OB general

Question 1

Can pregnant patient’s get Tamiflu?

Answer 1

YES!!! actually should be given

Question 2

Risk factors for an ectopic pregnancy?

Answer 2

Anything that causes disruption of the normal tubal anatomy is a risk for ectopic pregnancy. The correct and neutral answers are listed below with explanations. To get this question correct you needed to realize that a previous ectopic pregnancy, pelvic inflammatory disease, and history of tubal surgery were common risk factors for ectopic pregnancies with the highest increased risk of the options presented. Douching and in utero exposure to diethylstilbestrol may be tested, but were considered less high yield and so were neutral for this question. Cesarean delivery is associated with a very minimal increased risk of ectopic pregnancy but was also considered neutral.

An induced abortion is NOT a risk factor.

Question 3

Threatened abortion definition? Management?

Answer 3

Bleeding from the uterus or cervix, viable intrauterine pregnancy on ultrasound, closed cervix

Expectant management until:

• Symptoms resolve
• Progression to inevitable, incomplete, or complete

Question 4

Definition of inevitable abortion and management?

Answer 4

Bleeding from the uterus or cervix, viable intrauterine pregnancy on ultrasound, dilated cervix

Expectant management
Medical management
Surgical management

Question 5

Missed abortion definition and management?

Answer 5

Presence OR absence of bleeding, retained non-viable products of conception on ultrasound, closed cervix

Expectant management (less successful)
Medical management
Surgical management

Question 6

Definition and management of an incomplete abortion?

Answer 6

Bleeding from uterus or cervix, partially retained nonviable products of conception, open or closed cervix

Expectant management
Medical management
Surgical management

Question 7

Definition and management of a complete abortion?

Answer 7

Presence OR absence of bleeding, no retained products of conception, closed cervix

No further management needed as long as bleeding is stable and all products of conception have been passed

Question 8

Classic findings for a positive trisomy 21 screen are? What is the next big step that needs to be taken?

Answer 8

Classic findings on a positive screen for trisomy 21 include a markedly elevated Beta-HCG, decreased PAPP-A, and increased nuchal translucency on ultrasound. A patient with a positive screening test should be offered secondary screening using maternal cell-free DNA. or invasive testing with chorionic villus sampling or amniocentesis. Maternal cell-free DNA still caries a high false positive rate, and for patients who wish for the most definitive and expeditious test, a chorionic villus sampling should be offered.

Question 9

Patient with third trimester bleeding usually is? do what?

Answer 9

This patient is presenting with third trimester bleeding, which is a common and highly tested obstetrical problem. Painless and profuse bleeding is usually consistent with placenta previa although other causes should not be discounted. Diagnosis is made by transabdominal ultrasound followed by transvaginal ultrasound if necessary. Approximately 95% of placenta previa can be diagnosed in this manner. Placenta previa is due to abnormal implantation of the placenta. It can be classified as total, marginal or low-lying. The incidence is about 1 in 200. Risk factors for it include prior c-section, grand multiparity, advanced maternal age, multiple gestation, and prior placenta previa. It presents as painless bright red bleeding that often ceases in 1-2 hours with or without uterine contractions. The fetus is usually not in distress. It is diagnosed with transabdominal or transvaginal ultrasound, which will show an abnormally positioned placenta.

Question 10

What is a septic abortion?

Answer 10

Septic abortion occurs when signs of sepsis accompany a threatened, inevitable, missed, or incomplete abortion and is typically due to unsafe abortion techniques or prolonged retained products of conception. Presenting signs and symptoms include fevers, leukocytosis, hemodynamic instability, vaginal bleeding, and abdominal pain. These patients require both prompt administration of parenteral antibiotics and emergent uterine curettage to remove the nidus of infection.

