[Music] what's up guys to another video today we're gonna cover ob/gyn we're gonna do a super cram session to try and cover as much as we can in the time we have here this is intended to be basically a last minute overview to go over all the must know points for your OB going for either step 2 CK or for your shelf hopefully this is helpful so let's start first we're gonna cover obstetrics so postpartum hemorrhage is to find us over 500 milliliters vaginal delivery of bleeding or over 1 liter from c-section and the most common cause is due to uterine atony and that's from basically when you're in labor your uterus is contracting a lot and after delivery of the baby the uterus is weak and then the spiral arteries because of the decreased tone of the uterus it can't contract fast enough and the contraction of the uterus actually clamps the spiral arteries so when you have basically a flaccid weak uterus those spiral arteries are just open and dilated and they're basically just hemorrhaging and so the main thing I want you to look for in a vignette is when they say that the uterus is above the umbilicus because that basically means that it's foggy and big and when a uterus contracts it gets smaller and it should be below the level of umbilicus so then the first step is to diagnose it but then the next is to know what to do and the first-line treatment for that is uterine massage so you want to massage the uterus and help get it to a smaller size and then afterwards you can also administer oxytocin if needed there's another type of common cause of postpartum hemorrhage and that is due to retained placenta in a vignette usually you'll notice that they'll talk about the placenta coming out that it may have looked like an incomplete placenta and it doesn't you know clean and so they might talk about on ultrasound that you see and uneven endometrial lining so that unevenness is basically describing that there's retained placenta in the uterus which is causing that uneven lining and then what you want to do as a D&C to remove that retained placenta if it's not uterine atony or retained placenta and another common one is lacerations and so usually in a laceration vignette there will be it's associated with forceps delivery so when you put the instrument up the vagina or cervix it's at risk for laceration of course in that vignette then the uterus will be below the umbilicus and then ultrasound will show even endometrial lining so that kind of rules everything out so and if there's forceps involved in its most likely laceration and then to treat that you would do a pelvic examination and inspects for the laceration and then suture it closed so then what I wanted to talk about next is active phase of delivery so you know you have your latent phase which is from 0 to 6 centimeters cervical dilation and then 6 centimeters on to 10 centimeters that is called active phase why that's important is because you need to know a term called arrest of active phase so that's defined as four hours of adequate contractions or six hours of inadequate contractions so then you need to know what is adequate contractions so adequate contractions is loosely every two to three minutes you have contractions or if you want a precise definition it's greater than 200 Montevideo units in ten minutes so a Montevideo unit is basically the sum of the uterus pressure changes above baseline with each contraction in ten minutes so if that adds up to over 200 then you have adequate contraction the cervix is no longer dilated that's called arrest of active phase and then you want to do a c-section after ten centimeters when you have maximum dilatation of the cervix to delivery if that takes longer than three hours that's called arrest of descent and usually the number one cause of that is due to cephalo pelvic just proportion which basically means that the baby's head is too big to fit through mom's pelvis and you want to treat that with a c-section so uterus rupture the vignette will usually talk about how mom was in labor all of a sudden she had intense pain and the baby's head was originally at say zero station and now it's at the minus three station that's basically pathognomonic for uterine rupture and usually they'll also describe that it's difficult to palpate to find where the baby is in the uterus because the baby has most likely um is now slipped out of the uterus and in the peritoneal cavity so when that happens obviously you want to go into a c-section obviously you want to do a laparotomy and then take the baby out and then elapsed cord which is basically the umbilical cord has prolapsed through the cervix and obviously since the umbilical cord is in the way of the path of descent it's too dangerous to deliver vaginally so you want to deliver through c-section so when we talk about fetal tachycardia so basically heart rate that's normal for a fetus is between 110 to 160 so anything faster than that what do you think would be the cause of death so fetal tachycardia the causes are generally maternal fever so if the baby's heart rate is over you know 170 you shouldn't suspect an maternal fever common causes of mature fever would be infectious causes right so like like pyelonephritis chorioamnionitis or endometritis which I'll talk about later so taxi systole is defined as 5 plus uterine contractions every 10 minutes so this is too much contractions and this can cause fetal bradycardia which isn't good for the baby and so you want to treat