ALL APGO COMBINED - SB

IUGR seen with pre-existing diabtes or gestational diabetes?

*only* Pre-existing diabetes. *PR*-IUGR.

What factors are ass/w breech presentation?

-Prematurity -multiple gestation -genetic disorders -polyhydramnios -hydrocephaly -anencephaly -placenta previa -uterine anomalies -uterine fibroids

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.)

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?

. 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.

2 greatest RF for breast ca?

1. Age 2. Gender

indomethacin is associated with what 2 SE?

1. Premature PDA closure 2. oligohydramnios

A 58-year-old G3P3 has been postmenopausal for five years and is concerned about osteoporosis. She has declined hormone therapy in the past. Her mother has a history of a hip fracture at age 82. A physical exam is unremarkable. In addition to weight bearing exercise and vitamin D supplementation, what optimal daily calcium intake should she take?

1000-1200 mg

Endometritis in the postpartum period is most closely related to the mode of delivery

3 x higher in C-section. Also: -prolonged labor -prolonged ROM -multiple vaginal examinations -internal fetal monitoring -removal of the placenta manually -low socioeconomic status

A 19-year-old G0 woman presents with lower abdominal cramping. The pain started with her menses and has persisted, despite resolution of the bleeding. She thinks she may have a fever, but has not taken her temperature. No urinary frequency or dysuria are present. Her bowel habits are regular. She denies vomiting, but has mild nausea. A yellow blood-tinged vaginal discharge preceded her menses. No pruritus or odor was noted. She is sexually active, uses oral contraceptives and states that her partner does not like condoms. On examination: temperature is 100.2°F (37.9°C); pulse 90; blood pressure 110/60. She is well-developed and nourished and in mild distress. No flank pain is elicited. Her abdomen has normal bowel sounds, but is very tender with guarding in the lower quadrants. No rebound is present. Pelvic examination reveals a moderate amount of thick yellow discharge. The cervix is friable with yellow mucoid discharge at the os. Cervical motion tenderness is present. Uterus and the adnexa are tender without masses. Urine dip is negative for nitrates. Urine pregnancy test is negative. What is the most likely diagnosis?

Acute salpingitis

33 yo. 29 weeks. stable. confirmed PPROM. best med to delay labor onset?

Antibiotics. will prolong for 7 days.

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.

A 34-year-old G2P1 woman at 40 weeks gestation, with a history of one prior vaginal delivery, strongly desires an induction of labor, as she is unable to sleep secondary to severe back pain. Her cervical exam is closed, 20% effaced and -2 station. The cervix is firm and posterior. Which of the following is the most appropriate next step in the management of this patient? A. Wait until 42 weeks for induction B. Administer cytotec C. Insert a foley bulb in the cervix D. Perform artificial rupture of membranes E. Perform a Cesarean delivery

B. The patient is multiparous at term and waiting until she reaches 42 weeks may increase the risk of perinatal mortality. Since she is uncomfortable with back pain, it is reasonable to induce labor. Her cervix is unfavorable; therefore, cytotec administration is appropriate prior to pitocin induction. A foley bulb or artificial rupture of membranes cannot be achieved in a patient with a closed cervix. At this time, there are no indications to perform a Cesarean delivery in this patient.

A 32-year-old G1P0 woman comes to your office for her first prenatal care visit. She has recently read an article about the rising Cesarean section rate in the United States and asks you about the rate in your hospital. What do you explain as the major cause of higher Cesarean delivery rates? A. The rate of breech presentations has increased B. Less women are having vaginal births after Cesarean C. Obstetricians' reluctance to perform forceps delivery D. Increased rate of fetal macrosomia due to uncontrolled gestational diabetes E. Rate of twins has increased

B. The rate of vaginal birth after Cesarean (VBAC) has decreased in recent years due to studies that showed an increased risk of complications, especially uterine rupture. This is one factor that has led to the increased Cesarean section rate. In addition, although the rate of breech presentation is stable, there are significantly fewer obstetricians who are willing to perform vaginal breech deliveries. Many obstetricians do not perform instrumental vaginal deliveries, such as forceps and vacuum extractions, further contributing to the rising rate. Gestational diabetes is a well-known pregnancy complication with clear clinical guidelines.

