Emergency Medicine Notes, Cont

What to do for pulseless CPR and epinephrine

electrical activity

What to do for pulseless VTach After each step, do 5 cycles of CPR followed by pulse and rhythm check before
going on to next step.
1. Defibrillate
2. Defibrillate again
3. Epinephrine
4. Defibrillate
5. Amiodarone
6. Defibrillate
7. Epinephrine

What to do for VFib After each step, do 5 cycles of CPR followed by pulse and rhythm check before
going on to next step.
1. Defibrillate
2. Defibrillate again
3. Epinephrine
4. Defibrillate
5. Amiodarone
6. Defibrillate
7. Epinephrine

What to do for stable SVT Control rate with vagal maneuvers. If they don’t work, do adenosine followed by
other AV node blocking agents

What to do for unstable SVT Synchronized electrical cardioversion

What to do for unstable atrial Synchronized electrical cardioversion

fibrillation

What to do for stable a-fib Control rate (diltiazem or BB) and anticoagulate if it’s been > 48 hours. Can do
elective cardioversion right away if it’s been < 48 hours. Otherwise must first do a
TEE or anticoagulate

What to do for wolf Parkinson Procainamide – don’t give nodal blockers.

white arrhythmia

What to do for bradycardia Atropine. If it doesn’t work, then give transcutaneous pacing, dopamine, or
epinephrine

Abdomen pain: Parietal pain vs. Parietal: sharp, focal, guarding. Often don’t want to move.
visceral pain Abdomen: Midline or diffuse, crampy, achy. Often unable to lie still.

Atypical location for pneumonia Right or left upper quadrant

pain

How to dx appendicitis Clinical. Look at WBC for labs, but no imaging is needed unless dx is uncertain
(e.g., patient has an appetite). If imaging is going to be done, do CT with oral and
IV contrast. Can also do ultrasound.

Estimating BSA for burns 9: head, arm, arm

18: back, chest, leg, leg
1: perineum
Burns: first, second, third
degree
Parkland formula for fluids in
burns
Burn prophy abx?
When to transfer to a burn
center?
Issue to be aware of with
carbon monoxide poisoning and
pulse ox
Scorpion bite
Rodent bite
Rabies prophy in a vaccinated
person
Tetanus
- Clean wound
- Major/dirty wound
Poisoning:
- when to use orogastric
lavage
- When to use activated
charcoal
Treatment for malignant
hypertension
Central cord syndrome
Respiratory quotient
- what is it?
- What is the ratio for
proteins, fats, carbs?
First: sunburn, no blisters (through epidermis)
Second: blisters (some or all dermis)
Third: painless, white, charred (below dermis)
Electrical burns may not be obvious!
Applies to 2nd and 3rd degree. Give 4 mL per kg x % BSA. Give ½ in first 8 hours
and ½ in the next 16. Adjust to maintain UOP of at least 1 mL/kg/hr
Topical silver sulfadiazine when epidermis is not intact. Orals don’t really help.
- 10-50 years: > 20% BSA. If younger or older, > 10% BSA
- Any 2nd-3rd degree burns involving face, hands feet, genitals, perineum,
major joints.
- Any circumferential burns
- Chemical, electrical, lighting
- Inhalation injury
O2 sat can read normal if the pulse ox doesn’t distinguish carboxyhemoglobin
Benzos and pain meds
Atropine if salivation and respiratory distress
IV scorpion specific antibody
Local wound care. They don’t carry rabies and they have a low risk of infection
Give 2 more doses of vaccine (don’t need IvIG or 4 course vaccine)
- clean: give tetanus toxoid vaccine if < 3 lifetime vaccinations and last one >
10 years ago
- dirty wound: give tetanus toxoid if last one > 5 years ago. Give IVIG if had
< 3 tetanus vaccines ever
- life threatening ingestion < 1 hour ago
- within 2 hours of adsorbable substance – NOT for hydrocarbons, alcohol,
lithium, iron, lead
Nitroprusside
burning pain and paralysis of upper extremities, lower extremities are okay.
Commonly seen in the elderly with forced hyperextension of the neck
Ratio of O2 consumed to CO2 produced as fuel is burned. carbs have a ratio close
to 1, protein 0.8, fat 0.7. Normal RQ is 0.8 due to a mix of dietary intake.
Biggest danger with median nerve and/or brachial artery entrapment
supracondylar fracture of the
humerus

Approach to massive 1. Urgent brochoscopy for dx and tx (e.g., cautery, balloon tamponade)
hemoptysis 2. Pulmonary arteriography for embolization
3. thorocotomy

Bleeding lung should be in the dependent position

Treatment for MCL tear bracing and early ambulation

How long to wait to fix hydrocele 1 year

in an infant?

