Unit 15

A 25-year-old G0 woman presents to her doctor for preconception counseling. She is healthy without significant medical problems. She takes no medications. She smokes one pack of cigarettes per day since age 16 and drinks occasionally. She weighs 140 pounds and her vital signs and examination are normal. The patient is at increased risk of which of the following during her pregnancy? A. Fetal chromosomal abnormality B. Breech presentation C. Placental abruption D. Cerebral palsy E. Neural tubal defect

C. Smoking increases the risk of several serious complications of pregnancy, including placental abruption, placenta previa, fetal growth restriction, preeclampsia and infection. Women who smoke should be counseled vigorously to quit smoking prior to conception and to resist restarting after the baby is born.

A 28-year-old G1P1 presents to your office. She delivered four weeks ago and tearfully reports that she is not sleeping, feels anxious and has thoughts of jumping out her 15th floor window. What is the most likely diagnosis? A. Postpartum anxiety B. Postpartum blues C. Postpartum depression D. Postpartum psychosis E. Bipolar disorder

C The patient is describing symptoms of depression. Symptoms such as mood changes, insomnia, phobias and irritability are more pronounced than with the "blues." She has not described any of the even more advanced psychotic symptoms of visual or auditory hallucinations.

A 22-year-old G1 woman is undergoing treatment with magnesium sulfate for severe preeclampsia. She was delivered 10 hours ago via Cesarean section for a non-reassuring fetal heart rate tracing. She has oliguria and appears lethargic. On exam, no deep tendon reflexes can be appreciated. Her magnesium level is 11 mEq/L. Which of the following conditions is most likely to occur in this patient? A. Seizures B. Paralysis C. Respiratory depression D. Pulmonary edema E. Cardiac arrest

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

Review: what is nifedipine?

CCB for PTL tocolysis

Review: what does drug category A mean?

Controlled studies show no risk or find no evidence of harm.

A 29-year-old G1 woman at 31 weeks gestation presents with watery discharge from the vagina commencing several hours ago. Her prenatal course has been uncomplicated and she takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. On examination, her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). Which of the following is the most appropriate next step in the management of this patient? A. Nitrazine testing of mucus swabbed from cervix B. Examination of vaginal fluid for ferning C. Digital examination of cervix D. Determination of amniotic fluid index (AFI) E. Non-stress test

Correct answer is B. Methods to confirm rupture of membranes include testing the vaginal fluid for ferning and nitrazine testing. It is important to test the fluid from the vagina and not to test cervical mucus because of false positive ferning patterns. A digital exam should be avoided in a patient you suspect might have preterm rupture of membranes because of the risk of introducing bacteria into the uterine cavity and increasing risk for chorioamnionitis. Determination of AFI with ultrasound may reveal oligohydramnios and support the diagnosis of rupture of membranes, but does not confirm this diagnosis. Similarly, a non-stress test may reveal variable decelerations, which may be present in the setting of rupture of membranes.

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

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

A 29-year-old G2P1 woman at 39 weeks gestation presents in early labor after spontaneous rupture of the fetal membranes. Thirty minutes after arrival, she delivers a 2650 gram male infant. A globular pale mass appears at the introitus when attempting to deliver the placenta. Her blood pressure is 90/60; pulse 104; and temperature is 98.6°F (37.0°C). What is the most likely etiology for this event in this patient? A. Multiparity B. Twin gestation C. Leiomyoma D. Uterine inversion E. Rapid labor

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

A 34-year-old G1P0 woman presents with vaginal spotting. An ultrasound confirms a non-viable intrauterine pregnancy. She is otherwise healthy. Her partner accompanies her and is supportive. The patient wishes to avoid any unnecessary medical interventions and asks whether she can safely let nature take its course. What is the best next step in the management of this patient? A. Immediate dilation and suction curettage B. Dilation and suction curettage in one week C. Immediate treatment with misoprostol D. Treatment with misoprostol in one week E. Expectant management

E. Expectant management Patients experiencing early pregnancy loss can safely consider several different treatments, including expectant management, medical treatment to assist with expulsion of the pregnancy or surgical evacuation. Provided the patient is hemodynamically stable and reliable for follow-up, expectant management is appropriate therapy. At the gestational age described, expectant management portends no increase in risk of either hemorrhage or infection compared with surgical or medical evacuation. Regardless of method chosen, the patient's blood type should be checked and rhogam administered as indicated.

Review: what is the treatment for BV?

Metronidazole

Review: what are abortions that have fetal demise without cervical dilation or passage of POCs?

Missed abortion

Review: Does expectant management confer risk for infection?

No

Review: does a history of preeclampsia confer risk for spontaneous abortion?

No

Review: is terbutaline effective after 48 hours?

No -- both ineffective and dangerous if used for longer than 48 hours

Review: indomethacin is contraindicated at 33 weeks because of what reason?

Risk of ductus arteriosus closur

Review: do partners of patients with BV need treatment? Why or why not?

The partners do not need treatment. No germ (bacterium) is passed on between sexual partners to cause this condition. Often BV develops with a change in sexual partner

Review: What is the most common chromosomal aneuploidy in abortuses?

Tri. 16

Review: what is most important cause of sepsis in a pregnant woman?

UTI/pyelonephritis

Review: how do you diagnose appendicitis in pregnancy?

Via graded compression ultrasound

Review: does alcohol increase rate of spontaneous abortion?

Yes

Review: does radiation increase rate of spontaneous abortion?

Yes

Review: does smoking increase rate of spontaneous abortion?

Yes

Review: What causes asymmetrical IUGR? What causes symmetrical IUGR?

asymmetrical IUGR - uteroplacental insufficiency symmetrical IUGR - infection, aneuploidy, 1+ organ system anomaly

review: define Culdocentesis

extraction of fluid from the rectouterine pouch posterior to the vagina through a needle to diagnose PID or ectopic

Review: mag sulfate is contraindicated in which patients?

myasthenia gravis

A. What does the fetal heart rate tracing seen below show?

Earlyl decels

Review: what are first line agents for high BP in pregnancy?

Hydralazine Labeteolol

Review: why should you treat BV early during pregnancy?

Increased risk for PTL

Review: what is antiphospholipid antibody syndrome?

Increases risk of clots that can lead to increased risk of recurrent miscarriage, intrauterine growth restriction, and preterm birth

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. Treatment with intravenous zidovudine at the time of delivery Correct answer is 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.

Review: which diseases are associated with early pregnancy loss?

1. T1DM -- increased rates of spontaneous abortion, major congenital malformations. Risk is related to degree of metabolic control in first trimester 2. CKD 3. Lupus

Review: what is the criteria for SIRS?

1. Temp > 38 (100.4) or < 36 (96.8) 2. HR > 90 3. RR > 20 or PCO2 < 32 mmHg 4. WBC > 12,000, < 4000, or > 10% bands

Review: what are the conditions to administer methotrexate?

1. hemodynamically stable 2. nonruptured ectopic 3. size < 4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate 4. normal liver enzymes and renal function 5. normal white cell count 6. the ability of the patient to follow up rapidly (reliable transportation, etc.), if her condition changes.

Review: which systemic diseases need to ruled out in recurrent SAB?

1. lupus 2. thyroid 3. T1DM 4. Maternal and paternal karyotypes 5. Infection 6. Uterine anomalies

Review: what is definitive surgery for breast cancer during pregnancy without metastatic disease?

1. wide excisional biopsy, modified radical mastectomy, total mastectomy with axillary node staging.

Review: how many successive spontaneous abortions does someone have when it is called recurrent abortion?

3

Review: what is normotensive in pregnancy?

< 140/90

A 29-year-old G1P0 woman at 41 weeks gestation presents in early labor. The prenatal course was uncomplicated. Ultrasound at 21 weeks was consistent with gestational age. Her vital signs reveal a blood pressure of 128/76; pulse 74; and she is afebrile. Fundal height is 36 cm with estimated fetal weight of 2700 gm. Cervix is dilated to 1 cm, 50% effaced and the fetal vertex is at -2 station. The fetal heart tracing is shown below. Which statement best describes this tracing? A. Normal fetal heart rate with good variability and regular contractions B. Fetal tachycardia with good variability and regular contractions C. Normal fetal heart rate with poor variability and regular contractions D. Fetal tachycardia with poor variability and irregular contractions E. Normal fetal heart rate with poor variability and irregular contractions

A

A 25-year-old G2P1 woman presents at 26 weeks gestation with preterm labor. She is currently receiving tocolytic therapy with magnesium sulfate. The patient's nurse is concerned the patient may have magnesium sulfate toxicity. The patient is alert and has no complaints. Her contractions have stopped and her vital signs are stable. Which of the following findings associated with magnesium sulfate treatment would this patient experience before she develops respiratory depression? A. Areflexia B. Hyperreflexia C. Tachycardia D. Hypertension E. Oligouria

A High levels of magnesium sulfate may cause respiratory depression (12-15 mg/dl) or cardiac depression (>15 mg/dl). Prior to developing respiratory depression the patient should have diminished or absent deep tendon reflexes (areflexia).

A 35-year-old woman presents to the emergency department with heavy vaginal bleeding at seven weeks gestation. On examination, she has a dilated cervix with blood and tissue present at the cervical os. Which of the following is the most likely chromosomal abnormality to be found in the karyotypic evaluation of the products of conception? A. Autosomal trisomy B. Triploidy C. Tetraploidy D. Monosomy X (45X,0) E. Fragile X mutation

A. Autosomal trisomy

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. Fetal growth restriction 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 19-year-old G1 woman presents in labor at term. Her prenatal course was uncomplicated. She delivers a 3500 gram infant spontaneously after oxytocin augmentation of labor. Postpartum, she experiences excessive bleeding. Which of the following defines postpartum hemorrhage in this patient? A. Greater than 500 cc B. Greater than 750 cc C. Greater than 1000 cc D. Greater than 1500 cc E. Any amount of bleeding that leads to hypovolemia

A. Greater than 500 cc Postpartum hemorrhage is defined as bleeding in excess of 500 cc after a vaginal delivery or in excess of 1000 cc after a Cesarean delivery.

Review: what safety category are the following drugs? A. Levothyroxine B. Labetalol C. Acyclovir D. Lisinopril E. Amitriptyline

A. Levothyroxine -- Category A B. Labetalol -- Category C C. Acyclovir -- Category B D. Lisinopril -- Category D E. Amitriptyline -- Category C

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

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

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

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

A 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)

A. Paroxetine (Paxil) This patient has classic depression. The most commonly used antidepressants are the selective serotonin reuptake inhibitors (SSRIs.) One SSRI, Paroxetine (Paxil) has recently been changed to a category D drug because of the increased risk of fetal cardiac malformations and persistent pulmonary hypertension. The older SSRI compounds, fluoxetine and sertraline, have not been reported to cause early pregnancy loss or birth defects in animals or in humans. Because these agents have few side effects compared with other antidepressants, they are a good choice for pregnant women. Tricyclic antidepressants have a long record of use in pregnancy and there is no increase in the rate of fetal malformation. Bupropion is not an MAO inhibitor, nor is it an SSRI and a report by the Bupropion Pregnancy Registry reports no unusual effects in 90 exposed pregnancies.

A. Analyze FHT. A. Normal fetal heart rate pattern B. Sinusoidal rhythm C. Late deceleration D. Variable deceleration E. Early deceleration

C

A 20-year-old G1P1 woman delivered her first baby 24 hours ago. Delivery was uncomplicated and she had an epidural placed for analgesia at 5 cm of cervical dilation. Earlier in the afternoon, she was complaining of a headache and was given ibuprofen. Three hours later, she complained of increasing headache, photophobia and nausea. She denies heavy bleeding. Vital signs are pulse 110; respirations 20; temperature 101.5° F (38.6° C); and blood pressure 100/50. Physical examination reveals obvious distress, as she has her eyes covered and pain when she moves her neck. Her lungs are clear and heart has a regular rate. Her abdomen is nontender, and uterine fundus is easily palpable just below the umbilicus and is nontender. Her extremities reveal no erythema, swelling or tenderness. Which of the following would most helpful to establish a diagnosis in this patient? A. Chest x-ray B. Urinalysis C. Lumbar puncture D. CBC with differential E. Pelvic ultrasound

C. Lumbar puncture Epidurals are used commonly for pain relief during labor. Complications of epidural include spinal headache, localized back pain and meningitis. Symptoms of meningitis progress rapidly and require aggressive treatment with antibiotics. Diagnosis is made with evaluation of the cerebral spinal fluid from a lumbar puncture.

A 32-year-old G3P0 woman presents to the clinic for preconception counseling. Her prior three pregnancies resulted in first trimester losses. Which of the following tests should be ordered for this patient? A. Adrenal stimulation test B. Clomiphene citrate-FSH challenge test C. Lupus anticoagulant test D. Pelvic MRI E. CT scan of the pelvis

C. Lupus anticoagulant test It is important to rule out systemic disease in a patient with recurrent abortion (three successive first trimester losses). Testing for lupus anticoagulant, diabetes mellitus and thyroid disease are commonly performed. Maternal and paternal karyotypes should also be obtained. Infectious causes should also be considered. Uterine imaging to exclude a septum or other anomaly is routinely done using hysteroscopy or hysterography and not CT or MRI scanning. There is no role for clomiphene citrate-FSH challenge in the evaluation of this patient.

A 33-year-old G2P1 with a known twin gestation presents to your office at 23 weeks gestation and notes that two days prior she had a nosebleed. She has not been seen in your office for the last seven weeks. Ultrasound today shows a demise of one twin that has measurements consistent with 21 weeks gestation. What is the next step in the management of this patient? A. Immediate delivery of the surviving twin B. Continued management as a singleton pregnancy C. Maternal fibrinogen level D. Abdominal x-ray to assess for Spalding's sign E. Nonstress test of the surviving twin

C. Maternal fibrinogen level Correct answer is C. The incidence of the death of one twin in-utero is 2-7%. When a dead fetus has been in utero for three to four weeks, fibrinogen levels may decrease, leading to a coagulopathy. The patient's nosebleed may be a common pregnancy finding or be related to the demise, and a coagulopathy must be ruled out. Induction should be considered, but may be delayed after the death of a twin in order to allow the viable twin to mature. In these cases, fibrinogen levels should be monitored to detect a progressive coagulopathy. Usually this is performed weekly or biweekly, depending on the levels obtained. Spalding sign is an overlapping of fetal skull bones suggesting a fetal demise. It is not necessary to do an x-ray, since the diagnosis was confirmed on ultrasound and it would give unnecessary radiation exposure to the surviving twin. Although an ultrasound to assess fetal well-being of the surviving twin would be very helpful, at this gestational age and in a twin pregnancy a non-stress test would be less so.

Review: what problems in pregnancy do diabetics have?

1. Fetal growth restriction 2. Fetal macrosomia 3. Polyhydramnios 4. Congenital malformations (cardiovascular, neural tube defects, and caudal regression syndrome) 5. Preterm birth 6. hypertensive complications

Review: what is the criteria for severe sepsis?

1. Lactic aciosis 2. SBP < 90 or SBP drop >= 40 mmhg of normal

Review: how do ACEi cause fetal malformations?

1. Shut down baby's kidneys

Review: what is lisinopril?

ACEi

A 25-year-old G0 woman presents to the clinic for follow-up after having a first trimester spontaneous abortion. She wants to discuss the cause of this event. Which of the following etiologic categories accounts for the majority of first trimester spontaneous abortions? A. Immunologic abnormalities B. Conceptus genetic anomalies C. Maternal genetic anomalies D. Structural/uterine anomalies E. Uterine infections

B. Conceptus genetic anomalies

A 25-year-old G4P1 woman with a previous term delivery presents to the emergency department at 7 1/2 weeks gestation with vaginal bleeding. She has not passed any tissue. On examination, there is blood in the vault and cervical os is closed. Ultrasound confirms an intrauterine pregnancy and fetal cardiac activity is noted. Which of the following diagnoses most accurately describes her condition? A. Incomplete abortion B. Missed abortion C. Threatened abortion D. Complete abortion E. Recurrent abortion

C. Threatened abortion

Review: what does drug category D mean?