A 35-year-old G3P2 woman is at 18 weeks gestation. Her obstetrical history is significant for two previous low transverse Cesarean deliveries. Her first one was performed secondary to arrest of dilation in the active phase at 7cm. She delivered a healthy 3500-gram infant. Her second Cesarean delivery was an elective repeat. She delivered a healthy 3400-gram infant. The patient strongly desires to attempt a VBAC (vaginal birth after cesarean). Which of the following statements is correct? A. The likelihood of a uterine rupture after two Cesarean sections is is approximately 10% B. The likelihood of a successful VBAC is lower in patients with two previous Cesarean deliveries than in women with one prior Cesarean delivery C. The likelihood of a successful VBAC is not affected by the indication of the previous Cesarean delivery D. The likelihood of a successful VBAC after two Cesarean sections is approximately 30%. E. She can safely undergo a prostaglandin induction of labor at term

B. 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.

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

Braxton-Hicks contractions

A 25-year-old G1 woman at 41 weeks gestation presents to labor and delivery with painful contractions every four minutes. Her cervix is 5 cm dilated, 90% effaced. On cervical exam, you are able to feel a fetal body part but it is not the head. Which of the following is the most likely body part you were palplating? A. Foot B. Hand C. Buttocks D. Back E. Shoulder

C. 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 25-year-old G1 woman at term presents in active labor. Her cervix rapidly changes from 7 centimeters to complete dilation in 1 hour. She has been pushing for two hours. The fetal station has changed from -1 to +1. Fetal heart tracing is category I. The patient is feeling strong contractions every three minutes. Which of the following is the most appropriate next step in the management of this patient? A. Cesarean delivery B. Forceps delivery C. Continued monitoring of labor D. Augmentation with oxytocin E. Ultrasound for estimated fetal weight

C. Continued monitoring of labor is appropriate if clinical evaluation indicates that the fetus is not macrosomic or there is no obvious fetopelvic disproportion. If either were the case, then a Cesarean delivery would be indicated. At this time, there is no fetal or maternal indication to perform a forceps delivery because the station is +1. Augmentation would be indicated if the contractions were inadequate in intensity or frequency. An ultrasound at this stage of labor is inaccurate and one relies on clinical estimates of weight.

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.

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?

Cervical cancer can unfortunately complicate pregnancies and presents with bleeding. She is at risk due to lack of screening.

Antiretroviral therapy should be offered to all HIV-infected pregnant women to begin maternal treatment as well as to reduce the risk of perinatal transmission regardless of CD4+ T-cell count or HIV RNA level. The baseline transmission rate of HIV to newborns can be reduced from about 25% to 2% with the HAART (highly active antiretroviral therapy) protocol antepartum and continuing through delivery with intravenous zidovudine in labor and zidovudine treatment for the neonate.

Cesarean section prior to labor can reduce this rate to 2% (although the benefit is less clear in women with viral loads <1,000 particles per ml.) Multiple agents should be used in pregnancy to minimize the development of drug resistance.

Question 9 of 50Point value 0 - 1 A 62-year-old G0 postmenopausal woman is being referred to your gynecologic oncology colleague after an office endometrial sample demonstrated a FIGO grade 1 endometrioid adenocarcinoma. The patient has no significant medical, surgical or other gynecologic history. She does not smoke and drinks only occasionally at social events. She takes a multivitamin. Her physical exam is unremarkable. Which of the following additional tests is indicated for this patient?

Chest x-ray

moderate (15 mm) right hydronephrosis. Which of the following is the most likely cause of these findings in preggers?

Compression by the uterus and right ovarian vein

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. Proteinuri D. Poorly controlled blood pressures E. Hemoconcentration

Correct answer is 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.

