questions Flashcards

Question

mature teratoma - most likely cancerous component

Answer 1

squamous cancer cell transform w/ <2% chance usually in postmenopausal

Answer 2

clear cell adenocarcinoma (hobnail cells) / type of epithelial ovarian cancer

Answer 3

only paternal DNA (no fetal parts develp), higher hCG lvls, a/w lutein cysts, medical complications

Answer 4

distal 1/3 of vagina - drains to superficial and deep inguinal nodes then femoral nodes upper vagina - drains to external/internal iliac (pelvic) nodes

Answer 5

they EXFOLIATE malignant cells into peritoneal cavity = transcoelomic spread. they follow normal circulation (clockwise) of peritoneal fluid and implant in right pericolic gutter and undersurface of right hemi-diaphragm. the omentum and all other surfaces of the peritoneum are at risk of spread via this mechanism

Answer 6

poorly responsive to chemo. hence needs hyst also b/c mets are rare

Answer 7

BRCA 1 - 40% BRCA 2 - 15%

Answer 8

HPV 16 then 18

Answer 9

whole pelvic external beam radiation therapy with brachytherapy and concurrent weekly cisplatin therapy

Answer 10

type 1 - age 35-65, a/w cervical neoplasia , h/o STD, HPV, VIN, h/o warts, h/o smoking type 2 - 55-85yo, a/w vulvar inflammation, lichen sclerosis, squamous cell hyperplasia

Answer 11

1st degree relative of breast cancer genetic mutation carrier, but untested 20% lifetime risk of breast cancer radiation therapy to chest between 10-30yo age 25-29yo and know BRCA pathogenic variant

Answer 12

rapid onset of erythema, edema, peau de orange appearance, warm, with or w/o palpable mass duration of history no more than 6 months erythema occupying at least 1/3 of breast pathologic confirmation invasive carcinoma

Answer 13

lumpectomy with or without radiation or tamoxifen

Answer 14

1.3% = 1 of 75

Answer 15

presence of fetal parts, most common karyotype 69 XXX. happens when 23X containing haploid egg gets fertilized by 2 sperms (23 X or 23 Y). results in trisomy 69 XXX, 69 XYY, 69 XXY

Answer 16

no fetal parts seen. inactivated 23 haploid egg gets fertilized by 23X sperm which then replicates forming a 46XX diploid of full PATERNAL origin. it is also possible to be fertilized by 2 separates sperm and 46 XY diploid is possible, all from PATERNAL origin

Answer 17

early preg vag bleeding, snowstorm appearance on US w/o fetal parts preop: ABO, baseline labs, coags, CXR, bHCG, thyroid fxn if hyperT suspected d&c postop: trend bHCG to r/o GTN

Answer 18

cervical cancer

Answer 19

size of tumor >5cm is stage 1B

Answer 20

SSRIs - may theoretically reduce effectiveness of tamoxifen. SNRIs are fine

Answer 21

15% . may be as high as 35% in high risk dz

Answer 22

bc there is higher chance of having had multiple sexual partners, more likelihood of HPV exposure/STD exposure

Answer 23

upstaged to at least stage 1C, which will likely now require chemo

Answer 24

progestin like megace 80mg qD for 3 months, repeat EMB then reassess effectiveness of current therapy

Answer 25

resection of parametrial tissue medial to ureter for mod rad hyst rad hyst has ureters completely dissected down to insertion of bladder. all parametrial tissue and all other ligaments are resected at their attached points

Answer 26

genital tract epithelium, pancreas, gallbladder, stomach, kidney, lung, breast, heart. inflammation of any of these peritoneal surfaces may lead to elev CA125

Answer 27

NOT curative

Answer 28

bilat mastectomy - risk reduction of 85-100% in breast cancer BSO - risk reduction of 80% of ov cancer, 68% of all cause mortality

Answer 29

if there is a fixed mass, whether pre or post meno, refer to gyn onc

Answer 30

unilocular cyst solid components with largest being <=7mm largest diameter acoustic shadows smooth multilocular contour no detectable blood flow on doppler

Answer 31

irregular solid ascites >=4 papillary structures irregular multilocular solid tumor w/ greatest diameter of >=10cm very high color content on color doppler

Answer 32

any imaging modality and/or pathology findings

Answer 33

1 - 39-46% 2- 10-27%

Answer 34

cervical cancer

Answer 35

35-40 for 1 40-45 for 2

Answer 36

ileus - transient, dilated loops of bowel on KUB, pt may still pass flatus, decreased/absent bowel sounds SBO - air fluid lvls or areas of collapsed bowel distal to obstruciton, often n/v, high-pitched/tinkering bowel sounds

Answer 37

uterine perf, especially cervical perf --- high risk of bowel/bladder/vasculature injury. may needs hsc/cysto/DRE/lsc/ex lap

Answer 38

release of renin, aldosterone, ADH --> reduced GFR --> oliguria other physiologic changes w/ robot/t-berg --> decreased CO, acidemia, oliguria, difficulty with ventilation

Answer 39

expt mgmt A fever in the first 24 hours after surgery may represent a noninfectious pathway (atelectasis, hypersensitivity rxn, pyrogenic rxn to tissue trauma). In the absence of complications or definitive infection, no additional workup is needed. If the fever persists beyond the 24-hour period, additional testing may be necessary to identify both infectious and noninfectious causes

Answer 40

Severe wound infections involving purulent drainage and associated surrounding soft tissue infection require incision and drainage with debridement, wound culture, initiation of antibiotics, and daily wound care. Delayed closure is not contraindicated in a wound infection, provided the infection has been cleared and healthy granulation tissue has commenced.

Answer 41

Preoperatively, it is important to both ensure adequate glucose control and prevent hypoglycemia, ketosis, electrolyte or fluid imbalance, or marked hyperglycemia. Diabetes mellitus is also associated with increased risk of perioperative infection and postoperative cardiovascular morbidity and mortality. Although a preoperative target glucose level has not been precisely established, glucose generally should be below 200 mg/dL preoperatively and intraoperatively, and postoperatively glucose should be between 140 and 180 mg/dL. In patients with high glucose levels preoperatively, cancellation should be considered, especially with glucose readings above 400 mg/dL. With regard to medications: Patients taking long-acting insulin at night or in the morning should take one-half to two-thirds of the usual dose; with intermediate-acting insulin taken twice daily, the normal dose should be given the night before and long-acting insulin should be taken at one-half to two-thirds of the usual dose. Short-acting insulin should be held on the morning of surgery because it increases the risk of hypoglycemia. Sulfonylureas such as glyburide increase the risk of hypoglycemia and should be held on the morning of surgery. Thiazolidinediones may worsen fluid retention and can lead to heart failure and should be held on the morning of surgery. Metformin increases the risk of renal hypoperfusion, lactic acidosis, and tissue hypoxia and should be held on the morning of surgery. Sodium-glucose cotransporter 2 inhibitors increase the risk of hypovolemia and should be held on the morning of surgery.

Answer 42

Bowel preparation has shown no statistical difference in the incidence or morbidity of bowel injury during gynecological surgery

Answer 43

Topical hemostatic agents are a useful adjunct to manage bleeding during surgery. Hemostatic agents can be physical agents or biologically active agents. Physical hemostatic agents provide a matrix to concentrate hemostatic factors, absorb water and allow thrombi to easily form. They require an intact coagulation cascade. Physical agents are best used in situations with minimal bleeding/oozing and become less effective with brisk or heavy bleeding. Biologically active agents help augment hemostasis. These are more useful with brisk bleeding and can be used in the setting of coagulopathy. The main disadvantage of biologically active agents is that they are not always readily available and they can be expensive.

Answer 44

periumbilical pain

Answer 45

Patients with a pulmonary embolus (PE) or deep venous thrombosis (DVT) provoked by surgery or other transient risk factors should be treated with anticoagulation for 3 months.

Answer 46

unilocular, hypoechoic cyst with diffuse low-level echoes and ground-glass appearance.

Answer 47

The most common setting for a femoral nerve injury is during pelvic surgery, such as with an abdominal hysterectomy due to the use of deep and lateral retractors. The femoral nerve emerges from the border of the psoas muscle and can be compressed against the pelvic side wall when retractors are improperly positioned. Femoral nerve injuries result in both sensory and motor deficits, such as anesthesia of the anterior and medial thigh and weakness in the quadriceps and iliopsoas muscles. Consequently, patients with a femoral nerve injury are unable to flex the hip and extend the knee.

Answer 48

Antibiotic Treatment for Septic Abortion Triple therapy is necessary to cover the following 3 groups: -gram-positive anaerobes and aerobes -resistant gram-negative aerobes -gram-negative anaerobes ex) amp/gent/clinda Infection is often polymicrobial. Common organisms include E. coli, GBS, anaerobic streptococci, Bacteroides, and staphylococci.

Answer 49

COPD is nonreversible. It is a chronic disease leading to scarring in the lungs and decreasing a patient's ability to exchange oxygen and carbon dioxide. This often leads to baseline respiratory acidosis caused by hypercarbia. When performing laparoscopic surgery, carbon dioxide is used to insufflate the peritoneum and is rapidly absorbed and enters the bloodstream. When this occurs, the patient becomes more acidotic due to hypercarbia. For most patients without underlying respiratory disease, this can be managed by increasing the respiratory rate. However, for patients with severe COPD, the existing damage to the lung parenchyma inhibits carbon dioxide exchange out of the lungs, increasing the risk of complications during laparoscopic surgery. Thus, severe COPD places this patient at the highest risk of morbidity or mortality.

Answer 50

Cefazolin, a first generation cephalosporin, can be used alone as an antibiotic prophylaxis for patients undergoing a hysterectomy

Answer 51

uterus in which the fundus is indented >1 cm. This anomaly results from only partial fusion of the Müllerian ducts.

Answer 52

congenital absence of the vagina with variable uterine development.

Answer 53

normal external surface but has 2 endometrial cavities, in contrast to a bicornuate uterus which has an indented fundus and 2 endometrial cavities. A septate uterus results from a defect in canalization or resorption of the midline septum between the 2 Müllerian ducts.

Answer 54

asymmetric lateral fusion defect. One Müllerian duct develops normally, with a normal fallopian tube and cervix, but the other Müllerian duct fails to develop and can have various configurations

Answer 55

occurs when the 2 Müllerian ducts fail to fuse. This defect has the appearance of 2 uteri and 2 cervixes. Uterine didelphys has clinical significance in that it is associated with spontaneous abortion rates of 32% and preterm birth rates of 28%. Additionally, there also appears to be an increased rate of fetal growth restriction.