Category D: There is positive evidence of potential fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (i.e. life threatening condition to mother)

A 19-year-old G2P1 woman at 30 weeks gestation presents with preterm premature rupture of membranes six hours ago. She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior pregnancy was delivered vaginally at 41 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). Pertinent sonographic findings reveal a cervical length of 34 mm and an amniotic fluid index (AFI) of 3. What is the likelihood she will deliver within a week? A. 80% B. 40% C. 20% D. 10% E. 5%

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

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

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

A 19-year-old G1P0 woman presents to the hospital at 25 weeks gestation with vaginal bleeding for the past hour. She had intercourse earlier without discomfort. Currently she denies cramping or pain and feels the baby moving. Her prenatal course has been uncomplicated. She takes no medication besides prenatal vitamins and denies smoking, alcohol or drug use. Her vital signs are: blood pressure 110/70; pulse 68; and she is afebrile. Her abdomen and uterus are soft and non-tender. Fetal heart tones are in the 150s. Which of the following is the most appropriate next step in the management of this patient? A. Digital cervical examination B. Biophysical profile C. Pelvic ultrasound D. Blood transfusion E. Bed rest

C. Pelvic ultrasound An ultrasound should be performed to check for abnormal placentation. A biophysical profile is not appropriate in this patient. Placenta previa must be ruled out before proceeding with digital cervical examination because of the risk of injury to the placenta and hemorrhage. Bleeding from placenta previa often is without warning or pain.

Review: What are the stages of response to a fetal death?

Denial, Anger, Bargaining, Depression, Acceptance.

Review: Terbutaline and Ritodrine are contraindicated in which patients?

Diabetic patients

Review: what are abortions that have passed some, but not all, of the products of conception?

Incomplete abortion

Review: what is a clomiphene citrate-FSH challenge?

Looks to see how responsive the ovaries are to FSH. Determines ovarian reserve.

Review: what are the options for the treatment of syphilis in pregnancy?

Penicillin

Review: when breast cancer is diagnosed during pregnancy, regional LN are more like to contain what?

microscopic metastases

Review: signs of fraternal twins

1. Lambda sign 2. different fetal genders 3. two separate placentas (anterior, posterior) 4. dividing membranes > 2mm

Review: what are AE of lisinopril to fetus?

1. Oligo 2. Fetal growth retardation 3. neonatal renal failure 4. hypotension 5. pulm hypoplasia 6. joint contractures 7. death

Review: what is the criteria for septic shock?

1. Severe sepsis with 2. Hypotension despite 3. Adequate fluid resuscitation

Review: why would you repeat the b-hCG in this case?

1. She needs a definitive diagnosis. Ectopic will be diagnosed by --inappropriately rising bHCGs --bHCGs levels do not fall after D/C --fetal pole seen outside of uterus -- Beta-hCG level over the discriminatory zone but no IUP seen on ultrasound

Review: What should you do in a patient who has a penicillin allergy but needs penicillin for syphilis treatment in pregnancy?

1. Test skin to confirm risk of IgE-mediated anaphylaxis 2. If skin tests are reactive, then penicillin desensitization is recommended followed by intramuscular benzathine penicillin G treatment.

Review: What is progesterone level for healthy pregnancy?

> 25

Review: what is the requirement for mild preeclampsia?

> 300 mg/24 h or > 1 or >2 on dipstick BP > 140/90

Review: what is the definition for marcosomia in a diabetic? non-diabetic?

> 4000 g > 4500 g

Review: what is the requirement for severe preeclampsia?

> 5 mg/24 h or >3+ on dipstick BP > 160/110

A 29-year-old G1P0 at 42 weeks gestation presents in labor. She denies ruptured membranes. Her prenatal course was complicated by chronic hypertension. Her vital signs are: blood pressure 130/80; pulse 72; afebrile; fundal height 36 cm; and estimated fetal weight of 2400 gm. Cervix is dilatedto 4 cm, 100% effaced, -1 station, and bulging bag of water. The fetal heart rate tracing reveals five contractions in 10 minutes and repetitive late decelerations. What is the most likely cause of her late decelerations? A. Uteroplacental insufficiency B. Umbilical cord compression C. Uterine hyperstimulation D. Occiput posterior position E. Fetal head compression

A Late decelerations when viewed as repetitive and/or with decreased variability are an ominous sign. The can be associated with uteroplacental insufficiency as a result of decreased uterine perfusion or placental function, thus leading to fetal hypoxia and acidemia. Common causes include chronic hypertension and postdate pregnancies. Variable decelerations are associated with cord compression. Uterine hyperstimulation may cause prolonged bradycardia. Occiput posterior position should not be the cause of late decelerations. Fetal head compression may be associated with early decelerations.

A 27-year-old G1 presents to labor and delivery and is found to have a fetal demise at 34 weeks gestation. She did not have access to prenatal care during the pregnancy. Her vital signs are normal and she is not in labor. Her uterus is non-tender and she does not have any vaginal bleeding or ruptured membranes on exam. Which untreated condition is the most likely cause? A. Diabetes B. Anemia C. Hypothyroidism D. Herpes E. Rh-isoimmunization

A Uncontrolled glucose is associated with adverse fetal outcome. A patient with type 1 diabetes is at risk for many pregnancy complications, including fetal death and fetal macrosomia, although fetal growth restriction may also occur. Diabetics also have increased risk for polyhydramnios, congenital malformations (cardiovascular, neural tube defects, and caudal regression syndrome), preterm birth, and hypertensive complications. The anemia most often seen in pregnancy is mild and would not be the most likely cause. It is unlikely that she has an abruption causing the anemia, but this should be considered. Hypothyroidism is usually associated with menstrual irregularities and infertility, and is a less likely cause. Rh sensitization is unlikely since this is her first pregnancy and she did not have any bleeding or procedures during the pregnancy.

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

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

A 28-year-old G1 at approximately 40 weeks gestation presents to triage with mild contractions. You measure her fundal height at 34 cm. You are concerned about intrauterine growth restriction and you want to confirm her dates. In reviewing her records, she reports first feeling fetal movements at 18 weeks gestation. The crown-rump length measurements determined at eight weeks and femur length at 20 weeks are consistent with 40 weeks gestation. Today's assessment reveals biometrics consistent with 34 weeks, amniotic fluid index of 1, and placental calcifications. Which of the following is considered the most reliable method of determining the gestational age in this patient? A. Crown-rump length measurement B. Second trimester ultrasound C. Quickening date D. Third trimester composite biometry E. Placental calcifications

A In order to accurately confirm gestational age at term, one of the following criteria should be met: Fetal heart tones 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. The crown-rump length can reliably date a pregnancy within five to seven days.

A 27-year-old patient with no significant prior medical history reports three months of low energy, lack of enjoyment with her daily activities, early morning awakening, and trouble concentrating. What is the next best step in the assessment of this patient? A. Risk of suicide B. Willingness to accept medical treatment C. Family history of mental illness D. Good support system E. Current medication profile

A Most depressed patients who are suicidal are relieved to be asked about it. Although all the items listed are components of a complete history, the most important topic is assessment of suicide risk.

A 29-year-old G1 is at 42 weeks gestation based on her last menstrual period and a first trimester ultrasound. Of the following, what factor is most likely to be associated with postterm pregnancy? A. Placental sulfatase deficiency B. Fetal adrenal hyperplasia C. Fetal alpha-fetoprotein deficiency D. Fetal renal anomalies E. Fetal chromosomal abnormalities

A Postterm pregnancies are associated with placental sulfatase deficiency, fetal adrenal hypoplasia, anencephaly, inaccurate or unknown dates and extrauterine pregnancy.

A 25-year-old G2P1 woman at 20 weeks gestation is diagnosed with preterm premature rupture of the membranes. She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior pregnancy was delivered vaginally at 36 weeks after preterm rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). The patient's fetus is greatest risk for which of the following? A. Pulmonary hypoplasia B. Cardiac anamolies C. Urinary tract anamolies D. Microcephaly E. Compression fractures

A Preterm premature rupture of the membranes that occurs before viability is associated with significant risk of poor outcome. Neonatal survival when rupture occurs between 20 and 23 weeks is approximately 25%. Complications that may be found in the developing fetus include structural abnormalities that are primarily deformations (abnormalities that occur due to an insult after a structure has already formed) rather than malformations (abnormal development of the structure itself). Pulmonary hypoplasia is seen when rupture of membranes occurs before 25 weeks gestation because the lack of amniotic fluid interferes with the normal intrauterine breathing process. The result is failure of normal development and growth of the respiratory tree.

A 29-year-old G1P0 at 41 weeks gestation presents for a prenatal visit. Her prenatal course is complicated by tobacco abuse and intermittent prenatal care. Her last visit was at 35 weeks. Prenatal labs are unremarkable except cervical DNA probe positive for Chlamydia, which was treated, and a Pap smear with low-grade squamous intraepithelial lesion. Ultrasound at 21 weeks was consistent with gestational age. Her vitals reveal a blood pressure of 128/76; pulse 74; and temperature 98° F (36.7° C). Fundal height is 39 cm with estimated fetal weight of 2700 gm. Cervix is dilated to 1 cm, 50% effaced, -2 station. What is the next best step in the management of this patient? A. Non-stress test B. Vibroacoustic stimulation test C. Oxytocin challenge test D. Return visit in one week E. Cesarean section

A The non-stress test is an assessment of fetal well-being that measures the fetal heart rate response to fetal movement. The normal or reactive non-stress test occurs when there are two fetal heart rate accelerations of 15 beats/minute for 15 seconds within 20 minutes. Vibroacoustic stimulation is not indicated unless the NST is non-reactive. Contraction stress test assesses uteroplacental insufficiency and looks for persistent late decelerations after contractions (3/10 minutes); however, it is not necessary to perform, as the non-stress test will assess fetal well being, as well. Observation only would not be proper care as the patient is post-term. In the presence of abnormal testing, labor would be induced or a Cesarean section performed.

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

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

A 36-year-old female G1 presents for her prenatal care visit at 35 weeks gestation. She has good dating criteria that were confirmed by a first trimester ultrasound. Her previous medical history is positive for hypertension and type 2 diabetes. You have been following fetal growth with serial ultrasounds. At this visit, ultrasound reveals limited fetal growth over the past three weeks. Biometry is consistent with 32-5/7, EFW 2175 g, <10th percentile. What is the most appropriate next test indicated in the management of this patient? A. Amniotic fluid volume, umbilical artery Doppler systolic: diastolic ratio, non-stress test B. Daily fetal kick counts with follow up ultrasound to reassess fetal growth in one week C. Amniocentesis for fetal lung maturity D. Twice daily fetal kick counts with delivery at 37 weeks gestation E. None, delivery is indicated

A When a pregnancy is complicated by fetal growth restriction, various fetal physiologic parameters require assessment. In growth-restricted pregnancies, oligohydramnios is frequently found. This finding is presumably due to reduced fetal blood volume, renal blood flow and urinary output. Chronic hypoxia is responsible for diverting blood flow from the kidney to organs that are more critical during fetal life. The significance of the amniotic fluid volume with respect to fetal outcome has been well documented. Ninety percent of patients with oligohydramnios delivered growth restricted infants. These infants experienced a high rate of fetal compromise. The systolic/diastolic (S/D) ratio of the umbilical artery is determined by Doppler ultrasound. An increase in the S/D ratio reflects increased vascular resistance. It is a common finding in IUGR fetuses. A normal S/D ratio indicates fetal well-being. As vascular resistance increases, the S/D ratio increases. With severe resistance, there is absence and ultimately reversal of end-diastolic flow. These findings are associated with an increased rate of perinatal morbidity and mortality, and a higher likelihood of a long-term poor neurologic outcome. Options for antenatal testing include the non-stress test, contraction stress test, and the biophysical profile. Any of these may be used in a growth-restricted fetus as a means of detecting possible or probable fetal asphyxia. While fetal kick counts may be of value, additional fetal testing such as twice weekly NST with AFI and weekly umbilical artery Doppler studies is indicated in monitoring fetuses with IUGR.

A 26-year-old G2P0 woman presents for counseling following manual vacuum aspiration of an eight-week missed abortion. The patient asks whether an uncomplicated first trimester pregnancy termination three years ago might have predisposed her to the subsequent spontaneous abortion. What are the patient's risks associated with the prior surgical abortion in the first trimester? A. Does not predispose the patient to subsequent spontaneous abortion B. Increases the risk of spontaneous abortion two-fold C. Predisposes the patient to primary infertility D. Increases the likelihood of subsequent pregnancy loss in both the first and second trimesters E. Increases the likelihood of spontaneous abortion and future delivery complications

A. Does not predispose the patient to subsequent spontaneous abortion Neither controlled trials nor surveillance data support the contention that a single, prior first trimester surgical abortion increases the risk of subsequent first trimester pregnancy loss. Indeed, first trimester surgical abortion confers no subsequent obstetric disadvantage, particularly when compared with an appropriate control population. The clinician should reassure this patient that first trimester spontaneous abortion is a common occurrence and that she has not caused this missed abortion.

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

A. Methotrexate

A 27 year-old G1P0 at 22 weeks gestation with systemic lupus erythematosus (SLE) presents complaining of malaise, joint aches, and fever. Physical examination reveals the following: pulse 88, temperature 98.6°F (37.0°C), respiratory rate of 22, and BP 150/110 (baseline is 100/70.) Laboratory analysis reveals 1 + proteinuria, AST 35, and ALT 28. Which of the following is the most appropriate initial therapy for the treatment of this patient? A. steroids B. nonsteroidal anti-inflammatory drugs (NSAIDs) C. azathioprine D. cyclophosphamide E. magnesium sulfate

A. Steroids Lupus is notoriously variable in its presentation, course, and outcome. Clinical manifestations include malaise, fever, arthritis, rash, pleuropericarditis, photosensitivity, anemia, and cognitive dysfunction. A significant number of patients have renal involvement. There is no cure, and complete remissions are rare. Mild disease may be disabling because of pain and fatigue. Nonsteroidal anti-inflammatory drugs are used to treat arthralgia and serositis. Severe disease is managed with corticosteroids. Hydroxychloroquine is used to help control skin manifestations and may be associated with lupus flares if discontinued.

Review: what does drug category C mean?

Animal studies have shown risk to the fetus, there are no controlled studies in women, or studies in women and animals are not available.

Review: what does drug category B mean?

Animal studies show no risks, but there are no controlled studies on pregnant women.

A 32-year-old G2P1 woman at 36 weeks gestation presents with preterm premature rupture of the membranes. She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior pregnancy delivered vaginally at 34 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). The estimated fetal weight is 2700 grams. She is having one contraction per hour and fetal heart tracing is category I. Which of the following is the most appropriate next step in the management of this patient? A. Observation until spontaneous onset of labor B. Augmentation of labor C. Magnesium sulfate D. Nifedipine E. Corticosteroids

B In this patient, the benefits for delivery outweigh the risk of expectant management, so the patient should undergo augmentation of labor. Expectant management at 36 weeks poses a large risk to the development of chorioamnionitis. The role of tocolytics in the setting of preterm premature rupture of membranes is controversial and is contraindicated at 36 weeks gestation. Steroid administration after 32 weeks is controversial.

