OB/GYN: ACOG OBSTETRICS

Management of Late Decelerations

1. continuous fetal monitoring 2. position pt on her side 3. monitor BP 4. oxygen by face mask

Postpartum hemmorrhage is greater than ___cc.

500

A 24-year-old G1 woman at 32 weeks gestation presents with leaking watery fluid from the vagina. On evaluation, preterm premature rupture of membranes is confirmed. She has occasional Braxton Hicks contractions associated with fetal heart rate accelerations. She does not have vaginal bleeding and vaginal fluid phosphatidylglycerol is absent. Her blood pressure is 110/70; pulse 90; temperature 98.6°F (37.0°C). Fundal height is 30 cm and her fundus is tender. Amniotic fluid index (AFI) is 4. Which of the following findings is an indication for delivery in this patient? A. Tender uterine fundus B. Size less than dates C. Fetal heart rate accelerations D. Amniotic fluid index of less than 5 E. Absence of vaginal fluid phosphatidylglycerol

A. Maternal signs of chorioamnionitis or other evidence of intra-amniotic infection are indications for delivery. This patient has ruptured membranes and a tender fundus, which indicate chorioamnionitis. Labor at 32 weeks would be allowed to progress and prolonged non-reassuring fetal testing would prompt delivery. There are no criteria for amniotic fluid index or degree of oligohydramnios as an indication for delivery. Most authors agree that the achievement of fetal lung maturity (i.e. positive phosphatidylglycerol or 34 weeks gestational age) is the threshold at which the risk of morbidity and mortality of maintaining the pregnancy in utero outweighs the benefits of prolonging the pregnancy.

High levels of Magnesium used to treat seizures in pregnancy can cause?

At a magnesium level of 11 mEq/L, respiratory depression is most likely to occur. A therapeutic magnesium level is between 4-7 mEq/L. Seizures are prevented by the use of magnesium. Loss of deep tendon reflexes occurs at a level of 7-10 mEq/L. Cardiac arrest may occur at a level of 15 mEq/L. Pulmonary edema can occur with magnesium therapy, but is not related to toxicity from the drug.

Thirty-six hours ago a 23 year-old G1P1 delivered vaginally and sustained a 2nd-degree laceration. She had a prolonged first stage of labor, ruptured membranes for 26 hours and received penicillin for group B Strep prophylaxis. She now complains of increasing abdominal pain, cramping and heavy foul smelling lochia. Her vital signs reveal a temperature of 100.0° F, 37.8° C; pulse 80; blood pressure 120/60; and respirations 18. She has a tender uterine fundus that measures at the umbilicus. Her extremities reveal mild bilateral edema; no erythema or tenderness. Blood work reveals a white count of 12.2; hematocrit of 34%; and normal chemistries. Her urinalysis is positive for blood and negative for WBCs, leukocyte esterase and nitrites. In addition to ampicillin, which of the following would be the best antibiotic choice? A. Erythromycin B. Gentamicin C. Doxycycline D. Vancomycin E. Ciprofloxacin

B. Endomyometritis is a common complication of prolonged labor, prolonged rupture of membranes and multiple vaginal examinations. The infection is polymicrobial, mostly anaerobic and requires broad spectrum antibiotics for treatment until the patient is afebrile for 24 hours. By adding Gentamicin, you are covering the spectrum of gram-negative organisms. Erythromycin provides good coverage for upper respiratory infections. Vancomycin provides good coverage for S. aureus and penicillin-resistant gram-positive bacteria. Ciprofloxacin provides excellent coverage for gram-negative pathogens, including Pseudomonas.

A 37-year-old G3P0 woman at 29 weeks gestation presents with uterine contractions every five minutes. Her cervix is 1 cm dilated and 50% effaced. Fetal fibronectin test is negative. The patient stops having contractions after bedrest and hydration. What is the strength of using a fetal fibronectin test in patients with preterm contractions? A. Positive predictive value B. Negative predictive value C. High sensitivity D. Low false positive rate E. High false positive rate

B. Fibronectin is an extracellular matrix protein that is thought to act as an adhesive between the fetal membranes and underlying decidua. It is normally found in cervical secretions in the first half of pregnancy. Its presence in the cervical mucus between 22 and 34 weeks is thought to indicate a disruption or injury to the maternal-fetal interface. Fetal fibronectin is FDA approved for use in women with symptoms of preterm labor from 24 to 35 weeks and during routine screening of asymptomatic patients from 22 to 30 weeks gestation. Fetal fibronectin has a negative predictive value of 99.2% in symptomatic women — 99 out of every 100 patients with a single negative test result will not deliver in the next 14 days. The positive predictive value in symptomatic women is 16.7% — 17 out of 100 women with a positive test will deliver within 14 days. In asymptomatic women, a negative fetal fibronectin test has a negative predictive value of 96.7% for delivery before 35 weeks.

A 38-year-old G5P4 woman with a history of four Cesarean deliveries is at 36 weeks gestation with a singleton pregnancy. She presents to labor and delivery with complaints of vaginal bleeding for the last hour. Prenatal care has been unremarkable except for a second trimester ultrasound discovering an anterior placenta, which partially covers the cervical os. Follow up ultrasound exams have confirmed these findings. The patient denies uterine contractions and abdominal pain. She feels the baby moving. Her blood pressure is 110/60, pulse 110, and she is afebrile. Her abdomen and uterus are non-tender and soft. Fetal heart tones have a baseline of 140 and are reassuring. This patient is at greatest risk for which of the following complications? A. Vasa previa B. Placenta accreta C. Placental abruption D. Uterine rupture E. Preterm labor

B. Placenta accreta occurs when the placenta grows into the myometrium. This patient is at risk for this condition due to her history of four previous Cesarean deliveries, and the low anterior placenta. The scar tissue from the previous surgery prevents proper implantation of the placenta and it subsequently grows into the muscle. Vasa previa is a rare condition where the umbilical cord inserts into the membranes. Placental abruption is the premature separation of the normally implanted placenta. Risk of uterine rupture could be as high as 5% in this case, and the risk of placenta accreta with four prior c-sections approaches 50%. The patient is not experiencing contractions at the present time, so preterm labor is unlikely.

A 22-year-old G1P0 woman at 39-weeks gestation presents in active labor. Her pregnancy is complicated by diet controlled gestational diabetes. She has a history of uterine fibroids. On examination, she is found to be 4 cm dilated in breech presentation. An ultrasound confirms the breech presentation, amniotic fluid index is 5, and the estimated fetal weight is 3900 g. Which of the following is the most likely cause of the breech presentation in this patient? A. Gestational diabetes B. Uterine fibroids C. Oligohydramnios D. Macrosomia E. Gravidity

B. Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine fibroids are all associated with breech presentation.

Ectopic pregnancy criteria for medical treatment

B. The patient clearly has an abnormal pregnancy, as demonstrated by the slowly increasng Beta-hCG levels. Since the Beta-hCG level is above 2000 mIU/ml, and she has a thin endometrial stripe, this rules out an intrauterine pregnancy and the diagnosis is an ectopic pregnancy. She is a good candidate for medical treatment with methotrexate. Criteria to consider for medical treatment include hemodynamic stability, non-ruptured ectopic pregnancy, size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate, normal liver enzymes and renal function, normal white cell count, the ability of the patient to follow up rapidly if her condition changes (reliable transportation, etc.). Dilation and curettage and exploratory laparotomy are invasive procedures that can be avoided in this patient. She does not need another Beta-hCG level because the diagnosis is clear. There is no indication for a repeat ultrasound in this case.

An 18-year-old G1P0 woman is seen in the clinic for a routine prenatal visit at 28 weeks gestation. Her prenatal course has been unremarkable. 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 count 9,700/mL, hemoglobin 10.6 g/dL, mean corpuscular volume 88.2 fL (80.8 - 96.4) and platelets 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 G3P0 woman at 26 weeks gestation was brought to the hospital by paramedics. Her husband found her shivering and barely responsive. Two days prior, the patient noted that she was feeling sick, with a slight cough. She was having back pain at the time, but thought it was probably normal for pregnancy. Her pregnancy has been uncomplicated except for the recent diagnosis of gestational diabetes. On exam, vital signs are: temperature 100.2°F (37.9°C); pulse 160; and blood pressure 68/32; respiratory rate 32. Oxygen saturation is 82% on room air. There is no apparent fundal tenderness, although the patient exhibits pain with percussion of the right back. Fetal heart tones are not audible. There is no evidence of vaginal bleeding. Extremities are cool to touch. White blood cell count 24,000; hemoglobin 9.5; hematocrit 27%. Urine microscopic analysis shows many white blood cells. What is the most likely etiology for this patient's disease? A. Abruptio placentae B. Pyelonephritis C, Diabetic ketoacidosis D. Chorioamnionitis E. Pneumonia

B. This is a patient in septic shock. The most common cause of sepsis in pregnancy is acute pyelonephritis. Given the absence of bleeding, the clinical picture is not suggestive of placental abruption. Diabetic ketoacidosis is unusual in gestational diabetic patients. Chorioamnionitis and pneumonia may both lead to sepsis, but are less important causes than is pyelonephritis, and are not suggested by the clinical picture.