Answer 56

polymicrobial (type I) and monomicrobial infection (type II). Polymicrobial (type I) necrotizing infection is caused by aerobic and anaerobic bacteria. Monomicrobial (type II) necrotizing infection is usually caused by GAS or other beta-hemolytic streptococci. Infection may also occur as a result of Staphylococcus aureus

Answer 57

Intravenous pyelography (preferred) and retrograde pyelography

Answer 58

uses methylene blue (or sometimes indigo carmine) along with Pyridium. The patient ingests the Pyridium and the Methylene blue is instilled into the bladder using a urethral catheter. The Pyridium will turn the urine orange and the methylene blue will turn the urine blue. A tampon is then placed into the vagina. If the tampon turns blue, suspect a vesicovaginal fistula. If the tampon turns orange, suspect a ureterovaginal fistula. If the tampon turns both colors, suspect a combination of a vesicovaginal and a ureterovaginal fistula. however Oral pyridium alone is not sufficient enough to test for a ureterovaginal fistula to make formal dx if you suspect UV fistula, you should consider confirming on IV pyelography or retrograde pyelography

Answer 59

suction d&c. also consider starting transfusion as you roll out if they're very unstable

Answer 60

In a non-obese patient inserting the trocar at a 45 degree angle ensures that you are avoiding major vessels. At this angle, the abdominal wall thickness varies from 2 to 3 cm and distance to the major vessels averages 6 to 10 cm. Always remember: Patients should NOT be in Trendelenberg position during initial trocar placement. A 90 degree angle should never be used when entering the abdomen with a trocar; entering the abdomen at a 90 degree angle puts the surgeon at a largely increased risk of hitting the aorta with the trocar, as the aorta is generally less than 4 cm from the umbilical stalk.

Answer 61

The iliohypogastric nerves run along the lateral border of the rectus muscles bilaterally, but there are terminal branches that can be affected even if there is not a full transection of the nerve at the lateral border of the rectus muscle. Injury to iliohypogastric or ilioinguinal nerves may occur from entrapment of the nerves by sutures at the lateral poles of transverse fascial incisions, direct nerve trauma, neuroma formation, or from neural constriction caused by the normal scarring/healing process. Both of these nerves function to provide sensation in the suprapubic area. Damage to these nerves can cause numbness and pain. The characteristic triad of symptoms are: sharp, burning, lancinating pain radiating from the incision to the suprapubic area, labia/scrotum, or thigh paresthesias over these areas pain relief after infiltration with a local anesthetic.

Answer 62

If after 48–72 hours of treatment with antibiotics, patients with a TOA still do not improve, CT- or US-guided percutaneous drainage of the abscess should be arranged. Whereas, if patients worsen on IV antibiotics, surgery should promptly be performed.

Answer 63

A rounded and enlarged ovary compared with the contralateral ovary Decreased or absent Doppler flow within the ovary Heterogeneous appearance of the ovarian stroma Multiple small peripheral follicles coild vascular pedicle "whirlpool sign"

Answer 64

This patient has evidence of necrotizing fasciitis with sepsis. This is an emergency, as delay of surgery by as much as 24 hours increases mortality by a factor of 9. This patient also needs IV antibiotics that cover for a variety of organisms. Currently vancomycin, a carbapenem and clindamycin are used. Once the wound is debrided, it must be closed. Primary closure is simple closure with suture or staples and is appropriate for clean and uninfected wounds. Secondary closure is closure with wet to dry dressings or a wound vac, and is used for wound infections. Tertiary closure involves leaving a wound open to see if infection develops and if it doesn't, closure is done with suture or staples. Since this patient has an active wound infection, it should be closed by secondary intention. Therefore the best answer is antibiotics, emergent wound debridement with secondary closure.

Answer 65

Low serum albumin (< 3.0 g/dL in the absence of hepatic or renal failure) is the best predictor of nutritional status. It is a marker of a negative catabolic state and is the best predictor of poor outcome after surgery. Signs of Severe Malnutrition in the Elderly Risk Factor Parameter BMI BMI < 18.5 Serum albumin Serum albumin < 3.0 g/dL in the absence of hepatic or renal failure Unintentional weight loss > 10–15% within the most recent 6 months

Answer 66

The bladder layers in order from the inside of the bladder to the outside of the bladder are: transitional epithelium (urothelium) lamina propria submucosa detrusor muscle (muscularis propria) adventitia (serosa)

Answer 67

Immediate postoperative fever (38.0°C or 100.4°F) is common and, when present in the first 24 hours, is most likely of benign etiology – continue observation and routine postoperative care. Common causes of immediate postoperative fever include: reaction to medications blood transfusion reaction trauma and inflammation from the operation itself preexisting infections malignant hyperthermia (occasionally) Most commonly, such immediate fevers will abate spontaneously or after removing the offending insult, if identified. Thus, a workup for infection, DVT, abscess, or septic thrombophlebitis is not initially necessary or cost-effective at this point. Persistent postoperative fever, or one that begins after 1–2 days postoperatively, would be more concerning for an infectious process, soft-tissue abscess formation, or vascular etiology, indicating the need for further workup.

Answer 68

Androgen insensitivity is an absence of the X-chromosome gene responsible for testosterone receptor function. It has an estimated incidence of 1/60,000 and these individuals have an XY karyotype and normally functioning male gonads that produce normal male levels of testosterone. Because of the lack of receptors on target organs, there is lack of male differentiation of the external and internal genitalia. Because Müllerian duct regression is a product of anti-Müllerian hormone secretion, there are no female internal genitalia either. Breasts develop because of the increased aromatization of androgens to estrogens in the periphery. Testes that are intra-abdominal or in the inguinal canal have an increased risk of developing malignancy (gonadoblastoma), with an incidence reported to be approximately 20%. However, these malignancies rarely occur before the age of 20 and, therefore, it is usually recommended that the gonads be left in place until after puberty is completed to allow full breast development and full epiphyseal closure to take place.

Answer 69

A key point of this topic is fascial incision healing. According to TeLinde’s Operative Gynecology, fascial incisions heal rather slowly, at a rate of 10%, 25%, 40%, and 50% of their original preoperative strength by weeks 1, 2, 3, and 4, respectively. The majority of fascial dehiscences occur between postoperative day 2 and 12; however, it has been reported up to day 18. Thus, in most patients, 2 weeks is considered an adequate time for fascia to regain enough strength to resist average movement and stresses. Some high-risk patients (i.e., the patient in this question) may require 3 weeks. PDS and polyglyconate retain 80% of their initial tensile strength after 2 weeks and degrade slowly thereafter, which is why PDS is oftentimes the suture of choice for more complicated midline vertical fascial closures.

Answer 70

The strongest reason to order a karyotype in the described patient is to distinguish between androgen insensitivity syndrome (AIS) and Mayer–Rokitansky–Küster–Hauser syndrome (Müllerian agenesis). This is because MRKH and AIS have a different karyotypes: 46,XX and 46,XY respectively. both have absence of uterus

Answer 71

High yield statistics to keep in mind: EMB samples approximately 5–15% of the endometrial cavity. About 30–40% of patients noted to have complex hyperplasia have concomitant endometrial cancer.

Answer 72

PDS (polydioxanone) suture. 50% tensile strength at 4 wks vs vicryl (polyglactin) same but at 2 wks

Answer 73

Most women who choose sterilization do not regret their decision. The CREST study reported the at-5-years risk of regret is ~7%. Factors that are associated with increased risk of regret include young age, non-white race, unmarried marital status, marital discord, and change in marital status after sterilization.

Answer 74

Individuals heal through a sequence of physiologic events that include inflammation, epithelialization, fibroplasia, and maturation. Hysterectomies are classified as “clean contaminated” cases. Pre-op antibiotic prophylaxis decreases the risk of postoperative infection. However it still remains one of the most common postoperative complications. A wound infection is usually localized to the skin and fatty tissue above the fascia. The diagnosis of a postoperative wound infection is usually made several days after surgery, on postoperative day 4 or 5. Signs and symptoms include pain, tenderness, erythema, wound induration, fever, and drainage of pus from the incision. The diagnosis can usually be made by inspection and palpation of the wound. Infected wounds are opened, explored, drained, irrigated, debrided, and dressed. After exploration, the wound is packed until granulation tissue is present and then closed in a delayed fashion, or the wound is allowed to heal by secondary intention. The need for antibiotic therapy is determined by the extent of the infection, presence of systemic manifestations, and comorbidities of the patient (e.g., immunocompromise, diabetes, chronic steroids). Obesity is another major risk factor. As the BMI increases for women undergoing abdominal hysterectomy, so does the risk of surgical site infections and wound complication.

Answer 75

When a dermoid cyst ruptures, the abdomen should be copiously irrigated to avoid chemical peritonitis and chronic pain from adhesions

Answer 76

Risks of D&C risks associated with anesthesia vasovagal reaction perforation of the uterus bowel injury bleeding need for further procedures Indications of a vasovagal reaction may include hypotension, bradycardia, nausea, vomiting, diaphoresis, pallor, or loss of consciousness. Hypotension may also occur due to anesthesia.

Answer 77

imperforate hymen cruciate incision / drainage

Answer 78

Early ambulation, elevating the head of the bed, removing subglottic secretions, and using orogastric tubes all reduce the risk of postoperative pneumonia.

Answer 79

A transverse vaginal septum arises in the setting of a failure of the canalization of the vaginal plate or failed Müllerian duct fusion. They can develop at any level within the vagina. Thickness can vary from less than 1 cm to 6 cm. A septum may be obstructive or non-obstructive, and presentation will depend on this characteristic. In an obstructive transverse vaginal septum, an accumulation of blood and mucus may present as a pelvic mass. Symptoms may be similar to those of an imperforate hymen, including cyclic abdominal pain, lack of menstruation, and possibly a lower abdominal or pelvic mass.

Answer 80

Surgery for endometriosis has been shown to improve pain and increase chances of fertility. How much infertility is improved is unclear. Several randomized trials have concluded that surgery for endometriosis results in an increased chance of pregnancy and ongoing pregnancy rate after 20 weeks. Analysis of results showed the number needed to treat was 12 but this number depends on the severity of disease. Most patients with endometriosis who undergo surgery for their disease will experience a decrease in their pain. A more significant improvement has been found with worse disease. In the first double-blind, randomized, controlled trial approximately 62.5% of women had improvement in their chronic pelvic pain, especially when the implants were resected rather than cauterized. There is, however, a significant recurrence rate.

Answer 81

In the event of a hemostatic puncture injury or needle stick injury, copious irrigation and suction as well as administration of antibiotics are recommended

Answer 82

Minimizing the use of cautery at small bleeding vessels is appropriate to decrease nerve injury. Cautery is likely to injure terminal ends of sensory fibers that run alongside the vessel bundles.

Answer 83

The plasma fibrinogen level is decreased in acute DIC. In contrast there is an elevated in the fibrin split/fibrin degradation products and D-dimer. Answers A & B & C & E: In acute DIC activated partial thromboplastin time (aPTT) is elevated as well as prothrombin time (PTT) and thrombin time (PT). Additionally D-dimer is elevated as well as fibrin degradation products. Laboratory findings that are decreased include platelets, plasma fibrinogen, factor V, and factor VIII.

