DIP Episode 227 - USMLE Step 2CK Rapid Review Series 36 (OBGYN + Others)

Okay, welcome. My name is Divine. This is another episode of the Divine Intervention podcast. This is episode 227. And in this episode I'll be continuing the Rapid Review series for the USM list step 2 CK exam. This will be episode this will be series 36. Yeah, this will be series 36. So let's just go ahead and get started. Now I'll be covering a lot of stuff that's related to neuro and OBGYN in this podcast. And then I'll also see some physiological things if I have enough time. Hopefully, you know, people find this to be helpful. So let's go ahead and jump right into it. So what did they give you a question about a patient? And this patient, you know, had like an operator infection or like a UTI or like diarrhea a few days or maybe like two, three weeks ago. And in this patient, suddenly has been complaining of like, you know, like, you may have been like trouble walking and they're now beginning to complain of shortness or breath. If you see that on an MBME, what do you want to think about? Well, I would really hope you're thinking about Guillembré syndrome, right? Guillembré syndrome, right? To remember, most times many people are like, oh, they must have a GI infection, bloody diarrhea, and a low back to a junior, yes, that's a classic presentation, but that's not the only presentation you'd see on a test. Some other things you could see on a test, you could see a person with a UTI. And then they have the symmetric East Indian paralysis.

If you see that, think about GPS or you see a person with an OBGYN infection. If you see them with a symmetric East Indian paralysis, again, think about Guillembré syndrome, right? And remember, Guillembré syndrome, those people, especially when they're beginning to have shortness or breath, you can track their pulmonary status by measuring the FEV1, right? That's very high, you know? So you track it with the FEV1. And if the FEV1 begins to drop, then your next step in management is to go ahead and into the patient, right? You need to go ahead and into the patient, although if a patient has been intubated for a prolonged period of time, remember that can increase the risk of a tricumalicia, right? I mean, like the biggest MBME exam risk factor for tricumalicia is having a history of prolonged intubation, right? So that's why usually if you've done any kind of ICU rotation, you'd notice that when people have been intubated for a longer and an afternoon of time, you're then start having the family discussions about placing them on a tric tube after like five to seven days. So that's a, that's a high-o thing to know there. And obviously, if a person has Guillembré, right, you want to treat it with plasma exchange, right? And so putting plasma exchange, because the answer many people have come to expect is plasma ferrisis. Is it putting plasma ferrisis? They may pull plasma exchange on your test, right? So just kind of watch out for that.

And occasionally, I mean, if you don't see plasma ferrisis or plasma exchange, you can go ahead and do an IVIG. But the thing is, in general, doing plasma ferrisis is the right thing to do on an MDME exam. And one other thing I think I'll go ahead and mention is IVIG is actually a pretty common treatment for some diseases on tests, right? So that's just, you know, one of those things I kind of want you to know about, right? So don't forget that IVIG can be used to treat protons, e-gamma, global, andemia, right? IVIG can also be used to treat C-Ved, like a common variable immunodeficiency, right? If a person has Ig deficiency, you may even help them out a little with IVIG as well, right? But I'll say C-Ved, protons, e-gamma, global, andemia, those things respond very well to IVIG. And IVIG is like a second line treatment for ITP, right? When a person has like immune thrombocytopenia, right? Really make autoantibodies against GP2 B3. And then remember that if a person has Guillem-Barris syndrome, right? Like if you check their CSF, you'll find, you'll have this classic finding of something known as Albuminosytologic dissociation, right? So Albuminosytologic dissociation where, because usually if you check a person's CSF, if they have increased amounts of protein, they should have increased amounts of white blood cells, right? Because those, the protein you see in CSF is usually a derivative of the white blood cells and the inflammation that they carried out in the brain, right?

So if you're like, hmm, I see like four plus protein in this person's brain, but I see almost no white blood cells, or you're like seeing like zero to two white blood cells for high power field, right? Those two things are not congruent, right? So there's almost like a disagreement between the amount of protein and the amount of cells you're seeing, right? So that phenomenon is known as Albuminosytologic dissociation, right? That phenomenon is known as Albuminosytologic dissociation because Albumin is the primary protein in the body, right? And cytoming cells, right? So you have like, again, almost like a big disagreement between the protein amount and the cell count, right? So that's something high you do want to keep at the back of your mind for NV Me exams. And then one quick thing I want to kind of run through here is, you know, the things, because again, these things shop all the time on NV Me's. So let's kind of like get them out of our system right now, right? So in general, right, what are the things you do around like 10 weeks of pregnancy, right? You want to go ahead and, you want to go ahead, I mean, that's when you can, you know, you do like, you do like a your analysis, right? You typically do your analysis, you know, pretty early in pregnancy, I'd like the first visit, right? You know, you go ahead and check for bacteria in the urine, right? And if you find bacteria in the urine, you actually treat.

