173 PROM, Breech and Twins for the PANCE

Hello and welcome to episode 173 of the Physician Assistant Exam Review Podcast. This week we’re going to be covering intrapartum emergencies part two. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review where we have been helping students for over 15 years. It’s an absolute ton of fun. Thank you so much for being here. This program is built for long-term retention, not week-to-week quizzing, not week-to-week cramming.

That’s not what this is about. This is about building your base of knowledge, building the way that you work, whether you’re working on EORs, the PACKRAT, EOC, the PANCE, Clin Med, whatever you’re working on. We’re designed here to move through the content in a way that’s going to help you to store the information and score higher on everything that you do. Remember, our motto is think different, work different, score different. We don’t want you doing the same things, you’re doing the same scores. We want you improving every single day, getting better at this game that you’re playing.

All right. Just to get things off the bat and let you know what’s coming up here at Physician Assistant Exam Review, I have been working very, very hard on a new edition of The Final Step. It’s been kind of lounging, lounging, that’s not the right word. It has been coming for some time, but I’ve been so invested in the 33 Days program that I have sort of let that slide. Well, that’s going to end now, and I’m making a huge push to get that new version out by the end of October, which is only a month away at this point. So we really have, I have a ton of work to do, but I think it’s going to happen. If you want to be on the initial run of that book, if you’re curious about what’s coming, go to physicianassistantexamreview.com/newbook, and that’s going to get you some information on what’s coming and how that’s going to work.

That new edition’s only going to have 50 copies in the first run, because I just want to make sure that everything’s right, everything’s good, have some people go through it, then we’ll do a second run at some point. Once those kind of get sold out and people have a chance to look it over, I don’t know when that second run’s going to be, but that initial run’s going to be 50 copies. The Final Step, I just looked it up, has sold almost 8, no, over 8,000 copies. It’s like 8,600 and something crazy, absolutely insane. I didn’t realize the numbers had gotten that big over the years, but the new edition’s going to be absolutely fantastic.

All right, so let’s jump in and move along with our priming questions for this week. Nitrazine paper turning blue suggests what diagnosis? Nitrazine paper turning blue suggests what diagnosis? What’s the most common type of breech presentation? What’s the most common type of breech presentation? What antibiotic combination treats chorioamnionitis? Chorioamnionitis?

Probably still going to say that I’m going to butcher that throughout this whole show today, you’re going to hate me for it. There’s a couple too, when we do the twins at the end, that’s just going to be rough. Where are we? The lambda sign on first trimester twin ultrasound indicates what chorionicity? That’s another term for today. The lambda sign on first trimester twin ultrasound indicates what chorionicity? In a twin-twin transfusion syndrome, which twin develops polyhydramnios?

In a twin-twin transfusion syndrome, which twin develops polyhydramnios?

All right, so in episode 172 last week, we covered the emergencies at delivery this week. We’re going to cover what happens as things get set up and you start to realize that there’s going to be a problem and how we’re going to handle that. Then the next episode next week, we’re going to cover normal postpartum care. And then we should hopefully be getting towards the end of this. As you can tell, this is not my area of expertise. We are making our way through the content, making sure that we have it locked in and we know what we’re doing. But reproduction is not my number one.

As you each have something that’s not your number one, but we still have to learn it myself to go through it.

So let’s start with premature rupture of membranes. Premature rupture of membranes is the rupture of membranes before labor starts. This is important to note. All it means is that the amniotic sac is ruptured before labor has begun. That’s it. So premature means any time from 37 weeks or later, 37 weeks or 39 weeks of labor hasn’t begun, then it’s still premature rupture of membranes. Before 37 weeks, though, we call it preterm premature rupture of membranes, preterm premature rupture of membranes.

So whenever we go through this, we like to start with our risk factors. What are the risk factors for preterm premature rupture of membranes or premature rupture of membranes? This is pretty easy. You should be able to nail this even if you don’t know it like we do every single week. The number one risk factor is prior preterm rupture of membranes. I’m going to struggle this whole time. Apologize right now.