Management of duodenal Conservative - NG suction and parenteral nutrition. Should resolve in 1-2 weeks. If
hematoma not, consider surgery.

Management of meniscal injury Persistent mechanical symptoms → MRI. PRobably need surgery (not true for MCL
tears)

Appendicitis management lap appy if obvious. If not classic, imaging with CT or ultrasound

What dose of prednisone and > 20 mg for > 3 weeks. No risk if < 5 mg. Intermediate risk 5-20.
time frame of use raise concern
for adrenal suppression?

Normal ankle brachial index 0.9 to 1.3

Mnemonic for brachial plexus Rugby Teams Drink Cold Beer - roots, trunks, divisions, cords, branches
roots, cords, etc

When to avoid oro-tracheal Significant facial injuries. It’s okay with cervical spine injuries. If OT intubation isn’t
intubation an option, the next step is cricothyroidotomy.

Risk factor for nasopharyngeal EBV. Especially if mediterranean or Asian

cancer

Severe acute back pain, Ruptured AAA - the bleed can go into the retroperitoneum, lead to increased
hypotension, hematuria pressure that causes venous congestion in retroperitoneal structures like the
bladder. Can cause gross hematuria!!

Biostatistics:
Disease No disease

Exposure/positive test a b

No exposure/negative test c d

Likelihood ratio: positive and negative Likelihood ratios are the odds of disease if a test is positive or
negative. Diseased people like to go on top for both equations
 Positive Likelihood ratio = (a/b) = true positives/false positives =
diseased people with positive result/nondiseased people with a positive
result

Negative likelihood ratio = (c/d) = false negatives/true negatives =

diseased people with a negative result/non-diseased people with a
negative result

What are post test odds? Pretest odds x likelihood ratio

What happens to PPV and NPV when PPV and prevalence decrease together and NPV and prevalence are
prevalence decreases opposite.

Formulas to relate odds and odds = probability/(1 - probability)

probability probability = odds/(1 + odds)

Relative risk disease incidence in people who were exposed/disease incidence in

people who were not exposed

Think about risk of disease vs. odds of exposure

Odds ratio Odds that a diseased person was exposed/odds that a non-diseased
person was exposed (= a/c divided by b/d = ad/bc)

Attributable risk and the absolute risk Absolute difference in risk between exposed and not exposed
reduction Absolute difference in risk between treated and not treated.

Number needed to harm or number 1/attributable risk

needed to treat 1/absolute risk reduction

Standard deviations include what +/- one SD is 68% of the population

percent of the population +/- two SDs is 95%
+/- three is 99.7%

What does validity mean? Accuracy. It is the percentage of all true positives and true negatives
among all the test results

When are relative risk and odds ratios When the incidence of a disease is low, aka when the outcome is
similar? uncommon

What is the analytical tool used for Odds ratio

case control studies

5 Types of selection bias - Ascertainment/sampling bias: study population is not

representative of the target population because of nonrandom
sampling
- Nonresponse bias: If lots of non-responders, can get bias i the
nonresponders differ in some way from responders
- Attrition bias: Losing lots of study participants can create bias if
the study participants that remain are different than the ones who
left. Can happen even if rates of loss between control and
experimental arms are similar because the people might have left
for different reasons
- Berkson bias: Studies in only hospital patients
- Prevalence bias: Exposures that happen long before disease
assessment can cause study to miss diseased patients that die
early or recover

