uWISE Unit 2: Obstetrics A - Normal Obstetrics

A 23-year-old G1P1 woman delivered a healthy infant two days ago. She has had difficulty breastfeeding despite multiple attempts. Her nipples are sore and cracked and she is thinking about exclusively bottlefeeding. The patient's pregnancy was complicated by gestational diabetes and the patient has chronic hypertension and a history of an abnormal Pap. She had a cone biopsy two years ago and had a normal Pap with the current pregnancy. The patient's mother has a history of endometrial and colon cancer and her maternal grandmother and grandfather both had fatal heart attacks in their early sixties. Breastfeeding decreases the risk of which of the following for this patient? A. Type 2 diabetes B. Coronary artery disease C. Cervical cancer D. Ovarian cancer E. Colon cancer

D. Human milk is recognized by the American Academy of Pediatrics as an optimal feeding for all infants. The American Academy of Pediatrics recommends exclusive breastfeeding for the first six months after birth. Physicians can influence a patient's feeding choice, and prenatal education is important in the initiation and maintenance of breastfeeding. Nationally representative surveys have noted that women were more likely to initiate breastfeeding if their physicians or nurses encouraged it. Benefits to the mother include increased uterine contraction due to oxytocin release during milk let down and decreased blood loss. Breastfeeding is associated with a decreased incidence of ovarian cancer. Some studies have reported a decreased incidence of breast cancer. Breastfeeding has not been shown to decrease the risk for developing coronary artery disease, cervical dysplasia and cervical cancer or colon cancer in the mother. Breast milk is a major source of Immunoglobulin A which is associated with a decrease of newborn's gastrointestinal infections.

A 32-year-old G3P2 woman has delivered a previous child with anencephaly. What is the appropriate recommended dose of folic acid for this woman? A. 0.4 mg B. 0.8 mg C. 1.0 mg D. 4 mg E. 8 mg

D. In 1991, the Centers for Disease Control and Prevention recommended that all women with a previous pregnancy complicated by a fetal neural tube defect ingest 4 mg of folic acid daily before conception and through the first trimester. In one analysis, this dose of folic acid in women at high risk reduced the incidence of neural tube defects by 85%. According to ACOG, tThe recommended dose for non-high risk patients is at least 0.6 mg/day.

A 23-year-old G1P0 at 39 weeks gestation presents in spontaneous labor. Pregnancy was complicated by gestational diabetes. She delivers a 4200 gram infant with ruddy color and jitteriness. The infant is at immediate risk for which of the following conditions? A. Hyperglycemia B. Anemia C. Thrombocytopenia D. Polycythemia E. Hypercalcemia

D. Infants born to diabetic mothers are at increased risk for developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress. Thrombocytopenia is not a risk.

A 24-year-old G1P0 woman at 34 weeks gestation is planning to breastfeed her baby. Several hormones of pregnancy are responsible in order for the breasts to produce milk. Which of the following hormones is responsible for synthesis of milk? A. Estrogen B. Oxytocin C. Cortisol D. Prolactin E. Human placental lactogen

D. Progesterone, estrogen, and placental lactogen, as well as prolactin, cortisol, and insulin, appear to act in concert to stimulate the growth and development of the milk-secreting apparatus of the mammary gland. Prolactin is responsible for the synthesis of milk, but although present in large quantities during gestation, its action is inhibited by the hormones of pregnancy, particularly estrogen and progesterone. After delivery, large amounts of prolactin continue to be secreted, milk is produced after the inhibitory action of estrogen and progesterone is lifted.

An African-American couple comes to you for preconception counseling. Neither one has any significant family or genetic history. Based on their African-American descent, which of the following blood tests would you recommend? A. MCV and CBC B. Sickle cell preparation and CBC C. Peripheral blood smear and CBC D. Hemoglobin electrophoresis and CBC E. Sickle cell preparation with a hemoglobin electrophoresis, if the sickle preparation is abnormal

D. Screening for carriers of both alpha and beta thalassemia is possible by evaluation of red cell indices. Although solubility tests for hemoglobin S or sickle cell preparations can be used for screening, hemoglobin electrophoresis is definitive and preferable because other hemoglobinopathies can also be detected including hemoglobin C trait and thalassemia minor. Although sickle cells can be identified on a blood smear in individuals with sickle cell disease, the cells may be absent in individuals with milder types of sickle cell disease and even in some individuals with severe sickle cell disease. Evaluation of a peripheral smear is not useful in detecting carriers for sickle cell disease.

A 35-year-old G3P2 woman presents for her initial prenatal care visit at 15 weeks gestation, according to her last menstrual period. She reports that a home pregnancy test was positive about five weeks ago. Review of her history is unremarkable and her entire family is in good health. Physical examination reveals a ten-week size uterus. Which of the following is the most appropriate next step in establishing this pregnancy's gestational age? A. Checking fetal heart tones B. Hysterosonogram C. Quantitative Beta-hCG D. Obstetrical ultrasound E. Quadruple screen

D. The patient's gestational age based on her LMP and the findings on physical exam are discordant. In this case, the most reliable method of confirming gestational age is a dating ultrasound. A quantitative Beta-hCG will not reliably predict the gestational age. The uterine size on physical exam is not the most accurate way to date a pregnancy. An ultrasound performed between 14 and 15 6/7 weeks gestation should be used to date the pregnancy if there is greater than a 7 day discrepancy from the menstrual dates or more than a 10 day discrepancy if the ultrasound is performed between 16 and 21 6/7 weeks. . First trimester ultrasound provides the most accurate assessment of gestational age and can give an accurate estimated date of confinement (EDC) to within 3-5 days.

A 22-year-old G1P0 woman currently at eight weeks gestation is noted to have a missed abortion on ultrasound, along with a retroverted uterus. She elects to undergo suction dilation and curettage. During the procedure, "fatty appearing tissue" is noted to be coming through the curette. What is the next best step in the management of this patient? A. Continuing with the suction curettage B. Remove the tissue from the curette and replace it into the uterus C. Cut the tissue off at the cervical os D. Proceed with laparoscopy E. Stop the procedure and observe her the hospital for 48-hours

D. The tissue is consistent with omental tissue and may include segments of bowel. The suction should be turned off and the tissue gently removed from the curette. Laparoscopy will allow closer examination and should bowel appear to be involved, the surgeon should consider laparotomy for closer evaluation of the bowel for damage. The other options would place the patient at increased risk of complications and delay diagnosis.

A 34-year-old G1P0 woman at 39 weeks gestation presents in active labor. Her cervical examination an hour ago was 5 cm dilated, 90 percent effaced and 0 station. She just had spontaneous rupture of membranes and is found to be completely dilated with the fetal head is at +3 station. The fetal heart rate tracing is shown below. What is the most likely etiology for these decelerations? (late decels) A. Oligohydramnios B. Rapid change in descent C. Umbilical cord compression D. Uteroplacental insufficiency E. Head compression

D. This patient is having late decelerations. Late decelerations are associated with uterine contractions. The onset, nadir, and recovery of the decelerations occur, respectively, after the beginning, peak and end of the contraction. Late decelerations are associated with uteroplacental insufficiency. A rapid change in cervical dilation and descent are not associated with late decelerations. Umbilical cord compression is associated with variable decelerations. Oligohydramnios can increase a patient's risk of having umbilical cord compression; however, it does not cause late decelerations. Head compression is associated with early decelerations.

A 22-year-old G1P0 woman, who is at 38 weeks gestation with an estimated fetal weight of 2500 g, presents in active labor. She is completely dilated and effaced. The fetus is at +4 station and left occiput anterior with no molding. She has an epidural and has been pushing effectively for three hours. She is exhausted. What is the next step in management? A. Allow to continue pushing until the baby delivers B. Start Oxytocin to strengthen contractions C. Discontinue the epidural D. Forceps-assisted vaginal delivery E. Cesarean section

D. This patient meets all the requirements for an operative vaginal delivery. Forceps application requires complete cervical dilation, head engagement, vertex presentation, clinical assessment of fetal size and maternal pelvis, known position of the fetal head, adequate maternal pain control and rupture of membranes. Strict adherence to the guidelines suggested by the American College of Obstetricians and Gynecologists (ACOG) for low forceps delivery does not increase the fetal or maternal risks when performed by an experienced operator.

An 18-year-old G1P0 woman at 12 weeks gestation reports nausea, vomiting, scant vaginal bleeding and a "racing heart." These symptoms have been present on and off for the past four weeks. The patient has no significant past medical, surgical or family history. Vital signs are: temperature 98.6°F (37°C); heart rate 120 beats/minute; blood pressure 128/78. On physical examination: uterine fundus is 4 cm below the umbilicus; no fetal heart tones obtained by fetal Doppler device; cervix is 1 cm dilated with pinkish/purple "fleshy" tissue protruding through the os. Labs show: hemoglobin 8.2 gm/dL, quantitative Beta-hCG 1.0 Million IU/mL; thyroid-stimulating hormone (TSH) undetectable; free T4 3.2 (normal 0.7 - 2.5). An ultrasound reveals heterogeneous cystic tissue in the uterus (snowstorm pattern). Which of the following is the most appropriate next step in the management of this patient? A. Repeat quantitative Beta-hCG B. Repeat transvaginal ultrasound C. PET scan D. Chest x-ray E. CBC

D. This patient's presentation is classic for a molar pregnancy. Beta-hCG levels in normal pregnancy do not reach one million. A chest x-ray would be the most appropriate step, as the lungs are the most common site of metastatic disease in patients with gestational trophoblastic disease. Though a repeat quantitative Beta-hCG will be required on a weekly basis, an immediate post-operative value will be of little clinical utility. A PET scan is not indicated and the patient already had a CBC done.

A 24-year-old G0 woman presents to you for preconception counseling. Her medical history is notable for type 1 diabetes mellitus, hypertension, epilepsy, and hypothyroidism. Her medications include insulin, methyldopa, valproic acid and levothyroxine. Based on her medication exposure, her infant is at greatest risk of which of the following anatomical defects? A. Duodenal atresia B. Skeletal anomalies C. Renal tubular dysgenesis D. Neural tube defects E. Omphalocele

D. Valproic acid is associated with an increased risk for neural tube defects, hydrocephalus and craniofacial malformations. Insulin and methyldopa are not associated with fetal defects. Omphalocele and duodenal atresia are not increased in type 1 diabetic patients.