A 30-year-old G2P1 woman with last menstrual period 10 weeks ago presents for her first prenatal care visit. She is healthy and takes no medications. Her previous pregnancy was an uncomplicated vaginal delivery at 39 weeks. On examination, her vital signs are normal. Her exam is notable for a uterus measuring 14 weeks gestation. Ultrasound shows a diamniotic monochorionic twin gestation at 10 weeks. Which of the following obstetrical complications is more likely in this pregnancy compared to her previous pregnancy? A. Low maternal weight gain B. Congenital anomalies C. Induction after 40 weeks D. Macrosomia E. Rh isoimmunization

B The incidence of congenital anomalies is increased in twins, particularly monozygotic twins, compared to singletons. The majority of twin pairs in which an anomaly is present will be discordant for the anomaly. Twin gestations tend to deliver earlier than singleton gestations, with the average length of twin gestation being 35-37 weeks. The optimal length of twin gestation is a matter of some controversy. An observational study comparing perinatal mortality among twin and singleton gestations showed that perinatal mortality reached a nadir at 37-38 weeks in twins and then increased. There have been no prospective studies to demonstrate that induction of labor after 38 weeks in twin gestations improves perinatal outcome. Twins typically weigh less than singletons of the same gestational age, but their weights usually remain within the normal range. Macrosomia is, therefore, uncommon.

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

B A maternal blood type should be checked on all women with vaginal bleeding during pregnancy, unless it was documented earlier in the pregnancy. If the patient's blood type is Rh-negative, RhoGAM would be indicated to prevent Rh sensitization. Serial quantitative beta-hCGs can be useful in confirming an ongoing pregnancy before fetal heart rate activity can be noted, but in this case there is a non-viable intrauterine pregnancy. The patient is unlikely to have had significant blood loss making a blood or platelet count unlikely to be necessary at this time. Although progesterone levels can be useful in determining if a pregnancy is failing, the diagnosis is already clear in this case.

A 24-year-old G1P1 just delivered a healthy infant at term. She has a history of a psychiatric disorder and was treated for depression while in college. Which of the following is she at most increased risk for in the postpartum period? A. Postpartum blues B. Postpartum depression C. Postpartum psychosis D. Postpartum anxiety E. She is not at increased risk for a psychiatric disorder

B A patient's history of a psychiatric illness is a risk factor for the development of a postpartum depression. Patients with a prior history of depression, either situational or spontaneous, are at very high risk for postpartum depression. In fact, one-third of patients with a postpartum psychiatric problem report a prior history. These patients need careful follow up after delivery, which should include an early appointment for a postpartum visit. Questions at this time should be directed to her moods and thoughts.

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

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

A 19-year-old G2P1 woman presents with vaginal spotting and uterine cramping. Her last normal menstrual period was six weeks ago and she began spotting three days ago. She has no history of sexually transmitted infections. Her vital signs are blood pressure 120/70; pulse 78; respirations 20; and temperature 98.6 °F (37.0°C). On pelvic examination, she has no cervical motion tenderness, her uterus is normal size and non-tender; no adnexal masses are palpable. Quantitative Beta-hCG 48 hours ago was 1500 mIU/ml. Currently, Beta-hCG is 3100 mIU/ml. Progesterone is 26 ng/ml; hematocrit is 38%; and urinalysis is normal. What is the most likely finding on transvaginal ultrasound? A. Debris in uterus B. Viable intrauterine pregnancy C. Adnexal mass, empty uterus D. No adnexal mass, empty uterus E. Non-viable intrauterine pregnancy

B Correct! Transvaginal ultrasound will most likely show an intrauterine pregnancy. The Beta-hCG level is above the discriminatory zone for ultrasound (2000 mIU/ml), and the level has doubled in 48 hours. Additionally, the progesterone level is within expected range for a normal pregnancy (>25 ng/ml suggests healthy pregnancy) and up to 30% of all normal pregnancies experience first trimester spotting/bleeding. The findings of debris in the uterus, an empty uterus, with or without an adnexal mass, or free fluid (suggesting hemoperitoneum) would not be anticipated.

A 34-year-old patient is diagnosed with a fetal demise at 37 weeks. She and her husband seem stunned. They cannot believe the news. What is the next psychological response you would expect from this couple after the initial denial? A. Ambivalence B. Anger C. Assessment D. Annoyance E. Acceptance

B Couples who are presented with the news of a fetal birth defect or loss progress through a series of coping responses. The response to "bad news" varies with the severity, treatability and the coping level of the couple. As an individual starts to understand the situation, frustration or anger may be self-directed or directed to the spouse, the affected child or the caregiver without a rational basis. This is important to recognize to help the couple through these stages: Denial, Anger, Bargaining, Depression, Acceptance.

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

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

A 19-year-old G2P1 woman at 28 weeks gestation has been diagnosed with preterm labor. Her physician has chosen to treat her with magnesium sulfate. By what mechanism of action does magnesium sulfate work as a tocolytic? A. Decreases prostaglandin (PG) production B. Competes with calcium for entry into cells C. Increases cAMP in the cell D. Blocks calcium entry into muscle cells E. Inhibits calcium transport

B Magnesium sulfate works by competing with calcium entry into cells. Beta-adrenergic agents work by increasing cAMP in the cell, thereby decreasing free calcium. Prostaglandin synthetase inhibitors, such as Indomethacin, work by decreasing prostaglandin (PG) production by blocking conversion of free arachidonic acid to PG. Calcium channel blockers prevent calcium entry into muscle cells by inhibiting calcium transport.

A 32-year old G1 woman at 29 weeks gestation presents with preterm labor. She is started on indomethacin. What is a possible adverse fetal effect associated with indomethacin treatment? A. Polyhydramnios B. Premature constriction of the ductus arteriosus C. Fetal growth restriction D. Hypoxia E. Chorioamnionitis

B Maternal indomethacin exposure can result in premature constriction of the ductus arteriosus, especially if used after 32 weeks gestation. Polyhydramnios is not associated with indomethacin. In fact, indomethacin is associated with oligohydramnios. Fetal hypoxia and decreased uteroplacental blood flow have been associated with the use of calcium channel blockers, such as Nifedipine. Indomethacin should not cause chorioamnionitis.

A 36-year-old G1 woman presents in active labor. Her past medical history and prenatal course were complicated by chronic hypertension and superimposed preeclampsia. She received magnesium sulfate for seizure prophylaxis and oxytocin augmentation. She undergoes an uneventful spontaneous vaginal delivery. Postpartum, she has a 1000 ml hemorrhage due to uterine atony. Her blood pressure is 130/80; pulse 96; and she is afebrile. Which of the following uterotonic agents is contraindicated in this patient? A. Oxytocin B. Methylergonovine C. Prostaglandin F2-alpha D. Prostaglandin E2 E. Misoprostol

B Methergine, prostaglandins and oxytocin are all uterotonics and used to increase uterine contractions and decrease uterine bleeding. Methylergonovine is an ergot alkaloid, which is a potent smooth muscle constrictor. It is also a vasoconstrictive agent and should be withheld from women with hypertension and/or preeclampsia. Misoprostol, non-FDA approved, is used for cervical ripening and labor induction.

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. The laceration was repaired in layers in the customary fashion. She now complains of increasing perineal pain, 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 and the laceration edges are grey. The laceration site is nontender and without feeling but there is tenderness of the surrounding tissue. What is the most likely etiology for her fevers? A. Endomyometritis B. Necrotizing Fascitis C. Cellulitis D. Hematoma E. Proctocolitis

B Necrotizing fascitis, a dangerous infection caused by gas forming organisms, such as Clostridium, can quickly cause sepsis and death. Classic clinical manifestations include fever, pain and induration of the wound. Treatment involves early recognition, antibiotics and debridement of the necrotic tissue. Classic clinical findings for endomyometritis include fever and maternal tachycardia, uterine tenderness and no other localizing signs of infection. Cellulitis presents as swollen, erythematous, tender and warm area, but without grey necrotic edges. Hematoma findings include a swollen, tender and painful area that may be expanding.

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

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

A 22-year-old G1P1 with no prenatal care delivered a 2100 g male infant who looks like an old man. The pediatricians estimate the gestational age to be greater than 43 weeks. Of the following, which finding is not associated with the dysmature postdate infant? A. Peeling skin B. Smooth skin C. Meconium-stained D. Long nails E. Fragile

B The incidence of infants with dysmaturity approaches 10% when the gestational age exceeds 43 weeks. Infants are described as withered, meconium stained, long-nailed, fragile and have an associated small placenta. These infants are at great risk for stillbirth.

A 28-year-old G1P1 presents to your office. She delivered four days ago and tearfully reports that yesterday and the day before she had trouble sleeping, felt anxious and was irritable. She feels somewhat better today, but is still concerned. What is the most likely diagnosis? A. Hypothyroidism B. Blues C. Depression D. Normal postpartum state E. Anxiety

B The patient is describing symptoms of postpartum blues that affects 50% women within three to six days postpartum. Symptoms include insomnia, easy crying, depression, poor concentration, irritability or labile affect and anxiety. Symptoms often last a few hours per day and are mild and transient. "Blues" are probably related to biochemical changes of puerperium. Postpartum depression symptoms, such as mood changes, insomnia, phobias and irritability are more pronounced than with the "blues."

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

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

A 35-year-old G1P0 woman with a known twin gestation undergoes an ultrasound evaluation at 18 weeks. She would like to know if her twins are identical or fraternal. Which ultrasound marker is suggestive of dizygotic (fraternal) twins? A. Increased amniotic fluid volume in one of the twins B. Two separate placentas (anterior and posterior) C. Dividing membranes less than 1 mm D. Concordant growth of the twins E. Twin-twin transfusion syndrome

B Ultrasound markers suggestive of dizygotic (non-identical) twins include a dividing membrane thickness greater than 2 mm, twin peak (lambda) sign, different fetal genders and two separate placentas (anterior and posterior). The two different placental types in twin gestation are monochorionic and dichorionic. Dizygotic conceptions always have dichorionic placentas. Monozygotic conceptions may have either monochorionic or dichorionic placentation, depending upon the time of division of the zygote. Diamniotic dichorionic placentation occurs with division prior to the morula state (within three days post fertilization). Diamniotic monochorionic placentation occurs with division between days four and eight post-fertilization. Monoamniotic, monochorionic placentation occurs with division between days eight and 12 post fertilization. Division at or after day 13 results in conjoined twins. The ultrasound markers for determination of chorionicity described above have been used to assess risk for complications of pregnancy, most notably the twin-twin transfusion syndrome.

A 29-year-old G4P2 woman was diagnosed with twin-twin transfusion syndrome when an ultrasound was performed at 24 weeks gestational age. Which of the following is a complication of twin-twin transfusion syndrome? A. Fetal macrosomia in the donor twin B. Neurologic sequelae in the surviving twin C. Tricuspid regurgitation in the donor twin D. Heart failure in the donor twin only E. High perinatal mortality for donor twin only

B Untreated severe twin-twin transfusion syndrome has a poor prognosis, with perinatal mortality rates of 70-100%. Death in utero of either twin is common. Surviving infants have increased rates of neurological morbidity, with increased risk of cerebral palsy for the surviving twin. Excessive volume can lead to cardiomegaly, tricuspid regurgitation, ventricular hypertrophy and hydrops fetalis for the recipient twin. Although the recipient twin is plethoric, it is not macrosomic. The donor twin becomes anemic and hypovolemic, and growth is retarded. The recipient twin becomes plethoric, hypervolumic and macrosomic. Either twin can develop hydrops fetalis. The donor twin can become hydropic because of anemia and high-output heart failure.

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

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

A 34-year-old G1 is in a motor vehicle accident. While in the emergency department, the doctors order multiple x-rays to evaluate her injuries. At what gestational age would the fetus be most susceptible to developing mental retardation with sufficient doses of radiation? A. 0-7 weeks B. 8-15 weeks C. 16-25 weeks D. 26-30 weeks E. 31-35 weeks

B. 8-15 weeks Correct answer is B. The risk of developing microcephaly and severe mental retardation is greatest between eight and 15 weeks gestation. In 1990, the Committee on Biological Effects reported that no risk of mental retardation has been documented with doses even exceeding 50 rad at less than eight weeks or greater than 25 weeks gestation.

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. Administer cytotec 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 28-year-old Rh negative G1P0 woman at eight weeks gestation presents to the clinic for a first prenatal visit. Which of the following is the current recommendation for RhoGAM administration to prevent Rh isoimmunization? A. Routine administration for every Rh-sensitized woman at term B. Administration for Rh-negative patients with no Rh antibodies at 28 weeks C. Administration for every Rh-negative woman who delivers an Rh-negative infant D. Routine administration for all Rh-negative patients during first trimester E. Routine administration for all Rh-negative patients during each trimester

B. Administration for Rh-negative patients with no Rh antibodies at 28 weeks RhoGAM (Anti-D-immunoglobulin) is administered to Rh-negative women to prevent isoimmunization. Each dose provides 300 micrograms of D-antibody and is given to the D-negative non-sensitized mother to prevent sensitization after any pregnancy-related events that could result in fetal-maternal hemorrhage. Up to 2 percent of women with a spontaneous abortion and 5 percent of those undergoing elective termination become isoimmunized without D-immunoglobulin. The current recommendations for Rh-negative women without evidence of Rh immunization is prophylactically at 28-weeks gestation (after an indirect Coombs' test) and within 72 hours of delivering an Rh-positive baby, following spontaneous or induced abortion, following antepartum hemorrhage and following amniocentesis or chorionic villus sampling. If the father of the fetus is known to be Rh-negative, RhoGAM is not necessary, since the fetus will be Rh-negative and not at risk for hemolytic disease.

A 24-year-old G4P0 presents to your office at seven weeks gestation after two days of bleeding and cramping. She thinks that she miscarried at home and did not bring in the tissue for pathologic evaluation. What is the karyotype most likely to be found on chromosomal analysis? A. Turner Syndrome (45, X) B. Autosomal Trisomy C. Monoploidy D. Triploidy E. Tetraploidy

B. Autosomal Trisomy Autosomal trisomy is the most common abnormal karyotype encountered in spontaneous abortuses, accounting for approximately 40-50% of cases. The most common chromosomal aneuploidy noted in abortuses is Trisomy 16. Triploidy accounts for approximately 15%, and tetraploidy for 5% of cases. Monosomy X (45X, 0) is seen in 15-25% of losses.

A 33-year-old G1 at 22 weeks gestation presents to the office with a complaint of pelvic pressure. She reports that she had intercourse the night prior to presentation and noted some mucous mixed with blood this morning. Her history is significant for type 1 diabetes and she is on an insulin pump. She also has a history of obesity but reports that she lost about 30 pounds in the last two years prior to getting pregnant. Her current BMI is 26. Her surgical history is significant for a history of cone biopsy for treatment of abnormal Pap smear three years ago. On examination, she is noted to have a 2 cm dilated cervix with bulging membranes that break upon placing the speculum. Fetal parts are noted in the vagina. What is the most likely cause of this finding? A. Uncontrolled diabetes B. Cervical incompetence/insufficiency C. Preterm labor D. History of obesity E. Infection

B. Cervical incompetence/insufficiency The most likely cause of painless cervical dilation which leads to pelvic pressure, bulging membranes and fetal loss is cervical incompetence or insufficiency. This patient has a history of cone biopsy which can lead to cervical incompetence. Preterm labor by definition does not occur until 24 weeks gestation. Although uncontrolled diabetes can lead to fetal malformations and early miscarriage, it is not typically a cause of fetal loss in the second trimester. Obesity is more likely to cause infertility or difficulty getting pregnant.