Answer 84

Massive transfusion is defined as a transfusion of 10 or more units of packed red blood cells within 24 hours, transfusion of 4 units of packed red blood cells within 1 hour when ongoing need for more blood is anticipated, or replacement of a complete blood volume. The recommended initial transfusion ratio for massive transfusion protocol for packed red blood cells:fresh frozen plasma:platelets is in the range of 1:1:1 and is designed to mimic replacement of whole blood. Results from a number of observational studies suggest that patients with severe trauma, massive blood replacement, and coagulopathy have improved survival when the ratio of transfused Fresh Frozen Plasma (FFP, in units) to platelets (in units) to red blood cells (RBCs, in units) approaches 1:1:1. The physiology supporting the 1:1:1 (FFP:platelets:RBCs) approach derives from the existence of the acute coagulopathy of trauma and the dilute nature of conventional blood products. More of any one product merely dilutes the other two. Although transfusion is often lifesaving in obstetrics, usage of blood products, particularly in the setting of massive transfusion, is not without risk. Massive transfusion is associated with hyperkalemia from packed red blood cells and citrate (used as a preservative in stored blood products) toxicity that will typically worsen hypocalcemia. The combination of acidosis, hypocalcemia, and hypothermia all contribute to worsening coagulopathy and increased morbidity.

Answer 85

Bowel prep is indicated in gynecological surgeries when there is increased risk of adhesive disease. Procedures such as staging for gynecological cancers or laparotomy or laparoscopy for advanced endometriosis are examples of procedures for which a bowel prep may be used because of high risk of bowel injury.

Answer 86

When identifying the endpoint to a septoplasty, a level line at the level of the tubal ostia, serosal transillumination of the hysteroscope at the uterine fundus, increased tissue vascularity, and bleeding are signals for completion of the procedure

Answer 87

The copper IUD is the most effective form of emergency contraception. It is also the only form of emergency contraception that may provide continued contraception. Ulipristal is also highly effective alternative (not as high as copper IUD)

Answer 88

HIV ,Epstein-Barr virus, hepatitis C, hepatitis B, and human herpesvirus 8 etc can all be transmitted though a blood transfusion

Answer 89

Reeves et al. showed only a 40% positive predictive value for endometrial stripe thickness, even when adjusting the cutoff. The decision for surgical intervention in the setting of a missed abortion is a clinical decision. Ultrasonographic findings may help guide the decision, but there is no established cutoff for endometrial thickness following medical management of a missed abortion

Answer 90

Gastrografin, a water-soluble contrast, is a studied and effective conservative treatment for small-bowel obstruction that draws fluid into the lumen of the bowel, decreasing edema and increasing peristalsis.If initial treatment with Gastrografin is not successful in resolving a small-bowel obstruction, it can be repeated to a total dose of 100 mL.

Answer 91

Nonsteroidal anti-inflammatory drugs (NSAIDs) decrease inflammation by nonselectively inhibiting both cyclooxygenase (COX)-1 and cyclooxygenase (COX)-2 enzymes. Their effect on platelet function is mediated by COX-1 inhibition, thereby decreasing production of thromboxane A2, which decreases platelet aggregation.

Answer 92

Polydioxanone (PDS) is a synthetic absorbable suture that is a pliable monofilament. More than 90% of initial tensile strength is maintained by the end of the first postoperative week, 80% at 2 weeks, 50% at 4 weeks, and 25% at 6 weeks. Complete absorption time is 180 days (6 months). PDS is commonly used for closure of the fascia, especially in patients who are at high risk for wound infection and disruption.

Answer 93

Pelvic floor rehabilitation and medications (such as anticonvulsants and antidepressants) are the preferred treatments for vestibulodynia, a chronic pain disorder. When a patient diagnosed with vestibulodynia has failed all other medical therapies, the only remaining option is to surgically remove the vestibule via vestibulectomy Surgical treatment is reserved for patients who continue to be symptomatic despite these treatments and desire definitive management. Vestibulectomy is associated with a relief of symptoms in 50–60% of patients. The outer incision extends circumferentially from the periurethral glands along Hart’s line to the contralateral glands. The proximal vaginal margin is just inside the hymenal ring. This horseshoe-shaped epithelium is superficially excised and sent for histologic diagnosis, which usually shows chronic nonspecific periglandular inflammation. For patients with more limited areas of pain, the entire vestibule does not need to be removed.

Answer 94

Radical hysterectomy, where the upper one-third of the vagina is removed, carries the highest risk of VVF, with an estimated incidence of 1/81 cases.

Answer 95

The femoral nerve is the nerve that is injured in this case with compression of a self-retaining retractor against the psoas muscle. Femoral nerve injuries lead to loss in hip flexion, adduction, and knee extension. Sensory losses after femoral nerve injury include those of the anterior and inferomedial thigh and medial calf.

Answer 96

The general management of septic abortion is evaluation and stabilization of vital signs, initiation of broad-spectrum antibiotics, and prompt evacuation of uterine contents. However, this patient also presents with a Clostridium infection. Findings that may be noted in the presence of a Clostridium infection include lower abdominal tenderness, crepitation of pelvic and abdominal structures, a "woody-appearing" uterus on laparoscopy, and air within the myometrium on radiologic imaging. With the clinical presentation of a septic abortion and findings suggestive of Clostridium, the treatment of choice is hysterectomy with bilateral removal of the adnexa. The procedure can be performed with laparoscopic surgery if indicated.

Answer 97

A full-thickness injury to the small bowel should be repaired via double-layer closure with suture lines perpendicular to the long axis of the bowel to avoid narrowing of the bowel lumen. The first layer may be a continuous or interrupted 3-0 delayed absorbable suture that closes the mucosa and muscularis. The serosal layer is then closed with 3-0 interrupted silk sutures placed perpendicular to the long axis of the bowel. Irrigation and administration of IV antibiotics are necessary after the repair to decrease bacterial counts. Single-layer repair is appropriate for serosal injuries.

Answer 98

The corpus luteum is sustained when pregnancy occurs and the implanted embryo secretes chorionic gonadotropin. The corpus luteum is formed after ovulation from the follicle. The secretion of hCG sustains the corpus luteum so that it can produce progesterone. The secretion of progesterone sustains the pregnancy until the placenta takes over at around 10 weeks' gestation.

Answer 99

-Retrograde menstruation leading to attachment and implantation of endometrial glands and stroma on the peritoneum -Increase in cyclooxygenase-2 (COX-2) leading to local overproduction of prostaglandins -Increase in aromatase activity leading to overproduction of local estrogen -Progesterone resistance decreases the antiestrogenic effect of progesterone, which amplifies the local estrogenic effect

Answer 100

placement of a filter in the inferior vena cava (IVC). The rationale behind this decision is that the patient is at such a high risk of recurrent VTE that it is better to mechanically prevent emboli from traveling than to continue anticoagulation, which may be a detriment to the patient's health.

Answer 101

A difference in calf circumference is the most predictive sign of those listed in the diagnosis of DVT. Homans' sign is unreliable for the presence of DVT. Erythema, warmth, or tenderness are non-specific findings that may add to the overall clinical suspicion for DVT A full lower extremity Doppler ultrasound is the best first step in the evaluation of DVT where the pre-test probability is high. D-dimer is highly sensitive, but not specific, and can be falsely elevated postoperatively and is therefore not the best next step.

Answer 102

There are multiple trains of thought regarding the management of vulvar hematomas. The most preferred initial management is the observation of a hematoma assuming it appears stable and the patient appears stable. This will generally decrease the risk of infection and a potentially difficult surgery which often has no endpoint. Should the spread of the hematoma be diffuse or if the patient appears to be becoming unstable, it may be necessary to be more aggressive and perform a surgery. There are 2 separate thoughts on surgery. The first is to perform a large incision and attempt to identify a bleeding vessel to stop the bleeding. The other is to perform a small incision for drainage only and to place a drain to discontinue the growth of the lesion. Neither method is preferred or shown to have better outcomes and often the decision is based on the situation at hand. Interventional procedures and hemostatic agents may be a useful therapy if the bleeding is unable to be controlled and needs a different type of therapy.

Answer 103

It may help to classify Ureteral injuries based on location: 1. Ureteropelvic junction (UPJ) 2. Abdominal ureter - renal pelvis to the iliac vessels 3. Pelvic ureter - pelvic brim to the uterine artery -A pelvic ureteral injury should be repaired with ureteral reimplantation with/without psoas hitch and/or Boari flap -Abdominal ureter injury can be repaired by ureteroureterostomy, transureteroureterostomy or ureteral reimplantation -UPJ injury can be repaired with ureteropyelostomy or ureterocalycostomy.

Answer 104

This patient is having a NovaSure, or radiofrequency device, endometrial ablation. There are two major contraindications. They are pregnancy and cancer. When a pregnancy is not diagnosed, the procedure will cause an abortion. When cancer is not identified prior to the procedure, the procedure will cause difficulty adequately staging the cancer and determining subsequent therapy, which will be necessary. There are several other contraindications to performing the procedure, including the following: endometrial length less than 4 cm, uterine width less than 2.5 cm, IUD in place during the procedure, large fibroid or other structure distorting the endometrium, prior classical cesarean section, active infection or pelvic inflammatory disease, medicinally induced unstable endometrium, or desired future fertility.

Answer 105

When comparing LEEP to CKC, CKC is associated with approximately twice the risk of premature rupture of the membranes, preterm delivery, and very low birth weight of less than 2500g (SGA, not necessarily FGR); 5-8% vs 10-16%. It is important to know that cervical lengths will need to be monitored in those patients who have previously had a cervical excision procedure.

Answer 106

Surgical closure in 6–12 weeks allows maturation of the fistula, and bladder catheterization in the interim will prevent worsening of the fistula as well as reduce symptoms. Vesicovaginal fistulas may be diagnosed by instilling methylene blue into the bladder via a catheter. A tampon or piece of gauze is then placed into the vagina and checked for dye. Repair of a vesicovaginal fistula involves excising the vaginal epithelium around the fistula in a 2–3 cm diameter. Two or three layers of 2-0 or 3-0 absorbable sutures are placed in a transverse interrupted fashion to allow closure without tension.

Answer 107

Absolute contraindications to uterine artery embolization: asymptomatic fibroids (intramural fibroids are fine), pregnancy, pelvic inflammatory disease, uterine malignancy. Relative contraindications to uterine artery embolization: desire for future pregnancy, postmenopausal, pedunculated submucosal or subserosal fibroids, contraindication to radiologic contrast agents. FYI UAE is First line for bleeding due to uterine AV malformation

Answer 108

In preparation for surgery, patients need to shower with an antiseptic soap prior to their procedure, and they need to avoid shaving any hair surrounding the surgical site.

Answer 109

The incidence of imperforate hymen is approximately 1 in 1,000 live-born females. Although diagnosis is mostly clinical and depends on signs of secondary sexual characteristics, primary amenorrhea, and a bulge at the introitus, a transverse vaginal septum may present with the same features and is best treated with resection rather than a simple cruciate incision. Therefore, ultrasonography of the pelvis can help delineate what is behind the blockage.

Answer 110

This is a rare occurence and has a high incidence of concurrent absence of the ipsilateral kidney or portions of the urinary system. The complication describes a patient with a pregnancy within the horn, thought to occur when the sperm travels from the contralateral fallopian tube into the accessory horn. When this occurs, rupture of this structure generally occurs at less than 20 weeks; when identified, removal of the accessory horn should occur as soon as possible. There are 3 other variations that make up the class II Müllerian anomalies: unicornuate uterus without accessory structures unicornuate uterus with communicating accessory horn unicornuate uterus with nonfunctioning, noncommunicating accessory horn. The uterine septum is the most common of all anomalies and has a high rate of first- and second-trimester abortions. It is best resolved with hysteroscopic surgery. Müllerian agenesis of the vaginal portion of the Müllerian structures generally can be resolved if the uterus and vagina communicate. If they do not, however, there is a high risk of recurring infections when a communication is made, and these patients often require hysterectomy.

