It is important to Differential Diagnosis between Preeclampsia and SLE (systemic lupus sclerosis) in pregnancy because management is totally different.
SLE shows itself by:
- Hypertension in a pregnant woman in the setting of
o Massive proteinuria
o Malar rash
o Positive ANA titer
- Also pay attention to thse facts:I
- In SLE is especially at the point of hypertension, we would have Glomerulonephritis.
- SLE very rarely starts in pregnancy, so look for the history. (They sometimes provide you with history of positive signs and symptoms not the actual disease)
Treatment of SLE in pregnancy: Do not be aggressive, you can control it and save the baby.
Showing posts with label OB/GYN USMLE. Show all posts
Showing posts with label OB/GYN USMLE. Show all posts
Wednesday, September 19, 2007
Signs and Symptoms of Magnesium Sulfate toxicity
In order:
- Depressed DTR (deep tendon reflex) is the first sign for Magnesium Sulfate toxicity which requires stopping it and administration of Calcium Gluconate.
- Respiratory depression
- Coma
- Cardiac arrest
- Death.
- Depressed DTR (deep tendon reflex) is the first sign for Magnesium Sulfate toxicity which requires stopping it and administration of Calcium Gluconate.
- Respiratory depression
- Coma
- Cardiac arrest
- Death.
Eclampsia
Presentation: It is very easy to diagnose, as it shows itself by a generalized Tonic-Clonic seizure that manifest like grand mal, in a pregnant patient.
I know there are some other signs and symptoms, but knowing these two, you can both make the diagnosis of eclampsia and determine the management method, so do not waste time!
It occurs 25% Before Labor, 50% During Labor 25% After Delivery.
Attention: In post delivery seizure, rule out eclampsia, as well as other causes (drugs effect, …)
Attention: Most common etiology of death in Eclampsia is Hemorrhagic stroke due to Hypertension and thrombocytopenia.
I know there are some other signs and symptoms, but knowing these two, you can both make the diagnosis of eclampsia and determine the management method, so do not waste time!
It occurs 25% Before Labor, 50% During Labor 25% After Delivery.
Attention: In post delivery seizure, rule out eclampsia, as well as other causes (drugs effect, …)
Attention: Most common etiology of death in Eclampsia is Hemorrhagic stroke due to Hypertension and thrombocytopenia.
Preeclampsia
Do you really think that in the exam they provide you with a case with a pregnant woman with high blood pressure, edema and proteinuria who does not have any other problem and they want you to pick the answer, and you will happily choose Preeclampsia?
I wish the exam was like this ;)
The main point in Preeclampsia questions is to differentiate Mild Preeclapsia and Severe Preeclampsia from each other as the management is different.
This sentence is not correct but let me say it, I think in the exam it is more important to different Mild and Sever Preeclampsia form each other than differentiating Severe Preeclampsia from Eclampsia.
Criteria to diagnose Mild Preeclampsia are:
- Blood pressure of higher or equal of 140/90
- Proteinuria less than 3 gr. (and ofcourse more than 300 mg.)
Criteria to diagnose sever Preeclampsia are:
- Blood Pressure higher or equal to 190/110
- Proteinuria more than 3 gr.
- Having any of the following symptoms:
- Oligurea
- Blured Vision
- Epigastric pain
The most important complication of Preeclampsia is Eclampsia, due to cerebral vasospasm and resultant cerebral hypoxemia.
Treatment of Preeclampsia:
In Patient with Mild Preeclampsia:
The point here is to take care of the patient until she gets to 36 week of pregnancy and it would be safe to deliver at that time. So if the patient gestational age is less than 36 weeks, you need to be conservative and if it is more than 36 you need to be aggressive.
Seizure prophylaxis is performed during labor, delivery and within 24 hrs after delivery
In Patient with Severe Preeclampsia:The point here is that you need to be always aggressive. There is no room to waste the time, mom is in danger so rush and be aggressive.
I wish the exam was like this ;)
The main point in Preeclampsia questions is to differentiate Mild Preeclapsia and Severe Preeclampsia from each other as the management is different.