A 17-year-old G1P0 woman at 37 weeks gestation presents for a routine visit. She has no complaints, but is found to have an initial blood pressure of 138/89, and 144/91 on a repeat reading. This reading is noted to be a change from her previous visits, as her blood pressures have been in the 90-100/50-60 range since initiating care at eight weeks gestation. Her urinalysis is negative for protein and her comprehensive metabolic panel and the complete blood count are normal. Which of the following is the most likely diagnosis in this patient? A. Chronic hypertension B. Gestational hypertension C. Mild preeclampsia D. Severe preeclampsia E. Normotensive

B. Gestational hypertension Gestational hypertension is the correct diagnosis, since she lacks other defining criteria for preeclampsia. She has normal labs, liver function tests, no proteinuria and no symptoms. The only abnormal finding is mild thrombocytopenia, which may be a finding in gestational hypertension. Since her blood pressures were normal prior to this visit, chronic hypertension can be excluded. Up to one quarter of women with gestational hypertension will go on to develop preeclampsia.

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. Less women are having vaginal births after Cesarean 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 29-year-old G3P0 woman presents for prenatal care at eight weeks gestation. Her two prior pregnancies ended in spontaneous losses at 19 and 18 weeks, respectively. Records corroborate the patient's history of an uncomplicated gestation until the evening of the losses, when she experienced a pink-tinged discharge that prompted her to call her obstetrician. In both cases, the obstetrician noted that her cervix had dilated completely with the amnionic sac bulging into the vagina to the level of the introitus. The patient was afebrile without other complaints and there was no uterine tenderness on exam. She spontaneously delivered the fetus and placenta in both cases. A sonohysterogram confirmed normal uterine anatomy several weeks later. What is the most appropriate next step in the management of this patient? A. Begin weekly fetal fibronectin testing B. Placement of a cervical cerclage at approximately 14 weeks gestation C. Immediate placement of a cervical cerclage D. Administer low dose aspirin and heparin E. Administration of prophylactic progesterone

B. Placement of a cervical cerclage at approximately 14 weeks gestation This patient has an incompetent cervix and should have a cervical cerclage at 14 weeks. A positive fetal fibronectin does not indicate incompetent cervix and is used later in pregnancy as a negative predictor of preterm delivery. Pregnancy loss in the late second trimester is not usually related to genetic abnormality of the conceptus and most clinicians delay placement of a cerclage until after the first trimester, given the high background prevalence of first trimester pregnancy wastage. Although some clinicians strongly support the existence of an antiphospholipid antibody syndrome, the term most commonly refers to pregnancy loss or demise, rather than the clinical scenario of silent cervical dilation with delivery described. The patient would, therefore, not need aspirin or heparin. Although some clinicians use prophylactic progesterone to prevent recurrent abortion, as well as preterm labor, no controlled trials support the use of prophylactic progesterone in the treatment of cervical incompetence.

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

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

Question 1 of 10Point value 0 - 1 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

B. Placental abruption 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.

A 29-year-old G0 woman presents to your office for a routine visit. She has been trying to conceive for the last six months unsuccessfully. She requests fertility medications and hopes to get pregnant with twins. What counseling do you tell her regarding the risks of multifetal gestation? A. The morbidity with twin gestations is similar to triplet pregnancies B. The twin infant death rate is five times higher than that of singletons C. The rate of cerebral palsy is double in twin infants D. The incidence of abnormal fetal growth is similar to singleton pregnancies E. The incidence of prematurity is similar to singleton pregnancies

B. The twin infant death rate is five times higher than that of singletons The twin infant death rate is five times higher than that of singletons. The epidemic of multiple gestations resulting from assisted reproductive techniques is of great significance to individual parturients and to society because of the major morbidities associated with twinning as well as with triplets and higher order multiples. The risk for development of cerebral palsy in twin infants is five to six times higher than that of singletons. One study, with dichorionic twins, monochorionic twins and singletons, showed that twins had a higher incidence of IUGR (intrauterine growth restriction) than singletons. Fifty-eight percent of twins deliver prematurely, with an average gestational age at delivery of 35 weeks. Twelve percent of twins deliver very prematurely.

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

A 24-year-old G1P0 at 32 weeks gestation presents with vaginal bleeding most likely caused by placental abruption. She receives a standard dose of 300 micrograms of RhoGAM. What amount of fetal blood is neutralized by this dose? A. 10 cc B. 20 cc C. 30 cc D. 40 cc E. 50 cc

C 30 cc of fetal blood is neutralized by the 300 micrograms dose of RhoGAM. This is equivalent to 15 cc of fetal red blood cells. At 28-weeks gestation, 300 micrograms of Rh-immune globulin is routinely administered after testing for sensitization with an indirect Coombs' test. Administration is given following amniocentesis at any gestational age.

A 25-year-old G2P1 woman states her gestational age by sure LMP is 16 weeks, 3 days. She reports no complaints and is not yet feeling fetal movement. Her fundal height is 22 cm. The MSAFP (maternal serum alpha fetoprotein) result is elevated. Which of the following is the most likely cause for the abnormal MSAFP result? A. Fetal trisomy B. Polyhydramnios C. Twin gestation D. Fetal abdominal wall defect E. Fetal neural tube defects

C Alpha fetoprotein (AFP) levels in twin gestations are elevated and should be roughly twice that seen in singleton pregnancies. An additional clue to a possible diagnosis of twin gestation is the fundal height exceeding gestational age in weeks. Other causes of elevated maternal serum AFP include neural tube defects, pilonidal cysts, cystic hygroma, sacrococcygeal teratoma, fetal abdominal wall defects, and fetal death. Polyhydramnios is not by itself associated with abnormal MSAFP levels.

A 36-year-old G1P0 Asian woman presents to the office accompanied by her 32-year-old husband. She is thrilled that she is now pregnant with twins after undergoing in vitro fertilization. She has a history of polycystic ovarian syndrome and thought she would not be able to have a baby. Her husband has a twin brother. Which of the following is the most likely cause of twins in this patient? A. Advanced maternal age B. Ethnicity C. Assisted reproductive technology D. Nulliparity E. Paternal family history

C Assisted reproduction has led to an increase number of multiple gestations. The rates of multiple births after IVF (in-vitro fertilization) vary according to maternal age and the number of embryos transferred. Transfer of multiple embryos is more likely to result in multiple gestations in younger women than in older women. The frequency of multiple gestations increases with the use of ovulation inducing drugs. The risk is in the 5-6% range, but varies depending on the drug and dosage regimen used. Dizygous twinning results from the ovulation of multiple follicles and the rate of multiple gestation increases with advancing maternal age. Elevated follicle-stimulating hormone correlates with dizygous multiple births. A higher number of prior pregnancies and previous history of multiple births increases the chance of having a multiple gestation. These do not apply here because the patient's obstetrical history does not support this. Dizygous twinning appears to have a genetic component and rates of dizygous twins vary according to ethnicity, but are not related to paternal family history.

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 32-year-old G3P2 woman presents at 40 1/7 weeks gestation because of regular uterine contractions every five minutes for the last two hours. Her prenatal course was unremarkable. She states the baby is moving, but she has had a bright red, bloody discharge for the last 30 minutes. She does not think she has ruptured her membranes. Her blood pressure is 120/70, pulse 80 and she is afebrile. Her abdomen is soft and she has regular contractions of moderate intensity. Fetal heart tones have a baseline of 130 with a category I fetal heart rate tracing. Pelvic ultrasound reveals a fundal placenta and cephalic presentation of the fetus. Cervical examination reveals a friable cervix that bleeds easily and is 5 centimeters dilated and completely effaced. Membranes are confirmed to be intact. Which of the following is the most likely source of bleeding? A. Placental abruption B. Placenta previa C. Bloody show D. Cervical cancer E. Cervicitis

C During pregnancy the cervix is extremely vascular, and with dilation a small amount of bleeding may occur. This bloody show is not of clinical significance and often occurs with normal labor. Serious causes of bleeding, such as placental abruption and placenta previa, need to be ruled out in order to make the proper delivery plans. Cervical cancer and cervicitis are very unlikely causes for the bleeding in this situation.

23-year-old G2P0 woman at 33 weeks gestation presents to labor and delivery with acute nausea, vomiting and epigastric pain. Her blood pressure is 145/90; she has 1+ protein on a urinalysis. Her labs are shown below: Hematocrit: 42% Bilirubin: 1.4 mg/dL White blood count: 11,000/mcL Bilirubin: 1.4 mg/dL Platelets: 42,000/mcL Lipase: 11 u/L Aspartate aminotransferase (AST): 391 u/L Creatinine: 0.8 mg/dL Alanine aminotransferase (ALT): 444 u/L Uric acid: 7.7 mg/dL Glucose: 100 mg/dL Fibrinogen: 405 mg/dL Which of the following is the most likely diagnosis in this patient? A. Mild preeclampsia B. Hepatitis C. HELLP syndrome D. Cholecystitis E. Acute fatty liver

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

A 19-year-old G1 woman at 28 weeks gestation comes to labor and delivery because of the onset of contractions. The patient describes the contractions as progressively becoming more painful, each lasting 40 seconds and now occurring every five minutes. She reports good fetal movement and does not have any bleeding or leakage of fluid. On evaluation in triage, it is noted that she is having regular contractions, approximately every five minutes, has intact membranes and her cervical exam is 3 cm dilated and 50% effaced. What is the most frequent cause of this condition? A. Dehydration B. Fetal anomalies C. Idiopathic D. Uterine fibroids E. Cervical incompetence

C In most cases, preterm labor is idiopathic (i.e. no cause can be identified). Dehydration and uterine distortion (from uterine fibroids or structural malformations) can be associated with preterm labor. In some cases, preterm labor is due to iatrogenic causes; for example, when a physician induces a preterm patient who has severe preeclampsia. Fetal anomalies typically do not cause preterm labor. Cervical incompetence is usually diagnosed earlier in the second trimester.

A 36-year-old G1 with type 1 diabetes is diagnosed with intrauterine growth restriction at 33 weeks gestation. What is the most appropriate next step in management? A. Amniocentesis B. Immediate delivery C. Weekly ultrasounds to assess fetal growth D. Antenatal testing of fetal well-being E. Observation

C Once intrauterine growth restriction is detected, the fetus needs to be evaluated periodically for evidence of well-being until delivery is deemed necessary. This will result in once or twice weekly testing, depending on the modality of assessment that is being used. Testing includes: non-stress test (NST), where the fetal heart beat is recorded over a period of at least 30 minutes while looking for accelerations with fetal movement, and the biophysical profile, which includes an ultrasound evaluation of fetal movement, fetal tone, amniotic fluid and breathing. NSTs should be performed twice weekly with at least a weekly AFI. The BPP may be performed weekly. Ultrasound for fetal growth is not useful if more frequent than every two weeks. An amniocentesis for fetal lung maturity can be considered at more advanced gestational age.

A 29-year-old G1P0 is at 11 weeks gestation. She has a history of depression which has been well controlled with fluoxetine (Prozac). Although the medication is very helpful in controlling her depression, she is concerned about potential side effects on her neonate. Which of the following conditions in the neonate is associated with maternal use of Fluoxetine during pregnancy? A. Seizures B. Hypotonia C. Pulmonary hypertension D. Temperature instability E. Intracranial hemorrhage

C Paroxetine use during pregnancy has been associated with significant risks of fetal cardiac defects. Maternal exposure to SSRIs has been associated with persistent pulmonary hypertension of the newborn and a self-limiting neonatal behavioral syndrome. SSRI use in late pregnancy may be associated with clinical manifestations in as many as 30% of neonates. The clinical manifestations may include respiratory, neurobehavioral, somatic and gastrointestinal symptoms. Neonates may experience hyperirritability, hypertonus and jitteriness.

A 28-year-old G3P2 woman presents in labor at 39 weeks gestation and delivers a 3500 gram infant spontaneously after oxytocin augmentation of labor. Thirty minutes later, the placenta has not delivered. Her past medical history is significant for leiomyoma uteri. Her prenatal course was uncomplicated. What is the most likely risk factor for retained placenta in this case? A. Placental abruption B. Labor augmentation C. Leiomyomas D. Multiparity E. Circumvallate placenta

C Placental abruptions, labor augmentation, degree of parity and circumvallate placenta have no impact on the risk of retained placenta. The following are associated with retained placenta: prior Cesarean delivery, uterine leiomyomas, prior uterine curettage and succenturiate lobe of placenta.

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? A. Preeclampsia B. Intrauterine growth restriction C. Preterm birth D. Gestational diabetes E. Abnormal placentation

C Preterm delivery increases the risk of morbidity and mortality, increasing with higher orders of multiples. Preterm birth occurs in over 50% of twin pregnancies, 90% of triplet pregnancies, and almost all quadruplet pregnancies. While all the choices may occur with a multiple gestation, prematurity has the most significant consequences as it is associated with an increased risk of respiratory distress syndrome (RDS), intracranial hemorrhage, cerebral palsy, blindness, and low birth weight. Intrauterine growth restriction, intrauterine death of one or more fetuses, miscarriage and congenital anomalies are all more common with multiple gestations, as are the complications of preeclampsia, diabetes and placental abnormalities.

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 32-year-old G1 is at 36 weeks gestation. Ultrasound reveals limited fetal growth over the past three weeks. Biometry is consistent with 30-5/7, EFW 1900 g, less than 10th percentile. Which of the following is LEAST likely to be associated with this pregnancy? A. Fetal demise B. Perinatal demise C. Polyhydramnios D. Meconium aspiration E. Polycythemia

C This fetus had intrauterine growth restriction and, with the exception of polyhydramnios, all of the morbidities listed above may complicate intrauterine growth restriction. In general, the causes of polyhydramnios relate to amniotic fluid production (abnormalities of the fetal urinary tract) and removal (abnormalities of fetal swallowing and intestinal reabsorption of fluid). Some investigators report an increase in fetal urinary output when there is hyperglycemia and increased renal osmotic load, thus resulting in polyhydramnios. Abnormal fetal swallowing may be a result of a CNS or gastrointestinal tract abnormalities, such as anencephaly, esophageal or duodenal atresia, diaphragmatic hernia or primary muscular disease. Typically, polyhydramnios is not associated with asymmetric growth restriction (the most common form of IUGR), since an asymmetric growth pattern reflects poor uterine blood flow and limited substrate availability. In fact, oligohydramnios is frequently identified in pregnancies complicated by fetal growth restriction.

A 29-year-old G4P2 woman with no previous prenatal care presents at 24 weeks gestation with signs and symptoms of preterm labor. Her cervix is 3 cm dilated and 80% effaced. Fundal height is 30 cm and an ultrasound examination reveals a twin gestation. Estimated fetal weights on the twins are 850 gm and 430 gm. The maximum vertical amniotic fluid pocket around the smaller twin is 1 cm; the maximum vertical amniotic fluid pocket around the larger twin is 8 cm. Which of the following is the most likely associated with these ultrasound findings? A. Dichorionic diamniotic twins B. Monochorionic monoamniotic twins C. Monochorionic diamniotic twins D. Superfecundation E. Rh-isoimmunization

C Twin-twin transfusion syndrome is the result of an intrauterine blood transfusion from one twin to the other. It most commonly occurs in monochorionic, diamniotic twins. The donor twin is often smaller and anemic at birth. The recipient twin is usually larger and plethoric at birth. Clues to the presence of the twin-twin transfusion syndrome include the large weight discordance (although this is not necessary for diagnosis), polyhydramnios around the larger (recipient) twin, and oligohydramnios around the smaller (pump) twin. The two different placental types in twin gestation are monochorionic and dichorionic. Monozygotic conceptions may have either monochorionic or dichorionic placentation, depending upon the time of division of the zygote. Dizygotic conceptions always have dichorionic placentas. Diamniotic dichorionic placentation occurs with division prior to the morula state (within three days post fertilization). Diamniotic monochorionic placentation occurs with division between days four and eight post fertilization. Monoamniotic, monochorionic placentation occurs with division between days eight and 12 post fertilization. Superfecundation is the fertilization of two different ova at two separate acts of intercourse in the same cycle. Isoimmunization is associated with polyhydramnios and fetal hydrops and does not cause twin-twin transfusion.