Answer 111

According to the Rotterdam criteria of 2003, ultrasound findings for PCOS would include 12 or more small follicles on an ovary in women aged 18–35 years. The follicles may be oriented in the periphery, giving the appearance of a "string of pearls."

Answer 112

Surgical staging for ovarian and fallopian tube cancer includes total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, peritoneal biopsies, para-aortic and pelvic lymph node dissection, and partial or total omentectomy. Other indications for omentectomy include debulking of major omental tumor burden. The patient's overall prognosis is improved if immediate surgical staging and/or debulking is performed by a well-trained gynecologic oncology surgeon.

Answer 113

In a systematic review by Pritts, et al. (subsequently cited in the ASRM Practice Committee guidelines for the use of myomectomy to improve fertility), infertile women who underwent hysteroscopic removal of submucosal fibroids had pregnancy rates 2× higher than infertile women whose fibroids were left in situ. Of note, this trend was NOT seen with ongoing pregnancy or live birth rates which remained unchanged compared with infertile women who did not undergo myomectomy. Fibroids are the most common tumor in the female reproductive tract and have a cumulative incidence of 70% among reproductive age women. Submucosal fibroids and intramural fibroids that distort the endometrial cavity are associated with a reduced chance of achieving pregnancy.

Answer 114

Removing the ovaries at time of hysterectomy, in a premenopausal women, will increase her risk for all cause mortalityespecially if she is not taking estrogen therapy. Available evidence shows that performing a bilateral oophorectomy prior to menopause increases the rate of all cause mortality, especially in those women who do not take estrogen therapy. This is thought to be secondary to the hypoestrogenic state.

Answer 115

A Cochrane review published in 2015 demonstrated that laminaria may be more effective than misoprostol at ripening a cervix in preparation for hysteroscopy.

Answer 116

A dilatation and curettage (D&C) is the most appropriate treatment for the patient, who needs immediate relief of her prolonged and excessive bleeding and who has failed hormonal therapy. This patient may desire future fertility; therefore, an endometrial ablation or hysterectomy is not an appropriate choice for surgical management. For patients who have not yet failed medical therapy, there are a number of treatment modalities available. IV estrogen would be an appropriate first-line treatment for acute abnormal uterine bleeding with a thin endometrial lining, whereas a progestin would be more appropriate for a thickened endometrial lining. Tranexamic acid is an antifibrinolytic agent that may be used either intravenously or orally in the treatment of acute abnormal uterine bleeding. Intrauterine tamponade with a 30 mL Foley catheter is another modality that may assist in an episode of acute abnormal uterine bleeding.

Answer 117

Venous thromboembolism is a major cause of morbidity and mortality in the postoperative period. It can occur at any time and is a significant contributor to sudden death. Once a deep vein thrombosis (DVT) or pulmonary embolism (PE) is diagnosed, immediate anticoagulation is indicated. The initiation of anticoagulation is not to help dissolve the already-present clot, but to prevent more clots from forming. Two forms of therapy are acceptable in the acute period: low-molecular-weight heparin (i.e., Lovenox) 1 mg/kg twice daily or intravenous unfractionated heparin with varying protocols. Eventually, the patient will need to transition to warfarin for 3 months for a DVT and 6 months for a PE.

Answer 118

The risk of acquiring HIV from a blood transfusion is between 1 and 2 million transfused donor products. The risk of acquiring hepatitis B is much higher at 1 in 200,000 transfused donor products.

Answer 119

state of hypopituitarism resulting from an infarct of the pituitary secondary to postpartum hemorrhage or shock, causing partial or complete loss of the anterior pituitary hormones

Answer 120

another name for polycystic ovary syndrome. Although polycystic ovary syndrome can be associated with infertility, it is characterized by clinical or laboratory findings of hyperandrogenism, polycystic ovaries seen on imaging, and oligo or anovulation

Answer 121

46,XY complete gonadal dysgenesis. These individuals have normal female external genitalia, with normally formed fallopian tubes and uterus. The gonads are nonfunctional and are usually removed because of risk of cancer. These individuals may become pregnant with donor eggs/embryos.

Answer 122

An ovarian mass with papillary projections or excrescences, >3 mm in thickness, and location inside the cystic portion is most predictive of a malignant tumor. One in 70 women will develop ovarian cancer in their lifetime; it has a 90% survival rate in 5 years if caught in the early stages. It is therefore very important to be able to decipher the difference between benign and malignant masses on ultrasonography.

Answer 123

-Pregnancy -Pelvic infection (even if the patient is receiving antibiotic therapy) -History of a severe reaction to iodinated contrast (seizure, cardiac arrest, cardiac arrhythmia, unconsciousness) -Active undiagnosed vaginal bleeding

Answer 124

Although in a massive transfusion protocol ideally patients should receive blood products if possible, and in a 1:1:1 ratio of platelets to packed red blood cells (PRBCs) to plasma, this patient has refused this. Volume expanders are most appropriate for a patient who refuses blood products with hemorrhage: crystalloid and colloid solutions. In general, for patients with severe volume depletion or hypovolemic shock, crystalloids are typically preferred over colloid-containing solutions. Colloid-containing solutions are rarely used as first-line resuscitative fluids for the management of hypovolemia and hypovolemic shock. Hyperoncotic starch should, in general, be avoided since its use is associated with an increased risk of kidney dysfunction and mortality.

Answer 125

-Acute cardiopulmonary disease suspected on basis of history and physical exam. Includes patients who smoke, have asthma, or chronic obstructive pulmonary disease (COPD) -Older than age 70 with history of stable chronic cardiopulmonary disease and without a recent chest radiograph within the past 6 months -To establish baseline chest radiograph if patient may require an ICU stay -Undergoing major surgical operation including abdominal, thoracic, cardiac, some esophageal, thyroidectomy, other head and neck, neurosurgery, and lymph node procedures

Answer 126

Normal saline (NS), an isotonic low-viscosity fluid, is an appropriate fluid medium when performing mechanical or bipolar morcellation because it is associated with fewer side effects as a consequence of fluid overload. Although it has a more favorable profile than other media, NS still requires some monitoring because the overload can result in pulmonary edema and possibly death. In healthy patients, the cutoff is 2,500 mL. Answer A: 300 mL is the suggested cutoff for elderly patients when high-viscosity fluids are used. Answer B: 500 mL is the suggested cutoff for healthy nonelderly patients when high-viscosity fluids are used. Answer C: 1,000 mL is the suggested cutoff for healthy patients when a hypotonic solution is used.

Answer 127

Vesicovaginal fistula may be identified with multiple methods including visualization of dyes or laboratory evaluation. However, locating it is the next step for surgical evaluation and exploration. Cystourethroscopy directly visualizes the abnormality, and can assess the bladder for residual injury, surgical materials and the number of intravesical fistula orifices. Very small fistulas will be difficult to appreciate on bimanual or speculum examinations. Dye studies alone are not sufficient to completely evaluate the number and location of urogenital fistula. The intravenous pyelography (IVP) is less useful for noting any disruption in ureteral integrity, because it may miss ureteral leakage that is immediately adjacent to the trigone when dye filling the bladder obscures a small leak. Small amounts of dye may not show up on conventional radiography, and puddling may result from ureteral or bladder leakage, or both. When a normal renal unit is seen on IVP, but the ureter is never visualized, complete transection preventing accumulation of dye in the ureter must be considered. A recent study of obstetric vesicouterine fistula demonstrated that pelvic magnetic resonance imaging (MRI) may be more sensitive than IVP or computed tomography (CT). Dye tests are helpful in assessing whether or not a fistula is present, but are not sufficient to completely evaluate the number and location of urogenital fistulas. Dyed sterile fluid (e.g., sterile infant formula, or indigo carmine or methylene blue mixed with saline, where available) may be instilled into the bladder through a bladder catheter. In combination with the use of blue dye in the bladder, use of oral phenazopyridine (e.g., pyridium) will distinguish a fistula communicating between the vagina and ureter (orange urine) from located in the bladder (blue urine).

Answer 128

Vulvar abscesses can present as skin and hair follicle infections, bartholin gland abscess, skene gland abscess, or secondary to wound/hematoma infections. These are often polymicrobial and MRSA tends to be involved. Small abscesses <2cm should undergo incision and drainage (I&D). If the abscess is >5cm or the patient is immunocompromised, the I&D is better done in the OR rather than in the office. When drained, cultures should be collected. After incision and drainage, the wound can be packed daily with wet to dry dressings or a vessel loop can be placed to allow for drainage. Vulvar abscesses can recur and further management may involve marsupialization vs duct excision depending on the location. Patients with diabetes are considered immunocompromised; if they present with a vulvar abscess they should be admitted for inpatient care as there is always concern for necrotizing fasciitis until proven otherwise.

Answer 129

Methotrexate is the treatment of choice for cervical ectopic pregnancy. It can be administered either systemically or via intra-amniotic injection. Use of this modality avoids disturbing the pregnancy, thus decreasing the risk of catastrophic hemorrhage.

Answer 130

finish hyst first if possible then repair 2 layer closure for >=2cm injury, check w/ backfill, keep foley for 7-10 days then f/u cystogram to confirm closure of defect When there are multiple cystotomies in close proximity to each other in the bladder dome, an option is to incise the small defects to combine them into a single defect before beginning the repair. When the repair is completed, the closure should be tested to ensure it is water-tight by instilling dye into the bladder catheter and observing the repair site laparoscopically. The bladder will re-epithelialize within 3–4 days and will regain its normal strength after 21 days.

Answer 131

Diagnostic laparoscopy with chromopertubation remains the gold standard investigation in the assessment of tubal patency. It provides a direct view of the pelvic organs, and also offers the possibility to treat minor pathology discovered during the investigation. Methylene blue dye is inserted through a cannula in the cervix to demonstrate tubal patency. Spillage of the dye from each tube is noted via direct visualization as a confirmation of tubal patency. If a repair procedure for tubal occlusion is performed, chromopertubation is repeated at the end of the procedure. Diagnostic laparoscopy requires admission to hospital and general anesthesia and, as a result, is the most invasive and expensive.

Answer 132

Hysterosalpingogram (HSG) is typically the first-line test used for tubal patency. It involves inserting a cannula into the cervix and passing radio-opaque fluid into the uterine cavity and fallopian tubes, demonstrating their outline. The test is performed under X-ray screening on an outpatient basis. If the HSG is normal, this finding can be relied upon in 97% of cases. However, if the HSG is abnormal, the diagnosis can only be relied upon in 34% of cases (false positive rate 66%), and a laparoscopy is required to confirm the nature of the abnormality. Proximal tubal occlusion on HSG often represents testing artifact due to tubal spasm or poor catheter positioning leading to unilateral tubal perfusion. Given these deficiencies, findings of proximal tubal occlusion on HSG could be confirmed by secondary testing.

Answer 133

surgical exploration and ligation of bleeding source

Answer 134

In an elderly patient with multiple comorbidities who does not desire further sexual intercourse, which of the following is the MOST appropriate surgical option to treat symptomatic prolapse?