The terms are going to be tongue twisters. What are some other risk factors? So stop and think about for a second. What are some other risk factors? Again, don’t memorize. Think what are some other risk factors for rupture of membranes? Premature rupture of membranes.

How about infection? That’s a really good one, right? So bacterial vaginosis, group B strep. Anything like that. What about extra pressure in the uterus? How do you get extra pressure in the uterus or an overdistended uterus? What are some ways that might happen?

What about if you have twins or triplets, right? Do you think that increases the risk for rupture of membranes? Of course it does. Polyhydramnios will increase the risk, that kind of thing. Other risk factors. How about a short cervix? That makes sense, right?

Smoking is another one and bleeding in early pregnancy is another one. What does this look like when your patient walks through the door? Well, this is a sudden gush or steady leak of clear fluid without contractions, right? Because this is before labor. What are some things that it could be that fool people into thinking they’ve had rupture of membranes? Well, urine leakage, right? It becomes harder and harder to control the bladder as you have a child infant fetus sitting on top of your bladder, right?

So you can get some urine leakage just from the pressure there that mom is unaware of and then she feels fluid and it just turns out to be urine. It’s not uncommon. You can get the loss of the mucus plug that is normally inside the cervix, right? That could simulate it for someone who doesn’t, isn’t, who is unsure rupture membranes. So your question stem here is going to describe someone at about 30 weeks or so with a sudden gush of clear fluid and no contractions. Then you’re going to have to talk about what we’re going to do next. It’s my guess as to how the question is going to come.

So how do you diagnose this? How are you sure? So you have someone who comes in and they say, I think I have my water broke. I’m at 34 weeks. What do we do? Well, before you start anything else, you have to make sure that that’s what’s going on, right? I’ve had patients come in and say, well, you know, and we’ve, we’ve gone through everything with them and said, okay, we have to schedule your MRI for whatever your injury is.

And they say, well, what do we, how do we start treating this? And I, I’d really like to know what it is before I start giving you a treatment plan, right? So diagnostics is important. We’re going to start with a sterile speculum exam. You’re going to look for pooling, right? Fluid in the posterior fornix or leaking from the cervix. That’s going to show you a rupture of membranes.

If there’s fluid in the vagina, we’ve gone through this before, right? We did this with normal labor because it’s still part of normal labor. If you have ruptured membranes during labor, that’s normal. So we talked about this a couple of weeks ago. Nitrazine paper turns blue. That’s the amniotic fluid is alkaline. So you get a pH seven to 7.5.

The vagina is 3.8 to 4.5, right? So that’s going to change the paper on you. You get ferning, right? So dried amniotic fluid crystallizing into the fern pattern under the microscope. We talked about this a couple of weeks ago. Ultrasound is going to help. Oligohydramnios is going to support the diagnosis.

So we’ve got real low fluid levels when we had historically normal to high fluid levels. One thing you don’t want to do is a digital cervical exam unless she’s in labor, but if we’re at like 34 weeks, 35 weeks, you do not want to do a digital cervical exam because we’re introducing bacteria. And once membranes have ruptured, we’re fighting the clock as far as infections go, so we need to be really careful here. Once she’s in labor, we can do that to check the dilation of the cervix and where the baby is and all those things. But if we’re not in labor, we need to be careful about how we’re going to handle that.

All right. So what do we do? Well, 34 weeks is our defining line. At 34 weeks or later, we can go ahead and deliver the baby. That’s the standard. And we can do that with oxytocin, right? We’re going to induce labor at 34 weeks.

The lungs are mature and infection risk climbs as time goes by. So we’re balancing risks. It’s not that we want to deliver the baby, but we have to be careful because of infection. So 34 weeks is our dividing line under 34 weeks with no infection signs, we’re going to admit the patient and hope that we can buy them some time because at this stage, premature delivery is the bigger risk factor. And again, this is not a situation we want to be in. It’s not a, that there are good choices here. And this is something you have to understand in medicine for sure.