Septic abortion is rare in developed countries that have adequate access to abortion services. If termination is done appropriately and by a trained provider, then the risk of a septic abortion is exceedingly low. In the United States, the most common presentations are in those who are young, poor, and lack partner support and do not have adequate access to abortion care or are scared to seek appropriate access due to fear of repercussions. In developing countries, 5 million women a year are admitted for complications and infections related to unsafe abortion practices. Factors that increase the risk of septic abortion after unsafe abortion procedures include lack of provider skill, poor technique, nonsterile technique, lack of appropriate equipment, poor maternal health, use of toxic substances, and increasing gestational age at time of attempted abortion.

Question 11

How much radiation in pregnancy?

Answer 11

Radiation exposure less than 50mGy (5 rads) in pregnancy provides negligible risk to the fetus.

Question 12

What is a level 2 ultrasound?

Answer 12

level-II ultrasound (targeted ultrasound or anatomy scan) is indicated in patients who are at high risk for congenital abnormalities. Lithium use during pregnancy has been associated with Ebstein anomaly, which is a congenital malformation of the heart caused by apical placement of the posterior and septal tricuspid leaflets. This leads to atrialization of the right ventricle. Ebstein anomaly presents with symptoms of heart failure. Medical therapy with surgical correction of the underlying tricuspid malformation is indicated.

Question 13

What is Polyhydramnios? causes?

Answer 13

Polyhydramnios is an excessive volume of amniotic fluid. It has been associated with an increased risk of various adverse pregnancy outcomes, including preterm birth, placental abruption, and fetal anomalies. Polyhydramnios should be suspected clinically when uterine size is large for gestational age. Prenatal ultrasound is the first-line modality for diagnosis. The diagnosis of polyhydramnios is based upon sonographic visualization of increased amniotic fluid volume (AFV). It is diagnosed when there is a single deepest pocket ≥ 8 cm and an amniotic fluid index (AFI) ≥ 24 cm.
The most common cause of severe polyhydramnios are fetal anomalies (often associated with an underlying genetic abnormality or syndrome), while maternal diabetes, multiple gestation, and idiopathic factors are more often associated with milder cases. Polyhydramnios has been associated with fetal anomalies in most organ systems.

All of the above are causes of polyhydramnios. However, in this case, the most likely etiology in this patient is gestational diabetes mellitus (GDM). The mother had GDM during her first pregnancy and is at a higher risk of developing it again during her second pregnancy. Just like increased serum levels of glucose causes polyuria in adults, a similar effect occurs in the fetus and amniotic fluid is fetal urine.

Question 14

Placental abruption S/S?

Answer 14

Given the presentation of acute onset vaginal bleeding and severe abdominal pain with contractions, this patient is most likely suffering from placental abruption. This is a condition in which the placenta shears away from the uterine wall often due to trauma or mechanical event, but can also happen spontaneously. The diagnosis is made clinically. Most patients were present with some combination of abdominal pain or back pain (if the placenta is on the posterior uterine wall), may have contractions, and may and may not have vaginal bleeding, which can be clinically significant with hypotension and shock or quite minor. The presentation is quite variable. The amount of vaginal bleeding itself does not correlate with maternal or fetal risk, as significant bleeding can be hidden between the uterus and the placenta. Signs that do correlate with the severity of placental abruption include significant abdominal pain, hemodynamic compromise, and significant fetal heart rate abnormalities. Fetal compromise and disseminated intravascular coagulation (DIC) are much more likely when placental separation exceed 50%. 10-20% of placental abruption is present only with pre term labor, as the hemorrhage is contained between the placenta in the uterus, and only found on ultrasound. Even scant bleeding in the setting of preterm labor should prompt a search for placental abruption.

Question 15

what are risk factors for placental abruption?

Answer 15

The only significant risk factor in this patient’s presentation for placental abruption is smoking. The exact mechanism or connection between smoking and placental abruption is not known; however, it is felt to be due to placental ischemia secondary to the vasoconstrictive affects of tobacco, resulting in necrosis and hemorrhage and eventual placental separation. Smoking is associated with a 2.5-fold increase in the risk of placental abruption, and that risk increases by 40% more for each pack per day smoked.