A 21-year-old G1P0 woman delivered a 4000 gram infant by a low-forceps delivery after a protracted labor course that included a three-hour second stage. Her prenatal course was notable for development of anemia, poor weight gain and maternal obesity. Following the delivery, the patient was noted to have a vaginal sulcus laceration and a third-degree perineal laceration, which required extensive repair. Her hematocrit was noted to be 30% on postpartum day one. Which of the following factors places this patient at greatest risk for developing a puerperal infection? A. Third-degree perineal laceration B. Poor nutrition C. Obesity D. Anemia E. Protracted labor

E. Endometritis in the postpartum period is most closely related to the mode of delivery. Endometritis can be found in less than 3% of vaginal births and this is contrasted by a 5-10 times higher incidence after Cesarean deliveries. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status.

A 19-year-old G1P0 woman at 41-weeks gestation with two prior prenatal visits at 35-weeks and 40-weeks, presents in active labor. Review of available maternal labs shows: blood type O+; RPR non-reactive; HBsAg negative; and HIV negative. She delivers a small female infant who cries spontaneously. On examination, you find the infant has a slightly flattened nasal bridge. Her ears are small and slightly rotated. What is the most appropriate next step in the management of this patient? A. Tell the mother the infant will be fine B. Tell the mother that her newborn has Down syndrome C. Question the patient why an amniocentesis was not performed D. Further examine the infant for wide-spaced nipples and lymphedema E. Further examine the infant for sandal gap toes and hypotonia

E. A flattened nasal bridge, small size and small rotated, cup-shaped ears may be associated with Down syndrome and should prompt a survey looking specifically for other features seen with Down syndrome that include sandal gap toes, hypotonia, a protruding tongue, short broad hands, Simian creases, epicanthic folds, and oblique palpebral fissures. The initial physical findings may be a variant of normal, therefore, you should not share any concerns with the mother until you perform a detailed physical examination. Wide-spaced nipples and lymphedema are associated with Turner syndrome. It is not standard of care to offer amniocentesis to a 19-year-old, unless she has specific risk factors.

A 34-year-old G4P4 woman is diagnosed with endometritis following a Cesarean delivery three days ago. Which of the following is the most likely causative agent(s) of endometritis in this patient? A. Aerobic streptococcus B. Anaerobic streptococcus C. Aerobic staphylococcus D. Anaerobic staphylococcus E. Aerobic and anaerobic bacteria

E. Bacterial isolates related to postpartum endometritis are usually polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract. The most causative agents are Staphylococcus aureus and Streptococcus.

A 32-year-old G2P1 woman is 20 weeks gestation. Her prior pregnancy was complicated by postpartum endometritis and her son was diagnosed with early-onset neonatal sepsis due to group B streptococcus. Which of the following management options regarding Group B streptococcus is most appropriate for this patient? A. Recto-vaginal culture at 35-37 weeks and antibiotic treatment during labor if positive B. Recto-vaginal culture at 35-37 weeks and antibiotic treatment at the time the culture result returns if positive C. Recto-vaginal culture at 24-28 weeks and antibiotic treatment during labor if positive D. Recto-vaginal culture at 24-28 weeks and antibiotic treatment at the time the culture result returns if positive E. Do not perform recto-vaginal cultures and treat with antibiotics during labor

E. Cultures for group B streptococcus are not required in women who have group B streptococcal bacteriuria during the current pregnancy or who have previously given birth to a neonate with early-onset group B streptococcal disease because these women should receive intrapartum antibiotic prophylaxis. Universal screening with a recto-vaginal culture at 35-37 weeks of gestation is recommended for all women who do not have an indication for intrapartum antibiotic prophylaxis. All women with positive cultures for group B streptococci should receive intrapartum antibiotic in labor unless a cesarean delivery is performed before onset of labor in a woman with intact amniotic membranes.

At one minute of life, an infant has a heart rate greater than 120 beats/minute, is crying, has acrocyanosis, gags when suctioned and is vigorously moving all four extremities. What is the APGAR score for this infant? A. 5 B. 6 C. 7 D. 8 E. 9

E. Heart rate= 2, Respiratory rate= 2, Reflex = 2, Activity =2, Color =1. Therefore, the one-minute APGAR score is 9.

A 24-year-old G1P0 woman at 41 weeks gestation was noted to have meconium-stained amniotic fluid after an amniotomy was performed. What is the most appropriate management of this patient to attempt to prevent her newborn from experiencing meconium aspiration syndrome? A. Initiate amnioinfusion with sterile saline to dilute the meconium-stained amniotic fluid B. Suction the oropharynx and nasopharynx on the perineum after the delivery of the head but before the delivery of the shoulders C. Suction the oropharynx and nasopharynx on the perineum immediately after delivery before the baby takes his first breath D. Intubate the trachea and suction meconium and other aspirated material from beneath the glottis immediately after delivery E. Intubate the trachea and suction meconium and other aspirated material from beneath the glottis immediately after delivery only if the infant is depressed

E. Meconium-stained amniotic fluid is present in 12-22% of women in labor. Meconium aspiration syndrome occurs in up to 10% of infants who have been exposed to meconium-stained amniotic fluid. It is associated with significant morbidity and mortality. The American College of Obstetrics and Gynecology, the American Academy of Pediatrics and the American Heart Association recommend that all infants with meconium-stained amniotic fluid should not routinely receive suctioning at the perineum. If meconium is present and the newborn is depressed, the clinician should intubate the trachea and suction meconium or other aspirated material from beneath the glottis. If the newborn is vigorous, defined as having strong respiratory efforts, good muscle tone, and a heart rate greater than 100 beats per minute, there is no evidence that tracheal suctioning is necessary. Injury to the vocal cords is more likely to occur when attempting to intubate a vigorous newborn. Routine prophylactic amnioinfusion for meconium-stained amniotic fluid is not recommended as there is no definitive benefit.

A 39-year-old G1P0 woman presents in labor at term. The estimated fetal weight is 3200 g. She is 10 cm dilated with left sacrum anterior at +2 station. Which of the following is the most appropriate next step in the management of this patient? A. Attempt external version B. Attempt internal version C. Apply forceps D. Apply a vacuum E. Recommend a Cesarean section

E. Most recent data suggests that breech infants delivered vaginally are at higher risk for neonatal complications. Therefore, it would be recommended that this patient undergo a Cesarean section, especially since this is her first pregnancy. External cephalic version and internal versions are contraindicated in active labor. Forceps are used in breech deliveries to assist in flexion of the head and vacuum applications on breech presentations are contraindicated.

A 27-year old G3P1 woman is admitted to the orthopedic service after open reduction and internal fixation of her femur status post a motor vehicle accident. Her past medical history is significant for diabetes (controlled with metformin) and a history of a deep venous thrombosis three years ago while taking an oral contraceptive. She has been receiving ibuprofen for pain control and oxycodone for breakthrough pain as well as docusate sodium (Colace). Additionally, anticoagulation therapy was began with IV heparin, and is now therapeutic on warfarin. At a follow up visit, she has a positive pregnancy test and an ultrasound confirms a six-week intrauterine pregnancy. Which of the following medications should be discontinued now? A. Metformin B. Docusate sodium C. Ibuprofen D. Oxycodone E. Warfarin

E. Of the medications she is currently taking, none are contraindicated at this gestational age. Ibuprofen is safe to take until around 32 weeks gestation, when premature closure of the ductus arteriosis is a risk. While heparin is safe during pregnancy, warfarin has known teratogenic affects and should not be given. If continued anticoagulation is necessary, low molecular weight heparin is the drug of choice.

A 35-year-old G5P4 woman status post vaginal delivery desires postpartum tubal ligation. In obtaining informed consent, which of the following is the most likely risk associated with this procedure? A. Chronic cyclic pain with menstrual cycles B. Increased risk for ovarian cancer C. Decreased enjoyment with sexual intercourse D. Aspiration with general anesthesia E. Unplanned pregnancy

E. The most likely complication she will experience is future pregnancy. The failure rate associated with surgical sterilization is approximately one percent. Approximately one-third of pregnancies after tubal ligation are ectopic. The existence of a "post-tubal ligation syndrome" in which disruption of blood flow in the area of the fallopian tubes leads to menstrual dysfunction and dysmenorrhea has not been substantiated. Tubal ligation appears to have a protective effect on ovarian cancer incidence. There is no proven association between decreased sexual enjoyment and tubal ligation. Tubal ligations may be performed under regional or general anesthesia. Postpartum tubal ligations are generally performed using a spinal or epidural anesthesia. The risk of aspiration are low and range from 1/1000 to 1/14,000.

A 24-year-old G1P0 woman presents in active labor at 39 weeks gestation. She reports leaking fluid for the last two days. She develops a temperature of 102.0°F (38.9°C) and fetal heart rate is 180 beats/min with minimal variability. Maternal labs show: blood type O+; RPR non-reactive; HBsAg, negative; HIV negative; and GBS unknown. What will be the expected appearance of the baby at delivery? A. Vigorous, pink with normal temperature B. Vigorous, pale with low temperature C. Lethargic, pink with high temperature D. Lethargic, pale with low temperature E. Lethargic, pale with high temperature

E. This patient clearly has chorioamnionitis. The fetal tachycardia may be in response to the maternal fever. Fetal tachycardia coupled with minimal variability is a warning sign that the infant may be septic. A septic infant will typically appear pale, lethargic and have a high temperature.

A 34-year-old G2P1 woman presents at 17 weeks gestation. She did not seek preconception counseling and is worried about delivering a child with Down syndrome, given her maternal age. She has no significant medical, surgical, family or social history. Which of the following tests is most effective in screening for Down syndrome in this patient? A. Cell-free DNA screen B. Triple screen C. Quadruple screen D. Maternal serum alpha fetoprotein level E. Nuchal translucency measurement with serum PAPP-A (pregnancy associated plasma protein-A) and free Beta-hCG level

A. Cell-free DNA screening is the most effective screening test for Down syndrome. The test may be performed as early as 9 weeks gestation and until delivery. The test detects over 99% of cases of Down syndrome. The quadruple test (maternal serum alpha fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A) may be used to screen for Down syndrome in the second trimester. Down syndrome occurs in about 1 in 800 births in the absence of prenatal intervention. The efficacy of screening for Down syndrome is improved when additional components are added to the maternal serum alpha fetoprotein screening. The addition of unconjugated estriol and human chronic gonadotropin (the Triple Screen) results in a 69% detection rate for Down syndrome. Adding inhibin A to produce a quadruple screen achieves a detection rate of 80-85%. Nuchal translucency measurement with maternal serum PAPP-A and free Beta-hCG (known as the combined test) is a first trimester screen for Down syndrome. It detects approximately 85% of cases of Down syndrome at a 5% false positive rate.