This sentence is not correct but let me say it, I think in the exam it is more important to different Mild and Sever Preeclampsia form each other than differentiating Severe Preeclampsia from Eclampsia.
Criteria to diagnose Mild Preeclampsia are:
- Blood pressure of higher or equal of 140/90
- Proteinuria less than 3 gr. (and ofcourse more than 300 mg.)
Criteria to diagnose sever Preeclampsia are:
- Blood Pressure higher or equal to 190/110
- Proteinuria more than 3 gr.
- Having any of the following symptoms:
- Oligurea
- Blured Vision
- Epigastric pain
The most important complication of Preeclampsia is Eclampsia, due to cerebral vasospasm and resultant cerebral hypoxemia.
Treatment of Preeclampsia:
In Patient with Mild Preeclampsia:
The point here is to take care of the patient until she gets to 36 week of pregnancy and it would be safe to deliver at that time. So if the patient gestational age is less than 36 weeks, you need to be conservative and if it is more than 36 you need to be aggressive.
Seizure prophylaxis is performed during labor, delivery and within 24 hrs after delivery
In Patient with Severe Preeclampsia:The point here is that you need to be always aggressive. There is no room to waste the time, mom is in danger so rush and be aggressive.
Main Differential Diagnosis of HELLP in USMLE Questions
I really do not have any idea what the main or the most common differential diagnosis of HELLP syndrome is, but in the USMLE questions, I always tried to rule out Hemolytic Uremic Syndrome (HUS). To me HUS was the most challenging part, as you have very short time to read the question completely and both have Hemolysis, it is kinds of challenging, isn’t it?
Is that it? No… now check this out, in HUS you have Uremia (in the question high BUN, and high Cr). In the HELLP syndrome you will see rise in BUN and Cr! Damn it!
Is that is? Still now! … In HUS you do have Low Platelet, exactly like HELLP syndrome”
So just pay attention to these facts:
- In HUS usually there is a history of gastro-enteritis or Urethritis.
- In HUS, we could have complications like thrombosis of odds vessels (Budd chiari Syndrome)
Oops! I forgot to tell you that pregnant women can eat hamburger and can get HUS! So pregnancy does not rule out HUS ;)
By the way I just checked this out, the most common differential diagnoses of HELLP syndrome are:
- DIC
- Preeclampsia
- TTP (Transient Thrombocytopenic Purpura), Don’t worry about this, you will see confusion (mental status change) in it, so you won’t miss it.
- HUS
- Acute Fatty Liver of Pregnancy
Is that it? No… now check this out, in HUS you have Uremia (in the question high BUN, and high Cr). In the HELLP syndrome you will see rise in BUN and Cr! Damn it!
Is that is? Still now! … In HUS you do have Low Platelet, exactly like HELLP syndrome”
So just pay attention to these facts:
- In HUS usually there is a history of gastro-enteritis or Urethritis.
- In HUS, we could have complications like thrombosis of odds vessels (Budd chiari Syndrome)
Oops! I forgot to tell you that pregnant women can eat hamburger and can get HUS! So pregnancy does not rule out HUS ;)
By the way I just checked this out, the most common differential diagnoses of HELLP syndrome are:
- DIC
- Preeclampsia
- TTP (Transient Thrombocytopenic Purpura), Don’t worry about this, you will see confusion (mental status change) in it, so you won’t miss it.
- HUS
- Acute Fatty Liver of Pregnancy
HELLP Syndrome
Presentation: As it is a syndrome, we need to have bunch of different unrelated signs and symptoms. So here are the criteria:
HELLP
H: Hemolysis
EL: Elevated Liver enzymesLP: Low Platelet
Treatment of HELLP Syndrome:
- Main cobblestone in treatment of HELLP syndrome, is Exchange Transfusion or Plasmapheresis with FFPDelivery is definitive treatment for HELLP in women beyond 34 weeks, give MgSO4 to reduce blood pressure and vaginally deliver the baby.