A 17-year-old G2P0 female has severe right lower quadrant pain. Her last normal menstrual period seven weeks ago. She notes that last night she began having suprapubic pain that radiated to her right lower quadrant. This morning, the pain awoke her from sleep. She has had no vaginal bleeding, no nausea or vomiting. The patient's history is notable for two first trimester elective abortions and a history of Chlamydia treated twice. Vital signs are: blood pressure 90/60; pulse 99; respirations 22; and temperature 98.6°F (37°C). On physical exam, the patient is noted to be curled on a stretcher in a fetal position and says she hurts too much to move. She has rebound and voluntary guarding on abdominal examination. She has profound cervical motion tenderness and rectal tenderness. Her Beta-hCG level is 2500 mIU/ml; hematocrit 24%; and urinalysis negative. Ultrasound shows no intrauterine pregnancy, a right adnexal mass that measures 6 x 2 cm, and a moderate amount of free fluid. Which of the following is the most appropriate next step in the management of this patient? A. Admit for serial examinations B. Exploratory surgery C. Recheck Beta-hCG level in 48 hours D. Administer methotrexate E. Dilation and curettage

B. This patient has a ruptured ectopic pregnancy until proven otherwise. Her vital signs, examination and anemia are consistent with an intra-abdominal bleed. Exploratory laparoscopy/laparotomy is indicated at this point. Conservative management with observation, serial examinations or repeat Beta-hCG testing could be dangerous in a patient suspected of having a ruptured ectopic pregnancy. Medical management (methotrexate) is not used in a patient with an acute surgical abdomen. Dilation and curettage would not be the next step in management and might only be considered in this scenario after the patient's abdomen was explored.

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 three-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 31-year-old G3P0 woman at 27 weeks gestation is being managed expectantly for severe preeclampsia remote from term. Her blood pressure is 155/100 on methyldopa (Aldomet) 500 mg three times a day. Her recent 24-hour urine had 6.6 grams of protein. An ultrasound revealed a fetus with adequate growth, having an estimated fetal weight in the 10th percentile. Her labs are normal, except for a uric acid of 8.0 mg/dL; hematocrit 42% (increased from 37%); and platelet count 97,000. Which of these findings necessitates delivery at this time? A. Elevated uric acid B. Thrombocytopenia C. Proteinuria D. Poorly controlled blood pressures E. Hemoconcentration

B. Thrombocytopenia <100,000 is a contraindication to expectant management of severe preeclampsia remote from term (<32 weeks). Other contraindications include: inability to control blood pressure with maximum doses of two antihypertensive medications, non-reassuring fetal surveillance, liver function test elevated more than two times normal, eclampsia, persistent CNS (central nervous system) symptoms and oliguria. Delivery should not be based on the degree of proteinuria. Although elevated, uric acid and hemoconcentration are markers of preeclampsia, they are not part of the diagnostic or management criteria.

Chronic hypertension

Blood pressure elevation first detected before the 20th week of pregnancy that persists beyond 12 weeks postpartum. Women with gestational hypertension cannot be definitively classified until after this period has elapsed.

Breech

Breech presentation occurs in approximately 3-4% of women in labor overall, and occurs more frequently in preterm deliveries. Frank breech is the most common type, occurring in 48-73% of cases and the buttocks are the presenting part. Complete breech is found in approximately 5-12% of cases and incomplete breech (footling breech) occurs in approximately 12-38% of cases.

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.

A 17-year-old G1 woman at 24 weeks gestation presents with vaginal bleeding. She denies any pain, cramping or dysuria. She reports last having intercourse three weeks ago. Prenatal care and labs have been unremarkable. Her vital signs are normal and she is afebrile. Pelvic ultrasound reveals a fundal placenta and viable fetus. Abdominal examination is unremarkable. Vaginal examination reveals a uniformly friable cervix with a small amount of blood in the vault. Digital examination reveals a firm, closed cervix. What is the most likely diagnosis that explains the bleeding? A. Trauma B. Cervical cancer C. Cervicitis D. Bloody show E. Threatened abortion

C. Cervicitis caused by chlamydia, gonorrhea, trichomonas or other infections can present with vaginal bleeding. The cervix is much more vascular during pregnancy and inflammation can lead to bleeding. Evaluation for other causes of bleeding must be completed and then treatment for the infection should be initiated. The patient does not give any history of trauma and cancer is unlikely because of her age. She is not in labor, and a bloody show associated with cervical dilatation is not consistent with the history provided. Threatened abortion occurs during the first trimester.

A 28-year-old G1 woman at 31 weeks gestation presents with complaints of fluid leaking from the vagina. Preterm premature rupture of membranes is diagnosed. The patient has mild uterine tenderness concerning for early chorioamnionitis. An amniocentesis is performed. Which of the following amniotic fluid results is indicative of an intra-amniotic infection? A. Presence of leukocytes B. Low Interleukin-6 C. Amniotic glucose less than 20 mg/dl D. Elevated level of bilirubin E. Lecithin/sphingomyelin (L/S) ratio <2

C. In some cases of preterm rupture of the membranes, amniocentesis may be performed to detect intra-amniotic infection. The presence of amniotic leukocytes has the lowest predictive value for the diagnosis of chorioamnionitis. Interleukin-6 would be increased in the setting of chorioamnionitis. A low amniotic fluid glucose is an indication of intra-amniotic infection. L/S ratio is a marker for fetal lung maturity.

A 26-year-old G0 presents to the reproductive endocrinology clinic seeking an infertility evaluation for failing to conceive after 14 months of unprotected intercourse with her boyfriend, who has fathered two other children. She works as a janitor in a nearby elementary school and currently has Medicaid for her health insurance. The physician discourages her from pursuing treatment because she will likely have to pay for her visit with cash, check or charge, and is told that treatment for infertility often involves procedures and technology that are very expensive. She is also informed that, in most states, many of these therapies are not paid by insurance or Medicaid. This situation violates which of the following ethical principles? a. Patient autonomy b. Beneficence c. Justice d. Physician autonomy e. A patient's right to privacy

C. Justice requires that we treat like cases alike. It is the physician's duty to educate the patient about all her treatment options in a non-judgmental way regardless of the nature of the treatment and her socioeconomic status.

A 19-year-old G1 woman at 40 weeks gestation has an uncomplicated vaginal delivery followed by a brisk hemorrhage. Her past medical history is significant for steroid-dependent asthma. Her blood pressure is 110/70; pulse 84; and she is afebrile. Which of the following uterotonic agents should not be used in this patient? A. Intramuscular oxytocin B. Intravenous oxytocin C. Prostaglandin F2-alpha D. Prostaglandin E1 (Misoprostol) E. Methylergonovine

C. Methergine, prostaglandins and oxytocin are all uterotonics and used to increase uterine contractions and decrease uterine bleeding. Prostaglandin F2-alpha (Hemabate) is a potent smooth muscle constrictor, which also has a bronchio-constrictive effect. As such, it should be used with caution in any patient with a reported history of asthma. It is absolutely contraindicated in patients with poorly controlled or severe asthma. Misoprostol, non-FDA approved for this purpose, is often used for cervical ripening and labor induction.

A 25-year-old G3P2, who had recently undergone a primary Cesarean section, had her HIV status revealed to her mother when a nurse left her chart open in the recovery room. She speaks to patient relations and is thinking about seeking damages through legal avenues. When trying to explain the concept of patient privacy, which of the following statements is correct? a.Patient privacy is based on the ethical principle of justice b.Patient privacy is protected by federal law, primarily with the Federal Emergency Medical Treatment and Labor Act (EMTALA) statute c.Patient privacy is the responsibility of physicians; physicians may be fined and/or assessed criminal penalties for violating the privacy of a patient's protected health information d.The patient cannot win a lawsuit in this case because the mother should not have looked at the open record e.Patient privacy is based on the ethical principal of beneficence

C. Patient privacy is the responsibility of physicians. Physicians may be fined and/or assessed criminal penalties for violating the privacy of a patient's protected health information. It was the responsibility of the physicians and the other health care providers in this case to make sure the chart is not left open so someone walking by sees the information.

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 27-year-old G2P0 woman is diagnosed with an early first trimester spontaneous abortion. She has a history of type I diabetes mellitus, mild chronic hypertension and one prior termination of pregnancy. Which of the following is the most likely cause of this spontaneous abortion? A. Prior termination of pregnancy B. Chronic hypertension C. Diabetes mellitus D. Intrauterine adhesions E. Infection

C. Systemic diseases such as diabetes mellitus, chronic renal disease and lupus are associated with early pregnancy loss. In women with insulin-dependent diabetes, the rates of spontaneous abortion and major congenital malformations are both increased. The risk appears related to the degree of metabolic control in the first trimester. There are many other causes of spontaneous abortion, including genetic factors, endocrine abnormalities, reproductive tract abnormalities, immunologic factors and environmental factors. The patient's history of mild chronic hypertension and one prior termination of pregnancy do not increase her risk of a first trimester loss. Additionally, an uncomplicated termination of pregnancy, intrauterine adhesions and infection are not likely causes in this scenario.

A 35-year-old G1 woman with an IVF conceived 12 weeks gestation has a slightly elevated fetal nuchal translucency (2.5 multiples of the median), but her integrated first trimester screen shows no increased risk for Down syndrome or Trisomy 18. Still concerned about the increased nuchal translucency, the patient requests non-invasive testing to exclude other abnormalities. Which of the following is the next best step in the management of this patient? A. Reassurance B. Monthly ultrasound to assess for fetal growth C. Detailed ultrasound and fetal echocardiogram at approximately 18 - 20 weeks gestation D. Repeat first trimester screening E. Amniocentesis

C. The first trimester screen alone yields an 85% detection rate. 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 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. Amniocentesis would detect other chromosomal abnormalities, but is an invasive test. 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 30-year-old G3P2 woman, whose last normal menstrual period was eight weeks ago, began spotting three days ago and developed cramping this morning. She has a history of a chlamydia infection with a previous pregnancy. She smokes one pack of cigarettes per day and denies alcohol or drug use. On physical exam: blood pressure 120/70; pulse 82; respirations 20; and temperature 98.6°F (37.0°C). Abdominal examination is normal. Pelvic examination reveals old blood in the vaginal vault, closed cervix without lesions, slightly enlarged uterus and no adnexal tenderness. Pertinent labs: Quantitative Beta-hCG is 1000 mIU/ml; urinalysis normal; hematocrit = 32%. Transvaginal ultrasound shows no intrauterine pregnancy, no adnexal masses, no free fluid in pelvis. Which of the following is the most appropriate next step in the management of this patient? A. Treat with methotrexate B. Exploratory surgery C. Repeat Beta-hCG in 48 hours D. Repeat Beta-hCG in one week E. Admit the patient to the hospital for observation

C. The patient first needs to have an accurate diagnosis before a treatment plan is entertained. She has risk factors for ectopic pregnancy. Repeating the Beta-hCG is the next step in this patient's management. Inappropriately rising Beta-hCG levels (less than 50% increase in 48 hours) or levels that either do not fall following diagnostic dilation and curettage would be consistent with the diagnosis of ectopic pregnancy. Alternatively, a fetal pole must be visualized outside the uterus on ultrasound. The patient would need a Beta-hCG level over the discriminatory zone (the level where an intrauterine pregnancy can be seen on ultrasound) with an empty uterus. The level commonly used is 2000 mIU/ml. Treatment with methotrexate may be appropriate, but only after a definitive diagnosis is made. The patient does not yet have this level and is stable. She is, therefore, not a candidate for exploratory surgery. If she had unstable vital signs or an acute abdomen, a diagnostic laparoscopy/laparotomy would be indicated. Repeating the ultrasound in one week is not recommended because a delay in diagnosis could result in a ruptured ectopic pregnancy and increased risk to the patient. The patient is hemodynamically stable, therefore, she does not need to be admitted to the hospital.