this with the toe coletek and the first line tocolytics is terbutaline which is the beta-2 agonist don't forget at tocolytics their number-one adverse effect is almond area edema so beta thalassemia what would be a marker that would help you distinguish beta thalassemia from other microcytic anemias it has elevated hemoglobin a2 so that's a sign to look out for it so remember that there's certain changes that happen with pregnancy that are normal and so usually mom will have elevated cardiac output elevated GFR and because of the elevated GFR she'll also have glucose area which is perfectly normal she'll also have metabolic alkalosis which is expected to be normal too because she has to breathe for two people she'll have increased tidal volume and this will cause her to expire pco2 more so her pco2 is usually lower than average if it's above 40 that's usually not a normal sign so if you see alkalosis and a pregnant woman don't panic it's pretty physiologic also remember that basically when mom is pregnant she has increased plasma volume 2 and this dilutes the red blood cells and that's physiologic anemia of pregnancy so it's expected for moms who have anemia during pregnancy as well shoulder dystocia is basically when the anterior shoulder gets stuck behind Mom's pubic bone and the shoulder kind of gets locked in place so the first thing you want to do before you concede to the diagnosis of arrest of descent where it's impossible to get the baby out definitely is you want to try something called the McRoberts maneuver which is hyper flexion of the hips and this should hopefully pop the shoulder out and that's the first thing you want to do so remember prenatal risk factors for shoulder dystocia for a mom as if she's had a prior episode of shoulder dystocia if the baby's macro Soumik and usually macrosomia is caused by gestational diabetes and remember just a tional diabetes there's a difference between that and pre gestational diabetes which is the presence of diabetes before week 20 is called pre gestational diabetes and after week 20 diagnosis as gestational and they're different because they have different complications associated with them pre gestational diabetes is much more dangerous it associated with congenital malformations and cardiac defects whereas gestational diabetes is more associated with on preterm labor macrosomia shoulder dystocia etc remember with shoulder dystocia if you are able to deliver vaginally than some complications you could expect our Erbs palsy a clavicular fracture and sometimes hypoxia or death if the baby comes out and a few days after it's born and it's presenting with the classic or palsy presentation which has a hyper which is basically an arm that's internally rotated with the wrist flexed and elbow extended this is a Erbs palsy the parents will usually ask what to do about it and the correct answer is usually reassure because it tends to self resolved and the same of the clavicular fracture there will usually be you know crepitus over the clavicle and then there too is to reassure because it will heal on its own so an important concept to know is fetal bradycardia how that arises and there's multiple mechanisms but one of them is maternal hypotension so hypotension so if mom is hypotensive then she will have reflux vasoconstriction of her spiral arteries which are the arteries that are attached to her uterus but this also belongs to her circulatory system so when you have vasoconstriction of these spiral arteries that's an attempt to increase total peripheral resistance for moms circulatory system in order to get her blood pressure up however when this happens this also causes vasoconstriction of the fetal circulation and that increases the fetal total peripheral resistance big-time as well so this results in reflex fetal bradycardia so then applying that concept anything that causes vasoconstriction of the spiral arteries can cause fetal bradycardia so uterine atony is one of them why because it causes vasoconstriction of the spiral arteries another one is cord compression cord compression basically clamps down the umbilical artery and that increases TPR as well which needs to reflex bradycardia another important thing to know is fetal heart rate accelerations this is something that we use in non stress tests which is when you are measuring the fetal heart rate over a 20-minute period to see how many times the baby will have accelerations so adequate accelerations is the rule of 15 and teen two-and-twenty so 15 increase heart rate by 15 for 15 seconds that's one acceleration and if you see two of those in 20 minutes then that is a good sign so if you see two of those it means there's good oxygenation for the baby and that's a reassuring non-stress test you do a non-stress test when mom notices decreased movement in the baby also if the non-stress test is basically equivocal or non conclusive which means in that twenty minutes you did not see reassuring fetal heart rate accelerations then you move on to something called a biophysical profile and that basically is a more extensive version of the non-stressed test which includes breathing amniotic fluid measurements tone movements of the baby and the non-stressed test and it gets a square out of ten but basically if the score is less than four then you want to deliver right away so we were talking about causes common causes of maternal infection one of them is endometritis and this is basically inflammation of