Obstetrics

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BostonPhysicianAssist
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148965
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Obstetrics
Updated:
2012-04-20 22:01:14
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USMLE MMD PANCE review
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Obstetrics, stuff from some study books and lecture notes from MMD all related to what we are being tested on for the final
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  1. A 14 y.o. G1PO woman who is 29 wks pregnant with twins presents to the ED following a seizure. She was watching television and stood up to go to the bathroom when she "fell down and started shaking". The Pt has no hx of seizures and is otherwise healthy. She missed her last obstetrician's apt and her aunt states that her niece has had a lot of headaches and swelling over the past 2 days. On examination she is somnolent and difficult to arouse, and has edema of her hands and face. Her vitals are blood pressure 205/120 mmHg, pulse 80/min, respiratory rate 16/min the fetal heart rate is 130/min. Which is the most correct advice for the pt's aunt?
    A. your neice has a life threatening condition called eclampsia and needs to be put on strict bed rest and monitored until the baby can be delivered at term
    B. your niece has a life threatening condition called eclampsia and the baby needs to be delivered as soon as possible
    C. you niece has a life threating condition called eclampsia but this can be managed with antiseizure medications until the baby can be delivered at term
    D. your niece has a life threatening condition called preeclampsia and the baby needs to be delivered as soon as possible.
    B: the pts seizure, hypertension, headache and facial edema are consistent with a diagnosis of eclampsia. Eclampsia is defined as seizure activity or coma in an obstetric pt with preeclampsia. Delivery is an immediate necesity once the pt is stabilized to prevent maternal and fetal mortality
  2. 19 y.o. f at 32 wks gestation is the driver in a front end motor vehicle crash. The air bags did not inflate and the pt sustained blunt trauma to the abdomen. the pt is taken to a nearby ED in stable condtion where she notes a small amnt of bright red blood in her underware. Maternal vital signs are significant for a HR of 110 and a blood pressure of 110/55mmHg what is the next most appropriate step in managment?
    A. administration of Rho D immunoglobulin
    B. Disseminated intravascular coag pannel
    C. External fetal heart rate and uterine monitoring
    D. Immediate cesarean delivery
    E. Immediate vaginal delivery
    F. internal fetal heart rate and uterine monitoring
    C abruptio placentae refers to premature separation of a normally implanted placenta after 20 wks gestation but prior to delivery of the infant. Since the detached portion of the placenta is unable to exchange gases and nutrients the fetus can become compromised if teh area of separation is large. This pt is at risk for placental abruption secondary to compression-decompression and acceleration-deceleration stresses of the motor vehicle crash. Vaginal bleeding is this setting is concernign as bleeding is the first signs of abruption It is unlikely that a complete abruption has ocurred as the pt is not frankly hypotensive and her bleeding was minimal. All women > 24 wks of gestation subjected to abdominal trauma should have continuous fetal and uterine monioring with an external fetal heart rate to asses for preterm labor and/or abruption. Signs of fetal compromise are associated with moderate to severe abruption and would necessitate immediate delivery
  3. 16 y.o. girl presents to the ED cc of fever, chills, abdominal pain and vaginal bleeding. She gives hx of unprotected sex with her 17y.o. boyfriend over the past several months. her LMP was 8 wks ago. She reports having a dilatation and curettage procedure at an unlicenced abortion clinic recently to try to abort her pregnancy. Vital signs are significant for fever 38.7 degrees C (101.7F) a HR 120 and a BP of 100/70 mmHg. Pelvic exam reveals cervical mostion tenderness, tissue in the internal os, and foul smelling vaginal d/c. Urine Bhuman chorionic gonadotropin is postive what is the most likely diagnosis?
    A. Ectopic pregnancy
    B. Pelvic abscess
    C. Septic Abortion
    D. threatened abortion
    E. vaginal laceration
    C: septic abortion. common presenting sx include fever, malaise, chills, abdominal or pelvic pain, and vaginal bleeding with or without retained products of conception. Septic abortions do not commonly complicate spontaneous abortions, but can occur as complications of illegally performed induced abortions, foreign bodies, invaseive gynecologic proceedures, or incomplete spontaneous abortions
  4. 30 y.o. G3P2 f with no siginificant PMH is in active labor at 41 wks gestation. She had an uncomplicated preganacy with an appropriate prenatal evaluation. The pt ruptured membranes spontaneously 30 mins ago. Contractions occur regularly every 2-3 mins. Early decelerations are noted on fetal heart rate monitor with each of the past five contractions. Which is the most appropriate next step in managment?