A 20-year-old G1 woman at 40 weeks gestation presents to labor and delivery complaining of painful contractions every 3-4 minutes since midnight. Her examination on admission was 2 centimeters dilated, 90% effaced and 0 station. Three hours later, her exam is unchanged. The patient is still having contractions every 3-4 minutes. She is discouraged about her lack of progress. Which of the following is the most appropriate next step in the management of this patient? A. Laminaria placement B. Artificial rupture of membranes C. Counseling about latent phase of labor and rest D. Manual cervical dilation E. Cesarean section for arrest of labor

C. The patient is in the latent phase of labor and has not yet reached the active phase (more than 4 cm). A prolonged latent phase is defined as >20 hours for nulliparas and >14 hours for multiparas, and may be treated with rest or augmentation of labor. Artificial rupture of membranes is not recommended in the latent phase as it places the patient at increased risk of infection. Cervical dilation or laminaria placement are not indicated.

A 30-year-old G2P1 woman at 38 weeks gestation presents to labor and delivery with contractions every 2-3 minutes. Her membranes are intact. Her cervical examination is 5 centimeters dilated, 100% effaced, and -1 station. The fetal heart rate tracing is category I. Two hours later, she progresses to 7 cm and 0 station and receives an epidural for pain. Four hours after that, her exam is unchanged (7/100/0). Fetal heart rate tracing remains category I. Which of the following is the most appropriate next step in the management of this patient? A. Allow her to ambulate and return when she is ready to push B. Perform a contraction stress test C. Perform an amniotomy D. Perform a Cesarean delivery E. Place an internal fetal scalp electrode

C. This patient has secondary arrest of dilation, as she has not had any further cervical change in the active phase for over four hours. Amniotomy is often recommended in this situation. After it is performed, if the patient is still not in an adequate contraction pattern, augmentation with oxytocin can be attempted after careful evaluation. Although the patient requires close monitoring, it is too early to proceed with a Cesarean delivery. An internal scalp electrode is not necessary, since the fetal heart monitoring is reassuring.

An 18-year-old G1 woman presents for prenatal care at 16 weeks gestation without complaints. The patient denies any history of sexually transmitted disease, although admits to a history of multiple sex partners, with irregular use of condoms. She is allergic to penicillin, which causes anaphylaxis. Physical exam is unremarkable. Pertinent labs: rapid plasma reagin test (RPR) positive (titer = 32); fluorescent treponemal antibody absorption test (FTA-ABS) is positive. Which of the following is the best treatment for this patient? A. Oral erythromycin B. Oral doxycycline C. Desensitization and penicillin D. Intravenous erythromycin E. Intravenous cefazolin

C. This patient has syphilis, and the fluorescent treponemal antibody absorption test (FTA-ABS) confirms the diagnosis. The transmission rates for primary and secondary disease are approximately 50-80%. There are no proven alternatives to penicillin therapy during pregnancy and penicillin G is the therapy of choice to treat syphilis in pregnancy. Women with a history of penicillin allergy can be skin tested to confirm the risk of immunoglobulin E (IgE)-mediated anaphylaxis. If skin tests are reactive, penicillin desensitization is recommended and is followed by intramuscular benzathine penicillin G treatment. Erythromycin has an 11% failure rate. Doxycycline is contraindicated in pregnancy. Cefazolin is commonly used to treat urinary tract infections and is not effective in the treatment of syphillis.

A 38-year-old G0 woman comes to the office because she noted a persistent yellow, frothy discharge associated with mild external vulvar irritation. She denies any odor. She tried over the counter anti-fungal medication without success. The discharge has been present for over three months, gradually increasing in amount. Douching has resulted in temporary relief, but the symptoms always recur. Pelvic examination reveals mild erythema at the introitus and a copious yellow frothy discharge fills the vagina. The cervix has erythematous patches on the ectocervix. A sample of the discharge is examined under the microscope. What is the most likely finding? A. Strong amine fishy odor when KOH applied to sample B. Marked polymorphonuclear cells with multi-nucleate giant cells C. Motile ovoid protozoa with flagella D. Budding yeast and pseudo-hyphae E. Clue cells

C. This patient most likely has trichomoniasis. The erythematous patches on the cervix are characteristic of "strawberry cervicitis." Trichomonads are unicellular protozoans, which are easily seen moving across the slide with flagella. The slide must be examined immediately. The discharge is mixed with saline and placed on the slide with a cover slip. Women with trichomonas vaginal infections may have a frothy, yellow-green vaginal discharge. Clue cells are seen on a saline wet mount in women who have bacterial vaginosis. Clue cells are characterized by adherent coccobacillary bacteria that obscure the edges of the cells. A drop of KOH releases amines from the cells and a fishy odor is noted if bacterial vaginosis is present. Yeast vaginitis is characterized by a thick white clumpy discharge which results in erythema, swelling and intense pruritus. Multinucleate giant cells and inflammation may be herpes.

Placenta abruptio

Common presenting signs of an abruption include abdominal pain, bleeding, uterine hypertonus and fetal distress. Risk factors include smoking, cocaine use, chronic hypertension, trauma, prolonged premature rupture of membranes, and history of prior abruption. Treatment would involve an emergent Cesarean section with appropriate resuscitation, including intravenous fluids and blood products as needed. A placenta previa is an abnormal location of the placenta.

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

Correct answer is 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.

A 35-year-old G3P0 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% C. 5% D. 10% E. 15%

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

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. Carrier screening should be performed for all of the following conditions except: A. Fanconi anemia B. Tay-Sachs disease C. Beta thalassemia anemia D. Cystic fibrosis E. Niemann-Pick disease

Correct answer is 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 30-year-old G0 woman presents with her husband for preconception counseling. The patient is of Jewish Ashkenazi 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

Correct answer is 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 Gaucher's disease is approximately 1/15 for Ashkenazi Jews. The frequency of the disease is 1/900 in this population.

An 18-year-old G1P0 woman presents for prenatal care at 14 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

Correct answer is 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 30-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. Triple screen C. Quad screen D. Sequential screen E. Serum integrated screen

Correct answer is D. All of the tests screen for trisomy 21 and trisomy 18. 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 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

Correct answer is 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%. The recommended dose for non-high risk patients is 0.4mg/day.

A 17-year-old G0 high school student is brought in by her mother for her first gynecologic examination. She began her menses at age 12 and has had regular periods for the past three years. Her last menstrual period was one week ago. For privacy, you ask to examine the patient without her mother. Further history is obtained in the examination room. She admits that she has been sexually active with her boyfriend for the past three years. She uses condoms occasionally and is fearful about possible pregnancy. She requests that her mother not be informed about her sexual activity. On physical examination, she is anxious, but normally developed. Her pelvic examination reveals no vulvar lesions, minimal non-malodorous discharge, and a nulliparous appearing cervix. The bimanual examination reveals a normal size uterus, and her adnexa are non-tender and not enlarged. Urine pregnancy test is negative. In addition to discussing contraception. What is the next best step in the management of this patient? A. Obtain a serum Beta-hCG level B. Obtain a Pap smear C. Obtain DNA probes for gonorrhea and chlamydia D. Initiate treatment with doxycycline and ceftriaxone E. Order a pelvic ultrasound

D

A 45-year-old G4P3 woman presents with vaginal bleeding. Last week, she performed a home pregnancy test that was positive. She thinks her last menstrual period was four months ago. The last time she saw her doctor was eight years ago, with the birth of her last child. She has no serious medical problems, has smoked a pack of cigarettes a day since the age of 20, occasionally has a beer and does not exercise. Abdominal examination reveals a soft abdomen and the fundus palpable just below the umbilicus. Pelvic ultrasound reveals a fundal placenta and a fetus measuring 18 weeks with normal cardiac activity. Vaginal examination reveals a 3-centimeter lesion arising off the posterior lip of the cervix. It easily bleeds with palpation and is hard in consistency. Which of the following is the most likely cause of the bleeding? A. Cervicitis B. Cervical polyp C. Endometrial polyp D. Cervical cancer E. Nabothian cyst

D

A 36-year-old G2P1 woman presents for her first prenatal visit at 11 weeks gestation. She has a two-year history of chronic hypertension treated with lisinopril and labetalol. In addition, she has hypothyroidism treated with levothyroxine, and recurrent herpes, for which she is on chronic acyclovir suppressive therapy. She takes amitriptyline for migraine headaches. Which of her medications is contraindicated in pregnancy? A. Levothyroxine B. Labetalol C. Acyclovir D. Lisinopril E. Amitriptyline

D. Amitriptyline, levothyroxine, labetalol and acyclovir are medications that are frequently used in pregnancy and generally are felt to have acceptable safety profiles. The use of angiotensin converting enzyme inhibitors, such as Lisinopril, beyond the first trimester of pregnancy has been associated with oligohydramnios, fetal growth retardation and neonatal renal failure, hypotension, pulmonary hypoplasia, joint contractures and death. Amitriptyline is used in pregnancy to treat migraine headaches and has a good safety profile.