A 29-year-old G1P0 woman at 28 weeks gestation who is the wife of basketball player is diagnosed with gestational diabetes. Her mother had a delivery complicated by shoulder dystocia and she is concerned about her own risk. Which of the following is her biggest risk factor for shoulder dystocia? A. Family history B. Tall husband C. Age D. Gestational diabetes E. Parity

D. Fetal macrosomia, maternal obesity, diabetes mellitus, postterm pregnancy, a prior delivery complicated by a shoulder dystocia, and a prolonged second stage of labor are all associated with an increased incidence of shoulder dystocia. Although a family history can be indicative of large babies which might place her at additional risk, her gestational diabetes represents her largest risk factor.

#1 cause of adverse fetal outcome

DM

A 16-year-old patient has a new boyfriend and comes in to discuss contraception. She is well aware of the importance of preventing sexually transmitted infections and specifically wants to know about prevention of pregnancy. Other than abstinence, the most effective method of birth control in this patient is:

Depo-Provera

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

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.

A 27 year-old G2P1 at 18 weeks gestation presents to the emergency room complaining of fever, nausea, vomiting, and mid-abdominal pain for the last 24 hours. For the last 12 hours, she has had no appetite. She has been healthy, but reports that her 3 year-old son has had diarrhea for 2 days. Physical examination reveals a blood pressure of 100/60, pulse 88, respiratory rate 18, and temperature 102.0°F (38.9°C). Abdominal examination reveals decreased bowel sounds and tenderness more pronounced on the right than the left. Which of the following is the next best step in the management of this patient? A. Check a complete blood count B. Abdominal and pelvic ultrasound C. Plain abdominal radiograph D. Helical computed tomography E. Graded compression ultrasound

Graded Compression US Suspected appendicitis is one of the most common indications for surgical abdominal exploration during pregnancy. The diagnosis of appendicitis is more difficult to make in pregnancy because anorexia, nausea, and vomiting that accompany normal pregnancy are also common symptoms of appendicitis. In addition, the enlarged uterus shifts the appendix upward and outward toward the flank, so that pain and tenderness may not be located in the right lower quadrant. Appendicitis is easily confused with preterm labor, pyelonephritis, renal colic, placental abruption, or degeneration of a uterine myoma. Peritonitis and appendiceal rupture are more common during pregnancy. The diagnosis is made based on clinical findings and *graded compression ultrasonography* that is sensitive and specific especially before 35 weeks gestation. This noninvasive procedure should be considered first in working up suspected acute appendicitis. Selective imaging of the appendix using helical computed tomography may be a safe and potentially reliable tool to accurately identify appendiceal changes in appendicitis, except that radiation exposure using this test is higher than graded compression ultrasonography. A plain abdominal radiograph can be used to identify air fluid levels or free air but offers little diagnostic value for appendicitis.

Medical management of uterine fibroids

Growth of uterine fibroids is stimulated by estrogen. Gonadotropin-releasing hormone agonists inhibit endogenous estrogen production by suppressing the hypothalamic-pituitary-ovarian axis.

A 16-year-old nulliparous female presents to the emergency department with a two-day history of abdominal pain, nausea and vomiting. She is sexually active with a new partner and is not using any form of contraception. On examination, her temperature is 100.2°F (37.9°C), and she has bilateral lower quadrant pain, with slight rebound and guarding. On pelvic examination, she has purulent cervical discharge and cervical motion tenderness. Her white count is 14,000/mcL. What is the most appropriate next step in the management of this patient? A. Oral amoxicillin clavunate and doxycycline B. Oral metronidazole and doxycycline C. IV metronidazole and doxycycline D. IV cefotetan and doxycycline E. No treatment until culture results are back

IV cefotetan and doxycycline Acute salpingitis

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

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

Prostaglandin F2-alpha (Hemabate) is a potent smooth muscle constrictor, which also has a bronchio-constrictive effect Why is this important?

Its use is ContraIndicated w/ tocolysis in asthma patients.