Additional risk factors for placental abruption include history of placental abruption (this is the highest risk), followed by cocaine and drug use, followed by eclampsia and preeclampsia and chronic hypertension. The treatment of hypertension does not modify the risk for placental abruption. Smoking is one of the only modifiable risk factors.

Question 16

Pre-eclampsia diagnosis?

Answer 16

It should be noted that the guidelines for the diagnosis of preeclampsia have been altered, and no longer require the presence of proteinuria. Preeclampsia should be diagnosed based on a previously normotensive woman with new onset of hypertension (systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg on at least two occasions at least four hours apart) after 20 weeks of gestation AND new onset of 1 or more of the following:

• Proteinuria ≥0.3 g in a 24-hour urine specimen or protein/creatinine ratio ≥0.3 (mg/mg) in a random urine specimen or dipstick ≥2+ if a quantitative measurement is unavailable
• Platelet count < 100,000/microL
• Serum creatinine >1.1 mg/dL or doubling of the creatinine concentration in the absence of other renal disease
• Liver transaminases at least twice the upper limit
• Pulmonary edema
• Cerebral or visual symptoms (eg, new-onset and persistent headaches not accounted for by alternative diagnoses and not responding to usual doses of analgesics; blurred vision, flashing lights or sparks, scotomata)

Question 17

Sign for duodenal atresia? Associated with? Quad screen results for this disease?

Answer 17

The above picture represents duodenal atresia with the classic double bubble sign. The polyhydramnios is because the fetus is unable to swallow appropriately leading to excess amounts of amniotic fluid. Duodenal atresia is an extremely rare congenital anomaly that, in most cases, occurs sporadically, but, it is also seen in patients with Down syndrome. If this is seen on an ultrasound, an amniocentesis should be offered to assess the karyotype.

The beta-human chorionic gonadotropin (β-hCG) and inhibin are increased and the alpha-fetoprotein (AFP) and estriol are decreased on quad screen in Down syndrome. A quad screen is a blood test that is done in the second trimester between the gestational age of 15 and 20 weeks. The detection rate for Down syndrome is 81% using this test alone.

Question 18

Risk factors for placenta previa?

Answer 18

This patient is presenting with third trimester painless bleeding without contractions or fetal distress. The most likely diagnosis is placenta previa which occurs due to abnormal implantation of the placenta close to the cervical os. Of the choices listed, a prior C-section is the most likely risk factor for this condition. Other risk factors include multiparity and uterine surgery.

Question 19

Chorionic Villous sampling if done before 9 weeks increases risk of?

Answer 19

Chorionic villous sampling (CVS) can be used sooner than amniocentesis to assess fetal karyotype and is typically performed between 9 and 11 weeks of gestation. CVS involves transcervical or transabdominal aspiration of placental chorionic villi tissue. The advantage of using it is that it has a diagnostic accuracy comparable to that of amniocentesis, whereas the disadvantage is that is carries a risk of fetal loss and it cannot detect open neural tube defects. Amniocentesis is performed at 15 to 20 weeks and consists of transabdominal aspiration of amniotic fluid using ultrasound-guided needle evaluation of fetal cells for genetic studies.

Although preterm labor, premature rupture of membranes (PROM), and limb abnormalities are all potential complications of the procedure, performing CVS prior to 9 weeks of gestation specifically places the fetus at an increased risk for limb abnormalities.

Question 20

Guidelines for weight gain in pregnancy?

Answer 20

Current guidelines for changes in weight during the course of pregnancy are based on prepregnancy body mass index (BMI). An increase of 100 to 300 kcal/d is recommended during the course of pregnancy, whereas an increase of 500 kcal/d is recommended during breastfeeding in the postpartum period. Excessive weight gain is greater than 1.5 kg per month, whereas inadequate weight gain is less than 1 kg per month. Guidelines for weight gain according to BMI are divided into 4 categories: underweight (BMI <19.8), acceptable (BMI 19.8-26.0), overweight (BMI 26.1-29.0), and severely overweight (BMI >29.0). The recommended weight gain is greater than 35 pounds for underweight patients, 25 to 35 pounds for patients in the acceptable category, 15 to 25 pounds for overweight patients, and 11 to 20 pounds for severely overweight patients.

