects ZDV?
GI - lactic acidosis
hepatic steatosis - check LFTs
Thrombocytopenia
most predictable factor for HIV vertical transmission?
Viral Load
definition AIDS
CD4 <200
Identify how many bands on Blot?
2 out of 4 bands
Vertical transmission without ZDV
28%
Vertical transmission HIV with ZDV
8%
Vertical transmission HIV with ZDV + CD
2%
Vertical transmission HIV VD if VL<1000
1%
ACOG/CDC recommends opt in or out?
Opt out
sensitivity and specificity of Elisa and Western
99%
If positive what to check what labs?
VL CD4
CBC, LFT, Hep B, C, RPR,
If rapid HIV pos, what to do?
perform confirmatory test
CD if not in labor nor ROM
In pregnancy start ZDV 5x/day when?
14 weeks
until labor
CD performed when in HIV?
38 weeks
before onset labor
before ROM
If HIV and in labor, mode of delivery?
Individualize
discuss risks
check VL
Which twin higher transmission in HIV?
Twin A

At risk
AZT dose in labor
2 mg/kg then 1mg/kg/hr
can you VBAC if CD x 2 and but had a prior VD?
yes
no matter when it occurred in order.
Besdies MULIGI for IUFD/RPL, don't forget to check what?
Tox screen
Why does Lewis live?
It's an IgM/larger molecule

which does not cross the placenta.
Most common cause hydrops
Nonimmune

Parvo/CMV
Placenta AV malformations/chorioangioma
congenital heart defects
Poly amnio reduction for maternal comfort:
500cc/hr, total 1500cc
repeat every 2 weeks
% sensitivity DS for each test:
triple scree/first trimester anlytes only 65%
quad screen 75%
first trimester + sono 85%
combined FASTER 90%
can perform vag breech if:
26 weeks
750g
VBAC requisites:
on site anesthesia
can perform within 30 minutes
SBE prophylaxis is Recommended if bacteremia suspected in high and intermediate risk.
The following procedures - gynecologic
• Vaginal/abdominal hysterectomy (vagina involved)

• Vag delivery
• Urethral dilatation
• Cystoscopy
• Foley if infection



Endoscopic retrograde cholangiography with biliary obstruction

Biliary tract surgery

Surgical operations that involve intestinal mucosa
What are SBE Intermediate Risk cardiac lesion category?
Congenital heart malformations and unrepaired:
ASD
VSD
PDA


RHD with valvular dysfunction

HCM

MVP (regurg and/or thickened leaflets)
Contraindications to epidural
HSV on overying skin
coagulopathy
LMWH < 24 hours
local spinal anomaly
uncooperative pt
hypovolemia
SBE prophylaxis is Recommended if bacteremia suspected in high and intermediate risk.
The following proceudres - gynecologic
Vaginal/abdominal hysterectomy (vagina involved)
• Vag hysterectomy
• Vag delivery
• Urethral dilatation
• Cystoscopy
• Foley if infection



Endoscopic retrograde cholangiography with biliary obstruction

Biliary tract surgery

Surgical operations that involve intestinal mucosa
risk PP Depression
poor relationship with one's own mother
malformed infant
conceived <12 months after stillbirth
personal h/o depression
FH
lack of perceived emotional/financial support
single
had contemplated TOP
not breastfeeding
high number antepartum visits
h/o hyperemesis
not bonding with baby
Edinburgh PPD Scale

consider screening all new mothers before d/c home
10 item self-report quesitonnaire
max score 30
score 13 = identifies women with PPD
administration in first few days PP can predict mood for 1-2 months later PP
PPD treatment
Biopsychosocial support - new mom support group - reduces stress and depression