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

C Uterine atony is the most common cause of postpartum hemorrhage. Risk factors for uterine atony include precipitous labor, multiparity, general anesthesia, oxytocin use in labor, prolonged labor, macrosomia, hydramnios, twins and chorioamnionitis. Patients at risk for genital tract lacerations are those who have a precipitous labor, macrosomia or who have an instrument-assisted delivery or manipulative delivery i.e. breech extraction. Factors that lead to an over-distended uterus are risk factors for uterine inversion. Grand multiparity, multiple gestation, polyhydramnios and macrosomia are all risk factors. The most common etiology of uterine inversion, however, is excessive (iatrogenic) traction on the umbilical cord during the third stage of delivery. Although the patient is at risk for uterine dehiscence and uterine rupture because of her history of a prior Cesarean section, these are infrequent occurrences so the most likely cause of postpartum hemorrhage in this patient is uterine atony.

A 24-year-old G2P1 woman has a fetus that is affected by Rh disease. At 30 weeks gestation, the delta OD450 (optical density deviation at 450 nm) results plot on the Liley curve in Zone 3 indicating severe hemolytic disease. Which of the following is the most appropriate next step in the management of this patient? A. Immediate Cesarean delivery B. Induction of labor C. Intrauterine intravascular fetal transfusion D. Umbilical blood sampling E. Maternal plasmapheresis

C Values in Zone 3 of the Liley curve indicate the presence of severe hemolytic disease, with hydrops and fetal death likely within 7-10 days, thus demanding immediate delivery or fetal transfusion. At 30 weeks gestation, the fetus would benefit from more time in utero. An attempt should be made to correct the underlying anemia. Intravascular transfusion into the umbilical vein is the preferred method. Intraperitoneal transfusion is used when intravascular transfusion is technically impossible. If fetal hydrops is present, the reversal of the fetal anemia occurs much more slowly via intraperitoneal transfusion. Percutaneous umbilical blood sampling should not be used as a first-line method to evaluate fetal status. Maternal plasmapheresis is used in severe disease when intrauterine transfusions are not possible.

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

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

A 23-year-old G2P1 woman at 36 weeks gestation presents with her third episode of heavy vaginal bleeding. She has normal prenatal labs and a known placenta previa. She denies uterine contractions or abdominal pain and reports good fetal movement. Her vital signs are: blood pressure 100/60; pulse 110; and she is afebrile. Her abdomen and uterus are nontender. Fundal height measures 35 centimeters and fetal heart tones reveal a baseline of 140 and are reassuring. Pelvic ultrasound confirms a placenta previa and the fetus is in the cephalic presentation. Hematocrit is 29%. Which of the following is the most appropriate next step in the management of this patient? A. Tocolysis B. Induction of labor C. Cesarean delivery D. Amniocentesis E. Administer steroids

C. Cesarean delivery This patient is near term with a third episode of active bleeding from a placenta previa. The appropriate next step would be to move towards delivery via Cesarean section. The patient is not experiencing contractions, so tocolysis is not necessary and would not be used with heavy vaginal bleeding. Catastrophic bleeding could occur due to disruption of blood vessels as the cervix dilates if a vaginal delivery is pursued, and induction of labor would therefore be contraindicated. An amniocentesis is not indicated in this situation. Although the patient is not yet at term, delivery is appropriate due to the third episode of heaving bleeding at near term. Administering steroids is not appropriate at this gestational age.

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? A. Sitz baths B. Whirlpool therapy C. Debridement D. Repair of laceration site E. Incision and drainage of perineal laceration

C. Debridement Aggressive debridement of the necrotic areas is required to prevent further spread of the infection. Debridement should extend until vital tissue with good blood supply is encountered. Repair of the defect should be delayed until the infection has completely resolved. Sitz baths and whirlpool therapy will provide symptomatic relief for her discomfort, but not adequate treatment. Incision and drainage of perineal laceration is appropriate for an uncomplicated abscess.

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

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

A 22-year-old G1P0 woman presents to the emergency department at eight weeks gestation experiencing heavy vaginal bleeding. Pelvic examination demonstrates brisk bleeding through a dilated cervical os. The patient's hemoglobin is 7 g/dL (hematocrit 21%). Which of the following is the most appropriate next step in the management of this patient? A. Administration of intravaginal misoprostol B. Administration of oral misoprostol C. Dilation and suction curettage D. Endometrial ablation E. Expectant care to permit spontaneous abortion

C. Dilation and suction curettage This patient is actively bleeding and is anemic. She, therefore, requires immediate surgical treatment consisting of dilation and suction curettage. Although clinicians increasingly utilize both expectant management and various drug regimens to treat spontaneous abortion, a prerequisite for either is that the patient is hemodynamically stable and reliable for follow-up care. Endometrial ablation will not work in this case, as the products of conception need to be evacuated to control the bleeding.

A 25-year-old G2P1 woman at eight weeks gestation is diagnosed with a spontaneous abortion. Her husband is 40 years old. The patient's past medical history is noncontributory. She gets some exercise regularly and smokes two packs of cigarettes a day. Three years ago, she had a full-term delivery that was complicated by mild preeclampsia. Which of the following factors is most likely the cause of this spontaneous abortion? A. Infection B. Advanced paternal age C. Environmental factors D. Uterine anomaly (i.e. unicornuate uterus) E. History of preeclampsia

C. Environmental factors Environmental factors, such as smoking, alcohol and radiation are causes of spontaneous abortion. Although the risk increases with infections, such as listeria, mycoplasma, ureaplasma, toxoplasmosis and syphilis, advancing maternal or paternal age, advancing parity and some mullerian anomalies, the clinical scenario does not support these as possible causes. An isolated history of preeclampsia confers no increase in risk of spontaneous abortion.

A 16 year-old G1P0 African-American woman presents at 8 weeks gestation for prenatal care. She reports occasional spotting but denies pain or fever. The laboratory reports hemoglobin of 8 g/dL and a peripheral smear reveals hypochromia and microcytosis. Which of the following is the most likely diagnosis for this patient? A. sickle cell anemia B. folate deficiency C. iron deficiency D. β-thalassemia E. acute blood loss

C. Iron deficiency The two most common causes of anemia during pregnancy and the puerperium are iron deficiency and acute blood loss. Classical morphological evidence of iron-deficiency anemia is erythrocyte hypochromia and microcytosis. Serum ferritin levels are lower than normal and there is no stainable bone marrow iron on examination of a bone marrow aspirate. The spotting she reports would not lead to anemia due to blood loss.

A 19-year-old G1P0 woman with a desired pregnancy notes vaginal spotting early this morning and it has slightly increased. Her last normal menstrual period occurred six weeks ago. She has no pain or other symptoms. Her medical history is noncontributory. Vital signs are: blood pressure 120/68; pulse 68; respirations 20; and temperature 98.6°F (37.0°C). On pelvic exam, her cervix is normal; her uterus is small and nontender; there are no masses palpable. Labs show Quantitative Beta-hCG 750 mIU/ml; progesterone 3.8 ng/ml; hematocrit 38%. Which of the following is the most appropriate next step in the management of this patient? A. Order a transvaginal ultrasound B. Repeat Beta-hCG level in 24 hours C. Repeat Beta-hCG level in 48 hours D. Dilation and curettage E. Bed rest

C. Repeat Beta-hCG level in 48 hours Repeating the Beta-hCG level will show whether the pregnancy is viable or failing. The appropriate time interval for repeating the initial level is 48 hours, since during the first 42 days of gestation levels increase by approximately 50% every 48 hours in most viable pregnancies. Ordering an ultrasound would not be helpful, since the patient's Beta-hCG level is lower than the discriminatory zone (the level at which an intrauterine pregnancy should be seen on ultrasound, usually 2000 mIU/ml). There is no need to repeat the progesterone level. Dilation and curettage or treatment with methotrexate are both inappropriate without a diagnosis, since both could interrupt a viable pregnancy.

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

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

A 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. Treat her now Correct answer is 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.

Review: what does drug category X mean?

Category X: Studies in animals or human beings have demonstrated fetal abnormalities, or there is evidence of fetal risk. The drug is contraindicated in women who are or may become pregnant.

Review: In this case, what other management step should you take?

Check blood type and administer rhogam as needed

A 33-year-old G2P1 woman at 29 weeks gestation presents with confirmed preterm premature rupture of membranes. She denies labor. She takes prenatal vitamins and iron. She denies substance abuse, smoking or alcohol use. Her prior pregnancy was delivered vaginally at 41 weeks after spontaneous rupture of membranes. Her blood pressure is 110/70; pulse 84; temperature 98.6°F (37.0°C). Which of the following is the best medication to delay the onset of labor? A. Antibiotics B. Betamethasone C. Calcium channel blocker D. Beta mimetics E. Magnesium sulfate

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

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

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

You are counseling a 22-year-old G1 who is at 38 weeks gestation. She has been pushing for four hours and you recommend a trial of forceps. She asks whether a vacuum-assisted delivery is associated with a lower incidence of maternal and fetal trauma. Which of the following is less likely to occur during a vacuum delivery? A. Maternal lacerations B. Fetal cephalohematoma C. Neonatal lateral rectus paralysis D. Neonatal hyperbilirubinemia E. Neonatal retinal hemorrhage

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

A 32-year-old G1 presents at 35 weeks gestation with decreased fetal movement. Her prenatal course has been complicated by size less than dates. Serial ultrasounds show a decrease of the estimated fetal weight from 60th to 20th percentile. The non-stress test is reactive and the amniotic fluid index is 10. What is your next step in management? A. Continue with weekly non-stress tests B. Obtain umbilical artery systolic: diastolic ratio C. Admission for daily fetal surveillance D. Induction of labor today E. Cesarean section today

Correct answer is A. Since the patient reported decreased fetal movement, a non-stress was performed and was reassuring. The NST is based on the principle that when the fetus moves, its heartbeat normally accelerates. The NST assesses fetal health through monitoring accelerations of the heart rate in response to the baby's own movements. Amniotic fluid volume is important because a decreased amount raises the possibility that the fetus may be under stress. Since the fetus does not show growth restriction and fetal status was reassuring, there are no indications for Doppler studies or delivery. In light of the dramatic decrease in growth, it is reasonable to follow this patient with weekly non-stress tests.

A 33-year-old G2P1 presents at 34 weeks gestation for consultation because ultrasound revealed a 3900 gm fetus with biometrics consistent with 39 weeks. Her prior pregnancy was complicated by gestational diabetes and a shoulder dystocia. Which of the following complications is this fetus at greatest risk? A. Birth trauma B. Hyperglycemia C. Hypobilirubinemia D. Hypothyroidism E. Congenital anomalies

Correct answer is A. The fetus with enhanced general growth or macrosomia is defined by a birth weight at or above the 90th percentile for gestational age. The condition can usually be ascribed to one of three etiologies: enhanced growth potential (50-60%); abnormal maternal glucose homeostasis (35-40%); or underestimation of fetal age (5%). Macrosomic newborns of diabetic mothers experience excessive rates of neonatal morbidity, including birth trauma such as shoulder dystocia and brachial plexus injury. These infants have significantly higher rates of severe hypoglycemia and neonatal jaundice. Neonatal acidosis occurs with poor glycemic control, thus increasing the incidence of fetal demise. While poorly controlled pre-existing diabetes is associated with an increased risk of congenital anomalies, gestational diabetes is not associated with increased risk of congenital anomalies.

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

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

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

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

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

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

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

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

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

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

A 19-year-old G1P0 woman notes vaginal spotting. Her last normal menstrual period occurred six weeks ago. She began having spotting early this morning and it has increased only slightly. She has no pain and denies other symptoms. Her medical history is noncontributory. Vital signs are: blood pressure 120/68; pulse 68; respirations 20; and temperature 98.6°F (37.0°C). On pelvic exam, her cervix is normal; uterus is small and nontender; and no masses are palpable. Initial labs show quantitative Beta-hCG 2000 mIU/ml and hematocrit 38%. A repeat Beta-hCG level 48 hours later is 2100 mIU/ml. A transvaginal ultrasound shows an empty uterus with a thin endometrial stripe and no adnexal masses. What is the next best step in the management of this patient? A. Dilation and curettage B. Treat with methotrexate C. Exploratory laparotomy D. Repeat Beta-hCG level in 48 hours E. Repeat ultrasound in 24 hours

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

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

Correct answer is 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 23-year-old G1P0 patient at 24 weeks gestation requires treatment for depression. She has no other pregnancy complications. In addition to counseling, she begins therapy with fluoxetine (Prozac). Which of the following symptoms is the most common side effect of her therapy? A. Fatigue B. Sleep disturbance C. Headache D. Irritability E. Agitation

Correct answer is B. While all the side effects listed are reported in patients on fluoxetine, an SSRI antidepressant medication, the most common side effect is insomnia. Significant insomnia may affect one in five patients taking SSRIs. In addition to sleep disturbances, sexual dysfunction, such as decreased libido and delayed or absent orgasm, are common.

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

Correct answer is 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 33-year-old G2P1 presents at 36 weeks gestation for consultation because ultrasound revealed a fetus with biometry consistent with 30 5/7 weeks gestation. The EFW is less than the 5th percentile. Umbilical artery Doppler studies are abnormal. There is reverse end diastolic flow and the amniotic fluid volume is decreased. The AFI is 1.1 cm. Which of the following is the most appropriate next step in the management of this patient? A. Close observation with twice weekly NSTs and amniotic fluid assessments B. Close observation with twice weekly NSTs, amniotic fluid assessments and weekly umbilical artery Doppler studies C. Induction of labor D. Induction of labor at term (37 weeks gestation) E. Delivery by Cesarean section

Correct answer is C. Delivery is indicated in a fetus with IUGR at 36 weeks gestation with oligohydramnios and abnormal umbilical artery Doppler studies. Although there is an increased incidence of fetal intolerance of labor, induction of labor is generally preferred over elective Cesarean delivery. Delivery at term is indicated in fetuses with IUGR with reassuring fetal testing including a normal amniotic fluid volume.

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

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

A 24-year-old G2P1 at 42 weeks gestation presents in early labor. At amniotomy, there is thick meconium. Her sister-in-law had a procedure to dilute the meconium and she asks if this would be of benefit to her. Which of the following statements is the most accurate regarding the benefits of amnioinfusion? A. Decreases admissions to the neonatal intensive care unit B. Decreases post maturity syndrome C. Decreases repetitive variable decelerations D. Decreases the risk for Cesarean section E. Decreases meconium below the vocal cords

Correct answer is C. Meconium staining of the amniotic fluid is three to four times more common in the postterm pregnancy. This is likely due to two reasons: 1) greater length of time in utero allows for activation of a more mature vagal system; and 2) fetal hypoxia. Amnioinfusion is a procedure where normal saline is infused into the intrauterine cavity. Routine prophylactic amnioinfusion for thick meconium does not appear to decrease the incidence of meconium aspiration syndrome or have an impact on neonatal outcomes. Based on current literature, routine prophylactic amnioinfusion for meconium-stained amniotic fluid is not recommended. Amnioinfusion remains a reasonable approach in the treatment of repetitive variable decelerations, regardless of amniotic fluid meconium status.