And in a lot of different places in your life, right? There’s not always good choices. So sometimes we have to pick the best of a bad situation. So before 34 weeks, what do you do? Well, you’re weighing: is premature delivery riskier than waiting. We’re going to give corticosteroids, betamethasone, 12 milligrams, IM two doses about 24 hours apart to help mature the fetal lungs. That’s absolutely going to be a test question.

We can also give the patient antibiotics, right? Because we’re going to worry about infections. So IV ampicillin and erythromycin. We can do it, after that it becomes amoxicillin and erythromycin. I don’t think you need to get into the protocols necessarily, but knowing that that’s part of what’s going on here. These patients all also get magnesium sulfate. If it’s before 32 weeks, if delivery is likely.

Now I was a student on OB many a long, long time ago. My very first rotation was OB. And the very first thing I did was work on MFM, maternal fetal medicine. And my, one of my main jobs was to wake these patients up at like four or five a.m. When I got to the house, it felt like four, it was probably later than that. When I got to the hospital and asked them if they felt the baby move, if they had a good night, all these things. And I felt horrible having to wake these poor women up who had been in the hospital for 30 days, 40 days, 50 days.

And they were all on magnesium. And at the time I thought that was to prevent contractions. And I’m doing the notes for this section and I’m, and I realize that it’s not just about preventing contractions. It’s neuroprotective against cerebral palsy. I’m not going to go into details there, but just something you should understand. If the patient is GBS positive, we’re going to do prophylaxis, right? So we’re going to give them IV penicillin.

If it’s unknown, we’re probably going to go ahead and do that also.

Now, what happens if we’re before 34 weeks and we have infections? Then we have another problem. If we have a chorioamnionitis, I told you I’m going to butcher some of these. So if we have an actual infection, if we have an abruption, we’re going to deliver the fetus, if we have a non reassuring fetal heart tracing, probably going to go ahead and deliver the fetus. If the, if the mother goes into active labor, we’re probably going to go ahead and deliver the fetus, right? These are not things we have control over. Not a great position to be in, but knowing some of these dates is where I would land here.

Under 23 weeks, we have a major problem because the baby can’t survive. So that’s some counseling and moving forward from there. Chorioamnionitis, I’m probably butchering how that is said, is an infection of the amniotic fluid membranes and placenta. So now we’re, we have an infection and we have to deal with this. Maternal fever can make the diagnosis on its own. Fetal tachycardia, purulent or foul smelling fluid from the cervix is an obvious indicator. Uterine tenderness is an obvious indicator.

We’re going to do IV ampicillin and gentamicin and deliver the child if we run into this problem. This one, I want you to understand because you can group it with other things. So what’s important here is to understand that IV antibiotics alone don’t clear this type of infection. IV antibiotics do not clear this type of infection in the same way that if you have a, in orthopedics, if you have an infected joint replacement or an infected plate and screws that you fixed a fracture with and that gets infected, antibiotics will not clear it. If there’s something for the, that makes it difficult for the antibiotics to get to the, to the infection, or if there’s a substrate for the, the bacteria to grow on, it’s much, much harder to clear. So I kind of group these and this is, that’s not exactly true, but it’s close enough so that you can remember it. I grouped these in my head together so I can understand what works and what doesn’t work and I can hold on to it.

So in this case, if you have a chorioamnionitis, you’re going to have to deliver the kid, you’re going to want to give antibiotics on top of that, but you’re going to have to deliver the baby.

Okay. So that’s premature rupture of membranes and reasons we delivered the child early. It’s not a real happy section. So we’re going to move on.

Exam keys, premature rupture of membranes is before labor. I would really, really know that pre premature rupture of membranes is before 37 weeks. You’re going to do a sterile speculum exam to figure this out. What’s going on? 34 weeks later, we can go ahead and deliver under 34 weeks. We’re going to do steroids and antibiotics. That’s really to me out of everything that I just went through.