4 types of observational bias - Recall - participants with negative outcomes are more likely to
remember exposures
 - Observer - observers misclassify the data based on individual
differences in interpretation or preconceived expectations about
the study
- Reporting: Over or under report exposure history because of
stigma
- Surveillance/detection: Risk factor itself causes increased
monitoring in the exposed group → increased chance of
identifying the disease
- Measurement bias: E.g., Hawthorne effect - groups who know
that they’re being monitored act differently than groups who don’t -
remedy is to use placebo
- Procedure bias: Subjects in the two groups aren’t treated the
same

Bias involved in lots of study Selection bias. The control and experimental drop outs may leave for
participants being lost to follow up different reasons (eg. members of one group may be more likely to drop
out because of health problems vs. inconvenience of participating in a
study)

Relationship between PPV and NPV - PPV increases with both prevalence and pretest probability
and - NPV decreases with both prevalence and pretest probability
- prevalence
- pretest probability

Random error and systematic error - Random error reduces precision/reliability, systematic error reduces
which reduces accuracy/validity and accuracy/validity
which reduces precision/reliability?

Crossover study Subjects act as their own controls. E.g., everyone receives a sequence of
different treatments or exposures, all subjects receive the same number of
treatments and participate in the same number of periods.

Standard error of the mean How much variation is there between the sample mean and the true
population mean. SEM = SD/square root of # study participants

Confidence interval Mean +/- (Z * SEM), where Z = 1.96 for 95% CI and 2.58 for 99% CI

Positive skew, negative skew Asymmetry with longer tail on the right, longer tail on the left

ENT

Weber test - different results for the normal, sensineural Normal - no difference
loss, and conductive loss Sensineural - louder in normal ear
Conductive - louder in abnormal ear because this ear
doesn’t hear background noise!

Which antibiotics cover psuedomonas? - antipsuedomonal penicillins - ticarcillin,

piperacillin
- cephalosporins: ceftazadime (3rd gen) and
cefepime (4th gen)
- Aminoglycosides
- Floroquinolones
- aztreonam
- carbapenems (except ertapenem)
Gynecology notes

When to do an endometrial biopsy for Women in menopause: endometrium > 4 mm

abnormal uterine bleeding Women > 35: If risk factors for endometrial hyperplasia

Treatment for abnormal uterine bleeding 1. NSAIDs if ovulatory bleeding. OCPs, mirena
- not heavy 2. Anovulatory → progestins, OCPs, mirena

D&C if medical management fails, hysteroscopy, hysterectomy or

endometrial ablation

Treatment for heavy abnormal uterine 1. IV estrogen.

bleeding 2. If not controlled in 12-24 hours, D&C

Endometriosis symptoms cyclical pelvic and/or rectal pain and dyspareunia.OCPs are first line,
also GnRH analogs, danazol, NSAIDs, progestins

Adenomyosis symptoms and treatment noncyclical pain, menorrhagia, and enlarged uterus. NSAIDs are first
line, also OCP or progestins

Most likely types of vaginal cancer in Younger: adenocarcinoma, clear cell

younger and post menopausal women Older: squamous

CA-125 - epithelial cell tumor

- associated with what category of - In younger women, can be associated with endometriosis
tumor? - In older women, increased likelihood that the tumor is malignant
- What does it mean in
premenopausal women?
- In post menopausal?

Ovarian tumor markers - epithelial: CA 125

- epithelial - endodermal sinus: AFP
- endodermal sinus - embryonal carcinoma: AFP, beta HCG
- embryonal carcinoma - choriocarinoma: bHCG
- choriocarinoma - dysgerminoma: LDH
- dysgerminoma - granulosa cell: Inhibin, estrogens
- granulosa cell

Who needs surgery for ovarian mass Premenarche: > 2 cm

Premenopause: > 8-10 cm, complex, and/or unchanged on repeat
pelvic exams and ultrasound
Post menopause: > 5 cm, abnormal CA 125

Order of development for girls thelarche → adrenarche → growth spurt → menarche

Features of Noonan syndrome AD. Short, webbed neck, triangle face, delayed puberty, learning
problems

Work up for delayed puberty 1. Start with TSH, bone scan, prolactin
2. Then move to FSH

Age for early puberty - 7 and younger. Most often idiopathic central.
- most common cause - Hypothyroid: bone age is delayed, not advanced
- Sign that it’s hypothyroidism - McCune Albright - period comes first, before hair or breasts
- Sign that it’s McCune Albright

Who gets tested for G&C Anyone < 25 sexually active. Then it’s just risk factors.