A 22-year-old G1P0 woman at 38 weeks gestation has been pushing for four hours. You recommend an operative vaginal delivery. In obtaining informed consent, which of the following is less likely to occur during a vacuum delivery vs. forceps assisted delivery? A. Maternal lacerations B. Fetal cephalohematoma C. Neonatal lateral rectus paralysis D. Neonatal hyperbilirubinemia E. Neonatal retinal hemorrhage

A. Newer forms of vacuum extractors cause less maternal discomfort as they are applied to the vertex of the fetal head and do not take up additional space in the maternal pelvis. If properly applied, this leads to a decreased rate of maternal lacerations. Fetal and neonatal complications related to vacuum use include lacerations at the edges of the vacuum cup, particularly if torsion is applied. Torsion may also lead to separation of the fetal scalp from the underlying structures can cause a cephalohematoma and places the fetus at risk of jaundice. Transient neonatal lateral rectus paralysis has been found to occur more frequently in vacuum-assisted deliveries, but, because the paralysis resolves spontaneously, it is unlikely to be of clinical importance.

A 40-year-old G1 woman comes in for her first prenatal visit. This is an unplanned pregnancy and she had a positive urine pregnancy test a week ago. She is 16 weeks gestation based on her last menstrual period. She elects to have screening for aneuploidy and open neural tube defects. Her cell-free DNA test returns screen negative. Her maternal serum alpha-fetoprotein (MSAFP) is increased (2.6 MoM). What is the most likely explanation for the elevated MSAFP in this patient? A. Under-estimation of gestational age B. Over-estimation of gestational age C. Twins D. Neural tube defect E. Fetal demise

A. Ninety to ninety-five percent of cases of elevated MSAFP are caused by conditions other than neural tube defects including under-estimation of gestational age, fetal demise, multiple gestation, ventral wall defects and a tumor or liver disease in the patient. Incorrect dating, specifically under-estimation of gestational age, is the most common explanation for an elevated MSAFP. The next appropriate step in the management of this patient is to obtain an ultrasound to assess the gestational age, viability, rule out multiple gestation as well as a fetal structural abnormality.

A 38-year-old G1P0 woman presents to the hospital at 39 weeks in early labor. She has had routine prenatal care and no antepartum complications to date. She reports good fetal movement and denies vaginal bleeding and leakage of fluid. What is the next best step in the initial assessment of this patient? A. Physical examination B. Nitrazine test C. Fetal ultrasound D. Biophysical profile E. Contraction stress test

A. The initial evaluation of patients presenting to the hospital for labor includes a review of the prenatal records with special focus on the antenatal complications and dating criteria, a focused history and a targeted physical examination to include maternal vital signs and fetal heart rate, and abdominal and pelvic examination. A speculum exam with a nitrazine test to confirm rupture of membranes is indicated if the patient's history suggests this, or if a patient is uncertain as to whether she has experienced leakage of amniotic fluid. Performing a fetal ultrasound is not a routine part of an assessment in a patient who may be in early labor. A prenatal ultrasound may be used in cases to determine fetal presentation, estimated fetal weight, placental location or amniotic fluid volume.

A 28-year-old G1P0 internal medicine resident at 34 weeks gestation had pulmonary function tests performed two days ago because she was feeling slightly short of breath. She is a non-smoker, and has no personal or family history of cardiac or respiratory disease. Vital signs are: respiratory rate 16; pulse 90; blood pressure 112/70; temperature 98.6°F (37°C); oxygen saturation is 99% on room air. On physical examination: lungs are clear; abdomen non-tender; fundal height is 34 cm. The results of the pulmonary function tests are: inspiratory capacity (IC) increased; tidal volume (TV) increased; minute ventilation increased; functional reserve capacity (FRC) decreased; expiratory reserve capacity (ERC) decreased; residual volume (RV) decreased. What is the next best step in the evaluation of this patient? A. Routine antenatal care B. Chest x-ray C. Arterial blood gas D. Spiral CT of the lungs E. Echocardiogram

A. The results of her PFT are consistent with normal physiologic changes in pregnancy. Inspiratory capacity increases by 15% during the third trimester because of increases in tidal volume and inspiratory reserve volume. The respiratory rate does not change during pregnancy, but the TV is increased which increases the minute ventilation, which is responsible for the respiratory alkalosis in pregnancy. Functional residual capacity is reduced to 80% of the non-pregnant volume by term. These combined lead to subjective shortness of breath during pregnancy.

A 24-year-old G1P0 woman has just delivered 37 week male twins. On your initial assessment, you notice twin A is large and plethoric, and twin B is small and pale. A complete blood count (CBC) is obtained on both twins. What is the most likely potential neonatal risk in this case? A. Twin A is at high risk for polycythemia B. Twin A is at high risk for thrombocytopenia C. Twin B is at high risk for thrombocytopenia D. Twin B is at high risk for tachycardia E. Twin B is at high risk for hyperbilirubinemia

A. This case is suggestive of twin-twin transfusion syndrome (TTTS). Polycythemia is a common complication for the plethoric twin. TTTS is a complication of monochorionic pregnancies. It is characterized by an imbalance in the blood flow through communicating vessels across a shared placenta leading to under perfusion of the donor twin, which becomes anemic and over perfusion of the recipient, which becomes polycythemic. The donor twin often develops IUGR and oligohydramnios, and the recipient experiences volume overload and polyhydramnios that may lead to heart failure and hydrops.

A 34-year-old G4P2 woman at 18 weeks gestation presents with fatigue and occasional headache. She has a sister with Grave's disease. On physical exam, vital signs are normal. BMI is 27. Thyroid is difficult to palpate due to her body habitus. The remainder of her exam is unremarkable. Thyroid function studies show: Results Reference Range TSH 1.8 mU/L 0.30 - 5.5 mU/L Free T4 1.22 ng/dL 0.76 - 1.70 ng/dL Total T4 14.2 ng/dL 4.9 - 12.0 ng/dL Free T3 3.4 ng/dL 2.8 - 4.2 ng/dL Total T3 200 ng/dL 80 - 175 nd/dL What is the next best step in the management of this patient? A. Continue routine prenatal care B. Check anti-thyroid antibody levels C. Obtain a thyroid ultrasound D. Initiate propylthiouracil E. Initiate methimazole

A. Thyroid binding globulin (TBG) is increased due to increased circulating estrogens with a concomitant increase in the total thyroxine. Free thyroxine (T4) remains relatively constant. Total triiodothyroxine (T3) levels also increase in pregnancy while free T3 levels do not change. In a pregnant patient without iodine deficiency, the thyroid gland may increase in size up to 10%. This patient's thyroid function is normal for pregnancy, and her symptoms of fatigue can be explained by other physiologic changes in pregnancy, including anemia, difficulty with sleep, and increased metabolic demand.

A 30-year-old G2P1 woman has an ultrasound at 42 weeks for size greater than dates. The fetus had an isolated enlarged head measurement with a BPD of 11 cm, but otherwise appeared to have normal femur length and abdominal circumference. Polyhydramnios is noted. The estimated fetal weight is 3900 g. There is a 10 cm lower uterine segment fibroid protruding into the uterine cavity. The fetus is in the vertex presentation and the fetal head is above the level of the uterine fibroid. Which of the following is an indication for primary Cesarean section in this patient? A. Uterine fibroid B. Fetal hydrocephalus C. Polyhydramnios D. Macrosomia E. 42 weeks gestation

A. Uterine fibroids located in the lower uterine segment may obstruct labor by preventing the fetal head from entering the pelvis. A fetal head with measurements greater than 12 cm could benefit from delivery by Cesarean section. The fetus in the case presented does not necessarily have hydrocephalus. The fetus does not have macrosomia which may be defined as an estimated fetal weight greater than 4000 grams in a diabetic and greater than 4500 grams in a non-diabetic patient. Macrosomia defined as greater than 4000 grams, 42 weeks gestation, and polyhydramnios are not indications for primary Cesarean section.

A 19-year-old G1P0 woman at 39 weeks gestation presents in labor. She denies ruptured membranes. Her prenatal course was uncomplicated and ultrasound at 18 weeks revealed no fetal abnormalities. Her vital signs are: blood pressure 120/70; pulse 72; temperature 101.0° F (38.3° C); fundal height 36 cm; and estimated fetal weight of 2900 gm. Cervix is dilated to 4 cm, 100% effaced and at +1 station. She receives 10 mg of morphine intramuscularly for pain and soon after has spontaneous rupture of the membranes. Light meconium-stained fluid was noted and, five minutes later, the fetal heart rate tracing revealed variable decelerations with good variability. What is the most likely cause for the variable decelerations? A. Umbilical cord compression B. Meconium C. Maternal fever D. Uteroplacental insufficiency E. Umbilical cord prolapse

A. Variable decelerations are typically caused by cord compression and are the most common decelerations seen in labor. Placental insufficiency is usually associated with late decelerations. Head compression typically causes early decelerations. Oligohydramnios can increase a patient's risk of having umbilical cord compression; however, it does not directly cause variable decelerations. Umbilical cord prolapse occurs in 0.2 to 0.6% of births. Sustained fetal bradycardia is usually observed.

A 32-year-old G2P2 woman has just had a spontaneous vaginal delivery. She is concerned that no breast milk is yet being produced when she tries to feed her baby. You reassure her that colostrum is rich in protein and nutrients, and that her breast milk will come in 2-3 days when which of the following hormones have been cleared? A. Estrogen and progesterone B. Estrogen and oxytocin C. Human placental lactogen and prolactin D. Progesterone and prolactin E. Growth hormone and GnRH

A. With delivery, there is a rapid and profound decrease in the levels of progesterone and estrogen, which removes the inhibitory influence of progesterone on the production of alpha-lactalbumin by the rough endoplasmic reticulum. The increased alpha-lactalbumin serves to stimulate lactose synthase and ultimately to increase milk lactose. Progesterone withdrawal allows prolactin to act unopposed in its stimulation of alpha-lactalbumin production. This may take up to two days.

