Pregnancy, Childbirth and Puerperium II

Question 1

Postpartum urinary retention is typically related to bladder […].

Answer 1

Postpartum urinary retention is typically related to bladder atony.

temporary and reversible; confirmed by > 150 mL of urine upon urethral catheterization

Question 2

Preeclampsia is defined as hypertension with […] or […] after the 20th week of gestation.

Answer 2

Preeclampsia is defined as hypertension with proteinuria or end-organ dysfunction after the 20th week of gestation.

patients with evidence of end-organ damage have preeclampsia with severe features

Question 3

Preeclampsia is defined as hypertension with proteinuria or end-organ dysfunction after the […] week of gestation.

Answer 3

Preeclampsia is defined as hypertension with proteinuria or end-organ dysfunction after the 20th week of gestation.

patients with evidence of end-organ damage have preeclampsia with severe features

Question 4

Preterm labor refers to regular contractions causing cervical dilation and/or effacement at

Answer 4

Preterm labor refers to regular contractions causing cervical dilation and/or effacement at < 37 weeks gestation.

Question 5

Risk factors for placenta accreta include history of […] or […] and advanced maternal age.

Answer 5

Risk factors for placenta accreta include history of cesarean delivery or dilation & curettage and advanced maternal age.

Question 6

Second stage arrest of labor is defined as no fetal descent after pushing for > […] hours (nulliparous) or > […] hours (multiparous).

Answer 6

Second stage arrest of labor is defined as no fetal descent after pushing for > 3 hours (nulliparous) or > 2 hours (multiparous).

Question 7

Spontaneous abortion is unprovoked pregnancy loss at

Answer 7

Spontaneous abortion is unprovoked pregnancy loss at < 20 weeks gestation and is a common cause of first trimester bleeding.

Question 8

Spontaneous abortions are most commonly the result of […] abnormalities.

Answer 8

Spontaneous abortions are most commonly the result of fetal chromosomal abnormalities
also associated with congenital abnormalities.

(e.g. teratogens) and mullerian anomalies (e.g. uterine septum)

Question 9

Symptomatic maternal luteoma puts a female fetus at a high risk of […].

Answer 9

Symptomatic maternal luteoma puts a female fetus at a high risk of virilization.

Question 10

Symptoms of magnesium toxicity include somnolence, respiratory […], and […]-reflexia.

Answer 10

Symptoms of magnesium toxicity include somnolence, respiratory depression, and hypo-reflexia

more mild symptoms include nausea, flushing, and headache

Question 11

Symptoms of magnesium toxicity include […]-calcemia and cardiac arrest.

Answer 11

Symptoms of magnesium toxicity include hypo-calcemia and cardiac arrest.

more mild symptoms include nausea, flushing, and headache; hypocalcemia due to temporary suppression of PTH

Question 12

Systemic lupus erythematosus flare during pregnancy is distinguished from preeclampsia by the presence of […] on urinalysis and classic symptoms of SLE (e.g. joint pain, malar rash).

Answer 12

Systemic lupus erythematosus flare during pregnancy is distinguished from preeclampsia by the presence of RBC casts on urinalysis and classic symptoms of SLE (e.g. joint pain, malar rash).

other findings consistent with SLE flare include decreased complement levels and increased ANA titers

Question 13

The diagnosis of ectopic pregnancy is made by a pregnancy test combined with […].

Answer 13

The diagnosis of ectopic pregnancy is made by a pregnancy test combined with transvaginal ultrasound.

typically presents with a triad of vaginal bleeding, lower abdominal pain, and adnexal tenderness

Question 14

The first-trimester combined test analyzes the risk for fetal trisomy 18 & 21 by measuring maternal serum pregnancy-associated plasma protein and […], as well as […] translucency on ultrasound.

Answer 14

The first-trimester combined test analyzes the risk for fetal trisomy 18 & 21 by measuring maternal serum pregnancy-associated plasma protein and beta-hCG, as well as nuchal translucency on ultrasound.

performed between 9 - 13 weeks of gestation; not diagnostic

Question 15

The major risk factor for shoulder dystocia is fetal […].

