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137 Cards in this Set
- Front
- Back
What are the 2 MCC for C-section?
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1. previous C-section
2. failure to progress during labor |
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What are indications for C-section?
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1. cephalopelvic disproprotion
2. fetal and maternal anomalies; malformations 3. fetal malpresentation or posture 4. hx of uterine inversion 5. previous vaginal surgery; vertical uterine incision; reconstructive surgery 6. antepartum or intrapartum hemorrhage - previa abruption 7. medical or surgical disease of the fetus or mother 8. failed trial of or induction of labor 9. failed forceps or vacuum extractor delviery 10. cord prolapse 11. fetal distress 12. arrest of labor 13. fetal macrosomia 14. pelvic mass-firbroids 15. previous Cesarean with vertical incision 16. hx of complicated maternal birth injury, lacerations, fistulas 17. abnormal placenta or umbilicus - previa, abruption, cord prolapse |
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What are 5 steps we take to prepare patient for C-section?
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1. hydrate well
2. maintain Hct of 30% or higher 3. type and hold blood 4. +/- prophylactic antibiotics 5. antacids to reduce acidity |
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what are possible complications of anesthesia?
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hypotension, HA, decreased motor fnx
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What are the types of abdominal incisions used for c-sections?
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1. midline
2. paramedian 3. Pfannenstiel (MC) |
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Which surgical incision provides the most desired effect but takes the most time to perform?
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Pfannenstiel
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Which surgical incision is less time consuming and less bloody?
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Infraumbilical vertical midline incision
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what is the average blood loss during a c-section?
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1000ml
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What is the most common complication of C-section?
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Infection: *endometritis, *wound infection, salpingitis
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what percent of patients have complications with C-section?
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5%
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Complications of C-section include?
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1. infection
2. uterine rupture 3. hysterectomy 4. hemorrhage 5. injury to organs 6. atelectasis/pneumonia 7. ileus 8. fetal injury 9. maternal death 10. aspiration 11. DVT 12. Pulm. embolism 13. anesthetic complications 14. effects of C-section on fetus/newborn --> increased incidence of transient tachypnea |
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Candidates for VBAC include?
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patients with one or two prior low-transverse-C-section;adequate pelvis; no other uterine scars, anomalies or uterine rupture
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Contraindications to VBAC include:
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diabetes, htn, HSV infection, prior classical or T-shaped incision; inability to perform emergency C-section
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can we use oxytocin or and epidural with VBACs?
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yes
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Incision of perineum at send of second stage of labor is known as?
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episiotomy
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Common usage of episiotomy supported historically by alelged prevention of?
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perineal truama, pelvic relaxation and newborn injury
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What is the most common type of episiotomy in the US?
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Median episiotomy
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This type of episiotomy may be more difficult to repair, has more blood loss and is more difficult to heal but gives the most room.
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mediolateral
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What are the 4 types of forceps?
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Simpson, Tucker-McLean, Kielland and Barton, Piper
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Which forcep is used for occiput anterior?
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Simpson
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Which forceps it used to rotate from occiput posterior to occiput anterior and deliver?
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Tucker-McLean
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Which forceps is used to rotate occiput transverse to occiput anterior?
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Kielland and Barton
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which forceps is used to deliver the aftercoming head of breach?
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Piper
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When should perineal massage be done?
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should be done daily for at least 5-10 minutes starting 6 weeks prior to birthing
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what are contraindications to perineal massage?
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1. pelvic varicose veins
2. active herpes lesion |
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When might forceps be used nowadays?
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not common anymore. used where this is fetal distress or maternal compromise and the inability to do a C-section quickly
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what are the prerequisites for Forceps delivery?
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cervix must be completely dilated
position (vertex) must be known membranes must be ruptured bladder must be empty |
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What foreceps is used when fetal vertex is at 2+ station?
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low forceps
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this forceps are used with head is engaged and fetal head is above a 2+ station
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midforceps
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use this forceps when fetal head is at the perineum and scalp is visible at the introitus...
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outlet forceps
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What are the two types of vacuum extraction devices?
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1. malmstrom vacuum extractor
2. plastic cup extractor -- more widely used in USA |
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what is the major complications for using forceps?
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trauma to scalp, including
1. scalp abrasion or laceration 2. cephalohematoma 3. intracranial hemorrhage 4. retinal hemorrhage 5. soft tissue laceration |
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Define cervical incompetence:
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premature, painless dilatation of cervix (w/o being in labor), in the 2nd trimester of pregnancy that usually results in pregnancy loss.
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What is the MC risk factor for cervical incompetence?
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previous incompetence
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What is the MCC associated with stillbirth?
