Pregnancy, Childbirth and Puerperium III

Question 1

What is the next step in management after manual replacement of the uterus in a woman with uterine inversion with a retained placenta?

Answer 1

placental removal and uterotonics

uterotonics (e.g. oxytocin, misoprostol) cause uterine contraction, which helps prevent further hemorrhage and recurrence of the prolapse

Question 2

What is the next step in management for a healthy pregnant woman at 37 weeks gestation that desires a vaginal delivery? Ultrasound reveals the fetus is in a frank breech presentation.

Answer 2

External cephalic version

can be attempted in women with breech pregnancies at > 37 weeks of gestational age if there’s no contraindications to vaginal delivery and the fetus is in good health

Question 3

What is the next step in management for a mother with post-partum hemorrhage following a forceps-assisted vaginal delivery? The patient is afebrile and the uterus is normal-sized and firm.

Answer 3

Genital tract inspection

genital tract injury is a common cause of PPH after operative vaginal deliveries; other causes of PPH typically result in an enlarged, soft uterus (e.g. atony, retained placental tissue) and/or fever (e.g. endometritis)

Question 4

What is the next step in management for a pregnant woman at 12 weeks gestation with an abnormally elevated beta-hCG level and increased nuchal thickness on ultrasound?

Answer 4

Chorionic villous sampling (CVS)

this patient has a positive first-trimester combined test; diagnosis is made

Question 5

What is the next step in management for a pregnant woman at 25 weeks gestation that presents after feeling no fetal movement for the past two days? Fetal heart sounds are not heard on Doppler.

Answer 5

Transabdominal ultrasound

the patient likely has intrauterine fetal demise (fetal death at > 20 weeks), which must be confirmed by the absence of fetal cardiac activity on ultrasound

Question 6

What is the next step in management for a pregnant woman at 28 weeks gestation with confirmed intrauterine fetal demise? The fetus is in the breech position on ultrasound.

Answer 6

Induced vaginal delivery

vaginal delivery is preferred regardless of fetal position; prior to 24 weeks (e.g. 20-23 weeks), patients may elect to have dilation and evacuation

Question 7

What is the next step in management for a pregnant woman at 32 weeks gestation that presents with decreased fetal movement? Heart tones are heard by Doppler.

Answer 7

Non-stress test

i.e. recording the fetal heart rate while monit

Question 8

What is the next step in management for a pregnant woman at 34 weeks gestation that presents with decreased fetal movement? Non-stress testing reveals a normal FHR but is non-reactive despite vibroacoustic stimulation.

Answer 8

biophysical profile or contraction stress test

choice of test depends on resources available and contraindications (e.g. contraction stress test is contraindicated if there are contraindications to labor, such as placenta previa or prior myomectomy)

Question 9

What is the next step in management for a pregnant woman at 38 weeks gestation with chorioamnionitis after administration of antibiotics? Fetal heart tracing reveals tachycardia but is otherwise reassuring.

Answer 9

Induction of labor

cesarean delivery is reserved for standard obstetric indications (e.g. prior uterine surgeries, breech presentation, non-reassuring fetal heart tracing)

Question 10

What is the next step in management for a pregnant woman with a blood glucose > 140 mg/dL 1 hour after a 50g oral glucose load?

Answer 10

100g 3-hour glucose challenge

abnormally high glucose levels with the 3-hour challenge confirms the diagnosis of GDM

Question 11

What is the prophylactic agent of choice for pregnant women who test positive for group B Streptococcus?

Answer 11

Intrapartum penicillin

penicillin administration prior to labor is not beneficial; women with a history of GBS bacteriuria/UTI during current pregnancy or history of an infant with early-onset GBS disease should receive prophylaxis without testing

Question 12

What is the recommended management for a hemodynamically stable patient with an ectopic pregnancy?

Answer 12

Methotrexate

Question 13

What is the recommended management for a hemodynamically unstable patient with a suspected ectopic pregnancy?

Answer 13

Surgical exploration

Question 14

What is the recommended management for a hemodynamically unstable patient with an inevitable abortion?

Answer 14

Suction curettage

expectant and medical management (e.g. misoprostol) are only appropriate for hemodynamically stable patients; additionally the patient should receive Rho(D) immune globulin to prevent isoimmunization

Question 15

What is the recommended management for a laboring patient with > 6 cm dilation that experiences no further dilation for 4 hours and inadequate contractions?

Answer 15

Cervical examination in 2 hours

arrest of active labor is not diagnosed with inadequate contractions until there is > 6 hours of no cervical change

Question 16

What is the recommended management for a patient at 28 weeks gestation with the fetus in transverse lie position? The patient desires a vaginal delivery.

