OB&G-AIM4PG

FIGO prognostic score for GTN

Q. A 28 yr old G1P0 woman who is at 32 wks gestation with sickle cell anemia is admitted to the hospital for vaso-occlusive pain crisis due to severe pain of the back & hands. She is treated with i.v fluids & oxygen & pain control. On hospital day 2, she develops acute dyspnea, & has an oxygen saturation level of 85% on room air. Her vital signs are : T 98.2 degree F, BP 130/80 mmHg, HR 100bpm & RR 36/minute & laboured. Chest xray shows a new left lower lobe infiltrate. CT angiography study is negative. Which of the following is the best treatment for this patient? A. Anticoagulation B. Antibiotic therapy C. Beta-agonist respiratory therapy D. Diuretic therapy E. Exchange transfusion Ans. E This patient likely has acute chest syndrome, which is vaso-occlusive disease of the lungs, leading to a new pulmonary infiltrate, acute dyspnea & hypoxia. Pneumonia is a possibility but the patient does not have a fever or cough. Pulmonary embolism is less likely due to the negative CT angiography examination, which is treated with anticoagulation. There is no history of asthma or report of wheezing on examination, which would be treated with beta agonist therapy. Acute chest syndrome that is severe is usually treated with a partial exchange transfusion. Antibiotics are also administered in case pneumonia is present.

4 components of a Non Stress Test (NST) 1. Baseline fetal heart rate (normal is 110-160 bpm) 2. Beat to beat variability (normal 5 to 25 bpm): this is the variability we see in the fetal heart rate, It isn't constant like in adults, it changes every second. 3. Accelerations: at least 2 in a 20 minute trace. An acceleration is an increase in the heart rate by at least 15 bpm lasting for at least 15 seconds; this is seen with fetal movement. 4 decelrations: should be absent in a normal trace; they are the opposite of accelerations.

Approach To Nephritic Syndrome By: Dr Richa Aggarwal , MD Internal Medicine Watch Lecture Is Live https://youtu.be/pPqGsJJQd1w Listen To Lecture Podcast https://anchor.fm/aim4pg/episodes/Approach-To-Nephritic-Syndrome-e1bu5rp Download Lecture Pdf www.aim4pg.com/pdf More Lectures Of Faculty Coming Soon Stay Tuned

Q. A 32 years old P2A2L2, presents to your office for her annual examination. She has regular menses every 28 days, lasting 4 days each time. The patient reports 10 sexual partners in her lifetime, 3 in the past 6 months. She almost always uses condoms. The patient takes oral contraceptive pills but does not always remember to take them on a daily basis. She has never had an abnormal pap smear and the last one she had done was 3 years ago. The patient reports no significant past medical history and denies any health conditions in family members. What testing and/or examinations should be done during today's visit? (A) Pap smear (B) Gonorrhea and chlamydia cultures (C) Pap smear, gonorrhea, and chlamydia cultures (D) Pregnancy test (E) Mammogram Ans. C This patient is sexually active with multiple partners and does not always use con­doms, so she needs to be screened for sexual transmitted diseases (STDs). Her last pap smear was 3 years ago, so even though she has never had an abnormal one she should receive one today. One would consider co-testing with human papillomavirus (HPV) and cytology every 5 years between the ages of 30 and 65. She is too young for a mammogram and a pregnancy test is not indicated. • Screening Method tor Cervical Cancer Age --- Recommended Screening 1. <21 yrs - No screening 2. 21-29 yrs - Cytology alone every 3 y 3. 30-65 yrs - Human papillomavirus and cytology co-testing every, 5 y Cytology alone (acceptable) every 3 y 4.>65 - No screening necessary

Q. A 31 Yr old G3P2 woman at 34 wks gestation presents to the OB triage unit due to nausea & "not feeling well". BP is 110/82. FHR pattern is category 1. Hb level is 9g/dL, leukocyte count is 8000cells/mL & platelet count is 84000/fL, ALT of 500 IU/L, AST 550 IU/L & bilirubin of 2.5mg/dL. Which of the following is the most likely diagnosis? A. Acute leukaemia B. HELLP syndrome C. Hepatitis infection D. Pre-eclampsia with severe features E. Viral illness Ans. B This patient likely has HELLP syndrome, which is hemolysis, elevated liver enzymes, & low platelets. An elevated serum LDH or evidence of fragmented erythrocyte would clinch the diagnosis. It is unlikely to be preeclampsia with normal BP. There is no urine protein given which would be elevated in Pre-eclampsia. The leukocyte count is normal speaking against leukaemia. A viral illness can lead to mildly low platelets (1lac - 1.2 lac/ fL), and slightly elevated LFTs (ALT 100 - 150 IU/ml), but not to this extent. Acute hepatitis should not affect the platelet count, and usually leads to ALT levels above 1500IU/mL.