In general, when women have asymptomatic bacteria, you don't treat with the big exception being pregnancy. Okay, when a woman is pregnant, if she has dirty urine, right? So let's say you find like bacteria, even if she has zero symptoms, right? If I like bacteria, or you'll find like a positive lucoside esterase or a positive nitrite, right? You need to go ahead and treat. And after you treat, you need to perform a repeat your analysis as a test of cure. If it's not cured, you need to treat it again, right? That's a very high-yield thing to know, right? And you typically do that around like, again, at the first pre-neil visit, would you really happen around that 10 weeks? And remember that around that 10-week period, you can also do like a coronic villosample, right? And if you kind of want to check out the coronic villi, you just want to see like, oh, if you want to do like some kind of like a DNA, whatever, right? If you want to check like the Charles DNA, like you can do like CVS, you can do self-re-DNA, self-re-DNA, you can probably do it like just before 10 weeks or at 10 weeks. Coronic villosample is something that you know, you typically do like around like 12 weeks or thereabouts, right? So again, that's a high-yield thing to keep at the back of your mind. And one other thing, so I guess since we've kind of talked around 10 weeks, right?

Like if you're going between like, you know, like that 15 to 20-week mark, probably a little closer to the 20-week mark, you can begin to do things like an amniocentesis, right? You can do an amniocentesis, although you don't just jump to an amniocentesis, right? Like you need to have a reason for doing an amniocentesis. And usually that reason is you're like, hmm, you have an elevated maternal serum AFP, right? If the maternal serum AFP is elevated, right? They will try to ask for your next step in management on the MBMI and they will give you an amniocentesis as an answer choice. Resist the temptation to pick an amniocentesis as an answer choice because the thing is, if you see an elevated maternal serum AFP, it can be from a neuro tube defect, right? It can be from a neuro tube defect, but it can also be from an abdominal body or defect, like an omfalociel, for example, right? So the thing is, those are things you can see very easily on an ultrasound. So you better make sure an ultrasound has been done in the system before you pick an amniocentesis as an answer on an MBMI exam. If an ultrasound has not been done, that is your next step after an elevated maternal serum AFP, right? You do an ultrasound. If you don't see anything on an ultrasound, that's where you do an amniocentesis. And please do not forget, if you perform an amniocentesis, you need to give that woman a roguem at that point, right?

Because remember, yes, we typically give roguem, like, you know, between like 24 to 20 weeks, but if you have anything that causes mixing of fetal and maternal blood, you need to absolutely make sure that you give a roguem, right? Anything you have, any of those fancy things, like you do, like precutaneous or Biblical blood sampling or whatever, for example, you need to do, you need to give roguem during those situations, right? So again, that an atomic ultrasound, yada yada yada, right? You do it around like 18 weeks, but officially you can do it over like 15 to 20 weeks, right? And again, you can do an amniocentesis after 15 weeks, okay? And then one other thing you want to keep at the back of your mind is that, I guess with the 24 to 28 weeks, right? There are some things you can do, right? So you can give like roguem, right? That's when you screen for gestation or diabetes as well, right? Those are probably like the two big high-year things you want to remember between the 24 to 28 week period, right? And the thing is on MDM is if a woman is diagnosed with gestational diabetes, your next step in the management on an MDM is to give her insulin, right? The thing is according to ACOC, you can use, you can use a met forming, you can use some of the sulfonial urease, but according to the MDM, at least in very recent times, right? Insulin is still the diabetic drug of choice on MDM is, right? And remember, if a kid has a, if a woman has diabetes, right?

