Pregnancy, Childbirth and Puerperium I

Question 1

A non-stress test is considered reactive (normal) if there are at least […] in 20 minutes.

Answer 1

A non-stress test is considered reactive (normal) if there are at least 2 accelerations in 20 minutes.

accelerations are increases in heart rate > 15 beats/min above baseline lasting for at least 15 seconds; due to fetal sympathetic nervous system activity, which develops around 26 - 28 weeks

Question 2

A […] fetal fibronectin test prior to term is an indicator of high risk for preterm delivery.

Answer 2

A positive fetal fibronectin test prior to term is an indicator of high risk for preterm delivery.

typically performed in patients with contractions at < 34 weeks gestation; fetal fibronectin levels are high until 20 weeks gestation and thus are not a reliable marker of preterm delivery in early pregnancy

Question 3

Adequate contractions are defined as generation of > […] Montevideo units (MVUs) in 10 minutes.

Answer 3

Adequate contractions are defined as generation of > 200 Montevideo units (MVUs) in 10 minutes.

measured via an intrauterine pressure catheter

Question 4

After instructing the laboring patient to breath and not push, management of shoulder dystocia includes […] and application of suprapubic pressure.

Answer 4

After instructing the laboring patient to breath and not push, management of shoulder dystocia includes flexing the hips toward the abdomen (McRoberts manuever) and application of suprapubic pressure.

these maneuvers relieve ~50% of shoulder dystocias with no further intervention

Question 5

After instructing the laboring patient to breath and not push, management of shoulder dystocia includes flexing the hips toward the abdomen (McRoberts manuever) and application of […].

Answer 5

After instructing the laboring patient to breath and not push, management of shoulder dystocia includes flexing the hips toward the abdomen (McRoberts manuever) and application of suprapubic pressure.

these maneuvers relieve ~50% of shoulder dystocias with no further intervention

Question 6

All pregnant women should be screened for gestational diabetes mellitus at […] - […] weeks gestation.

Answer 6

All pregnant women should be screened for gestational diabetes mellitus at 24 - 28 weeks gestation.

placental hormones in the 2nd and 3rd trimester create increased maternal insulin resistance; patients with risk factors (e.g. obesity, previous GDM) should be screened earlier and re-screened at 24-28 weeks if negative

Question 7

Amniocentesis may be performed between […] to […] weeks.

Answer 7

Amniocentesis may be performed between 15 to 22 weeks.

diagnostic for aneuploidies

Question 8

Amphetamine abuse during pregnancy is associated with fetal […]. (size)

Answer 8

Amphetamine abuse during pregnancy is associated with fetal growth restriction. (size)

other complications include preterm delivery, preeclampsia, placental abruption, and intrauterine fetal demise

Question 9

An abnormal biophysical profile score (0 - 4) is consistent with […] due to placental dysfunction.

Answer 9

An abnormal biophysical profile score (0 - 4) is consistent with fetal hypoxia due to placental dysfunction.

Question 10

Antenatally diagnosed placenta accreta is delivered by planned […].

Answer 10

Antenatally diagnosed placenta accreta is delivered by planned cesarean hysterectomy.

Question 11

Can a non-reactive non-stress test effectively rule in fetal acidemia?

Answer 11

No

a non-reactive NST has a low positive predictive value for fetal acidemia (high rate of false positives)

Question 12

Can a reactive non-stress test effectively rule out fetal acidemia?

Answer 12

Yes

a reactive NST has a high negative predictive value for fetal acidemia

Question 13

Cell-free fetal DNA testing can be ordered at > […] weeks gestation.

Answer 13

Cell-free fetal DNA testing can be ordered at > 10 weeks gestation.

Question 14

Chorionic villus sampling may be performed between […] to […] weeks.

Answer 14

Chorionic villus sampling may be performed between 10 to 13 weeks.

earlier than amniocentesis, but higher risk of fetal loss; diagnostic for aneuploidies

Question 15

Complications of inadequate weight gain during pregnancy include […] and preterm delivery.

Answer 15

Complications of inadequate weight gain during pregnancy include fetal growth restriction and preterm delivery.

Question 16

Complications of oxytocin include […]-natremia, […]-tension, and uterine […].