A 22-year-old G2P1 is at 42 weeks gestation dated by an ultrasound performed five weeks ago. Her cervix is long and closed. She does not report contractions and states there is good fetal movement. She would like to wait until she goes into labor spontaneously. Which of the following treatment options is optimal at this time? A. Allow the patient to go into labor spontaneously B. Perform an ultrasound to determine gestational age C. Perform a non-stress test (NST) and amniotic fluid index (AFI) twice a week, with induction of labor for a nonreactive NST or oligohydramnios. D. Patient should perform daily fetal movement counts and proceed with induction for decreased fetal movement. E. Perform daily biophysical profiles and deliver if 4 or less

Correct answer is C. Optimal management for the patient with an unfavorable cervix at an uncertain 42 weeks gestation is arguable. Given the uncertainty of her dates, it is reasonable to follow this patient with antepartum fetal testing, such as twice weekly non-stress tests with amniotic fluid index. The risk of fetal death is 1-2/1000 high-risk pregnancies with a reassuring NST, contraction stress test or biophysical profile. The addition of amniotic fluid assessment may improve the predictive value of a reactive NST and reduce the risk of antepartum fetal demise to even lower levels. Ultrasound for gestational age determination in the third trimester is not useful since the measurement error is +/- 3 weeks. Allowing spontaneous onset of labor is okay, but not without some type of antepartum testing.

A 35-year-old G1 woman at 30-weeks gestation is transferred from an outside hospital in preterm labor. Her cervix is 3 cm dilated, 50% effaced and the vertex is at 0 station. She is having contractions every five minutes and has no signs consistent with an intra-amniotic infection (chorioamnionitis). She was initially treated with terbutaline prior to her transfer. Which of the following side effects would you expect? A. Premature constriction of the ductus arteriosus B. Respiratory depression C. Tachycardia D. Tachypnea E. Headache

Correct answer is C. Terbutaline is a beta-adrenergic agent. Side effects include tachycardia, hypotension, anxiety and chest tightening or pain. Tachypnea and headaches are not usual side effects. 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. The drug may still be used on a short-term basis in patients with active contractions, such as those being transferred to another hospital for tertiary care. Alternative tocolytic agents should be used for longer term treatment of preterm labor.

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

Correct answer is 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

Correct answer is 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 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

Correct answer is 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 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

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

Correct answer is D. Cervical cancer can unfortunately complicate pregnancies and presents with bleeding. She is at risk due to lack of screening. Other causes of bleeding need to be ruled out such as cervical incompetence, infection or trauma. Treatment for cervical cancer during pregnancy requires difficult decisions that consider the stage of cancer, appropriate therapy, maternal welfare and fetal welfare.

A 24-year-old Rh-negative G2P1 woman is found at 10 weeks gestation to have anti-D antibodies. You follow her closely during this pregnancy and order serial ultrasound examinations. Which of the following fetal ultrasound findings would be most explained by the presence of Rh disease? A. Meconium B. Fetal bladder obstruction C. Oligohydramnios D. Pericardial effusion E. Placenta previa

Correct answer is D. Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence of decreased hepatic protein production. It is defined as a collection of fluid in two or more body cavities, such as ascites, pericardial and/or pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be evidence of hepatosplenomegaly. Placentomegaly (placental edema) and polyhydramnios are also seen on ultrasound. Meconium, fetal bladder obstruction, oligohydramnios and placenta previa do not fit the clinical scenario.

A 20-year-old G2P1 is at 41 weeks gestation. Her prenatal course and past history are unremarkable. She has not had any complications with her pregnancy and fetal surveillance is reassuring. Which of the following complications is most likely to occur in this pregnancy? A. Preeclampsia B. Retained placenta C. Postpartum hemorrhage D. Macrosomia E. Placenta abruption

Correct answer is D. Postterm pregnancies are associated with macrosomia, oligohydramnios, meconium aspiration, uteroplacental insufficiency and dysmaturity. Gestational diabetes is associated with macrosomia, but is not alone a risk factor for postterm pregnancies. There is no associated risk for preeclampsia in postterm gestations.

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

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

A 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

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

A 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

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

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

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

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

A 39-year-old G1 presents in labor at term. The estimated fetal weight is 3200 g. She is 10 cm dilated with left sacrum anterior at +2 station. Which of the following is the most appropriate next step in the management of this patient? A. Attempt external version B. Attempt internal version C. Apply forceps D. Apply a vacuum E. Recommend a Cesarean sectio

Correct answer is E. Breach presentation: Left sacrum anterior (LSA)—the buttocks, as against the occiput of the vertex presentation, like close to the vagina (hence known as breech presentation), which lie anteriorly and towards the left. Most recent data suggests that breech infants delivered vaginally are at higher risk for neonatal complications. Therefore, it would be recommended that this patient undergo a Cesarean section, especially since this is her first pregnancy. External cephalic version is contraindicated in active labor.

A 32-year-old G1 is seeing you in consultation at 35 weeks gestation. Ultrasound reveals limited fetal growth over the past three weeks. Biometry is consistent with 30-5/7, EFW 1900 g, less than 10th percentile. You counsel her about short and long-term complications for her baby. This fetus is at increased risk for all of the following adult disorders EXCEPT: A. Cardiovascular disease B. Chronic hypertension C. Chronic obstructive lung disease D. Diabetes E. Osteoporosis

Correct answer is E. Epidemiologic studies indicate that fetal growth restriction is a significant risk factor for the subsequent development of cardiovascular disease, chronic hypertension, chronic obstructive lung disease and diabetes. Researchers suggest that the phenomenon of programming may be operable and that an adverse fetal environment during a critical period of fetal growth helps to promote these adult diseases. Osteoporosis risk factors include family history, slender body composition, prior history of osteoporosis, Asian and Caucasian ethnicity, alcohol consumption, smoking, sedentary lifestyle, excess thyroid or corticosteroids and use of anticonvulsant medications.

A 24-year-old G2P1 woman is diagnosed with Rh hemolytic disease at 24 weeks gestation. Measurement of which of the following in the amniotic fluid is best indicative of the severity of the disease? A. Hemoglobin B. Iron C. Anti-D antibody titer D. Glucose E. Bilirubin

Correct answer is E. In the presence of a severely erythroblastotic fetus, the amniotic fluid is stained yellow. The yellow pigment is bilirubin, which can be quantified most accurately by spectrophotometric measurements of the optical density between 420 and 460nm, the wavelength absorbed by bilirubin. The deviation from linearity of the optical density reading at 450nm is due to the presence of heme pigment, an indicator of severe hemolysis.

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

Correct answer is E. 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.

A 35-year-old G5P4 is at 39 weeks gestation. She does not want to have any more children and would like to have permanent sterilization. She is concerned about the risks associated with postpartum tubal ligation. Which of the following is the most likely complication she might experience? A. Chronic cyclic pain with menstrual cycles B. Increased risk for ovarian cancer C. Decreased enjoyment with sexual intercourse D. Aspiration with general anesthesia E. Future pregnancy

Correct answer is E. The existence of a "post-tubal ligation syndrome" in which disruption of blood flow in the area of the fallopian tubes leads to menstrual dysfunction and dysmenorrhea has not been substantiated. Tubal ligation appears to have a protective effect on ovarian cancer incidence. The failure rate associated with surgical sterilization is approximately one percent. Approximately one-third of pregnancies after tubal ligation are ectopic. There is no proven association between decreased sexual enjoyment and tubal ligation. Tubal ligations may be performed under regional or general anesthesia. Postpartum tubal ligations are generally performed using a spinal or epidural anesthesia.

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

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

A 21-year-old G1 presents to labor and delivery at 39 weeks gestation with a chief complaint of decreased fetal movement over the last two days. An ultrasound shows a fetus with biometry consistent with 34 weeks gestation with no cardiac activity. The head circumference and biparietal diameter are consistent with 37 weeks and the abdominal circumference, femur and humerus lengths are all lagging by approximately five weeks. The amniotic fluid volume is slightly decreased. No other abnormalities are identified. The patient's medical history is notable for a deep venous thrombosis which she had three years ago while she was using oral contraceptives. She had a reassuring quad screen. She denies any history of fever or viral illnesses during the pregnancy. She works as a preschool teacher. The patient had a fetal ultrasound at 20 weeks gestation. At that time all of the fetal anatomy was well-visualized and no abnormalities were identified. Which of the following is the most likely explanation for the fetal demise in this case? A. Umbilical cord accident B. Trisomy 18 C. Poorly controlled undiagnosed diabetes mellitus D. Fetal parvovirus infection E. Factor V Leiden mutation

Correct answer is E. This patient is most likely to have the autosomal dominant Factor V Leiden (FVL) mutation based on her history. FVL is the most common inherited thrombophilic disorder affecting approximately 5% of Caucasian women in the United States. It is a point mutation which alters factor V making it resistant to inactivation by protein C. The thrombophilic effect of a FVL mutation has been clearly established. Heterozygosity for FVL is associated with a five to ten-fold increased risk of thrombosis, while homozygosity is associated with an 80-fold increased risk. The FVL mutation is associated with obstetric complications including stillbirth, preeclampsia, placental abruption and IUGR. Fetuses with Trisomy 18 are likely to have congenital anomalies that are detectable on prenatal ultrasound. Over 90% of cases of trisomy 18 may be detected with the quad screen. A congenital parvovirus infection associated with a fetal demise would likely cause hydrops in the fetus which would be identified on ultrasound. Although poorly controlled diabetes mellitus and cord accidents are associated with fetal demise, they are not the most likely etiologies in this patient whose presentation is classic for the FVL mutation.

A 38-year-old G2P0 woman at 28 weeks gestation has been diagnosed with preterm labor and is currently stable on nifedipine. Her cervical exam has remained unchanged at 2 cm dilated, 75% effaced and -2 station. Her vital signs are stable and fetal heart tracing is category I. You recommend treatment with betamethasone (a steroid). Which of the following is associated with betamethasone therapy in the newborn? A. Enhancement of fetal growth B. Increased risk of infection C. Increased incidence of necrotizing enterocolitis D. Increased incidence of intracerebral hemorrhage E. Decreased incidence of intracerebral hemorrhage

Correct answer is E. Treatment with betamethasone from 24 to 34 weeks gestation has been shown to increase pulmonary maturity and reduce the incidence and severity of RDS (respiratory distress syndrome) in the newborn. It is also associated with decreased intracerebral hemorrhage and necrotizing enterocolitis in the newborn. It has not been associated with increased infection or enhanced growth.

A 19-year-old G3P0 with spontaneous rupture of membranes for 13 hours presented to labor and delivery. She had no prenatal care. Her vital signs are:blood pressure 120/70; pulse 72; afebrile; fundal height 36 cm; and estimated fetal weight of 2700 gm. Cervix is dilated to 1 cm, 50% effaced, -2 station. Which statement best describes the tracing seen below? A. Normal fetal heart rate with good variability and regular contractions B. Fetal tachycardia with good variability and regular contractions C. Normal fetal heart rate with poor variability and irregular contractions D. Fetal tachycardia with poor variability and regular contractions E. Normal fetal heart rate with good variability and irregular contractions

D

A 23-year-old G1P0 woman presents in labor at term. Her prenatal course was uncomplicated. She delivers a 3500 gram infant spontaneously after oxytocin augmentation of labor. Immediately postpartum, there is excessive bleeding greater than 2000 cc. There are no lacerations and the uterus is found to be boggy. Her blood pressure is 90/40; pulse is 120. Conservative and medical management have failed and you proceed with an exploratory laparotomy. Which of the following is the most appropriate next step in the management of this patient? A. Cervical artery ligation B. Ovarian artery ligation C. External iliac artery ligation D. B-Lynch suture E. Hysterectomy

D A uterine compression suture such as a B-Lynch has been shown to be effective in the management of unresponsive uterine atony. Ligation of a number of pelvic vessels can lead to reduction in the vascular pressure in the pelvis thus controlling hemorrhage. This is especially true with internal iliac artery (hypogastric artery) ligation. However, ligation of the ovarian arteries should not be undertaken as a primary approach. Ligation of the external iliac artery results in devascularization of the leg and, therefore, should not be performed. If these more conservative maneuvers fail, hysterectomy may be necessary but should be a last resort considering the age and parity of the patient.

A 36-year-old G5P4 woman with no prenatal care presented in active labor with a blood pressure of 170/105 and 3+ proteinuria. Fundal height is 28 cm. Fetal heart tones were found to be in the 170s with decreased variability and a sinusoidal pattern. Resting uterine tone was noted to be increased and she was having frequent contractions (every 1-2 minutes). The patient complained of bright red vaginal bleeding for the past hour. Based on this history, what is the most likely etiology of her vaginal bleeding? A. Uterine rupture B. Placenta previa C. Bloody show D. Abruption placenta E. Cervical trauma

D Although all the options above can result in third trimester vaginal bleeding, the most likely cause in this patient is placental abruption. This diagnosis goes along with the tachysystole on tocometer and evidence of fetal anemia (tachycardia and sinusoidal heart rate pattern) on the heart rate tracing. Hypertension and preeclampsia are risk factors for abruption. She has no history of cervical trauma.

A 22-year-old G2P1 has a history of a previous postterm pregnancy. She delivered a 3500 g healthy male infant at 42-½ weeks gestation via a Cesarean section secondary to fetal distress. She is currently 15 weeks pregnant, based on an irregular last menstrual period. What is the most appropriate management at this time? A. Plan for a repeat Cesarean section at 38 completed weeks B. Schedule for a repeat Cesarean section if she does not go into spontaneous labor by 40 weeks gestation C. Plan to admit the patient for an induction of labor (a VBAC) if she does not go into spontaneous labor by 41 weeks gestation D. Obtain a fetal ultrasound to date the pregnancy E. Start weekly non-stress tests and amniotic fluid indexes at 40 weeks gestation and proceed with either induction of labor or Cesarean section for a nonreactive non-stress test or oligohydramnios or if patient has not gone into spontaneous labor by 41 weeks gestation

D Approximately 50% of patients with a history of a postterm pregnancy will experience prolonged pregnancy with the next gestation. The diagnosis of postterm pregnancy is based on the establishment of an accurate gestational age. In a patient with irregular menses, it is important to obtain an ultrasound prior to 20 weeks to accurately date the pregnancy. It is reasonable to allow a patient with reassuring fetal surveillance to go past 41 weeks gestation. However, because of a prior Cesarean birth, consideration should be given to delivery before 41 weeks.

A 19-year-old G1 at 40 weeks gestation reports that she is postterm and wants to be induced. She has had an uncomplicated pregnancy. Her blood pressure is 124/76 and her pulse is 84. What gestational age would define postterm pregnancy? A. The due date B. 40 completed weeks C. 41 completed weeks D. 42 completed weeks E. 43 completed weeks

D By definition, a postterm pregnancy is a pregnancy that has progressed past 42 completed weeks or 294 days.

A 19-year-old G1 presents at 41 weeks gestation with a fever, spontaneous ruptured membranes and no contractions. Her temperature is 102.6° F (39.2° C); pulse 126. Ultrasound reveals a singleton with decreased amniotic fluid and placenta partially covering the os. The cervix appears long and closed. Why should this patient be delivered by Cesarean section? A. Chorioamnionitis B. Unfavorable cervix C. Oligohydramnios D. Placenta covering the cervical os E. Spontaneous ruptured membranes not in labor

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

A 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 is 5 days post-operative from a Cesarean section for arrest of labor at 7 centimeters. She now complains of minimal abdominal pain and drainage from the right side of the incision. Lochia is normal and she has no urinary complaints. Her vital signs are normal and she is afebrile. On physical exam, her lung and cardiac examinations are normal. Her abdomen and uterine fundus are nontender. Her Pfannenstiel incision has erythema extending 3 centimeters from the incision and there is purulent, bloody drainage coming from the right side. What is the next best step in the management of this patient? A. Initiate intravenous antibiotics B. Initiate oral antibiotics C. Occlusive dressing to the wound D. Open drainage of wound E. Tropical antibiotics to the wound

D Mixed bacteria originating from the skin, uterus and vagina cause wound infections after a Cesarean section. Treatment requires opening the wound, checking for fascia dehiscence and drainage of the purulent material. Packing the wound until it has healed from the bottom up prevents persistent infection. Broad spectrum antibiotics are started, but alone will not treat the abscess. Hot packs may relieve some minor symptoms, but is not adequate treatment alone.