You know, they can give you a question where essentially the size will be greater than this from polyhydramins, right? The size will be greater than this from the, from the polyhydramins, right? Because again, all that glucose in the mom's blood will flow into the baby's blood, so the baby will pee a ton, because remember, amniotic fluid is literally a baby, peen and swallowing, peen and swallowing is pee, peen and swallowing is pee, right? So that can be one high yield cause of polyhydramins on an MDM. I mean, there are many other things that can cause polyhydramins, for example, right? Like, if you have like an obstruction of the GI tract, like say, T.E. fistula or the water and the latrisia or the genalatrizia, right? Then the baby will swallow, but the swallow thing cannot move forward, so the baby will stop swallowing after a while. That can cause polyhydramins, again, that will present a size greater than this. So the woman may be at like 32-weeks gestation, and the length from the pubic synthesis to the fondus of the uterus is like 37 centimeters, another thing that can cause polyhydramins is if the, if the rust-road european feels too close, right? Then the swallowing center is gone, right? If the swallowing center is gone, then that keep can get into trouble with, that keep can get into trouble with, you know, like anacetylene, right? So you essentially wear with the cortex and that wear with the swallowing center, right?

That's a high yield thing to keep in mind, for example. And then, oligo hydramins, right? That will be the reverse, right? Size less than this. That will be something like porous sequence where you're not, you know, you're not peeing as a child. If a child has like posterior retrovouse, that's causing like an obstructive nephrapathy, right? Again, the peo would not come out, so you would not see that amniotic fluid. So again, those are all kind of high yield things to know, for exams, right? And then the thing is, if a woman is around like 32-34-weeks, one high yield thing to keep at the back of your mind is you can begin to, especially if it's a woman that, you know, like, you know, like, has, you know, multiple sexual partners, you know, like very high risk of ST Is, you can actually begin to test your four diseases like, in fact, the way I remember this is, I remember this as SHGC, right? Cifilis HIV gonorrhea and chlamydia. You test for those things, I forgot to mention, you test for those things at the first prenatal visit around like 10 weeks, well, if a woman again is high risk, you need to repeat that testing around like 32-ish to like 34 weeks. And then some key things you want to remember around those time-free days. If a woman is about to have a baby, like a preterm baby and it's less than 32 weeks, there are two things you need to give. You need to give steroids, right? To promote fetal lung maturity, you give it as two doses over a 24-hour period.

And then you also need to give magnesium to decrease the risk of cerebral palsy, right? The Boswadimation of the test is for neuro protection, if you may, right? And then remember that if a woman is less than 34 weeks, right? But greater than 32 weeks, the only thing you need to give is Bethamethazone for fetal lung maturity. You don't need to give mag. Mag is only given if you're less than 32 weeks for neuro protection. And then one thing to remember, between like 35 to 37 weeks, that's when you start testing for group B strap, right? That's when you start testing for group B strap, right? You start testing for group B strap to caucus and if it's positive, obviously you're going to treat. And usually those women, when they come in labor, right, you give them like like ampicelli, just to you know, make sure the baby does not get a stripper in a lactate. And then in general, right? Like once a woman is like more than 41 weeks along, you need to start like telling her, okay, you're not having labor. Let's go ahead and you know, give like, prostaglandins or something to kind of ripen your cervix so you can go ahead and have this, then go ahead and have have this baby, right? So again, those are all high-yield things to keep at the back of your mind for exams. And one, I guess since I've kind of talked about these dates, let me just say some other things around that pregnancy period. Again, my apologies. I'll try to keep this up podcast pretty short.

I know it's pretty info dense. Well, this is all floridly high-yield information that I want you guys to know for for exams, right? So in general, right? Like, there's this thing that you may check for in moms, there's this thing you may check for in moms blood, right? You may check for this, I think it's called like pregnancy associated plasma protein A, like pap A, like P A double P A, right? Typically, that is usually decreased when a kid has like a trisomy or something like that, right? So that's one of those weird things you want to keep at the back of your mind. And then remember, if you do the quartz screen, right? You remember in Down Syndrome, the beta H CG and the in-heat being A will be increased on a quartz screen. The other stuff will be normal or decreased, right? And then, if a person has Edward Syndrome, right? So trisomy 18, they'll have low levels of alpha-fiddle protein, astriol and beta H CG. Then he'll be maybe increased on normal, okay? But you'll have low levels of AFP, astriol and beta H CG on an MBME exam, right? And again, remember, I said around 10 weeks, you can do the self-redeany. And in general, if they can actually give you like a very weird question on the test, where, oh, you know, this person has a positive self-redeany and what's your next best step in management? Your next best step is actually to do like a coronavirial template, right? Or you can do an anus synthesis, right? The thing is, again, the self-redeany is great and all, right?