the endometrium we can also call it endo Myo metritis which is inflammation of the endometrium and myometrium usually this is caused from ascending infection or it's also commonly associated with c-sections which is suspected due to contamination and the signs will be tender uterine fundus a fever and foul-smelling lochia and so lochia is postpartum discharge of the blood mucus and tissue so when you see endometritis you want to treat that first line with clindamycin and gentamicin another common maternal infection something called chorioamnionitis which is caused by ascending infection and it's commonly associated with prolonged rupture of the membranes prolonged rupture of the membranes means that that there's been 18 hours that have elapsed since the water has broken and if mom is still in labor for over 18 hours she's at risk for an infection how you want to treat that is by ampicillin and gentamicin so if you see nuchal translucency on a chance vaginal ultrasound that's a sign of Down syndrome or trisomy 18 if you see something that's described as greater than 2 to 2.5 multiples of the median that's equivalent to saying that there's a neural tube defect elevated AFP is usually I think about things that are associated with like an incompetent body wall in the fetus it could be either gastroschisis omphalocele which is basically abdominal wall defects or neural tube defects and deep through these defects AFP leaks out another common one that can cause elevated AFP which is actually the most common cause is underestimation of age so you'll see an AFP much higher than it should be that's because the baby is actually older you think the baby might be 10 weeks for example but in reality it's 13 weeks old so it's making more AFP and you would expect remember as common buzzwords associate of town syndrome would be second nuchal fold nuchal translucency and remember the echogenic bowel which is caused by duodenal atresia where you'll see the double bubble sign which is a very common association with Down syndrome so yeah most common abnormal triple scream is wrong dating so twins have complications as well and they have a higher rate of term delivery congenital malformations preeclampsia and postpartum hemorrhage clomiphene is a drug that's used to induce ovulation and it promotes maturation of multiple follicles leading to multiple eggs being released and it's used in PCOS polycystic ovarian syndrome how coma fein works is adds up estrogen receptor antagonist at the level of the hypothalamus so what this does it basically blocks the negative feedback so it tricks the brain into thinking that there's not enough estrogen in the UM being made by the ovaries so this stimulates the hypothalamus to release more GnRH LH FSH to make more estrogen and by doing this this promotes ovulation then there's the kleihauer-betke test remember that this is a test that's used before administering rhogam rhogam is basically the antibodies that prevent sensitization versus the ROE antigens found on the fetus in a row negative mom a mom who has for example blood type a negative that negative denotes that she has no rh antigens on her blood and as you remember from your step one knowledge and your basic sciences knowledge that whatever you're missing on your own blood you create antibodies for what you don't have so if you're a blood type o which means you don't have a you don't have B and if your minus means you don't have Rh then you'll have antibodies against a B and Rh so if a mama is Rh - she will have RH antibodies that are IgM they would only switch to IgG if she happens to see antigens that are found in her circulation so a lot of times in maternal fetal hemorrhage so like placental abruption anything that can cause the fetal circulation to mix with mom circulation that means the fetuses red blood cells will enter mom circulation which means that the baby red blood cells have Rh positive on it for example the baby might have gotten it from the Rh positive father right if the dad was Rh negative then the there's no way the baby would have had Rh positive one of the parents has to have it so if the moms IgM antibodies see that Roe antigen on the fetal red blood so it will type switch to IgG and that means for the second pregnancy it'll automatically cross the placenta and destroy any red blood cells that may have roll positive antigen on the fetal red blood cells which means the second the younger brother or the younger sister will end up with polyhydramnios due to like massive destruction of the fetal red blood cells so my point is the kleihauer-betke test you take the sample of mom's blood and you look at under a slide and they put a substance on the plate which basically tells you what percentage it eliminates mom's blood it dissolves it but basically it tells you what percentage of that blood sample has fetal red blood cells if it's like 50/50 then you give a certain dose of rhogam if it's like only 10% fetal red blood cells then you give a lower dose of bro gamma and row gammas antibodies that will take out the fetal red blood cells in order to hide it from Mom's pre-existing antibodies so then she doesn't have sensitization so next is preeclampsia preeclampsia is defined as hypertension with proteinuria so you have to have proteinuria and how do you define proteinuria that's a protein to at one ratio of greater than 0.3 or greater than 300 milligrams of protein per day if you have that plus hypertension which is one