1
Q
- A low PAPP-A value has a positive predictive value for ____.
- Elevations in maternal serum β-hCG and alpha-fetoprotein levels (ie, both levels are greater than 2.0 MoM) in the second trimester are associated with what pregnancy complications?
A
- Small-for-gestational-age fetus; IUGR, preE, PTL, abruption
- Late fetal loss, PreE, intrauterine growth restriction, preterm delivery
2
Q
75g 2hr GTT for GDM Dx Values
A
F: 92
1hr: 180
2hr: 153
3
Q
Defintion of Chorio:
Define isolated mat fever:
2 g of cefazolin in patients weighing more than __ kg.
3 g in patients weighing more than __ kg.
If allergic to a PCN and allergy not severe, can you still give ancef?
When do we redose ancef?
Azithro at the time of CD has been shown to dec rate of __.
Ampicillin is added to the endometritis treatment regimen in a patient who has not improved after 48–72 hours of gentamicin and clindamycin for coverage of ___.
A
Fever plus one more: Discharge, WBC, fetal tachy (no mat tachy or ut ttp anymore)
Isolated mat fever: > 100.4 and still high in 30 min, or 102.2 x1. ACOG recommends administration of intrapartum antibiotics for patients with isolated maternal fever unless a source other than intraamniotic infection is identified.
1g of cefazolin in patients weighing
2 g of cefazolin in patients weighing > = 80 kg
3 g in patients weighing > 120 kg.
Yes. Less than 1% of patients with penicillin allergy are allergic to cephalosporins. Unless severe alergy to PCN, can give.
EBL > 1500, 4hrs
endometritis and SSI
Ampicillin is added to the endometritis treatment regimen in a patient who has not improved after 48–72 hours of gentamicin and clindamycin for coverage of Enterococcus species.
4
Q
ACE inhibitors are associated with what fetal outcomes?
A
- Neonatal renal failure (anuria, oligohydramnios, arterial hypotension)
- intrauterine growth restriction
- limb defects
- Respiratory distress syndrome, pulmonary hypoplasia
- death
5
Q
- Accreta US Findings
- State % Risk of acretta w/ Previa and history of cesarean delivery.
- Endometrial ablation, age, uterine manipulation, and IVF all inc risk of accreta. T or F
A
- Ultrasonographic findings strongly associated with placenta accreta include
- lacunae (MOST SENSITIVE, hypoechoic spaces) within the placenta;
- hypervascularity in the myometrium or placenta;
- loss of the retroplacental hypoechogenic zones, which represents an absence of the normal decidua basalis between the myometrium and placenta;
- myometrial thinning at the placental bed
- placenta bulging into the bladder.
Previa + h/o CD
1 CS 3% (if no previa .03%)
2 CD 11%
3 CD 40%
4 CD 61%
5 CD 67% (no previa .8%)
True
6
Q
Neonatal signs of an acute intrapartum event include…
A
- Apgar score of less than 5 at 5 minutes and 10 minutes;
- fetal umbilical artery acidemia with fetal umbilical artery pH less than 7 or a
- base excess of more than 12 mmol/L;
- magnetic resonance imaging consistent with hypoxic-ischemic changes
- multisystem organ failure
7
Q
- Most common sign of an amnioti fluic embolus?
A
- Hypoxemia
8
Q
- Regarding care for a patient with prior alloimmunization, how do you interpret titers? so then what do you do?
- If first affected pregnancy, how often and when do you start to titer?
- What antigens do we worry about?
- Which do we NOT worry about?
A
- You cannot. Start MCA dopplers at 18 weeks GA.
————
- Start monthly when known, and at 24 weeks switch to every weeks.
If you reach a critical titter (1:16 antiD or 1:8 Kell) start MCA dopplers.
If those elevated, fetal Hg determination.
- D, Kell (K), Duffy (Fy), E, Kidd (Jk) c
————————-
- Lewis and I
9
Q
Anemia w/up Algorith from ACOG.
A
10
Q
What are the common features of the following chromosomal defects?
(A) 45,XO
(B) 47,XXY
(C) 47,XX,+21
(D) 47,XY,+18
(E) 47,XX,+13
A
a) Turner’s: cystic hygroma (specially 2nd tri), hydrops fetalis, short femur, coarctation of the aorta, hypoplastic left heart, and renal anomalies.
b) Kleinfelter: Klinefelter syndrome (47,XXY) is only detected prenatally in 10% of cases. There are no characteristic prenatal ultrasound findings for Klinefelter syndrome.
c) T21: duodenal atresia, cardiac anomalies, cystic hygroma, inc NT, hypoplastic or absent nasal bone, echogenic intracardiac foci, pyelectasis, short femur length, choroid plexus cysts, echogenic bowel, thickened nuchal skin fold, and ventriculomegaly. Most common cause is non-dysjunction.
d) T18: choroid plexus cysts, clinodactily, rocker bottom feet, hypoplastic nails, prominent occiput, low set ears, horshoe kidney.
e) T13: THINK MIDLINE DEFECT (midface, eye, forebrain), holoprosecephaly, microcephaly, low set ears, polydact,cleft lip/palette, cystic kidney
11
Q
Risk of anorexia in pregnancy?
A
low birth weight, small for gestational age, hemorrhage.
12
Q
- MOA of UFH and side effects.
- MOA of LMWH.
- MOA of Warfarin.
- Fetal warfarin syndrome characteristics.
- Warfarin is considered safe in women who are breast feeding. T or F.
- For patients who are on low-molecular-weight heparin for anticoagulation during pregnancy, transitioning to unfractionated heparin is recommended at approximately __ weeks of gestation.
- After delivery, when do we start anticoag for Vaginal Del and Csections? what if has an epidural?
- If on ppx or theraptic anticoag, how long b4 delivery do we discontinue?
A
- Inactivating thrombin and activated factor X (factor Xa).The risk of heparin-induced thrombocytopenia is 2.6%. Use of unfractionated heparin for 1 month or more has been associated with a 2–3% risk of symptomatic vertebral fractures.
- Predominately binds to antithrombin, and functions as a factor Xa inhibitor. The risk of heparin- induced thrombocytopenia is 0.2%. The risks of osteoporosis and decreased bone mineral density are significantly lower among those patients treated with low-molecular- weight heparin than with unfractionated heparin.
- Inhibition of Vit K dep factors.
- Fetal warfarin syndrome is caused by exposure to war- farin between 6 weeks and 12 weeks of gestation. Fetal warfarin syndrome can be characterized by nasal hypoplasia, stippled bone epiphyses, chondrodysplasia, hydrocephaly, microcephaly, ophthalmologic abnormalities, IUGR, and developmental delay. There also is an increased risk of spontaneous abortion, stillbirth, and neonatal death in pregnancies exposed to warfarin.
5. Warfarin is considered safe in women who are breastfeeding because it does not accumulate in the breast milk.
- Transitioning to unfractionated heparin is recommended at approximately 36–37 weeks of gestation.
7. For women with a high risk of thrombosis, anticoagulation should be restarted following delivery. For a vaginal delivery, anticoagulation may be restarted 4–6 hours after delivery. Anticoagulation can be restarted 6–12 hours after a cesarean delivery. If the patient had neuraxial anesthesia, anticoagulation should be restarted 24 hours afterward and 4 hours after the removal of the epidural.
8. 12h for ppx, 24 for therapeutic
Pearl:
Low-molecular weight heparin has a longer half-life, a more predictable therapeutic response, less bone mineral density loss, and a lower risk of heparin-induced thrombocytopenia. Neither can cross the placenta.
13
Q
What malformations are the following antiepileptics at risk for?
- Valproic Acid
- Carbamazepine
- Phenytoin
- Tricyclic antidep.
- Drug of choice for bipolar disorder med while breastfeeding?
A
- NTD (WORST): highest risk of fetal malformations of the antiepileptic medications and is associated with neural tube defects, heart defects, cleft palate, hypospadias, polydactyly, craniosynostosis, limb anomalies, facial dysmorphism, neurodevelopmental delay, and autism spectrum.
- NTD
- Hypoplastic nails, flat facies, IUGR, VSD, cleft palette
- Limb anomalies
- valproic acid
14
Q
APGAR stands for?
Assign scoreS:
A newborn girl is pink; the soles of her feet and hands are blue; and her heart rate is 99 beats per minute (bpm). She is crying with active motion and good respiratory efforts.
A newborn boy is pale and has a weak cry, grimaces, and some flexion. His heart rate is 160 bpm.
A newborn boy is completely pink and his heart rate is 120 bpm. He has a weak cry, flexes somewhat, and grimaces in response to stimulation.
A
Appearance, Pulse, Grimace, Activity, Respirations
8
5
7
15
Q
Who gets baby ASA in pregnancy?
A
Low-dose aspirin (81 mg/day) prophylaxis is recommended in women at high risk of preeclampsia and should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks) and continued daily until delivery.
One of these:
- Hx of Preeclampsia
- Twins
- autoimmune disease (lupus, antiphopholipid)
- Hypertention
- Diab type 1 or 2
- Renal disease
Two or more of thesE:
- First pregnancy
- Obese
- Adv mat age
- low socioecomic status
- mom os sister with h/o preE
- Personal hx (low birth weight, preior poor outcome)
16
Q
- What are the Asthma Severity Categories.
- Examples of inhaled corticosteroids? Long acting beta agonists?