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fetal growth restriction (43%)
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Termination of pregnancy medically or operatively before viability is known as?
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induced abortion
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What are the two types of induced abortion?
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therapeutic, elective
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Interruption of pregnancy for the purpose of safeguarding the health of the mother is known as?
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therapeutic abortion
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when did therapeutic abortions become legal?
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1973
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When can therapeutic abortions be performed?
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Can be induced up to approximately 20-24 weeks gestation
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what is the treatment for cervical incompetence?
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cervical cerclage - placement of encircling suture around cervical os with heavy , nonabsorbable suture. Suturing prevents protrusion of amniotic sac and rupture.
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What are the two techniques for cervical cerclage?
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1. The shirodkar
2. The McDonald |
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This cerclage technique is the most complicated. vaginal mucosa is dissected away from the cervix before placing suture. It is permanent
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The Shirodkar
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This cerclage technique is the simplest. Less trauma to cervix and less blood loss. no mucosal dissection and it is temporary
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The McDonald
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The simple purse string cerclage is also known as?
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The mcDonald
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what is the method of choice for early ddetection of cervical dilation in cervical incompetence?
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US. look for the "short cervix".
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The birth of a dead fetus is known as?
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stillbirth
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What is the etiology of 50% of stillbirths?
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unknown etiology
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What are some genetic causes of stillbirth?
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1. thrombophilias
2. chromosome abnormalities 3. single-gene disorders |
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When a patient has a stillbirth what should we do to follow up and evaluate?
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review genetic, medical and OB hx
urge autopsy dx imaging, xray, MRI conduct chromosomal analysis, infection dz workup provide counseling |
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A spontaneous abortion is defined by the fetus being...
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less than 20 wks, or less than 500g
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interruption of pregnancy at the request of the mother is known as?
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elective voluntary abortion
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What does a pre-abortion work-up consist of?
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1. US to assure dates correspond with uterine size
2. Labs: ABO /Rh typing 3. administer Rhogam in Rh neg moms 4. careful patient counseling should be performed |
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Maternal indications for therapeutic abortion
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1. CV dz
2. genetic syndromes 3. hematologic dz 4. metabolic 5. neoplastic 6. neurologic 7. renal 8. intrauterine infection 9. severe pre-eclampsia/eclampsia |
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Which is a safer method of abortion? Surgical or medical?
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surgical
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This substance is used to dilate cervix slowly and gently before evacuation
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Laminaria
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The safest and most effective method to terminate pregnancies of 12 weeks or less is?
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Dilation of cervix and evacuation (D and E) - also known as suction curettage.
Over 90% of US induced abortions done this way |
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What medical substances are being used for abortion?
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Abortifacients:
1. intravaginal prostglanding E2 with urea 2. methotrexate + misoprostol 3. mifepristone + misoprostol |
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What is Mifepristone/Mifeprex made up of? How effective is it?
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19 norsteroid analogue. Progesterone antagonist (RU 486). 95% effective
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How does Mifepristone work?
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First, you need patient and prescriber agreement.
The norsteroid analogue blocks progesterone receptor sites in deciduas which leads to bleeding. It also increases prostaglandin levels which leads to uterine contractions. Pt. will have abd. pain for 1-2 weeks with bleeding. Requires 3 office visits. On day 14 confirm pregnancy termination. |
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What are some complications of Abortion?
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1. hemorrhage
2. cervical injury 3. coagulation defects 4. retained products of conception 5. infection 6. perforation 7. infertility 8. Rh sensitization 9. embolism 10. live-born fetus 11. uterine rupture 12. asherman's syndrome |
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What is the lay term for a second or third trimester abortion?
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Partial birth abortion. sometimes referred to as "intact dilation and extraction"
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What is the incidence of drug use in pregnancy?
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0.4 - 27%
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What are some signs of substance abuse?
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1. agitation
2. sedation 3. disorientation 4. tachycardia 5. hallucinations 6. hypertension 7. skin infections |
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Prof. Lord wants us to know all the ways cocaine can be used:
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1. it can be smoked as crack
2. taken intranasally (my preferred method --JK!! obvi) 3. injected IV the use of cocaine in pregnancy is increasing |
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Pharmacologic effects of cocaine include:
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1. cardiovascular effects (fetal tachy and increased fetal o2 consumption
2. interferes with dopamine and Norepi reuptake = CNS irritability 3. maternal and fetal vasoconstriction and tachy, plus stimulation of uterine contractions |
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What are the maternal complications of Cocaine use?*
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1. neurologic - seizure, rupture of aneurysm
2. cardiovascular - MI, HTN, arrhythmias, aortic rupture, sudden death 3. Infections 4. Obstetric - increase in preterm labor and delivery, IUGR, low birth weight, etc |
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How do we manage cocaine use in pregnancy?