Answer 135

Foley catheter drainage and decompression of the bladder may enable reepithelialization and closure of small vesicovaginal fistulas. In the remainder of cases in which conservative measures fail, surgical management is the best and most effective option. The Latzko procedure is a technique for fistula repair via the vaginal route and provides the highest chance for successful closure at 80%–90%.

Answer 136

suction d&c

Answer 137

A Foley catheter should be placed on initial inspection of a vulvar hematoma because it may be difficult to pass a catheter without sedation if swelling from the initial trauma or hematoma continues. Swelling from trauma can make it difficult to void after trauma, secondary to edema or pain. Stable vulvar hematomas may be managed conservatively with Foley catheter placement, ice packs, and pain medications. Expanding hematomas require surgical evaluation.

Answer 138

When an operative hysteroscopy is performed with a monopolar electrosurgical device, the distending fluid medium must be electrolyte-poor, such as glycine, sorbitol, or mannitol. Normal saline contains electrolytes and cannot be used with monopolar electrosurgical energy. Its use is acceptable during resections with bipolar electrosurgical devices.

Answer 139

Surgery for adnexal masses in pregnancy is dependent on a number of factors. Ovarian masses are seen in up to 6% of women up to 14 weeks. Up to 4% of these women have complications from these cysts: torsion, malignancy, or dystocia at delivery. Intermittent pain may represent ovarian torsion, which occurs most often with cysts that are between 5–10 cm in size. Given our patient’s history, absent reversed or reduced doppler flow likely indicates torsion and thus that ultrasound finding would be most indicative of requiring surgery. The best time for a surgery to occur is in the second trimester. Complications increase significantly when surgery occurs after 23 weeks. The risk of a preterm delivery increases greatly, as high as 50% in one study. Ultrasound findings may be the key portion of an exam to indicate the need for surgery vs. expectant management.

Answer 140

Bottom Line: When a corpus luteum is removed prior to 10 weeks' gestation, progesterone must be supplemented until 10 weeks' gestation, by which time the placenta will be the primary producer of progesterone. Progesterone supplementation is required as progesterone is largely produced by the corpus luteum until about 10 weeks of gestation. Pulsatile pituitary luteinizing hormone and eventually human chorionic gonadotropin from the implanting pregnancy stimulate progesterone production by the corpus luteum, which is essential for pregnancy maintenance until about the seventh week, when progesterone production is sufficient. The seventh to tenth week is considered a period of shared function between the corpus luteum and the placenta, at which point the placenta emerges as the major source of progesterone synthesis, and maternal circulating levels progressively increase. When a corpus luteum is removed while treating adnexal torsion in pregnancy prior to 10 weeks' gestation, progesterone must be supplemented until 10 weeks' gestation, by which time the placenta is the primary site of progesterone production. Suitable progesterone regimens are listed below. Pregnancy is associated with an increased risk of ovarian torsion, accounting for 10–22% of cases of torsion. The incidence of torsion in pregnancy is unknown, but some studies show that if a persistent adnexal mass measures equal to or greater than 4 cm, the incidence is 15%. Torsion is most likely to occur between 10 and 17 weeks of gestation, but can occur at any time including the postpartum period.

Answer 141

This patient has a hemorrhage following a D&C for a missed abortion that is unresponsive to uterotonics. She has tried 2 medications, but neither has been successful. The most likely cause of a postoperative hemorrhage in this condition is atony. Atony should first be treated using medication. Generally, this works, but if it is unsuccessful, other questions need to be asked. The first is whether there are still retained products in the uterus. This is best accomplished using a repeat curettage, possibly under ultrasound guidance. Once the absence of retained tissue is confirmed and if the hemorrhage persists, uterine artery embolization or a Foley balloon in the uterus may be used.

Answer 142

When intrauterine adhesions are suspected, a hysterosalpingogram is indicated. Intrauterine adhesions characteristically appear within the uterine cavity as irregular and angulated filling defects. Intrauterine adhesions may develop in up to 8% of patients after a single curettage for pregnancy loss. Asherman syndrome includes a wide spectrum of scarring, including filmy adhesions, dense bands, and complete obliteration of the uterine cavity. Although many affected patients are asymptomatic, the most common presenting problem is infertility, which occurs in up to 40%–45% of patients. Amenorrhea may be observed with extensive intrauterine scarring. In less severe cases, patients may present with hypomenorrhea or with recurrent pregnancy loss. Hysteroscopic lysis of adhesions is the preferred surgical management. High-dose estrogen therapy or placement of an intrauterine Foley catheter can prevent postoperative recurrence of adhesions.

Answer 143

Once the decision for surgery has been made, the type of entry is the next decision to be made. Prior to completion of the first trimester, an infraumbilical laparoscopic entry is appropriate. After the first trimester, open technique is preferred with placement of a towel clamp if air escapes the trocar site. Palmer's point is reserved for more advanced pregnancies when entry using an umbilical approach would increase risk of uterine damage or entry. As the uterus reaches 20 weeks' gestation, the uterus will be closer to the umbilicus. Open abdominal incisions are best reserved for larger lesions or patients who are more unstable. When deciding between laparoscopy or laparotomy, common sense should dictate the decision. When performing abdominal insufflation, it is important to remember that insufflation greater than 15 mm Hg can lead to hypercarbia, acidosis, and uteroplacental hypoperfusion. This patient is in the first trimester and is best served by infraumbilical laparoscopic entry.

Answer 144

Most patients with necrotizing fascitis (75%) have edema that extends beyond the erythema. Significant edema may cause compartment syndrome with myonecrosis and require immediate fasciotomy. Necrotizing fasciitis is an infection of the deep soft tissues. It results in the destruction of the muscle fascia and the overlying subcutaneous fat. Risk factors for necrotizing fasciitis include recent trauma or surgery, immunosuppression (including HIV, diabetes, and neutropenia), malignancy, obesity, and alcoholism. Necrotizing fasciitis can be divided into 2 categories of microbes: Polymicrobial (type 1) necrotizing infection is caused by aerobic and anaerobic bacteria. At least one anaerobic species (most commonly Bacteroides, Clostridium, or Peptostreptococcus) is isolated in combination with Enterobacteriaceae (e.g., Escherichia coli, Enterobacter, Klebsiella, Proteus) and at least one facultative anaerobic streptococci. Monoclonal (type II) necrotizing infection is caused by group A strep (GAS) or other beta-hemolytic streptococci. Less commonly, the infection may be caused by Staphylococcus aureus. Differentiating between cellulitis and necrotizing fasciitis can be challenging when presenting symptoms are non-specific. Since necrotizing fasciitis spreads within the subcutaneous tissue with relative sparing of the overlying skin, treating clinicians commonly underestimate the extension and seriousness of the infection.

Answer 145

Trichloroacetic acid is an immune-based treatment for treating genital warts and is the preferred treatment in pregnancy because it has no systemic absorption. When using medical treatment, a response should be observed in 3 weeks with resolution in 6–12 weeks.

Answer 146

Patients with a history of multiple abdominal or pelvic surgeries are likely to have severe intraabdominal adhesions. Entry at Palmer's point is typically above the level where adhesions are found in patients who are at risk. Palmer’s point is 3 cm lateral of midline and 3 cm below the left rib cage, and the trocar/Veress needle is directed 15° cephalad. Unless the patient has had a splenectomy or significant intraabdominal trauma, this is the best place to enter the abdomen, even when performing pelvic surgery, and longer instruments may be necessary.

Answer 147

inhibiting or delaying ovulation. While levonorgestrel delays follicular development, ulipristal acetate inhibits follicular rupture. The copper IUD affects sperm viability and function to prevent fertilization.

Answer 148

An adnexal mass greater than 5 cm places the patient at increased risk of ovarian torsion. The most common etiologies in those with ovarian torsion are functional ovarian cysts or dermoid cysts. In a series of cases with suspected torsion, the most sensitive and specific sonographic findings were ovarian edema and relative enlargement of ipsilateral ovary. Other findings include absent arterial flow, which is present in only 40% of cases. absent blood flow on doppler is very specific but not sensitive as a half the times blood flow is normal

Answer 149

urodynamics The patient described in the question has an increased postvoid residual and therefore the best next step is urodynamic testing to evaluate for overflow incontinence. TrueLearn Insight: Urodynamic testing does not improve outcomes in women treated with mid-urethral slings for uncomplicated stress urinary incontinence and is therefore not indicated in patients with a normal postvoid residual.

Answer 150

1) Crystalloid 2) Colloid 3) Blood. In the event you have already provided crystalloid and the patient is refusing blood, opt for an appropriate colloid, like Albumin.

Answer 151

follow up with phone / clinic, recommended by FDA

Answer 152

branch of the external iliac artery with its origin just above the inguinal ligament. It courses superiorly and medially towards the umbilicus. It lies just medial to the round ligament as the ligament passes through the deep inguinal ring into the inguinal canal and lateral to the obliterated umbilical vessels. It pierces the fascia transversalis to enter the rectus sheath anterior to the arcuate line. It ascends behind the rectus muscle, supplying the lower central part of the anterior abdominal wall, and anastomoses with the superior epigastric artery.

Answer 153

The normal female menstrual cycle typically lasts 28–35 days. Day 1 is the first day of the menstrual cycle by convention. The follicular phase includes the first 14–21 days of the menstrual cycle, and the luteal phase is 14 days. The luteal phase typically does not change in length; however, the follicular phase may vary by several days. Ovulation typically occurs within 24–36 hours of the luteinizing hormone (LH) surge, and formation of the corpus luteum is noted as early as 1 hour after ovulation. In a typical 28-day cycle, the corpus luteum would be expected to be seen on imaging as early as day 14.

Answer 154

The normal female menstrual cycle typically lasts 28–35 days. Day 1 is the first day of the menstrual cycle by convention. The follicular phase includes the first 14–21 days of the menstrual cycle, and the luteal phase is 14 days. The luteal phase typically does not change in length; however, the follicular phase may vary by several days. Ovulation typically occurs within 24–36 hours of the luteinizing hormone (LH) surge, and formation of the corpus luteum is noted as early as 1 hour after ovulation. In a typical 28-day cycle, the corpus luteum would be expected to be seen on imaging as early as day 14.

Answer 155

Though venous pressure refers to the average blood pressure in the venous system, central venous pressure (CVP) describes the blood pressure in the thoracic vena cava as it empties into the right atrium. It is the best approximation for the right atrium filling pressure, and by extension the right ventricle filling pressure. It is important not to increase the pressure in the abdomen above the CVP because it will decrease cardiac output by decreasing the preload. During gynecologic surgery, common pneumoperitoneum pressures are low (8 mm Hg), standard (12 mm Hg), and high (15 mm Hg). However, intraabdominal pressures over 20–24 mm Hg create excessive resistance for ventilation.

Answer 156

Postexposure prophylaxis for HIV in the nonoccupational setting includes 28 days of multidrug HAART therapy and is most effective when administered within 72 hours of exposure.