- What happends to FeV1 and FEV1 / FVC in asthma?
A
- See Photo
- Corticosteroids: Budesinide, beclomethasone, fluticasone
LABA: salmeterol
- Both go down (in restricitve, FEV!/FVC normal)
17
Q
When can you use bactrim? What is the fetal risk?
How about Macrobid? What is the fetal risk?
A
Bactrim
- 2nd tri only (risk: kernicterus in preterm or < 2m age)
Macrobid
- avoid 1st tri or if preterm or <1m age (risk hemolytic anemia)
18
Q
- Citrate in blood products chelates __ and __. What about K?
- Blood transfusions resulst in what pH change ___.
A
- Calcium (mostly) and Mag (less so).
Contains K!
- Citrate is metabolized and used to generate bicarbonates. If the latter is not adequately excreted in the urine, metabolic alkalosis can occur.
19
Q
- T or F: Termination of pregnancy has been shown to improve the prognosis of pregnant women with breast cancer.
- During what trimesters can chemo for breast cancer be administered in pregnant women?
A
- False
- Adjuvant chemotherapy is known to decrease the risk of breast cancer recurrence. Because of its teratogenic effects, chemotherapy in the first trimester is contraindicated. Chemotherapeutic agents used for the treatment of breast cancer can be used in the second and third trimesters without increased risk of fetal malformations.
20
Q
- Strict contraindications to brestfeeding…
- Stage 1 vs stage 2 lactogenesis…how do they differ?
3. How is a clogged duct different from a galatocele?
- There is no contraindication to breastfeeding after gadolinium administration for an MRI. T or F
A
- HIV, HTLV, active TB, galactosemia, illicit drug use, cancer chemotherapy, radiation, antiretrovirals, methotrexate
- Stage 1 during the second half of pregnancy. Stage 2 triggered by decrease in Progesterone and increase in Prolactin.
- Galactoceles are not painful.
- T
21
Q
- Mechanism of action of bupenorphine vs methadone.
- Suboxone (bupe+naloxone) is usually not used in preg. T or F
3. Can women breastfeed on these?
A
- Bupenorp: partial agonist & Methadone: full agonist
- True!
- Yes. ACOG recomends so!
Salient points:
the first-line medications for the treatment of opioid use disorder during pregnancy are methadone and buprenorphine opioid agonists, which have been shown to be safe in pregnancy, decrease the use of illicit drugs during pregnancy, improve maternal health and nutrition, improve compliance with prenatal care, and reduce maternal and neonatal morbidity and mortality. For pregnant women, pharmacotherapy for opioid use disorder is typically administered via an induction and maintenance regimen. This regimen consists of medication initiation, the incremental uptitration of medication dose until the patient’s withdrawal symptoms are eliminated, and the continuation of medication through the postpartum period and as long as needed.
22
Q
Indications for Cerclage
A
History
- History of one or more second-trimester pregnancy losses related to painless cervical dilation and in the absence of labor or placental abruption
- Prior cerclage due to painless cervical dilation in the second trimester
Physical Examination
• Painless cervical dilation in the second trimester
Ultrasonographic Finding With a History of Prior Preterm Birth
Ultrasonographic Finding With a History of Prior Preterm Birth
•Current singleton pregnancy, prior spontaneous preterm birth at less than 34 weeks of gestation, and short cervical length (25 mm or less) before 24 weeks of gestation.
23
Q
Cystic Fibrosis
- Inheritance pattern?
- What is the next step if a couple in which male has no vas def and had a neg panel?
A
- AR
- Assume that the male is a positive carrier of a denovo mutation and test mother.
24
Q
Cholecystitis management in pregnancy.
Who goes to the OR, always?
In the absence of such indications for urgent or emergency surgery, the optimal treatment for acute cholecystitis depends on the gestational age:
- If 1st or 2nd tri: __
- If 3rd tri: __
A
Definitive, prompt surgical therapy is required for any patient with cholecystitis and signs of sepsis, suspected gangrene, or perforation, as well as disease progression while on antibiotic therapy.
- Operating Room! (OR)
- OR
3. Antibiotics, Fluid
25
**Cholestasis:**
Maternal characteristics associated with a higher risk...
Maternal characteristics associated with a higher risk of ICP include **multiple gestation**, **in vitro fertilization treatment**, **hepatitis** C positive status, and advanced **maternal age**
26
Potential benefits fo circumcision..
Decreased urinaty tract infections, decreased HIV, decreased penile cancer, decrease cervical CA, increased hygiene
27
0. CMV is the most common congenital viral infection. T or F
1. T or F. CMV is the leading cause of **non-hereditary hearing loss**.
2. What are the symptoms of infection?
3. How do we test mom? Fetus?
4. When interpreting IgG, a new finding of positive IgG or a 4x increase in titer is indicative of new infection. T or F
5. Fetal sequelae include...
6. Neonatal squelae include...
7. Fetus most vulnerable during what trimester?
0. T (2% of all neonates)
1. True
2. Often **asymptomatic (90%)** in adults, but symptoms of infection may include fever, chills, myalgias, and malaise (**flu like**).
3. IgM & IgG. We Use avidity testing (low =new). CANNOT use IgM alone, **must always use IgG avidity to help you.** PCR of amniotic fluid for infant.
4. T
5. **_Echogenic bowel**_, _**IUGR, *periventricular*_** *calcification*s, **hepatosplenomegaly**
6. **_Hearing loss**_, _**neurodev delay,_** microcephaly, retinopathy, cns, hepatosplenomegaly, dec visual acuity
7. **2nd**
28
1. Criteria for confirmation of term pregnancy include...(3)
1. **US measurement at less than 22 wk supporting a diagnosis of \>39 weeks**
2. **FHT present for 30 weeks by doppler**
3. **36 weeks elapsed since +UPT/HCG**
29
1. Normal cord blood gases.
2. What component of the umbilical cord blood that is most consistent with a neurologic injury that is a result of an acute intrapartum event?
1. Ph **7.28**, CO2 **50**, Bicarb **23**, Bace defecit **-3.6**
2. **Base excess!**
30
What is the preferred treatment for a C-section scar ectopic?
Intrasac MTX + KCL
When a D&C is performed, it should be preceded by uterine artery embolization to minimize risk of bleeding.
31
How does one interpret a CST?
What does one do with an equivoval CST?
T or F: CST has good negative predictive value.
+ (lates w/ \>50% CTX)
neg (no decels)
eq (some lates or variables) -\> **repeat in 24 hrs**
True
32
Delivery timing:
1. Poly
2. **Oli**
3. Mono-mono twins, mono di twins, didi twins
4. Prior Classical
5. **Prior myomectomy**
6. Prior rupture
7. **Vasa previa**
8. Accreta, increta, percreta
9. **Previa**
1. **Poly**: **39w0d**
2. **Oli**: as early as **36w0d**
**3.** Mo-Mo **32** (admit at 28 wk) 2. Mo-di **34** 3. di-di **38**
4. Prior Classical: 36w0d
5. Prior myomectomy: 37w0d
6. Prior rupture: 36w0d
7. Vasa previa: 34w0d
8. Accreta, increta, percreta: 34w0d
9. Previa: **36w0d**
33
Depression:
1. Blues vs Depression
2. Score for + scale: \_\_\_
3. Score for ED referral: \_\_
4. In non pregnant pts, what is the initial SSRI of choice?
1. Postpartum blues is a transient condition characterized by several mild depressive symptoms such as sadness, crying, irritability, anxiety, insomnia, exhaustion, and decreased concentration, as well as mood lability that may include elation. Symptoms typically develop within two to three days of delivery, peak over the next few days, and **resolve within two weeks of onset.**
The two disorders are distinguished in that the diagnosis of postpartum blues does not require a minimum number of symptoms, whereas major depression requires a minimum of five symptoms. In addition, the symptoms of postpartum blues are generally self-limited and resolve within two weeks of onset.
**\>=12 or 10**
**\>=20 / HI/SI**
Although scores of 12 and above identifies most women with postpartum depression, a cut-off of 10 or more is preferred in many practices. **Patients with a score between 5 and 9 should be re-evaluated within a month**
**Sertraline**
34
(A) Atopic eruption of pregnancy
(B) Intrahepatic cholestasis of pregnancy
(C) Pemphigoid gestationis
(D) Polymorphic eruption of pregnancy (PUPPS)
(E) Psoriasis
**(A) Atopic eruption of pregnancy:** the **most common pruritic skin condition** of pregnancy. Pruritus, prurigo lesions/ excoriations, and eczematous-like skin lesions; secondary infection due to excoriations. 66% present with widespread eczematous changes affecting typical atopic sites; 33% have small pruritic, erythematous papules on trunk and limbs.
**(B) Intrahepatic cholestasis of pregnancy:** Severe pruritus with no primary skin lesions occurring with or without jaundice. Onset on palms and soles to later become generalized; secondary lesions such as excoriations, scratch marks, and prurigo nodules might develop.