A 26-year-old G1 with last menstrual period 10 weeks ago presents to your office for her first prenatal visit. She reports vaginal spotting for the last two days. You perform an ultrasound that shows an intrauterine pregnancy consistent with nine weeks gestation with no cardiac activity. She denies cramping or abdominal pain. What is the most important laboratory test to check for this patient? A. Quantitative beta-hCG B. Maternal blood type C. Hemoglobin and hematocrit D. Platelet count E. Progesterone

Maternal blood type

Milk ejection hormone: Milk production hormone:

Milk ejection hormone: oxytocin Milk production hormone: prolactin

fibronectin is a good test b/c of its what type of stat power?

Negative predictive Value 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

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

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 27 year-old G1P0 at 14 weeks gestation presents with a 2-month history of insomnia, feeling depressed, and unintentional weight loss. Symptoms began after the unexpected death of her father. She is not excited about this pregnancy and reports no suicidal ideation. Physical examination reveals a woman of stated age with a flat affect. Which of the following therapies is contraindicated in this patient? A. Paroxetine (Paxil) B. Sertraline (Zoloft) C. Fluoxetine (Prozac) D. Nortriptyline (Norpress) E. Bupropion (Wellbutrin)

Paroxetine!

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?

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 37-year-old G4P3 woman presents in labor at term. Her medical history and prenatal course are uncomplicated. She delivers a 3500 gram infant spontaneously after oxytocin augmentation of labor. Immediately postpartum, there is excessive bleeding greater than 2000 cc. She has an IV in place. There are no lacerations and the uterus is found to be boggy. Which of the following is the most appropriate next step in the non-operative management of this patient? A. Intravenous misoprostol B. Intramuscular misoprostol C. Intravenous prostaglandin F2-alpha D. Intramuscular prostaglandin F2-alpha E. Intravenous oxytocin push

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.

Why are CS rates going up?

The rate of vaginal birth after Cesarean (VBAC) has decreased in recent years due to studies that showed an increased risk of complications, especially uterine rupture.

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:

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 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

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 24-year-old G1P0 woman at 28 weeks gestation reports difficulty breathing, cough and frothy sputum. She was admitted for preterm labor 24 hours ago. She is a non-smoker. She has received 6 liters of Lactated Ringers solution since admission. She is receiving magnesium sulfate and nifedipine. Vital signs are: 100.2°F (37.9°C); respiratory rate 24; heart rate 110; blood pressure 132/85; pulse oximetry is 97% on a non-rebreather mask. She appears in distress. Lungs reveal bibasilar crackles. Uterine contractions are regular every three minutes. The fetal heart rate is 140 beats/minute. Labs show white blood cell count 17,500/mL with 94% segmented neutrophils. Potassium and sodium are normal. Which of the following has most likely contributed to this patient's respiratory symptoms?

This patient has pulmonary edema. Plasma osmolality is decreased during pregnancy which increases the susceptibility to pulmonary edema. Common causes of acute pulmonary edema in pregnancy include tocolytic use, cardiac disease, fluid overload and preeclampsia. Use of multiple tocolytics increases the susceptibility of pulmonary edema, especially with the use of isotonic fluids. Systemic vascular resistance is decreased during pregnancy.

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?

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.

A 22-year-old G1, who is at 38 weeks gestation with an estimated fetal weight of 2500 g, presents in active labor. She is completely dilated and effaced. The fetus is at +4 station and left occiput anterior with no molding. She has an epidural and has been pushing effectively for three hours. She is exhausted. What is the next step in management?

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

A 28-year-old G2P1 woman presents at 20 weeks gestation for a routine prenatal care visit. This pregnancy has been complicated by scant vaginal bleeding at seven weeks and an abnormal maternal serum alpha fetoprotein (MSAFP), with increased risk for Down syndrome, but had a normal amniocentesis: 46, XX. Her previous obstetric history is significant for a Cesarean delivery at 34 weeks due to placental abruption and fetal distress. Prenatal labs at six weeks showed blood type A negative, antibody screen positive: anti-D 1:64. Which of the following is the most likely cause of the Rh sensitization? A. ABO incompatibility B. Placental abruption C. Amniocentesis D. Abnormal maternal serum alpha fetoprotein (MSAFP) E. First trimester bleeding

This patient was sensitized during her first pregnancy that was complicated by abruption and required Cesarean delivery. Transplacental hemorrhage of fetal Rh-positive red blood cells into the circulation of the Rh-negative mother may occur following a number of obstetric procedures and complications, such as amniocentesis, chorionic villus sampling, spontaneous/threatened abortion, ectopic pregnancy, dilation and evacuation, placental abruption, antepartum hemorrhage, preeclampsia, cesarean section, manual removal of the placenta and external version.