Answer 157

A simple left ovarian cyst with thickened irregular cyst wall is the most likely ultrasound finding to support mittelschmerz. Mittelschmerz is pain that occurs around the time of ovulation; for many patients this is acute in nature and single sided. In terms of the menstrual cycle, an average cycle is 28 days, with 14 days in the follicular phase and 14 days in the luteal phase. On day 14, ovulation occurs, and the follicle previously containing the oocyte becomes the corpus luteum. If an ultrasound were to be performed at this time, a corpus luteum would likely be seen and would appear as a simple cyst with a thickened irregular cyst wall.

Answer 158

Mild endometriosis consists of superficial implants that are less than 3 cm in aggregate and are scattered on the peritoneum and ovaries. No significant adhesions are present.

Answer 159

This patient is in end-stage lung disease. Thus, it is already difficult to create oxygen exchange, to maintain oxygenation, to obtain lung compliance, and to overcome intra-abdominal pressure (IAP). Endoscopic, vaginal, and open abdominal surgery, though generally higher in morbidity secondary to infection and healing, are not going to increase abdominal pressure directly during the case. Of these, vaginal surgery is the least invasive option. Laparoscopic surgery creates a pneumoperitoneum and when this occurs IAP exceeds physiological thresholds. With this increased abdominal volume, compliance declines and IAP continues to climb. In these situations, the degree of oxygenation is based on the patient's position. When the patient is placed into the steep Trendelenberg, as often is needed on the Robotic system, there is increased risk of laryngeal edema increasing risk of stridor. There is also decreased functional residual capacity (FRC), and ventilation/perfusion mismatch is worsened. This significantly worsens the morbidity and mortality in the patient with end-stage respiratory disease.

Answer 160

The patient described in this case has classical findings of Fitz-Hugh–Curtis syndrome. This ascending pelvic inflammatory infection is most commonly caused by chlamydia or gonorrheal infection. Acute Fitz-Hugh–Curtis syndrome can be identified laparoscopically by a patchy purulent exudate on the anterior surface of the liver. Chronic periphepatic fibrosis appears as fibrinous exudate often described as "violin string-like" adhesions. This ascending infection could have been prevented with treatment of the venereal infection with ceftriaxone and doxycycline. Cefoxitine and oral doxycycline are recommended for inpatient treatment of PID. Metronidazole is added on when PID is complicated by wet mount positive for bacterial vaginosis OR when pelvic abscesses are seen on imaging. Ceftriaxone alone is not recommended for PID. Ceftriaxone does treat gonorrhea; however, when treating for gonorrhea you should empirically treat for chlamydia too. Doxycycline alone is not the recommended treatment for PID. Doxycycline would only treat chlamydia

Answer 161

repeat US in 3-6months Ultrasonographic findings suggestive of a benign adnexal mass include unilocular, thin-walled, sonolucent cysts with smooth, regular borders. The majority of these types of cysts are benign regardless of menopausal state or cyst size. In a large prospective study, more than 2,700 postmenopausal women with unilocular cysts measuring 10 cm or less were followed with ultrasonography every 6 months. After a follow-up of more than 6 years, no cancers were detected, and spontaneous resolution of the cyst occurred in two-thirds of the women. Therefore, simple cysts up to 10 cm in diameter measured by ultrasonography are almost universally benign.

Answer 162

Geriatric patients are at increased risk for falls, especially when they are postsurgical and in unfamiliar environments. A single fall may have catastrophic consequences for the patient. The American College of Surgery and National Surgical Quality Improvement Program (NSQUIP) recommend that all geriatric patients who are scheduled for surgery be evaluated for fall risk. They recommend using the timed up and go test (TUGT) to assess their fall risk. This involves the patient standing up from a standard chair, walking 10 feet, turning around, returning to the chair and sitting down. This task should be completed unassisted and should take no more than 15 seconds. Patients who take more than 15 seconds are at high risk of falls and the provider should consider referral to physical therapy.

Answer 163

Ultrasound is an excellent imaging modality to detect adnexal torsion, with reported sensitivity up to 92% in recent studies Ovarian torsion is a clinical diagnosis, and these patients present with acute, severe, unilateral, lower abdominal and pelvic pain, in addition to nausea and vomiting. Ultrasound is the imaging modality of choice. While older studies reported sonographic sensitivity of 50–75% for ovarian torsion, other more recent studies have reported sensitivities of 72.1%–80% and specificities of 95%–99% in the general population. In the adolescent population, ultrasound is the imaging modality of choice with 92% sensitivity and 96% specificity in detecting adnexal torsion. There are several sonographic findings suggestive of ovarian torsion: Unilateral ovarian enlargement Ovarian edema – hyperechogenic ovary with echogenic stroma Peripherally displaced follicles Free fluid Coiled vascular pedicle "whirlpool sign" If the ovary is normal sized on ultrasound, it is unlikely to be twisted, although it is possible for torsion to occur with a normal-appearing ovary or fallopian tube.

Answer 164

When laparoscopy is performed during pregnancy, regardless of gestational age, the patient needs to be in the left lateral recumbent position to prevent uterine compression on the IVC. Laparoscopy during pregnancy has been proven safe through a number of retrospective studies. It is safe in all trimesters but is preferred during the second trimester because the first trimester is associated with increased risks of pregnancy loss and spontaneous abortion and the third trimester is associated with increased risk of preterm labor. Regardless of the gestational age at which surgery is performed, the positioning—left lateral recumbent—is the same because the uterus is displaced in order to prevent compression of the vena cava and venous return.

Answer 165

Abdominal entry with an open, Hasson, technique is associated with lower risk of vascular injury. While this is generally thought to be the case, there are no randomized controlled trials to evaluate this. There is no statistical difference in bowel injury rates. Laparoscopic Entry Technique Risk of Vascular Injury Open (Hasson) 0% Closed (Veress) 0.44% Therefore, of all of the answer choices, decreased risk of vascular injury is the most appropriate answer.

Answer 166

Leiomyomas (fibroids) can be located in various places. Their location will determine the method of treatment. Type 1 fibroids are submucosal with less than 50% of the fibroid being located in the uterine cavity. Type 0 fibroids are pedunculated (intracavitary). Type 0 and type 1 fibroids can be removed via hysteroscopy. A laparoscopic myomectomy is more appropriate for type 2–7 fibroids, as they are more easily accessible from the abdominal cavity.

Answer 167

Intravenous administration of estrogen is an appropriate initial medical management option that is the only FDA-approved treatment for acute abnormal uterine bleeding. This works well particularly in the pediatric population, and is extremely efficacious at halting the continuous flow. Studies have shown that oral therapy is, also, an efficacious therapy. The estrogen works by rapidly causing proliferation of the endometrium to prevent shedding and works on most forms of dysfunctional uterine bleeding. Caution is advised with estrogen use in older women. Although it still may be efficacious, there is a higher chance of thromboembolism as women age, and particularly if there are other risk factors (e.g., smoking).

Answer 168

Once the diagnosis is made, the bladder must be drained via Foley catheter for 4 weeks for resolution of symptoms. Occasionally, this may result in healing of the fistula. If the fistula is still present then surgery must be performed. Most vesicovaginal fistulas can be closed transvaginally and the technique most commonly used for simple fistulas is called the Latzko technique. This surgical technique involves cannulating the vesicovaginal fistula with a lacrimal duct probe, small feeding tube, or pediatric Foley catheter to help the surgeon pull the involved area of vagina toward the introitus to facilitate vaginal dissection. The vaginal epithelium is incised around the fistula. Vaginal epithelial flaps are then raised and removed in a circle with a diameter of 2–3 cm around the fistula tract. Two layers of 2-0 or 3-0 absorbable sutures are placed in a transverse interrupted fashion to close the defect without tension. However, surgical repair of a vesicovaginal fistula should be delayed 6–12 weeks after the gynecologic surgery to allow granulation tissue to dissipate. During this waiting period, catheterization of the bladder may decrease symptoms.

Answer 169

The first half of the menstrual cycle is the proliferative phase, where endometrial epithelial and stromal cells divide under the influence of estrogen. The second half is the progesterone-dependent secretory phase, characterized by hypertrophy of uterine glands and decidualization of stromal cells. After ovulation occurs, the secretory phase is initiated by the production of large amounts of progesterone by the corpus luteum, leading to increasingly elongated glands and abundant spiral arterioles. Answer A: Atrophic endometrium is typically seen in postmenopausal women or in those who do not have proper hormonal stimulation of the endometrium. Answer B: Dyssynchronous endometrium would be expected on the pathology report of an individual who has irregular shedding of the endometrium secondary to unopposed estrogen or as a result of anovulation. Answer C: Hyperplastic endometrium is an abnormal finding on an endometrial biopsy and is a precursor lesion to endometrial cancer.

Answer 170

The endometrium goes through cyclical changes throughout the menstrual cycle, beginning with preparing for possible implantation from an embryo and ending with sloughing of the lining when no embryo is received. The appearance of the endometrium is also demonstrable on transvaginal ultrasonography; using average thicknesses, a rough estimate about timing of the menstrual cycle can be made. In general, the endometrial thickness increases most dramatically during the follicular period because of estrogen secretion from the dominant follicle. The luteal phase is marked by continued growth, but at a slower rate, and proliferation of secretory glands that prepare the surface for the pending embryo. Finally, when progesterone supplementation from the corpus luteum is not rescued by an embryo, the lack of progesterone causes sloughing of the endometrium, and the cycle starts anew the next month. The endometrium is thickest at the time of ovulation (highest estrogen content), and the presence of an adnexal cyst most likely confirms a corpus luteum. The patient has 28- to 30-day cycles, meaning she ovulates on day 14–16; thus, day 20 would be firmly in the luteal phase of the menstrual cycle. You would therefore expect to see a thickened endometrium with the presence of a corpus luteum.

Answer 171

Ultrasound is the inital imaging study of choice for patients with suspected ovarian torsion. Ultrasound findings that are suggestive of ovarian torsion include all of the following: an enlarged ovary compared to the contralateral ovary, an ovarian mass, heterogeneous appearance of the ovarian stroma, abnormal ovarian location, and decreased or diminished Doppler flow within the ovary. echogenic finding would be peripheral not central due to displaced follicles from edematous changes

Answer 172

An IUD can become malpositioned in the uterus and lead to pain and irregular bleeding. This can present as an IUD embedded in the myometrium, protruding through the serosa, partially expelled through the cervix, or rotated on its axis. If the IUD is not positioned correctly, there is concern for contraceptive failure, as well as organ perforation so it must be removed when recognized. Answer A: Actinomyces noted on Pap smear cytology is a common finding in approximately 7% of patients. It generally requires no treatment. Answer B: It is not necessarily the patient's IUD causing the fever. Answer C: A history of gonorrhea is not a contraindication to IUD insertion. Answer D: Pelvic inflammatory disease may be treated with antibiotics and the IUD can remain in place.

Answer 173

An IUD can become malpositioned in the uterus and lead to pain and irregular bleeding. This can present as an IUD embedded in the myometrium, protruding through the serosa, partially expelled through the cervix, or rotated on its axis. If the IUD is not positioned correctly, there is concern for contraceptive failure, as well as organ perforation so it must be removed when recognized. Answer A: Actinomyces noted on Pap smear cytology is a common finding in approximately 7% of patients. It generally requires no treatment. Answer B: It is not necessarily the patient's IUD causing the fever. Answer C: A history of gonorrhea is not a contraindication to IUD insertion. Answer D: Pelvic inflammatory disease may be treated with antibiotics and the IUD can remain in place.