**(C) Pemphigoid gestationis:** Pruritic urticarial papules and annular plaques followed by vesicles and finally large tense bullae on an erythematous background. Eruption site **is the _periumbilical area (most common)_**,
rest of the abdomen, thighs, palms, and soles. Rx: Oral and topical corticosteroids. ***_Risk of premature birth and small-for-gestational-age infants._***
**(D) Polymorphic eruption of pregnancy (PUPPS):** Intensely pruritic urticarial rash with erythema- tous, edematous papules, and plaques, developing into polymorphic features such as papulovesicles, erythema, and annular wheals. Onset on the abdomen with **sparing of the umbilical region** as a characteristic finding, which later spreads to thighs, buttocks, and back. Topical corticosteroids; oral antihistamines; oral corticosteroids. **3rd tri. Primes. inc mat weight gain. multifetal gest.**
**(E) Psoriasis:** silvery, scaled plaque with an erythematous base that is itchy and painful, and may crack or bleed. The majority of patients with psoriasis will have **improvement in their symptoms** during pregnancy, but the symptoms appear to worsen in approximately 20% of pregnant patients. Initial management is accomplished with topical corticosteroids.
35
1. **Most common cause of adult diarrheal illness:**
2. Most common cause of child diarrheal illness:
3. Treatment for giardia:
4. Treatment for shigella, salmonella, ecoli:
5. **Treatment for campylobacter:**
6. Travelers diarrhea cause and **treatment**? **prophylaxis**?
7. **C. Diff treatment.**
1. Most common cause of adult diarrheal illness: **norovirus**
2. Most commonca use of child diarrheal illness: **rotavirus**
3. Treatment for giardia: **metronidazole**
4. Treatment for shigella, salmonella, ecoli: **cipro**
5. Treatment for campylobacter: **erythro**
6. Enterotoxigenic e coli; Cipro or Azithro (pregnant); Antimicrobial prophylaxis is not routinely recommended but may be indicated in patients at high risk of complications from diarrheal illness. **Rifaximin is the prophylactic drug of choice.**
7. **PO Vanc** or oral **fidaxomicin** are first line! PO flagyl is second line
36
**Degeorge is casued by a deletion in 22q11**
What are its features?
Mode of inheritance?
**CATCH22**
**C**ardiac anomalies
**A**bnormal facies
**T**hymic abnormalities
**C**left palete
**H**ypoCalcemia
22
**Autosomal dominant**
37
T or F: complete breech position is associated with greater ECV succes (compared to frank breech).
True
38
Echogenic Intracardiac Focus
1. How to manage in preg with normal genentics?
2. If no prior genetic testing or AMA?
1. Routine follow-up
2. Offer dx testing + targetted anatomy scan
39
**Hydralazine**, **Labetalol**, **Nifedipine** are the drugs of choice for hypertensive emergencies....what are the:
- Doses
- Timing intervals for administration
- Side effects
- Mechanism of action
Hydral (**10mg--\>10mg--\>labetalol 20mg**) (mat hypotenison, HA, tremor) Measure **q20min**
*peripheral smooth muscle relaxant.*
Lab (20/40/80) (avoid if asthma, heart diseasez, heart failure) Measure q10min
**Nonselective beta + and Alpha 1 Blocker.**
Nifedipine (**10/20/20**) (reflex **tachy**, **HA**) Measure q20min
Ca channel blocker.
40
Prophylaxis against infective endocarditis is not recommended for **non-dental** procedures in the absence of active infection. **T or F**
Prophylaxis against infective endocarditis is reasonable for the following patients at highest risk of adverse outcomes from infective endocarditis:
**True**
* -Patients with **prosthetic cardiac valve** or prosthetic material used for cardiac valve repair
* -Patients with **previous infective endocarditis**
* -Patients with **CHD**:
* --Unrepaired cyanotic CHD, including palliative shunts and conduits
* --Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure.
* --Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (both of which inhibit endothelialization)
* -**Cardiac transplant recipients** with valve regurgitation due to a structurally abnormal valve.
The use of prophylactic antibiotic therapy be considered for vaginal delivery in patients with the highest risk of adverse outcomes from endocarditis. Those at highest risk are **women with cyanotic cardiac disease, or prosthetic valves, or both**. Mitral valve prolapse is not considered a lesion that ever needs infective endocarditis prophylaxis. For those not already receiving intrapartum antibiotic therapy for another indication that would also provide coverage against endocarditis, antibiotic regimens for endocarditis prophylaxis can be administered as close to 30–60 minutes before anticipated time of delivery as is feasible.
41
Epidural timing in the setting of anticoagulation. ACOG chart.
For prophylactic anticoagulation, 12hrs.
For therapeutic anticoagulation, 24hrs.
42
What is the most common preventive casue of intellectual dissability and its features?
Fetal Alcohol Syndrome:
short palpebral fissure, thin vermillion border, smooth philthrum
43
Fetal Head Injuries
1. Caput sucedaneum
2. Cephalohemoma
3. Subgaleal
4. Which is most common with vaccum?
1. pitting edema that crosses suture lines
2. over parietal bones, DOES NOT CORSS SUT lines
3. crosses lines
4. cephalohematoma
44
T or F: Cesarean delivery is the most common complication associated with myomas.
True
## Footnote
This increased rate is likely secondary to an increased rate of malpresenta- tion, dysfunctional labor, placental abruption, intrauterine growth restriction, placenta previa, and preterm prelabor rupture of membranes.
45
Flu
1. What is the prophylaxis after exposure
2. Treatment
3. Treatment of pyelonephritis if admitted and pregnant
Postexposure antiviral chemoprophylaxis can be con- sidered for pregnant women and up to 2 weeks postpa tum for women who have close contact with someone likely infected with influenza.
1. Chemoprophylaxis is **oseltamivir phosphate 75 mg daily for 10 days**.
2. **oseltamivir phosphate 75 mg** BID x5days
----------------------
3. Pyelo: amp/gent *or* 3rd ger ceph
46
Specific uses for:
Piper
Kielland
SimpsOn
-------
T or F: Moter vehicle accidents are the most common cause of trauma in pregnancy.
What is the diffetence between outlet, low, and mid forceps?
Pipper: Breech
Kielland: Rotation/Asynclitic
SimpsOn: mOlding
***Domestic violence* is the most common cause of trauma in pregnancy.**
**Low: +2 or greater**
**mid: less than +2**
**outlet: scalp visible at introitus**
**rotation f \>45degree correction**
47
1. How do we treat Group A Strep?
2. What if allergic? What is the microbiological description of the bacteria?
--------------------------
3. What is the Rx for **Necrotising fasciatis** in addition to emergent surg debridement?
--------------------------------
4. Toxic shock syndrome is a life-threatening condition caused by the release of toxins from what bacteria?
------------------
5. What is the difference between staphylococcal and streotococcal toxic shock syndrome?
1. Penicilling + Clinda (Treats toxin)
(**M Protein** is the major virulence factor)
2. Vanc if allerigic
**G+ cocci in pairs and chains**
---------------------------------
3. A Penem (or Zosyn) + Vanc + Clinda
------------------------------
4. Toxic shock syndrome is a life-threatening condition caused by the release of toxins from the **Staphylococcus aureus** bacteria.
------------------
The casusative agent agent.
48
What are the approved Rxs for GBS+ in non-PCN allergic patients?
**Penicillin G**, 5 million units IV as initial dose, then 2.5–3 million units every 4 hours until delivery
**OR**
Ampicillin, 2 g IV as initial dose, then 1 g IV every 4 hours until delivery
49
1. What should the diet of gestation diabetic consist of?
2. What types of agents are glyburide and metformin?
**Carbs: 40%**
**Fat: 40%**
**Protein: 20%**
Generally will start with restricting daily caloric intake to approximately 2,000 calories per day depending on patient’s body mass index.
Metformin:biguanide that inhibits hepatic gluconeogenesis and glucose absorption and stimulates glucose uptake in peripheral tissue
Glyburide: sulfonylurea, increases insulin secretion, avoid if sulfa allergy!
50
# Define:
1. Plietropy
2. Variable Expresivity
3. Incomplete Penetrance
* Plietropy: The phenomenon in which a single gene disorder manifests in multiple organ systems or in multiple ways, such as in Marfan syndrome.
* Variable expressivity refers to a phenomenon in which all patients manifest the disease in some fashion, but patients are affected differently. An example is cystic fibrosis.
* Incomplete penetrance, in which some patients have no manifestations
51
Genetics Yield after IUFD
## Footnote
T or F Amniocentesis before delivery provides the greatest yield.
T or F Umbilical cord proximal to placenta if amniocentesis declined.
T or F Fluorescence in situ hybridization may be useful if fetal cells cannot be cultured.
All true
52
Fetal or embryonic tissue.
Hydatidiform swelling of chorionic villi.
Trophoblastic hyperplasia.
Trophoblastic stromal inclusions.
Genetic parentage.
Karyotype.
Persistent b-hCG.
53
1. Diagnostic criteria for HELLP.
**Hemolysis** characterized by **schistocytes** on blood smear, **total bilirubin of 1.2** mg/dL or more, **lactate dehydrogenase greater than 600** international units/L, or serum **haptoglobin concentration 25 mg/dL** or less
**Elevated liver enzyme**s with alanine aminotransferase and aspartate aminotransferase greater than 70 international units/L, or twice the upper limits of normal
**Platelet** count less than 100,000/mm3
\*\*\*Unlike preeclampsia, proteinuria and hypertension are absent approximately 15% of the time in women diagnosed with HELLP syndrome.\*\*\*
54
HepB
1. At what VL do we treat and with what agent?
2. How are newborns of mothers with hepB treated?
**6–8 log10 copies/mL (\>200,000 Copies)**.
**Tenofovir** has been suggested as the first-line agent for this antiviral therapy.
Newborns get the **vaccine** + **IVIG**.