A 30-year-old G1P0 woman with type 1 diabetes mellitus presents at 10 weeks gestation for a routine visit. She smokes a half a pack of cigarettes per day. Her hemoglobin A1C level is 9.7. What structural anomaly is the fetus at highest risk of developing? A. Cardiac anomalies B. Caudal regression malformation C. Hydrocephalus D. Microcephaly E. Limb reductions

A. Women with poorly controlled diabetes immediately prior to conception and during organogenesis have a four- to eight-fold risk of having a fetus with a structural anomaly. The majority of lesions involve the central nervous system (neural tube defects) and the cardiovascular system. Genitourinary and limb defects have also been reported. Although caudal regression malformation occurs at an increased incidence in individuals with diabetes, this condition is very rare.

A 25-year-old G6P2 woman in active labor is treated with mepiridine (Demerol). The patient reports the use of marijuana to control nausea during her pregnancy. She quickly progresses from 4 cm to fully dilated in 1 hour and is now pushing. A limp unresponsive infant is delivered. Heart rate is greater than 90 beats/minute. The infant has no respiratory effort. Which of the following is the most appropriate next step in the management of the neonate? A. Give positive pressure ventilation and prepare to intubate B. Give positive pressure ventilation and prepare to give naloxone C. Give stimulation only and continue to monitor heart rate D. Suction thoroughly and check heart rate E. Suction thoroughly and give naloxone

A. You should give positive pressure ventilation and prepare to intubate the infant, if necessary. Any history of substance abuse may be a relative contraindication to the use of naloxone (Narcan) because the mother may have used narcotics during the pregnancy and administration of naloxone to the infant can cause life-threatening withdrawal. Stimulation may not be sufficient for this infant. Suction will not necessarily stimulate a respiratory effort.

A 32-year-old G3P1 woman at 37 weeks gestation is admitted to labor and delivery for a scheduled repeat Cesarean delivery. Maternal labs show: HIV positive; blood type B+; RPR non-reactive; HBsAg negative; GBS negative; PPD positive; CXR negative. She received adequate antiretroviral therapy prior to and during the pregnancy. Her viral load was undetectable throughout the second and third trimester. A live male infant is delivered with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. Which of the following is the most appropriate next step in the management of the newborn? A. Order HIV testing on the infant immediately on admission to the nursery B. Treat the infant with zidovudine (AZT) immediately after delivery C. Encourage breastfeeding D. Start zidovudine at 24 hours of life E. Isolate the infant from the other infants in the nursery

B. A usual protocol is to start AZT immediately after delivery. HIV testing begins at 24 hours. There is no reason to isolate the infant even though the mother is PPD positive, because her CXR is negative. Breastfeeding would not be encouraged in a mother with HIV.

A 29-year-old G1P1 woman had an uncomplicated vaginal delivery and breastfed immediately postpartum. She has a significant amount of abdominal soreness secondary to a tubal ligation performed on postpartum day two. She is breastfeeding on her side with the baby lying on her side, well away from the abdomen to prevent pain at the incision site. She developed bleeding and cracked nipples. Which of the following is the most likely cause? A. Feedings not frequent enough B. Poor positioning of infant C. Feedings too frequent D. Not enough milk production E. Irritation from the bra

B. Although the side lying position is a good one for breastfeeding, it is important for mother and baby to be belly-to-belly in order for the infant to be in a good position to latch on appropriately, taking a large part of the areola into its mouth. The pain experienced by the patient from her tubal may be interfering with appropriate position and she should be counseled about a different, more comfortable position.

A 36-year-old woman requests prenatal diagnosis. She is healthy and excited about finally getting pregnant. She is interested in genetic counseling and asks about the advantages of chorionic villus sampling versus amniocentesis. Which of the following is true when chorionic villus sampling is compared to amniocentesis? A. Reduced post-procedure loss rate B. Performed earlier C. More likely to obtain an adequate sample D. Lower rate of procedure related birth defects E. Less risk of alloimmunization

B. Chorionic villus sampling (CVS) is a prenatal test that can detect genetic and chromosomal abnormalities of a fetus. The loss rate with amniocentesis is quoted as 0.5% vs. ~1 to 3% for chorionic villus sampling. CVS is performed between 10 and 12 weeks gestation, while amniocentesis is performed after 15 weeks. Early CVS (<10 weeks gestation) is associated with an increase in rare limb abnormalities. It is more likely that a CVS will involve multiple attempts - a failure to obtain an adequate sample of cells and the woman requiring a repeat test later on - when compared with amniocentesis. Pregnancies complicated by isoimmunization can be followed by serial assessment of the amniotic fluid for bilirubin.

A 25-year-old G1P0 woman presents to labor and delivery with contractions. She is at 40 weeks gestation. Her cervix is 6 cm dilated and 100% effaced. The fetus is in the occiput anterior presentation at +1 station. Fetal heart tones are reassuring with a baseline in the 140s, multiple accelerations and no decelerations. The patient had a fetal ultrasound three days ago which reported an EFW of 2900 grams. The patient's older sister had a forceps assisted vaginal delivery and has anal incontinence. The patient would like to avoid having this same complication. Which of the following management plans is most appropriate for this patient? A. Cesarean delivery B. Vaginal delivery with no episiotomy C. Vaginal delivery with a small, controlled midline episiotomy D. Forceps assisted delivery with no episiotomy E. Vacuum assisted delivery with no episiotomy

B. Historically, the purpose of performing an episiotomy was to facilitate completion of the second stage of labor to improve both maternal and neonatal outcomes. Maternal benefits were thought to include a reduced risk of perineal trauma, subsequent pelvic floor dysfunction and prolapse, urinary incontinence, fecal incontinence, and sexual dysfunction. Current data does not demonstrate these theoretical maternal and fetal benefits and there are insufficient objective evidence-based criteria to recommend episiotomy, and especially routine use of episiotomy. The risk of incontinence increases with increasing degrees of pelvic trauma. One study of extended episiotomies demonstrated that the occurrence of a fourth-degree extension was more highly associated with anal incontinence. Performance of a median episiotomy is the single greatest risk factor for third- or fourth-degree lacerations. Avoiding the use of episiotomies may be the best way to minimize the risk of subsequent extensive damage to the perineum. This patient is in active labor and has a high chance of having a vaginal delivery. A cesarean delivery is not indicated. There is no indication to perform a forceps or vacuum assisted vaginal delivery in this patient at this time.

A 17-year-old G1P1 female delivered a term infant two days ago. She is not interested in breastfeeding and she asks for something to suppress lactation. Which of the following is the safest method of lactation suppression in this patient? A. Bromocriptine B. Breast binding, ice packs and analgesics C. Medroxyprogesterone acetate D. Oral contraceptives E. Manual milk expression

B. Hormonal interventions for preventing lactation appear to predispose to thromboembolic events, as well as a significant risk of rebound engorgement. Bromocriptine, in particular, is associated with hypertension, stroke and seizures. The safest method to suppress lactation is breast binding, ice packs and analgesics. The patient should avoid breast stimulation or other means of milk expression, so that the natural inhibition of prolactin secretion will result in breast involution.

A 25-year-old G2P1 woman at 38 weeks gestation presents to labor and delivery with spontaneous onset of labor and spontaneous rupture of membranes. Her cervical exam was 5 cm dilated, 90 percent effaced and 0 station at presentation two hours ago. Presently, the patient is uncomfortable and notes strong contractions. The cervical examination is unchanged from admission. You decide to place an intrauterine pressure catheter (IUPC). On placement, approximately 300 cc of frank blood and amniotic fluid flow out of the vagina. What is the most appropriate next step in the management of this patient? A. Emergent Cesarean delivery B. Withdraw the IUPC, monitor fetus and then replace if tracing reassuring C. Begin amnioinfusion D. Begin Pitocin augmentation E. Keep IUPC in position and connect to tocometer

B. If an intrauterine pressure catheter is placed, and a significant amount of vaginal bleeding is noted, the possibility of placenta separation or uterine perforation should be considered. In this case, withdrawing the catheter, monitoring the fetus and observing for any signs of fetal compromise would be the most appropriate management. If the fetal status is found to be reassuring, then another attempt at placing the catheter may be undertaken.

A 16-year-old G1P0 woman at 39 weeks gestation presents to labor and delivery reporting a gush of blood-tinged fluid approximately five hours ago and the onset of uterine contractions shortly thereafter. She reports contractions have become stronger and closer together over the past hour. The fetal heart rate is 140 to 150 with accelerations and no decelerations. Uterine contractions are recorded every 2-3 minutes. A pelvic exam reveals that the cervix is 4 cm dilated and 100 percent effaced. Fetal station is 0. After walking around for 30 minutes the patient is put back in bed after complaining of further discomfort. She requests an epidural. However, obtaining the fetal heart rate externally has become difficult because the patient cannot lie still. What is the most appropriate next step in the management of this patient? A. Place the epidural B. Apply a fetal scalp electrode C. Perform a fetal ultrasound to assess the fetal heart rate D. Place an intrauterine pressure catheter (IUPC) E. Recommend a Cesarean delivery

B. If the fetal heart rate cannot be confirmed using external methods, then the most reliable way to document fetal well-being is to apply a fetal scalp electrode. Putting in an epidural without confirming fetal status might be dangerous. Although ultrasound will provide information regarding the fetal heart rate, it is not practical to use this to monitor the fetus continuously while the epidural is placed. An intrauterine pressure catheter will provide information about the strength and frequency of the patient's contractions, but will not provide information regarding the fetal status. Closer fetal monitoring via a fetal scalp electrode should be performed.

