Obsetrics&Gynecology

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 33-year-old G2P1 woman with a singleton pregnancy at 10 weeks gestation asks about weight gain during pregnancy. Her body mass index is 42. What is the recommended weight gain for this patient? A. Maintain current weight; no weight gain B. 10 pounds for the entire pregnancy C. 11-20 pounds for the entire pregnancy d. 25-35 pounds for the entire the pregnancy e. Maintain current weight or lose up to 10 pounds as long as the fetal growth is appropriate

C. The Institute of Medicine (2009 guidelines) and the 2013 ACOG Committee Opinion recommend that obese women with a singleton pregnancy gain 11-20 pounds. The majority of weight gain occurs in the second half of pregnancy.

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

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

A 19-year-old G1 woman at 36 weeks gestation presents for her first prenatal visit, stating she was recently diagnosed with HIV after her former partner tested positive. The HIV Western Blot is positive. The CD4 count is 612 cells/µl. The viral load is 9,873 viral particles per ml of patient serum. Which of the management options would best decrease the risk for perinatal transmission of HIV? A. Treatment with intravenous zidovudine at the time of delivery B. Treatment of the newborn with oral zidovudine only if HIV-positive C. One week maternal treatment with zidovudine now D. Cesarean section in second stage of labor E. Single drug therapy to minimize drug resistance

A. 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.

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

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

A 22-year-old G3P0 woman at 37 weeks gestation with an uncomplicated pregnancy presents to labor and delivery with decreased fetal movements for one day. She denies contractions, loss of fluid, or bleeding. Vital signs are temperature 98.6°F (37.0°C); blood pressure 100/60; pulse 79; respiratory rate 13; fetal heart rate 140s, reactive, with no decelerations. Tocometer reveals one contraction every eight minutes. Fundal height 36 cm, amniotic fluid index is 9. Cervix is firm, long, closed and posterior. What is the next best step in the management of this patient? A. Discharge home with labor warnings B. 24 hour observation C. Biophysical profile D. Contraction stress test E. Induction of labor

A. The patient has reassuring fetal testing and may be discharged home with labor warnings: contractions every five minutes for one hour, rupture of membranes, fetal movement less than 10 per two hours or vaginal bleeding. A reactive non-stress test and normal AFI (modified biophysical profile) are sufficient to assess fetal well being at this time. Additional testing and interventions are not indicated at this time.

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

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

A 28-year-old G0 woman presents to your office for preconception counseling. She has a history of type 1 diabetes, diagnosed at age six, and uses an insulin pump for glycemic control. She has a history of proliferative retinopathy treated with laser. Her last ophthalmologic examination was three months ago. Her last hemoglobin A1C (glycosylated hemoglobin level) six months ago was 9.2%. Which of the following complications is of most concern for her planned pregnancy? A. Fetal growth restriction B. Fetal cardiac arrhythmia C. Group B Streptococcal infection D. Oligohydramnios E. Macrosomia

A. The patient with type 1 diabetes is at risk for many pregnancy complications. 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. Overt diabetic patients are also at an increased risk for fetal growth restriction, although fetal macrosomia may also occur. The former becomes a greater concern as in this patient, with longer-term diabetes and vascular complications, such as retinopathy. Diabetics also have increased risk for polyhydramnios, congenital malformations (cardiovascular, neural tube defects, and caudal regression syndrome), preterm birth and hypertensive complications.

A 34-year-old G2P1 woman presents at 17 weeks gestation. She did not seek preconception counseling and is worried about delivering a child with Down syndrome, given her maternal age. She has no significant medical, surgical, family or social history. Which of the following tests is most effective in screening for Down syndrome in this patient? A. 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

A. 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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A 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.

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 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? A. Increased plasma osmolality B. Use of tocolytics C. Chorioamnionitis D. Preterm labor E. Increased systemic vascular resistance

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

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

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

A 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 24-year-old G2P1 woman at 18 weeks gestation with a history of asthma presents to the office with worsening symptoms, needing to use her inhaler more frequently. The symptoms began with the pregnancy and have gradually increased. She is using her albuterol inhaler as needed, recently three times a day. She denies any illness or fever. She has had asthma since she was a child. On exam, the patient appears comfortable. Her temperature is 100.2°F (37.9°C) and respiratory rate is 18. Auscultation of the lungs shows good air movement with mild scattered end expiratory wheezes. There are no rales or bronchial breath sounds. Which of the following is the most appropriate next step in the management of this patient? A. Oral theophylline B. Subcutaneous terbutaline C. Inhaled corticosteroids D. Oral zafirlukast (leukotriene inhibitor) E. Antibiotic treatment