Answer 16

Complications of oxytocin include hypo-natremia, hypo-tension, and uterine tachysystole.

uterine tachysystole is defined as > 5 contractions in 10 minutes; hyponatremia may occur due to structural similarities between oxytocin and ADH

Question 17

During pregnancy, the size of the pituitary gland […], but blood supply does not change significantly.

Answer 17

During pregnancy, the size of the pituitary gland doubles, but blood supply does not change significantly.

thus increased risk of infarction (Sheehan syndrome)

Question 18

During the surveillance period following removal of a hydatidiform mole, patients must take […] for 6 months.

Answer 18

During the surveillance period following removal of a hydatidiform mole, patients must take contraceptives for 6 months.

pregnancy during this time period would make it difficult to determine the significance of a rising beta-hCG

Question 19

Eclampsia is defined as preeclampsia with new-onset […].

Answer 19

Eclampsia is defined as preeclampsia with new-onset seizures.

most common cause of new-onset seizures in pregnant patients with hypertension; maternal morbidity may result from placental abruption, DIC, and cardiopulmonary arrest

Question 20

Evaluation of a newborn with fetal growth restriction at delivery includes histopathologic examination of the […] to assess for infection and/or infarction.

Answer 20

Evaluation of a newborn with fetal growth restriction at delivery includes histopathologic examination of the placenta to assess for infection and/or infarction.

urine toxicology, serology, and karyotype should be considered as well; additional management is dependent on symptoms (e.g. antibiotics for suspected sepsis, surfactant therapy for suspected NRDS, etc.)

Question 21

Evidence of a retained placenta includes an echogenic mass or […] endometrial stripe on ultrasound.

Answer 21

Evidence of a retained placenta includes an echogenic mass or thickened endometrial stripe on ultrasound.

Question 22

Examination findings consistent with uterine rupture include the presence of […] and/or the loss of […].

Answer 22

Examination findings consistent with uterine rupture include the presence of abdominally palpable fetal parts and/or the loss of fetal station.

loss of fetal station may be described as no presenting fetal parts vaginally or a “bulging bag” and is pathognomonic; other symptoms include abdominal pain and bleeding (vaginal or intra-abdominal)

Question 23

Examination findings consistent with […] include the presence of abdominally palpable fetal parts and/or the loss of fetal station.

Answer 23

Examination findings consistent with uterine rupture include the presence of abdominally palpable fetal parts and/or the loss of fetal station.

loss of fetal station may be described as no presenting fetal parts vaginally or a “bulging bag” and is pathognomonic; other symptoms include abdominal pain and bleeding (vaginal or intra-abdominal)

Question 24

External cephalic version can be attempted for breech presentations at > […] weeks gestation.

Answer 24

External cephalic version can be attempted for breech presentations at > 37 weeks gestation.

if the patient refuses ECV, cesarean delivery is typically performed at 39 weeks gestation

Question 25

External cephalic version is relatively contraindicated in patients with [...] amniotic fluid.

Answer 25

External cephalic version is relatively contraindicated in patients with **decreased** amniotic fluid. i.e. oligohydramnios or ruptured membranes; also contraindicated if there are contraindications to vaginal delivery

Question 26

Fetal anemia typically presents with a [...] fetal heart tracing.

Answer 26

Fetal anemia typically presents with a **sinusoidal** fetal heart tracing.

Question 27

Fetal complications of maternal hypertension include oligohydramnios, preterm delivery, and fetal [...]. (size)

Answer 27

Fetal complications of maternal hypertension include oligohydramnios, preterm delivery, and fetal **growth restriction.** (size) maternal complications include superimposed preeclampsia and placental abruption

Question 28

Fetal complications of preeclampsia include oligohydramnios and [...] due to chronic uteroplacental insufficiency.

Answer 28

Fetal complications of preeclampsia include oligohydramnios and **fetal growth** restriction due to chronic uteroplacental insufficiency. pathophysiology of preeclampsia likely involves abnormal placental spiral artery development

Question 29

Fetal growth restriction is an ultrasound-estimated fetal weight

Answer 29

Fetal growth restriction is an ultrasound-estimated fetal weight 10th percentile for gestational age.

Question 30

Following suction curettage for a hydatidiform mole, [...] levels are measured weekly until undetectable and then monthly for 6 months.

Answer 30

Following suction curettage for a hydatidiform mole, **beta-hCG** levels are measured weekly until undetectable and then monthly for 6 months.