That’s the part I’d hold on to. When is premature rupture, when is premature rupture of membranes? When is preterm, premature rupture of membranes? How do you tell when membranes have been ruptured? 34 weeks is our dividing line steroids and antibiotics before deliver after. If you can hold onto that, I think you’ll get 75% of the questions right on this section, something like that. You’ll be in pretty good shape.

All right. Let’s talk about breech presentation. Breech presentation is when we do not have a head down. We have the buttocks or feet present first instead of the head. This is kind of normal early on, about one in four and 28 weeks, but it’s only three to 4% at term. So I’m going to run through some types of breech presentations. I would know these.

A frank breech is the hips are flexed. Excuse me. The knees are straight. The feet up by the face. And this is the most common. So I would know this one. A complete breech is the hips and knees, both flexed, sitting cross-legged.

A footling or incomplete is one or both feet first. And this is the highest risk for cord prolapse, which we talked about before. Cord prolapse is a major, major problem. Right. When that, when something’s not engaged into the cervix, it leaves a room for the cord to come down. Risk factors for breech, prematurity. This is the most common.

It makes sense, right? Because the babies turn as we get more mature, so they don’t have time. If they don’t get to that, then there you go. So risk factor, prematurity. Another risk factor would be too much room inside the uterus. So if you have poly, polyhydramnios and you have a lot of space in there, this will contribute as a risk factor, also to little room, which seems counterintuitive, but it makes sense, right? Anything that’s going to change how the baby’s going to move.

So oligohydramnios and multiple gestations will affect it here as well. If there’s something in the way of the baby turning, that can be a problem. So if you have something like placenta previa or uterine fibroids, a mass inside the uterus that keeps the baby from turning. The other one that I should have put at the top of the notes and I put down at the bottom is prior breech, right? That’s another risk factor, clinical presentation. So you can do Leopold maneuvers, four hand positions on the abdomen that map how the fetus is lying. You can actually kind of feel where the baby is and you get better at this over time.

You can listen to fetal heart sounds over the umbilicus and your questions, I would likely describe a hard round movable mass in the fundus at 37 weeks. That would be kind of a breech presentation, but really how we actually going to do this, we’re going to get an ultrasound. That’s how we’re really going to tell. You can absolutely feel the baby in the abdomen, but you’re going to get an ultimately, you’re going to get an ultrasound. You’re going to know exactly what type of breech, what the amniotic fluid levels are like, what the placenta location is, what the fetal anomalies are, anything that’s going on inside that uterus. You’re going to have a pretty good idea. You’re not really going to be doing, at least I don’t think you’re, you’re going to be relying on your physical exam findings here.

All right. Treatments under 37 weeks, we’re going to wait. We’re not going to do anything. We have some time. Most babies will turn on their own. We don’t really need to do anything here after 37 weeks, you can start to do some maneuvers, let’s call it. So external cephalic version, you put the hands on the abdomen and rotate the baby head down.

I don’t know how effective this is. My notes say it succeeds about half the time. I, I am skeptical of that, but you know, I’m getting, this is not my area.

So let’s just call it that I wouldn’t worry about it. Cause it’s not going to be in your test. I didn’t, I can’t imagine they’re going to say how often do external cephalic versions work. I don’t think that’s what they’re going to be asking you. You’re not going to do this though.

Let’s maybe though, the question they are going to ask is when should you not do this? When should you not try to manually turn the baby? And again, this is a list you can come up with. This is a list you can think about. And so this isn’t that complicated. Don’t memorize this. What is it?

Just stop and think for a second. What are two different reasons why you wouldn’t try to manually turn the baby after 37 weeks? How about placenta previa? That seems like a good one. Prior, prior classical incision is another good one. Multiple gestations, probably a good one. Non reassuring tracing might be a good one.

So another list you don’t have to memorize, but you can build.

