Differential And Steps

Question 0

Management of placenta previa?

Answer 0

1. Bedrest
2. C-section if unstoppable labor, fetal distress, life-threatening hemorrhage
3. If bleeding, venous access, HCT, type and screen, PT/PTT, Kleinhauer-Betke,
4. tocolysis and steroids if under 34 weeks

Question 1

Patient with antepartum bleeding – differential?

Answer 1

OBSTETRIC causes

1. Placental – previa, abruption, vasa previa
2. Maternal – uterine rupture
3. Fetal – fetal vessels rupture

NON-OBSTETRIC causes

1. Cervical – cervicitis, polyps, cancer
2. Vaginal – lacerations, varices, cancer
3. Other – bleeding disorder, trauma

Question 2

Placental abruption - management?

Answer 2

1. IV access, type and screen, CBC, PT/PTT, fibrin split products, RhoGAM
2. Prepare for preterm deliver
3. C-section if life-threatening bleed, and non-reassuring tracing

Question 3

Uterine rupture - management?

Answer 3

1. Laparotomy and delivery of the fetus
2. Hysterectomy if repair not possible
3. Discourage future pregnancies, at minimum no trial of labor in future

Question 4

ruptured fetal vessel - management?

Answer 4

emergent c-section

Question 5

Suspect Preterm rupture of membranes - diagnosis?

Answer 5

1. Pooling, nitrazine, and ferning
2. if evoquivical, use ultrasound for AFI
3. If still unconfirmed, inject dye into amnionic sac and examine vaginal for leakage

Question 6

Preterm rupture of membranes - management?

Answer 6

1. If under 32, prolong with ampicillin, give steroids (tocolysis has little benefit)
2. If 32-36, physician decision
3. If over 36, deliver (longer wait increase risk for Chorioamnionitis)
4. If signs of infection or fetal distress, deliver

Question 7

Labor fails to progress - Ddx?

Answer 7

1. Pelvis - too small?
2. Power - IUPC and ptosin
3. Passenger - macrosomia?

Question 8

Cephalopelvic Disproportion - management?

Answer 8

1. Trial of labor unless US has documented fetal head larger than pelvis

Question 9

Breech presentation - management?

Answer 9

1. External version if after 37 weeks (earlier and it will revert back)
2. Trial of breech vaginal delivery (if favorable pelvis, weight 2000-3800, and not foot/compound breech)
3. If compound breech, watch for umbilical cord prolapse
4. C-section

Question 10

Vasa previa - management?

Answer 10

1. Do NOT artificially rupture membranes

2. If vasa previa, can undergo a trial of labor if they wish

Question 11

Fetal bradycardia - tx?

Answer 11

1. Move pt to side (may be due to IVC compression)
2. O2 to mother
3. Vaginal exam (for blood, uterine tetany, rapid descent)
4. If hypotensive, hydration and ephedrine
5. For tetany, give nitroglycerin and terbutaline
6. If umbilical cord prolapse, c-section

Question 12

Shoulder dystocia - management?

Answer 12

1. McRoberts
2. Wood’s corkscrew
3. Delivery of posterior arm
4. Suprapubic pressure
5. Zavanelli

Question 13

Pregnant with seizure - management?

Answer 13

1. ABCs
2. Assess fetal status
3. Mag sulfate
   4 lorazepam
   5 phenytoin
4. If no response, phenobarbital
   7.

Question 14

SGA - Ddx?

Answer 14

1. Decreased growth potential - trisomies, congenital infections, teratogens
2. IUGR with symmetric restriction - insults <20 weeks gestation (malnutrition, maternal anemia, renal disease, hypertension, SLE, twins)
3. IUGR with asymmetric restriction - insults over 20 weeks

Question 15

Risk factors for SGA vs LGA

Answer 15

1. Trisomies vs other chromosomal (Beckwith-Wiedemann)
2. Large vs small maternal stature
3. Substance abuse vs food abuse (obesity/diabetes)
4. IDDM vs gestational diabetes
5. Females vs males
   6 intrauterine infections vs old, multips

Question 16

LGA fetus - management?