Answer 15

The major risk factor for shoulder dystocia is fetal macrosomia.

i.e. fetal weight > 4.5 kg (9.9 lb); conditions that predispose to macrosomia include post-term pregnancy, maternal obesity, gestational diabetes, and excessive weight gain during pregnancy

Question 16

The optimal fetal positioning is occiput […].

Answer 16

The optimal fetal positioning is occiput anterior.

deviations from this position may cause arrest of the second stage of labor

Question 17

The presence of amniotic fluid may be detected with the […] and/or […] test.

Answer 17

The presence of amniotic fluid may be detected with the nitrazine and/or fern test
a positive nitrazine test turns the test strip blue.

Question 18

Theca lutein cysts arise due to ovarian hyperstimulation secondary to markedly elevated […] levels.

Answer 18

Theca lutein cysts arise due to ovarian hyperstimulation secondary to markedly elevated beta-hCG levels.

e.g. complete hydatidiform mole, multifetal gestation

Question 19

Treatment for eclampsia includes blood pressure control, […] for seizure prevention, and expedient delivery.

Answer 19

Treatment for eclampsia includes blood pressure control, magnesium sulfate for seizure prevention, and expedient delivery.

if magnesium sulfate does not control seizures, diazepam or phenytoin are second-line options

Question 20

Universal screening for group B Streptococcus colonization is typically done by vaginal and rectal culture at […] - […] weeks gestation.

Answer 20

Universal screening for group B Streptococcus colonization is typically done by vaginal and rectal culture at 35 - 37 weeks gestation
the result is most accurate within 5 weeks of the anticipated delivery.

Question 21

Uterine rupture classically occurs in a woman with prior […].

Answer 21

Uterine rupture classically occurs in a woman with prior uterine surgery.

e.g. prior cesarean delivery or myomectomy; inelastic scar may not be able to withstand labor contractions

Question 22

What acid-base disturbance is physiological during normal pregnancy?

Answer 22

Chronic respiratory alkalosis

due to increased minute ventilation

Question 23

What are the current recommendations for influenza vaccination during pregnancy?

Answer 23

All pregnant women should receive the inactivated (injectable) influenza vaccine

the intranasal (live) influenza vaccine is contraindicated

Question 24

What are the first-line agents (3) for maternal hypertensive crisis?

Answer 24

nifedipine, hydralazine, or labetalol

Question 25

What are the most common causes (2) of hyperandrogenism in pregnancy?

Answer 25

luteomas and theca luteum cysts may manifest as new-onset hirsutism and/or acne

Question 26

What are the most common causes of acute cervicitis?

Answer 26

Chlamydia trachomatis and Neisseria gonorrhoeae infection

Question 27

What are the target 1-hour and 2-hour postprandial blood glucose levels in patients with gestational diabetes mellitus?

Answer 27

Question 28

What changes detected by maternal quadruple screen are indicative of trisomy 18 (Edward syndrome)? AFP: [...] Estriol: [...] beta-hCG: [...] Inhibin A: [...]

Answer 28

AFP: **decreased** Estriol: **decreased** beta-hCG: **decreased** Inhibin A: **normal** decreased hCG and normal inhibin A help differentiate trisomy 18 from trisomy 21 (increased hCG and inhibin A)

Question 29

What changes detected by maternal quadruple screen are indicative of trisomy 21 (Down syndrome)? AFP: [...] Estriol: [...] beta-hCG: [...] Inhibin A: [...]

Answer 29

AFP: **decreased** Estriol: **decreased** beta-hCG: **increased** Inhibin A: **increased** elevated hCG and inhibin A help differentiate trisomy 21 from trisomy 18 (decreased hCG, normal inhibin A)

Question 30

What complication of shoulder dystocia manifests as a "claw hand", an impaired grasp reflex, and Horner syndrome in a newborn?