Now, if the baby doesn’t turn, what are we going to do? If we have an ultrasound, it’s a breech presentation. What are we going to do? We’re going to plan a C-section, right? We’re going to plan our C-section for 39 weeks and know that if she goes into labor, we’re going to go ahead with it. Do also understand that after birth, breech babies have a risk of developmental dysplasia of the hips. So we’re going to ultrasound the hips at about six weeks, just to make sure everything’s okay.

But to me, that’s really all you need to know here. It’s not, this is not super complicated. The premature rupture of membranes, I made it sound more complicated than it is as far as your test goes. At least I think so. We went into more detail. I stumble over some words, but the reality is it’s pretty straightforward. Like I gave you in the exam keys breech presentation is really, we could turn the baby.

We’re going to hope it turns on its own at 37 weeks. We can try at 39 weeks. We’re scheduling a C-section and we’re going to talk about sections and move on, right? So not super complicated.

Let’s talk about multiple gestations, two or more fetuses. This is, now this is what’s going to get a little bit complicated. And again, I’m going to apologize up front. I don’t know that you need to know all this. You need to know twin-twin transfusion for sure. After that, it gets a little bit into the weeds, I think, but I want to cover it just so that you’ve heard of these terms, but I wouldn’t kill myself to memorize each and every one personally. I wouldn’t spend a lot of time on this.

I’m going to go over it for the sake of completeness, but it’s not the kind of thing that I think is going to come up in more than a question tops on your PANCE, let alone on your EORs, not to mention, you’re just going to have to listen to me and laugh as I try to pronounce these terms, chorionicity, how many placentas, right? So this is the, what, where the risk factors come in. How many placentas are, are there? The chorion is the outer membrane that forms the placenta, the outer membrane that forms the placenta. So dichorionic, each one has its own placenta and blood supply. If they’re dichorionic, each one has its own placenta and blood supply. If they’re monochorionic, they have one shared placenta with shared blood vessels.

This is obviously the higher risk. If we’re sharing blood vessels, we have an increased risk. So monochorionic is more dangerous than dichorionic.

Let’s go another step down. We can have fraternal or identical twins. So dizygotic is fraternal, right? Two eggs, two sperm, about two thirds of twins. Dizygotic equals fraternal. I would absolutely know that term.

Now, if we have dizygotic, if we have fraternal twins, will we have dichorionic or monochorionic? Do you think, will they be sharing a placenta or not sharing a placenta if they’re fraternal twins? Stop and think. This isn’t just where you listen to me and laugh at me for my mispronunciations. This is where you think. Well, dizygotic fraternal twins are going to be dichorionic, right? And diomniotic.

So they have two placentas and two sacs. They’re fraternal twins. Two eggs, two sperm, you will have two placentas and two sacs.

Now, identical twins, we can change things a little bit or things can get a little bit trickier. Here we have one fertilized egg that splits, right? We all know that. So that’s a monozygotic. This is about one third of twins. And what’s important here is the later the split, the more they share. Again, I don’t think you’re going to get this kind of detail in your PANCE.

I’m just covering it to be thorough. If they split early, day zero to three, you’re just like fraternal twins. As far as the placenta goes, you have two placentas and two sacs. Day four to eight, you’re monochorionic, diamniotic. So one placenta with two sacs. This is the most common identical type. That’s at the split of four to eight days.

At days eight to 12, you’re monochorionic, mono amniotic. So you’re sharing everything. One placenta, one sac. Obviously more dangerous. Day 13 or later, this is where you have conjoined twins. Risk factors. So risk factors for dizygotic twins are, the main one is right now is assisted reproduction.

So in vitro fertilization, ovulation induction, we’re bringing in more eggs. So we’re increasing the risk. I’m saying risk. I’m not sure that that’s the right term. We’re increasing the odds that you’re going to wind up with dizygotic twins. Advanced maternal age, maternal family history, black race, and higher parity will give you an increased risk for dizygotic twins. What does it look like when a patient comes in and has twins?