Question 31

Following suction curettage for a hydatidiform mole, beta-hCG levels are measured weekly until undetectable and then monthly for [...].

Answer 31

Following suction curettage for a hydatidiform mole, beta-hCG levels are measured weekly until undetectable and then monthly for **6 months**.

Question 32

Gestational diabetes is a result of pancreatic beta-cell hyperplasia and increased [...] secondary to elevated levels of human placental lactogen during the third trimester of pregnancy.

Answer 32

Gestational diabetes is a result of pancreatic beta-cell hyperplasia and increased **insulin resistance** secondary to elevated levels of human placental lactogen during the third trimester of pregnancy. hPL (a type of placental somatomammotropin) production ceases after delivery resulting in resolution of GDM

Question 33

Gestational diabetes is a result of pancreatic beta-cell hyperplasia and increased insulin resistance secondary to elevated levels of [...] during the third trimester of pregnancy.

Answer 33

Gestational diabetes is a result of pancreatic beta-cell hyperplasia and increased insulin resistance secondary to elevated levels of **human placental lactogen** during the third trimester of pregnancy. hPL (a type of placental somatomammotropin) production ceases after delivery resulting in resolution of GDM

Question 34

Healthy patients in preterm labor at \< 34 weeks should receive [...] to postpone delivery.

Answer 34

Healthy patients in preterm labor at \< 34 weeks should receive **tocolytics** to postpone delivery. e.g. indomethacin (preferred if given with magnesium), nifedipine; the risks of tocolytics do not outweigh the benefits after 34 weeks

Question 35

Healthy patients in preterm labor at

Answer 35

Healthy patients in preterm labor at 34 weeks should receive tocolytics to postpone delivery. e.g. indomethacin (preferred if given with magnesium), nifedipine; the risks of tocolytics do not outweigh the benefits after 34 weeks

Question 36

HELLP syndrome is a potential manifestation of severe preeclampsia characterized by a triad of [...], [...], and [...].

Answer 36

HELLP syndrome is a potential manifestation of severe preeclampsia characterized by a triad of **hemolysis, elevated liver enzymes, and low platelets**. this triad may present clinically as hypertension, anemia, RUQ pain, and bruising/bleeding

Question 37

How do the following laboratory values change during normal pregnancy? ## Footnote BUN: [...] Creatinine: [...] Renal protein excretion: [...]

Answer 37

How do the following laboratory values change during normal pregnancy? BUN: **decrease** Creatinine: **decrease** Renal protein excretion: **increase** due to increased GFR and basement membrane permeability

Question 38

How do the following laboratory values change during normal pregnancy? ## Footnote Plasma volume: [...] RBC volume: [...]

Answer 38

How do the following laboratory values change during normal pregnancy? Plasma volume: **50% increase** RBC volume: **30% increase** this disparity results in a mild dilutional anemia, which is protective in the case of postpartum hemorrhage

Question 39

Hyperemesis gravidarum is differentiated from typical vomiting of pregnancy by the presence of laboratory abnormalities, changes in volume status, and/or [...] on urinalysis.

Answer 39

Hyperemesis gravidarum is differentiated from typical vomiting of pregnancy by the presence of laboratory abnormalities, changes in volume status, and/or **ketones** on urinalysis. may also have weight loss of \>5% of prepregnancy weight

Question 40

Hyperemesis gravidarum is more common in patients with [...], hydatidiform mole, or history of GERD.

Answer 40

Hyperemesis gravidarum is more common in patients with **multiple gestation**, hydatidiform mole, or history of GERD. typically unresponsive to oral antiemetics

Question 41

Hyperemesis gravidarum is more common in patients with multiple gestation, [...], or history of GERD.

Answer 41

Hyperemesis gravidarum is more common in patients with multiple gestation, **hydatidiform mole**, or history of GERD. typically unresponsive to oral antiemetics

Question 42

Hypopituitarism may be caused by Sheehan syndrome, which is a pregnancy-related [...] of the pituitary gland.

Answer 42

Hypopituitarism may be caused by Sheehan syndrome, which is a pregnancy-related **infarction** of the pituitary gland. occurs as a complic

Question 43

Indications for prophylactic administration of RhoGAM in Rh(D)- women include women at [...] weeks gestation or within 72 hours of any procedure in which there is a possibility of feto-maternal blood mixing.