over 140 over 90 this is defined as preeclampsia preeclampsia is dangerous because it is associated with a lot of complications such as preterm delivery placental abruption fetal hypoxia etc but it's also dangerous for the mom in that she can have a lot of complications because she's urinating out so much protein she's prone to getting edema from third spacing due to decreased intravascular oncotic pressure and she can get pulmonary edema etc and so also the most feared complication as the progression of preeclampsia to preeclampsia with severe features to the most feared one which is a clamp SIA and a clamp SIA is basically just preeclampsia which now has gotten so severe that it's caused seizures and that's called eclampsia preeclampsia with severe features is defined as preeclampsia where the blood pressure is over 160 over 110 or with evidence of end organ damage whether it's a kidney damage like a cute kidney injury or elevated liver enzymes or encephalopathy so first-line treatment for pulmonary edema would be furiosa mite which is a loop diuretic another thing is a mom who has herpes simplex virus you want to give her a psych levere leading up to delivery and if she's adherent to the acyclovir then she can deliver vaginally if there are no new genital lesions however if she's experiencing prodrome such as like itchiness or pain or new genital lesions or then she should do a c-section next is chancroid which is caused by Hema Phyllis Duke reaiiy and remember this is action this is the one of the few genital ulcers that are painful the other one would be herpes and so shank roid will be described as having ragged edges on necrotic base and on histology it has the school of fish description and then you want to treat it with ceftriaxone and as a throw Meissen versus a chancre which is a painless ulcer which has a smooth hard border and this is caused by syphilis and you want to treat that with intramuscular penicillin and remember it can advance to the second stage which has the condyloma Lata with the palmer ash and it can also advance to the tertiary stage which causes neurosyphilis tabes dorsalis cephalic a or Titus and Saif Titus etc and those ones you want to treat that with longer IV penicillin so risk factors for placental abruption are trauma previous abruption hypertension cocaine polyhydramnios because I just think of it as the the amniotic sac is so heavy that it can cause detachment and then cigarette use and you know if you think about it like cocaine hypertension cigarette use these are all associated with decreased arteriolar diameter and that can cause poor blood flow to the placenta which makes it weaker which can cause it to detach and abruption is one of the types of third trimester leading remember that it's very painful the mom will have abdominal pain a lot of uterine contractions and it's an vaginal bleeding but this is painful compared to placenta previa which is painless bleeding and that's caused by the abnormal position the placenta covering the cervical Oz when you do a c-section you're now at an increased risk for placenta previa because of that scar tissue it makes it so that the human body is very smart it'll notice that that scar tissue is a bad site for plantation due to like the uneven surface so that causes mom to be increased for having placenta previa also it increases the risk once you have placenta previa you're also at increased risk for something called placenta in Crito placenta accreta placenta percreta placenta accreta is the shallowest form where your placenta basically attaches to the beginning of the myometrium listen to accreta it goes into the myometrium and then placenta percreta goes all the way through the uterus and sometimes it might even start invading the bladder and then this can cause hematuria if mom has any of these cases of placenta accreta percreta in Krita which basically means that the placenta is fused to the endometrium then the only option is to do c-section at delivery because that placenta more detach and it'll cause massive postpartum hemorrhage next is the big three cutaneous manifestations of pregnancy the first is intrahepatic cholestasis of pregnancy this is characterized by really severe itching at night especially on the palms and soles there will be elevated liver enzymes due to liver damage but the key here is elevated systemic bile acid levels these bile acids or bile salts will deposit on the skin which causes severe pruritus so remember it's very itchy elevated bile salts elevated lfts and you want to treat this with Urso dial which basically lowers serum bile acid levels next is pup which is paretic Dudek aerial acts papules of pregnancy mama when she is pregnant will develop stretch marks over her abdomen but these stretch marks will actually start to get really itchy she'll also develop plaques and papules and of like an eczema like dermatitis type of presentation over these striae and then it's very very itchy but it's benign and you treat it with steroids next is herpes just de chillon us which is basically like bullous pemphigoid of pregnancy if you remember you know like pemphigus vulgaris and bullous pemphigoid bullous pemphigoid is when you have the antibodies the IgG that attacks the Hemi desmosomes which are intermediate filaments that anchor cells to the basement membrane you get antibodies attacking that and then she met with this is corticosteroids and its presence with you know vesicles on the abdomen