Q. 36 Yr old G2P1 woman at 24 wks gestation is noted to have fatigue of 4 wks duration. Her Hb level is 8g/dL, leukocyte counts are 2cells/microlitre & platelet counts are 20000/microlitre. Which of the following is the most likely diagnosis? A. Iron deficiency anemia B. HELLP syndrome C. Pre-eclampsia with severe features D. Acute leukaemia Ans. D Pancytopenia, a reduction in the number of RBCs, WBCs and platelets circulating throughout the body, suggests a bone marrow process. None of the answer choices involve low leukocyte counts (leukopenia). Low platelets (thrombocytopenia) may also be a manifestation of severe preeclampsia, and is part of the criteria for HELLP syndrome as well. Iron deficiency anaemia involves low hemoglobin levels and is common in pregnancy due to decreased iron stored prior to the pregnancy, and increased demands for iron during pregnancy. Since this patient's Blood Work showed low WBCs, a bone marrow biopsy should be done. A pregnant woman with leukaemia may require chemotherapy, which poses a risk of intrauterine growth retardation to the developing foetus. Acute leukaemia itself carries a risk for preterm labour, spontaneous abortion and stillbirth.

Q. 29 Yr old G2P1 woman at 28 wks gestation, who had normal Hb level 4 wks ago at her 1st prenatal visit, complains of 1 wk of fatigue & now has a Hb level of 7g/dL. She noted dark coloured urine after taking an antibiotic for a urinary tract infection. Which of the following is the most likely diagnosis? A. Iron deficiency anemia B. Thalessemia C. Hemolysis D. Folate deficiency E. Vitamin B12 deficiency Ans. C This 29 yr old woman at 28wks gestation complains of fatigue. She took an antibiotic for urinary tract infection and then developed in dark coloured urine. She was also probably icteric. Currently, her Hb level is low, reflecting anemia. This constellation of symptoms likely reflects a hemolytic process probably due to G6PD deficiency. The dark urine suggests bilirubinuria. Other causes of hemolysis could include malaria, HELLP syndrome, autoimmune hemolytic anemia, or sickle cell crisis. In this case, the woman ingested an antibiotic, which likely was nitrofurantoin, a commonly prescribed medication for pregnant women. She doesn't have hypertension, symptoms of SLE or other autoimmune diseases, or pain suggestive of sickle cell disease.

Q. A 26-year-old woman presents complaining of intermenstrual spotting over the last 3 months, accompanied by minimal flow during her menses. She has been taking the same low-dose combined oral contraceptive faithfully for the last 5 years. Her physical examination is unremarkable. The most probable explanation for her symptoms is: A. Endometrial hyperplasia B. Progesterone breakthrough bleeding C. Pregnancy D. Bleeding disorder E. Estrogen breakthrough bleeding Ans. B Progestin-only contraceptive methods and combined oral contraceptives alike rely on the progestin component to block ovulation in order to prevent pregnancy. The estrogen component of combined oral contraceptives serves to add cycle control that is not present with progestin-only contraceptive methods such as the “mini-pill,” DMPA, or progestin implants. Although low-dose combined oral contraceptives contain estrogen and progestin, the effect is still predominantly progestational, and progesterone breakthrough bleeding occurs as the ratio of progesterone to estrogen is unfavorably high. The endometrial lining is most likely atrophic due to long-term effects of the pro-gestin, and endometrial hyperplasia is unlikely given her long-term use of combined oral contracep-tives. Estrogen breakthrough bleeding occurs when there is unopposed estrogen stimulation causing excess glandular proliferation that results in an unstable, thickened endometrium prone to irregular shedding. The possibility of pregnancy must be ruled out in anyone of reproductive age with abnormal uterine bleeding, even with contraceptive use. Low-dose combined oral contraceptives are highly effec-tive in prevention of pregnancy but do carry a low failure rate even with perfect use. The timing and not the quantity of abnormal uterine bleeding is the issue and therefore it is unlikely that this represents a bleeding disorder.