Answer 43

Indications for prophylactic administration of RhoGAM in Rh(D)- women include women at **28 - 32** weeks gestation or within 72 hours of any procedure in which there is a possibility of feto-maternal blood mixing. e.g. spontaneous or induced abortion, amniocentesis, delivery

Question 44

Initial treatment of postpartum hemorrhage includes bimanual massage and uterotonics (e.g. [...]).

Answer 44

Initial treatment of postpartum hemorrhage includes bimanual massage and uterotonics (e.g. **oxytocin**). oxytocin is a first-line agent; other agents, such as methylergonovine and carboprost may be administered if oxytocin fails

Question 45

Intrapartum penicillin is indicated without routine screening in pregnant women with a history of GBS [...] during current pregnancy or those with a prior delivery complicated by neonatal GBS infection.

Answer 45

Intrapartum penicillin is indicated without routine screening in pregnant women with a history of GBS **bacteruria** or UTI during current pregnancy or those with a prior delivery complicated by neonatal GBS infection.

Question 46

Labor and vaginal delivery are contraindicated after a [...] cesarean delivery or extensive myomectomy.

Answer 46

Labor and vaginal delivery are contraindicated after a classical cesarean delivery or extensive myomectomy. due to significant risk of uterine rupture

Question 47

Labor and vaginal delivery are contraindicated after a classical cesarean delivery or extensive [...].

Answer 47

Labor and vaginal delivery are contraindicated after a classical cesarean delivery or extensive **myomectomy**. due to significant risk of uterine rupture

Question 48

Laboring patients at high risk of uterine rupture require urgent [...].

Answer 48

Laboring patients at high risk of uterine rupture require urgent laparotomy and **delivery**. e.g. patients with a history of extensive myomectomy or classical cesarean delivery

Question 49

Late- and post-term pregnancies are commonly complicated by [...]-hydramnios.

Answer 49

Late- and post-term pregnancies are commonly complicated by **oligo**-hydramnios. the presence of oligohydramnios is an indication for delivery; aging placentas may have decreased fetal perfusion, which causes decreased renal perfusion and urinary output

Question 50

Late- and post-term pregnancies require antenatal fetal surveillance beginning at 41 weeks with a [...] to screen for fetal hypoxia.

Answer 50

Late- and post-term pregnancies require antenatal fetal surveillance beginning at 41 weeks with a **biophysical profile** to screen for fetal hypoxia. late- and post-term pregnancies are at risk for uteroplacental insufficiency (e.g. oligohydramnios, late decelerations)

Question 51

Leakage of CSF after epidural placement may result in postural headaches, which are worse with [...] and better with [...].

Answer 51

Leakage of CSF after epidural placement may result in postural headaches, which are worse with **sitting up** and better with **lying down**. occurs if the dura is mistakenly punctured during epidural placement

Question 52

Magnesium is solely excreted by the [...].

Answer 52

Magnesium is solely excreted by the **kidneys**. thus patients with renal insufficiency are at increased risk for toxicity

Question 53

Maternal adaptations to pregnancy include a(n) [...] cardiac output.

Answer 53

Maternal adaptations to pregnancy include a(n) **increased** cardiac output. due to increased stroke volume (early pregnancy) or increased heart rate (late pregnancy); may be accompanied by a systolic ejection murmur

Question 54

Maternal adaptations to pregnancy include a(n) [...] tidal volume and [...] respiratory rate.

Answer 54

Maternal adaptations to pregnancy include a(n) **increased** tidal volume and **normal** respiratory rate. due to effects of progesterone; results in an increased minute ventilation (minute ventilation = tidal volume x respiratory rate)

Question 55

Maternal complications associated with placental abruption include [...] and hypovolemic shock.

Answer 55

Maternal complications associated with placental abruption include **DIC** and hypovolemic shock. fetal complications include hypoxia and preterm delivery

Question 56

Maternal complications associated with placental abruption include DIC and [...].

Answer 56

Maternal complications associated with placental abruption include DIC and **hypovolemic shock**. fetal complications include hypoxia and preterm delivery

Question 57

Maternal contraindications to breastfeeding include active untreated tuberculosis or [...] infection and herpetic breast lesions.