Answer 16

1. Get good dating or assess lung maturity from amniocentesis
2. Induced before fetus becomes macrosomic (over 4500g)

Question 17

Oligohydramnios - causes?

Answer 17

1. Uteroplacental insufficiency
2. Renal agenesis/ GU obstruction
3. Rupture of membranes/leakage

Question 18

Oligohydramnios - management?

Answer 18

1. Plan for Labor at term or post date or with rupture of membranes
2. Frequent antenatal testing
3. Amnioinfusion if meconium or cord compression

Question 19

Polyhydramnios - Management?

Answer 19

1. Expect Malrotation and Risk of cord prolapse so be careful after ROM
2. RhoGAM to prevent Isoimmunization

Question 20

Fetal demise - management?

Answer 20

1. Delivery to prevent DIC (prostaglandins/oxytocin after 20 weeks)
2. Test mother of CVD, hypercoagulable state, TORCH

Question 21

Postterm pregnancy - management?

Answer 21

1. Week 41 - NST
2. Week 42 - BPP and NST
3. After 42nd week, induce

Question 22

Mild preeclampsia - management?

Answer 22

1. If over 34 weeks, induce with ptosin, prostaglandins, amniotomy
2. If stable preterm, steroids and bedrest
   3 Mag sulfate during L&D

Question 23

Severe preeclampsia – management?

Answer 23

1. Magnesium sulfate for seizure prophylaxis (Continue 24 hours postpartum)
2. Hydralazine for blood-pressure control
3. If less than 32 weeks, steroids
4. Beyond 32 weeks, delivery

Question 24

Eclampsia – management?

Answer 24

1. Seizure management with magnesium 2. Blood pressure control with hydralazine 3. Calcium chloride or calcium gluconate if magnesium toxicity 4. No cesarean section unless obstetrics indications (nonreassuring fetal tracing, hemodynamic instability)

Question 25

Patient with chronic hypertension in pregnancy – management?

Answer 25

1. Labetalol 2. Nifedipine 3. Methyldopa less effective

Question 26

PMS tx?

Answer 26

1. Exercise and vitamin A, E, B6 2. OCP 3. SSRIs

Question 27

Diabetes during pregnancy - evaluation?

Answer 27

1. 50g 1 hour glucose tolerance at 24-28 weeks (positive if over 140) 2. If positive 3 hour GTT (gestational diabetes if 2+ values are elevated)

Question 28

Gestational diabetes - pregnancy management?

Answer 28

1. Diabetic diet A1 2. Insulin (short acting since fasting values usually normal while postprandial elevated) A2 3. If A2, NST or BPP between 32-36 weeks 4. US for macrosomia at 34-37 weeks

Question 29

Gestational diabetes - delivery management?

Answer 29

1. Induction at 39-40 weeks (if poor sugar control, at 37-39 weeks) 2. C-section if over 4000-4500

Question 30

Pt with diabetes - obstetric complications?

Answer 30

``` Polyhydramnios Preeclampsia (4x) Miscarriage (2x) Infection Postpartum hemorrhage ```

Question 31

Regular diabetes during pregnancy - management?

Answer 31

1. ECG, 24 urine analysis, HbA1c, TSH 2. Tight Glucose control 3. 4mg frolic acid daily (neural tube) 4. After week 32, weekly NST. After week 36, biweekly 5. After pregnancy, insulin requirements decrease due to removal of placenta (fewer insulin antagonists)

Question 32

Ddx postpartum hemorrhage with vaginal delivery?

Answer 32

Vaginal - hematoma/lacerations Cervical - lacerations Uterus - atony, inversion, rupture Placental - accreta, retained POCs

Question 33

Ddx postpartum hemorrhage with c-section delivery

Answer 33

Placenta - accreta | Uterus - atony, rupture

Question 34

Uterine atony - management?

Answer 34

1. Oxyoxin with uterine massage 2. If fails, methergine (unless HTN) 3. If fails, prostaglandin F2a (unless asthmatic) 4. If fails, D&C to r/o retained POC 5. If fails, uterine artery embolization 6. I fails, hysterectomy

Question 35

Accreta management?

Answer 35

Laparoscopy