A 26-year-old African-American G1P0 woman presents to your office at seven weeks gestation with her husband, who is also African-American. The patient's brother has sickle cell anemia, and has been hospitalized on numerous occasions with painful crises requiring narcotic pain medication and blood transfusions. What are the odds that this couple will have a child with sickle cell anemia, if the carrier rate for sickle cell disease in the African American population is 1/10? A. 1 in 15 B. 1 in 60 C. 1 in 100 D. 1 in 160 E. 1 in 400

B. Sickle cell anemia is an autosomal recessive condition that occurs in 1/500 births in the African-American population. The carrier state, or sickle-cell trait, is found in approximately 1/10 African-Americans. Since the patient's brother is affected, both of their parents have to be carriers. Each time two carrier parents for an autosomal recessive condition conceive there is a 1/4 chance of having either an affected or an unaffected child and a 1/2 chance of having a child who is a carrier. Since the patient is unaffected, she has a 1/3 chance of not being a carrier and a 2/3 chance of being a carrier. The patient's husband has a 1/10 chance of being a carrier (the general population risk for African-Americans). Thus, the chance that this couple will have a child with sickle cell anemia is: 2/3 X 1/10 X 1/4 = 1/60.

A 30-year-old G2P0 woman at 38 weeks gestation has just delivered a male infant. She has a history of type 1 diabetes since age 11. Maternal labs show: blood type B+; RPR non-reactive; HBsAg negative; HIV negative; and GBS negative. She had moderate control of blood sugar during her pregnancy. Which of the following would be the most likely finding in the newborn? A. Large and hypoglycemic B. Small and hypoglycemic C. Large and hyperglycemic D. Small and hyperglycemic E. Normal size and euglycemic

B. Small babies are more common with type 1 diabetes than with gestational diabetes, and the blood sugar level of all newborns of diabetic mothers should be monitored closely after delivery, as they are at increased risk for developing hypoglycemia. Macrosomic (large) infants are typically associated with gestational diabetes.

A 42-year-old G5P4 woman at eight weeks gestation presents for her first prenatal appointment. She has glycosuria noted on urine dipstick in the office. She has a history of four prior vaginal deliveries at full-term with birth weights ranging from 9 to 10.5 pounds. Family history is positive for type 2 diabetes in her mother and two siblings. Weight is 265 pounds and height is 5 feet 4 inches (BMI is 45.5 kg/m2). Which of the following recommendations concerning weight gain during this pregnancy is most appropriate? A. Maintain current weight B. Gain 11 - 20 pounds C. Gain 15 - 25 pounds D. Gain 25 - 35 pounds E. Gain 28 - 40 pounds

B. The Institute of Medicine (IOM) has developed guidelines (2009) on weight gain in pregnancy. Historical data show that women who gained within the IOM guidelines experienced better outcomes of pregnancy than those who did not. The recommendations are: underweight (BMI < 18.5 kg/m2) total weight gain 28 - 40 pounds; normal weight (BMI 18.5 - 24.9 kg/m2) total weight gain 25 - 35 pounds; overweight (BMI 25 - 29.9 kg/m2) total weight gain 15 - 25 pounds; and obese (BMI > 30 kg/m2) total weight gain 11 - 20 pounds.

A 24-year-old G4P2 woman at 34 weeks gestation complains of a cough and whitish sputum for the last three days. She reports that everyone in the family has been sick. She reports a high fever last night up to 102°F (38.9°C). She denies chest pain. She smokes a half-pack of cigarettes per day. She has a history of asthma with no previous intubations. She uses an albuterol inhaler, although she has not used it this week. Vital signs are: temperature 98.6°F (37°C); respiratory rate 16; pulse 94; blood pressure 114/78; peak expiratory flow rate 430 L/min (baseline documented in the outpatient chart = 425 L/min). On physical examination, pharyngeal mucosa is erythematous and injected. Lungs are clear to auscultation. White blood cell count 8,700; arterial blood gases on room air (normal ranges in parentheses): pH 7.44 (7.36-7.44); PO2 103 mm Hg (>100), PCO2 26 mm Hg (28-32), HCO3 19 mm Hg (22-26). Chest x-ray is normal. What is the correct interpretation of this arterial blood gas? A. Acute metabolic acidosis B. Compensated respiratory alkalosis C. Compensated metabolic alkalosis D. Hypoventilation E. Hyperventilation

B. The increased minute ventilation during pregnancy causes a compensated respiratory alkalosis. Hypoventilation results in increased PCO2 and the PO2 would be decreased if she was hypoxic. A metabolic acidosis would have a decreased pH and a low HCO3. The patient's symptoms are most consistent with a viral upper respiratory infection.

A 35-year-old G3P0020 woman presents at 11 weeks gestation for chorionic villus sampling (CVS). She has had two prior first trimester losses. What is the risk of miscarriage associated with CVS in this patient? A. 0.1% B. 1% D. 10% E. 15% C. 5%

B. The risk of fetal loss associated with CVS is approximately 1% and is not related to her prior miscarriage history.

A 33-year-old G2P1 woman delivered a male infant after a precipitous second stage. On initial assessment, the infant has no respiratory effort. You decide to proceed with positive pressure ventilation. Which of the following techniques will impede positive pressure ventilation on this newborn? A. Adjusting head position to modified flex position B. Adjusting the head to sniffing position C. Securing mask for a good seal D. Compressing the bag just until chest rise is seen E. Having the oxygen flow at minimum 10 L/minute

B. The sniffing position (tilting the neonate's head back and lifting the chin) is the correct position for application of positive pressure ventilation in a newborn infant. It is important to also secure the mask to the infant's face and to observe an initial chest rise. A recommended rate of oxygen flow is 10 L/minute.

An 18-year-old G1P0 Asian woman is seen in the clinic for a routine prenatal visit at 28 weeks gestation. Her prenatal course has been unremarkable but she has been reporting increased fatigue. She has not been taking prenatal vitamins. Her pre-pregnancy weight was 120 pounds. Initial hemoglobin at the first visit at eight weeks gestation was 12.3 g/dL. Current weight is 138 pounds. After performing a screening complete blood count (CBC), the results are notable for a white blood cell count 9,700/mL; hemoglobin 10.6 g/dL; mean corpuscular volume 88.2 fL (80.8 - 96.4); and platelet count 215,000/mcL. The patient denies vaginal or rectal bleeding. Which of the following is the best explanation for this patient's anemia? A. Folate deficiency B. Relative hemodilution of pregnancy C. Iron deficiency D. Beta thalassemia trait E. Alpha thalassemia trait

B. There is normally a 36% increase in maternal blood volume; the maximum is reached around 34 weeks. The plasma volume increases 47% and the RBC mass increases only 17%. This relative dilutional effect lowers the hemoglobin, but causes no change in the MCV. Folate deficiency results in a macrocytic anemia. Iron deficiency and thalassemias are associated with microcytic anemia.

A 24-year-old G1P0 woman at 28 weeks gestation reports difficulty breathing, cough and frothy sputum. She was admitted for preterm labor 24 hours ago. She is a non-smoker. She has received 6 liters of Lactated Ringers solution since admission. She is receiving magnesium sulfate and nifedipine. Vital signs are: 100.2°F (37.9°C); respiratory rate 24; heart rate 110; blood pressure 132/85; pulse oximetry is 97% on a non-rebreather mask. She appears in distress. Lungs reveal bibasilar crackles. Uterine contractions are regular every three minutes. The fetal heart rate is 140 beats/minute. Labs show white blood cell count 127,500/mL. Potassium and sodium are normal. Which of the following has most likely contributed to this patient's respiratory symptoms? A. Increased plasma osmolality B. Use of magnesium sulfate and nifedipine C. Chorioamnionitis D. Preterm labor E. Increased systemic vascular resistance

B. This patient has pulmonary edema. Plasma osmolality is decreased during pregnancy which increases the susceptibility to pulmonary edema. Common causes of acute pulmonary edema in pregnancy include tocolytic use, cardiac disease, fluid overload and preeclampsia. Use of multiple tocolytics increases the susceptibility of pulmonary edema, especially with the use of isotonic fluids. Systemic vascular resistance is decreased during pregnancy. Women with chorioamnionitis are also more likely to develop pulmonary edema, but this is not usually the main cause unless the patient is in septic shock and this patient does not have chorioamnionitis.

A 26-year-old G2P1 woman at 26 weeks gestation presents for a routine 50-gram glucose challenge test. After receiving a one-hour blood glucose value of 148 mg/dl, the patient has a follow up 100-gram 3-hour oral glucose tolerance test with the following plasma values: Fasting 102 mg/dl (normal ≤95 mg/dl) 1-hour 181 mg/dl (normal ≤180 mg/dl) 2-hour 162 mg/dl (normal ≤155 mg/dl) 3-hour 139 mg/dl (normal ≤140 mg/dl) What is the most appropriate next step in the management of this patient? A. Repeat the glucose tolerance test at 28 weeks gestation B. Begin a diabetic diet and blood glucose monitoring C. Begin a diabetic diet, an oral hypoglycemic agent, and blood glucose monitoring D. Begin a diabetic diet, insulin, and blood glucose monitoring E. Reassurance and routine prenatal care

B. This patient has three values on the three-hour glucose tolerance test that were abnormal. Initial management should include teaching the patient how to monitor her blood glucose levels at home on a schedule that would include a fasting blood sugar and one- or two-hour post-prandial values after all three meals, daily. Goals for blood sugar management would be to maintain blood sugars when fasting below 90 and one- and two-hour post-meal values below 120. A repeat glucose tolerance test would not add any value, as an abnormal test has already been documented. Oral hypoglycemic agents and insulin are not indicated at this time, as the patient may achieve adequate glucose levels with diet modification alone. Gestational diabetes varies in prevalence. The prevalence rate in the United States has varied from 1.4 to 14% in various studies. Risk factors for gestational diabetes include: a previous large baby (greater than 9 lb), a history of abnormal glucose tolerance, pre-pregnancy weight of 110% or more of ideal body weight, and member of an ethnic group with a higher than normal rate of type 2 diabetes, such as American Indian or Hispanic descent.

A 23-year-old G1P1 woman develops a fever on the third day after an uncomplicated Cesarean delivery that was performed secondary to arrest of descent. The only significant finding on physical exam is moderate breast engorgement and mild uterine fundal tenderness. What is the most likely diagnosis in this patient? A. Urinary tract infection B. Mastitis C. Endometritis D. Wound cellulitis E. Septic pelvic thrombophlebitis

C. The most common cause of postpartum fever is endometritis. The differential diagnosis includes urinary tract infection, lower genital tract infection, wound infections, pulmonary infections, thrombophlebitis, and mastitis. Endometritis appearing in a postpartum period is most closely related to the mode of delivery and occurs after vaginal delivery in approximately 2 percent of patients and after Cesarean delivery in about 10 to 15 percent. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status. Uterine fundal tenderness is commonly observed in patients with endometritis.