55
1. Immune due to natural infection.
2. Immune due to vaccination
3. Acutely Infected
4. Chronic Infection
5. The risk of vertical transmission of hepatitis C is approximately 2-8%. The top 2 risk factors are:
5. _High maternal titer_ and _prolonged rupture of the membranes_ (OR 9.3).
56
Drug of choice for anticoagulation if history of HIT and pregnant? What is the mechanism of action?
MOA of:
**Dabigatran.**
**Edoxaban**, **betrixaban**, and **rivaroxaban.**
**Fondaparinux** is the drug of choice for anticoagulation in patients with a history of heparin-induced thrombocytopenia. Fondaparinux binds to antithrombin III and accelerates the **_inhibition of factor Xa_**.
**Dabigatran** is an **_oral thrombin inhibitor._**
**Edoxaban, betrixaban, and rivaroxaban** are *anti-Xa inhibitors*.
These medications should be avoided in pregnancy because there is inadequate information on safety. These medications do cross the placenta and may compromise fetal coagulation.
57
1. Why do we avoid efavirenz in pregnancy?
2. What do we do with patients on Stavudine or Didanosine?
3. The concomitant use of methergine and protease inhibitors has been associated with what?
4. If VL \> 1000, what are the recommendations?
5. Artificial rupture of membranes and duration of rupture of membranes are not associated with an increased risk of perinatal transmission when VL \< 1000. T or F
6. Studies have shown that the risk of HIV transmission from breastfeeding is up to approximately 15%. In the USA is is alwasy contraindicated to BF. T or F.
7. What is the risk for vertical transmission w/ viral load \>1000 and:
- AZT+SVD
- CD + AZT
- SVD VL\<1000
1. No **Efavirenz** before 8 weeks of gestation because of the medication’s increased risk of **neural tube defects**.
2. Those on a combination of stavudine and didanosine before pregnancy should be switched to a different regimen because of this combination’s adverse effect of **lactic acidosis** in pregnant women.
3. **Exaggerated vasoconstrictive response**!
4. Intravenous zidovudine **at least 3 hours before cesarean delivery**. Additionally, cesarean delivery should be performed at **38 weeks** of gestation before onset of labor, or rupture of amniotic membranes (and without an amniocentesis for fetal lung maturity), or both.
5. True
6. True
7. risk for VT w/ VL \>1000 and
- AZT+SVD **25%**
- CD + AZT **5%**
- SVD VL\<1000 **2%**
58
1. For women with a CD4 count less than 200, what vaccines are contraindicated?
2. What is the next step following a 4th gen positive HIV test?
3. What is the preferred regimen for HIV treatment in preg?
4. If using \_\_, delay pregnancy 8 weeks.
1. Live ones such as Varicella, zoster, and MMR
2. HIV1/2 differentiation assay -\> if neg, RNA levels sent
3. x2 NRTI (usually zidovudine/lamividine)+ 1 protease inhibitor
4. efavirenz
59
How is HSIL cytology managed in pregnancy?
Colpo, no ECC, with biopsy.
If CIN2-3, surveillance colpo Q12 weeks is preferred.
Repeat biopsy if invasion suspected or lesion appearance worsens
Do not RX!
60
The highest risk of vertical transmission of herpes simplex virus is \_\_\_\_. With ruptured membranes, the risk is estimated at \_\_\_%.
Among women with recurrent lesions at the time of delivery, the rate of transmission with a vaginal delivery is \_\_\_%.
3rd tri nonprim 1st episide or primary episode, you can offer CD. T or F
How long is assymptomatic shedding in recurrent episode.
The highest risk of vertical transmission of herpes simplex virus is during a **primary** outbreak at the time of delivery. With ruptured membranes, the risk is estimated at 30–60%.
Among women with **recurrent** lesions at the time of delivery, the rate of transmission with a vaginal delivery is only 3%. These women should also undergo cesarean delivery.
True
2weeks
61
1. What are theca lutein cysts (hyperreactio luteinalis)?
2. Pregnancy luteoma?
3. Hilus cell tumors?
4. Sertoli-Leydig?
1. Bilateral cystic ovarian enlargement; usually resolves PP; usually no fetal virilization.
2. Pregnancy luteomas are benign and can vary in their ultrasonographic appearance with solid, cystic, or complex ovarian masses. The masses often are 6–10 cm, multinodular.
3. Rare in pregnancy!
4. usualyl small, at the hilus, usually secrete androgens and prevent ovulation so rare in preg
Other causes of hyperandrogenism include: congenital adrenal hyperplasia, ovarian or adrenal tumors benign and malignant, placental aromatase deficiency, and exogenous androgen exposure.
62
Hyperemesis gravidarum
1. 1st line treatment? if this fails, how to escalate?
2. Why was high dose ondansetron removed from the market? What is the risk of methylpref before 10wk GA?
3. The first-line treatment for nutritional support should be:
4. Why include thiamine in the IVF?
1. Pressure points, convert PNV to just folic acid, ginger capsules. If fails, Pyridoxine (vitamin B6) as monotherapy, or in combination with doxylamine, is safe and effective.
NEXT: **benadryl**, **compazine** (prochloperazine), **phenergan** (promthazine).
Next: **Zofran** or **trimethobenzaprine**
Worst: methylpred or thorazine (chlorpromazine)
Ondansetron is associated with maternal risk of arrhythmia, in particular **prolongation of the QT interval**
Methylprednisolone use in the first trimester has been associated with **fetal oral clefts** so this medication should be avoided before 10 weeks.
The first-line treatment for nutritional support should be **enteral tube feeding** through either nasogastric or nasoduodenal tube while continuing with antiemetic pharmacotherapy.
Thiamine should be included with the intravenous hydration for the described patient to prevent Wernicke encephalopathy.
63
1. Neonatal symptoms of hypothyroidism?
2. Hyperthyroidism increases the risk of fetal what? Hypothyroidism increasses fetal risk of what?
3. T or F : **Both** methimazole and PTU are associated with transient leukopenia.
4. When does acog recomend thyroid screening in the general population?
1. Lethargy, hoarse cry, feeding difficulty, constipation.
2. Thyroid
* hyperthyroidism: increases the risk of **heart failure, hydrops**, and risk of **preeclampsia** with severe features among others, **PTB**
* **hypothyroidism:** sab, PTB, stillbirth, abruption, low birth weight, neurodevelopmental delay
3. True
4. Screening should begin at **older than 19 years in women with risk factors** such has family history of hypothyroidism, symptoms of hypothyroidism (cold intolerance, dry skin, forgetfulness, abnormal uterine bleeding, fatigue), and personal history of autoimmune diseases. The American College of Obstetricians and Gynecologists also recommends **routine screening at the age of 65 years**.
64
1. PKU (and avoid what food)
1. Phenylketonuria is an **autosomal recessive disorder** of Phenylalanine (Phe) metabolism.** Avoid protein**. Increased blood Phe levels are toxic to the developing fetal brain.
65
Isotretinoin
Thalidomide
Fetal **hydrocephaly** and **microtia**, **craniofacial**, **cardiovascular**, neurologic, and thymic.
The pharmacokinetics of elimination varies among patients, so there is not a clear recommendation for the duration of contraception after therapy, **but 3 months has been suggested.**
**Phocomelia** is the most dramatic birth defect associated with prenatal use of thalidomide.
66
What are the laboratory studies most likely to provide useful information after delivery regarding the cause of fetal death?
**placental histology, perinatal postmortem evaluation**, and karyotype of the infant
67
1. When do we deliver IUGR in general?
2. How do doppler results affect delivery timing?
1. **38w0d**-39w6d
68
1. Types of Labor Anesthesia (Photo)
2. Into what space is the spinal needle placed?
3. Pudendal Nerve roots.
1. see photo
2. subarachnoid
3. S2-S4 (vs T10-L1)
69
Lemon and banana sign =?
NTD
70
Sx of Listeria...
How is *Listeria* managed if:
1. Exposed and no symptoms...
2. Symptoms but no fever...
3. Symptoms and fever
In pregnant patients, the disease course is usually mild, with symptoms similar to **influenza**, but the fetal effects may be severe. Preterm birth, neonatal sepsis, meningitis, death, and intrauterine fetal demise have all been reported in association with listeriosis in pregnancy.
The management of patients with exposure depends on subsequent symptoms.
**Those who are asymptomatic do not need testing or treatment and should be instructed to report symptoms within 2 months of the suspected exposure.**
Patients who have symptoms but **_no fever**_ may be managed expectantly or have blood cultures drawn. Health care providers can consider empiric antibiotics pending _**blood_** culture results if the patient’s history is compelling for true illness.
**_Patients who have an exposure and develop symptoms and a fever (ie, temperature greater than 38.1°C [100.6°F]) should be tested and treated at the same time._ Treatment typically is accomplished with intravenous ampicillin, often with (gentamicin) [use trimethoprim-sulfamethoxazole for penicillin-allergic patients]. Because listeriosis is a nationally reportable illness, health care providers _should notify local health departments_.**
_Granulomatosis infanticeptica (abcesses)._
71
Low-lying placenta is defined by placental tissue lying within __ cm of the internal os.