Answer 30

Klumpke palsy (due to lower trunk injury involving C8 and T1)

Question 31

What complication of shoulder dystocia manifests as a "Waiter's tip" with an impaired biceps/moro reflex in a newborn?

Answer 31

Erb-Duchenne palsy (due to upper trunk injury involving C5 and C6) most common type of brachial plexus injury

Question 32

What exercise regimen is recommended for healthy women with uncomplicated pregnancies?

Answer 32

20 - 30 minutes of moderate-intensity exercise on most or all days of the week contact sports and activities with high fall risk should be avoided; women with risk for preterm delivery, preeclampsia, or severe cardiopulmonary disease should also avoid exercise

Question 33

What is the best screening test for gestational diabetes mellitus?

Answer 33

50g 1-hour glucose challenge more sensitive than a fasting glucose

Question 34

What is the first step in evaluating risk of preterm delivery in a patient with a history of cervical surgery (e.g. cold knife conization)?

Answer 34

transvaginal ultrasound measurement of cervical length in the 2nd trimester short cervical length is a strong predictor of preterm labor

Question 35

What is the first-line intervention for a woman in the first stage of labor with recurrent variable decelerations and moderate variability on fetal heart tracing?

Answer 35

Maternal repositioning (e.g. left lateral decubitus) amnioinfusion is a possible second-line intervention; assisted vaginal delivery could be indicated if the patient was fully dilated

Question 36

What is the first-line treatment for magnesium toxicity?

Answer 36

Calcium gluconate magnesium becomes toxic at concentrations \> 8 mg/dL

Question 37

What is the initial management for a hemodynamically unstable pregnant patient that presents with abruptio placentae following a motor vehicle accident?

Answer 37

IV fluid resuscitation and left lateral decubitus positioning left lateral decubitus position displaces the uterus off the aortocaval vessels and maximizes cardiac output

Question 38

What is the initial screening test of choice for fetal aneuploidy in pregnant women with high-risk factors (e.g. age \> 35)?

Answer 38

Cell-free fetal DNA testing higher sensitivity and specificity for detecting aneuploidies than both the first-trimester combined test and second-trimester quadruple screen; not diagnostic (must confirm with CVS or amniocentesis)

Question 39

What is the likely diagnosis in a hemodynamically unstable patient with a gestational sac in the uterine cornu and free fluid in the posterior cul-de-sac on transvaginal ultrasound?

Answer 39

Ruptured ectopic pregnancy i.e. a cornual or interstitial ectopic pregnancy; often presents as abdominal pain and vaginal bleeding

Question 40

What is the likely diagnosis in a laboring patient with \> 6 cm dilation that experiences abnormally slow cervical dilation?

Answer 40

Protraction of active labor the active stage of labor typically begins at \> 6 cm dilation

Question 41

What is the likely diagnosis in a laboring patient with \> 6 cm dilation that experiences no further dilation for 4 hours despite adequate contractions?

Answer 41

Arrest of active labor arrest of active labor is also diagnosed if there is no cervical change for \> 6 hours with inadequate contractions (\< 200 MVUs in a 10-minute period)

Question 42

What is the likely diagnosis in a newborn with thin, loose skin, a thin umbilical cord, and a wide anterior fontanel?

Answer 42

Fetal growth restriction risk factors include maternal hypertension, gestational diabetes, genetic abnormalities, and congenital infection

Question 43

What is the likely diagnosis in a patient that is 6 hours postpartum that presents with inability to void, diffuse lower abdominal tenderness, and persistent urinary dribbling?

Answer 43

Postpartum urinary retention risk factors include primiparity, regional anesthesia, operative vaginal or cesarean delivery, and perineal injury

Question 44

What is the likely diagnosis in a patient that presents one week after an elective abortion with fever, vaginal bleeding, abdominal pain, and purulent vaginal discharge? Pelvic ultrasound reveals a thickened endometrial stripe.

Answer 44

Septic abortion pelvic examination typically reveals an enlarged, boggy, tender uterus

Question 45

What is the likely diagnosis in a postpartum patient on post-operative day 2 that presents with fever, uterine tenderness, and purulent lochia?