A 33-year-old G2P1 woman at eight weeks presents to the clinic. This is an unplanned pregnancy. She had planned a tubal ligation six years ago when she was diagnosed with pulmonary hypertension, but was unable to have the procedure. She states her pulmonary hypertension has been stable, but she gets short of breath when climbing stairs. She sleeps on one pillow at night. What is the concern for her during this pregnancy? A. There are no additional concerns compared to a normal pregnancy B. She will need a Cesarean section at delivery C. Her baby is at increased risk for pulmonary hypoplasia D. The mother's mortality rate is above 25% E. Epidural analgesia is contraindicated

D. Among women with cardiac disease, patients with pulmonary hypertension are among the highest risk for mortality during pregnancy, a 25-50% risk for death. Management of labor and delivery is particularly problematic. These women are at greatest risk when there is diminished venous return and right ventricular filling which is associated with most maternal deaths. Similar mortality rates are seen in aortic coarctation with valve involvement and Marfan syndrome with aortic involvement. The baby is not at increased risk of pulmonary hypoplasia or Marfan's due to the mother's condition.

A 23 year-old G1P1 delivered her first baby two days ago after an uncomplicated labor and vaginal delivery. She wants to breast feed and has been working with the lactation team. Prior to discharge, her temperature was 100.4°F, 38°C (other vitals were normal). She denies urinary frequency or dysuria and her lochia is mild without odor. On examination, her lungs are clear, cardiac exam normal, and abdomen and uterine fundus are nontender. Her breasts are firm and tender throughout, without erythema and nipples are intact. Which of the following is the most likely cause of her fever? A. Endomyometritis B. Septic pelvic thrombophlebitis C. Mastitis D. Breast engorgement E. Vaginitis

D. Breast engorgement is an exaggerated response to the lymphatic and venous congestion associated with lactation. Milk "let-down" generally occurs on postpartum day 2 or 3. If the baby is not feeding well, the breast can become engorged, which can cause a low-grade fever. Lactating women are encouraged to feed their baby frequently, and use a breast pump to prevent painful engorgement and mastitis. Postpartum fever differential includes endometritis, cystitis and mastitis. These are easy distinguished, based on clinical findings. Vaginitis is not accompanied by fever. Septic pelvic thrombophlebitis is a rare condition and characterized by high fever not responsive to antibiotics and is a diagnosis of exclusion.

A 24-year-old G2P1 woman is undergoing a Cesarean section for placental abruption. She presented to labor and delivery with severe abdominal pain and heavy vaginal bleeding. The fetus was delivered uneventfully. The placenta delivered with a significant clot attached to the maternal surface. The patient continues to bleed from the placental bed. Estimated blood loss is 1500 ml. The operative team decides to give her fresh frozen plasma (FFP) to replace which of the following components? A. Platelets B. Von Willebrand's factor C. Red blood cells D. Fibrinogen E. Factor X

D. Correcting coagulation deficiencies requires replacing all necessary blood components. Fresh frozen plasma contains fibrinogen, as well as clotting factors V and VIII. Cryoprecipitate contains fibrinogen, factor VIII and von Willebrand's factor. Neither of these preparations contains red blood cells or platelets, which must be given separately.

A 23-year-old G0 woman reports having a solitary, painful vulvar lesion that has been present for three days. This lesion has occurred twice in the past. She states that herpes culture was done by her doctor during her last outbreak and was negative. She is getting frustrated in that she does not know her diagnosis. She has no significant previous medical history. She uses oral contraceptives and condoms. She has had four sexual partners in her lifetime. On physical examination, a cluster of three irregular erosions with a superficial crust is noted on the posterior fourchette. Urine pregnancy test is negative. You suspect recurrent genital herpes. How do you explain the negative culture? A. Cultures were taken too early B. Oral contraceptives affect the growth of the virus C. The cultures were refrigerated prior to transport to the lab D. Herpes cultures have a 10-20% false negative rate E. The herpes virus cannot be recovered with recurrent infections

D. Culture is the gold standard in the diagnosis of herpes. They are highly specific, yet sensitivity is limited. It is best to culture the lesion very early in the course. The blister is unroofed and the base is vigorously scraped. The herpes virus can theoretically be isolated from both primary and recurrent infections. This patient very likely presented too late in the course for a useful culture. Oral contraceptives do not affect the growth of viruses. While serum antibody screening can be performed, it indicates lifetime exposure and would not answer the question as to the etiology of the specific lesion. Alternatively, DNA studies such as the polymerase chain reaction can be done, if available.

A 28-year-old G0 woman whose last normal menstrual period was four weeks ago presents with a two-day history of spotting. She awoke this morning with left lower quadrant pain of intensity 4/10. She has no urinary complaints, no nausea or vomiting, and the remainder of the review of systems is negative. She has no history of sexually transmitted infections. She smokes one pack of cigarettes per day and denies alcohol or drug use. Her vital signs are: blood pressure 124/68, pulse 76, respirations 18, and temperature 100.2° F (37.9°C). On examination, she has mild left lower quadrant tenderness, with no rebound or guarding. Pelvic exam is normal except for mild tenderness on the left side. Quantitative Beta-hCG is 400 mIU/ml; progesterone 5 ng/ml; hematocrit 34%. Ultrasound shows a fluid collection in the uterus, with no adnexal masses and no free fluid. What is the most likely diagnosis? A. Ovarian torsion B. Missed abortion C. Early intrauterine pregnancy D. Unable to establish a diagnosis E. Ectopic pregnancy

D. It is difficult to establish a definitive diagnosis at this time. When the Beta-hCG level is below the discriminatory zone (2000 mIU/ml), an early intrauterine pregnancy may not be visualized on ultrasound. Missed abortion, early intrauterine pregnancy and ectopic pregnancy could only be confirmed by serial Beta-hCG levels (at least every 48 hours until a trend is established, usually three levels). Ovarian torsion is a possible diagnosis, however, this is more common with an ovarian mass.

A 30-year-old G4P3 woman at 24 weeks gestation is found to have an anterior placenta previa. She has a history of three prior Cesarean deliveries. What is the most likely serious complication that can lead to obstetric hemorrhage in this woman? A. Placental abruption B. Uterine dehiscence prior to labor C. Uterine inversion D. Placenta accreta E. Uterine atony

D. Placental abruption and uterine atony are both common, but, in the presence of a low-lying anterior placenta in a patient with a history of multiple Cesarean births, the diagnosis of the placenta accreta must be entertained. Placenta accreta is an abnormally firm attachment of the placenta to the uterine wall. The incidence of placenta accreta may be increasing because of the rise in the number of women with previous Cesarean sections. This is a serious obstetric complication leading to retained placenta and severe postpartum hemorrhage. Hysterectomy is frequently required due to intractable hemorrhage at delivery.

A 22-year-old G2P1 woman presents for prenatal care at approximately 10 weeks gestation. Her first pregnancy was complicated by preterm premature rupture of the membranes at 28 weeks gestation. Which of the following interventions could reduce the risk of preterm premature rupture of the membranes during this pregnancy? A. Bedrest B. Placement of a cerclage C. Placement of a Tertbutaline pump D. 17 alpha-hydroxyprogesterone E. Nifedipine

D. Premature rupture of the membranes occurs in approximately 10-15 % of all pregnancies. Preterm premature rupture of the membranes between 16 and 26 weeks gestation is identified in 1% of pregnancies. Preterm premature rupture of the membranes occurs in 1/3 of all preterm deliveries. The reported recurrence rate for preterm premature rupture of the membranes is approximately 32% when it occurred in the index pregnancy. Bedrest and tocolytics have not been shown to reduce the risk for PPROM, and may have detrimental effects to the mother. A cerclage may be indicated for patients with a history of an incompetent cervix. 17 alpha-hydroxyprogesterone has been shown to reduce the risk of premature labor.

A 20-year-old G1P0 woman has vaginal spotting and mild cramping for the last three days. She had her last normal menstrual period approximately seven weeks ago. She had a positive home pregnancy test. Vital signs are: blood pressure 120/72; pulse 64; respirations 18; temperature 98.6°F (37°C). On pelvic exam, she has scant old blood in the vagina, with a normal appearing cervix and no discharge. On bimanual exam, her uterus is nontender and small, and there are no adnexal masses palpable. Quantitative Beta-hCG 48 hours ago was 750 mIU/ml; today, current Beta-hCG 760 mIU/ml; progesterone 3.2 ng/ml; hematocrit 37%. Transvaginal ultrasound shows a fluid collection in the uterus with a yolk sac but no fetal pole. A 3x3 cm cyst is seen on the left ovary. There is no free fluid in the pelvis. Which of the following is the most appropriate next step in the management of this patient? A. Exploratory laparoscopy B. Treat with methotrexate C. Treat with mifepristone D. Dilation and curettage E. Repeat ultrasound in one week

D. The pregnancy is abnormal based on the abnormal Beta-hCG levels and the progesterone level. In a normal pregnancy, the level should rise by at least 50% every 48 hours until the pregnancy is 42 days old (after that time, the rise in level may not follow the curve). A progesterone level of <5 ng/ml suggests an abnormal or extrauterine pregnancy. In this instance, the pregnancy is intrauterine because of the presence of a yolk sac. Dilation and curettage is an option for treatment. Other options include expectant management, misoprostol or manual vacuum aspiration. Laparoscopy and methotrexate are not indicated as this is a confirmed intrauterine pregnancy. Mifepristone is a progestin receptor antagonist and can be used as emergency contraception to prevent ovulation and blocks the action of progesterone which is needed to maintain pregnancy. In the US, Mifepristone is also used with misoprostol for pregnancy termination.