Answer 16

Expectant management

most fetuses in transverse lie spontaneously convert to vertex presentation prior to term; persistent malpresentation may require external cephalic version or C-section

Question 17

What is the recommended management for a patient with arrest of active labor?

Answer 17

Cesarean delivery

differentiated from protraction of active labor by the absence of cervical dilation (versus abnormally slow cervical dilation)

Question 18

What is the recommended management for a patient with protraction of active labor?

Answer 18

Oxytocin

differentiated from arrest of active labor by the presence of slow cervical dilation (versus no further cervical dilation)

Question 19

What is the recommended management for a pregnant patient with history of preterm labor and a normal cervix (> 2.5 cm) on TVUS?

Answer 19

IM progesterone with serial cervical length measurements until 24 weeks

Question 20

What is the recommended management for a pregnant patient with history of preterm labor and a short cervix (

Answer 20

IM progesterone and cerclage with serial cervical length measurements until 24 weeks

Question 21

What is the recommended management for a pregnant patient with no history of preterm labor and a short cervix (

Answer 21

Vaginal progesterone

progesterone maintains uterine quiesence and protects against premature rupture of membranes

Question 22

What is the recommended management for a pregnant woman at 28 weeks gestation that presents in labor for a fetus diagnosed with anhydramnios and anencephaly?

Answer 22

Allow spontaneous vaginal delivery

the priority for patients with lethal fetal anomalies (e.g. anecephaly) is to minimize maternal morbidity/mortality; C-section has an increased risk of maternal complications

Question 23

What is the recommended management for a pregnant woman at 32 weeks gestation with gestational hypertension and a biophysical profile score of 6 at today’s visit?

Answer 23

Repeat biophysical profile in 24 hours

pregnant women with gestational hypertension need weekly BPPs starting at 32 weeks gestation; a BPP of 6/10 is equivocal and should be repeated in 24 hours

Question 24

What is the recommended management for a pregnant woman at 35 weeks gestation that presents in preterm labor with a fetus in vertex presentation on ultrasound?

Answer 24

Expectant management

betamethasone +/- penicillin may be administered as well

Question 25

What is the recommended management for a pregnant woman at 35 weeks gestation that presents in preterm labor with the fetus in breech presentation on ultrasound?

Answer 25

Cesarean delivery betamethasone +/- penicillin may be administered as well

Question 26

What is the recommended management for a pregnant woman at 37 weeks gestation that presents with placenta previa?

Answer 26

Cesarean delivery patients diagnosed antenatally should have C-section delivery at 36-37 weeks; vaginal delivery is contraindicated

Question 27

What is the recommended management for a pregnant woman that is rubella-nonimmune?

Answer 27

Immediate postpartum vaccination (e.g. MMR) contraindicated during pregnancy but safe during breastfeeding

Question 28

What is the recommended management for a pregnant woman with a suspected luteoma?

Answer 28

Observation and expectant management masses typically regress spontaneously after delivery; luteomas are occasionally complicated by ovarian torsion or symptoms related to mass effect (e.g. hydronephrosis)

Question 29

What is the recommended management for a pregnant woman with a suspected theca luteum cyst secondary to a complete molar pregnancy?

Answer 29

Suction curettage of the hydatidiform mole theca luteum cysts typically resolve following removal of the hydatidiform mole

Question 30

What is the recommended management for a woman in the third trimester of pregnancy that presents with lower back pain that radiates down the legs, especially with activity? Physical exam is benign.

Answer 30

reassurance and conservative management e.g. behavioral modifications, analgesics; back pain occurs due to postural changes, weakened abdominal muscles, and joint/ligament laxity

Question 31

What is the recommended management for an asymptomatic patient with incidentally discovered endometriosis during an unrelated surgery?

Answer 31

Observation intraoperative findings may include adhesions, powder-burn lesions, and "chocolate cysts"; asymptomatic patients do not require any treatment

Question 32

What is the recommended management for patients that present in false labor?

Answer 32

Expectant management

Question 33

What is the recommended management for patients with PPROM at \< 34 weeks gestation and NO signs of infection/fetal compromise?

Answer 33

antibiotics, corticosteroids, and expectant management e.g. ampicillin, erythromycin, and betamethasone; deliver at 34 weeks gestation or if signs of infection/fetal compromise develop

Question 34

What is the recommended management for patients with PPROM at \< 34 weeks gestation and signs of infection/fetal compromise?

