ExamPro
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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