promote adequate sleep

pharmacotherapy

light therapy

ECT
f/u when after starting on PPD meds?
1-2 weeks
assess suicidal risk
Pharm therapy for PPD?
SSRI
SNRI venlafexine - monitor BP (SNRI)
Anxiolytic - 2 weeks, low dose/addictive potential
sides of SSRI and SNRI
GI (n/v/d)
HA
Insomnia
Sexual
Jittery
What if PPD needs help with sleep?
Benzodiazepine/alprazolam qhs
Trazodone qhs
MOA of Trazodone?
unknown
Heterocyclic antidepressant used also as a sedative
antidepressant that alleviates sexual side sffects from SSRI
Bupropion - can cause seizures
Clinical response expected when from antidepressants?
4-6 weeks
refer when?
no response to meds
relapse
suicidal ideation
bipolar
ECT for which PPD patients?
risk for suicide or infanticide
psychotic symptoms
acute mania
Incidence factor 5 leiden
5%
Factor 5
inheritance factor 5 leiden
autosomal dominant
most common inherited cause thrombosis
Hereditary coagulopathies. Risk for thrombosis
Factor V Leiden
Antithrombin III deficiency
Protein C, S deficiency
HYPERHOMOCYSTENEMIA
Prothrombin G20210A gene mutation
Impedence plethysmography, what is sens and spec?
Highly sensitive, but not specific.
Factor 5 Leiden risk thrombosis if heterozygous:
5x
factor 5
Factor 5 Leiden risk thrombosis if homozygous:
50x
Which coagulopathies if tested while on heparin will have a false negative result? (falsely elevated)
Antithrombin III (hep potentiates ATIII)
Protein C,S (increased resistance in pregnancy)
How to test for hyperhomocystenemia?
fasting homocystine level
Why does LMWH have more bioavailaility?
due to reduced heparin binding
How do you act on neg V/Q scan results?
angiography if still have high suspicion
How do you act on intermed/high probability V/Q scan results?
start meds
PE work up
EKG
CXR
ABG
V/Q or Spiral CT
Angiography
Lung exam with PE?
Rales
Heart exam with PE?
Friction rub
CXR PE?
WNL or
Hampton's Hump- opaque triangular wedge points to hilum
Westermark sign - decreased vascularity
ABG finding on PE?
PaO2 < 90mmHg
EKG on PE?
sinus tachycardia
RAD - right axis deviation
S1Q3T3
Besides potentiating antithrombin III, what else does heparin do?
Increases inhibition of thrombin and Factor Xa

So can't cascade to clot
Why spatulate?
reduces stricture formation when it heals
"I would not do this, but an ultimate option would be to perform a ureteroneocystotomy by a specialist."
Good Quote
What suture for ureter repair?
4-0 chromic, full thickness
What suture to repair bladder?
3-vicryl
Which ureter anastomosis can always be done regardless of location as long as there is no tension?
end to end reanatomosis
When using vicryl layer on bowel repair, how is it closed?
interrupted

vicryl interrupted
bowel prep
Option #1
Golytely 1/hr q hour until clear
Cefoxitin 2g IV 30 minutes pre-op
Option#2
Neomycin 1g and Erythromycin 1g at 2,4,10p
Who gets mass closure?
obesity
Malignancy
Steroid therapy prolonged
poor nutrition
Poorly controlled DM
XRT
Monofilament suture, delayed absorbable
Maxon
PDS
Signs of drug fever
clinically better appearing than temp suggests

eosinophilia
When performing Vag Hyst, which is ligated first, cardinals or USL?
USL then Cardinals in VH.

In TAH alpha order on the way down, so in VH, it is the reverse.

So, USL then Cardinals in VH.
normal urinary frequency in voids/ day.
8/day
Nightime void normal frequency?
1 time/ night
PMH to ask about in eval incontinence?
DM
COPD
spinal cord injury
MS
PSH to ask about in eval incontinence?
Bladder
Back
Prior incontinence/prolapse surgery
XRT
continuous incontinence means
fistula
frequent dribble means
overflow incontinence
urolog how many days?
3 days
during work week
Normal bladder capacity
300-400 cc
Burch/sling success rate?
90%
sling for what?
SUI
ISD
Burch for what?
SUI
treatment kidney stone
IVF
analgesics
antibiotics
double pigtail stents
urteroscope/removal
percutaneous nephrostomy
lithotripsy
lithotripsy okay for pregnancy?
No
What's in TPN?
glucose
amino acids
lipids
if don't repair RVF right away, how long should you wait for inflammation to subside?
3-6 months
Culdocentesis, what gauge needle?
18 Gauge
Name 3 medical probs that are contraindicated for use of MTX in ectopic?
Active pulmonary disease
Liver disease
PUD
side effects MTX
stomatitis
thrombocytopenia
abdominal pain
leucopenia

elevated LFTs
MTX MOA
dihydrofolate reductase inhibitor
Two things to remind patients on MTX
No PNV/Folate
Reliable contraception

also avoid NSAIDS
Risk of ectopic if one prior and prior tubal surgery (not BTL)?