Answer 34

corticosteroids, antibiotics, delivery +/- magnesium e.g. evidence of chorioamnionitis

Question 35

What is the recommended management for patients with PPROM at \> 34 weeks gestation?

Answer 35

delivery, antibiotics +/- corticosteroids decreases the incidence of chorioamnionitis

Question 36

What is the recommended treatment for a patient with suspected postpartum endometritis?

Answer 36

Clindamycin plus gentamicin postpartum endometritis is a polymicrobrial infection, thus requires broad-spectrum coverage

Question 37

What is the recommended treatment for a pregnant patient with a penicillin allergy that is diagnosed with syphilis?

Answer 37

IM penicillin (patients need to be desensitized) penicillin is the treatment of choice for syphilis in pregnancy regardless of drug allergies

Question 38

What is the recommended treatment for a pregnant woman with antiphospholipid syndrome?

Answer 38

aspirin and LMW heparin warfarin is contraindicated during pregnancy

Question 39

What is the recommended treatment for acute cervicitis?

Answer 39

azithromycin and ceftriaxone provides coverage for both Chlamydia trachomatis and Neisseria gonorrhoeae

Question 40

What is the recommended treatment for patients with gestational diabetes that continue to have elevated glucose levels despite lifestyle modifications?

Answer 40

insulin or oral medications (e.g. metformin)

Question 41

What is the recommended treatment for patients with septic abortion?

Answer 41

broad-spectrum antibiotics and suction curettage medical emergency; urgent treatment required to reduce risk of sepsis

Question 42

What is the recommended treatment for septic pelvic thrombophlebitis?

Answer 42

anticoagulation and broad-spectrum antibiotics

Question 43

What is the recommended treatment for symptomatic postpartum pubic symphysis diastasis?

Answer 43

Supportive (e.g. NSAIDs, physical therapy) typically resolves witin the first 4 weeks postpartum

Question 44

What is the strongest risk factor for preterm delivery?

Answer 44

preterm delivery in a prior pregnancy

Question 45

What is the target fasting blood glucose level in patients with gestational diabetes mellitus?

Answer 45

Question 46

What is the typical prognosis for newborns with Erb-Duchenne or Klumpke palsy secondary to shoulder dystocia?

Answer 46

Spontaneous resolution within 3 months (80%) rarely surgical intervention is considered for infants with no improvement by age 3 - 6 months

Question 47

What is the underlying cause of early decelerations on fetal heart tracing?

Answer 47

Fetal head compression occurs as an autonomic response to alterations in intracranial pressure

Question 48

What is the underlying cause of late decelerations on fetal heart tracing?

Answer 48

Placental insufficiency due to transient fetal hypoxia

Question 49

What is the underlying cause of variable decelerations on fetal heart tracing?

Answer 49

Fetal cord compression compression causes transient fetal hypertension, triggering a parasympathetic response that slows the heart rate

Question 50

What is the underlying pathophysiology of hypotension after administration of epidural anesthesia?

Answer 50

vasodilation and venous pooling sympathetic nerve fibers responsible for vascular tone may be blocked by the anesthesia resulting in vasodilation and venous pooling

Question 51

What level of proteinuria is required to make a diagnosis of preeclampsia?

Answer 51

≥ 300 mg/day (or a protein/creatinine ratio \> 0.3)

Question 52

What screening test is used to determine if an Rh(D)- pregnant woman has already alloimmunized?

Answer 52

Antibody screen (indirect Coombs test) detects the presence of any RBC antibodies; Rh(D)- women with a negative antibody screen should receive anti-D immune globulin at 28 - 32 weeks gestation

Question 53

What type of miscarriage is characterized by no vaginal bleeding and a closed cervical os with no fetal cardiac activity?

Answer 53

Missed abortion patients are typically asymptomatic or have loss of pregnancy symptoms (e.g. nausea, breast tenderness) with decreasing beta-hCG levels; ultrasound reveals a non-viable pregnancy (e.g. no fetal heartbeat, empty gestational sac)

Question 54

What type of miscarriage is characterized by vaginal bleeding and a closed cervical os with normal fetal cardiac activity?

Answer 54

Threatened abortion management is typically expectant with observation and repeat ultrasound

Question 55

What type of miscarriage is characterized by vaginal bleeding and a dilated cervical os without expulsion of products of conception?

Answer 55

Inevitable abortion ultrasound typically reveals a nonviable gestation in the lower uterine segment

Question 56

What type(s) of fibroids are most associated with bulk-related symptoms and irregular uterine enlargement?