HELLP
H: Hemolysis
EL: Elevated Liver enzymesLP: Low Platelet
Treatment of HELLP Syndrome:
- Main cobblestone in treatment of HELLP syndrome, is Exchange Transfusion or Plasmapheresis with FFPDelivery is definitive treatment for HELLP in women beyond 34 weeks, give MgSO4 to reduce blood pressure and vaginally deliver the baby.
Differential Diagnosis of High Blood Pressure in Pregnancy
When a pregnant woman comes with high blood pressure, we need to think of 6 specific differential diagnoses:
- Transient Hypertension
- Chronic Hypertension
- Pre-eclampsia
- Eclampsia
- Chronic Hypertension with superimposed gestational Hypertension
- HELLP syndrome
- Transient Hypertension
- Chronic Hypertension
- Pre-eclampsia
- Eclampsia
- Chronic Hypertension with superimposed gestational Hypertension
- HELLP syndrome
Why Rh Antibody is more important than ABO in Pregnancy?
Do you really think that it is because Rh Antibody are more immunologic than ABO ones? Ofcourse not! Just think about a patient that has received a non-matched blood transfusion, and see how dangerous that could be. So ABO Antibodies are even more immunologic than Rh ones.
The reason is that Antibodies to ABO antigens belong to IgM antibody class so they do not cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies (the major part of Rh Antibodies) that are responsible for Rh alloimmunization belong to IgG class and do cross placenta.
The reason is that Antibodies to ABO antigens belong to IgM antibody class so they do not cross placenta and hence mother and baby can have different blood type. But Anti-D antibodies (the major part of Rh Antibodies) that are responsible for Rh alloimmunization belong to IgG class and do cross placenta.
Differential Diagnosis of Hypertension after 20 week of pregnancy
When a pregnant woman shows up with hypertension in the third trimester or even after the 20th week of pregnancy, on the top of our list we need to think of:
- Pre-eclampsia (Proteinuria >300 mg)
- Transient Hypertension (Is not accompanied by Proteinuria or it is less than 300 mg)
Ofcourse we need to consider other causes like eclampsia, HELLP Syndrome, etc, as well, however these diagnosis need specific other criteria that should have been mentioned in the exam. (Seizure, Hemolysis, Elevated Liver Enzymes, Low Platelet, …)
- Pre-eclampsia (Proteinuria >300 mg)
- Transient Hypertension (Is not accompanied by Proteinuria or it is less than 300 mg)
Ofcourse we need to consider other causes like eclampsia, HELLP Syndrome, etc, as well, however these diagnosis need specific other criteria that should have been mentioned in the exam. (Seizure, Hemolysis, Elevated Liver Enzymes, Low Platelet, …)
Differential Diagnosis of Hypertension before 20 week of pregnancy
When a pregnant woman shows up with hypertension in the first trimester or even within the first 20 weeks, on the top of our list we need to think of:
- Molar Pregnancy
- Chronic Hypertension
Rule out Molar pregnancy and the diagnosis of chronic hypertension can be made. Lack of “Snow Storm” in ultrasound will rule out molar pregnancy.
- Molar Pregnancy
- Chronic Hypertension
Rule out Molar pregnancy and the diagnosis of chronic hypertension can be made. Lack of “Snow Storm” in ultrasound will rule out molar pregnancy.
Bilateral Lower Extremity Edema in Pregnancy
Bilateral edema of lower extremities in pregnancy is most commonly a benign problem.
Attention: Pre-eclampsia should be suspected if the edema is associated with hypertension or proteinuria
Attention: Pre-eclampsia should be suspected if the edema is associated with hypertension or proteinuria
Epridural Anesthesia and Pregnancy
Question: 27 year old patient, G1 P0, is right now in the labor, after receiving the epidural Anesthesia, gets hypotensive, what is the reason?
Answer: Blood Redistribution and venous pooling. Basically because of loss of autonomic effect, blood traps in the lower extremity and consequently patient gets hypotensive
Answer: Blood Redistribution and venous pooling. Basically because of loss of autonomic effect, blood traps in the lower extremity and consequently patient gets hypotensive
Treatment of Graves Disease in Pregnancy
As you may know the main part of treatment of Graves Disease in US in non-pregnant patients is radioactive Iodine, however in Pregnancy using radioactive Iodine is contraindicated, so surgery is considered the main part.