and extremities next is a cute fatty liver of pregnancy when you hear this remember this is an emergency the baby is at an immediate high risk of death and you want to deliver right away so how do you define this main thing is like nausea and vomiting hypoglycemia elevated liver enzymes this is caused by mitochondrial dysfunction of breaking down fatty acids and yeah you want to deliver this baby immediately remember that pregnant women are at increased risk of DVT via compression of the IVC which leads to stasis and also due to the increased systemic estrogen which puts you in a hypercoagulable state and then if mom develops symptoms of a DVT which is you know one leg bigger than the other that is in a lot of pain you wanna do a venous duplex what what's dangerous is that a DVT can lead to a pulmonary embolism a PE and the main things you want to look for in a PE is abrupt onset of dyspnea tachycardia and tachypnea with the low pulse ox or low pao2 if you have that then it's most likely a PE and remember Ana pregnant you don't want to do a CT angio because the radiation is toxic to the baby so you want to do a VQ scan also to treat a PE you start with heparin or you can treat with rivaroxaban amniotic fluid embolism is another complication of delivery and this is when the amniotic fluid gets into the maternal bloodstream through delivery and this is basically presents like a PE - but it causes confusion and then rash on the chest and its associated with c-section and abruption and then treatment for this is mainly just supportive and then remember that amniotic fluid embolism can cause di C anytime someone with preeclampsia has severe features or has progressed to eclampsia then you want to remember two things you give magnesium and you deliver right away and why do you give magnesium that's because it prevents seizures and if they have a clamp SIA they already have seizures so you give magnesium as well but sometimes you have to monitor because it's easier to have toxic magnesium levels so they tend to ask you what is the first sign of magnesium toxicity and that's usually hyporeflexia and that's the first line so yeah di c is associated with abruption preeclampsia and amniotic fluid embolism so there's three drugs you can give leading up to term and remember term as described as a start of week 37 the start of week 42 is considered a term it fits before week 32 you want to give magnesium because this helps development of the nervous system of the fetus and it helps prevent cerebral palsy you give magnesium all the way up to week 32 after that you don't need to give magnesium anymore the next thing you want to think about giving for preterm deliveries is tocolytics so tocolytics can be used up to week 34 common tocolytics would be like butylene indomethacin and you want to give this up to week 34 to help delay delivery so the baby can mature more and then the last one is betamethasone which is a steroid and you can give this up to week 37 and the reason why you want to give steroids up to week 37 is to help promote lung maturity yeah so steroids have been proven to minimize the chance of respiratory distress syndrome so if it's week 32 you want to give magnesium tocolytics and steroids at week 34 tocolytics and steroids up to week 37 you give just steroids after that you don't need to supplement so neonatal infections remember the big three bacteria that are associated with infections in babies less than three months old and that's Group B Strep eagle-eye and Listeria so that spells up l ee l and those are the three kind of neonatal infections which are so she'd of like meningitis another mechanism I want to talk about is preterm premature rupture of the membranes so with preterm premature rupture of the membranes you'll have leakage of amniotic fluid which leads to a logo hi jam nose when you have a Lego hi jam nose this basically means that the baby is no longer floating in like a low gravity environment and its weight can compress the umbilical cord when this compresses it can cause recurrent variable decelerations which is what you'll see on the fetal heart rate tracing where the heart rate of the baby dips down really quick and then comes back up really quickly because the normal deceleration is usually the head compression one is when you have the uterus contracting and then the heart rate will come down and up gradually as a mirror image hypoxia is the second one where it will go down gradually and come back up but it's late it's always late after the uterine contraction and then the last one is recurrent variable decelerations which is random dips and heart rate that come back up very quickly it's not gradual it's very sudden and this is a sign of cord compression so if you see the recurrent variable decelerations you should think that there's a cord compression and what you want to do is reposition the mom so that she doesn't so that the baby isn't squishing the umbilical cord or you want to give amnio infusion another mechanism i want to talk about is parvo virus so parvo virus can present very subtly and the pregnant mother which presents with arthralgias malaise and myalgias I kind of think of it as very similar sounding to rheumatoid arthritis she'll have like metacarpal phalangeal joint pain not feeling well but it's more transient compared to rheumatoid arthritis which is more like over the course of months but adult parvo virus is more like acute onset last the last few days and so