Treatment for salpingitis If fever, admit and give IV clindamycin and gentamycin - treat before
cultures returnd
Urinary symptoms with a negative Suspect urethritis - gonorrhea, chlamydia, trichomonas
culture

Vaccinations in pregancy - avoid mmr, varicella, HPV

- which to avoid - okay to do pneumococcus, tetanus, Hep B
- which are okay

Order of hormonal changes in First AMH, then inhibin B, then estradiol

menopause

Who is depo good for? Sickle cell and epilepsy - get fewer episodes

Medical abortion meds Mifepristone (anti progesterone) followed by misoprostol to induce

uterine contractions. If bleeding is very heavy, do a D&C

Surgical abortion Manual vacuum aspiration up to 8 weeks

D&C < 16 weeks
Dilation and evacuation > 16 weeks

PMS risk factors (vitamins) B6, Ca, Mg deficiency. Treat with vitamins A,B6, E

Irregular bleeding - heavy - fibroids

- heavy bleeding - in between - endometrial hyperplasia, endometrial polyp,
- in between periods uterine cancer
- Irregular - irregular - anovulatory

Management: - ASCUS - three options

- ASCUS - HPV DNA testing - if high risk, then colposcopy. If
- CIN1 negative, resume regular screening
- CIN2 and CIN3 - Pap at 6 months and 1 year.
- Colposcopy
- CIN1: Close observation. Do Pap at 6 months and 1 year. Or
women > 21 can have HPV testing at 1 year
- CIN2: Manage like CIN1 if < 25, and like CIN3 if 25+
- CIN3: Ablation, excision, hysterectomy if recurrent. Pap at 1
year if negative margins, at 6 months if positive margins.

When to excise breast mass If any red flags on triple assessment: Imaging, biopsy, and physical
exam. A reassuring result on 1 or 2 can’t negate a red flag!

Treatment for endometrial hyperplasia - If no atypia: progesterone - whether oral or UID. Repeat bx in 3-
6 months
- If atypia: generally hysterectomy, but can do progresterone if
want to maintain fertility

Differences between type 1 and type 2 - Type 1: estrogen dependent. Typical endometriod cell, during
endometrial cancer menopause or soon after
- Type 2: papillary serous or clear cell. Estrogen independent.
Atypical patients - late menopause, thin, regular periods

Treatment for endometrial cancer Hysterectomy is first line, but can do progesterone and monitorying for
grade 1 if want to become pregnant

Management VIN: excise, skinning vulvectomy

- high grade VIN invasive: Radical vulvectomy and regional lymphadenectomy
- Invasive vulvar cancer

Most common cause of endometrial Atrophic endometrium

bleeding

How to manage endometrial polyp Remove if > 1.5 cm because might be malignant
Types of epithelial tumors Serous, mucinous, endometroid, clear cell. Often present late, can have
early GI symptoms.

Miggs syndrome Ovarian fibroadenoma (stromal tumor), associated with ascites and
pleural effusions

Derm conditions - what does the rash - LSC: chronic itching → purple leathery skin
look like? - lichen sclerosis: white. Risk of cancer
- Lichen simplex chronicus - LP: lacy reticulated mucocutaneous rash, usually involves the
- Lichen sclerosis vagina, can obliterate it
- Lichen planus

Post op fever: - PNA or atelectasis on day 1

- Wind - UTI day 3
- Water - DVT or PE day 5
- Walking - wound infection day 7
- Wound - Wonder drugs > 1 week
- Wonder drugs

Granuloma inguinale Small painless nodules in areas of sexual contact → extensive beefy
red ulcers that totally destroys the tissue. Caused by klebsiella
granulomatis.