A 32-year-old G1 woman with an IVF conceived pregnancy at 12 weeks gestation has a slightly increased fetal nuchal translucency (3.0 mm), but her first trimester screen shows no increased risk for Down syndrome or Trisomy 18. Still concerned about the increased nuchal translucency, the patient requests additional testing to exclude chromosomal abnormalities. Which of the following is the next best step to rule out a chromosomal abnormality in this patient? A. Cell-free DNA testing B. Genetic sonogram C. Amniocentesis D. Sequential screen E. Detailed sonogram and fetal echocardiogram at approximately 18 - 20 weeks gestation

C. Amniocentesis is a diagnostic test that may detect Down syndrome as well as other chromosomal abnormalities. Cell-free DNA testing detects over 99% of cases of Down syndrome. The first trimester screen, which consists of a nuchal translucency and maternal serum PAPP-A and beta-hCG, yields an 85% detection rate for Down syndrome. The NT is the measurement of the fluid collection at the back of the fetal neck in the first trimester. A thickened NT may be associated with fetal chromosomal and structural abnormalities as well as a number of genetic syndromes. Patients who desire non-invasive assessment of their risk for aneuploidy can have first trimester screen (a fetal nuchal translucency (NT) measurement and a maternal serum PAPP-A) and a second trimester quadruple screen. The sequential screen which combines the first trimester screen with a quadruple screen yields a 95% detection rate for Down syndrome at a 5% false-positive rate. Since the fetus in this case had a thickened NT, this patient should be scheduled to have a detailed fetal ultrasound and echocardiogram at 18-20 weeks to rule out anomalies. However, it is not possible to diagnose a chromosomal abnormality with an ultrasound. Similarly, although genetic sonograms (targeted sonogram) focus on markers associated with Down syndrome, they are not diagnostic. Approximately 50% of cases of Down syndrome do not have ultrasound findings. Of note, the American Congress of Obstetrics and Gynecology (ACOG) recommends that all patients be offered aneuploidy screening and invasive prenatal diagnosis as indicated.

A 23-year-old G1P0 woman at 38 weeks gestation, with an uncomplicated pregnancy, presents to labor and delivery with the complaint of lower abdominal pain and mild nausea for one day. Fetal kick counts are appropriate. Her review of symptoms is otherwise negative. Vital signs are: temperature 98.6°F (37.0°C); blood pressure 100/60; pulse 79; respiratory rate 14; fetal heart rate 140s, reactive, with no decelerations; tocometer shows irregular contractions every 2-8 minutes; fundal height 36 cm; cervix is firm, long, closed and posterior. A urine dipstick is notable for 1+ glucose with negative ketones. Which of the following is the most likely diagnosis in this patient? A. Appendicitis B. Gestational diabetes C. Braxton-Hicks contractions D. First stage of labor E. Dehydration

C. Braxton Hicks contractions are characterized as short in duration, less intense than true labor, and the discomfort as being in the lower abdomen and groin areas. True labor is defined by strong, regular uterine contractions that result in progressive cervical dilation and effacement. This patient's history does not suggest she is in the first stage of labor. Patients with appendicitis usually present with fever, decreased appetite, nausea and vomiting. Gestational diabetes is diagnosed based on glucose challenge tests. The first test with a 50 gram load is typically performed at 24-28 weeks gestation. It is not abnormal for patients to have glucosuria. This finding is not diagnostic for gestational diabetes. Patients with dehydration frequently present with maternal tachycardia and have ketonuria.

A 37-year-old G3P2 woman presents with her husband at 11 weeks gestation for genetic counseling due to advanced maternal age. The patient and her husband are interested in chorionic villus sampling (CVS). In addition to obtaining a karyotype, which of the following can be detected with this procedure? A. Spina bifida B. Fetal omphalocele C. Cystic fibrosis D. Anencephaly E. Fetal cardiac anomaly

C. CVS is generally performed at 10-12 weeks gestation. The procedure involves sampling of the chorionic frondosum, which contains the most mitotically active villi in the placenta. CVS can be performed using a transabdominal or transcervical approach. The sampled placental tissue may be analyzed for fetal chromosomal abnormalities, biochemical, or DNA-based studies including testing for the mutations associated with cystic fibrosis. CVS cannot be used to detect neural tube defects. Omphaloceles and neural tube defects are generally diagnosed using prenatal ultrasound. Both of these conditions are associated with an increased MSAFP (maternal serum alpha-fetoprotein).

A 22-year-old G1P0 woman at 38 weeks gestation presents in labor. Her prenatal course and past history are uncomplicated. She is having regular contractions and, on examination, the cervix is 5 cm, 100% effaced and fetal head at +1 station. The fetal heart rate tracing is shown below. What is the most likely interpretation? Trough of fetal heart rate prior to peak of CTX A. Normal reassuring B. Bradycardia C. Early deceleration D. Variable decelerations E. Late decelerations

C. Early decelerations are thought to represent the fetal response to head compression during the contraction and the fetal heart rate inversely mirrors the changes noted during the contraction. Variable contractions are thought to be due to cord compression and can occur at any time in relation to a contraction. Generally, they have an abrupt onset and return of the fetal heart rate deceleration to the baseline heart rate. Late decelerations are thought to represent uteroplacental insufficiency. The deceleration of the fetal heart rate occurs at or after the peak of the uterine contraction and returns to baseline after complication of the contraction. Bradycardia is defined as fetal heart rate less than 110 beats per minute.

A 28-year-old G0 woman presents with her husband for preconception counseling. Her family is Ashkenazi Jewish from Poland. Her husband is 30 years old and is also Jewish. They seek information about preconception and prenatal screening. The patient is at increased risk for having a fetus affected with all of the following conditions except: A. Fanconi anemia B. Tay-Sachs disease C. Beta thalassemia anemia D. Cystic fibrosis E. Niemann-Pick disease

C. Fanconi anemia, Tay-Sachs disease, Cystic Fibrosis, and Niemann-Pick disease are all autosomal recessive conditions that occur at an increased incidence in Jews of Ashkenazi descent. The Beta thalassemia is seen mainly in Mediterranean populations.

A 28-year-old G1P0 woman is at 15 weeks gestation. Her husband's cousin has moderate mental retardation. The most common cause of inherited mental retardation in this patient's child would be? A. Undiagnosed phenylketonuria (PKU) B. Neonatal hypothyroidism C. Fragile X syndrome D. Down syndrome E. Autism

C. Fragile X syndrome is the most common form of inherited mental retardation. The syndrome occurs in approximately 1 in 3,600 males and 1 in 4,000 to 6,000 females. Down syndrome is genetic but the majority of cases are not inherited.

A 26-year-old G2P1 woman at 41 weeks gestation is brought in by ambulance. The emergency medical technician reports that a pelvic examination performed 20 minutes ago when the patient had a severe urge to push revealed that she was fully dilated and the fetal station was +2. Fetal heart tones were confirmed to be in the 150s, with no audible decelerations. When the patient is placed on the fetal monitor, the heart rate is noted to be in the 60s. The maternal heart rate is recorded as 100. Without pushing, the fetal scalp is visible at the introitus. A repeat pelvic exam shows that the infant is in the occiput anterior position. What is the most appropriate next step in the management of this patient? A. Emergent Cesarean delivery B. Amnioinfusion C. Assisted operative vaginal delivery D. Confirm the fetal heart rate with an internal fetal scalp electrode E. Use ultrasound to assess the fetal heart rate

C. If the patient cannot deliver the infant with one or two pushes, the next best choice given the fetal station and presentation is to perform an emergent outlet forceps or vacuum-assisted delivery. None of the other options offer an expedient mode of delivery. Since the patient's heart rate is distinct from the fetal heart rate, it is not necessary to check the fetal heart rate with an ultrasound. This will potentially delay the time until delivery of the fetus. Amnioinfusion is not indicated given the imminent delivery.

A 35-year-old G4P3 woman comes in for a postpartum visit. She had a normal uncomplicated vaginal delivery two weeks ago. She has a history of postpartum depression, which required treatment with antidepressants with her last pregnancy. Which of the following signs or symptoms of postpartum depression are most useful to distinguish it from postpartum blues and normal changes that occur after delivery? A. Anhedonia B. Crying spells C. Ambivalence toward the newborn D. Sleeplessness E. Weight loss

C. In addition to the more common symptoms of depression, the postpartum patient may manifest a sense of incapability of loving her family and manifest ambivalence toward her infant. Anhedonia is an inability to experience pleasure from normally pleasurable life events such as eating, exercise, and social or sexual interaction.

A 29-year-old G2P1 woman at 36 weeks gestation is seen for management of her gestational diabetes. Despite diet modification, the patient has required insulin to control her serum glucose levels. She has gained 25 pounds with the pregnancy. Which of the following complications is least likely to occur? A. Polyhydramnios B. Neonatal hypoglycemia C. Intrauterine growth restriction D. Preeclampsia E. Fetal macrosomia

C. Intrauterine growth restriction is typically seen in women with pre-existing diabetes and not with gestational diabetes. Shoulder dystocia, metabolic disturbances, preeclampsia, polyhydramnios and fetal macrosomia are all associated risks of gestational diabetes.

A 30-year-old G0 woman presents with her husband for preconception counseling. The patient is of Ashkenazi Jewish descent. Her husband is Irish. The patient has a brother who has a child diagnosed with attention deficit hyperactivity disorder. Which of the following genetic diseases is the most likely to affect their future children? A. Canavan disease B. Bloom syndrome C. Cystic fibrosis D. Tay-Sachs disease E. Gaucher's disease

C. Non-Hispanic white individuals, including Ashkenazi Jews, are at increased risk for being carriers for cystic fibrosis. The carrier frequency is approximately 1/25 in the non-Hispanic white population. Since the patient's husband is not of Ashkenazi Jewish or French Canadian descent, he is not at increased risk for being a carrier for Tay-Sachs disease. The carrier frequency for Tay-Sachs disease is estimated at 1/30 for Ashkenazi Jews. The gene occurs at a much lower frequency (1 in 300) in most other populations. Canavan disease, Bloom syndrome and Gaucher's disease occur at an increased incidence in the Ashkenazi Jewish population. The carrier frequency for Canavan is 1:55, for Bloom 1:134, and for Gaucher is approximately 1/15 in Ashkenazi Jews.