Within 2 cm of the internal os
72
There are two main types of malpractice policies: **occurrence** and **claims-made**.
What is tail coverage?
Define these...
**Occurrence** policies provide coverage for incidents that occur while the policy is in place, regardless of when the claim is filed.
**claims-made policies** cover liabilities that happen while the policy is in effect.
**Tail coverage** allows claims-made policies to cover ongoing liabilities after changing jobs, insurance carriers, or in retirement
Claims-made policy assures coverage for claims that arise from events that take place and are reported while the policy is in force. The premiums are initially low because the potential for claims is minimal, but the rates are raised over time as the likelihood for claims increases. A claims-paid policy provides coverage when a claim is made regardless of when the claim occurred. Tail coverage protects the physician against claims reported after the termination of a claims-made policy for events that occurred when the policy was in effect.
73
Management of :
1. Mentum anterior
2. Mentum posterior
3. Brow
4. Compound
5. Shoulder
1. A ok!
2. CD
3. frontum...expectant if large pelvis, small baby, adequate progress
4. SVD
5. CD
74
Marfan
1. Inheritance pattern
2. Aortic Root that is "OK" to labor:
1. AD
2. \<40mm
75
Mastitis:
1. Most common organism.
2. Rx (2 most common). PCN all?
3. If MRSA?
4. Breastfeed or not after I&D?
1. The most common organism is **Staphylococcus aureus**, including strains of methicillin-resistant S. aureus. Streptococci and Staphylococcus epidermidis also are frequently identified.
2. Diclox (or keflex); erithro if PCN allergy
3. MRSA (bactrim or clinda); dont use doxy because can stain teeth of infant; dont use bactrim if \< 1yr and breastfeeding
4. Feed!
If admitted, vanc!
76
Miso is PGE\_
Dinoprostone is PGE\_
Mothers taking **amioderone** are exposed to excess Iodione and have an increased risks of fetal \_\_\_.
1. 1
2. 2
3. hypothyroidism and neurodevelopmental issues
77
1. Gentamycin is is a/w:
2. What meds CI in G6PD?
3. How are ESBL urinary infections treated?
4. Treatment for pyelo
1. fetal ototoxicity
2. TMSM, macrobid
3. Extended Spectrum Beta-Lactamase (ESBL); meropenem
4. 3rd gen cephalosprin
78
1. Contraindications to Mg Sulfate? Alternatives?
2. What is the order and the levels of Mg for toxicity? (loss of reflexes at \_\_? resp depression at \_\_? Cardiac toxcity at \_\_?)
3. Reversal agent?
4. Intrmuscular Magnesium course is: 10g then \_\_g Q4hours.
1. **myesthenia**, **hypoCa**, **renal failure**, cardiac **ischemia**, heart **block**, **myocarditis**;
Alternatives: Keppra/Phenytoin/diazepam
2. Photo
3. Cagluconate 10% IV
4. 5g q4
79
Monochorionic Pregnancies
1. When to start fluid checks?
2. Deliver at?
3. Quintero
1. 16 weeks
2. 32 weeks (admit at 28)
3. Oli/poly, bladder, doppler, hydrops, death
80
Certain medications can unmask or worsen the symptoms of myasthenia gravis and should be avoided in pregnancy. Which are these?
These medications include **succinylcholine** and related anesthetics as well as **antiarrhythmic** medi- cations such as **quinidine**, **calcium channel blockers**, **β-blockers**, **aminoglycosides**, **fluoroquinolones**, **macrolides**, and **magnesium** salts.
81
What do you do after needle stick injury if Hep C?
The exposed health care worker, as well as the source, should be **tested for the antibody to hepatitis C virus.** Postexposure prophylaxis against hepatitis C virus is not effective and is not recommended.
82
1. Anterior perineum is innervated by what 2 nerves \_\_.
1. Ileoinguinal + genitofemoral
83
NRP
1. Next step if gasping, apnea, or HR \<100
2. HR \<60
\_\_\_\_ is the most succesful indication of responce.
1. PPV
2. Chest Comp
Heart Rate is the most succesful indication of responce.
84
Increased nuchal translucency also is an important marker for what congenital issue?
\<3 disease
## Footnote
Major cardiac defects were diagnosed in 4.5% of fetuses with an increased nuchal translucency measurement and a normal karyotype in a study conducted in a large referral unit for fetal medicine and fetal cardiology
85
Omphalocele can be seen with what conditions?
Beckwith-Wiedeman
Pentology of Cantrel
Cloacal extrophy
86
1. How do you treat stage 1C germ cell ov cancer in pregnancy?
1. BEP after 1st tri if \> stage 1B.
87
Duchanne-Erb
Klumpkys
(Name the defect and spinal levels)
Which is most common after SD?
DE: **C5-7**, paralysis of shouolder and elbow flexor (Waiter's tip)
KL **C7-T1** Claw hand
Erb is most common.
88
ParvoB19 is a respiratory virus to which 50% of women are immune.
1. What are the symptoms in adults?
2. What fetal cells does Parvo attack?
3. How do you test for Parvo in mom? fetus?
4. If a patient is exposed, how are the following managed:
**IgM pos**
**IgM neg**
5. T or F: Patients with _documented parvovirus infection_ during pregnancy should be followed with serial ultrasound evaluation for at least 8 weeks after exposure to evaluate for hydrops (and anemia by middle cerebral artery peak systolic velocity).
1. Although children typically demonstrate the classic “slapped cheek” facial rash, adults who develop symptoms of the infection more often present with a **reticular rash** on the trunk and peripheral **arthropathy**. The fetus is most vulnerable to infection in the **second** trimester
2. RBC precursors, placing infant at risk for non-immune hydrops (most common cause).
3. IgG and IgM; PCR of Fluid
4. IgM pos --\> sono for hydrops --\> if present, MCA dopplers --\> PUBS --\> transfuse.
If IgM neg, repeat IgG in 3-4 weeks.
5. True
89
\_\_% of patients with penicillin allergy are allergic to cephalosporins.
What are the characteristics of SEVERE PCN allergy?
1%
Patients with type I reactions classically present with urticaria, angioedema, laryngeal edema, wheezing, and hypotension, with or without cardiorespiratory failure.
90
PCO \> __ is abnormal in pregnancy.
35
91
1. OB conjugate vs diagonal conjugate.
2. GYN, Anthro, android, plat
1. OB (mid PS to sacrum), Dig (lower edge of PS to sacrum)
2. Photo
92
PEP for HIV should be given within what timeframe from exposure? If passed this timeframe, when do you retest?
HIV screening is recommended once during what age range?
72 hours. If past 72 hours, retest at 6w, 3m, 6m.
13-64
93
After CPR for how many minutes should an emergent c-section be done?
4min
94
Peripartum CMO typical drugs of choice, and order of drugs used.
T or F: Combined hormonal contraceptives are contraindicated in all women with peripartum cardiomyopathy.
The best data support that women who recover with an ejection fraction \<**50%** have a recurrence risk of \_\_% and \_\_% risk of maternal mortality.
Peripartum cardiomyopathy is defined as heart failure in the **last month of pregnancy**, or **within the 5 months after delivery**.
1. **Diuretics** are the first-line treatment for heart failure. These dec preload and improve pulm congestion.
2. **β-blockers**, especially metoprolol, carvedilol, and bisoprolol, have been shown to ***decrease mortality in heart failure*** and, therefore, are recommended for all patients with heart failure unless specific contraindications exist, once euvolemia established.
3. _vasodilator, such as an **ACE** inhibitor or **ARB (not if Breast feeding)**, usually is added after diuretics are initiated_.
True. Progesterone-only options and intrauterine devices are reasonable alternatives.
The best data support that women who recover with an ejection fraction of at least 50% have a **recurrence risk of 21% and no statistically increased risk of maternal mortality**. Women who **recover with an ejection fraction \<50% have a recurrence risk of 50% and maternal mortality risk of almost 16%.**
95
**Periviable Birth**
1. T or F: All interventions can be **considered** at \>= ? weeks.
2. T or F: All interventions are **recommended** at \>= ?.
3. At what GA is CD recommended for periviable birth?
4. What can be ordered at 20-21weeks vs 22weeks?
1. True
2. True
3. 25 weeks
4. At 20 can consider ABX. At 22 weeks can consider ABX + Resusitation.
96
T or F: The greater the AFI, the more likely the etiology is related to a fetal abnormality.
T or F: Idiopathic polyhydramnios accounts for nearly 50% of polyhydramnios cases.
AFI peaks at __ GA.
The greater the AFI, the more likely the etiology is related to a fetal abnormality. In one study, severe polyhydramnios, which is defined as 35 cm or greater, was associated with the highest rates of prenatally diagnosed congenital anomalies (79%).
True
32-33
97
Post-term pregnancy risks
**oligohydramnios**, **meconium**, **macrosomia**, birth trauma, long nails, dry skin, lanugo, hypoglycemia, polycyhtemia, PPHTN, asphyxia, sezires, palsy, iufd
98
Values for the PP 75g GTT.
99
Restart PP anticoagulation how long after VD or CD?
What if had an epidural?