A 20-year-old G2P1 woman at 28 weeks gestation presents to labor and delivery with contractions every four minutes. On physical examination, her vital signs are: temperature 100.5°F (38.0°C); heart rate 120; respiratory rate 18, and blood pressure 110/65. Her uterine fundus is tender and the rest of the physical exam is normal. Her cervix is dilated 1 cm and is 50% effaced. Baby is in vertex presentation. Fetal heart tones are in the 150s with a category I tracing. Her white blood cell count (WBC) is 18,000/mcL. Which of the following is the most appropriate next step in the management of this patient? A. Observation B. Tocolysis C. Contraction stress test D. Labor induction E. Cesarean section

D. This patient has a fever, a tender fundus, and elevated white blood cell count, which are concerning for an intra-amniotic infection. Delivery is warranted and in the case of reassuring heart tones, there are no contraindications for labor induction and a Cesarean section is not indicated at this time. Tocolytics should not be used in the case of an intra-amniotic infection. Conservative management with observation would delay diagnosis and would not be appropriate. A contraction stress test is not indicated since the patient is already contracting with reassuring fetal heart tones.

A 29-year-old G1 woman presents at 31 weeks gestation with preterm rupture of membranes six hours ago. She notes that for the last hour she has had some occasional contractions. Her prenatal course has been uncomplicated and she takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). What is the role of tocolysis in this patient? A. Prevent delivery B. Delay delivery until fetal lung maturity is reached C. Delay delivery for one week D. Delay delivery in order to administer steroids E. Contraindicated

D. While the role of tocolysis in the setting of preterm rupture of membranes is controversial, it may be appropriate in limited settings. Tocolysis may be administered in an attempt to prolong the interval to delivery to gain time for steroids to obtain maximum benefit for the fetus. The risks of chorioamnionitis with continuing tocolytics beyond 48 hours outweighs the benefit of awaiting lung maturity. This may be reasonable in women without evidence of infection or advanced preterm labor. Admittedly, the likelihood of success in this setting is relatively poor, but the potential benefit to the fetus probably outweighs any maternal complication from tocolysis.

A 32-year-old G5P3 woman presents with left-sided abdominal pain. Her last normal menstrual period was eight weeks ago. She began having pain early this morning and it has increased to a severity of 8/10. She denies nausea or vomiting or vaginal bleeding. Her gynecological history is notable for a history of right-sided ectopic pregnancy four years ago. At that time, she had a right salpingectomy and a left tubal ligation. On physical examination: blood pressure is 90/54; pulse 108; respirations 22; and temperature 98.6°F (37.0°C). On abdominal examination, she has rebound and guarding in all quadrants, and on pelvic exam, her uterus is very tender and there is left adnexal fullness. A transvaginal ultrasound shows an empty uterus, left pelvic mass with a gestational sac and fetal pole, and a large amount of free fluid in the pelvis. Her hematocrit is 26%. What would be the next best step in the management? A. Admit for observation B. Repeat Beta-hCG level in 48 hours C. Treat with methotrexate D. Perform a laparoscopy E. Perform a dilation and curettage

D.This scenario is consistent with the patient having a ruptured ectopic pregnancy. Signs of hypovolemia (tachycardia, hypotension) with peritoneal signs (rebound, guarding and severe abdominal tenderness) and a positive pregnancy test lead to the diagnosis of ruptured ectopic pregnancy. Conservative management, with observation and repeating the Beta-hCG level in 48 hours is not indicated since a diagnosis is clear and waiting can potentially be dangerous to the patient. Dilation and curettage would only be considered after laparoscopy, if needed.

A 28-year-old G2P2 woman returns today for follow up on her abnormal pap smear which reveals atypical squamous cells of undetermined significance (ASCUS). Reflex HPV testing is positive for high risk type. She has never had a prior abnormal pap smear, and has been following the recommended screening guidelines. She is asymptomatic. Her pelvic exam reveals a normal cervix with a small amount of cervical mucous. What is the next best step in the management of this patient? A. Routine screening B. Repeat Pap smear in one year C. Repeat HPV testing in one year D. Repeat co-testing with Pap and HPV in one year E. Colposcopy

E

A 24-year-old Rh-negative G2P1 woman at 18 weeks gestation is positive for anti-D antibodies. In discussing the risks of Rh sensitization with her, you tell her that her fetus may be at increased risk of significant perinatal disease including fetal anemia. Which of the following non-invasive tests can detect severe fetal anemia? A. Umbilical artery systolic-diastolic ratio B. Biophysical profile C. Amniotic fluid index D. Umbilical artery blood flow E. Middle cerebral artery peak systolic velocity

E. Noninvasive diagnosis of fetal anemia has been performed with Doppler ultrasonography. The use of middle cerebral artery peak systolic velocity in the management of fetuses at risk for anemia because of red cell alloimmunization has emerged as the best test for the noninvasive diagnosis of fetal anemia. All the other listed tests are for assessment of fetal well-being and non-specific to detect fetal anemia. Amniocentesis and cordocentesis have been used for many years to diagnose fetal anemia due to red cell alloimmunization. These techniques, however, are invasive and many complications are associated with their use.

A 23-year-old G1P0 woman at 40 weeks gestation presents to labor and delivery with contractions. At 10:00 am, her cervical exam is 2 centimeters dilated, 70% effaced and the vertex at 0 station. Clinical pelvimetry reveals an adequate pelvis and membranes are intact. The fetus is in a cephalic presentation and EFW is 3500 gms. Contractions are occurring every 3-4 minutes, based on the external monitor. Her labor slowly progresses and, at 1:00 pm, the patient has spontaneous rupture of membranes. Fetal surveillance remains reassuring. Her cervical exam is 5 centimeters dilated, 100% effaced, and 0 station. At 4:00 pm, the patient's cervical exam is unchanged. Contractions are occurring every 5-6 minutes. Which of the following is the most appropriate next step in the management of this patient? A. Perform a biophysical profile B. Have the patient ambulate C. Consent the patient for a Cesarean section secondary to failure to progress D. Continue fetal surveillance and reexamine the patient in two hours E. Begin oxytocin augmentation

E. The patient has an arrest of dilatation in the active phase of labor. She is only having contractions every 5-6 minutes, so it is reasonable to start oxytocin to increase the frequency and strength of this patient's contractions. If the patient does not have cervical change once she is having more frequent contractions on oxytocin, it would be reasonable to place an IUPC (intrauterine pressure catheter) to assess the strength of the contractions. It is not yet necessary to perform a Cesarean delivery. Further observation and having the patient ambulate do not facilitate delivery. A biophysical profile is not indicated in this situation.

A 19-year-old G2P1 African American woman at 30 weeks gestation presents with preterm rupture of membranes six hours ago. Her prenatal course has been complicated by two episodes of bacterial vaginosis for which she was treated. She takes prenatal vitamins and iron. She denies substance abuse or alcohol use, but admits to smoking five cigarettes each day. Her prior pregnancy was delivered vaginally at 41 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). Pertinent sonographic findings reveal oligohydramnios and a cervical length of 30 mm. Which of the following is the most likely cause of preterm premature rupture of membranes in this patient? A. Ethnicity B. Smoking C. Previous premature rupture of membranes D. Cervical length E. Genital tract infections

E. The primary risk factor for preterm rupture of membranes is genital tract infection, especially associated with bacterial vaginosis. All of the other listed options are risk factors. Smoking and prior preterm premature rupture of membranes (which she did not have previously because she delivered at 41 weeks) increases the likelihood of preterm rupture of membranes two-fold. A shortened cervical length is also a risk factor, but her cervical length is normal.

A 24-year-old G0 woman presents with multiple painful ulcers involving the vulva. The sores initially were fluid filled, but are now open, weeping and crusted. She reports a fever and is having difficulty voiding due to pain. She uses a vaginal ring for contraception. She has multiple sexual partners and uses condoms for vaginal intercourse. She is distraught that she may have a sexually transmitted infection. She is healthy and does not smoke or use drugs. On physical exam, she is in obvious distress. Temperature is 100.2°F (37.9°C), pulse 100. Examination of the genital tract is limited due to her discomfort. Multiple ulcers and erosions of variable size are localized to the perineum, labia minora and vestibule. Swelling is diffuse. The lesions are eroded, some with a purulent eschar. There is exquisite tenderness to touch. What further testing should be offered to this patient? A. RPR (rapid plasma regain) B. HIV C. Herpes culture D. Cervical DNA probe for gonorrhea and chlamydia E. All of the above

E. This patient has classic primary herpes with painful genital ulcerations, fever and dysuria. Given the presence of one sexually transmitted infection, screening should be offered for other STIs. Resolution of the acute episode is required before a speculum can be inserted to allow endocervical sampling for gonorrhea and chlamydia. If it was a high-risk exposure, prophylactic empiric treatment could be offered to cover gonorrhea and chlamydia. The patient should be counseled that primary herpes can be acquired despite condoms and even by oral-genital inoculation. Hepatitis B vaccination should be offered to protect her against any future exposures. She should be encouraged to discuss her diagnosis with all sexual partners and to continue to reliably use latex condoms.

A 27-year-old G2P1 woman at 36 weeks gestation is admitted with severe preeclampsia. Her blood pressure is 200/105. She has received two doses of IV hydralazine to lower her blood pressure. What diastolic blood pressure should you aim for in this patient? A. 50-55 mm Hg B. 60-65 mm Hg C. 70-75 mm Hg D. 80-85 mm Hg E. 90-95 mm Hg

E. Treatment with an antihypertensive is indicated for blood pressures persistently greater than 160 systolic and 105 diastolic. First-line agents include hydralazine (a direct vasodilator) 5 mg IV followed by 5-10 mg doses IV at 20-minute intervals (maximum dose = 40 mg); or labetalol (combined alpha & beta-adrenergic antagonist) 10-20 mg IV followed by 20 mg, then 40 mg, then 80 mg IV every 10 minutes (maximum dose = 220 mg). The goal is not a normal blood pressure, but to reduce the diastolic blood pressure into a safe range of 90-100 mm Hg to prevent maternal stroke or abruption, without compromising uterine perfusion.