Question 21

Abx of choice for cystitis in pregnancy

Answer 21

This young woman is presenting with symptoms of simple cystitis with symptoms of frequency, urgency, and dysuria and suprapubic tenderness noted on examination. Her urinalysis is also consistent with a urinary infection given the marked pyuria, positive nitrite, and elevated bacterial count. She has no systemic symptoms concerning for pyelonephritis at this time and should be treated for a suspected simple urinary tract infection (UTI) with an appropriate agent for pregnancy. Of the agents listed, the only appropriate empiric therapy would be with cefpodoxime.

UTIs are the most common bacterial infections during pregnancy, with over 80% of these infections caused by Escherichia coli. Both symptomatic and asymptomatic pregnant patients with bacteriuria should be treated due to risk of progression to pyelonephritis and risk of poor fetal outcomes. Not all antibiotics are safe during pregnancy. The best treatment would be based on a culture and sensitivities; however, empiric treatment is often started to prevent delays and should be broad enough to cover common pathogens and safe enough that it will not cause problems for the fetus. Examples of medications that fit this criteria include cefpodoxime, amoxicillin-clavulanate, and fosfomycin.

Question 22

Any abnormal alpha fetoprotein level could be caused by? What should you do?

Answer 22

Any abnormal alpha-fetoprotein (low or high) could be caused by a dating error; thus, this should be ruled out before searching for a pathological cause. At 17 weeks, ultrasound is the most accurate dating method. Folic acid is itself not biologically active, but its biological importance is due to tetrahydrofolate and other derivatives after its conversion to dihydrofolic acid in the liver. Vitamin B9 (folic acid and folate inclusive) is essential to numerous bodily functions. The human body needs folate to synthesize DNA, repair DNA, and methylate DNA, as well as to act as a cofactor in biological reactions involving folate. It is especially important in aiding rapid cell division and growth, such as in infancy and pregnancy. Children and adults both require folic acid to produce healthy red blood cells and prevent anemia. Folic acid supplementation during pregnancy has been shown to reduce the incidence of neural tube defects.

Question 23

How do we treat hyperthyroidism in pregnancy?

Answer 23

Thioamide drugs are considered to be the first-line treatment for hyperthyroidism in pregnancy. Because propylthiouracil (PTU) has been least associated with fetal scalp defects, aplastic cutis, or choanal atresia, it should be the first choice over methimazole and carbimazole in the first trimester. After the first trimester, the patient may switch to methimazole or continue with PTU. Switching to methimazole may increase the risk of maternal or fetal hypothyroidism, since methimazole is more potent than PTU. However, PTU has more serious hepatotoxicity than methimazole. Thioamide agents work by competing with iodine for the peroxidase enzyme, the effect being inhibition of iodination of thyroglobulin and thus decreased thyroglobulin synthesis. Patients diagnosed after the first trimester should start with methimazole. Thyroidectomy during pregnancy is rarely necessary but is an option for women who cannot tolerate thionamides.

The thyroid of the fetus is more sensitive to the action of antithyroid medications. Therefore, the goal of treatment is to keep the mother in mild hyperthyroidism as to not overtreat the fetus and cause fetal hypothyroidism. In order to accomplish this, the goal for the free thyroxine (T4) concentration of the mother should be at the upper limit or just above the upper limit for normal range for pregnancy depending on the trimester.