The optimal time to restart anticoagulation therapy postpartum is unclear. A reasonable approach to minimize postpartum bleeding complications is resumption of anticoagulation therapy no sooner than **4–6 hours after vaginal delivery or 6–12 hours after cesarean delivery.**
In cases in which **epidural anesthesia was used**, the American Society of Regional Anesthesia recommends waiting **12–24 hours before resuming prophylaxis.**
100
1. When doe PP thyroiditis usually present?
2. How does PPT usually present?
3. How does one differentiate it from new onset graves?
4. How is is treaeted?
1. 3-6m Postpartum.
2. Postpartum thyroiditis can present as isolated **hypothyroidism**, isolated **thyrotoxicosis**, or the classic form, which manifests with **thyrotoxicosis followed by transient hypothyroidism** and then a return to a euthyroid state at 12 months postpartum. So...**usually resoved by 1 year.**
3. Common findings in patients with Graves disease are goiter with bruit and ophthalmopathy. Patients with postpartum thyroiditis in a thyrotoxic phase **_will not_** have these stigmata but often present with weight loss, dehydration, and ketonuria.
4. Beta blockers may be needed during the thyrotoxic stage; levothyroxine may be needed during the hypothyroid phase. We do not use meth/ptu in PPT becasue most of the time in the thyrotoxic phase the Thyr hormone levels are not very high.
101
PPH Drugs and Dosing
MOA of:
1. **Methergine**
2. **Carboprost**
3. **Misoprostol**
4. **Dinoprostone**
See Photo
1. Methergine: contraction of smooth uterus muscle via **5-HT2A serotonin receptors**
2. Carboprost: PG**F2alpha**
3. Misoprostol: PG**E1**
4. Dinoprostone: PG**E2**
102
What are the options for latency ABX?
What if penicillin allergic?
* Azithromycin 1 gram orally upon admission, plus
* Ampicillin 2 grams intravenously every 6 hours for 48 hours, followed by
* Amoxicillin 875 mg orally every 12 hours or 500 mg orally every 8 hours for an additional five days
**Ampicillin** and **amoxicillin** specifically target GBS, many aerobic gram-negative bacilli, and some anaerobes. **Azithromycin** specifically targets *Ureaplasma*, which can be an important cause of chorioamnionitis in this setting. Azithromycin also provides coverage of Chlamydia trachomatis, which is an important cause of neonatal conjunctivitis and pneumonitis.
Vs. **Amp/erytho --\> amox + azithro**
---------------
**Sev PCN allergy w/ known GBS sens:**
Azithromycin 1 gram orally upon admission, plus
* Clindamycin 900 mg intravenously every 8 hours for 48 hours, plus
* Gentamicin 5 mg/kg actual body weight intravenously every 24 hours for two doses, followed by
* Clindamycin 300 mg orally every eight hours for five days
**Sev PCN allergy w/ unknown GBS sens:**
* Azithromycin 1 gram orally upon admission, plus
•Vancomycin 20 mg/kg every 8 hours (maximum single dose 2 grams) for 48 hours
103
How is a microprolactinoma managed in pregnancy?
How is a macroprolactinoma managed in pregnancy?
T or F. 1/3 of macroprolactinomas advance in pregnnacy?
Do you follow Prolactin levels in Pregnancy?
If needs treatment in preg, which med to use?
Can women **breastfeed** with dopamine agonist rx?
Discontinue medication.
Larger tumors abutting the optic chiasm require continued rx with dopamine agonists during pregnancy. for smaller tumors away from the chaism, can DC meds as in microadenomas.
True
No trearment usually needed. ask about symptoms.
Bromocriptine has more safety data (n/v, hypoTension...so outside preg we use cabergoline)
**_Cannot_** BF with D agonist
104
1+ :
2+:
3+:
4+:
1+ : 30 and 100 mg/dL
2+: 100 and 300 mg/dL
3+: 300-1000
4+: \> 1,000 mg/dL.
105
T or F: Ultrasound-indicated cervical cerclage is an option for women with a history of preterm delivery of a singleton fetus at less than 34 weeks of gestation and cervical length less than 25 mm before 24 weeks of gestation.
2. Vaginal progesterone is an option for patients who do not have a history of preterm birth and are incidentally found to have a short cervical length of __ mm or less on the anatomy ultrasonography
3. What is the source of fetal fibronectin?
T. cervical length assessments **start at 16 weeks of gestation and continue every 2 weeks up to 24 weeks of gestation.**
2. **20mm**
3. decidual-chorionic interphase
106
Pulmonary Changes
1. TLC
2. Tidal Volume
3. FRC
4. Minute Ventilation
5. End Residual Volume
6. Resp Rate
7. CO2
During pregnancy, both anatomical and physiological changes occur to the respiratory tract. As the uterus grows, the diaphragm rises and the thoracic circumference increases. As the diaphragm rises, the residual volume (RV) and expiratory reserve volume (ERV) decrease, which results in decreased functional residual capacity (FRC). There is an increased tidal volume (TV) and inspiratory capacity (IC). There is a small decrease to no change in the total lung capacity (TLC). The respiratory rate is unchanged, however, the increased tidal volume results in an increased minute ventilation. This is attributed primarily to progesterone, which increases respiratory effort by increasing the sensitivity of the chemoreceptors to carbon dioxide. The increased minute ventilation decreases PaCO₂, resulting in a state of respiratory alkalosis. The decreased partial pressure of carbon dioxide facilitates transfer of CO₂ away from the fetus, while the alkalotic state, through 2,3-diphosphoglycerate, shifts the oxygen dissociation curve to the right, enhancing oxygen release to the fetus.
1. TLC: dec
2. Tidal Volume: inc
3. FRC: dec
4. Minute Ventilation: inc
5. End Residual Volume: dec
6. Resp Rate: same
7. Decreases (resp alkalosis)
107
What is the most common symptom of PE?
What is the sequence of tests to be ordered?
SOB
## Footnote
If a patient **has** clinical evidence of a lower extrem- ity deep venous thrombosis and is suspected to have a pulmonary embolus, then lower extremity compres- sion ultrasonography is the recommended first imaging test.
In women without lower extremity findings, a chest X-ray is the first imaging study to perform because results allow the physician to choose between a ventilation/perfusion scan and computed tomography angiography. Abnormal chest X-ray --\> ventilation/perfusion scan is not appropriate --\> escalate to CT PE.
108
1. qSOFA Identifies high risk patients with suspected infections for in-hopsital morality
AMS
Syst BP \< 100
RR 22
\>=2: 3-14x mortality risk
109
Components of quad:
**inhibin a**
**estriol** (E3)
hcg
afp
110
Upper limit of normal for radiation exposure in pregnancy?
50 milliGrays (or 5 Rads)
111
1. Most common genetic abn?
2. T or F: commonly affects **accrocentric** chromosomes
3. The two main uterine anomalies that are associated with recurrent pregnancy loss include:
1. Robertsnonian translocations
2. 13/14/15/21/22 (short p arm: \_\_.\_\_\_\_\_\_\_\_)
bicornuate uterus and **uterine septum (#1)**
112
1. Criteria for redating pregnancy early on based on US.
Date preg with US if
**\> 5d** & \<9wk
**\>7d** & 9-14 wk
113
Rhogam dose should be50mcg if patient is \< __ wks gestation.
12 week
114
1. What are the maternal sx of rubella infection?
2. How do we dignose it?
3. Fetal sequelae...
4. Neonatal sequelae...
1. **rash**, **head** --\> spreading to toes over 1-3 days; peiauricular **adenopathy**, **conjunctivitis**, flu-like sx.
2. IgG/IgM. Rubella is a devastating infection during pregnancy, and patients should be vaccinated at least 1 month prior to pregnancy. Non-immune mothers who have known exposure should be watched carefully *and **if any symptoms** of rubella develop, they should be offered maternal serum testing and amniocentesis.* Eighty percent of women with rubella infection in the first 12 weeks of pregnancy have an affected fetus, and this decreases to 25% by the end of the second trimester.
3. IUGR, hydrops, microcephaly, pulmonary stenosis, congenital cataracts
4. Deafness, eye defects, cardiac malformation, CNS malformations
115
Rx of appy in pregnancy?
Appendectomy. laparoscopic preferred.
116
1. treatment of pyelonephritis in pregnancy?
2. what if non-pregnant?
1. 3rd gen cephalosporin or amp/gent
2. Quinelone or **bactrim** if non-preg
117
1. What are the SIRS criteria?
2. Define Sepsis, Severe Sepsis, Septic Shock, MOF
3. ___ is the first-line single agent vasopressor in patients who remain hypotensive following initial management.
**Norepinephrine** is the first-line single agent vasopressor in patients who remain hypotensive following initial management.
118
Dx criteria for Sheehan Syndrome
The classic criteria to diagnose Sheehan syndrome are a **massive postpartum hemorrhage** that results in hypotension or shock and requires transfusions or fluid replacement, **failure to lactate**, **failure to resume menses**, **partial or complete anterior pituitary insufficiency**, and **partial or complete empty sella** (confirmed by magnetic resonance imaging or computed tomography).
119
T or F: Hydroxyurea is contraindicated during pregnancy.
In treating Sickle Cell, hydroxyurea **is contraindicated** during pregnancy because it may increase the risk of congenital malformations and stillbirth.