Chlamydia small shallow ulcers, matted lymph nodes, large/painful/fluctuant

boboes, sinus tracts

Vaginitis - yellow mucopurulent discharge and erythematous, friable

cervix - looks just like gonorrhea but is more common. (vs. trichomonas
- frothy discharge and strawberry cervix)

Causes of bleeding in between periods Endometrial/cervical cancer, uterine polyp, endometrial hyperplasia

Causes of heavy periods Consider fibroids

- How do progestin containing Both progestin and anti-progestin (ulipristal) delay ovulation.
emergency birth control pills
prevent pregnancy Progestin: 3 days. Ulipristal, more effective, up to 5 days
(levonorgestrel, OCP)?
- How does ulipristal work?
- What is the time frame for use?

Management of endometriosis if strong 1. NSAIDs and OCPs, unless that’s not an option (e.g., desire
suspicion pregnancy) or it doesn’t wor
2. Diagnostic laparoscopy

Obstetrics
Pregnancy milestones - visible sac: 5 weeks
- visible gestational sac - fetal pole: 6 weeks
- visible fetal pole - fetal heart on ultrasound: 6-7 weeks
- fetal heart on ultrasound - earliest hearbeat by doppler: 10-12 weeks
- earliest heartbeat by doppler - fetal movement: 17-18 weeks
- fetal movement

Frequency of prenatal visits 1st 7 months: monthly

29-35 weeks: biweekly
36 weeks: weekly

Timing and tests for First trimester screen 9-14 weeks: PAPP-A, beta HCG, nuchal transparency +/- CVS (10-
and Second trimester screen 12 weeks)

Abnormalities in AFP, beta HCG, estriol and
inhibin A for
- trisomy 18
- trisomy 21
Duration of labor stages for first time and
multiparous
- First stage - latent labor and active
labor
- Second stage
- Third stage
Definition of prolonged labor
- first delivery - latent, active, second
stage (with and without epidural)
- multiparous - latent, active, second
stage (with and without epidural)
Definition of adequate contractions
How often to review fetal heart tracings in
first stage and second stage for women with
complications and no complications
Normal fetal HR and variability
Definition of early, late, and variable decels
Average # of movements in 20 minutes
Nonstress test - reactive and nonreactive
Contraction stress test - positive and
negative
15-22 weeks: AFP, beta HCG, estriol, inhibin A, +/- amniocentesis
(15-20 weeks)
- AFP: increased with body wall defects, multiples, placenta
abnormalities. Decreased with trisomy 21 and 18
18: all decreased!
21: decreased AFP and estriol, but increased inhibin A and beta
HCG
- First stage is < 4 cm dilation: 6-11 hours vs. 4-8 hrs
- Second stage is from full dilation: 4-6 hours at 1.2 cm/hr vs.
2-3 hours at 1.5 cm/hr
- Third stage: 30 minutes for everyone
First baby:
- Latent > 20 for first baby, 14 for second,
- Active
- Prolonged is > 2 hours without change
for both - if contractions are adequate,
- Arrest is > 4 hours without change if
contractions are adequate, and > 6 hours
without change if contractions are
inadequate
- Second stage
- first baby: > 2 hours without change if no
epi or > 3 hours without change if epi
- Second baby: > 1 hour, > 2 hours
Every 2-3 mins for 40-60 seconds. Or 200 montevideo units in 10
minutes
- first stage (latent and active): every 30 minutes if no
complications, every 15 if complications.
- second stage (pushing) 15 minutes if no complications,
every 5 if complications
110-160, 6-25 bpm
- Early: mirror contractions, with onset to nadir > 30 seconds
(gradual)
- Late: onset, nadir, and recovery begin after contraction
onset, peak, and recovery, respectively. Onset to nadir is >
30 seconds (Gradual)
- Variable: Fast drops (< 30 seconds to nadir) that last at least
15 seconds
10
- Reactive is > 2 accels of at least 15 bpm (or 10 bpm if < 32
weeks) for at least 15 seconds
- If non-reactive, follow with biophysical profile
Positive: late decels after > 50% of contractions in 10 minutes
 - Biophysical profile - what does it - BPP - get 2 points for each, 8-10 is normal, 4 or less means
measure? deliver
- What does the modified BPP - Fetal tone (at least one episode of flexion or
measure? extension),
- Breathing - at least one stretch for 30 seconds
- Movement - at least 3
- Amniotic fluid - deepest vertical pocket more than 2
cm or AFI > 5 cm
- non-stress test - reactive
- NST and AFI

What is a normal AFI? > 5 cm → otherwise oligohydromanios and needs further work up.