Answer 57

Maternal contraindications to breastfeeding include active untreated tuberculosis or **varicella** infection and herpetic breast lesions. other contraindications include HIV infection in developed countries and active abuse of street drugs or alcohol

Question 58

Maternal contraindications to breastfeeding include chemo- or radiation therapy and [...] use.

Answer 58

Maternal contraindications to breastfeeding include chemo- or radiation therapy and **illicit drug** use. e.g. alcohol, marijuana, cocaine, opioids

Question 59

Maternal hypertensive crisis is defined as a SBP \> [...] or DBP \> [...] mmHg for \> 15 minutes.

Answer 59

Maternal hypertensive crisis is defined as a SBP \> **160** or DBP \> **110** mmHg for \> 15 minutes.

Question 60

Newly detectable beta-hCG levels within 6 months following suction curettage for a hydatidiform mole is diagnostic for [...].

Answer 60

Newly detectable beta-hCG levels within 6 months following suction curettage for a hydatidiform mole is diagnostic for **gestational trophoblastic disease**. (e.g. choriocarcinoma)

Question 61

Normal postpartum changes include shivering, lochia, and a [...] uterus. (relaxed or contracted)

Answer 61

Normal postpartum changes include shivering, lochia, and a **contracted** uterus. (relaxed or contracted) the uterus should be palpable at or below the level of the umbilicus

Question 62

Normal pregnancy is associated with a [...]-coaguable state.

Answer 62

Normal pregnancy is associated with a **hyper-**coaguable state. changes include increased fibrinogen and decreased protein C/S activity; protective against postpartum hemorrhage

Question 63

Oligohydramnios is characterized by an amniotic fluid index

Answer 63

Oligohydramnios is characterized by an amniotic fluid index 5 cm or a single deepest pocket

Question 64

Patients in preterm labor at \< 37 weeks should receive [...] to reduce risk of neonatal respiratory distress syndrome.

Answer 64

Patients in preterm labor at \< 37 weeks should receive **corticosteroids** to reduce risk of neonatal respiratory distress syndrome. e.g. betamethasone

Question 65

Patients in preterm labor at \< 32 weeks should receive [...] for fetal neuroprotection.

Answer 65

Patients in preterm labor at \< 32 weeks should receive **magnesium sulfa**te for fetal neuroprotection. decreases risk of neonatal neurological morbidities (e.g. cerebral palsy)

Question 66

Patients in preterm labor at

Answer 66

Patients in preterm labor at 32 weeks should receive magnesium sulfate for fetal neuroprotection. decreases risk of neonatal neurological morbidities (e.g. cerebral palsy)

Question 67

Patients with HELLP syndrome may present with severe RUQ abdominal pain due to [...].

Answer 67

Patients with HELLP syndrome may present with severe RUQ abdominal pain due to liver swelling with distention of the **hepatic (Glisson's) capsul**e. pathogensis involves systemic inflammation with platelet consumption and activation of the coagulation cascade

Question 68

Patients with placenta previa should be advised to avoid [...].

Answer 68

Patients with placenta previa should be advised to avoid sexual intercourse. digital vaginal examination is also contraindicated; both can cause trauma to the placenta and trigger massive hemorrhage

Question 69

Physiologic changes during normal pregnancy include a(n) [...] GFR and [...] basement membrane permeability.

Answer 69

Physiologic changes during normal pregnancy include a(n) **increased** GFR and **increased** basement membrane permeability. renal function increases graduallly in the first trimester, reaching 40-50% above the nonpregnant state by midpregnancy

Question 70

Placenta accreta presents with no separation of the placenta after delivery and [...].

Answer 70

Placenta accreta presents with no separation of the placenta after delivery and **heavy post-partum bleeding.** usually caught on ultrasound prior to delivery

Question 71

Placenta [...] is the abnormal attachment of the placenta to the myometrium, without penetrating it.

Answer 71

Placenta **accreta** is the abnormal attachment of the placenta to the myometrium, without penetrating it.

Question 72

Placenta [...] is attachment of the placenta to the lower uterine segment over the internal cervical os.

Answer 72

Placenta **previa** is attachment of the placenta to the lower uterine segment over the internal cervical os.

Question 73

Polyhydramnios is characterized by an amniotic fluid index \> [...] cm or a single deepest pocket \> 8 cm.

Answer 73

Polyhydramnios is characterized by an amniotic fluid index \> **24** cm or a single deepest pocket \> 8 cm.