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1. detection
2. treatment |
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How can we detect cocaine use in pregnancy?
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1. educate patients
2. question ALL patients about any drug use 3. examine patients for inflammation or nasal alae and IV sites 4. consider urine toxicology screening |
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How do we treat patients who use cocaine during pregnancy?
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1. refer pt to a chemical dependency treatment center
2. obtains assistance from social services 3. prevent and treat premature labor and IUGR 4. begin biophysical testing no later than 32 wks 5. watch for abdominal pain |
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How do we treat cocaine overdose?*
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1. control seizures, hyperthermia and HTN. Must decrease CNS irritability and sympathetic nervous system overactivity.
(treat seizures with MgSulfate, HTN and tachy with Propranolol, nitropursside, phentolamine) |
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The branch of science concerned with the production, development, anatomy and classification of malformed fetuses is known as?
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Teratology
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What is the definition of Teratogen? *
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Any chemical (drug), infection, physical condition or deficiency that upon fetal exposure can alter fetal morphology or subsequent function.
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this drug was used as an anti-anxiolytic and anti-nausea agen in the first trimester before found to be teratogenic
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thalidomide
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This estrogenic hormone was meant to prevent a variety of reproductive problems but by the 1960s was found to cause increased risk of adenocarcinoma of the cervix and vagina and male reproductive anomalies.
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Diethylstillbesterol (DES)
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This development stage is from day 0 to 11 and known as the "all or none" phenomenon.
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Resistant period
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The period in which the fetus is most susceptible to adverse effects of teratogens is?
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from day 11 to 57 of gestation. Embryonic period
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A teratogen at this stage may cause a reduction in cell size and number.
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Lowered susceptibility stage (fetal period). From day 57 to gestation
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The ____ and _____ of administration of a teratogen alter the type and severity of the malformation produced.
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route and length. Abnormal developments increase in frequency and degree as dosage increases.
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What are the three types of structural defects?
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1. malformations
2. deformations 3. disruptions |
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What kind of structural defect comes from an intrinsic abnormality in the process of development, usually in the first trimester; primary structural defect from a localized error of morphogenesis
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morphologic defect
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This type of structural defect is characterized by abnormal forms, shapes, or positions of a previously normal body part; caused by a non-disruptive mechanical force
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deformations
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club feet from oligohydramnios is an example of what kind of defect?
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structural defect
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This type of structural defect is a morphologic defect from extrinsic interference with a normally developing organ system, usually occurs later in gestation.
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Disruptions
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amniotic band syndrome is an example of what kind of structural defect?
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disruption
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What is amniotic band disruption syndrome?
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A group of fetal malformations associated with multiple fibrous strands of amnion that appear to develop or entangle fetal parts in utero. This leads to structural malformations and defromations and disruptions of function. ex: limb defects, amputations, simian creases, visceral defects, etc.
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What percent of pregnant women in the USA ingest over-the-counter or prescription drugs during pregnancy?*
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45-95%
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Risk factors for adverse fetal effects have been assigned to all drugs by the FDA based on what?*
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the teratogenic risk that the drug poses to the fetus
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What category? Controlled studies fail to show risk to fetus; possibilty of fetal harm appears remote
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Category A
ex. prenatal vitamins |
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What category?
No evidence of risk in humans. |
Category B
ex: PCN, digoxin, epi |
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What category?
Risk cannot be ruled out. Animal studies have shown either teratogenic or embryocidal effects on fetus OR appropriate animal data is not available. |
Category C
ex: furosemide, verapamil, beta blockers give only when benefit outweighs potential fetal harm. |
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What category?
Positive evidence of risk. Benefit may outweigh fetal risk in certain circumstances. |
Category D
ex: phenytoin |
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What category?
Contraindicated in pregnancy |
Category X
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What is the most commonly abused substance during pregnancy? *
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ETOH
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what is the most common known teratogenic cause of mental retardation? *
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ETOH
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The effect of ETOH is related to the _____ in which it is consumed.
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trimester
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What is a safe level of ETOH consumption in pregnancy?
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NONE!
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FAS is associated with ____ ounces or more of ETOH a day. *
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1-2
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What are some features of FAS?
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1. mental retardation
2. growth retardations 3. abnormal facies 4. ocular and joint anomalies 5. CNS abnormalities 6. Behavioral disturbances 7. cardiac effects |
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What features is maternal smoking of marijuana associated with?
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1. increased perinatal morbidity
2. preterm delivery 3. premature rupture of membranes 4. bleeding during pregnancy |
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Has marijuana been shown to cause birth defects? Has Heroin?