when the mom is affected with parvo virus this actually attacks on the fetal erythrocytes the reticulocyte and when it destroys all the funeral reticulocytes this causes something called aplastic anemia which shouldn't be confused with aplastic crisis aplastic anemia is when you have destruction of all three cell lines which destroys you know platelets white blood cells and red blood cells aplastic crisis is when you have just decreased red blood cells when you have decreased red blood cells then the baby's heart rate will speed up tachycardia to try and optimize perfusion to make up for the decreased amount of red blood cells but what will happen is this will lead to heart failure and then when it leads to heart failure that will lead to pulmonary edema and third spacing and this leads to high drops Vitalis but remember that also when the red blood cells are being destroyed so much delivery we'll try to make up for it by trying to make more red blood cells but by doing that it has to compromise it makes less albumin and when you have less elbe you mean that has less intravascular oncotic pressure and that exacerbates even more third spacing and that's kind of like the mechanism for hydrops fetalis sign what would be a fetal heart rate tracing sign of anemia that's sinusoidal heart rate pattern which you see the sign waves that would be something you would see in a parvovirus infection of the fetus what would you see in a mother who has lupus a mother who has lupus is associated in the fetus with a complete heart block next is CMV and CMV is characterized by having mnemonic for cytomegalovirus so C stands for Koryo retinitis M stands for microcephaly and V stands for ventricular calcification and you prevent this by hand washing and not sharing utensils with kids and that's one of the common perinatal infections another one has Toxoplasma which is caused by eating undercooked meats or cysts from cat feces and this has a triad of cranial calcifications Koryo retinitis and hydrocephalus and you treat the mom with Spira my son and the fetus with Pyrrha F amine or sulfadiazine there's also rubella and rubella triad is cataracts deafness and cardiac anomalies do you remember what the cardiac anomaly is it's patent ductus arteriosus or pulmonic stenosis normal amniotic fluid volume is usually from 5 to 25 centimeters it's important to know this because sometimes they'll indirectly tell you oh look oh hi dream yes or polyhydramnios so if it's 3 centimeters and that's Allegro Hydra meiosis if it's 30 that's polyhydramnios so what's another way to diagnose anemia in the fetus other than the fetal heart rate which would be sinusoidal another way is you can do the middle cerebral artery Doppler studies if you see increased flow this is anemia this is a way that also detect it in babies who have sickle cell another way to diagnose intrauterine growth restriction which is defined as size of the fetus below the 10th percentile is to measure the umbilical artery Doppler and then reverse flow in the umbilical artery as a bad sign that's basically saying if there's fetal hypoxia and you want to deliver right away in the baby who was just born air horn - getting conjunctival infections and you want to cover for chlamydia and gonorrhoea so gonorrhea happens in day 3 to 5 and chlamydia tends to happen on day 7 for come on a caucus that's where you give the erythromycin topical eye drops that prevents a monocle conjunctivitis but for chlamydia it's not effective with topical eyedrops you want to give oral systemic and that's if you have conjunctivitis on day 7 so an HIV mom can only deliver vaginally if her viral load is less than a thousand copies of RNA per mil if it's greater than that then she has to do a c-section if a mom has hepatitis B then you should give hepatitis B antibodies and vaccinations at birth so there's also something called postpartum thyroiditis which is found in patients who have the same antibodies as Hashimoto's thyroiditis which is anti-thyroid peroxidase and anti microsomia antibodies but basically what happens after birth is you get inflammation of the thyroid which leads to destruction of the gland and then this basically releases all the preformed thyroid hormone which causes transient hyperthyroidism at this point if you do an iodine uptake it'll be low and iodine uptake they like to test you on this because they want you to know how to conclude certain things based on the iodine studies and radioactive iodine uptake if there's a lot of uptake that's a sign that the thyroid is actively making new thyroid and if it's not taking anything up then that means that the thyroid gland isn't making any more new thyroid so in postpartum thyroiditis you will be hyper thyroid but there will be decreased uptake because this hyperthyroidism is caused by an inactive thyroid gland that is leaking out all the preformed thyroid after that happens it becomes hypothyroid and then recovers back to you thyroidism so for example someone with like Graves disease you know the TSH receptor antibodies are causing you to make so much thyroid hormone all the time so if you were to give someone with Graves disease a radioactive iodine uptake then you'll see diffuse uptake because that iodine is getting sucked up into the thyroid gland and it's the thyroid making factory and they're hyper thyroid because they're actively making thyroid but in postpartum thyroiditis this is due to inflammation and leakage and not due to active