C. Asthma generally worsens in 40% of pregnant patients. One of the indications for moving to the next line of treatment includes the need to use beta agonists more than twice a week. The appropriate choice for her treatment would be inhaled corticosteroids or cromolyn sodium. Theophylline would be used in more refractory patients. Subcutaneous terbutaline and systemic corticosteroids would be used in acute cases. Zafirlukast, a leukotriene receptor antagonist, is not effective for acute disease. There is little experience with their use in pregnancy, thus the safety of zafirlukast in pregnancy is not well established. Antibiotic treatment is only used when a pulmonary infection is diagnosed.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A 22-year-old G4P1 woman at 26 weeks gestation presents with a postcoital musty odor and increased milky, gray-white discharge for the last week. This was an unplanned pregnancy. She had her first pregnancy at age 15. She reports that she has no new sex partners, but the father of the baby may not be monogamous. On examination, there is a profuse discharge in the vaginal vault, which covers the cervix. Pertinent labs: wet mount pH >4.5 and whiff test positive. Microscopic exam reveals clue cells, but no trichomonads or hyphae. Which of the following is the most appropriate next step in the management of this patient? A. Delay treatment until postpartum B. Treat her now and again during labor C. Treat her now D. Treat her and her partner E. No treatment necessary

C. The patient has bacterial vaginosis. All symptomatic pregnant women should be tested and treatment should be not be delayed because treatment has reduced the incidence of preterm delivery. The optimal regimen for women during pregnancy is not known, but the oral metronidazole regimens are probably equally effective. Once treated antepartum, there is no need to treat during labor unless she is reinfected.

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.

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

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

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

A 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 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.

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

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

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

D. In 1991, the Centers for Disease Control and Prevention recommended that all women with a previous pregnancy complicated by a fetal neural tube defect ingest 4 mg of folic acid daily before conception and through the first trimester. In one analysis, this dose of folic acid in women at high risk reduced the incidence of neural tube defects by 85%. The recommended dose for non-high risk patients is 0.4mg/day.

A 34-year-old G1 woman at eight weeks gestation presents for prenatal care. She is healthy and takes no medications. Family history reveals type 2 diabetes in her parents and brothers. She is 5 feet 2 inches tall and weighs 220 pounds (BMI 40.2 kg/m2). Which of the following is the best recommendation to screen her for gestational diabetes? A. No screening required B. Screen at 24 - 28 weeks with a 50-g oral glucose challenge test C. Screen at 16 - 20 weeks with a 50-g oral glucose challenge test D. Screen now with a 50-g oral glucose challenge test E. Begin an oral hypoglycemic agent now

D. Screening should be performed between 24 and 28 weeks in those women not known to have glucose intolerance earlier in pregnancy. This evaluation can be done in two steps: a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if initial results exceed a predetermined plasma glucose concentration. Patients at low risk are not routinely screened. For those patients of average risk screening is performed at 24 - 28 weeks while those at high risk (severe obesity and strong family history) screening should be done as soon as feasible.

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

D. The patient's gestational age based on her LMP and the findings on physical exam are discordant. In this case, the most reliable method of confirming gestational age is a dating ultrasound. A quantitative Beta-hCG will not reliably predict the gestational age. The uterine size on physical exam is not the most accurate way to date a pregnancy. An ultrasound performed between 14 and 20 weeks gestation should be used to date the pregnancy if there is greater than a 10 day discrepancy from the menstrual dates. First trimester ultrasound provides the most accurate assessment of gestational age and can give an accurate estimated date of confinement (EDC) to within 3-5 days

A 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? A. Oligohydramnios B. Rapid change in descent C. Umbilical cord compression D. Uteroplacental insufficiency E. Head compression

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

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

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

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

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

A 27-year old G3P1 woman is admitted to the orthopedic service after open reduction and internal fixation of her femur status post a motor vehicle accident. Her past medical history is significant for diabetes (controlled with metformin) and a history of a deep venous thrombosis three years ago while taking an oral contraceptive. While inpatient, she has been receiving ibuprofen for pain control and oxycodone for breakthrough pain. Additionally, anticoagulation therapy was began with IV heparin, with a goal of transitioning to warfarin therapy. During her hospital stay, her preoperative labs showed a positive urine pregnancy test and an ultrasound confirmed a six week intrauterine pregnancy. Which of the following medications should be discontinued because of potential teratogenicity? A. Metformin B. Heparin C. Ibuprofen D. Oxycodone E. Warfarin

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

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

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