When to check for gestational diabetes and 50 g BG test: 24-28 weeks, > 140.
what is an abnormal 50 gm response? What Goal fasting BG < 90, 1 hour > 140, 2 hours after meals < 120
is goal fasting and post prandial BG?

HTN in pregnancy - drugs to avoid ACE and diuretics. Both can cause uterus ischemia

Threshhold for HTN in pregnancy and for 140/90, 160/110. Goal is < 160/110 (DBP at least 90-110 to maintain
severe preeclampsia. Goal BP for treatment fetal blood flow)
of severe preeclampsia.

When to give rhogham 28 weeks, after delivery, any exposure to fetal blood

When to give baby steroids? < 34 weeks for steroids. Help with lungs, reduce risk of IV
When to give baby Mg sulfate for brain? hemorrhage, and reduce risk of necrotizing enterocolitis
< 32 weeks for Mg sulfate

Definition of preterm labor and late term 20-37 weeks with contractions and cervical change (> 2 cm and at
labor least 80% effaced), late term is 41-42 weeks, post term is 42+ weeks

Definition of premature rupture of Premature < 1 hr before labor, prolonged > 18 hours
membranes and prolonged rupture

When to use tocolysis Delivery < 34 weeks if no chorioamniotis. It does increase the risk of
chorioamnionitis, so generally done short term

Who gets GBS prophy during labor? Don’t bother testing for GBS (usually done at 35-37 weeks) - just
treat
- GBS positive in that pregnancy, even if treated
- Prior baby with GBS sepsis

GBS status is unknown and

- Delivery < 37 weeks (preterm)
- ROM > 18 hours
- intrapartum fever

Signs of septic thrombophlebitis Picket fence fevers (high spikes then normal) and back/abdominal
pain

Treatment of UTI in pregnancy Amoxicillin, amoxicillin-clavulanate, nitrofurantoin, cephalexin

Risk of transmitting HIV to baby if viral load < 1%

is undetectable

When to do elective C section for HIV mom viral load > 1000

Affect of pregnancy on total t4 and t3, free Total hormones increase a lot, because HCG stimulates thyroid
T4 and T3, and TSH hormone production! But at the same time, estrogen increases TBG,
so free T4 and T3 only increase a little. This causes TSH to
 decrease

Chorioamnionitis management Give antibiotics, induce labor. Baby will have tachycardia, but that
should come down with antipyretics for mom. Only do a c-section if
the baby has late or variable decels, not based on the tachycardia
alone.

STD screening at first prenatal visit - who to Screen everyone for syphillis, hep B, HIV
screen for G, C, syphilis, HIV, Hep B, Hep G&C: Screen women < 25 and women at increased risk
C? Hep C: increased risk

Time frame for external cephalic version 37 weeks to labor. Make sure the provider is equipped to do an
emergency c section in case something goes wrong

Causes of hyperandrogenism in pregnancy. - Luteoma = yellow SOLID tumors, high risk of virilizing
Features of: female infant. Treatment is just to watch them, they regress
- luteoma after delivery. 50% are bilateral
- krukenberg tumor - Theca lutean cyst = bilateral CYSTS, associated with molar
- theca-lutein cyst pregnancy and multiple gestation. Regress after delivery
- Krukenberg tumor - bilateral ovarian mets from primary GI
cancer

28 weeks pregnant, mom says no fetal Ultrasound! That is the way to confirm an intrauterine fetal demise.
movement. Doppler shows no heart tones. More accurate than doppler. Look for movement and cardiac activity.
Next step?

Abnormal NST - what next? BPP or contraction stress test. If normal, then repeat in 1 week.

Testing for PE in pregnancy Note - d-dimer is always elevated in pregnancy! not useful

Pyelonephritis treatment in pregnancy E coli is most common bug. Treat with IV cephalosporin or amp and
gent

Weird aspects of molar pregnancy Do not biopsy choriocarcinoma - bleeds too much! Diagnose with
beta HCG. Wait 6 months after HCG goes to zero before trying for
pregnancy again.