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No evidence of either causing birth defects
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The major adverse fetal effect in heroin addicts is? *
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severe neonatal withdrawal
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what is the DOC for heroine addiction in pregnancy?
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Methadone
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This caused clear cell carcinoma in mom and offspring!
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Diethylstillbesterol (DES)
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What are the teratogenic risks from chemotherapy in pregnancy?
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high risk of fetal loss due to spontaneous abortion and stillbirth. After the period of organogenesis (1st trimester), there is no teratogenic risk from chemo in pregnancy.
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Sustained temps above _____ are teratogenic and associated with CNS defects, growth retardation, facial anomalies, minor limb anomalies.
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102F. ex: frequent saunas, febrile infections
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VSDs are a very common congenital heart defect associated with this maternal medical disorder:
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Diabetes Mellitus.
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This maternal disease is associated with mental retardation, microcephaly, congenital heart dz and low birthweight.
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phenylketonuria (PKU)
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Epileptics on anticonvulsants during pregnancy have a ____ fold increase in malformations of fetus*
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2-3 fold
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Growth and mental retardation, microcephaly, eyelid ptosis, depressed nasal bridge, craniofatial abnormalities and digital anomalies are associated with which syndrome?
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Fetal Hydantoin Syndrome
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Why might untreated epileptics be at an increased risk of delivering infants with birth defects?*
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maybe due to hypoxia from seizures
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"snuffles" rhinitis is associated with this infection
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syphilis
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what is the organism associated with syphilis?
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treponema pallidum
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All infants born to women with primary and secondary infection will be _____, but ____% will be asymptomatic*
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infected, 50%
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how should we treat a pregnant mother with syphilis?
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adequate abx therapy for the mother thought to provide adequate therapy for unborn child
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Congenital malformations in offspring of women who develop chickenpox in the first ___ weeks of pregnancy
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20 weeks
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There is ______ evidence proving herpes zoster causes congenital anomalies. *
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There is no good evidence
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Are Mumps teratogenic?*
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Not strictly but neonates exposed in utero are known to have cardiac, ear and eye malformation and urogenital abnormalities
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this disease can cause serious fatal illness in fetus including cardiac malformations, hepatitis, pneumonities, pancreatitis and adrenal necrosis
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enterovirus (Coxsackie B) "Fifths dz"
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highest risk of birth defects in first trimester including CNS, cardiovascular lesions, ocular defects, inner ear problems and IUGR are seen in this dz
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Rubella (german Measles)
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Risk of severe complications much higher for infants of mothers who had a primary infection in pregnancy compared to those with recurrent infection with this disease:
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CMV
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Neonatal effects of fetal CMV include?
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microcephaly, chorioretinities, deafness, HSM, cerebral calcification, mental retardation, heart block, petechiae
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If mother is infected with Herpes Simplex (HSV-D) what do you want to watch for in the infant?
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eye involvement and encephalitis
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This infection is associated with spontaneous abortion, perinatal death, abnormal growth, chorioretinities, microcephaly
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Toxoplasmosis
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what is the organism called in Toxoplasmosis?
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toxoplasma gondii
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What are the prerequisites for Forceps Delivery?
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1. cervix must be completely dilated
2. position (vertex) must be known 3. membranes must be ruptured 4. bladder must be empty |
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Prereqs for forceps delivery include:
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1. cervix must be dilated
2. position must be known 3. membranes must be ruptures 4. bladder must be empty |
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most common condition associated with still birth is ?
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fetal growth restriction (43%)
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what are two fetal indications for therapeutic abortion?
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Tay Sachs dz - genetic
anencephaly - major malformations |
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Anti-D antibody titers provide limited info on severity of dz. T/F?
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True
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Indirect Coomb's titer greater than _______ is significant
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1:32
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High titers require______ to determne severity of fetal anemai
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amniocentesis
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How often do we repeat antibody titers if they have an Rh+ dad?
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monthly
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intrauterine transfusion and intravascualr transfusion are used to treat what dz?
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erythroblastosis fetalis
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When do we give Rh Immune globulin?
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1. 28 week for non-immunized mom
2. pospartum (72) if woman remains non immunized 3. following amnio or CVS 4. following evacuation of molar pregnancy 5. following ectopic 6. after tubale ligation or pregnancy termination 7. aftera accidental transufion 8. after platelet transfussion 9. afer clnical situation associated with spill of fetal cells into maternal circulation |
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What is the standard dose of Rh Immune Globulin?
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300mcg cover fetal hemorrage of 30ml of fetal whole blood or 15ml of rbc
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what test do we do anytime a fetomaternal hemorrhage is suspected?
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kleihauer - betke test
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