Attention: If Grave’s Disease is being left untreated, there is a chance of Thyrotoxoicosis due to passage of Thyroid Stimulating Immunoglobin (TSI) across the placenta.
Attention: If Grave’s Disease is being left untreated, there is a chance of Thyrotoxoicosis due to passage of Thyroid Stimulating Immunoglobin (TSI) across the placenta.
Normal Laboratory Changes in Pregnancy
In pregnancy body fluid (water) increases, so many lab tests can be predicted upon this simple fact.
Blood changes in pregnancy:
- RBC is increased during pregnancy
- Plasma volume is increased during pregnancy
- Hemoglobin and Hematocrit are decreased during pregnancy, as the plasma volume increase is much more than the RBC increase
Cardiac (Heart) changes during pregnancy:
- Stroke Volume increases during pregnancy
- Heart Rate increases during pregnancy
- Cardiac Output increases during pregnancy
Pulmonary changes during pregnancy:
- I have forgotten this, so I will write it later ???
Thyroid Changes during pregnancy:
The important part here is to know that proteins and subsequently globulins are increased during pregnancy, so:
- TBG (Thyroxine Binding Globulin) increases during pregnancy
- Total T4 and Total T3 during pregnancy (these are because of increase in TBG)
- Free T4 and overall Thyroid Function is remain the same.
Renal changes during pregnancy:
- Cr (Creatine) decreases during pregnancy
- BUN (Blood Urea Nitrogen) also decreases during pregnancy
Attention: Do not forget, as I just mentioned most of the things are based on Plasma Volume change (increase) during pregnancy.
Attention: Upon knowing this fact, never ever high BUN or Cr, is considered normal during pregnancy!
Alkaline Phosphates increases during pregnancy.
Blood changes in pregnancy:
- RBC is increased during pregnancy
- Plasma volume is increased during pregnancy
- Hemoglobin and Hematocrit are decreased during pregnancy, as the plasma volume increase is much more than the RBC increase
Cardiac (Heart) changes during pregnancy:
- Stroke Volume increases during pregnancy
- Heart Rate increases during pregnancy
- Cardiac Output increases during pregnancy
Pulmonary changes during pregnancy:
- I have forgotten this, so I will write it later ???
Thyroid Changes during pregnancy:
The important part here is to know that proteins and subsequently globulins are increased during pregnancy, so:
- TBG (Thyroxine Binding Globulin) increases during pregnancy
- Total T4 and Total T3 during pregnancy (these are because of increase in TBG)
- Free T4 and overall Thyroid Function is remain the same.
Renal changes during pregnancy:
- Cr (Creatine) decreases during pregnancy
- BUN (Blood Urea Nitrogen) also decreases during pregnancy
Attention: Do not forget, as I just mentioned most of the things are based on Plasma Volume change (increase) during pregnancy.
Attention: Upon knowing this fact, never ever high BUN or Cr, is considered normal during pregnancy!
Alkaline Phosphates increases during pregnancy.
Substance Abuse (Drugs) in Pregnancy
Please just read this once, and try to memorize keywords for example knowing the relation of Cocaine and Abruptio Placenta is fine, read it fast and if you need just take some notes.
Marijuana: Small for Gestational Age (SGA) and Intra Uterine Growth Retardation (IUGR)
Cocaine (crack): Cocaine is a highly addictive drug, and in pregnancy may cause Placental Abruption as well as preterm labor.
Heroin: If heroin is used during pregnancy, it can cause:
- Preterm birth
- Fetal death
- Addiction in the fetus
- Stunted fetal growth
PCP: Many PCP users become violent and out of control. Babies exposed to PCP during pregnancy may be smaller than normal, and have poor muscle control.
Ketamine during the pregnancy may cause behavioral or learning problems.
LSD during pregnancy: LSD users may have violent behavior and flashbacks. During pregnancy, use of LSD may lead to birth defects in the baby.