But if it's positive, you need to follow it up with a diagnostic test, like an anus synthesis or Chorionica Villosa sampling, right? And then don't forget, the moment a baby is born, before the baby leaves the hospital, the baby is supposed to get the HB vaccine, right? The baby, again, it's very high you to know, the baby is supposed to get the HB vaccine when they have, before they leave the hospital, at least the very first series in the HB vaccine. And again, don't forget that, before you, I said that you give a mom, rogam, between 24 to 28 weeks, right? The thing is, you also need to give mom rogam before she leaves the hospital after she has just delivered the baby, right? So the thing you typically do though, before you give the rogam, is you need to determine, you need to do a test to figure out how much of baby's blood has mixed with mom's blood. You don't just give rogam willingly, right? The reason there is, the reason there is, when a person has, when if you see that, oh, there's almost no, there's very little baby's blood that mix with mom's blood, right? The pretty thing to do is to give low amount, like very little amount of rogam, right? But if you see that, there's a ton of baby's blood mixing with mom's blood, right? You give larger amounts of rogam, right? So it may be like, okay, divine, who cares, why do I care about this? Well, the thing is, there is a test you do to determine how much maternal phylo blood mixing has happened.

And that test is something that your friends at the MBM expect you to know. And that test is known as the Klyhawabeki test, okay? The Klyhawabeki test, it's K-L-E-I-H-A-U-E-R, the Klyhawabeki test. The B-E-T-K-E, you know, B-E-T like the TV station, no, the K-B-O channel, the T-E-S-O-T-V station. So B-E-T-K-E, so the Klyhawabeki test, okay? Again, that's how you to know a friend being the exams. And then, I think those are kind of like the big things I want to say around the, around the, I think those are kind of like the big things I want to say around pregnancy. Or the one other thing I want to say is, it's just a classic question that people kind of scrub on exams. If a woman has HIV, right? And she delivers a baby and you're like, ooo, does this shout out to HIV? That's a classic question. If you find IgG against like the P-24 antigen in the baby's serum, it doesn't mean the baby has HIV, right? Because that IgG, if you remember from step one, it may have cross the placenta, right? It may have cross the placenta and that would have, that would give you like a, almost like essentially like a false result, right? So that IgG you find in the baby's serum, it doesn't mean the baby has been exposed to HIV. The thing that will make you super, super worried on an MD mix them is if you notice that, this baby has IgM against like a HIV protein, like the P-24 protein.

If you see that, then because you won't be, remember, IgM is the first antibody you're making response to any antigen, right? So if you see IgM, or the baby has a HIV and then at that point you have to do like HIV, your next step on the test will be to do some kind of like HIV RNA testing. Now, one other thing I want to talk about here is, this is a phenomenon I've kind of talked about in other podcasts, but I want to talk about it here because there's some new things I want to add, right? So the thing is, I've described this in like some old cardiology podcast, but remember that your systolic blood pressure is a surrogate for your cardiac output, right? Because many people think that, oh, the moment I'm done with step one, I break free from all these physiology questions that the NV Me loves to test. Well, sorry, newsflash. Your friends at the NV Me, they don't stop testing physiology questions after you take step one. On step two, see again on step three, you'll still see all these questions that have arrows or they give you lab values, like for different disorders and you need to pick out the one that matches to the diagnosis in the question, right? So let me describe a physiologic scenario that again, many people tend to scroll up on exams. The thing is, your cardiac output is a surrogate for your systolic blood pressure, your systemic vascular resistance is a surrogate for your deastolic blood pressure. Why is that important?

The thing is the NV Me, they love to ask questions about things that could widen a person's pulse pressure. For example, I already talked about and again, I've described the spath of physiology in other podcasts because these are rapid review podcasts that I'm not going waste a ton of time with that. But you've heard me say this many times in many podcasts that if a person has a patent doctor's at your uses or they have, or they have a audit pre-gurge, those things will cause a white pulse pressure on NV Me exams, right? Another one I've said is I've talked about how a person taking like a drug like murinoid, right? Remember, murinoid is a force for deistries inhibitor. So by inhibiting force for deistries, right? It would increase sickly KMP. When you have high levels of sickly KMP in cardiac muscle, it causes more contraction. So if you have more contraction, you have an increased cardiac output, so your systolic blood pressure will go up, but the thing is by being a force for deistries inhibitor, it also raises sickly KMP in other kinds of muscle, like smooth muscle for example. And the thing is when sickly KMP is elevated in smooth muscle, that causes smooth muscle relaxation. So that will cause visodilation and that will decrease the systemic vascular resistance. If you decrease the systemic vascular resistance, right, that will decrease the person's diastolic blood pressure.