A 29-year-old woman, gravida 1 para 1, is evaluated in the emergency department for a headache. Three days ago, she had an uncomplicated vaginal delivery with neuraxial anesthesia. This morning, the patient developed an occipital headache that has not improved with acetaminophen. The headache has become progressively worse, and the patient cannot sit without becoming nauseated and vomiting. The patient has no chronic medical conditions and does not use tobacco, alcohol, or illicit drugs. Temperature is 36.7 C (98.1 F), blood pressure is 162/96 mm Hg, pulse is 98/min, and respirations are 18/min. On examination, heart sounds are normal with no rubs or murmurs, and the lungs are clear to auscultation. Cranial nerves are intact and deep tendon reflexes are 3+. There is 5/5 strength in the right lower extremity and 3/5 strength in the left. The next best step in the management of this patient is A. 100% oxygen B. CT scan of the head C. Epidural blood patch D. Lumbar puncture E. Sumitriptan therapy Ans. B This postpartum patient with worsening headache and severe hypertension (eg, systolic 2160 or diastolic 2110 mm Hg) has preeclampsia with severe features, which can present up to 6 weeks after delivery. The most common presenting symptom is a severe headache in the bilateral occipital or frontal regions that does not improve with acetaminophen or nonsteroidal anti-inflammatory drugs. Patients with preeclampsia are at increased risk of hemorrhagic and ischemic stroke due to acute elevations in cerebral perfusion pressure and vessel rupture (hemorrhagic), as well as preeclampsia-mediated vascular endothelial damage and microthrombi formation (ischemic). To decrease this risk, preeclamptic patients with severe-range blood pressures require aggressive antihypertensive therapy (eg, labetalol, nifedipine) and magnesium sulfate, which helps prevent eclamptic seizures that can worsen stroke symptoms. Most preeclamptic patients do not require imaging; however, in those with focal neurologic deficits, such as this patient with asymmetric motor deficits (strength right > left), CT scan of the head should be performed to evaluate for possible stroke and help guide management (Choices A and E) Oxygen administration is used to alleviate cluster headaches, which typically present with a short-lived, unilateral, orbital headache with autonomic symptoms (eg, ptosis, lacrimation). Triptans (eg, sumatriptan) are used to treat migraines, which can present as occipital headaches with nausea, vomiting, and occasionally motor aura (eg, hemiplegic migraine). However, CT scan should be performed in this patient prior to attempting symptomatic therapy in order to exclude life-threatening causes of neurologic deficit (Choice C) An epidural blood patch is used to treat postdural puncture headaches, which can occur after neuraxial anesthesia and may present as an occipital headache that worsens with sitting or standing due to cerebrospinal fluid (CSF) leakage. However, this type of headache is not associated with hypertension or focal neurologic deficits. (Choice D) Lumbar puncture can evaluate for CSF infection (eg, meningitis, encephalitis), which may present with headache after neuraxial anesthesia. This patient is afebrile, making this diagnosis less likely. In addition, lumbar puncture is usually performed after CT scan to exclude a brain mass because there is a risk of herniation with mass effect. TAKE HOME POINT 👇 Preeclampsia can present up to 6 weeks postpartum with headache and hypertension. Patients with preeclampsia are at increased risk of stroke, and those with focal neurologic deficits should be evaluated with CT scan of the head.

Q. A patient with a history of three miscarriages presents to your OPD. The only workup she has had done so far was a laboratory evaluation that showed the following results: Lupus anticoagulant screen negative, Anticardiolipin IgA high positive, IgG low positive, and IgM normal. What would you offer the patient next? A. Discuss with her that she has APS and devise a treatment plan based on this diagnosis B. Repeat antiphospholipid screen in 6 to 8 weeks C. Start heparin and baby aspirin treatments immediately D. Start baby aspirin with next pregnancy E. None of the above Ans. E The patient does not have APS based on these laboratory results. Anticardiolipin IgA being positive is not part of the diagnostic criteria, and the low-positive IgG is also not positive. There is no need to repeat these tests again. Since the patient does not have the syndrome, there is no need to initiate anticoagulant therapy, but alternative causes of her RPL should be sought.

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Q.Sarita, a 30 year old woman develops a deep vein thrombosis in her left calf on fourth post operative day following cesarean section done for fetal distress. The patient is started on heparin and is scheduled to begin a 6 weeks course of warfarin therapy. The patient is a devoted mother who wants to breast feed her baby. What is the advice which is given to the patient ? a. Patient may continue breast feeding at her own risk. b. Patient should breast feed her baby only if her INR is at <2.5 c. Patient can breast feed her baby after 6 weeks course of warfarin isover d. Warfarin is not a contraindication for lactation e. Warfarin is absolutely contraindicated during lactation Ans. D • Warfarin is contraindicated in the first trimester of pregnancy as it can lead to contradi syndrome comprising of microcephaly, opticatrophy, nasal hypolplasia and chondrodysplasia punctate. It can also lead to IUGR, abortions and IUD. • But warfarin is absolutely safe during lactation as an extremely minute quantity of it is excreted in breast milk.