Think of it as whether had MTX treatment or salipingostomy/salpingectomy, will have same future risk
20%
Risk of ectopic if two prior ectopics or BTL?
50%
Risk of ectopic if ART?
5%
Vet or works on farm with positive serum BHCG. Could possibly mean what?
False positive.
Heterophile antibody
How to tell if false positive BHCG:
do urine BHCG
serially dilute serum
do a different assay

important when following BHCG s/p mole.
How do filshie clips compare to hulka?
Filshie's are longer, so can reach better.
Not studied in CREST study because came out afterwards.
Prog IUD failure rate
5%

Think of prog level = 5
Copper IUD failure rate
15%

like Bipolar
ectopic risk bands
7 %
lucky 7
failure rates higher for older women, ectopic rates higher for
younger women
pregnancy with IUD can cause
SAB
septic abortion
PTL
dose of rocephin for GC
125 mg IM
Does LVSI affect staging in Cervical CA?
No.

Only treatment.
Treatment of early stage breast CA with positive nodes varies depending on:
Menopausal status
Treatment of early stage breast CA with positive nodes
Premenopausal treatment
CAF

Cyclophosphamide (Breasts are cyclic)
Adriamycin
5-Fluoro-urocil
Treatment of early stage breast CA with positive nodes.
Postmenopausal treatment
Tamoxifen
most common cause solid breast mass
fibroadenoma
What % Pagets of breast are associated with underlying breast adenocarcinoma
20%
False positive rate mammo
10%

Same for false negative rate = 10%
Excisional breast bx if
bloody fluid - send for cytology/pos cytology
mass fails to resolve after attempted aspiration
clearing and subsequent reforming of mass
If pt HTN, what is their risk of UTERINE cancer?
5x risk!

think of estrogen and HTN
2nd trimester Cervical Ca.
What to do?
Terminate and treat!
1st trimester cervical cancer.
What to do?
No change. Usual treatment
Late 2nd and 3rd timester cervical cancer, what to do.
Individualize.
Consider risks/benefits.
Prematurity v. delayed treatment.
Point B represents location of what?
Obturator nodes
Point A represents location of what?
where uterine artery and ureter transect.
High risk HPV types:
16, 18, 31, 33, 35
External beam uses what element?
Cobalt

Tele = Tally = Talbot = Cobalt
Is Brenner solid or cystic?
Solid
serous cystadenoma bilaterality
10%
serous cystadenocarcinoma bilaterality
66%
germ cell tumors bilaterality

exception is gonadoblastoma =
15%

except gonadoblastoma 40%
mucinous ADENOMA b/l
virtually 0%
For mucinous, Think colon ca? order what marker?
CEA
think mucinous tumor? what marker?
CEA, CA 19.9
Criteria for borderline tumor (3)
PEN the Borderline

Papillations
Epithelial stratification
Nuclear atypia

No stromal invasion
dysgerminoma b/L?
15%

b/l and bimodal
What tumor is exquisitely radiosensitive?
Dysgerminoma
How to treat dysgerminoma in young patient?
USO
washings
ipsi nodal dissection

follow HCG and LDH
How do you follow dysgerminoma up after surgery?
follow tumor markers
LDH
HCG
Dysgerminoma chemosensitive, too?
yes
Granulosa cell tumor histology
Call-Exner bodies
Coffee bean nuclei
organs involved in Lynch II
endometrium
ovary
breast
colon
According to WHO classification for metastatic GTN, which blood type is bad?
B is Bad.
theca lutein cysts are more common in which type of mole?
Complete
single agent treatment of metastatic GTN (low risk)
MTX 50 mg/m2 weekly

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