Early Deceleration

Early decelerations are physiologic caused by fetal head compression during uterine contractions, resulting in vagal stimulation and slowing of the heart rate. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Thus, it has the characteristic mirror image of the contraction.

What is the most common risk factor of uterine inversion?

Factors that lead to an over-distended uterus are risk factors for uterine inversion. Grand multiparity, multiple gestation, polyhydramnios and macrosomia are all risk factors. The most common risk factor, however, is excessive (iatrogenic) traction on the umbilical cord during the third stage of delivery. Although leiomyomas may spontaneously prolapse, it is unlikely during the peripartum period.

Gestational Diabetes.

Fasting serum glucose concentration ≥ 95 mg/dL (5.3 mmol/L) One-hour serum glucose concentration ≥ 180 mg/dL (10 mmol/L) Two-hour serum glucose concentration ≥ 155 mg/dL (8.6 mmol/L) Three-hour serum glucose concentration ≥140 mg/dL (7.8 mmol/L) Screening for gestational diabetes is important because there are many risks associated with it, including: preeclampsia fetal macrosomia (large babies who also may have a disproportionately large trunk to head ratio, increasing risks for shoulder dystocia in labor) birth trauma need for operative delivery neonatal mortality newborn complications (hypoglycemia, hyperbilirubinemia, hypocalcemia, and others)

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

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.

In HELLP syndrome due to liver dysfunction what happens in the pregnant female wrt fibrinogen, albumin, cholesterol, clotting times, and sugar levels?

HELLP syndrome is a disease process in the spectrum of severe preeclampsia. The acronym stands for "hemolysis, elevated liver enzymes, low platelets" and can lead to swelling of the liver capsule and possibly, liver rupture. It may or may not be accompanied by right upper quadrant pain. It is possible to only have thrombocytopenia and elevated transaminases, without clear hemolysis (elevated bilirubin and anemia), especially if a diagnosis is made early. This patient does not have seizures and, therefore, does not have eclampsia. The clinical scenario is not consistent with hepatitis or cholecystitis. Acute fatty liver almost always manifests late in pregnancy. Symptoms develop over several days to weeks and include malaise, anorexia, nausea and vomiting, epigastric pain, and progressive jaundice. In many women, persistent vomiting in late pregnancy is the major symptom. About half of all women have hypertension, proteinuria, and edema signs suggestive of preeclampsia. There is usually severe liver dysfunction with hypofibrinogenemia, hypoalbuminemia, hypocholesterolemia, and prolonged clotting times. As acute fatty liver worsens there is marked hypoglycemia.

A 41-year-old G3P2 woman presents with cramping, vaginal bleeding and right lower quadrant pain for five days which has progressively worsened. Her last normal menstrual period occurred seven weeks ago. Her surgical history is notable for a bilateral tubal ligation following her last delivery. On physical exam, vital signs are: blood pressure 110/74; pulse 82; respirations 18; temperature 98.6°F (37.0°C). On abdominal exam, she has right lower quadrant tenderness, with rebound and bilateral guarding in the lower quadrants. On pelvic exam, she has scant old blood in the vagina and a normal appearing cervix. Her uterus is normal size and slightly tender. She has cervical motion tenderness on bimanual examination, and marked tenderness on rectal examination. Her quantitative Beta-hCG is 4000 mIU/ml; progesterone 6.2 ng/ml; hematocrit 34%; and WBC 15,400/mcL, with 88% segmented neutrophils and no bands. The transvaginal ultrasound shows an empty uterus with endometrial thickening, a mass in right ovary measuring 3.8 x 2 cm, and a small amount of free fluid in the pelvis. What is the most likely diagnosis in this patient? A. Pelvic inflammatory disease B. Ectopic pregnancy C. Heterotopic pregnancy D. Missed abortion E. Ruptured corpus luteum cyst

IB. The diagnosis of ectopic pregnancy is made when either: 1) a fetal pole is visualized outside the uterus on ultrasound; 2) the patient has a Beta-hCG level over the discriminatory zone (the level at which an intrauterine pregnancy should be seen on ultrasound, usually 2000 mIU/ml) and there is no intrauterine pregnancy (IUP) seen on ultrasound; or 3) the patient has inappropriately rising Beta-hCG level (less than 50% increase in 48 hours) and has levels which do not fall following diagnostic dilation and curettage. This patient meets criteria #2, as her Beta-hCG is >2000 mIU/ml with no intrauterine pregnancy seen on ultrasound. The history, physical exam and lab data are not consistent with pelvic inflammatory disease, ovarian torsion, appendicitis or a ruptured corpus luteum cyst. With a heterotopic pregnancy, there should be a visible pregnancy in the uterus. With a missed abortion there should also be some visible tissue or a fetal pole within the uterus.

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. She is at risk for all the following complications, except: A. Polyhydramnios B. Neonatal hypoglycemia C. Intrauterine growth restriction D. Preeclampsia E. Fetal macrosomia

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.

In postpartum hemorrhage which vessel can be ligated to help? What should be avoided?

Ligation of a number of pelvic vessels can lead to reduction in the vascular pressure in the pelvis thus controlling hemorrhage. This is especially true with internal iliac artery (hypogastric artery) ligation. However, ligation of the ovarian arteries should not be undertaken as a primary approach. Ligation of the external iliac artery results in devascularization of the leg and, therefore, should not be performed.

A 40-year-old G1P0 woman at 34 3/7 weeks gestation was found on the floor at work having a grand mal seizure. Her airway was secured. Blood pressure in the ambulance was 140/90. What is the initial treatment for her condition? A. Magnesium sulfate B. Valium C. Hydantoin D. Phenobarbital E. Naloxone

Magnesium sulfate is the treatment of choice for eclampsia, which is her most likely diagnosis. Valium, hydantoin, tiagabine, and barbiturates can also be used to treat seizures, but are not first-line therapy for eclampsia. They can be added as second agents, or used if magnesium is contraindicated. Naloxone (Narcan) is a drug used to counter the effects of opioid overdose, for example heroin or morphine overdose, and is specifically used to counteract life-threatening depression of the central nervous system and respiratory system.

Causes for retained placenta

Prior Cesarean delivery, uterine leiomyomas, prior uterine curettage and succenturiate lobe of placenta.

Postpartum Contraception

Progestin-only pills (B), injectable progestin (Depo-Provera) (C), and progestin implants (Implanon) (D) can be started immediately post partum. Advantages to these methods include the minimal effect of progestins on blood pressure, coagulation factors or lipid levels, and the lack of increased risk of stroke, myocardial infarction, or venous thromboembolism with progestin-only contraceptives.

How are prostaglandin F2a, misoprostol and oxytocin administered?

Prostaglandin F2-alpha should be administered intramuscularly. It could also be injected directly into the uterine muscle. Prostaglandin F2-alpha should not be administered IV, as it can lead to severe bronchoconstriction. Oxytocin is administered as a short time, rapid infusion of a dilute solution (20-80 units in a liter) and not as an IV bolus/push. Misoprostol (800 to 1000 mcg) can be administered orally or rectally and is not administered IV or IM.

A 22 year-old delivered her first baby five days ago after a prolonged labor and subsequent Cesarean section for arrest of cervical dilation at 7 centimeters. Fever was noted on postoperative day 2 and, despite broad spectrum antibiotics, she continues to have temperature spikes above 101.3°F, 38.5°C. She is eating a normal diet and ambulating normally. On physical examination, her breasts have no erythema and nipples are intact. Her abdomen is soft, uterine fundus is firm and nontender, and her incision is healing without induration or erythema. She has normal lochia and her urinalysis is normal. Pelvic examination reveals a firm nontender uterus and no adnexal masses or tenderness. Which of the following is the most likely cause of her fevers? Septic pelvic thrombophlebitis Ovarian abscess Endometritis Mastitis Cystitis

Septic thrombophlebitis involves thrombosis of the venous system of the pelvis. Diagnosis is often one of exclusion of other causes, but sometimes a CT scan will reveal thrombosed veins. Treatment requires addition of anticoagulation(heparin) to antibiotics and resolution of fevers is rapid. Anticoagulation treatment is short-term. Classic clinical findings for endometritis include fever and maternal tachycardia, uterine tenderness and no other localizing signs of infection. The clinical manifestations of cystitis include lower abdominal pain, frequency, urgency and dysuria. The clinical findings in patients with mastitis include fever, tenderness, induration and erythema of the affected breast.

What factor highly influences preeclampsia? What are the other risk factors?

The incidence of preeclampsia is commonly cited to be about 5 percent and is markedly influenced by parity. It is related to race and ethnicity and to genetic predisposition. Environmental factors are also likely to play a role. Other risk factors for preeclampsia include a previous history of the disease, chronic hypertension, multifetal pregnancy and molar pregnancy. In addition, patients at extremes of maternal age or with diabetes, chronic renal disease, antiphospholipid antibody syndrome, vascular or connective tissue disease or triploidy are at increased risk for developing preeclampsia

A 34-year-old G2P1 woman presents at 13 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 the second trimester? A. Quadruple screen B. Triple screen C. Amniotic fluid for alpha fetoprotein level D. Maternal serum alpha fetoprotein level E. Nuchal translucency measurement with serum PAPP-A (pregnancy associated plasma protein-A) and free Beta-hCG level

The quadruple test (maternal serum alpha fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A) is the most effective screening test 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%. An amniotic fluid alpha fetoprotein level is unnecessary. 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.

