Physician Assistant Exam Review

This post will bring us to a close on OB.  I should probably cover gyn next, but I'm not sure if I can take it back to back.  I'll have a decision obviously by next weeks post.  If you have an area you prefer I cover sooner than later feel free to let me know either in the comments or by emailing me.   Please remember I am not an expert on these topics.  If you are please let me know of any additional information that may help the community.  Thank you. Problems with Labor and Delivery Problem with the cervix -- not dilated Problem with the fetus Macrosomia no true definition >4000 grams or as high as > 4500 grams associated with maternal diabetes Shoulder dystocia Abnormal presentation vertex = normal - head down transverse -- highest risk of cord prolapse breech -- butt down frank breech - hips flexed, knees extended complete breech -  hips flexed, knees flexed footling breech - leg extended with foot down either single or double Cord prolapse The concern with cord prolapse is that the cord can be stretched during delivery or it can become compressed between the birth canal and the fetus.  Hypoxia is the biggest concern Tests and Labs U/S used to estimate fetal size and weight used to determine fetal presentation Treatment If the cervix is not progressing cervidil may may be used.  It is a prostoglandin applied directly to the cervix typically to aid with induction Depending on the size of the baby in relation to the pelvic outlet of the mother a c-section may be indicated and obviously a good physician assistant would do his best to control the patients blood sugar though out prenatal care. A baby in the breech position may be manually turned with careful monitoring. This does not always work and the baby may return to the breech position even if initially successful. For a baby that’s head is engaged and the cervix is dilated mechanical assistance may be indicated.   This includes forceps and a vacuum. Cesarean section   Cesarean sections C-sections account for about 25% of deliveries in the United Sates Indications Fetal distress Transverse for breech position Baby’s head to big for mamma’s hips (Cephalopelvic Disproportion) repeat C-section Placenta Previa Active vaginal infection (herpes) Doc wants to go home and have dinner with family (more sections are performed between 4 and 6 pm then at any other time of day.) Complications Bleeding Thromboembolic event Infection -metritis (uterine wall infection) is the most common and is often polymicrobial.  It presents with fever and a tender uterus. Treatment Antibiotics are given pre-op to help prevent infection however a broad spectrum IV antibiotic is necessary for metritis. Oxytocin is typically given once the baby is out in order to increase uterine tone and decrease blood loss VBAC - Vaginal birth after cesarean -- successful in 60-80% of cases requires careful monitoring Rupture of uterine scar classic incision --  4-9% will rupture and half of which occur before the onset of labor.  A rupture of a classic incision will usually result in the fetus emptying out into the abdominal cavity.  (very bad!) low transverse scar -- 0.7-1.5% will rupture typically in active labor and the rupture is not as detrimental as a ruptured classic incision. Postpartum Period This is typically considered the 6-12 weeks postpartum The first office visit should be at 4-6 weeks postpartum. Things a good Physician Assistant will check and discuss Bleeding and/or vaginal discharge Pelvic pain sex and contraception requirements - OK for most at 6 weeks but 12 weeks is better (Giver her a break guys.  She’s tired and not feeling great) Bowel and bladder function -- incontinence may be an issue so ask Breast vs bottle feed -- continue with vitamins if breast feeding Emotional well being  this may not show up on the exam,

Group B Strep This is probably the most often discussed infection in pregnant women.  As high as 30% of pregnant women are asymptomatic carriers.  An active Group B strep infection at the time of delivery can be very bad for both the mother and the baby whether the child is delivered vaginally or by C-section.  The mother can develop endometritis and the newborn may develop sepsis.  This is rare but in a term infant can be fatal in nearly 25% of those affected.  All women are recommended to have vaginal cultures taken for group B strep at 35-37 weeks.  If these cultures are positive or the results are unknown patients are to receive antibiotic treatment during labor.  Penicillin G is recommended and cefazolin or vancomycin if the patient is allergic. Urinary Tract Infection The urinary tract is very susceptible to infection during pregnancy.  A urine culture is performed as part a routine prenatal care.   This may increase the risk for preterm labor.  Treatment of a positive culture would include ampicillin, cephalexin or nitrofurantoin. HIV/AIDS HIV/AIDS does not have any effect the ability to get pregnant nor does it alter the course of the pregnancy.  On a similar note there is no evidence that pregnancy has any effect on the AIDS virus and its progression.  The issue much like Rh incompatibility is the mixing of fluids between the mother and infant especially during the trauma of delivery.  Before routine screening and the use of antiretrovirals at the time of delivery as many as 25% of babies born to mothers with HIV were infected.  This number has dropped down to between 1 and 8% with proper treatment.  Mom is on an antiretroviral regiment throughout her pregnancy and the newborn is treated for 6 weeks. Herpes Genitalis Women with a primary infection late in pregnancy may require acyclovir in order to decrease the possibility of active lesions at the time of delivery.  A history of recurrent herpes infection should be monitored throughout the pregnancy.  If there is an active infection a C-section is indicated.  Typically acyclovir starting at 36 weeks decreases the rate of detectable virus. Syphilis Syphilis may cause still birth, late term abortions, transplacental infection and congenital syphilis.All women should be tested for syphilis during prenatal visits. Cholecystitis Cholecystitis and gallstones due occur during pregnancy.  An U/S should be able to diagnose gallstones.  If the case warrants surgery then surgery should be performed.  It is safest to perform laparotomy or laparascopy in the second trimester. Appendicitis Right sided abdominal pain should be a red flag for appendicitis in a pregnant patient.  Obviously the anatomy is all in different places, so tenderness over Mcburne’s point may not be helpful.  Nausea and vomiting are difficult symptoms to use in pregnant patient.  Appendicitis is often over looked and needs to be considered.  As stated above surgery if indicated is perfectly appropriate.  A ruptured appendicitis is far more dangerous and may cause premature labor or abortion. Mastitis I’m not sure where to put this so it’s going here.Presentation Usually within 3 months of delivery Typically only one breast is affected Red, tender and warm Lumpy breast Swelling Fever Nipple discharge cracked nipples TreatmentMost commonly this is a Staph. aureus infection.  An antibiotic that is effective against penicillin resistant Staph is the treatment of choice.  A cephalosprin for 5-7 days.  The mother is encouraged to continue to breast feed as this will empty the breasts.  If not continuing to nurse mechanical emptying is necessary.  An abscess may form which would require I&D.  Generally speaking the baby does just fine without being treated with antibiotics. ------------------------------------------------------------------------------------------------------------------------- If you are preparing for the PANRE/PANCE check back for weekly updates.

This is the very first episode of the Physician Assistant Exam Review Podcast. This introductory episode is a short 9 minutes. It lays out the platform and gives a little bit of my background. During this episode we also discuss the purpose of the podcast as well as the website. To be perfectly honest, producing this introductory episode also has given me an opportunity to learn about podcasting with a nice short audio file.  I have worked out some of the kinks and the audio and content will continue to improve. Thanks for listening. I can't wait to get the next episode posted.