We always talk about clinical presentation. This one seems a little bit funny, but you know, what are we going to look at for a clinical presentation? Well, the uterus is going to be larger than the date should be. HCG and alpha-fetoprotein are higher than what we expect. The other part of this is they have higher rates of every pregnancy complication. Higher rates of preterm birth, average delivery of twins is 35 weeks. Increased risk of preeclampsia.

In fact, twins alone. The recommendation is a low dose aspirin for 12 weeks, 81 milligrams. Increased risk of gestational diabetes, of anemia, postpartum hemorrhage, growth restrictions, and discordant growth. What the reason I bring that up here is because if you have a patient who comes in with some of these findings, you may be thinking, well, maybe they have twins.

Now, again, we’re going to have ultrasound. We’re going to have ways of telling all this early on. You have to consider where you are in the world and in your clinic and how things work. So I’m just putting this out because these may be ways that would tune you into the fact that there could possibly be twins. Your diagnosis, like I said, is going to be the ultrasound. That’s simple, straightforward. And you’re going to get that probably early on in the first trimester before 14 weeks.

So in a normal setting, you’re going to have all this information, but we’re not always in a normal setting. That’s what I’m trying to point out. The lambda sign that we mentioned in your priming questions is a triangle of placenta wedging into the dividing membrane. This is dichorionic. This is going to show you that you’ve got twins. The T sign is a thin membrane meeting the placenta at the right angle, monochorionic, diamniotic. No dividing membrane is going to be monoamniotic.

And if you have monochorionic twins, you’re also going to be watching them every few weeks for an ultrasound for twin-twin transfusion. Again, I’m just going to say it one more time. We’ve gone through a lot here. I’m not sure the relevance of all of it. I just want you to have heard it.

Now, here’s where it gets important. And I am sure that this is something that can come up. Monochorionic complications. So twin-twin transfusions. This is something you do need to know. This is vessels in the shared placenta connect the circulation and blood flows one way, about 10 to 15% of mono-di twins. So you need to know the difference between which twin is the donor, which one is the recipient, and what happens to them.

For sharing vessels, we can get a basically what the way I think about this, and again, it may not be right, but it helps me to remember it, is that one twin is just basically is getting more blood, one twin’s getting less blood, right? So our donor twin is getting less blood, which means they have less urine. If there’s less blood and less urine, what else will they have less of? Again, think for a second. They will have less fluid in the sac, right? Because that’s essentially what amniotic fluid is, is its urine. So they’ll have less of it.

So less blood, less urine, oligohydramnios for the donor twin. That twin can’t move as much because of that. And it can get stuck or pinned against the uterine wall because it doesn’t have as much fluid. It can get growth restricted and also on top of that can become anemic. The recipient twin, the one that gets more blood is going to have what with its urine? Well, it’s going to have more. It’s also going to have polyhydramnios.

It’s going to have more fluid. Here, they can get polycythemia, volume overload, heart failure, and hydrops because of these things, right? The amniotic fluid, like I said, is fetal urine. So that’s going to tell you which twin is which.

Now, the really cool part here, and I didn’t know anything about this, is that the treatment is a fetoscopic laser, which is really fun to say, a fetoscopic laser ablation of the connecting vessels. It’s actually go into the mother’s body and ablate the vessels and break the connection, and that’s just mind blowing. I need to, I’m curious to look more into that. But, and someone please correct me if I’m wrong, but to me, that’s amazing. And that’s the current treatment that I came across. One other concern in a mono-mono, so monochorionic twins, is that if there’s no dividing membrane between them, you can get cord entanglement, right? So if there’s no dividing membrane, you can get cord entanglement, which can obviously be a major issue.

OK, so what do we do? Uncomplicated twins. What the treatment, again, this treatment is such a weird word, I don’t need to mess, I don’t need to say that, but if we have di-di twins, we’re going to deliver at 38 weeks pretty normally. Mono-di twins is going to be 34 to 37 weeks, and mono-mono is probably going to end up being 32 to 33 weeks by cesarean, because all the complications and the more they share, the earlier we do it. Delivery route depends on twin A, the twin closest to the cervix, twin A is a vertex, so again, that may be useful to you, twin A is the one closer to the cervix, if twin A is vertex, it’s a vaginal delivery, you can attempt vaginal delivery. If twin A is breech or transverse, then we’re going to do a cesarean. Triplets or more, we’re doing cesarean.