A summary of treatment of hyperthyroidism in pregnancy is below:

Timeline Treatment

Diagnosed prior to pregnancy Options include:
Elect to have definitive therapy with surgery or radioiodine prior to pregnancy
Switch to PTU before trying to conceive (better for younger women with reliable periods)
Switch to PTU when pregnancy is confirmed (better for older women having difficulty conceiving)
Discontinue methimazole with careful monitoring of thyroid function tests (for women on low doses who have been stable over a year)

Diagnosed in the first trimester
PTU
May consider switching to methimazole after first trimester

Diagnosed after the first trimester
Methimazole

Question 24

Patients who get pregnant with an IUD in place what do we do?

Answer 24

Patients who become pregnant with an IUD in place have an increased risk of spontaneous abortion, placental abruption, and preterm delivery. Management depends on the patients’ desire to continue or terminate the pregnancy, gestational age, IUD location, and if the strings are visible on exam. When the strings are visible on exam, the IUD should be removed by applying gentle traction on the strings. In general, IUDs should be removed prior to 12 weeks’ gestation if possible. After 12 weeks, the risk of miscarriage after removal goes up.

If the strings are not visualized on exam or the IUD is not within the cervical canal on ultrasound, then management becomes more difficult. The IUD may be left in situ, understanding that it increases the risks of infection, miscarriage, and preterm birth. Attempted removal under ultrasound guidance as well as hysteroscopic removal can be attempted with extensive patient counseling. The risks of pregnancy loss with aggressive attempts at IUD removal must be weighed against the risks of adverse maternal and fetal outcomes later in pregnancy, including infection and preterm delivery, if the device is left in place.

Question 25

What is PPROM? what is a common findings associated with this?

Answer 25

preterm premature rupture of membranes (PPROM), which is defined as rupture of membranes before the onset of labor in the preterm period (prior to 37 weeks’ gestation). This patient’s presentation is also concerning for chorioamnionitis, given the maternal fever, abdominal tenderness, and fetal tachycardia. PPROM typically presents as a “gush of fluid” or “leaking of fluid” from the vagina. The diagnosis is confirmed by a sterile speculum exam that will reveal pooling of clear fluid in the vaginal vault, which is nitrazine positive and reveals “ferning” under the microscope. Oligohydramnios, defined as an amniotic fluid index (AFI) < 5 or a maximum vertical pocket (MVP) < 2 cm, is a common finding associated with PPROM.

Question 26

What is the biophysical profile?

Answer 26

Biophysical profile is an ultrasound test that assesses four fetal biophysical parameters: fetal tone, fetal movement, fetal breathing, and amniotic fluid level (either AFI or MVP). Each measure is given either 0 or 2 points for its absence or presence. A BPP of 8/8 is reassuring for fetal well-being. Assuming adequate fetal well-being, the rest of the biophysical profile (BPP) should be normal.

Question 27

What is the management of PPROM depending on timing?

Answer 27

Viability up to 33w6d gestation

No signs of maternal infection, chorioamnionitis: latency antibiotics, expectant management until 34w
Clinical signs of maternal infection, chorioamnionitis: delivery (CS v induction pending cervical exam, maternal status)
34w to 36w6d

No signs of maternal infection, chorioamnionitis: delivery USUALLY recommended; however, can manage expectantly until 37w with close monitoring and clear patient counseling of risks (per new ACOG guidelines)
Clinical signs of maternal infection, chorioamnionitis

Question 28

What is the management of PROM? (not PPROM)

Answer 28

Rupture of membranes prior to the start of labor at term (> 37 weeks’ gestation)

Delivery
Induction of labor if no contraindications for vaginal delivery exist
If planning repeat c-section, proceed to OR
Consider c-section if maternal decompensation or fetal distress is present

Question 29

What is Erb-Duchenne Palsy?