A 32 year-old G2P2 delivered five days ago by uncomplicated vaginal delivery. Her postpartum course thus far has been unremarkable and she is breast feeding without difficulty. She woke up in the middle of the night with terrible upper abdominal pain and chills. She admits that she has had pain like this before, but never this severe. Vital signs reveal blood pressure 120/70; pulse 110; and temperature 101.8°F, 38.8°C. On physical examination, she has abdominal pain located in the right upper quadrant with rebound. Her uterine fundus is well below the umbilicus and nontender. Her lochia is normal. Laboratory tests reveal mild anemia, a slightly elevated white count and slightly elevated liver function tests. What is the most likely etiology of her pain? A. Endomyometritis B. Ruptured ovarian abscess C. Gastric ulcer D. Cholecystitis E. Appendicitis

D Non-pregnancy related conditions must be considered when evaluating women in the postpartum period. Pregnancy puts women at risk for cholelithiasis and, therefore, cholecystitis. Classic symptoms include nausea, vomiting, dyspepsia and upper abdominal pain after fatty foods. Treatment would be dependent on the severity of symptoms, but often involves cholecystectomy that is usually performed laparoscopically. Classic clinical findings for endomyometritis include fever and maternal tachycardia, uterine tenderness and no other localizing signs of infection. This patient is unlikely to have an ovarian cyst. A gastric ulcer would most likely have caused some symptoms during pregnancy. Appendicitis presents with nausea, vomiting, anorexia and abdominal pain.

A 32-year-old G2P1 is at 42 weeks gestation. Her prenatal course was uncomplicated and she had a first trimester ultrasound confirming dates. Her cervix is 4 cm dilated and 100% effaced. She does not report contractions and states there is good fetal movement. What is the next best step in the management of this patient? A. Ultrasound to assess amniotic fluid volume B. Twice weekly non-stress test (NST) and amniotic fluid index (AFI) C. Daily biophysical profiles D. Induction E. Ultrasound to assess fetal growth

D Optimal management for the patient with a favorable cervix at greater than or equal to 41 weeks gestation is delivery. Her dilation and effacement make it likely her induction will be successful. Induction of labor in a patient with an unfavorable cervix increases the risk of Cesarean section significantly, compared to a patient who goes into spontaneous labor. It is not advisable to follow a patient who is >42 weeks with antepartum fetal testing, such as twice weekly non-stress tests with amniotic fluid index, if the gestational age is certain. Performing an ultrasound to assess fetal growth and/or amniotic fluid volume should not change the management plan which should be induction of labor at this gestational age.

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

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

A 22-year-old patient with regular periods reports tension, depressed mood and decreased productivity towards the end of each cycle. She is otherwise healthy and maintains a high-profile job. Her past medical history is benign and she denies prior psychiatric problems. She denies smoking and drinks alcohol socially. What is the next best step in the management of this patient? A. Reassure her that her monthly symptoms are normal B. Initiate anti-depressant therapy C. Psychiatry consult D. Ascertain the timing of her symptoms each month E. Initiate psychotherapy

D Symptoms of Premenstrual Dysphoric Disorder occur in the luteal phase and are absent in the beginning of the follicular phase. It is therefore important to document the timing of symptoms each month when considering a diagnosis of Premenstrual Dysphoric Disorder. Additionally, it is important to ascertain that these symptoms are not an exacerbation of an underlying psychiatric disorder before initiating therapy.

A 22-year-old G1 presents at 42 weeks gestation. Her cervix is long and closed. She does not report contractions and states there is good fetal movement. You discuss the benefits of induction at this time versus waiting until she goes into labor spontaneously. She agrees to proceed with an induction. Which of the following means should be used to ripen the cervix in this patient? A. Artificial rupture of membranes B. Membrane stripping C. Oxytocin infusion D. Prostaglandin E1 tablet E. RU486 (progesterone antagonist)

D The American College of Obstetricians and Gynecologists (ACOG) recommendations for the management of postterm pregnancy includes: patient records fetal kick counts, and fetal surveillance using one of the following: NST, CST, biophysical profile and delivery for nonreassuring testing. If the patient has a favorable cervix, induce at 42 weeks and, if the cervix is unfavorable, use cervical ripening agents. Membrane stripping (digital separation of chorioamnion from lower uterine segment) and artificial rupture of membranes cannot be performed in a patient with a closed cervix. Prostaglandins applied locally are the most commonly-used cervical ripening agents. RU486 is not used for cervical ripening.

A 23-year-old G1 undergoes a vaginal delivery and an episiotomy is performed. Upon inspection, you notice that the episiotomy has extended into the rectal sphincter and mucosa. What is the classification for this laceration? A. 1st degree B. 2nd degree C. 3rd degree D. 4th degree E. Mediolateral episiotomy

D The degree of the lacerations range from 1 through 4. They increase along with the extent of the laceration. A 4th degree laceration involves the rectal sphincter and rectal mucosa. Careful attention to identification and repair of the disrupted ends of the sphincter is important to try to minimize the risk of future fecal or flatus incontinence. A 1st degree laceration involves only the vaginal mucosa. A 2nd degree laceration involves the vaginal fascia and perineum. A 3rd degree laceration involves the rectal partial or complete transection of the rectal sphincter. A 4th degree laceration involves the external anal sphincter, the internal anal sphincter and the rectal mucosa.

A 36-year-old G1 began prenatal care at eight weeks gestation. At that time, the gestational age was confirmed by a transvaginal ultrasound. She is now at 36 weeks gestation. Her previous medical history reveals hypertension for eight years and class F diabetes for five years (baseline proteinuria = 1 g). She smokes one half-pack of cigarettes per day. On examination at 32 weeks gestation, her fundal height was 29 cm. At 33 weeks, biometry was consistent with 31-3/7, EFW 1827g, 25th percentile. Today, ultrasound reveals limited fetal growth over the past three weeks. Biometry is consistent with 31-5/7, EFW 1900 g, <10th percentile. What is the most likely etiology of the intrauterine growth restriction in this case? A. Genetic factors B. Congenital anomaly C. Tobacco use D. Uteroplacental insufficiency E. Perinatal infection

D There is substantial evidence from experimental animal studies that suggests that alterations in uteroplacental perfusion affect the growth and status of the fetus, as well as the placenta. This patient has significant medical diseases that are affecting her vasculature and, ultimately, limiting the substrate availability to the fetus with resultant uteroplacental insufficiency. The vascular disease is evidenced by retinopathy and proteinuria. The other choices above may all result in fetal growth restriction; however, they are not the most likely etiology in this clinical scenario.

A 33-year-old G1 at 38 weeks gestation with pregnancy complicated by type 1 diabetes was admitted for induction due to oligohydramnios. She received Cervidil (prostaglandin E2) overnight and her cervix was noted to be 3 cm dilated in the morning so oxytocin was started. After three hours on oxytocin induction, fetal heart rate was noted to be in the 160s with minimal variability and late decelerations despite resuscitation with oxygen, fluids and left lateral position. Thirty minutes after discontinuing the oxytocin, she continued to have contractions every three to four minutes with late decelerations. Her blood pressure was noted to be 138/88 and her pulse was 110. Her cervical exam was noted to be 4 cm dilated. What is the most appropriate next step in the management of this patient? A. Perform a biophysical profile B. Administer morphine C. Administer terbutaline D. Proceed with a Cesarean section E. Restart the oxytocin

D This fetus is clearly not tolerating labor. Unfortunately, there is no good way to assess fetal status at this point. A biophysical profile is not of any value in labor. The presence of late decelerations in a patient with diabetes and oligohydramnios is not reassuring and unlikely to recover. Although terbutaline may slow down the contractions, it is not recommended in a patient whose heart rate is 110. Morphine will not resolve the late decelerations.

An 18-year-old G1 woman at 32 weeks gestation presents with severe abdominal pain and a small amount of bleeding. She has received routine prenatal care, smokes one pack of cigarettes per day and admits to using crack cocaine. On exam, her blood pressure is 140/80, pulse 100 and she is afebrile. Her uterus is tense and very tender. Pelvic ultrasound reveals a fundal placenta, cephalic presentation of the fetus and no other abnormalities. Cervical examination reveals blood coming through the os and is one centimeter dilated. Fetal heart tones have a baseline of 160s, with a category III tracing. Which of the following is the most likely diagnosis? A. Placenta previa B. Premature rupture of the membranes C. Preterm labor D. Placental abruption E. Chorioamnionitis

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

A 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? A. Allow to continue pushing until the baby delivers B. Start Oxytocin to strengthen contractions C. Discontinue the epidural D. Forceps-assisted vaginal delivery E. Cesarean section

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

A 34-year-old chronic hypertensive G1 comes to see you for a consultation at 34 weeks for size less than dates. Her prenatal course has been uncomplicated and the genetic amniocentesis obtained at 15 weeks revealed a normal male. Biometrics today reveal a biparietal diameter consistent with 33 weeks, abdominal circumference of 28 weeks, EFW 1600 g, less than 10th percentile, and an amniotic fluid index of 6. What is the most likely cause of fetal growth restriction in this patient? A. Chromosomal abnormality B. Fetal infection with Rubella C. Fetal infection with cytomegalovirus (CMV) D. Uteroplacental insufficiency E. Maternal infection with Varicella

D Uteroplacental insufficiency can lead to asymmetric growth restriction. Asymmetric growth restricted infants typically have a normal length, but their weight is below normal. On ultrasound, there is a head-sparing effect, meaning that the head/brain is spared of the reduced blood flow that is a result of uteroplacental insufficiency. Thus, the fetal abdomen measures below normal and the head remains very close to normal. There is an asymmetrical growth pattern that is usually detected during the third trimester and reflects uteroplacental insufficiency. Symmetric fetal growth restriction indicates that all fetal measurements are below normal. As a general rule, such a finding indicates an intrinsic growth failure or an "early event" secondary to one or more organ system anomalies, fetal aneuploidy or chronic intrauterine infection. Infectious diseases are known to cause IUGR, but the number of organisms is poorly defined. There is sufficient evidence to show a causal relationship between rubella and CMV infections and fetal growth restriction. Other viruses to consider are syphilis and varicella. The protozoan toxoplasmosis results in IUGR as well. There are no bacteria known to cause IUGR. Symmetrical growth restriction is usually detected in the mid-trimester of pregnancy.

A. Analyze FHT A. Normal fetal heart rate pattern B. Sinusoidal rhythm C. Late deceleration D. Variable deceleration E. Early deceleration

D Variable decelerations show an acute fall in the FHR, with a rapid down slope and a variable recovery phase. They are characteristically variable in duration, intensity, and timing, and may not bear a constant relationship to uterine contractions. They are typically associated with cord compression, especially in the setting of low amniotic fluid volume. Early decelerations are physiologic caused by fetal head compression during uterine contraction, resulting in vagal stimulation and slowing of the heart rate. This type of deceleration has a uniform shape, with a slow onset that coincides with the start of the contraction and a slow return to the baseline that coincides with the end of the contraction. Thus, it has the characteristic mirror image of the contraction. A late deceleration is a symmetric fallin the fetal heart rate, beginning at or after the peak of the uterine contraction and returning to baseline only after the contraction has ended. Late decelerations are associated with uteroplacental insufficiency. The true sinusoidal pattern is a regular,smooth, undulating form typical of a sine wave that occurs with a frequency of two to five cycles/minute and an amplitude range of five to 15 beats/minute. It is also characterized by a stable baseline heart rate of 120 to 160 beats/minute and absentbeat-to-beat variability.

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

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

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

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

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

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

A 34-year-old G4P3 woman at 36 weeks with a twin gestation presents in labor. She has three prior normal spontaneous vaginal deliveries at term, with the largest infant weighing 3400 grams. Twin A is breech with an estimated fetal weight of 2800 gm and twin B is vertex, with an estimated fetal weight of 3200 gm. Which of the following is an appropriate delivery option for this patient? A. Total breech extraction of twin A, vaginal delivery of twin B B. External cephalic version for twin A, vaginal delivery twin of B C. Operative vaginal delivery for twin A and vaginal delivery for twin B D. Cesarean delivery E. Vaginal delivery for twin A and Cesarean delivery for twin B

D. Cesarean delivery The optimal mode of delivery for twins in which the first twin is in the breech presentation is by Cesarean section. Similar to singletons, if the first twin is breech problems can occur including head entrapment and umbilical cord prolapse. When the presenting twin is vertex and twin B is not vertex, controversy exists as to the optimal mode of delivery. A small randomized study comparing Cesarean delivery with vaginal delivery for vertex-non-vertex twins failed to show an advantage for Cesarean delivery, but did not have statistical power to address rare neonatal morbidities. Some authors have advocated external cephalic version for management of the second twin; however, observational studies have not shown any advantage of this approach compared to total breech extraction.

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

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

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

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

A 22-year-old G1 currently at eight weeks gestation is noted to have a missed abortion on ultrasound, along with a sharply retroverted uterus. She elects to undergo suction dilation and curettage. During the procedure, "fatty appearing tissue" is noted to be coming through the curette. What is the next best step in the management of this patient? A. Continuing with the suction curettage B. Remove the tissue from the curette and replace it into the uterus C. Cut the tissue off at the cervical os D. Proceed with laparoscopy E. Stop the procedure and observe her the hospital for 48-hours

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

A 24-year-old G2P1 woman at 30 weeks gestation is sensitized to the D antigen. She is Rh negative and received RhoGAM during her first delivery one year ago. Which of the following statements best explains these findings? A. The patient initiated her prenatal care late during the present pregnancy B. The patient was sensitized during the previous pregnancy by receiving the RhoGAM C. Current pregnancy is too close to the first pregnancy D. The amount of fetal maternal hemorrhage was more than previously estimated E. The cause is most likely idiopathic in this case

D. The amount of fetal maternal hemorrhage was more than previously estimated On rare occasion, an Rh-negative woman will subsequently be sensitized, despite prophylaxis. The protection afforded by a standard RhoGAM administration is dose-dependent. One dose will prevent Rh sensitization to an exposure of as much as 30 cc of Rh-positive red blood cells. With greater exposure, there is only partial protection and Rh sensitization may occur as a result of failure to diagnose massive transplacental hemorrhage. Alternatively, an Rh-negative woman may be sensitized in the latter part of pregnancy or soon after delivery before the post-delivery prophylaxis dose is given. Inadvertent maternal transfusion of Rh-positive blood may result in Rh sensitization to the D or another red blood cell antigen. Patients may become sensitized if they do not receive RhoGAM following an episode of antenatal bleeding or after an invasive procedure, such as amniocentesis or chorionic villus sampling. In addition, RhoGAM only confers protection against the D antigen. Therefore, despite administration of RhoGAM to Rh-negative patients, they may still become sensitized to other red blood cell antigens. Pregnancy spacing does not affect the presence of the antibody.

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. The mother's mortality rate is above 25% 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 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? A. Qualitative serum hCG B. Quantitative serum hCG C. Ultrasound measurement, gestational sac D. Ultrasound measurement, crown-rump length E. Uterine size on pelvic exam

D. Ultrasound measurement, crown-rump length All the above can potentially be used to help date a pregnancy; however, ultrasound measurement of crown-rump length is considered the most reliable (+/- 4 to 5 days) in the first trimester. Other means to date the pregnancy include: fetal heart tones that have been documented for 20 weeks by a non-electronic fetoscope or for 30 weeks by Doppler; it has been 36 weeks since a positive serum or urine 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.