PROM go into labor %

The time from premature rupture of membranes to labor is inversely related to gestational age. At term, 90% will spontaneously go into labor within 24 hours of PROM. At 28 weeks to 34 weeks, 50% will go into labor within 24 hours and 80% within 48 hours.

Sinusoidal pattern

The true sinusoidal pattern is a regular, smooth, undulating form typical of a sine wave that occurs with a frequency of two to five cycles/minute and an amplitude range of five to 15 beats/minute. It is also characterized by a stable baseline heart rate of 120 to 160 beats/minute and absent beat-to-beat variability.

A 21-year-old G1 woman at 36 weeks gestation presents with sudden onset of abdominal pain and bleeding. She smokes a pack of cigarettes a day, but otherwise her pregnancy has been uncomplicated. She takes no medications other than prenatal vitamins. Her blood pressure is 150/90, pulse 90 and she is afebrile. Her uterus is tense and very tender. Pelvic ultrasound shows the placenta to be posterior and fundal, with a cephalic presentation of the fetus. Cervical examination reveals no lesions, blood coming through the os and is one centimeter dilated. Fetal heart tones have a baseline of 150, with a category III fetal heart rate tracing. Tocometer reveals contractions every 30-45 seconds. Which of the following is the most appropriate next step in the management of this patient? A. Amniotomy B. Cesarean delivery C. Induction of labor D. Tocolysis E. A double set-up examination

This patient is undergoing a placental abruption, with a deteriorating fetal condition. An emergent Cesarean delivery is necessary. The mother risks excessive blood loss, DIC and possible hysterectomy. The fetus risks neurological injury from anoxia or death. Risk factors for abruption include smoking, cocaine use, abdominal trauma, chronic hypertension, multiparity and prolonged premature rupture of membranes. Since immediate delivery is needed, amniotomy, induction, or tocolysis are not appropriate. A double set-up examination (performed in the operating room with a Cesarean section team scrubbed and ready) is not indicated, since the ultrasound determined the location of the placenta to be fundal.

VBAC

Women attempting a vaginal birth after Cesarean (VBAC) after one previous low transverse Cesarean delivery have a 70-80% chance of having a successful VBAC and approximately 70% with two previous cesarean sections. The risk of uterine rupture with a history of one previous low transverse Cesarean section is approximately 1 percent or less. There are no data to demonstrate the exact increased risk of uterine rupture with a history of two previous Cesarean deliveries. The indication for the previous Cesarean delivery may affect the success rate of a future VBAC. Patients who had a prior Cesarean delivery for a nonrecurring indication, such as placenta previa or breech presentation are more likely to have a successful VBAC compared to patients whose previous Cesarean delivery was performed secondary to cephalopelvic disproportion. Prostaglandin induction in this patient would is contraindicated.

Variable Deceleration

ariable decelerations show an acute fall in the FHR, with a rapid down slope and a variable recovery phase. They are characteristically variable in duration, intensity, and timing, and may not bear a constant relationship to uterine contractions. They are typically associated with cord compression, especially in the setting of low amniotic fluid volume. Variable decelerations are reflex mediated usually associated with umbilical cord compression as a result of cord wrapped around fetal parts, fetal anomalies or oligohydramnios.

What do you give to ripen the cervix and induce labor?

misoprostol (cytotec)

A 17-year-old G1P0 female at 39 weeks gestation presents with increased swelling in her face and hands over the last two days. Her blood pressure is 155/99. She has 2 plus pitting edema of the lower extremities. A 24-hour urine collection shows 440 mg of protein. What is the next best step in the management of this patient? A. Fluid restriction B. Magnesium sulfate C. Furosemide D. Hydralazine E. Delivery

E. Regardless of disease severity, the only definitive therapy for preeclampsia is delivery of the fetus and placenta. This solution can occasionally be delayed in the setting of stable disease (mild or severe) when it occurs at an extremely early gestational age. Fluid management must be monitored closely in this person. Magnesium sulfate is the mainstay of therapy during labor and for 24 hours postpartum to lower the seizure threshold. Low-dose aspirin may have some benefit in decreasing the risk of preeclampsia in a subset of high-risk patients. Hydralazine is often the antihypertensive agent of choice for controlling elevated blood pressures in the acute setting.

Features of Down Syndrome

Flat facial profile Poor Moro reflex Excessive skin at nape of the neck Slanted palpebral fissures Hypotonia Hyperflexibility of joints Dysplasia of pelvis Anomalous ears Dysplasia of midphalanx of fifth finger Transverse palmar (Simian) crease

Fetal tachycardia

Maternal fever, chorionamionitis

Gestational HTN

The presence of persistent systolic blood pressure of ≥140 mmHg and/or a diastolic blood pressure of ≥90 mmHg, without proteinuria, in a previously normotensive pregnant woman at or after 20 weeks of gestation. Tends to recur in subsequent pregnancies and also increases the risk of developing hypertension later in life. Women who have gestational hypertension may be further characterized depending on subsequent findings, such as the presence of proteinuria (preeclampsia).

Normal or reactive non-stress test

Two fetal heart rate accelerations of 15 beats/minute for 15 seconds within 20 minutes

What medication doesn't ripen the cervix but is good for contraction induction?

oxytocin (pitocin)

Evidence of fetal anemia

tachycardia and sinusoidal heart rate pattern

Late deceleration

A late deceleration is a symmetric fall in the fetal heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended. Late decelerations when viewed as repetitive and/or with decreased variability are an ominous sign. They can be associated with uteroplacental insufficiency as a result of decreased uterine perfusion or placental function, thus leading to fetal hypoxia and acidemia. Common causes include chronic hypertension and postdate pregnancies.

A 37-year-old G2P1 woman with poorly controlled chronic hypertension presents in labor at term. Her prenatal course was uncomplicated. She delivers a 3500 gram infant spontaneously after oxytocin augmentation of labor. Immediately postpartum, she experiences excessive bleeding. Her blood pressure is 130/90; pulse 84; and she is afebrile. On examination, uterine fundus is firm and the placenta is intact. Which of the following is the most appropriate next step in the management of this patient? A. Exploration for lacerations B. Methylergonovine C. B Lynch suture D. IV push of oxytocin E. Uterine artery embolization

A. After ensuring appropriate backup, establishing intravenous access and stabilizing a patient as needed, the first steps in the management of postpartum hemorrhage are to make sure the uterus is well-contracted, there is no retained placental tissue and to look for lacerations. This patient has a firm fundus, which indicates a contracted uterus. Her placenta is complete, which typically rules out retained placental tissue, so it is important to rule out lacerations, which can lead to hemorrhage. Methylergonovine, prostaglandins and oxytocin are all uterotonics and used to increase uterine contractions and decrease uterine bleeding. Methylergonovine is an ergot alkaloid, which is a potent smooth muscle constrictor. It is also a vasoconstrictive agent and should be withheld from women with hypertension and/or preeclampsia. B Lynch suture is used at time of laparotomy for uterine atony. Oxytocin should not be given as an IV push. Uterine artery embolization can be considered after other sources of bleeding such as lacerations are ruled out.

What medications is given for PROM that has been shown to delay the onset of labor by 5-7 days?

A. Antibiotic therapy given to patients with preterm premature rupture of the membranes has been found to prolong the latency period by 5-7 days, as well as reduce the incidence of maternal amnionitis and neonatal sepsis. Corticosteroids (betamethasone) and tocolytics may also prolong the pregnancy for various lengths of time, but generally not seven days.

A 20-year-old G1P0 woman at 28 weeks gestation presents to triage with uterine contractions every four minutes. On exam, her cervix is long, closed and posterior. Her urinalysis is normal. Fetal fibronectin is negative. In addition to hydration, which of the following is the most appropriate next step in the management of this patient? A. Expectant management B. Bedrest C. Tocolysis D. Cerclage E. Administer betamethasone

A. Approximately 50% of patients with preterm contractions have spontaneous resolution of abnormal uterine activity. The patient should be observed until a correct diagnosis is made. If there is evidence the patient is dehydrated and she is unable to tolerate PO fluids, then IV hydration would be indicated. Preterm labor, which is defined as the presence of regular uterine contractions leading to cervical change, needs to be promptly treated. Tocolysis is not necessary in this case because a diagnosis of preterm labor has not been made (no cervical change). The patient should not be sent home until diagnosis and treatment plans are determined. Since fetal fibronectin is negative and the patient is not in labor, she can be expectantly managed. Cerclage is not necessary, since she does not have an incompetent cervix. Treatment with betamethasone is not indicated unless there is evidence that the patient is at increased risk of delivering preterm. Bedrest is not indicated and has not been shown to reduce preterm birth.

A 27-year-old G1 at 12 weeks gestation presents for first prenatal care visit. She is previously healthy and takes no medications. An ultrasound is performed and a viable pregnancy is confirmed. At the end of the visit, the patient discusses with you her desire to have a Cesarean section for delivery, as she does not wish to go through the pain of labor. Her husband, an orthopedic surgeon, expresses concerns as they desire to have at least three children and he is worried about potential complications with repeated Cesarean sections. What is the most appropriate next step in the counseling of this patient? a.Agree with her decision after proper counseling and perform a Cesarean section at 39 weeks gestation b.Agree with her decision after proper counseling and perform a Cesarean section at 41 weeks gestation if she has not gone into labor by then c.Advise her that it is not possible to plan a Cesarean section for delivery d.Advise her to listen to her husband and plan for a vaginal birth e.Refer her to psychiatric counseling

A. Elective cesarean section on demand has been getting more popular among women for a variety of reasons. Although, it might sound unreasonable to undergo a Cesarean section for being afraid of pain, the patient has the right to request it and the physician's duty is to make sure she understands all the risks and potential complications associated with such a decision. Her husband is appropriately concerned but it is up to her to make the decision regarding an elective procedure.