Glues and Solvents: Sniffing of Glues and solvents may cause different birth defects:
- Short height
- Low Birth weight
- Small head
- Joints problems
- Limbs problems
- Abnormal facial features
- Heart defects
Amphetamines: Amphetamines during pregnancy can prevent mom from getting enough nutrients, so it can interfere in normal growth of fetus. Also Amphetamine use can cause placental abruption or even fetal death.
Ecstasy: Using ecstasy in pregnancy may cause long-term learning and memory problems.
Marijuana: Small for Gestational Age (SGA) and Intra Uterine Growth Retardation (IUGR)
Cocaine (crack): Cocaine is a highly addictive drug, and in pregnancy may cause Placental Abruption as well as preterm labor.
Heroin: If heroin is used during pregnancy, it can cause:
- Preterm birth
- Fetal death
- Addiction in the fetus
- Stunted fetal growth
PCP: Many PCP users become violent and out of control. Babies exposed to PCP during pregnancy may be smaller than normal, and have poor muscle control.
Ketamine during the pregnancy may cause behavioral or learning problems.
LSD during pregnancy: LSD users may have violent behavior and flashbacks. During pregnancy, use of LSD may lead to birth defects in the baby.
Glues and Solvents: Sniffing of Glues and solvents may cause different birth defects:
- Short height
- Low Birth weight
- Small head
- Joints problems
- Limbs problems
- Abnormal facial features
- Heart defects
Amphetamines: Amphetamines during pregnancy can prevent mom from getting enough nutrients, so it can interfere in normal growth of fetus. Also Amphetamine use can cause placental abruption or even fetal death.
Ecstasy: Using ecstasy in pregnancy may cause long-term learning and memory problems.
Prohibited Medication in Pregnancy
The following list is a very complete list however you do not need to know all of them for USMLE, just read it once, what ever sticks your memory would be fine:
ACE inhibitors (eg, captopril, enalapril) - D
Acetohydroxamic acid (AHA) - X
Aminocaproic acid - D
Androgens (eg, Danazol) - X
Angiotensin II receptor antagonists (eg, losartan, valsartan) - D
Antineoplastics (alkylating agents) - D
Antineoplastics (antimetabolites) - X
5-Fluorouracil
Methotrexate
Methylaminopterin
Cytarabine
Aminoglycosides (eg, gentamicin, streptomycin) - D
Aspirin - D
Busulfan
Chlorambucil
Azathioprine
Cyclophosphamide
Mechlorethamine
Cisplatin
Bleomycin
Atenolol - D
Benzodiazepines - D and X
Flurazepam (X)
Temazepam (X)
Triazolam (X)
Bromides - D
Carbamazepine - D
Colchicine - D
Corticosteroids - C
Danazol - X
Diethylstilbestrol - Not on market
Ergotamine - X
Finasteride - X
Fluconazole - C
Folic acid antagonists
Phenytoin - D
Methotrexate - X
Lithium - D
Methimazole - D
Methylene blue - C
Mifepristone, RU-486 - D
Minoxidil - C
Misoprostol - X
Mysoline - D
Penicillamine - D
Phenobarbital or methylphenobarbital - D
Potassium iodine and medications that effect iodine levels (diatrizoate) - D
Progestins - X (except megestrol and norethindrone - D)
Raloxifene (Evista) - X
Retinoic acid, isotretinoin (Accutane), acitretin (Soriatane), etretinate, topical tazarotene - X
Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) - X
Tamoxifen - D
Tetracycline - D
Thalidomide - X
Valproic acid - D Warfarin - X
ACE inhibitors (eg, captopril, enalapril) - D
Acetohydroxamic acid (AHA) - X
Aminocaproic acid - D
Androgens (eg, Danazol) - X
Angiotensin II receptor antagonists (eg, losartan, valsartan) - D
Antineoplastics (alkylating agents) - D
Antineoplastics (antimetabolites) - X
5-Fluorouracil
Methotrexate
Methylaminopterin
Cytarabine
Aminoglycosides (eg, gentamicin, streptomycin) - D
Aspirin - D
Busulfan
Chlorambucil
Azathioprine
Cyclophosphamide
Mechlorethamine
Cisplatin
Bleomycin
Atenolol - D
Benzodiazepines - D and X
Flurazepam (X)
Temazepam (X)
Triazolam (X)
Bromides - D
Carbamazepine - D