120
Single umbilical artery
1. What is offered after diagnosis?
2. T or F: ECHO needed.
1. Genetics, consider growth
2. No need to ECHO unless abn 4view on anat
121
SMA
1. Inhearitace Pattern?
2. Least sensitive in what racial group?
3. Which chromosomal layout is most concerning?
1. AR
2. AA
3. See Photo (-cis)
122
1. What are the 5As?
2. Nicotine Replacement ok in pregnancy?
3. Wellbutrin: MOA, Contraindications
4. Verenicline: MOA.
5. What is the black box warning for both?
**6. All should stop smoking prior to surgergery for at least __ wks.**
**7. Which can you use when BF?**
1. See Photo
2. Not been sufficiently studied in pregnancy and lactation to determine safety or efficacy. Use of nicotine replacement therapy should be undertaken with close supervision and after a discussion with the patient of the known risks of continued smoking and the possible risks of nicotine replacement therapy.
3. Norepinephrine-dopamine reuptake inhibitor, or **NDRI**. Contraindicated in patients with **seizure** **disorders** or prior **diagnosis of eating disorders**.
4. Acts on nicotine receptors in the brain. Because of this drug’s association with worsening mental illness, clinicians must address psychiatric illness with patients before initiation and follow closely for changes in mood or behavior. **nasuea**, abn **dreams**
Cant use nic, or the pharm agents if BF.
Varenicline and buproCion **both carry black box warnings regarding risk of psychiatric symptoms and suicide associated with their use.**
**4 wks**
**Buproprion ok with breastfeeding**
123
T or F: In treating SPT, abx are d/c-ed after 48 hrs afebrile on antibiotics and **_theraputic_** heparin.
True.
124
Starting Insulin Tree
1/2AM 1/2 PM
2/3N 1/3R 1/2N 1/2R
.7 1st
.8 2nd
.9 3rd
125
1. The 4 P’s: Clinical Screening Tools for **Prenatal Substance Use and Abuse**
2. CRAFFT: Substance Abuse Screen for **Adolescents and Young Adults**
3. TACE: **Alcohol Screen**
4. The National Institute on Alcohol Abuse and Alcoholism in the United States defines the consumption of more than __ drinks per day or per episode of drinking, or more than __ drinks per week on average as an amount of consumption that can increase health risks for women.
**Parents**: Did either of your **parents** ever have a problem with alcohol or drugs?
**Partner**: Does your **partner** have a problem with alcohol or drugs?
**Past**: In the **past** month have you drunk on beer, wine, or liquor?
**Pregnancy**: In the month before you knew you were **pregnant**, how many cigarettes did you smoke?
\_\_\_\_\_
**CRAFFT** \>=2 is positive
C Have you ever ridden in a **CAR** driven by someone (including yourself) who was high or had been using alcohol or drugs?
R Do you ever use alcohol or drugs to **RELAX**, feel better about yourself, or fit in?
A Do you ever use alcohol or drugs while you are by yourself or **ALONE**?
F Do you ever **FORGET** things you did while using alcohol or drugs?
F Do your **FAMILY** or friends ever tell you that you should cut down on your drinking or drug use?
T Have you ever gotten in **TROUBLE** while you were using alcohol or drugs?
\_\_\_\_\_
\>=2 is positive
**T**olerance
**A**nnoyance
**C**ut Down
**E**ye Oppener
The National Institute on Alcohol Abuse and Alcoholism in the United States defines the consumption of more than **3 drinks per day** or per episode of drinking, or more than **7 drinks per week** on average as an amount of consumption that can increase health risks for women.
126
Syphillis Rx
1) 1 or 3 doses?
2) Who gets a lumbar puncture at the time of dx?
3) REgarding congenital syphillis at what stages is the greatest risk for fetal transmission?
4) US findings
1) Patients with known primary or secondary syphilis (visible clinical manifestations and previous negative testing) can be treated with a single intramuscular injec- tion of benzathine penicillin. Patients with latent syphilis of unknown duration, such as that in the described case, require three injections 1 week apart.
2) Signs or symptoms of tertiary (late) syphilis, or patient is HIV positive or otherwise immunocompromised
3) 1ry and 2ry
4) **placentomegaly**, is most commonly indicative of syphilis, although rarely there can be other findings such as growth restric- tion. Neonates with congenital syphilis can be born with **hepatosplenomegaly**, **thrombocytopenia**, and a diffuse maculopapular rash. **IUGR**, microcephaly
127
T or F: Diagnosis of latent tuberculosis requires a positive tuberculin skin test in the absence of disease symptoms.
## Footnote
The interferon-gamma release assay is an alternative method for diagnosing latent tuberculosis and can be used in all instances in which the tuberculin skin test would be recommended.
A chest X-ray is often normal in early active disease.
What is the treatment for latent tuberculosis infection in pregnancy?
All True.
300 mg of isoniazid daily for 6–9 months.
128
1. What Hg types are elevated in Beta thal?
2. Alpha thal: AA vs asian (trans or cis)
3. name:
aa/a-
aa/-- or a-/a-
a-/--
--/--
4. name:
b/-
b-/b-
- /-
5. pregnant patients with sickle cell anemia should be prescribed __ mg of folic acid per day.
1. A2 and Fetal (Fetuses affected by beta-thalassemia major (Cooley anemia) are unaffected in utero because production of beta globin does not begin until infancy. The predominant form of hemoglobin in the fetus after 8 weeks gestation is Hb F, which consists of 2 alpha-chains and 2 gamma-chains.)
2. AA (a-/a-)
Asian is Trans (--/aa)
3. Trait, Minor, H disease, Barts
4. Minor, intermedia, major
5. 1mg
129
**VERY IMPORTANT**
## Footnote
**1. TTP: how to treat? How to tell appart from TTP-HUS?**
**2. ITP: When to treat? What level for CD? How to Rx?**
**3. NAIT: what causes? what are the maternal platelet levels?**
_TTP-HUS_: FAT RN (fever, anemia, thrombocytopenia, renal dysfunction, and neurologic changes). **ADAMTS13**. ***_Plasma exchange_*** is used for patients with **thrombotic thrombocytopenic purpura**, not ITP. *In contrast to thrombotic thrombocytopenic purpura, most patients with **hemolytic uremic syndrome** do not have neurologic abnormalities on examination and do have a history of infection with ecoli.*
_ITP_: dx of exclusion, **CAN cross placenta and dec fetal plt count** (autoimmune). With ITP, platelet function is usually normal; therefore, bleeding disorders are unlikely to occur spontaneously at levels greater than 20,000/mm . However, in pregnant patients with ITP, **maintaining a platelet level greater than 50,000 is preferable near term** because that level is considered adequate for delivery. **Treatment is initiated when the patient has symptomatic bleeding, when the platelet counts falls below 30,000/mm** , **or to increase the platelet counts to a level considered safe for procedures (eg, 50,000/mm3 for cesarean delivery).** Treatment for ITP is **_prednisone_** (or DEX) at a dose of 1–2 mg/kg/day until platelet levels of greater than 50,000/mm3 are achieved. In cases refractory to steroid therapy, **_intravenous immune globulin_** IVIG can be administered. **Megathrombocytes** on peripheral smear.
NAIT: -mat alloimmume rx to fetal plt antigens (HpAg1a) -mom has **normal plts**, baby low plts -CAN affect 1st pregnancy -**Rx IvIg and prednisone**. 100% affected preg #2.
**Maternal platelet counts are almost always normal in fetuses/newborns affected by neonatal alloimmune thrombocytopenia (NAIT)**
130
Who gets VTE testing?
High risk vs low risk thrombophilias?
T or F: Antepartum, prophylactic anticoagulation therapy may be withheld in women with prior venous thromboembolism **in the context of a nonrecurrent risk factor** and a negative inherited thrombophilia evaluation and **no additional risk factors.**
T or F: PPx anticoagulation therapy is recommended in all women with a prior venous thromboembolism.
What thrombophilias can you test for during an active clot?
Screening may be considered in patients with a **personal history** of venous thromboembolism(even if associated with a nonrecurrent risk factor such as a fracture or surgery). Also, patients with a **first-degree relative** with a history of high-risk thrombophilia may be tested.
Low-risk thrombophilias include factor V Leiden heterozygous; prothrombin G20210A heterozy- gous; and protein C and protein S deficiencies. High-risk thrombophilias include antithrombin deficiency; double heterozygous for prothrombin G20210A mutation and factor V Leiden; homozygous for factor V Leiden and prothrombin G20210A. **LRTs with no prior hx of clot get no anticoag during preg, and PP they do IF they have risk factors (obesity, CD, prolonged immobility)**
Both true.
131
What are the major and minor risk factors for VTE after CD?
T or F: For women undergoing cesarean delivery without additional risk factors for thrombosis, use of thromboprophylaxis is not recommended other than early mobilization.
T or F: For women with increased risk of thrombosis after cesarean delivery with **one major** or at **least two minor risk factors**, pharmacologic thromboprophylaxis or mechanical prophylaxis in those in whom anticoagulation is contraindicated is recommended while still in the hospital.
T or F: For women undergoing cesarean delivery with very high risk of venous thrombosis and who have addi- tional risk factors for thromboembolism in the post- partum period, prophylactic low-molecular-weight heparin combined with mechanical prophylaxis is recommended.
T or F: For women with significant risk factors for thrombosis that persist after delivery, extended prophylaxis for up to 6 weeks after delivery is recommended.
