OB 3

Question 1

Implantation of developing oocyte outside the endometrial cavity

Dx? and 3 RFs?

Answer 1

Ectopic Pregnancy

• Prior ectopic pregnancy
• Previous tubal surgery
• Hx of PID

Question 2

98% of ectopic occur in Fallopian Tube, if they do not occur here what is the next likely location?

Answer 2

Ampullary portion of tube

Question 3

3 sxs of ectopic?

Answer 3

• Pelvic/abd pain (95%)
• Vaginal bleeding (60-80%)
• Orthostatic sxs: dizziness, fainting, wkness d/t blood loss

Question 4

Medical tx for ectopic pregnancy?

Answer 4

• RhoGAM in Rh neg women
• Methotrexate IM
  
  • inhibits DNA synthesis & fetal cell reproduction
  • MUST HAVE these 3 criteria: HCG <5,000, no cardiac activity, sac ,4cm
  • Repeat HCG on days 4 & 7 after Methotrexate (if HCG did not drop by 15%, meds did not work!)

Question 5

What are contraindications to medical tx for ectopic w/ Methotrexate?

Answer 5

• Renal, liver, pulm compromise
• At risk for loss to FU (risk of death)
• Breastfeeding
• Heterotopic pregnancy
• Immunodeficiency

Question 6

Surgical tx for ectopic pregnancy & indications for

Answer 6

• RhoGAM in Rh neg women
• Laparoscopy vs. Laparotomy (Salpingostomy vs. Salpingectomy)
• No difference in future reproductive outcomes (based on contralateral tube)
• Indications: hemodynamically unstable, impending/active rupture, failure of methotrexate, heterotopic pregnancy

Question 7

Abnormal proliferation of placental epithelium secondary to abnormal fertilization

Answer 7

Gestational Trophoblastic Disease

Question 8

3 RF of Gestational Trophoblastic Disease

Answer 8

• Previous molar pregnancy
• Advanced maternal age >40
• Asian/American Indian ancestry

Question 9

4 types of Gestational Trophoblastic Disease

Answer 9

• Hydatiform Mole
• Invasive Mole
• Placental site nodule
• Choriocarcinoma

Question 10

Describe a Hydatiform Mole (Gestational Trophoblastic Disease)

Answer 10

• Most common (80% of Gestational Trophoblastic Disease)
• Paternal genes control placental growth
• ↑ Genes = ↑proliferation
• Complete vs. Partial

Question 11

Describe a complete Hydatiform Mole

(Gestational Trophoblastic Disease)

Answer 11

• Sperm fertilizes an abnormal ooctye = no chromosomes
• Chromosomes from the sperm duplicate = 2 copies of paternal chrom, 0 maternal chrom

Question 12

Describe a partial hydatiform mole

Answer 12

• 2 sperm fertilize normal oocyte at same time
• 2 paternal DNA vs. 1 maternal DNA

Question 13

Which type of GTD?

Villi from Hydatiform Molar pregnancy invade deeply into myometrium of uterus

• Is complete or partial more common?

Answer 13

Invasive Mole

(Gestational Trophoblastic Disease)

Complete

Question 14

What occurs following a FT pregnancy?

(Gestational Trophoblastic Disease)

Answer 14

Placental site nodule

Question 15

Dx? Tx?

• Abnormal uterine bleeding or amenorrhea
• Uterine size greater than dates
• Absent fetal heart tones
• Hyperemesis
• Pre-eclampsia “like” sxs prior to 20 weeks

Answer 15

Choriocarcinoma (gestational troph dz)

• Caused by persistent complete Hydatiform Mole
• Can follow any type of pregnancy (abortion, ectopic, normal)
• HIGHLY malignant epithelial tumor (vascular invasion w/ widespread mets)

Tx: chemo vs. hysterectomy + chemo

Question 16

What is PE of Choriocarcinoma?

Answer 16

Uterine enlargement

+/- adnexal masses

b HCG

US:“snow storm” or “grape like clusters” within the endometrium

Question 17

Tx for Hydatiform Mole? (4)

Answer 17

• Dilation & Curettage
• Pelvic rest 4-6 weeks
• Monitor HCG closely x6-12 months
• Avoid pregnancy for 12 months

Question 18

Describe a placental abruption and the cause

Answer 18

Premature separation of a normally implanted placenta after 20th week

• Cause: rupture of maternal vessels –> accumulation of blood leading to separation of decidua from placental attachment
• Detached placenta is unable to exchange gas and nutrients leading to fetal compromise

Question 19

Dx? How dx? Tx?