Colchicine - D
Corticosteroids - C
Danazol - X
Diethylstilbestrol - Not on market
Ergotamine - X
Finasteride - X
Fluconazole - C
Folic acid antagonists
Phenytoin - D
Methotrexate - X
Lithium - D
Methimazole - D
Methylene blue - C
Mifepristone, RU-486 - D
Minoxidil - C
Misoprostol - X
Mysoline - D
Penicillamine - D
Phenobarbital or methylphenobarbital - D
Potassium iodine and medications that effect iodine levels (diatrizoate) - D
Progestins - X (except megestrol and norethindrone - D)
Raloxifene (Evista) - X
Retinoic acid, isotretinoin (Accutane), acitretin (Soriatane), etretinate, topical tazarotene - X
Statins (3-hydroxy-3-methylglutaryl coenzyme A [HMG-CoA] reductase inhibitors) - X
Tamoxifen - D
Tetracycline - D
Thalidomide - X
Valproic acid - D Warfarin - X
Complications of Excessive use of Oxytocin in Labor
Oxytocin acts like ADH (AntiDiuretic Hormone) so it may cause water retention, hyponatremia and even consequently seizure (it is sometimes called water intoxication)
Also uterine hyperactivity could the complications. In this case discontinuing the oxytocin and rest could be enough for most of the cases. However Ritodrine may be necessary in refractory cases. Recently it has been shown that an oxytocin antagonist named Atosiban could be used to control Uterine Hyperactivity following using excessive Oxytocin.
Also uterine hyperactivity could the complications. In this case discontinuing the oxytocin and rest could be enough for most of the cases. However Ritodrine may be necessary in refractory cases. Recently it has been shown that an oxytocin antagonist named Atosiban could be used to control Uterine Hyperactivity following using excessive Oxytocin.
Effect of Pregnancy on Different Diseases
Effect of Pregnancy on Graves Disease
- Pregnancy improves the process of Graves Disease.
Effect of Pregnancy on Migraine
- Pregnancy improves the process of Migraine.
Effect of Pregnancy on Peptic Ulcer Disease (PUD)
- Pregnancy improves the process of Peptic Ulcer Disease (PUD)
- Pregnancy improves the process of Graves Disease.
Effect of Pregnancy on Migraine
- Pregnancy improves the process of Migraine.
Effect of Pregnancy on Peptic Ulcer Disease (PUD)
- Pregnancy improves the process of Peptic Ulcer Disease (PUD)
Low Back Pain in Pregnancy
Having Low Back Pain during pregnancy is mostly common in third trimester.
Etiology of low back pain in pregnancy is considered:
- Lordosis
- Relaxation of ligaments
Etiology of low back pain in pregnancy is considered:
- Lordosis
- Relaxation of ligaments
Group B Streptococcal infection Screening in Pregnancy
Epidemiology of Group B streptococcal Infection during pregnancy: Between 10 and 30 percent of pregnant women carry GBS bacteria in the vagina or rectal area, where they may pass it to their babies during labor or birth.
There are 2 completely different methods to look for this and determine who has it and who does not.
Method 1: Screening for group B strep should be done 36-37 week gestation, using swab or urine culture.
Method 2: Any patient with history of positive group B streptococcus infection during this pregnancy and/or previous one.
Treatment of Group B Streptococcal infection during pregnancy is probably to get oral Antibiotic right away and more importantly administering IV Penicillin G during labor.
There are 2 completely different methods to look for this and determine who has it and who does not.
Method 1: Screening for group B strep should be done 36-37 week gestation, using swab or urine culture.
Method 2: Any patient with history of positive group B streptococcus infection during this pregnancy and/or previous one.
Treatment of Group B Streptococcal infection during pregnancy is probably to get oral Antibiotic right away and more importantly administering IV Penicillin G during labor.
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