A 34-year-old G3P1 woman at 26 weeks gestation reports "difficulty catching her breath," especially after exertion for the last two months. She is a non-smoker. She does not have any history of pulmonary or cardiac disease. She denies fever, sputum, cough or any recent illnesses. On physical examination, her vital signs are: blood pressure 108/64; pulse 88; respiratory rate 15; and she is afebrile. Pulse oximeter is 98% on room air. Lungs are clear to auscultation. Heart is regular rate and rhythm with II/VI systolic murmur heard at the upper left sternal border. She has no lower extremity edema. A complete blood count reveals a hemoglobin of 10.0 g/dL. What is the most likely explanation for this woman's symptoms? A. Pulmonary embolism B. Mitral valve stenosis C. Physiologic dyspnea of pregnancy D. Peripartum cardiomyopathy E. Anemia

C. Physical examination findings are not consistent with pulmonary embolus (e.g tachycardia, tachypnea, hypoxia, chest pain, signs of a DVT) or mitral stenosis (diastolic murmur, signs of heart failure). Physiologic dyspnea of pregnancy is present in up to 75% of women by the third trimester. Peripartum cardiomyopathy is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic function towards the end of pregnancy or in the several months following delivery. Symptoms include fatigue, shortness of breath, palpitations, and edema. The history and physical do not suggest a pathologic process, nor does her hemoglobin level.

A 45-year-old G2P2 woman presents for a six-week postpartum check. She reports crying spells, loss of appetite, difficulty sleeping and a feeling of low self-worth that began one week after her delivery. She denies any suicidal or homicidal ideations. She is frustrated because she has not been able to breastfeed and feels that she is a bad mother. She has a previous history of anxiety. Which of the following is the most likely diagnosis in this patient? A. Normal puerperium B. Postpartum blues C. Postpartum depression D. Anxiety disorder E. Bipolar disorder

C. Postpartum depression is a common condition estimated to affect approximately 10-15% of women and often begins within two weeks to six months after delivery. Signs and symptoms of depression which last for less than two weeks are called postpartum blues; it occurs in 40-85% of women in the immediate postpartum period. It is a mild disorder that is usually self-limited. This patient does not have signs/symptoms of anxiety disorder or bipolar disorder.

A 28-year-old G3P3 woman status post an uncomplicated spontaneous vaginal delivery of 4150 gram infant experiences profuse vaginal bleeding of 700 cc. Prior obstetric history was notable for a previous low uterine segment transverse Cesarean section, secondary to transverse fetal lie. The patient had no antenatal problems. The placenta delivered spontaneously without difficulty. Which of the following is the most likely cause of this patient's hemorrhage? A. Vaginal lacerations B. Cervical lacerations C. Uterine atony D. Uterine dehiscence E. Uterine rupture

C. Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or Cesarean delivery. Uterine atony is the most common cause of PPH and occurs in one in every twenty deliveries. It is important to detect excessive bleeding quickly and determine an etiology and initiate the appropriate treatment as excessive bleeding may result in hypovolemia, with associated hypotension, tachycardia or oliguria. The most common definition of PPH is an estimated blood loss of greater than or equal to 500 ml after vaginal birth, or greater than or equal to 1000 ml after Cesarean delivery.

A 21-year-old G1P1 woman presents to the office with amenorrhea since the birth of her one-year-old daughter. She reports extreme fatigue, forgetfulness, and depression. She was unable to breastfeed because her milk never came in. She notes hair loss including under her arms and in her pubic area. Her delivery was complicated by a postpartum hemorrhage, hypovolemic shock, requiring aggressive resuscitation. She is afebrile. Vital signs are: blood pressure 90/50; pulse 84. The patient appears tired. Her exam is normal but she is noted to have dry skin. A urine pregnancy test is negative. Which of the following is the most likely diagnosis in this patient? A. Hyperprolactinemia B. Hyperthyroidism C. Sheehan Syndrome D. Asherman Syndrome E. Major depressive disorder

C. Sheehan Syndrome is a rare occurrence. When a patient experiences a significant blood loss, this can result in anterior pituitary necrosis, which may lead to loss of gonadotropin, thyroid-stimulating hormone (TSH) and adrenocorticotropic hormone (ACTH) production, as they are all produced by the anterior pituitary. Signs and symptoms of Sheehan syndrome may include slow mental function, weight gain, fatigue, difficulty staying warm, no milk production, hypotension and amenorrhea. Sheehan's syndrome frequently goes unnoticed for many years after the inciting delivery. Treatment includes estrogen and progesterone replacement and supplementation with thyroid and adrenal hormones.

A 38-year-old G1P1 woman who delivered by a Cesarean delivery three weeks ago presents to the clinic with concerns that the baby is not getting enough milk and is fussy. She reports that she is feeding on demand and not supplementing. Which of the following is indicative that the baby is getting adequate milk? A. Sleeps through the night B. Spits up a small amount of milk after feeding C. 3-4 stools in 24 hours D. 3-4 diapers wet with urine in 24 hours E. Coverage of the entire areola with his mouth when he breastfeeds

C. Signs that a baby is getting sufficient milk include 3-4 stools in 24 hours, six wet diapers in 24 hours, weight gain and sounds of swallowing.

A 17-year-old G1P0 woman at 32 weeks gestation complains of right flank pain that is "colicky" in nature and has been present for two weeks. She denies fever, dysuria and hematuria. Physical examination is notable for moderate right costovertebral angle tenderness. White blood cell count is 8,800/mL and urine analysis is negative. A renal ultrasound reveals no signs of urinary calculi, but there is moderate (15 mm) right hydronephrosis. Which of the following is the most likely cause of these findings? A. Smooth muscle relaxation due to declining levels of progesterone B. Smooth muscle relaxation due to increasing levels of estrogen C. Compression by the uterus and right ovarian vein D. Elevation of the bladder in the second trimester E. Iliac artery compression of the ureter

C. Some degree of dilation in the ureters and renal pelvis occurs in the majority of pregnant women. The dilation is unequal (R > L) due to cushioning provided by the sigmoid colon to the left ureter and from greater compression of the right ureter due to dextrorotation of the uterus. The right ovarian vein complex, which is remarkably dilated during pregnancy, lies obliquely over the right ureter and may contribute significantly to right ureteral dilatation. High levels of progesterone likely have some effect but estrogen has no effect on the smooth muscle of the ureter

A 25-year-old G1P0 woman is seen for an initial obstetrical appointment at eight weeks gestation. She has had a small ventricular septal defect (VSD) since birth. She has no surgical history and no limitations on her activity. Vital signs are: respiratory rate 12; heart rate 88; blood pressure 112/68. On physical examination: her skin appears normal; lungs are clear to auscultation; heart is a regular rate and rhythm. There is a grade IV/VI coarse pansystolic murmur at the left sternal border, with a thrill. Chest x-ray and ECG are normal. Which of the following is the correct statement regarding cardiovascular adaptation in this patient? A. Approximately 2% of women will normally have a diastolic murmur B. Maternal pulmonary vascular resistance is normally less than systemic vascular resistance C. The maternal cardiac output will increase up to 33% during pregnancy D. Maternal systemic vascular resistance increases throughout pregnancy E. The increase in cardiac output is only due to the increase in the maternal stroke volume

C. The cardiac output increases up to 33% due to increases in both the heart rate and stroke volume. The SVR falls during pregnancy. Up to 95% of women will have a systolic murmur due to the increased volume. Diastolic murmurs are always abnormal. The systemic vascular resistance (SVR) is normally greater than the pulmonary vascular resistance. If the pulmonary vascular resistance exceeds the SVR, right to left shunt will develop in the setting of a VSD, and cyanosis will develop.

A 30-year-old G1P1 woman who underwent an urgent vacuum extraction of a baby girl two months ago is experiencing persistent depressive symptoms suggestive of postpartum depression. She is recently divorced and has no immediate family or close friends. She works as a mechanic in a local garage and is planning on going back to school. She contemplated terminating the pregnancy but ultimately decided to have the baby despite no support from her ex-husband. She has a history of depression in the past but has not required any medications for the last three years. Which of the following is her most significant risk factor for postpartum depression? A. Single parent B. Consideration to terminate the pregnancy C. Personal history of depression D. Urgent delivery E. Social isolation

C. The most significant risk factor for developing postpartum depression is the patient's prior history of depression. Other risk factors for postpartum depression include marital conflict, lack of perceived social support from family and friends, having contemplated terminating the current pregnancy, stressful life events in the previous twelve months, and a sick leave in the past twelve months related to hyperemesis, uterine irritability or psychiatric disorder.

A 42-year-old G5P4 woman is exclusively breastfeeding her two-month-old baby when she develops a fever and a red tender wedge-shaped area on the outer quadrant of her left breast. Which of the following is the most appropriate treatment for this condition? A. Cessation of breastfeeding for 48 hours B. Cessation of breastfeeding until afebrile C. Antibiotics D. Warm compresses E. Incision and drainage

C. The patient has a classic picture of mastitis that is usually caused by streptococcus bacteria from the baby's mouth. Mastitis is easily treated with antibiotics. The initial choice of antimicrobial is influenced by the current experience with staphylococcal infections at the institution. Most are community-acquired organisms, and even staphylococcal infections are usually sensitive to penicillin or a cephalosporin. If the infection persists, an abscess may ensue which would require incision and drainage. However, this patient's presentation is that of simple mastitis. There is no need for the mother to stop breastfeeding because of the mastitis.

An 18-year-old G1P0 woman presents for prenatal care at 6 weeks gestation. Her medical, surgical, gynecologic, social and family history are unremarkable. Her dietary history includes high carbohydrate intake with no fresh vegetables. Her physical examination is within normal limits except that she is pale and has a BMI of 42. Nutritional counseling should include the following: A. 25-30 grams of protein in her diet every day B. A strict diet to maintain her current weight C. Folic acid supplementation D. Intake of 1200 calories a day E. Initiation of a vigorous weight loss exercise program

C. There should be folic acid supplementation, as well as evaluation for deficiencies in her iron, protein and other nutrient stores. In general, a patient needs approximately 70 grams of protein a day, along with her other nutrients. It would be prudent to caution her that, though aerobic exercise is recommended and would be a benefit to her, it is not advisable to initiate a vigorous program in a woman who has not been routinely working out. Women should gain weight during their pregnancy, and 1200 calories a day is not sufficient for a pregnant woman.