**See Photo for Risk Factors.**
132
1. Rx of thyroid storm in pregnancy.
2. SE of methimazole
3. mOA of thionamides
4. Thyroid tests in preg...what happens
**1. B blockers** 2. Thionamide (**PTU** has added benefit of T4-\>t3 block peripherally) 3. Iodine (after PTU to block the release of thyroid hormone) 4. Steroids 5. Bile acid sequestrant
2. aplasia cutis, esophageal and choanal atresia
3. compete with thyroglobulin for I and inhibit thr hormone formation, prevent peripheral conv T4-\>T3
4. BHCG stims TSH R (neg feedback) -\> TSH dec, T4 goes up. total T4/T3 go up but free levels are the same. THBG inc.
133
1. Nifedipine is contraindicated in women with hypotension and preload-dependent cardiac lesions, such as aortic insufficiency. T or F.
2. After what GA is indomethacin contraindicated?
3. Side effects of indomethacin?
4. Magnesium sulfate is contraindicated in women with myasthenia gravis or known structural cardiac defects. T or F
5. MOA of terb, SE, and contraindications.
1. True. SE nausea, flushing, dizziness, and palpitations
2. 32 weeks
3. Potential neonatal effects of indomethacin include **constriction of the ductus** arteriosus, oligohydramnios, and **necrotizing enterocolitis** in preterm newborn.
4. Magnesium sulfate is contraindicated in women with myasthenia gravis or known cardiac **conduction** defects.
5. Terbutaline, a β-adrenergic receptor agonist. pulmonary edema, hypokalemia, and hyperglycemia. Terbutaline is contraindicated in women with tachycardia-sensitive heart disease and poorly controlled diabetes mellitus.
134
1. What are the symptoms of maternal Toxo?
2. What do we use to diagnose maternal infection.
3. Fetal sequelae
4. Neonatal sequelae
5. RX
- mom without fetal infection
- fetal infection
1. In most adults, infection with toxoplasmosis is **asymptomatic**. When present, symptoms may include lymphadenopathy, malaise, and night sweats. Consuming **_undercooked pork and lamb products_** are the most likely causes of maternal toxoplasmosis infection.
2. IgG/IgM
3. **inTracranial** calcifications and microcephaly (cm**V**, peri**V**entricular)
4. chorioretinitis, hearing loss, and neurodevelopmental delay
5. MOM alone (spiramycin)
Fetal: **pyrimethamine** + **sulfadiazine** + **folinic acid**
135
1. Safest window to operate is __ - __ wks.
2. Masses that are solid or \> 10cm should come out in pregnancy. T or F
3. What do you do if malig at time of CD?
1. 14-22 weeks
2. T
3. refer to gyn onc for staging in 1-2 weeks
136
Risk of death and neuro injury if a twin dies in a mono or didi preg?
**Monochorionic** gestations have placental anastomoses; thus, the death of one twin can lead to profound hypotension in the surviving twin. **After 14 weeks, the risk of neurological injury to the surviving twin is 18%, and the risk of death is 15%.**
Dichorionic twins have their own placentas; thus, there is only a **1% chance of neurological injury in the surviving fetus when the other fetus dies after 14 weeks. The risk of death is 3%**. Immediate delivery does not reduce this risk in either monochorionic or dichorionic gestations and thus should not be done unless the gestational age is greater than 34 weeks or the surviving twin shows signs of distress.
137
1. MOA
2. Dosing OB and GYN
TXA is a synthetic reversible competitive inhibitor to the Lysine receptor found on **plasminogen**. The binding of this receptor prevents plasmin (activated form of plasminogen) from binding to and ultimately stabilizing the fibrin matrix.
in OB: 1g, can be repeated after 30 minutes
in GYN: 1.3 g three times daily for up to 5 days during monthly menstruation
138
Uterine inversion: what do you do once the uterus is reduced? What are the two surgical interventions?
**After repositioning, uterotonic agents should be administered to control maternal bleeding and prevent recurrence of the inversion.**
If the placenta is still attached, then manual extraction can be done after the uterus has been repositioned.
Two procedures have been described for these circumstances. The **Huntington** procedure involves serial clamping and upward traction on the round ligaments to restore the uterine position. In the **Haultain** procedure, the cervical ring is incised posteriorly to aid in repositioning of the uterus. Both procedures are then followed by uterotonic therapy.
139
Doses and MOA:
1. Oxy
2. TXA
3. Ergots
4. Carboprost
5. Miso
6. Dino
7. RF7a
Which is CI in pts on protease inhibitors?
Methergine CI in pts on pretease inhibitors.
Carboprost if PF2a
140
1. T or F: Rabies vaccine is safe in preg.
2. A pregnant patient who has never received immunization against tetanus should complete the vaccine series when?
1. True
2. A pregnant patient who has never received immunization against tetanus should complete the vaccine series starting in pregnancy with vaccinations at 0 weeks, 4 weeks later, and 6–12 months after the initial dose. A dose of Tdap should replace one of the Td doses, ideally around 27– 36 weeks gestation in order to provide passive immunity against pertussis to the fetus.
141
Vaccum
## Footnote
1. Suction value?
2. When to stop criteria?
1. \<600mmHg
2. 3 popoffs, 3 pulls, 20'
142
Valproic acid is associated with...
Associated with a risk of neural tube defects, cardiac defects, and craniofacial abnormalities.
143
1. What are the potential sequelae ON MOTHER of varicella in pregnancy?
2. Sally with unknown vaccination status gets exposed and calls you. What is step 1?
3. If IgG neg, what do we give exposed mother? Does it prevent fetal desease?
4. If mother has acute infection, what do we do?
5. during what tri is infection trasnmisison highest?
6. What timeframe for infection is concerning for neonatal VZV? How do we treat it?
7. For **NONPREGNANT** individuals who have no evidence of immunity to varicella (laboratory evidence of immunity, documented history of the disease itself, or documented history of vac- cination) and are exposed to the disease, ___ is recommended.
8. What we see on the fetus?
1. **PNA** (20%), encephalsiits, liver dysfnct, myocardia dysfunct.
2. Test for immunity.
3. IgG neg, give **VZVIG w/in 96hours (4 days) but up to 10 days**. Prevents maternal disease, unclear if dec transplacental passage
4. Admit! Acyclovir.
5. 2nd
6. **5d before and 2 days PP**. No maternal IgG to protect.
- Give **VZVIG to infant** to try to prevent infection, or if you can, delay delivery. Give acyclovir if si of fetal infection.
7. Vaccination, not the IVIG
8. Fetal:
* echogenic foci in the fetal liver
* limb anomalies
* fetal growth restriction
* microcephaly
* **ventriculomegaly**
144
Risks of Vit D deficiency is highest for what populations?
Recommended dose in pregnancy?
Max dose?
Those populations at high risk of hypovitaminosis D include ethnic minorities with **darker skin,** patients who observe a **vegetarian** diet, **obese** women, **bariatric** surgery patients, and women with **limited sun** exposure as a result of cold climate, northern latitude, or protective clothing.
Rec: 600IU
Max: 4000IU
145
1. T or F: in a VSS patient with a vulvar hematoma that is expanding, IR intervention is contraindiacted if a coagulopathy is present.
2. Most common blood vessel source for vulvar hemotoma?
3. Most common blood vessel source for vaginal hemotoma?
4. retroperitoneal?
1. T
2. Pudendal
3. Vag or Uterine
4. hypogastric
146
1. Tests for vWD
2. What tests are elevated?
3. Rx
1. vW **antigen** level, ristocein cofactor, **F8 activity**
2. PTT
3. Desmopressin (releases vWF)
147
Weight Gain Recommendations in Pregnancy
\>30: 11-20
25-29.9: 15-25
18.5-24.9: **25-35 (NORMAL)**
\<18.5: 28-40
148
1. How does one acquire zika? What are the sx? how do you test?
2. What are the maternal sx?
3. Effects on fetus?
4. Women with possible exposure to Zika virus who want to get pregnant, regardless of symptom status, should consider waiting at least __ weeks from symptom onset or exposure to attempt pregnancy.
5. If a male partner has possible Zika virus exposure, regardless of his symptom status, the couple should consider waiting at least __ months after the male's symptom onset or last possible Zika virus exposure
6. T or F. Asymptomatic pregnant women with possible Zika virus exposure but without ongoing possible exposure are recommended routinely to have Zika virus testing
7. For pregnant women with laboratory evidence of possible Zika infection, what is the next step?
1. May be acquired through mosquito, sexual contact, blood transfusion, or exposure in a clinical laboratory. Symptoms are nonspecific and may include **fever**, **rash**, **arthralgia**, and **conjunctivitis**. Test with **PCR from blood if within 3-7 days**. **IgG IgM if after 1 week**.
2. Approximately 20% of infected individuals will experience a mild illness characterized by at least one of the following: **fever, rash, arthralgia, and conjunctivitis.**
3. Pregnancy loss, **microcephaly**, intracranial calcifications, and **eye** malformations, **IUGR**
4. 2 m
5. 3 m
6. False. Asymptomatic pregnant women with possible Zika virus exposure but without ongoing possible exposure **are not recommended** routinely to have Zika virus testing. **Symptomatic pregnant women with possible Zika virus exposure or women who are pregnant with a fetus showing abnormalities consistent with congenital Zika virus syndrome _should be tested_ as soon as possible**.
7. For pregnant women ***_with_*** laboratory evidence of possible Zika infection, **use of ultrasonography to evaluate for fetal abnormalities consistent with congenital Zika virus syndrome is recommended**.