So the pulse pressure, which is the difference between the systolic blood pressure and the diastolic blood pressure will get wider. It would increase when a person is given murinoid. Well, one other thing your friends at the NV Me have started caring about in recent times is a person that is in septic shock. What happens to the pulse pressure in septic shock? So let's think about this for a second. In septic shock, right, this person has systemic inflammation. And because they have systemic inflammation, right, because they have systemic inflammation, right, they've released all these inflammatory mediators like histamine, bradykine, heprin and all that stuff. And it's very high yield to remember that those things increase vascular permeability and those things dilate blood vessels. So when a person has septic shock, they actually have a decrease in systemic vascular resistance. And if you have a decrease in systemic vascular resistance, it will be much easier for blood to flow out of the heart, right, because there's essentially like less of an impediment to blood flow from the heart, right? So if that happens, right, the cardiac output actually does increase, at least early in a person that has a septic shock, they'll have an increase in cardiac output and they have a decrease in systemic vascular resistance. So based on what I've said, you should already begin to imagine that the post pressure gets wider in septic shock, right?

And in generally, people have wide post pressure, they'll begin to have because when you check a presence like radio pulse, for example, that pulse you're feeling is the spread between those people's systolic and dastolibular pressures. So if the spread between a presence systolic and dastolibular pressure goes up, which is again, what is known as post pressure, it should come as no surprise that people that have wide post pressure physiology tend to have bounding pulses and headbubbing and all that fancy stuff that is here on a physical exam. So those are again, all higher things that unfortunately you do need to know for purposes of the USM in. So I'm going to go ahead and pause here. As I do at the end of every podcast, I do offer one or one tutoring for many exams, right? Step one, step two CK, I'll talk about my life lesson at the end, but you know, step one step two CK, step two CS, step three, pre-clinical medical medical exams, 30-ish-off exams, and I offer these booster courses. It's 20 hours for step one, step two CK, step three, and basically it's like a very high-end course, very rapid fire course, where we review the most notes for those respective USM-L exams. Again, I've done it with tons of people, many people have found the helpful, many people have found like very big scoring increases from going through those those states, right?

And then obviously I also do traditional tutoring where I tutor you for like your entire dedicated period, or there are these things I call like longitudinal tutoring, I've done it with a bunch of people where if you're like a first year student studying off-med school, I tutor you through all your block exams in med school, and then I tutor you for your dedicated period, or if you're you know like a newly minted 30-year med student, I know there's not much of that with this virus that's kind of going around. If you're you know like a newly minted med student, I mean 30-year med student and you're studying off rotations, I tutor you for your shelf exams, and then I tutor you for step two. The thing is you may say why does this thing help? The thing is as I tutor you for those exams that come before your USM-L exam, I essentially teach you the most notes, the high yields, like I'm essentially prepped, it's almost like a one year prep or two year prep in the case of the first year med student for step one, and by the end of that period, as I work with you, you would have built up like a super solid base of knowledge, many of those these people that I've done this with end of taking very little dedicated time to study for the exams and they crush it really hard, right? So if that's something you're interested in, feel free to reach out to me, and then I also offer tutoring for like the MCAT, right?

So like if you have like a college body that needs students for any of the MCAT subjects, so for like Gen Chem, O Chem, Physics, Bio Chem, Histology, Physiology, Etude or for all those things, and then if you are a med student applying to residency, so like an ERAS application or a college student applying to Med School, so I can amcass application, again I've worked with tons of people from pretty much every specialty, and again most people have worked with, they've much of the first year, so if you have like an often about your application, low scores, graduated from Med School years ago, fail the US Emily exam, I have worked with people with all these kinds of problems, again I've been an admissions committee member, right?