Answer 174

Abnormal uterine bleeding (AUB) may be acute or chronic and is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the absence of pregnancy. Acute AUB refers to an episode of heavy bleeding that, in the opinion of the clinician, is of sufficient quantity to require immediate intervention. Hormonal management is considered the first-line of medical therapy for patients with acute AUB without known or suspected bleeding disorders. Treatment options include IV conjugated equine estrogen, combined oral contraceptives (OCs), and oral progestins. Antifibrinolytic drugs, such as tranexamic acid, are also a considered treatment option. Tranexamic acid works by preventing fibrin degradation.

Answer 175

Elderly patients who have limited functional capacity are at higher risk of significant postoperative morbidity, as the deconditioned patient has little reserve to recover from the stress of surgery. This places the patient at risk for poor health outcomes, falls, decreased mobility, prolonged hospitalization, and death. When considering surgery on a geriatric patient, it is important to assess the patient's preoperative functional status. Functional status can be estimated in the office by evaluating the following: Components of functional status Nutritional status, eating, feeding Continence Transferring Dressing Bathing A proper assessment of functional status can assist pre- and postoperative planning. Some patients may benefit from rehabilitation, improved nutrition, or physical therapy.

Answer 176

Endometriosis is a common cause of pelvic pain and can lead to infertility. The mechanism of infertility is not specifically known, but endometriosis can damage the fallopian tubes and cause unfavorable inflammatory environment in the pelvis that can hinder sperm function. Removal of endometriomas has been found to increase fertility rates. Pregnancy Rate Endometrioma excision 60.9% Endometrioma drainage and ablation 23.4% Surgical management of endometriosis can improve pregnancy rates dramatically. Excision of an endometrioma results in a pregnancy rate of 60.9%, whereas drainage and ablation of an endometrioma results in a pregnancy rate of 23.4%.

Answer 177

If the strings are not seen protruding from the cervical os, a pelvic US should be performed. If the IUD is not seen in the uterus on US, an X-ray of the abdomen and pelvis should be obtained. If imaging reveals that the IUD has perforated the uterus, the patient should undergo laparoscopic removal.

Answer 178

Using the single-dose protocol, a decline ≥15% on days 4 to 7 is considered a success. Beta-hCG values can then be followed weekly, and as long as there is at least a 15% decline, surveillance can be continued. If there is < 15% decline, the dose can be repeated. An important point is that treatment day 1 is considered day 1, which is a common misunderstanding for some residents. Beta-hCG levels should rise between days 1 and 4, rather than decline. This is due to the rupture of ectopic syncytiotrophoblasts and the hCG they contain. This should be expected and should not alert the physician to failure of treatment unless the levels between days 4 and 7 do not decline as expected. The dosage of leucovorin, a folic acid analogue given on non-methotrexate treatment days in the multidose protocol, is 0.1 mg/kg rather than 1.0 mg/kg.

Answer 179

Excision of endometriomas 3 cm or larger is recommended to improve fertility.

Answer 180

thin-walled cyst with fibrin strands and low-level echoes.

Answer 181

The appropriate work-up for a thickened endometrial stripe in an asymptomatic postmenopausal woman is not well-defined. According to the American College of Obstetrics and Gynecology, an endometrial stripe of 4 millimeters or less can be considered normal, but the significance of the presence of an endometrial stripe greater than 4 millimeters in a postmenopausal woman without vaginal bleeding has not been established, and may not necessitate further evaluation. Each woman’s risk factors should be evaluated individually to determine the appropriate evaluation. In this patient with no significant medical or family history, routine gynecologic care is acceptable.

Answer 182

A hypoechoic, thin-walled cyst is a simple cyst. These types of cysts are very likely to be benign in any age group and resolve spontaneously. Expectant management is an option in patients with benign adnexal masses such as simple ovarian cysts. However, if there is any suspicion for malignancy or if the adnexal mass is causing symptoms, surgical intervention is warranted. Endometriomas and hydrosalpinges can cause issues with fertility and surgical intervention is indicated in those instances. Characteristics suspicious for malignant ovarian masses include: wall thickening or septations measuring > 3 mm in width papillary excrescences solid components. This patient likely has a simple cyst with minimal symptoms, and desires to maintain fertility. Simple cysts usually resolve spontaneously. Surgical intervention is only recommended if the patient is symptomatic or if the cyst is greater than 10 cm. Gynecologic oncology referral is not warranted unless there is suspicion for malignancy. Fertility preservation should be paramount in adolescent patients and premenopausal patients who have not completed childbearing. Observation with repeat ultrasound in 6 months is the treatment of choice for asymptomatic simple cysts and benign-appearing masses measuring up to 10 cm because there is < 1% chance of malignancy, even in postmenopausal women.

Answer 183

The yolk sac is a concentric structure that definitively identifies the location of the pregnancy, and its location in the endometrial cavity confirms an intrauterine pregnancy. This sonographically appears after the double decidual sign. The double decidual sign is defined as 2 concentric echogenic rings surrounding the gestational sac and usually appears around 4–5 weeks; however, it is not the most reliable as it can be confused with a pseudogestational sac.

Answer 184

Long-acting reversible contraception is considered first-line contraception therapy for adolescents. ACOG recommends that adolescents have access to all contraceptive methods that are approved by the FDA. Ultimately, patient choice should be the principal factor when prescribing contraception to adolescents. ACOG, CDC, and AAP all support the use of LARCs for adolescents given their high efficacy and good safety profile. Evidence shows that 82% of adolescents at risk of unintended pregnancy were using contraception, but only 59% used a highly effective method, including hormonal method or IUD. IUDs and contraceptive implant should be offered routinely to adolescents. The US MEC classifies IUDs in nulliparous women and adolescents (aged 20 years or younger) as Category 2 and the contraceptive implant as Category 1. Data suggest that LARC use by adolescents remains much lower than in other age groups, although discontinuation for dissatisfaction is no higher in this group than in others. In the Contraceptive CHOICE study, 62% of the 1,054 adolescents and young adults, aged 14–20 years, chose LARC; satisfaction and continuation rates were high. Use of LARC increased substantially in nulliparous women, from 2.1% in 2009 to 5.9% in 2012. Satisfaction and continuation of LARC methods are high among adolescents. Continuation at 12 months was 81% for LARC methods (75.6% for the copper IUD, 80.6% for the levonorgestrel IUD, 82.2% for the implant) compared with 44% for non-LARC methods (47.3% for DMPA, 46.7% for OCPs, 40.9% for the patch, 31.0% for the ring) among 15–19 year olds. Concerns with difficulty in placement of IUDs appears to limit providers' willingness to offer IUDs to nulliparous and adolescent women. Evidence shows high success rates in placement of IUDs during the first attempt, at 95.5%. Uterine perforation rate is no higher in adolescents than in adult women. There is some evidence to show that IUD expulsion rates are higher in adolescents than in older women, but this should not be a deterrent to placement in adolescents.

Answer 185

UTI is a frequent diagnosis made in women. The incidence may be stated as 0.5–0.7 per person-year. The most common causative agent is E. coli.

Answer 186

Screens and Tools to Detect Abuse BASE (Brief Abuse Screen for the Elderly) Validated tool to assess the risk of elder abuse EAI (Elder Assessment Instrument) To identify victims of elder abuse CTS (Conflict Tactics Scale) Validated tool to assess the risk of abuse CASE (Caregiver Abuse Screen) To identify abuse of older people by an informal caregiver

Answer 187

Tamoxifen is a selective estrogen receptor modulator (SERM) that has a pro-estrogenic effect on the endometrium leading to focal or diffuse thickening (hyperplasia or malignancy). Abnormal uterine bleeding associated with tamoxifen use is most often caused by endometrial polyps. Sonohysterogram helps in visualizing focal lesions as endometrial polyps or submucosal fibroids by outlining the endometrial cavity. The examination is typically scheduled early in the first 10 days of the menstrual cycle, as focal irregularities in the contour of the secretory endometrium may be mistaken for small polyps or focal areas of endometrial hyperplasia if done later in the menstrual cycle. Saline infusion sonohysterography better outlines the endometrial cavity and is of great value in outlining focal lesions such as endometrial polyps or submucosal fibroids. The examination is typically scheduled early in the first 10 days of the menstrual cycle. Sonohysterography is contraindicated in active pelvic inflammatory disease (PID). Abnormal uterine bleeding associated with tamoxifen use is mostly caused by endometrial polyps, which can be visualized by sonohysterogram.

Answer 188

Mirabegron is a β3 adrenergic receptor agonist used to treat overactive bladder. β3 adrenergic receptors facilitate relaxation of the detrusor muscle. Therefore, by stimulating this receptor, symptoms of overactive bladder are ameliorated. Overactive bladder (OAB) affects 16% of women and is characterized by urinary urgency with or without urinary incontinence and is manifested by increased daytime frequency and nocturia. Increased excitability of the detrusor muscle leads to an exagerated response to stimuli and involuntary contractions. Overactive bladder can be diagnosed based on patient history and physical exam. A urinalysis should be performed to rule out infection. A voiding diary or urodynamic testing may assist in making the diagnosis of OAB. First line treatment involves behavior modification and lifestyle changes followed by pharmaceutical agents, and lastly, procedure-based interventions.

Answer 189

For pituitary adenomas, a lactotroph macroadenoma is a lesion that is 1 cm or greater in diameter and arises from the anterior pituitary with an increase in serum prolactin above the normal range. A lactotroph microadenoma is a lesion that is less than 1 cm in diameter arising from the anterior pituitary with an increase in serum prolactin above the normal range.

Answer 190

Most cases of A. israelii have been described in women with an IUD in place for an average of 8 years. It has been implicated in the development of pelvic inflammatory disease (PID), but incidentally diagnosing the bacteria on a Papanicolaou smear in an asymptomatic woman is not grounds for removal. The IUD should be removed and antibiotics given only when the patient is symptomatic.

Answer 191

Most cases of A. israelii have been described in women with an IUD in place for an average of 8 years. It has been implicated in the development of pelvic inflammatory disease (PID), but incidentally diagnosing the bacteria on a Papanicolaou smear in an asymptomatic woman is not grounds for removal. The IUD should be removed and antibiotics given only when the patient is symptomatic.

Answer 192

DSM-V defines the criteria for female sexual dysfunction. The following are recognized as female sexual dysfunctions: female sexual interest/arousal disorder female orgasmic disorder genito-pelvic pain/penetration disorder substance/medication-induced sexual dysfunction other specified sexual dysfunction other unspecified sexual dysfunction DSM-V Criteria for Female Orgasmic Disorder Symptoms present for a minimum of 6 months Marked delay in, marked infrequency of, or absence of orgasm OR markedly reduced intensity of orgasmic sensations in almost all occasions of sexual activity Cause clinically significant distress

Answer 193

Group A beta-hemolytic Streptococcus (GAS) is the most common infectious agent found in prepubertal females. GAS is found in 7% to 20% of pediatric girls with vulvovaginitis and is treated with amoxicillin 40 mg/kg TID for 10 days. Infectious vulvovaginitis often presents with a malodorous, yellow or green purulent discharge and vaginal cultures are routinely obtained. Children may transmit respiratory flora from the nose and oral pharynx to the vulva. These respiratory pathogens include: GAS (Streptococcus pyogenes), Staphylococcus aureus, Haemophilus influenzae, Streptococcus pneumoniae, Neisseria meningitidis, and Moraxella catarrhalis. Infectious Causes of Vulvovaginitis in Prepubertal Females Organism Incidence Group A beta-hemolytic Streptococcus 20% Candida 3–4% Gardnerella vaginalis 4.2% Neisseria gonorrhoeae Rare

Answer 194

The appropriate age to start vaccinations to prevent meningococcal disease is 11–12 years old. A booster dose is required at the age of 16–18 years during the ages when adolescents are at highest risk of meningococcal disease. Children with coexisting conditions that result in immunosuppression, such as asplenia or HIV, can receive the vaccine earlier.