When would we use tocolytics in the setting of Preterm rupture of membrane?

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 28-year-old G0 comes to the office for preconception counseling and the inability to conceive for one year. She and her husband of three years are both in good health. She has normal cycles every 28-33 days. She has intercourse about once a month, depending on her schedule. She is an airline pilot and travels a lot. Her examination is normal. She asks about when to best have intercourse during her cycle to maximize her chances of pregnancy. What is the most appropriate advice to give her?

Use ovulation predictor kits and attempt intercourse after it turns positive

tachycardia and sinusoidal heart rate pattern

abruption placenta

A 32 year-old delivered a 9-pound baby and sustained a 4th-degree laceration two days ago. The delivery was complicated by a shoulder dystocia. Her laceration was repaired in layers in the customary fashion. She now complains of increasing pain in her perineal area, fever chills and weakness. Her vital signs are: blood pressure 90/50; pulse 120; and temperature 102.2°F, 39°C. Her abdomen is soft, nontender and her uterine fundus is firm and nontender. Her perineum is erythematous, swollen, but the laceration edges have separated and are grey. The laceration site is nontender and without feeling but there is tenderness of the surrounding tissue. In addition to broad spectrum antibiotics, what is your next step in the management of this patient?

aggressive debridement of the necrotic areas is required to prevent further spread of the infection

most common abnormal karyotype encountered in spontaneous abortuses,

autosomal trisomy

MC type of breech?

buttocks first

twins. 1 is breach. nbsim

c-section.

A 17-year-old G0 female presents with a three-year history of severe dysmenorrhea shortly after menarche at age 14. Her menstrual cycles are regular with heavy flow. She has been treated with ibuprofen and oral contraceptives for the last year without significant improvement. She misses 2-3 days of school each month due to her menses. She has never been sexually active. Physical examination is remarkable for Tanner Stage IV breasts and pubic hair. Pelvic examination is normal, as is a pelvic ultrasound. Both the patient and her mother are concerned. What is the next best step in the management of this patient? A. Sonohysterogram B. CT scan of the pelvis C. Diagnostic laparoscopy D. MRI of the pelvis E. Hysterosalpingogram

c. diagnostic laparoscopy Chronic pelvic pain is the indication for at least 40% of all gynecologic laparoscopies. Endometriosis and adhesions account for more than 90% of the diagnoses in women with discernible laparoscopic abnormalities, and laparoscopy is indicated in women thought to have either of these conditions. Often, adolescents are excluded from laparoscopic evaluation on the basis of their age, but several series show that endometriosis is as common in adolescents with chronic pelvic pain as in the general population. Therefore, laparoscopic evaluation of chronic pelvic pain in adolescents should not be deferred based on age. Laparoscopy can be both diagnostic and therapeutic in this patient in whom you suspect endometriosis. None of the other imaging modalities listed will help in the further workup of this patient.

multiple spon. ab and prolonged dilute Russell viper venom time,dx and trt?

dx: antiphospholipid ab syndrome trt: ASA+heparin

35. fat. intermenstrual intermittent bleeding. NBSIM

endometrial biopsy.

MCC of inherited MR

fragile X syndrome

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?

his 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.

MCC of preterm labor

idiopathic

MCC of PPROM

infections (think bacterial vaginosis)

A low amniotic fluid glucose is an indication of?

intra-amniotic infection

what test to determine rhogam dose in placental abruption?

kleihauer-betke test. routine rhogam neutralizes 30 cc of fetal blood.

A 34-year-old G1P0 woman at 39 weeks gestation presents in active labor. Her cervical examination an hour ago was 5 cm dilated, 90 percent effaced and 0 station. The baseline is 140 beats/minute. There is a deceleration after the onset of each of the last four contractions. She just had spontaneous rupture of membranes and is found to be completely dilated with the fetal head is at +3 station. What is the most likely etiology for these decelerations?