• Abrupt PAINFUL vag bleeding
• Abd/back pain
• Contractions

Answer 19

Placental Abruption

Dx: clinical and US showing retroplacental hematoma

Tx:

• Monitor fluids, blood products
• Continuous fetal monitoring
• Expectant management (stable mothers w/ no fetal distress)
• C-section (unstable mother/fetus)

Question 20

Definition of what?

• Abnormal location of the placenta over or in close proximity to the internal cervical os

Answer 20

Placenta Previa

Question 21

What are 4 RF of Placenta Previa?

Answer 21

• Prior C-section
• Multiple gestation
• Prior hx of previa
• Advanced maternal age

Question 22

Presentation of what?

• PAINLESS vaginal bleeding after 20 weeks gestation

Answer 22

Placenta Previa

Question 23

Which type pf Placenta Previa?

• Located near, but NOT directly adjacent to internal os (can have a normal vag delivery)

Answer 23

Low Lying

Question 24

Which type pf Placenta Previa?

• Internal os is partially covered

Answer 24

Partial

Question 25

**Which type pf Placenta Previa?** * Internal os is completely covered (worse one = NO VAG DELIVERY)

Answer 25

Complete

Question 26

How is Placenta Previa diagnosed?

Answer 26

* US * **NEVER** do cervical exam bc/ it can hemorrhage!!!

Question 27

Tx for pt w/ **PAINLESS vag bleeding** after 20 weeks?

Answer 27

**Placenta Previa** * _Asymptomatic:_ * avoid intercourse & ↓ physical activity * educate pt it may resolve w/ advanced gestational age * _Symptomatic:_ * Admit for close maternal/fetal monitoring * Deliver via C-section

Question 28

What is PROM?

Answer 28

**Premature Rupture of Membranes** * Rupture of membranes before onset of uterine contractions (normal)

Question 29

What is Pre-PROM?

Answer 29

Rupture of membranes _before 37 weeks_ gestation **w/o** presence of **uterine contractions** (abnormal)

Question 30

What is the MC cause for pre-term delivery?

Answer 30

**Pre-PROM** (rupture of membranes before 37 weeks gestation w/o presence of uterine contractions)

Question 31

What are the 3 RF of Pre-PROM? Which one is the biggest RF??

Answer 31

* Genital Tract Infection **(Bacterial Vaginosis)\*\*\*** * Smoking * Previous pre-term delivery

Question 32

Woman at 35 weeks gestation presents w/ "gush" of clear/pale yellow fluid, initially thought it was urine, and is now realizing it is coming from vagina. _What is the dx? How is it diagnosed? (4)_

Answer 32

**Pre-PROM** * Speculum exam reveals amniotic fluid coming out of cervical os / pooling of fluid in vaginal fornix * Sample vaginal fluid & look for "ferning" under microscope * pH of vag fluid = 7 - 7.3 * + alpha-fetoprotein (amniotic fluid)

Question 33

Woman at **33 weeks** presents w/ gush of yellow fluid, speculum exam reveals amniotic fluid coming from os, under microscope "ferning" is seen. _What is the dx and tx? (3)_

Answer 33

**Pre-PROM** * Administer corticosteroids to promote lung maturity bc/ _gestation is \<34 weeks_ * _GBS status unknown:_ abx prophylaxis (Ampicillin 2g or Clinda if pcn allergy) * Expectant management until delivery

Question 34

What is the definition of Post-Partum Hemorrhage? (2)

Answer 34

* Vaginal delivery w/ 500cc+ blood loss * C-section w/ 1,000cc+ blood loss

Question 35

What is the #1 etiology for Post-Partum Hemorrhage? What are 2 other causes?

Answer 35

* **#1:** Uterine Atony (lack of effective contractions following delivery) * Trauma (lacerations, uterine rupture) * Coagulopathy

Question 36

_Dx? What is seen on PE? (4)_ * Weakness * Palpitations Confusion * SOB * Syncope

Answer 36

**Post-Partum Hemorrhage** _PE:_ * Tachycardia * Oliguria * ↓ O2 sats * Hypotension

Question 37

Patient w/ _uterine atony_ loses 600 CC of blood after vag delivery and is now tachycardic, hypotensive, weak, confused. _What is dx & tx? (4 things + 3 meds)_

Answer 37

**Post-Partum Hemorrhage** * Uterine massage * IV fluids * Oxytocin/Misoprostol/Methergine * Blood transfusion * Surgery