Answer 29

Erb-Duchenne palsy is most commonly caused by traumatic stretching of the brachial plexus during childbirth. Shoulder dystocia is the major complication that leads to this injury. The most commonly involved nerve roots are C5 and C6, and the most common nerves are the suprascapular nerve, musculocutaneous nerve, and the axillary nerve. Other signs of Erb palsy include loss of sensation in the arm and paralysis and atrophy of the deltoid, biceps, and brachialis muscles. The position of the limb, under such conditions, is characteristic: the arm hangs by the side and is rotated medially; the forearm is extended and pronated. The arm cannot be raised from the side; all power of flexion of the elbow is lost, as is also supination of the forearm. The resulting biceps damage is the main cause of this classic physical position, commonly called “waiter’s tip.” If the injury occurs at an age early enough to affect development, it often leaves the patient with stunted growth in the affected arm with everything from the shoulder through to the fingertips smaller than the unaffected arm. This also leaves the patient with impaired muscular, nervous, and circulatory development. The lack of muscular development leads to the arm being much weaker than the unaffected one, and less articulate, with many patients unable to lift the arm above shoulder height unaided, as well as leaving many with an elbow contracture.

The lack of development to the circulatory system can leave the arm with almost no ability to regulate its temperature, which often proves problematic during winter months when it would need to be closely monitored to ensure that the temperature of the arm was not dropping too far below that of the rest of the body. The damage to the circulatory system also leaves the arm with another problem. It reduces the healing ability of the skin, so that skin damage takes far longer than usual to heal, and infections in the arm can be quite common if cuts are not sterilized as soon as possible.

Question 30

What do we do with an adnexal mass seen in pregnancy?

Answer 30

The prevalence of adnexal masses in pregnancy is 0.5-3.2% of live births with malignancy only diagnosed in 1.2-6.8% of persistent masses. Evaluation of an adnexal mass in pregnancy is similar to that of the non-pregnant premenopausal female. Surgical intervention is typically reserved for cases where the mass is present after the first trimester and is >10 cm (>3.9 in) or is solid and has solid/cystic areas, papillary projections, or septations. These characteristics make the mass more likely to be malignant and/or increase the risk of torsion, rupture, and labor obstruction. Since this mass is simple in nature, it is likely to be benign, and no surgical intervention is indicated at this time. However, this patient will be getting a fetal anatomy ultrasound at 18-22 weeks’ gestation, and this serves as a good opportunity to evaluate the mass to ensure stability or resolution. If the mass had grown during that time, surgical intervention could be considered; since the anatomy ultrasound is during the second trimester, it serves as good timing for evaluation as the best time for any surgical procedure in pregnancy is the second trimester.

Question 31

What is Mastitis? Treatment?

Answer 31

This patient is presenting with mastitis, which is a cellulitis of the periglandular tissues of the breast. This infection usually occurs in breastfeeding mothers 2-4 weeks postpartum. The most common bacteria are Staph aureus. Symptoms include breast pain and redness along with high fever, chills, and flu-like symptoms. This must be distinguished from breast engorgement, which presents as swollen, firm, tender breasts with low-grade fever. Another diagnosis to exclude is breast abscess, which presents with erythema, point tenderness, and fluctuance. Diagnosis of mastitis includes breast milk cultures and complete blood count. Treatment of mastitis should include oral antibiotics such as dicloxacillin in addition to continuation of breastfeeding.

Question 32

What is fetal fibronectin?

Answer 32

Fetal fibronectin is an adhesive protein that is present at the maternal-fetal interface. Fetal fibronectin should not be found in vaginal sections between 22 and 35 weeks of gestation. Disruption of the maternal-fetal interface causes the release of fetal fibronectin into the vaginal secretions. This is an indicator of preterm birth risk. The fetal fibronectin test is collected with the aid of a speculum. Collection is contraindicated outside of those gestational ages and in the presence of rupture of membranes, active vaginal bleeding, or anything in the vagina in the past 24 hours, such as intercourse. With a negative fetal fibronectin result, the physician can be 99% sure that the patient will not go into preterm labor in the next 2 weeks.

Question 33

Preterm birth, what medication do we administer? What risks does this help avoid?