Answer 56

subserosal and pedunculated fibroids (leiomyomata) e.g. constipation, incomplete voiding, pelvic pressure

Question 57

What type(s) of fibroids are most associated with heavy menstrual bleeding and/or recurrent pregnancy loss?

Answer 57

submucosal and intracavitary fibroids (leiomyomata)

Question 58

Which TORCH infections are routinely screened for in pregnant women during their first prenatal visit?

Answer 58

rubella and syphilis other routinely screened infections include HIV, hepatitis B, and Chlamydia trachomatis

Question 59

Which type(s) of decelerations may be indicative of fetal hypoxia and/or acidosis?

Answer 59

late and recurrent variable decelerations

Question 60

[...] fetal growth restriction begins in the second/third trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension).

Answer 60

**Asymmetric** fetal growth restriction begins in the second/third trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension). characterized by normal growth in vital organs (e.g. brain, heart, placenta) at the expense of less vital organs (e.g. abdominal viscera)

Question 61

Asymmetric fetal growth restriction begins in the [...] trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension).

Answer 61

Asymmetric fetal growth restriction begins in the **second/third** trimester and is associated with conditions that cause placental insufficiency (e.g. hypertension). characterized by normal growth in vital organs (e.g. brain, heart, placenta) at the expense of less vital organs (e.g. abdominal viscera)

Question 62

Asymmetric fetal growth restriction begins in the second/third trimester and is associated with conditions that cause [...].

Answer 62

Asymmetric fetal growth restriction begins in the second/third trimester and is associated with conditions that cause **placental insufficiency (e.g. hypertension).** characterized by normal growth in vital organs (e.g. brain, heart, placenta) at the expense of less vital organs (e.g. abdominal viscera)

Question 63

[...] is a blood pressure \> 140/90 mmHg before the 20th week of gestation.

Answer 63

**Chronic hypertension** is a blood pressure \> 140/90 mmHg before the 20th week of gestation. elevated blood pressure must be seen on 2 separate measurements taken at least 4 hours apart

Question 64

Chronic hypertension is a blood pressure \> 140/90 mmHg before the [...] week of gestation.

Answer 64

Chronic hypertension is a blood pressure \> 140/90 mmHg before the **20th** week of gestation. elevated blood pressure must be seen on 2 separate measurements taken at least 4 hours apart

Question 65

[...] maternal serum alpha-fetoprotein (AFP) is associated with aneuploidies (e.g. trisomy 18 & 21)

Answer 65

**Decreased** maternal serum alpha-fetoprotein (AFP) is associated with aneuploidies (e.g. trisomy 18 & 21)

Question 66

[...] is a blood pressure \> 140/90 mmHg after the 20th week of gestation with no proteinuria, pre-existing hypertension, nor end-organ damage.

Answer 66

**Gestastional hypertension** is a blood pressure \> 140/90 mmHg after the 20th week of gestation with no proteinuria, pre-existing hypertension, nor end-organ damage.

Question 67

[...] refers to normal vaginal discharge containing blood and/or mucus in the postpartum period.

Answer 67

**Lochia** refers to normal vaginal discharge containing blood and/or mucus in the postpartum period can occur for up to 2-3 months.

Question 68

[...] fetal growth restriction begins in the first trimester and is typically caused by chromosomal abnormalities.

Answer 68

**Symmetric** fetal growth restriction begins in the first trimester and is typically caused by chromosomal abnormalities. global growth lag that affects fetal organs uniformly; less frequently occurs due to congenital or intrauterine infection

Question 69

Symmetric fetal growth restriction begins in the [...] trimester and is typically caused by chromosomal abnormalities.

Answer 69

Symmetric fetal growth restriction begins in the **first** trimester and is typically caused by chromosomal abnormalities. global growth lag that affects fetal organs uniformly; less frequently occurs due to congenital or intrauterine infection

Question 70

Elevated maternal serum alpha-fetoprotein (AFP) is associated with [...] defects, [...] defects, and [...].

Answer 70

Elevated maternal serum alpha-fetoprotein (AFP) is associated with **neural tube** defects, **abdominal wall** defects, and **multiple gestation.** typically measured between 15 - 20 weeks and correlated with ultrasound evaluation

Question 71

[...] maternal serum alpha-fetoprotein (AFP) is associated with neural tube defects, abdominal wall defects, and multiple gestation.

Answer 71

**Elevated** maternal serum alpha-fetoprotein (AFP) is associated with neural tube defects, abdominal wall defects, and multiple gestation. typically measured between 15 - 20 weeks and correlated with ultrasound evaluation