    A. Change in maternal position
    B. No further managmetn is required
    C. Place fetal scalp probe
    D. prepare for emergent cesarean delivery
    E. start amnioinfusion of saline
    B: Early decelerations are shallow, symmetric deceleration in which the nadir of the decelration is coincident with the peak of uterine contraction. They are mediated by vagal stimulation due to fetal head compression from the contracting uterus and thus indicate a normally functioning fetal autonomic nervous system. They are not associated with fetal hypoxia, acidosis or poor neonatal outcome no further managment is nessisary
  5. A 25 y.o. G2P1 woman who is 36 wks pregnant presents to her obstetrician c/o restlessness and weakness for the past month. She states that her boyfriend recently left her and their 2 y.o. son, and she feels overwhelmed with this pregnancy. She denies feeling depressed but does report that she has trouble sleeping. She had a upper respiratory infection last month "caught it from my son", and states that she still has a sore throat. Her blood is drawn and shows
    WBC 80,000
    Hemoglobin 11
    Hematocrit 40%
    Platelet count 250,000
    TSH 0.5
    Free thyroxine 4.0
    Which is the most appropriate next step
    A. radioiodine treatment
    B. postpartum thyroid levels
    C. propylthiouracil treatment
    D. levothyroxine
    E. partial thyroidectomy
    C. She is showing signs of subacute thyroiditis, consistent with a low thryroid stimulating horomoen and high thyroxine. This commonly follows a viral upper respiratory infection, and pain from teh thyroid can be referred to the throat. Thyroid disorders are common during pregnancy and may be subtle and/or present in the context of normal or near normal thyroid horomone levels. Medical managment is the treatmetn of choice in pregnant pts or in those with mild hyperthyroidism
    (this multiple choice question has been scrambled)
  6. 36 y.o. G1P0 pregnant F with twins presents to her obstetrician for her routine 32 wk apt. She has gained 5.4 kg (12lbs) inteh past 2 wks. When questioned about her wt gain she states that she has had headaches and some blurred vision for the past 2 wks, which she thinks is secondary to dehydration. To circumvent this she has been drinking alot of water which she claims "is not really working and is making me swell even my hands" she also has had some epigastric pain for the past 2 wks which she attributes to "all the water ive been drinking". Her vitals are blood pressure 142/90 mmHg, pulse 105/min, and respiratory rate 18/min. Her urine reveals 1+ glucosuria and 4+ proteinuria. What is the next best step in managment?
    A. Administer magnesium sulfate only
    B. Expectant managment
    C. Magnesium sulfate therapy, steroids and induction of labor
    D. oral antihypertensive therapy
    E. platelet transfusion
    This woman has preeclampsia which is characterized by her hypertension >140/90 and her proteinuria. nondependant edema such as facial or hand edema is usually present as well but not necessary criterion. Proteinuria is defined as excretion of >300 mg of protein in 24 hrs. The pt is experiencing both subjective as well as objective signs of severe disease, as evidenced by her headaches, visual changes, epigastric pain and urine dipstick >3. A dipstick of 1+ to 2+ is more consistent with mild disease. The underlying pathophysiology of preeclampsia is vasospasm and leeky vessels but the origin is unclear. Vasospasm and endothelial leakage causes local hypoxemia of tissue which can lead to hemolysis, necrosis, and end-organ damage. It is cured only by termination of pregnancy and almost always resolves in delivery. Thus the managment of the disease will depend on the gestational age of the fetus, together with the severity of the disease. If the pregnancy is at term then delivery is indicated. If the pregnancy is preterm then the severity of disase is assessed. If severe preeclampsia is present then delivery is usually indicated reguardless of gestational age. Administration of magnesium sulfate serves as an anticonvulsatn therapy and should be given during labor to prevent eclampsia

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