A 39-year-old G4P1 at 36 weeks gestation presents to labor and delivery. Upon initial evaluation, no fetal heart tones were noted on Doptone. Ultrasound confirms a stillbirth. Problems during the pregnancy include diagnosis of an open neural tube defect, estimated fetal weight >90th percentile, polyhydramnios and a nonreactive NST (non-stress test) the week prior to admission. What is the most likely etiology of this stillbirth? A. Uncontrolled hypertension B. In-utero viral infection C. Antiphospholipid antibody syndrome (APAS) D. Uncontrolled diabetes E. Untreated maternal hypothyroidism

D. Uncontrolled diabetes Uncontrolled diabetes during organogenesis is associated with a high rate of birth defects. The most common sites affected are the spine and the heart of the fetus, although all birth defects are increased. Fetuses in utero exposed to high levels of glucose transplacentally have increased growth and polyuria resulting in an increase in the amniotic fluid. While some viral infections are also associated with placentomegaly and polyhydramnios, the fetus will have normal or decreased growth depending on the timing of the infection. Severe hypertension and active APAS is often associated with oligohydramnios and intrauterine growth restriction. The risk of miscarriage is increased if hypothyroidism goes untreated.

An 18 year-old G1P0 presents at 32 weeks for a routine visit. She complains of intense itching for the past 2 weeks and cannot stop scratching her arms, legs, and soles of her feet. She has tried over the counter lotions and antihistamines with no relief. She also states that her family noticed she is slightly yellow. Her vital signs are normal and there are scattered excoriations over her arms and legs. Which of the following is the best treatment in the management of this patient? A. Aggressive hydration B. Antivirals such as Acyclovir C. Antihistamines D. Ursodeoxycholic acid E. Steroids

D. Ursodeoxycholic acid This patient has 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 just delivered a 32-year-old patient at term while covering for your partner. She had an uneventful pregnancy, followed by a normal spontaneous vaginal delivery. She is taking Sertraline (Zoloft), a selective serotonin uptake inhibitor (SSRI) as an antidepressant and wants to breastfeed. What is the next best step in management of this patient at this time? A. Decrease her SSRI dose by 50%, since these drugs are concentrated in the breast milk B. Consult psychiatry about changing medications and discard the expressed milk in the meantime C. Discontinue the medications so she can breastfeed D. Increase her SSRI dose, since these drugs are not concentrated in the breast milk and she is at great risk for postpartum depression E. Continue the medications, since there is negligible risk for the newborn

E Breastfeeding is beneficial to both mother and infant. Current recommendations state that SSRI medications can be safely used during lactation. Several studies show that SSRIs are secreted in breast milk, however no detectable levels of the drug were found in the infants' serum. In addition, no adverse effects were noted in the infants by either their parents or pediatricians following the infants.

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

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

A 22 year-old delivered her first baby five days ago after a prolonged labor and subsequent Cesarean section for arrest of cervical dilation at 7 centimeters. Fever was noted on postoperative day 2 and despite intravenous broad spectrum antibiotics, she continues to have temperature spikes above 101.3°F, 38.5°C. She is eating a normal diet and ambulating normally. On physical examination, her breasts have no erythema and nipples are intact. Her abdomen is soft, uterine fundus is firm and nontender, and her incision is healing without induration or erythema. She has normal lochia and her urinalysis is normal. Pelvic examination reveals a firm nontender uterus and no adnexal masses or tenderness. Which of the following treatments is indicated for this patient? A. Addition of antifungal therapy B. Addition of oral antibiotic therapy C. Addition of antiviral therapy D. Surgical exploration E. Heparin anticoagulation

E Septic thrombophlebitis involves thrombosis of the venous system of the pelvis. Diagnosis is often one of exclusion of other causes, but sometimes a CT scan will reveal thrombosed veins. Treatment requires addition of anticoagulation to antibiotics and resolution of fevers is generally rapid. Anticoagulation treatment is short-term. The addition of oral antibiotics has no extra benefit on a patient who is already on broad spectrum IV antibiotics. She has no evidence of fungal or viral infections, so therapy for these is not indicated. There is also no indication she needs surgery.

A 23-year-old G1P1 diagnosed with postpartum depression at three months after a spontaneous vaginal delivery, has suicidal ideation and is desperate for help. Which of the following is the most appropriate next step in the treatment of this patient? A. Behavioral psychotherapy B. Anti-depressant medication C. Anxiolytic agent D. Anti-psychotic medication E. Inpatient psychiatric admission

E This patient offered thoughts of suicidal ideation, thus inpatient management is the most appropriate choice. While behavioral psychotherapy is necessary to establish long-term strategies for coping skills, newer regimens for postpartum depression include the use of SSRI medication. SSRI medications have been shown to hasten recovery to a fully functioning state.

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

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

A 32-year-old G1P0 woman at 10 weeks gestation presents to your office after an ultrasound evaluation has revealed a diamniotic, dichorionic twin gestation. She is very concerned about the risk for preterm delivery. Which intervention would you recommend as a possible means to reduce the risk of a preterm, low-birthweight infant? A. Bed rest B. Cervical cerclage C. Tocolytics starting at 24 weeks D. Home uterine monitoring E. Early, good weight gain

E lthough prematurity has been recognized as a major cause of morbidity and mortality among twin gestations, interventions for prevention of prematurity have, in general, been unsuccessful. Studies show that an adequate weight gain in the first 20 to 24 weeks of pregnancy is especially important for women carrying multiples and may help to reduce the risk of having preterm and low-birth weight babies. These pregnancies tend to be shorter than singleton pregnancies, and studies suggest that a good early weight gain aids in development of the placenta, possibly improving its ability to pass along nutrients to the babies. Bed rest, long prescribed by obstetricians for the prevention of preterm birth, has never been shown to be efficacious, and may be associated with thromboembolic complications. An observational study of prophylactic cerclage for twin gestations failed to show any benefit. Tocolytic drugs for prevention of preterm labor in asymptomatic women with twin gestations have not been shown to be effective. Home uterine activity monitoring is another intervention that has been shown to be ineffective.

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. Begin oxytocin augmentation (no explanation)

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

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

A 42-year-old G5P2 woman at 36 weeks gestation is diagnosed with preeclampsia. Her previous pregnancy was complicated by twins and preeclampsia at 36 weeks gestation. She also has had two spontaneous abortions at seven weeks gestation. Which of the following conditions is not associated with her increased risk for preeclampsia in this pregnancy? A. Previous history of preeclampsia B. Chronic hypertension C. Multifetal pregnancy D. Age E. Previous spontaneous abortion

E. Previous spontaneous abortion Correct answer is E. The previous history of spontaneous abortion does not put the patient at increased risk. The incidence of preeclampsia is commonly cited to be about 5 percent and is markedly influenced by parity. It is related to race and ethnicity and to genetic predisposition. Environmental factors are also likely to play a role. Other risk factors for preeclampsia include a previous history of the disease, chronic hypertension, multifetal pregnancy and molar pregnancy. In addition, patients at extremes of maternal age or with diabetes, chronic renal disease, antiphospholipid antibody syndrome, vascular or connective tissue disease or triploidy are at increased risk for developing preeclampsia

What is the most likely interpretation? A. Normal reassuring B. Bradycardia C. Early deceleration D. Variable decelerations E. Late decelerations

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

Review: A missed abortion, early intrauterine pregnancy, and ectopic pregnancy can only be confirmed by what?

Serial Beta-hCG levels (at least every 48 hours until a trend is established, usually three levels).

A 38-year-old G0 presents for a preconception evaluation. She has a history of long-time anxiety and depression, and is interested in continuing her medications in pregnancy, which includes sertraline (Zoloft). In what FDA pregnancy category is this drug? A. Category A B. Category B C. Category C D. Category D E. Category X

Sertraline is a Category C drug. Depression is more common in women than men. Appropriate treatment, including during the antepartum period, is a component of good medical care. As in all cases, when considering treatments, the benefits should outweigh the risks. With Category A drugs, there are adequate, well-controlled studies in pregnant women that have not shown an increased risk of fetal abnormalities to the fetus in any trimester of pregnancy. With Category B, animal studies have revealed no evidence of harm to the fetus; however, there are no adequate and well-controlled studies in pregnant women or animal studies that have shown an adverse effect, but adequate and well-controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester. Category C drugs have animal studies that show an adverse effect and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Category D drugs have adequate well-controlled or observational studies in pregnant women and are known risks to the fetus. Category X drugs should not be used in pregnancy, because adequate well-controlled or observational studies in animals or pregnant women have demonstrated positive evidence of fetal abnormalities or risks.

A 24 year-old G1P0 at 12 weeks gestation presents for prenatal care. She is 5 feet 4 inches tall and weighs 220 pounds (BMI: 37.8 kg/m2). She wants to know if there is an increased risk on her pregnancy because of her size. Which of the following is the most common complication in this patient? A. Hypertension B. Preterm labor C. Post-term pregnancy D. Small for gestational age E. Shoulder dystocia

The correct answer is A. The body mass index (BMI) is equal to a person's weight in kg divided by their height in meters squared. The National Heart, Lung, and Blood Institute identify a normal BMI as 18.5 to 24.9 kg/m2; overweight as a BMI of 25 to 29.9 kg/m2; and obesity as a BMI of 30 kg/m2 or greater. Obesity is further categorized as class I (BMI: 30 to 34.9 kg/m2), class II (BMI: 35 to 39.9 kg/m2), and class III (BMI: > or=40 kg/m2). Increased maternal morbidity results from obesity and includes chronic hypertension, gestational diabetes, preeclampsia, fetal macrosomia, as well as higher rates of Cesarean delivery and postpartum complications. This patient's BMI is approximately 38 so she is a class II and has over a 7-fold increase risk for preeclampsia and a 3-fold risk for hypertension.

A 19 year-old G1P0 woman at 18 weeks gestation presents with a 3-month history of palpitations and intermittent chest pain. Physical examination reveals a pulse of 96 and grade II/VI systolic ejection murmur with a click. The ECG shows normal rate and rhythm and an echocardiogram is ordered. Which of the following is the best treatment in the management of this patient? A. Anxiolytics B. β-blockers C. Calcium-channel blockers D. Digitalis E. No treatment needed at this time

The correct answer is B. Most women with mitral valve prolapse are asymptomatic and diagnosed by routine physical examination or as an incidental finding at echocardiography. A small percentage of women with symptoms have anxiety, palpitations, atypical chest pain, and syncope. For women who are symptomatic, beta-blocking drugs are given to decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias. Because she is symptomatic, the option of no treatment is not correct.

An 18-year-old G1P0 woman at 16 weeks gestation was admitted four days ago because of back pain, chills and fever. She was placed on ceftriaxone intravenously but continues to have spiking fevers up to 102.0°F (38.9°C). Her urine culture shows E. coli. An IVP reveals a right ureteral obstruction secondary to calculi. Which of the following is the most appropriate next step in the management of this patient? D. Double-J ureteral stent placement A. Aggressive diuresis C. Surgical exploration E. Extracorporeal lithotripsy B. Additional antibiotic coverage

The correct answer is D. Renal infection is the most common serious medical complication of pregnancy. Initially aggressive intravenous hydration is given to ensure adequate urinary output. Antimicrobials are begun promptly after diagnosis. The majority of patients are afebrile by 72 hours. If there is no clinical improvement by 72 hours, further evaluation is warranted including sonography to look for urinary tract obstruction (abnormal ureteral or pyelocaliceal dilatation) or calculi. Obstruction can be relieved by cystoscopic placement of a double-J ureteral stent unless long-term stenting is foreseen, then percutaneous nephrostomy is indicated. Surgical exploration is required in up to 2% of women if other conservative therapies are not successful.

A 27-year-old G1P0 woman at 32 weeks gestation presents complaining of cough, fever, chest pain, and dyspnea. Vital signs are pulse 108; temperature 100.5° F (38.0° C); respiratory rate 22 per minute. Physical examination reveals right lower lobe bronchial breath sounds. Which of the following tests would be most appropriate for making a diagnosis for this patient? A. Complete blood count B. Sputum culture C. Lower extremity dopplers D. Chest x-ray E. Pulmonary function tests

The correct answer is D. This woman presents with classic symptoms and findings for pneumonia. The typical symptoms include cough, dyspnea, sputum production, and pleuritic chest pain. Mild upper respiratory symptoms and malaise usually precede these symptoms, and mild leukocytosis is usually present. Chest radiography is essential for diagnosis, although radiographic appearance does not accurately predict the etiology of the pneumonia. Pulmonary function tests, sputum culture, serological testing, cold agglutinin identification, and tests for bacterial antigens are not recommended in uncomplicated pneumonia.

Review: T/F Risk for SAB increases with infections, such as listeria, mycoplasma, ureaplasma, toxoplasmosis and syphilis, advancing maternal or paternal age, advancing parity and some mullerian anomalies

True

A 19-year-old G1P0 at 39 weeks gestation presents in labor. She denies ruptured membranes. Her prenatal course was uncomplicated and ultrasoundat 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 ratetracing revealed variable decelerations with good beat-to-beat variability. What is the most likely cause for the variable decelerations? A. Umbilical cord compression B. Meconium C. Maternal fever D. Uteroplacental insufficiency E. Morphine administration

Variable decelerations are reflex mediated usually associated with umbilical cord compression as a result of cord wrapped around fetal parts, fetal anomalies or oligohydramnios. The presence of light meconium-stained fluid is not associated with a specific fetal heart rate tracing. Uteroplacental insufficiency is associated with late decelerations. Maternal drugs may cause loss of variability.

Review: Is it normal to have first semester spotting/bleeding?

Yes (30%)

Review: When should glucose tolerance be tested if... --no history of glucose intolerance -- low risk --average risk --high risk

a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) i -- no history = 24-28 weeks -- low risk = 24-48 weeks/not routinely screened --medium risk = 24-28 weeks --high risk = severe obesity, family hx = screening should be done as soon as feasible

Review: how do prostaglandin synthetase inhibitors work as a tocolytic?

decreasing prostaglandin (PG) production by blocking conversion of free arachidonic acid to PG.

A 34 year-old G2P1 at 18 weeks gestation presents with a newly discovered lump in her left breast. Fine needle aspiration reveals adenocarcinoma. Which of the following is NOT a recommended therapy for breast cancer during pregnancy? A. Wide local excision biopsy B. Modified radical mastectomy C. Total mastectomy and node dissection D. Chemotherapy E. Radiotherapy

e. Radiotherapy There is no doubt that breast cancer is more aggressive in younger women. Whether it is more aggressive during pregnancy in young women is debatable. Slight delays (1 to 2 months) in clinical assessment, diagnostic procedures, and treatment of pregnant women with breast tumors are common. Approximately 30 percent of pregnant women with breast cancer have stage I disease, 30 percent have stage II, and 40 percent stages III or IV. Many clinical reports maintain that when breast cancer is diagnosed during pregnancy, the regional lymph nodes are more likely to contain microscopic metastases. Surgical treatment may be definitive for breast carcinoma during pregnancy and in the absence of metastatic disease a wide excisional biopsy, modified radical mastectomy, or total mastectomy with axillary node staging can be performed. Non-pregnant women receive adjunctive radiotherapy with breast-conserving surgery. However, this is not recommended during pregnancy due to sizeable abdominal scatter placing the fetus at significant risk for excessive radiation.

Review: A positive pregnancy test + hypovolemia (tachycardia, hypotension) + peritoneal signs (rebound, guarding and severe abdominal tenderness) = ?

ectopic pregnancy

Review: what is the discriminatory zone?

hCG below 1500 mIU/ml for transvaginal ultrasound or 2000 mIU/ml for abdominal ultrasound, you cannot detect an intraurine pregnancy by ultrasound.

Review: how do beta adrenergics work as a tocolytic?

increasing cAMP in the cell, thereby decreasing free calcium

Review: how do CCB work as a tocolytic?

prevent calcium entry into muscle cells by inhibiting calcium transport.