Answer 45

Postpartum endometritis most common cause of postpartum fever

Question 46

What is the likely diagnosis in a postpartum patient on post-operative day 5 with a fever that is unreponsive to broad-spectrum antibiotic therapy with a negative infectious workup?

Answer 46

Septic pelvic thrombophlebitis diagnosis of exclusion; due to an infected thrombosis of the deep pelvic or ovarian veins

Question 47

What is the likely diagnosis in a postpartum woman that presents with lactation failure, amenorrhea, fatigue, and hypotension for months after a spontaneous vaginal delivery complicated by uterine atony?

Answer 47

Sheehan syndrome symptoms are due to hypopituitarism secondary to ischemic infarction and necrosis of the pituitary gland following massive obstetric hemorrhage

Question 48

What is the likely diagnosis in a pregnant patient that develops encephalopathy, nystagmus, and gait ataxia after several days of hyperemesis gravidum?

Answer 48

Wernicke encephalopathy secondary to thiamine deficiency

Question 49

What is the likely diagnosis in a pregnant patient that presents with painless third-trimester bleeding with a normal fetal heart tracing?

Answer 49

Placenta previa painless bleeding helps rule out placental abruption; normal FHR helps distinguish placenta previa from vasa previa

Question 50

What is the likely diagnosis in a pregnant patient that presents with painless third-trimester bleeding with bradycardia on fetal heart tracing?

Answer 50

Vasa previa fetal bradycardia is an important distinguishing feature from placenta previa; occurs because the hemorrhage is of fetal origin (versus maternal origin in placenta previa)

Question 51

What is the likely diagnosis in a pregnant woman at 10 weeks gestation that presents with hyperemesis gravidarum? Pelvic ultrasound reveals an intrauterine gestation enlarged for gestational age and bilateral 10-cm, multilocular ovarian masses.

Answer 51

Theca lutein cysts (secondary to a complete hydatidiform mole) occurs due to ovarian hyperstimulation from markedly elevated beta-hCG levels

Question 52

What is the likely diagnosis in a pregnant woman at 35 weeks gestation that experiences irregular uterine contractions (~3-5 per hour) with a closed cervix on pelvic examination?

Answer 52

False labor characterized by mild, irregular contractions (Braxton Hicks contractions) that cause no cervical change

Question 53

What is the likely diagnosis in a pregnant woman at 35 weeks gestation that has experienced leakage of fluid over the past two days? The fluid is nitrazine-positive.

Answer 53

Preterm premature rupture of membranes (PPROM) defined as rupture of membranes at \< 37 weeks gestation (preterm) and before labor has begun (premature)

Question 54

What is the likely diagnosis in a pregnant woman at 35 weeks gestation that presents with abdominal pain, vaginal bleeding and a firm, tender uterus?

Answer 54

Abruptio placentae (placental abruption) also may have high-frequency, low-intensity uterine contractions; bleeding may be concealed

Question 55

What is the likely diagnosis in a pregnant woman with preeclampsia that develops sudden-onset dyspnea, hypoxia, and crackles?

Answer 55

Pulmonary edema rare but life-threatening complication of severe preeclampsia

Question 56

What is the likely diagnosis in a sexually active woman that presents with postcoital bleeding and mucopurulent discharge with a friable cervix on pelvic examination?

Answer 56

Acute cervicitis less common symptoms include dysuria, dyspareunia, and vulvovaginal pruritus

Question 57

What is the likely diagnosis in a stillborn fetus with multiple limb fractures and a hypoplastic thoracic cavity?

Answer 57

Type II osteogenesis imperfecta due to mutations in type 1 collagen; type II OI is the most severe type and often manifests as fatal perinatal disease

Question 58

What is the likely diagnosis in a woman that develops abdominal pain and hemorrhagic shock after failing to deliver the placenta? There is a smooth, round mass protruding through the vagina.