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

A 17-year-old nulliparous female presents to your office with vaginal spotting for the last three days. Her last menstrual period was six weeks ago. Vitals signs are normal. Abdominal and pelvic examination reveals a 10-week sized uterus. Beta-HCG is 80,000 mIU. What is the best next step in the management of this patient? A. Repeat Beta-HCG in 24 hours B. Repeat Beta-HCG in 48 hours C. Perform a pelvic ultrasound D. Perform dilation and curettage E. Routine prenatal care

n the face of discrepancy between dates and uterine size, a pelvic ultrasound in indicated to confirm dates, exclude multiple gestation, uterine abnormalities, and molar pregnancy. There is no single Beta-hCG value that is diagnostic for a molar pregnancy. A quantitative Beta-hCG, though, is crucial at determining whether or not a pelvic (transvaginal) ultrasound will confirm a very early gestation. With a Beta-HCG above the discriminatory zone (>1500), an IUP should be easily identified on transvaginal ultrasound. If an IUP is not seen, the ultrasound findings (in conjunction with the Beta-hCG level) should identify a mole (multiple internal echoes) or an ectopic (absence of intra-uterine gestation). Additional Beta-HCG levels are not indicated at this time. Suction curettage will provide a pathologic specimen that can distinguish between a normal and molar pregnancy, but it is used only as a therapeutic intervention. Routine prenatal care would be appropriate only after establishing a normal pregnancy.

valproic acid and preggers effects

neural tube defects

A 41 year-old G3P3 woman reports heavy menstrual periods occurring every 26 days lasting 8 days. The periods have been increasingly heavy over the last three months. She reports soaking through pads and tampons every 2 hours. She has a history of three uncomplicated spontaneous vaginal deliveries and a tubal ligation following the birth of her last child. On pelvic examination, the cervix appears normal and the uterus is normal in size. Which of the following tests or procedures would be most useful in further evaluation of this patient's complaint?

pelvic ultrasound

vaginal delivery is contraindicated in patients with WHAT TYPE OF placenta?

placenta previa. duh.

BRCA1/2 testing when?

premenopausal 1st degree relative

A 38-year-old G4P2 woman was diagnosed with triplets when an ultrasound was performed at 12 weeks gestational age. Which of the following is the most concerning complication for this multiple gestation?

preterm birth

Uterine hyperstimulation may cause

prolonged bradycardia

pruritus gravidarum

pruritus gravidarum a common pregnancy-related skin condition that is a mild variant of intrahepatic cholestasis of pregnancy. There is retention of bile salt, and as serum levels increase they are deposited in the dermis. This, in turn, causes pruritus. The skin lesions are secondary to scratching and excoriation. Antihistamines and topical emollients may provide some relief and should be used initially. Ursodeoxycholic acid relieves pruritus and lowers serum enzyme levels. Another agent reported to relieve the itching is the opioid antagonist naltrexon. Hydroxychloroquine is used to treat lupus and is not indicated in this patient.

you give mag for mom during delivery for htn. look for what in baby?

respiratory distress

hirusitism and on OCPs. NBSIM?

spironolactone. aldosterone antagonist diuretic

terbutaline and ritodrine are CI in what type of patient for tocolytic? What about magnesium sulfate? What about indomethacin?

terbutaline and ritodrine are CI in what type of patient for tocolytic? -Diabetics What about magnesium sulfate? -myastenia gravis What about indomethacin? -CI @ 33 weeks d/t to premature ductus arteriosus closure

A 28-year-old G1 presents for prenatal care. Her periods have been irregular and she does not recall when the last one occurred. She is healthy and denies any medical problems. The uterus is 10 weeks in size and there are no adnexal masses. At this point in time, what is the best way to date the pregnancy?

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

fever, a tender fundus, and elevated white blood cell count, which are concerning for an intra-amniotic infection. Intra-amniotic infcection. CS vs. labor induction?

very 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.