A 20-year-old G1P0 woman at 18 weeks gestation with a history of epilepsy has conceived while taking valproic acid. She is scheduled for an ultrasound. What is the most common anomaly associated with prenatal exposure to valproic acid? A. Cardiac defects B. Caudal regression syndrome C. Neural tube defects D. Cleft lip and palate E. Holoprosencephaly

C. Valproic acid use during pregnancy is associated with a 1 to 2% incidence of neural tube defects, specifically lumbar meningomyelocele. Fetal ultrasound examination at approximately 16 to 18 weeks gestation is recommended to detect neural tube defects. Other malformations have been reported in the offspring of women being treated with valproic acid and a fetal valproate syndrome has been described which includes spina bifida, cardiac defects, facial clefts, hypospadius, craniosynostosis, and limb defects, particularly radial aplasia. Case reports have associated prenatal exposure to valproic acid with omphalocele and lung hypoplasia. Caudal regression syndrome is a rare syndrome observed in offspring of poorly controlled diabetics.

A 35-year old G2P1 woman is at 11 weeks gestation. She had a triple screen with her last pregnancy and would like to have aneuploidy screening with the current pregnancy. Which of the following screening tests will provide the highest detection rate for trisomy 21 for this patient? A. First trimester combined test B. Sequential screen C. Quad screen D. Cell-free DNA screen E. Serum integrated screen

D. All of the tests screen for trisomy 21 and trisomy 18. Cell-free DNA screening has a trisomy 21 detection rate of over 99% at a 0.2% false-positive rate. The other options may also be used to screen for trisomy 21. Detection rates provided at a 5% false positive screen rate. • First trimester combined test: first trimester nuchal translucency, PAPP-A (pregnancy associated plasma protein A) and Beta-hCG - 85% Detection Rate • Triple screen: second trimester AFP (alpha fetoprotein), Beta-hCG, uE3 (unconjugated estriol) - 69% Detection Rate • Quad screen: (second trimester Triple screen + inhibin A) - 81% Detection Rate • Sequential screen: (first trimester NT and PAPP-A + second trimester quad screen) - 93% Detection Rate • Serum integrated screen, when unable to obtain nuchal translucency: (first trimester PAPP-A + second trimester quad screen) - 85-88% Detection Rate

A 33-year-old G5P4 woman just delivered her fourth baby without complications. She had gained 50 pounds during this pregnancy and would like to begin a weight loss program as soon as possible. She desires long-term effective contraception, because she doubts she wants more children. She also desires to breastfeed exclusively for six months and has had trouble with this in the past. Which of the following is the most appropriate contraceptive choice for this patient? A. Depot medroxyprogesterone B. Combined estrogen-progestin contraceptives C. Tubal ligation D. Intrauterine device (IUD) E. Essure (Bilateral occluding tubal coils)

D. A paucity of data exists regarding the effect of hormonal contraception on breastfeeding. There are concerns that hormones, especially estrogen, may have a negative impact on the quantity or quality of breast milk. Although Depot medroxyprogesterone is a progesterone only contraceptive, it is known to cause weight gain and would not be a good choice in this patient. The IUD is the best choice because it is long term but reversible, and does not affect milk production. Tubal ligation and Essure are permanent sterilization and would not be best for a patient who may desire more children.

A 28-year-old G1P0 woman presents for prenatal care. Her periods have been irregular and she does not recall when the last one occurred. She is healthy and denies any medical problems. The uterus is 10 weeks in size and there are no adnexal masses. At this point in time, what is the best way to date the pregnancy? A. Serum Progesterone B. Quantitative serum Beta-hCG C. Ultrasound measurement, gestational sac D. Ultrasound measurement, crown-rump length E. Uterine size on pelvic exam

D. All the above can potentially be used to help date a pregnancy; however, ultrasound measurement of crown-rump length is considered the most reliable (+/- 4 to 5 days) in the first trimester. Other means to date the pregnancy include: fetal heart tones that have been documented for 20 weeks by a non-electronic fetoscope or for 30 weeks by Doppler; it has been 36 weeks since a positive serum or urine Beta-hCG pregnancy test was performed by a reliable laboratory; an ultrasound measurement of the crown-rump length obtained at six to twelve weeks supports a gestational age of at least 39 weeks; and an ultrasound obtained at 13-20 weeks confirms the gestational age of at least 39 weeks determined by clinical history and physical examination. Clearly, these means are not as useful in early pregnancy, but in confirming the length of pregnancy. Serum progesterone levels are used to help establish if a pregnancy is progressing normally and not an ectopic, miscarriage, or fetal demise.

A 19-year-old G1P0 woman presents at 41 weeks gestation with a fever, spontaneous ruptured membranes and no contractions. Her temperature is 102.6° F (39.2° C); pulse 126. Ultrasound reveals a singleton with decreased amniotic fluid and placenta partially covering the os. The cervix appears long and closed. Which of the following is an indication for Cesarean delivery in this patient? A. Chorioamnionitis B. Unfavorable cervix C. Oligohydramnios D. Placenta covering the cervical os E. Spontaneous ruptured membranes not in labor

D. Cesarean delivery is indicated in this patient because of a placenta previa (placenta covering the internal os). A vaginal delivery is contraindicated in patients with a placenta previa. Post-term pregnancies, chorioamnionitis, oligohydramnios, and term premature rupture of membranes are all acceptable indications for induction of labor and delivery if the patient is a good candidate for initiation of labor. An unfavorable cervix is not a contraindication for a vaginal delivery.

A 28-year-old G1P1 woman delivered three days ago and desires to breastfeed her infant, but is having problems since her milk came in with full tender breasts. She is uncomfortable and has engorged breasts. Which of the following strategies may help relieve her discomfort? A. Discontinue breastfeeding for 24 hours to decrease the milk supply B. Cover the breast with cool lettuce leaves C. Increase the interval between breastfeeding sessions to decrease the milk supply D. Nurse every 1.5-3 hours around the clock E. Don't wear a bra until the engorgement subsides

D. Engorgement commonly occurs when milk comes in. Strategies that may help include frequent nursing, taking a warm shower or warm compresses to enhance milk flow, massaging the breast and hand expressing some milk to soften the breast, wearing a good support bra and using an analgesic 20 minutes before breastfeeding.

A 23-year-old G3P2 woman wants to exclusively breastfeed her baby. She is deciding at which hospital she will deliver. Hospital policies that promote breastfeeding include which of the following? A. Uninterrupted sleep for the mother on her first night in the hospital B. Use of a breast pump to help increase the milk supply C. Use of pacifiers to prevent sore nipples D. Unlimited access of mother to baby E. Use of metoclopramide to increase the milk supply

D. Hospital policies that promote breastfeeding include getting the baby on the breast within a half hour of delivery and rooming-in for the baby to ensure frequent breastfeeding on demand (i.e. unlimited access).

A 34-year-old G2P1 woman is 40 weeks gestation. She was admitted to labor and delivery in active labor 2 hours ago. Her cervix was 6 cm dilated and 100% effaced on admission. Her fetus was vertex and - 3 station. You are called to examine the patient after she experiences spontaneous rupture of membranes. The cervix is completely dilated and the fetal head is occiput anterior (OA) at +1 station. You palpate a 5 cm long section of umbilical cord in the patient's vagina. The fetal heart tracing is reassuring. The baseline is 130 beats per minute. There are multiple accelerations and no decelerations. The patient is having regular uterine contractions every 2-3 minutes. She has an epidural and is not feeling the contractions. What is the most appropriate next step in the management of this patient? A. Allow for passive descent of the fetal head with continuous fetal monitoring B. Have the patient start pushing with the contractions C. Gently attempt to replace the umbilical cord segment back up into the uterus D. Perform a forceps assisted vaginal delivery E. Elevate the fetal head with a vaginal hand and perform a Cesarean delivery

E. This patient has an umbilical cord prolapse. Although fetal surveillance is reassuring, the most appropriate management is to continue to elevate the fetal head with a hand in the patient's vagina and call for assistance to perform a Cesarean delivery. It is important to elevate the fetal head in an attempt to avoid compression of the umbilical cord. Once an umbilical cord prolapse is diagnosed, expeditious arrangements should be made to perform a cesarean section. It is not appropriate to replace the umbilical cord into the uterus or allow the patient to continue to labor or perform a forceps-assisted vaginal delivery.

A 22-year-old G2P1 woman comes to your clinic today with her three-month-old daughter. She was breastfeeding without problems until about two weeks ago, when she began to experience sore nipples. The nipples are very sensitive and there is a burning pain in the breasts, which is worse when feeding. The tips of the nipples are pink and shiny with peeling at the periphery. Which of the following organism is the most likely cause of these findings? A. Group A streptrococcocus B. Group B streptrococcocus C. Staphylococcus aureus D. Staphylococcus epidermidis E. Candida

E. This presentation is classic for candidiasis and should prompt an inspection of the baby's oral cavity. Candida of the nipple is associated with severe discomfort and pain. All the other above organisms are associated with classic mastitis and do not usually cause intense nipple pain. Localized candida of the nipple may be treated with an antifungal, topical medication such as clotrimazole or miconazole cream. The treatment plan may include a topical antibiotic ointment because nipple fissures can concurrently present with candida of the nipples, and S. aureus is significantly associated with nipple fissures. Either a triple antibiotic ointment or mupirocin can be prescribed. A topical steroid cream can be used to facilitate healing for cases in which the nipples that are very red and inflamed. Every treatment regimen must include the simultaneous treatment of the mother and baby. Oral nystatin is the most common treatment for the baby, followed by oral fluconazole.

A 30-year-old G1P1 woman is breastfeeding her baby and feels there is not enough milk. She is pumping in order to improve the supply of milk. You tell her that more frequent suckling would be better as it will stimulate which of the following hormones? A. Progesterone B. Insulin C. Cortisol D. Prolactin E. Oxytocin

E. While prolactin is responsible for milk production, oxytocin is responsible for milk ejection. Production of oxytocin is stimulated by suckling which works better than a breast pump for stimulating the secretion of milk. Cortisol and insulin act in concert with other hormones to stimulate the growth and development of the milk-secreting apparatus.