So I know how to essentially help you put your best foot forward with your with your application, mock interviews, personal statements, rec letters, editing your application, all that stuff, again I can help you with those things and again most people have worked with a much of their first choices, and then if you're a resident I need to learn for like the if you're a medicine resident or a peach resident I need to learn for the in-training exam or the board exam for each of those specialties, I do offer tutoring for those things, and then my life lesson and actually please don't forget to subscribe to the You Tube channel, thank you for all those that have been subscribing, it's called a Divine Intervention, US Emily Podcasts and Videos, please subscribe to the You Tube channel, subscribe to the Word Press website, or also subscribe to the podcast, it's like an Apple Podcasts and Spotify, so in our Google Play, so please subscribe, some people have asked me about like putting the earlier podcasts on those things, I've tried, for whatever reason there's like a limit on how many podcasts I can put on those things, so I will try to reach out to like Apple customer care or something to see if we can help, but I can guarantee anything now with these virus things that come up busy on my end, so I'll try to see what I can do about that, and if you want to reach out to me, for like tutoring or anything you can either reach out to me through the website, or you can, I mean it's called Divine Intervention Podcasts with an SADN.com, or you can send me or just do a Google search for Divine Intervention Podcasts, you'll find it there, or you can send me an email at Divine Intervention Podcasts with an SADN at gmail.com, and I tend to respond pretty quickly, so my life lesson for today is the value of not comparing yourself with other people, what do I mean by that, this is a very common med student problem, right?

You see some people, they feel that the only way they can make headwind life is by putting other people down, or they feel that they have to hide certain things from people in life for them to move forward. The thing is to be honest with you, the person that is devoted to helping other people is the person that tends to succeed the most, and the person that tends to succeed the fastest, and is the person that ends up being on top, that's the truth, right? Many times people think that oh by trying to warn up another person you can succeed that way, don't get me wrong, you can, but that success is usually very transient, and that thing at some point in your career, or at some point in your medical life will backfire, right? The thing is it's always better to just help people out, but let me say this though, here's one area you need to be careful, you can help people, right? But you can't help people more than, I mean there's this Bible verse that says, love your neighbor as you love yourself, right? Not more than you love yourself, right? So don't let people walk all over you, right? Or don't put yourself in like a terrible circumstance because you're trying to help people, but the thing is you can construct win-win relationships, you can help other people, you can help yourself and both of you succeed, right? That's the thing like comparing yourself with other people, that's just usually not a good idea, usually not a good idea, right?

So always try to help people, don't always try to warn up other people, don't be the person that you're on a rotation and you bring cookies and cake for all the residents, right? Or you all agree with your classmates, oh let's all come in at 6 a.m., and you're coming at 430? No, that's not a good thing to do. And the thing is residents and attendants see through this, right? And you can almost guarantee you probably get bad evils doing that. Some people get away with that, but it's just eaky, it's just not a good way to be a team player, I mean I would not want to work with those kinds of people in residency, to be perfectly honest with you. So that's my life lesson for today, so thank you for listening and please stay safe, be careful, practice social distancing, and remember that at least that's my prayer that this thing kind of passes off, passes off soon because I mean it's killing a lot of people and it's I mean I've never seen anything like this in my life, but you know just be careful, stay safe, stay indoors, protect others by staying indoors, that's a very important thing. Thank you for listening, I'll see you in the next podcast whenever I have the time, thank you and God bless you.

Albuminocytologic dissociation (high protein, low/normal WB Cs).

Detailed fetal anatomy ultrasound.

PDE inhibitors (e.g., Mannitol).

Before any procedure that involves mixing fetal and maternal blood.

IgG antibodies can cross the placenta, leading to false positives; IgM is more concerning for acute infection.

Septic shock.

Increased Beta-hCG and In-[heat]B-hCG; normal or decreased AFP/Estriol.

Between 35–37 weeks gestation.

Karyotype test (or similar blood grouping/mixing assessment).

Insulin.

Gestational diabetes mellitus (hyperglycemia $\rightarrow$ increased urine output) or GI tract obstruction (e.g., atresia).

Steroids (for fetal lung maturity) and Magnesium Sulfate (for neuroprotection/preventing cerebral palsy).

Increased Beta-hCG and In-[heat]B-hCG; normal or decreased AFP/Estriol.

Between 35–37 weeks gestation.

Karyotype test (or similar blood grouping/mixing assessment).

Insulin.

Gestational diabetes mellitus (hyperglycemia $\rightarrow$ increased urine output) or GI tract obstruction (e.g., atresia).

Steroids (for fetal lung maturity) and Magnesium Sulfate (for neuroprotection/preventing cerebral palsy).