Answer 58

Uterine inversion risk factors include nulliparity, fetal macrosomia, placenta accreta, and rapid labor & delivery

Question 59

What is the likely diagnosis in a woman with a history of transient ischemic attacks and recurrent miscarriages?

Answer 59

Antiphospholipid syndrome diagnosis is confirmed by the presence of at least one of the antiphospholipid antibodies; hypercoaguable state results in increased risk for placental thrombosis and miscarriage

Question 60

What is the likely diagnosis in an adolescent girl at 15 weeks gestation that presents with symptoms of preeclampsia with severe features?

Answer 60

Hydatidiform molar pregnancy the presence of preeclampsia with severe features at \< 20 weeks gestation can be a complicati

Question 61

What is the likely diagnosis in an afebrile patient that recently delivered a macrosomic baby and now presents with sharp lower midline abdominal pain that radiates to the legs and is exacerbated by ambulation?

Answer 61

Pubic symphysis diastasis physiologic diastasis normally occurs during pregnancy but traumatic delivery (e.g. to a macrosomic baby) can result in symptomatic diastasis

Question 62

What is the likely diagnosis in an afebrile postpartum woman that presents with bilateral, symmetric warmth and tenderness of the breasts 3 days after delivery?

Answer 62

Breast engorgement common 3-5 days after delivery when colostrum is replaced by milk; improves with breastfeeding

Question 63

What is the likely diagnosis in an afebrile postpartum woman that presents with unilateral firmness and tenderness of the breast?

Answer 63

Plugged duct differentiated from mastitis by the lack of fever and systemic symptoms and from galactocele by the presence of pain

Question 64

What is the likely diagnosis in an African-American woman at 20 weeks gestation that presents with new-onset hirsutism and acne? Pelvic ultrasound reveals an intrauterine gestation consistent with dates and bilateral 8-cm solid ovarian masses.

Answer 64

Luteoma versus theca luteum cysts, which typically arise due to high hCG levels (e.g. molar pregnancy or multiple gestation)

Question 65

What is the likely diagnosis in an intrapartum patient that presents after \>18 hours of membrane rupture and prolonged labor with fever and tachycardia? Fetal heart tracing demonstrates fetal tachycardia.

Answer 65

Chorioamnionitis (intra-amniotic infection) intra-amniotic infection caused by migration of vaginal or enteric flora through the cervix, typically in a patient with premature or prolonged rupture of membranes; intrapartum fever is a distinguishing feature

Question 66

What is the likely diagnosis in an obese, multiparous pregnant woman at 34 weeks gestation that presents with intermittent leakage of clear fluid and a negative nitrazine/fern test?

Answer 66

Stress urinary incontinence differentiated from rupture of membranes by negative nitrazine/fern tests and absence of vaginal pooling

Question 67

What is the most common cause of a non-reactive non-stress test?

Answer 67

Fetal sleep cycle vibroacoustic stimulation may be used to awaken the fetus; sleep cycles can last as long as 40 minutes therefore a non-reactive test should be extended to 40 - 120 minutes

Question 68

What is the most common cause of primary postpartum hemorrhage?

Answer 68

Uterine atony results from failure of the uterus to contract and compress the placental site blood vessels

Question 69

What is the most common cause of second stage arrest of labor?

Answer 69

Fetal malposition (e.g. occiput transverse) the optimal fetal position is occiput anterior

Question 70

What is the most common risk factor for placental abruption?

Answer 70

Hypertension other important risk factors include maternal trauma and cocaine use

Question 71

What is the most common site of implantation for ectopic pregnancy?

Answer 71

Fallopian tube

Question 72

What is the most likely cause of postpartum hemorrhage in a patient that presents with profuse vaginal bleeding with a soft, enlarged uterus on pelvic examination? Ultrasound reveals a thin endometrial stripe.

Answer 72

Uterine atony risk factors include prolonged labor, fetal weight \> 4000g, induction of labor, and operative vaginal delivery

Question 73

What is the next step in management after IV lines have been placed in a woman with uterine inversion with a retained placenta?

Answer 73

Manual replacement of the uterus should be performed prior to placent