A 25-year-old G0 woman is scheduled to discuss her recent abnormal Pap smear which showed atypical squamous cells of undetermined significance (ASCUS). She has had one Pap smear at age 22 which was normal. Her only significant gynecologic history is genital warts that have not responded to treatment with local application of trichloroacetic acid. She has had eight sexual partners. She uses condoms and oral contraceptives. She has smoked a pack a day for the past two years. Which of the following is the most appropriate next step in the management of this patient? A. HPV typing B. Repeat Pap smear in three years C. Cone biopsy D. Cryotherapy E. Loop Electrosurgical Excision Procedure (LEEP)

A. HPV typing

A 29-year-old G1P0 at 42 weeks gestation presents to labor and delivery because of intermittent contractions. She denies ruptured membranes. Her prenatal course was uncomplicated. Her vital signs are: blood pressure 140/96; pulse 72; afebrile; fundal height 32 cm; and estimated fetal weight of2900 gm. Cervix is closed, 25% effaced, -2 station. The fetal heart rate tracing shows occasional late decelerations. Of the following, what is the nextbest step in management? A. Maternal left lateral position B. Intrauterine resuscitation with terbutaline C.Start an amnioinfusion D. Begin magnesium sulfate E. Augment labor with oxytocin

A. Initial measures to evaluate and treat fetal hypoperfusion include a change in maternal position to left lateral position which increases perfusion to the uterus, maternal supplemental oxygenation, treatment of maternal hypotension, discontinue oxytocin, consider intrauterine resuscitation with tocolytics and intravenous fluids, fetal acid-base assessment with fetal scalp capillary blood gas orpH measurement. An amnioinfusion may be used to treat patients with variable decelerations. Measures to improve uteroplacental blood flow should be attempted prior to proceeding with Cesarean delivery. Magnesium sulfate is not yet indicated in this patient with one slightly elevated blood pressure. Augmentation of labor mayaccentuate the late decelerations.

A 26-year-old G2P1 woman at 33 weeks gestation presents in preterm labor. She has a history of a prior preterm birth at 32 weeks gestation. She has insulin dependent diabetes and has a history of myasthenia gravis. She has regular contractions every three minutes and fetal heart tones are reassuring. Cervix is 3 cm dilated and 0 station. Her blood pressure is 140/90. Which of the following is the most appropriate tocolytic agent to use in this patient? A. Nifedipine B. Terbutaline C. Magnesium sulfate D. Indomethacin E. Ritodrine

A. Nifedipine, a calcium channel blocker is the best option for her as she has contraindications to the other agents listed. Terbutaline and ritodrine are contraindicated in diabetic patients and the FDA made a formal announcement in 2011 warning against using terbutaline to stop preterm labor stating that terbutaline is both ineffective and dangerous if used for longer than 48 hours; magnesium sulfate is contraindicated in myasthenia gravis; and indomethacin is contraindicated at 33 weeks due to risk of premature ductus arteriosus closure.

A 39-year-old G0 woman presents to the clinic reporting non-tender spots on her vulva for about a week. No pruritus or pain is present. She also notes a brownish rash on the palms of her hands. She admits to IV drug abuse. She was diagnosed as HIV-positive two years ago, but has not been compliant with suggested treatment. On examination, three elevated plaques with rolled edges are noted on the vulva. They are non-tender. A brown macular rash is noted on the palms of her hands and the soles of her feet. What is the most appropriate next step in the management of this patient? A. Obtain a treponemal-specific test B. Biopsy of the lesion C. Colposcopic evaluation of the vulvar lesions D. Culture the base of the lesion E. Initiate empiric treatment with doxycycline and ceftriaxone

A. The diagnosis of syphilis is often established by serologic testing. Non-treponemal tests (VDRL or RPR) are non-specific. In this patient with high suspicion for syphilis, specific testing with treponemal antibody can confirm infection. The classic coiled spirochete is easily seen with dark-field microscopy but availability is limited. A characteristic finding is a macular rash on the palms and soles that are often described as copper penny lesions. Colposcopy would not be diagnostic, but certainly is helpful to evaluate for any vulvar lesions thought to be dysplastic. Biopsies can be stained for spirochetes and may show a necrotizing vasculitis, but certainly would not be the most expedient way to make the diagnosis. Penicillin G is the preferred drug for treating all stages of syphilis.

A 23-year-old G1P0 woman presents with cramping, vaginal bleeding and right lower quadrant pain. Her last normal menstrual period occurred seven weeks ago. On physical exam, vital signs are: blood pressure 110/74; pulse 82; respirations 18; and temperature 98.6°F (37°C). On abdominal exam, she has very mild right lower quadrant tenderness. On pelvic exam, she has scant old blood in the vagina and a normal appearing cervix. Her uterus is normal size and slightly tender. On bimanual exam, there is no cervical motion tenderness, and she has slight tenderness in right lower quadrant. Quantitative Beta-hCG is 2500 mIU/ml; progesterone 6.2 ng/ml; hematocrit 34%. The transvaginal ultrasound shows an empty uterus with endometrial thickening, a mass in the right ovary measuring 3 x 2 cm and a small amount of free fluid in the pelvis. Which of the following is the most appropriate next step in the management of this patient? A. Methotrexate B. Antibiotics C. Observation D. Dilation and curettage E. Culdocentesis

A. The next best step in management is methotrexate administration. Certain conditions must be met prior to initiating methotrexate therapy for treatment of an ectopic pregnancy. These include: hemodynamic stability, nonruptured ectopic pregnancy, size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate, normal liver enzymes and renal function, normal white cell count, and the ability of the patient to follow up rapidly (reliable transportation, etc.), if her condition changes. There is no indication for antibiotics in this scenario. Offering observation delays treatment and pain control would not address the underlying cause of the patient's problem. Culdocentesis is not indicated and does not change the management of this patient.

A 34-year-old G4P3 woman at 19 weeks gestation presents to the emergency department with chest pain, palpitations and sweating, which began 2-3 hours ago. On further questioning, she states that she has been very anxious lately and is not sleeping well, which she attributes to the pregnancy. She reports that she has lost 40 pounds in the last year without trying. She denies significant medical problems. On exam, the patient appears diaphoretic and anxious, her eyes are wide open, prominent, with easily visible sclera surrounding the pupil. Vital signs are: temperature 100.2°F (37.9°C); pulse 132; and blood pressure 162/84. Her height is 5 feet 10 inches and weight is 128 pounds. Her thyroid is palpably enlarged, with an audible bruit. Electrocardiogram shows sinus tachycardia. Remaining labs are pending. Which of the following therapies is contraindicated at this time? A. Radioactive iodine (I-131) B. Propylthiouracil (PTU) C. Propranolol D. Inorganic iodide E. Intravenous fluid replacement

A. This is a patient in thyroid storm, an acute, life-threatening, hypermetabolic state. Radioactive iodine (I-131) concentrates in the fetal thyroid and may cause congenital hypothyroidism, so it should not be intentionally used in pregnancy. Acute treatment of thyroid storm may include thioamides (i.e. PTU), propranolol, sodium iodide and dexamethasone. Oxygen, digitalis, antipyretics and fluid replacement may also be indicated. Maternal mortality with thyroid storm exceeds 25%.

A 27-year-old G1P0 woman at 34 weeks gestation presents with increased swelling in her face and hands over the last two days. Blood pressure is 155/99. A 24-hour urine sample for protein is 440mg/dL. BMI is 27. Repeat blood pressure two days later is 150/92. Which of the following is the most likely diagnosis in this patient? A. Mild preeclampsia B. Severe preeclampsia C. Gestational hypertension D. Prehypertension E. Chronic hypertension

A. This patient has met criteria for the diagnosis of mild preeclampsia based on her persistent elevation of blood pressure and 24-hour urine results. The amount of protein excreted in the urine varies throughout the day, therefore a sample is collected over a 24-hour time period. Twenty-four hour urine protein values greater that 300 mg are required for the diagnosis of mild preeclampsia. Values greater than 5000 mg (or 5 g) are required for the diagnosis of severe preeclampsia (assuming no other defining criteria are present such as SBP >160 or DBP >110). Blood pressure between 120/80 and 139/89 is termed prehypertension, which is indicative of developing hypertension in the future.

A 24-year-old Rh-negative G1P1 woman just delivered a healthy term infant who is Rh-positive. You recommend RhoGAM administration but she declines because she does not desire any blood products. What is her approximate risk of isoimmunization if she does not receive the RhoGAM? A. Less than 20% B. 40% C. 60% D. 80% E. 100%

A. While 75% of all gravidas have evidence of transplacental hemorrhage during pregnancy or immediately after delivery, 60% of these patients have <0.1 cc of fetal blood in the maternal circulation, which is enough to sensitize a patient. The incidence and size of transplacental hemorrhage increases as pregnancy advances. During the second month of gestation, 5-15% of women will have evidence of feto-maternal hemorrhage. By the third trimester, this number increases to 45% of patients. The risk of isoimmunization is 2% antepartum, 7% after full term delivery, and 7% with subsequent pregnancy.

A 23 year-old G1P1 delivered vaginally a 42-week infant after a prolonged induction of labor. She had an epidural, with an indwelling catheter for 36 hours and three IV sites for her intravenous medications. She now complains of lower abdominal pain, frequency and dysuria. Her vital signs are temperature 98.6°F , 37°C; pulse 70; blood pressure 100/60; and respirations 12. On examination, her lungs are clear, cardiac exam is normal, abdomen is soft, uterine fundus is firm and nontender, and she has mild suprapubic tenderness. Which of the following organisms is most likely causing her discomfort? A. Group A streptococcus B. Gardnerella vaginalis C. Chlamydia trachomatis D. Escherichia coli E. Group B Streptococcus

Acute cystitis is a common complication after vaginal delivery and the risk increases with the use of an indwelling catheter. The most common cause of acute cystitis infection is gram-negative bacteria. The major pathogens are E. coli (75%), P. mirabilis (8%), K. pneumoniae (20%), S. faecalis (<5%), and S. agalactiae.