When is ibuprofen safe in pregnancy? Up to 32 weeks

Criteria for using methotrexate with an not ruptured, < 3.5 cm, beta < 5000, in the tube (not elsewhere), no
ectopic fetal HR, mom will follow up, mom doesn’t have liver problems, etc.

Threshold for anemia in pregnancy 10.5

Most common type of thyroiditis after lymphocytic - painless

pregnancy

When to place cerclage? Incompetent cervix → 14 weeks (2 weeks into 2nd trimester)

When to do a c section for placenta previa? 34 weeks - once lungs are mature

Risk of isoimmunization if Rh negative mom delivery - 20%. SAB - 2%. Elective 5%.
delivers without rhogham? What about SAB
or elective termination?

Treatment for hyperemesis gravidarum B6, ginger, support

Herpes gestationis Very itchy erythematous blisters that begin on the arms and legs and
move to the abdomen. Do immunoflourescent staining of bx -
caused by IgG to basement membrane. Increased risk of still birth
and low growth. Treat with oral steroids.
Management of vasa previa Avoid digital exams, plan for c-section between 35 and 36 weeks to
avoid going into labor at term (contrast previa, which will have a c
section at 34 weeks)

When is the baby at risk of pulmonary < 25 weeks

hypoplasia?

CI for tocolytics - Rotadrine and terubutaline are beta 2 agonists, don’t use
- rotadrine and terbutaline with cardiac arrhythmias or diabetes
- nifedipine - Nifedipine - don’t use in cardiac disease or mix with Mg (risk
- indomethacin of pulmonary edema)
- Indomethacin - avoid > 33 weeks

Management of late term (41 weeks) and 41 weeks: induce with misoprostol if cervix is favorable
post term (42 weeks) pregnancy 42 weeks: induce

What is misoprostol? Prostaglandin E1

Treatment for variable decels amnioinfusion (to relieve cord compression)

Cardinal movements Engage

Descend
Flexion
Internal Rotate
Extend
External rotate
Expulsion

Why avoid needle aspiration of ovarian Not curative for benign masses, and risk of spilling cancer cells if
mass malignant

When to deliver in HELLP or preeclampsia > 34 weeks or at any stage if baby or mom is tanking

Treatment for endometrial hyperlasia - if atypia → hysterectomy is preferred

- If no atypia → progestin

APGAR Scores A - activity/color - 0 for blue, 1 for pink body but acrocyanosis, 2
for all pink
P - pulse - 0 for none, 1 for below 100, 2 for above 100
G- grimace - 0 for none, 1 for grimace, 2 for sneeze or cough
A for activity - 0 for none, 1 for some flexion, 2 for active
R for respiration - 0 if none, 1 if slow or irregular, 2 if good effort
and crying

What to do for irregular respiration? HR < First two - PPV by bag mask. IF HR < 60, then chest compressions
100? HR < 60?

Ways to increase uterine tonicity and CIs 1. oxytocin

2. methergine - = methylergonovine. Avoid if HTN or
preeclampsia
3. prostagladin F2 alpha = hemabate - avoid in asthma, must
give IM because can cause bronchoconstriction IV

Okay to ligate these pelvic arteries for Ascending branch of the uterine artery, hypogastric artery = internal
uterine hemorrhage iliac

Management of uterine inversion Place 2 large bore IVs - they are going to bleed (can’t contract). Give
tocolytics (magnesium, terbutaline). Use halothane anesthetic if
really difficult to get back in
Bleeding 10-14 days after delivery subinvolution of the placental site - eschar falls off. Just give
methergine, misoprostol, or prostaglandin F2 to help the uterus
contract

Septic thrombophlebitis Suspect if mom has fevers but otherwise seems fine - eating,
walking, etc. Sometimes see with CT. Treat with short term
anticoagulation and abx

When to begin supplementing Vitamin D 2 months

Signs that baby is getting enough milk 3-4 stools in 24 hours, 6 wet diapers per day