After twin A delivers, watch for abruption and twin B cord prolapse can be a concern. So again, that’s just a ton of ground to cover. I wouldn’t get too wrapped up in the details here. Just kind of let it wash over. You understand what we’re talking about. If you need to go over to the website, physicianassistantexamreview.com/173. This is episode 173.

You can find all the notes and stuff over there. So if you want to go through it again, and with the actual stuff in front of you, some people like to sit with the, I have the podcast hosted right on the site. So you can just hit play and go through the notes that may be really helpful for this sections, maybe not one that lends itself to drive it in the car and really retaining a whole lot. Let me get back to where I was in my notes. So exam keys for this section. The later the split, the more they sharing, right? The lambda sign indicates two placentas.

The T sign indicates one placenta, the donor twin, it will be oligohydramnios, the recipient twin, polyhydramnios and may have issues with heart failure. Ooh. Okay. I think that’s enough for today. Let’s quit there. I apologize. Let’s stop there.

So let’s talk about our, our study tips for the week. I’m going to change it on the fly here and talk about our study tips for the week. One of the study tips you have to understand, and this is a great time to go through this is you need to start deciding what you need to learn, what you don’t need to learn, what you can hold onto, what you can’t hold onto. You could spend a week or two on what we covered today, trying to make sure you understand it, make sure it gets into your brain, but you don’t have a week or two. You have a test tomorrow. You have another test the next day after that.

So some things you have to decide whether you’re going to study them, whether you’re not going to study them. And that was something I came up with in PA school because I knew I just didn’t have the time. I couldn’t possibly get to everything. I wasn’t really an option. I come up with a system to do that, but that’s not what’s important. What’s important is that you think about it this way. Some things are more important to learn than other things.

Let me say it again. Some things are more important to learn than other things. So when I’m doing these notes, when I’m looking over this stuff, it’s what I’m keeping in mind and I’m hoping you’re keeping in mind. So when I look at today’s, for example, I like to think about like, okay, so what if I only had, I can only remember one thing. What would it be? Well, for me, it’d be premature rupture membranes, 34 weeks. That would be a key factor for me.

What I did before 34 weeks, what I do after 34 weeks. What’s the next thing? Probably twin-twin transfusion. So when people say I don’t have time to study everything, it’s too much. How do I do it? You can’t study everything. I agree, but trying to is a fool’s game.

Like you can’t do it. So stop trying, start deciding what you’re going to study. That’s going to be our study tip for today.

All right, let’s jump into our priming questions and get those answers for you. See if we learned anything today. Nitrazine paper turning blue suggests what diagnosis? This is a rupture of membranes. What’s the most common type of breech presentation? Frank breech. What antibiotic combination treats chorioamnionitis?

IV ampicillin plus gentamicin? The lambda sign on a first trimester twin ultrasound indicates what chorionicity? Dichorionic two placentas. In a twin-twin transfusion syndrome, which twin develops polyhydramnios? The recipient twin extra blood volume means extra urine.

Fantastic. All right. Well, thank you guys so much for coming today. Really appreciate you guys being here. So much fun. I really enjoy being doing, getting to do this. So thank you for supporting me and allowing me to do this.

Like I said, the newest version of The Final Step has been in the process for over two years now. I’ve been putting it off and working on other things. This has become the number one thing on my list to get done and it will be done by the end of October. If you want to find out more about that, you can go to physicianassistantexamreview.com/newbook to be notified as soon as that becomes available. It’s going to be 2000 questions, only the most important stuff to lock it into your brain and make sure that you have it on exam day.

All right, folks, take care. Can’t wait to talk to you next week and I look forward to moving through reproduction.