Answer 33

Adminstration of corticosteroids before an anticipated preterm delivery is one of the most important therapies to improve neonatal outcomes and is strongly associated with decreased neonatal morbidity and mortality. Neonates who are exposed to low-dose corticosteroids prior to preterm birth have a significantly lower frequency and/or severity of respiratory distress syndrome, intracranial hemorrhage, necrotizing enterocolitis, and death compared to neonates who are not exposed to antenatal steroids. Betamethasone and dexamethasone are the two most widely studied corticosteroids and are the preferred treatment for acceleration of fetal organ maturation. Steroids are given over a 24-hour time frame, and their effect is noted to be the greatest 2-7 days after adminstration. Ideally, steroids are given to patients with a high risk of premature delivery within the next 7 days and are from 24 to 34 weeks gestation (although some patients are candidates up to 36 weeks, known as “late preterm steroids”). This is the only intervention of the options listed above which will reduce the multiple risks associated with premature birth.

A short course of low-dose corticosteroids can reduce morbidity and mortality associated with prematurity, specifically with the reduction of respiratory distress, intraventricular hemorrhage, and necrotizing enterocolitis.

Question 34

Early physical exam signs of pregnancy?

Answer 34

During early pregnancy, several physiologic changes are noted. It is typical for the vagina and cervix to turn bluish in color, which is referred to as Chadwick’s sign. Common early signs of pregnancy include the following:

Chadwick’s sign: Bluish discoloration of the vagina and cervix
Goodell’s sign: Softening and cyanosis of the cervix at, or after, 4 weeks’ gestation
Ladin’s sign: Softening of the uterus after 6 weeks’ gestation

Question 35

What is Hyperemesis gravidarum? Diagnostic criteria? Management?

Answer 35

Hyperemesis gravidarum (HG) is a condition that causes frequent vomiting in pregnant women. It is similar to morning sickness, except the symptoms are much more severe. Diagnosis is based on symptoms of severe nausea and vomiting in conjunction with a loss of > 5% of the patient’s prepregnancy weight. It usually occurs in the first trimester, and symptoms usually resolve by mid-pregnancy regardless of severity and need for therapy.

Pregnant women with severe vomiting should present to the emergency room if they have symptoms of hypovolemia, which include decreased energy, postural dizziness, thirst, tachycardia, or decreased urine volume or frequency. These women should be treated with IV fluids. It is also important to replenish other vitamins and minerals such as thiamine, folic acid, magnesium, calcium, and phosphorus. Antiemetic medications may be used, but the risks of a small increase in congenital anomalies for patients under 10 weeks’ gestation must be considered. The first line antiemetic medication in hospitalized patients with HG is ondansetron. If these measures don’t work given glucocorticoids.

Once vomiting is controlled and the patient is sent home, there are a variety of options to manage nausea. These include ginger-containing foods, vitamin B6 (Pyridoxine), and the combination doxylamine-pyridoxine. Doxylamine is an antihistamine that is traditionally used as a sleep aid medication. Ginger has been found to decrease nausea, but it has not been found to reduce vomiting. Pyridoxine has also been found to significantly reduce nausea, but not vomiting. It is often used first line due to its efficacy and minimal side effects. The combination doxylamine-pyridoxine has been found to help with both nausea and vomiting. Other alternative treatments such as acupuncture and hypnosis have also been found to be helpful in some patients.

Question 36

What is a protraction disorder? definition? Most common cause? How do we monitor this and what do we do?

Answer 36

The patient in this scenario is experiencing a protraction disorder. Protraction is defined as a slow rate of cervical change less than 1.2 cm/h for the nullipara and less than 1.5 cm/h for the multipara. Arrest disorders consist of complete cessation of progress. Arrest disorders include secondary arrest of dilation (no progress in cervical dilation in more than 2 hours), arrest of descent (fetal head does not descend for more than 1 hour in nullipara and more than 0.5 hours in multipara), and failure of descent (no descent). The patient in this scenario is continuing to make slow progress.