Q. A 30 Yr old G1P0 woman complains of nausea and vomiting for the first 3 months of pregnancy. She is noted to have a Hb level of 9g/dL & MCV of 110fL (normal 90-105 fL). Which of the following is the most likely etiology of the anemia? A. Iron deficiency B. Folate deficiency C. Vitamin B12 deficiency D. Physiologic anemia of pregnancy Ans. B This is a macrocytic anemia because the MCV is above normal. Macrocytic anemia include folate deficiency & vitamin B12 deficiency ; however, folate deficiency is more commonly seen in pregnancy than vitamin B12 deficiency. Iron deficiency is a microcytic anemia (MCV < normal), & it is the most common cause of anemia in pregnancy. Physiologic anemia of pregnancy is a result of the physiologic hemodilution that occurs in the vasculature. There is a disproportionate increase in plasma volume over the increased RBC volume, & this " diluted state " also gives the appearance of a fall in the laboratory values of Hb & hematocrit.

Q. 25 year old G2P1001 is noted to have a baseline FHR of 150 BPM with moderate VARIABILITY. She is noted to have repetitive late deceleration shortly after the placement of an epidural catheter for pain control. Her BP is 90/55 mm HG and heart rate is 100 beats per minute. What is the next best step in managing this patient? A. Amnioinfusion B. C-section C. Ephedrine D. Expectant management E. Rupture membranes F. Terbutaline Ans. C The vasopressive sympathomimetic agent ephedrine may help. This patient is having late decelerations likely due to the hypotension from the epidural analgesia. IV fluid hydration would be the first course of action, and if unsuccessful, then a vasopressor agent such as ephedrine would be useful, theoretically ephedrine causes vasoconstriction of the peripheral vasculature and spare the uterine arteries. The corrective actions usually lead to resolution of the late decelerations fairly rapidly. The mechanism of action of the epidural induced hypotension is sympathetic blockade leading to vasodilation. Prior to administration of regional anaesthesia, a patient typically will receive an IV fluid bolus as a preventive measure.

Contraceptive of Choice in With Various Medical Disorders. 1) Cardiac Disease:: Vasectomy > Barriers > IUCD (In options,, If Vasectomy is not there-- then Contraceptive of choice in Cardiac disease is (Barriers>>IUCD) 2) PreEclampsia = IUCD. 3) Diabetes = IUCD. 4) Seizure Disorder = IUCD. 5) Lactating Mother = IUCD. 6) Sickle cell anaemia = IUCD. 7)Previous H/O Ectopic pregnancy = OCP's. 8)Porphyrias = IUCD. 9) Thyroid Disorders = IUCD. 10) HIV ++ = Barriers.

Which of the following statements is incorrect in relation to pregnant women with epilepsy? A. The rate of congenital malformation is increased in the offspring of women with epilepsy B. Seizure frequency increases in approximately 70% of women C. Breast feeding is safe with most anticonvulsants D. Folic acid supplementation may reduce the risk of neural tube defect Ans. B Seizure frequency increases in approximately 70% of women. Seizure frequency is increased in approximately 30% of women during pregnancy.

Dysfunctional Uterine Bleeding(DUB) CAUSES ⚡Cervical problems : polyps, carcinoma ⚡Ovarian cysts or tumors ⚡Neoplasm (cervix, uterus, ovary) ⚡Trauma ⚡Rare - foreign body ⚡Anticoagulants +Adrenal disease ⚡Clotting disorders +Congenital abnormalities of uterus +Congenital hemorrhagic diathesis ⚡Endocrine disorders : hyperprolactinemia, thyroid disease, etc. +Endometriosis ⚡Polycystic ovarian disease +Pelvic inflammatory disease (PID) +Platelet inhibitors +Pregnancy +Polyps (uterine) ⚡Thrombocytopenia ⚡Infection : cervicitis ⚡Oral contraception ⚡Not known cause

Common points to remember 1. MC variety of endometrial cancer -adenocarcinoma 2. MC malignant variety of endometrial carcinoma : clear cell ca and papillary serous tumor 3. 1st investigation done in case of endometrial ca-Endometrial aspiration biopsy 4. Best investigation for diagnosing endometrial ca- Hysteroscopy and biopsy 5. In all gynaecological ca FIGO system followed except in ca vulva where both FIGO and TNM staging can be done 6.Staging for endometrial ca is surgical i.e TAH with BSO with pelvic and paraaortic lymphnode dissection being performed @ time of sx only 7. Most characteristic histological finding in clearcell type of endometrial cancer : Hobnail cells 8. Referred pain in endometrial cancer to hypogastrium or both iliac fossa is simpsons pain