formation and then you should know about symmetric growth and asymmetric growth in babies who have intrauterine growth restriction they can have symmetric growth which means the head and body or equal size versus asymmetric growth which is where the head is really big and that and then the body is a lot smaller in comparison and the symmetric ones are caused by chromosomal or like the torch congenital infections like Toxoplasma syphilis rubella CMV herpes but asymmetric growth is caused by hypoxia like placental insufficiency so like hypertension smoking poor nutrition this causes the baby during its development to shot all the blood supply to the head and favor development of head over the body as a sacrifice so remember asymptomatic bacteriuria and pregnancy is high risk for pyelonephritis so that's why you do the urine culture in the first trimester and if it's asymptomatic you still give prophylactic antibiotics so the first line UTI is in pregnancy are like amoxicillin cephalosporin and nitro for aunt Owen but in non pregnant UTI is the first lines first line is like TPMS MX nitro fianto in or fluoroquinolones well in pregnant people you can't give TPMS MX because it can cause neural tube defects because it inhibits folate and you can't give fluoroquinolones because fluoroquinolones hurt the bones and it causes tendinopathy yes so basically remember the the first-line drugs for pregnant UTI or amoxicillin cephalosporins or nitro for an twin also you want to know when to give ampicillin prophylaxis for mom in terms of Group B Strep prior to delivery and usually you give it four hours before delivery the scenarios where you give a prophylactic ampicillin or penicillin is if the mom has had a prior pregnancy where a kid has had infection by Group B Strep or during this pregnancy she was found to have Group B in her urine culture or if during this pregnancy she's had a UTI whether it's symptomatic or asymptomatic then you're gonna give prophylaxis for a group B strep no matter what word by default - during weeks 35 to 37 you usually give you do a genital culture anyways an anal culture to check for Group B Strep if that's positive then you're gonna give ampicillin penicillin prophylaxis four hours to delivery as well if the mom you don't know her Group B Strep status because she wasn't following up to her clinic visit they you give Group B Strep under three conditions one is maternal fever two is prolonged rupture of the membranes which has created than 18 hours of rupture of the membranes which I talked about earlier and the third is if you don't know her status and she's preterm then you're gonna give ampicillin or penicillin prophylaxis remember the most common cause of post c-section fever is endo Myo metritis and you treat that with gentamicin and clindamycin then there are breast abscesses the main cause is staph aureus and this is a red block Xuan is the key word fluctuate means that it feels like there's fluid underneath the skin and you want to treat that with dicloxacillin and incision and drainage and if it's hard to tell the difference between that and cellulitis then you want to use the ultrasound remember breastfeeding has all the vitamins except which to vitamin D and vitamin case you want to supplement that you should also know the differences between breast milk and formula milk breast milk has two proteins way and calcium and formula milk also has them but it has a way higher ratio of calcium than breast milk and Cassie has a lot more harder to digest which is why we prefer breast milk exclusively for the first six months before giving any food or eating anything else the baby should be purely dependent on breast milk for the first six months because it has a lot of antibodies and lysozymes and protective factors in it and it's been studies have shown that babies who are breastfed have lower rates of allergies and infections and also it helps up mom because when mom breast feeds she has lower chances of getting breast cancer remember that gestational diabetes so this is another thing to the prenatal visit the week 28 visit and then the week 35 to 37 are very important the first visit you wanna do all everything your standard like CBC UA um s check for all the STDs HIV you want to check for rubella um check for blood typing do pap smear but then in week 28 that's when you check for three things diabetes you want to do a follow-up CBC to see how anemic she is if she's like still within range and then give rhogam shot if she is uh ro- but this is where you will check for diabetes and how you do that as you first do the 50 gram glucose load after one hour if it's greater than 140 then that means she might have diabetes so we advance to the second stage which is the glucose tolerance test you give her a hundred grams of glucose this time and you measure her glucose at hours one two and three if it's greater than 180 161 48 hours one two and three respectively and two out of those three are too high and you diagnosed her with gestational diabetes and then with gestational diabetes the first-line treatment is going to be diet but then if she doesn't improve her glucose levels with diet then the second line you want to start is insulin if you do a fundal height test and you notice that it's incongruent with the baby's age then the next step you want to do is an ultrasound to see what's happening that is it probes tetrax and then the next part we're going to talk about fine ecology [Music]