The most common cause of a protraction disorder is inadequate uterine activity. The patient described above is only experiencing contractions every 3 to 5 minutes while on oxytocin. Although external tocodynamometry can only evaluate the time interval between contractions, a contraction interval of 4 to 7 minutes is likely not sufficient to cause cervical change. Internal tocodynamometry via an intrauterine pressure catheter (IUPC) allows the physician to evaluate contraction interval and strength of contractions. An IUPC is frequently used when inadequate uterine activity is suspected owing to a protraction or arrest disorder. Once inadequate uterine activity is diagnosed with an IUPC, oxytocin is usually administered.

Question 37

What are the tests that we use to determine if someone is having ruptured membranes?

Answer 37

Patients who present with a “gush of fluid” should be suspected of having ruptured membranes, although this is often mistaken for stress incontinence related to pregnancy. Patients suspected of having ruptured membranes should undergo speculum examination for vaginal pooling, along with nitrazine and fern tests for confirmation. These tests are described below.

Vaginal pooling: A sterile speculum is used to examine the vaginal vault. Pooling appears as a collection of fluid in the vagina, which can be enhanced by having the patient Valsalva to promote fluid escaping from the cervix.
Nitrazine test: Vaginal secretions tend to be acidic compared to amniotic fluid, which is alkaline. If amniotic fluid is present, the nitrazine paper will turn blue due to the alkaline environment, indicating a positive test.
Fern test: Estrogens in the amniotic fluid cause crystallization of amniotic salts, which appear as blades of a fern on microscopic evaluation, indicating a positive test.

Answers A & B & E: Fetal fibronectin (fFN) is used as a marker to assess the likelihood of preterm labor between 22-34 weeks of pregnancy.

Question 38

Late decelerations represent?

Answer 38

The FHT strip is representative of late decelerations caused by uteroplacental insufficiency. Late decelerations begin at the peak of a uterine contraction and return to baseline after the end of the contraction. They are worrisome and may warrant emergent delivery if bradycardia occurs or variability is lost.

Question 39

Early decelerations correspond to what?

Answer 39

Early decelerations begin and end simultaneously with the contracting uterus and result from increases in vagal tone secondary to fetal head compression.

Question 40

Umbilical cord compression results in what decelerations?

Answer 40

Variable decelerations result from umbilical cord compression.

Question 41

In pregnant women with preexisting diabetes what diabetic complication is rapidly accelerated?

Answer 41

Multiple studies have shown that in up to 85% of pregnant women with preexisting diabetes, there will be a marked progression in diabetic retinopathy irrespective of blood glucose control.

Question 42

Management of Intra-amniotic infection?

Answer 42

Intraamniotic infection occurs in 15-25% of PPROM cases, with a higher incidence occurring at earlier gestational ages. Diagnostic criteria include maternal fever, maternal tachycardia, fetal tachycardia (fetal heart rate > 160/min), leukocytosis, or presence of purulent vaginal discharge. When chorioamnionitis is diagnosed, then IV antibiotics should be started and delivery should occur. In the absence of maternal decompensation or fetal distress, then prompt induction or augmentation of labor is recommended, with a c-section reserved for standard obstetric indications (history of prior CS, fetal distress, fetal malposition, labor dystocia, etc.). This patient is stable and shows no signs of maternal decompensation and the fetal heart tracing is overall reassuring; therefore there is no indication for a c-section at this time. Additionally, her cervical exam is favorable and she has a history of two prior term vaginal deliveries, increasing the chance of a successful vaginal delivery.

Question 43

Pregnancy GDM screening?

Answer 43

Pregnant patients with no risk factors should be screened for GDM in the second trimester. Women with increased risk factors, like obesity or previous GDM, should be screened twice–in the first trimester, to decrease the adverse effects of hyperglycemia, and then during the second trimester, to check for GDM. The screening test is performed between 24 and 28 weeks of pregnancy. The test may be done earlier if patients have higher glucose levels checked at routine prenatal visits.