Answer 195

Blood Pressure Category Systolic Diastolic Normal < 120 < 80 Elevated 120–129 < 80 Stage 1 130–139 80–90 Stage 2 >140 >90 Blood pressure levels need to be reproducible in order to diagnose a patient with hypertension. Causes for secondary hypertension should be evaluated in patients who are resistant to treatment or were diagnosed with hypertension at a young age.

Answer 196

1) He or she has a WPI (widespread pain index score) ≥7 and symptom severity scale (SS) score ≥5 or a WPI 3 to 6 and SS score ≥9 2) Symptoms have been present for at least 3 months 3) He or she does not have a disorder that would otherwise explain the pain A patient with pain in both upper and lower arms, shoulders, chest, and abdomen and SS score of 9 has a WPI of 7 and therefore meets the diagnostic criteria. Symptom areas include: Neck Left jaw Right jaw Left shoulder Right shoulder Left upper arm Right upper arm Left lower arm Right lower arm Chest Abdomen Upper back Lower back Left buttock Right buttock Upper left leg Lower left leg Upper right leg Lower right leg These are added up to get a widespread pain index (WPI) score. Symptoms are then scaled and added up: 0 no problem 1 mild or intermittent 2 moderate, often present 3 severe, constant

Answer 197

In general, Actinomyces is a rare infection. However, about 7% of asymptomatic women with an intrauterine device may have Actinomyces found on cytology. An incidental finding of Actinomyces on cytology does not need to be treated if there are no symptoms of pelvic inflammatory disease. The IUD can be left in place and no antibiotics are warranted. If pelvic actinomycosis were to occur, it is characterized by granulomatous pelvic abscesses. The prevalence of pelvic actinomycosis is estimated to be less than 0.001%.

Answer 198

There are many potential methods for discontinuation of drug use. One of the more controversial topics recently is the notable improvement in compliance noticed with incentive-based rehabilitation therapy. Also useful is the tracking of these patients with drug testing, which has been demonstrated with nicotine. Behavioral support has been shown to be beneficial in treating substance abuse and has been noted as useful in tobacco cessation when treating prior drug users. Answer A: Behavioral support has been found to significantly improve compliance with substance abuse. Tobacco cessation is improved with these methods. Answer C: Financial incentives to patients actually provides significant cost savings to the government and to the patient if utilized adequately and, despite the dislike of this idea by others, it may be a future direction for substance abuse. Answer D: Immediate gratification offers great potential in cessation programs, creating improved reliability for patients undergoing treatment. Answer E: Drugs have different levels of addictiveness. Cocaine and heroin are cited as two of the more addictive ones.

Answer 199

Exercise is an important component of weight loss, weight maintenance, and overall health maintenance. The CDC recommends that people exercise at a vigorous rate for a total of 75 minutes per week, or at a moderate rate for 150 minutes per week. CDC Recommendations According to Exercise Type and Duration Vigorous exercise (75 mins per week) Jogging/Running Swimming laps Roller boarding Most competitive sports Jumping rope Moderate exercise (150 mins per week) Walking (15-minute mile) Yard work Shovelling snow Actively playing with children Biking at a casual pace The best answer is jogging (10-minute mile) for 30 minutes, 3 times per week, as this is vigorous exercise for a total of 90 minutes, which is higher than the 75 minutes recommended.

Answer 200

Women who present with concerning nipple discharge should certainly have an ultrasound performed. Women over the age of 30 should also have a mammogram performed. Any intraductal findings on imaging should be further evaluated with biopsy. Additionally, if the discharge is bloody or uniductal, regardless of imaging results, the patient should be referred to a surgeon for further evaluation, which may include galactography or ductoscopy. Pathologic nipple discharge characteristics uniductal unilateral nipple expressed without manipulation (spontaneous discharge) persistent associated with a mass or skin changes bloody in color Characteristics of nipple discharge that are less concerning for intrinsic disease of the breast bilaterality multiductal non-spontaneous milky or green color

Answer 201

indicative of galactorrhea and is usually multiductal and bilateral. In premenopausal women, pregnancy should first be ruled out. Galactorrhea is not a disease intrinsic to the breast; however, it cannot be considered completely harmless since it is caused by hyperprolactinemia, which is seen in a number of health issues; these include hypothyroidism and prolactin-secreting tumors. Additionally, medications that inhibit dopamine can cause hyperprolactinemia. Poor fitting brassieres that cause chronic breast stimulation can also be to blame.

Answer 202

All patients who experience a sexual assault should be offered prophylaxis for sexually transmitted infections (STIs). The CDC recommends treatment for gonorrhea, chlamydia, hepatitis B, and trichomonas as outlined in the table below. CDC Recommendations for STI Prophylactic Treatment Pathogen Treatment (prophylaxis) Chlamydia Doxycycline 100 mg PO BiD for 7 days OR azithromycin 1 g PO Gonorrhea Ceftriaxone 500 mg IM for weight <150 kg OR 1000 mg for wight >150 kg Trichomoniasis Metronidazole 2 g PO Hepatitis B Initiate hepatitis B vaccine series (1st dose at presentation) HIV postexposure prophylaxis is recommended if the assailant is known to be HIV positive, and other prophylaxis depends on the individual situation for each patient.

Answer 203

Cardiovascular conditions are the leading cause of pregnancy-related deaths in the U.S. Cardiovascular disease affects approximately 1–4% of the nearly 4 million pregnancies in the United States each year. This rising trend in maternal deaths related to cardiovascular disease appears to be due to acquired heart disease. Cardiovascular diseases constitute 15.3% of U.S. pregnancy-related deaths. Per ACOG PB 212, in the United States disease and dysfunction of the heart and vascular system, collectively referred to as “cardiovascular disease”, is now the leading cause of death in pregnant women and women in the postpartum period. Cardiovascular disease accounts for 4.23 deaths per 100,000 live births. In fact, some of the most recent data indicate that the number of pregnancy-related deaths secondary to cardiovascular diseases is even higher, up to 26.5% of U.S. pregnancy-related deaths.

Answer 204

Bottom Line: Lichen planus can have cutaneous, oral, and vulvovaginal manifestations. Although lichen planus is only found in 1% of the population, oral lichen planus coexists with vulvovaginal lichen planus 20–25% of the time. TrueLearn Insight: Remember that lichen Planus is characterized by Pruritic Purple Polygonal Papules. This can help distinguish it from lichen sclerosus and lichen simplex chronicus.

Answer 205

Bottom Line: Lichen planus can have cutaneous, oral, and vulvovaginal manifestations. Although lichen planus is only found in 1% of the population, oral lichen planus coexists with vulvovaginal lichen planus 20–25% of the time. TrueLearn Insight: Remember that lichen Planus is characterized by Pruritic Purple Polygonal Papules. This can help distinguish it from lichen sclerosus and lichen simplex chronicus.

Answer 206

Leuprorelin (Lupron) is a common therapy for endometriosis. Prolonged use (i.e., greater than 6 months) can lead to GnRH-associated bone loss. Add-back therapy offers the benefit of stopping bone loss while not reducing the efficacy of the medication in the treatment of endometriosis-related pain. Norethindrone 5 mg each day is an FDA-approved medication for add-back therapy in patients taking leuprorelin for more than 6 months

Answer 207

Perinatal depression includes both major and minor depressive episodes that occur during pregnancy or the first 12 months postpartum. It is extremely common and affects approximately 1 in 7 women (14.3%).

Answer 208

Hereditary syndromes, in particular BRCA germline mutations, make up approximately 10% of ovarian cancers that are diagnosed but only 3–5% of breast cancer. BRCA1 is found on chromosome 17 and BRCA2 on chromosome 13. The lifetime risk of ovarian cancer is 39–46% with BRCA1.Hereditary syndromes, in particular BRCA germline mutations, make up approximately 10% of ovarian cancers that are diagnosed but only 3–5% of breast cancer. BRCA1 is found on chromosome 17 and BRCA2 on chromosome 13. The lifetime risk of ovarian cancer is 39–46% with BRCA1. risk associated with BRCA2 (12–20%).

Answer 209

Calcium and Vitamin D are important for the development of bones. A deficiency in calcium can lead to osteoporosis, whereas a deficiency in vitamin D can result in softer bone that is poorly mineralized. This poorly mineralized bone develops into rickets in children and osteomalacia in adults. For this reason, the Institution of Medicine has issued recommendations for individuals starting at age 9 regarding the daily amount of calcium (mg/day) and vitamin D (international units/day). As you age, you need less calcium in your diet and more vitamin D. The Institution of Medicine's Recommendations for Daily Intake of Calcium and Vitamin D Age Calcium Allowance (Recommended Dietary) Vitamin D (Recommended Dietary) 9–18 1,300 mg/day 600 IU/day 19–50 1,000 mg/day 600 IU/day 51–70 1,200 mg/day 600 IU/day 71+ 1,200 mg/day 800 IU/day

Answer 210

Nabothian cysts, also known as epithelial inclusion cysts, are benign cervical lesions that are often smooth, clear, and white or yellow in appearance. They may also have small, branching blood vessels that course over the lesion. These cysts occur during squamous metaplasia, when squamous epithelium covers over glandular, columnar cells; mucoid material from these glandular cells continues to accumulate beneath the squamous cells, leading to the appearance of a cyst. Asymptomatic nabothian cysts typically require no therapy but do have the potential to grow. Large nabothian cysts can cause vaginal fullness or pain. At times, these cysts can be obstructive, making Pap testing or cervical examination difficult. Treatment typically consists of ablation with electrocautery or excision.

Answer 211

Nabothian cysts, also known as epithelial inclusion cysts, are benign cervical lesions that are often smooth, clear, and white or yellow in appearance. They may also have small, branching blood vessels that course over the lesion. These cysts occur during squamous metaplasia, when squamous epithelium covers over glandular, columnar cells; mucoid material from these glandular cells continues to accumulate beneath the squamous cells, leading to the appearance of a cyst. Asymptomatic nabothian cysts typically require no therapy but do have the potential to grow. Large nabothian cysts can cause vaginal fullness or pain. At times, these cysts can be obstructive, making Pap testing or cervical examination difficult. Treatment typically consists of ablation with electrocautery or excision.

Answer 212

This patient presents with a palpable mass for the past 6 months. The basic differential for this presentation includes cyst, benign solid mass, and a malignancy. This patient's presentation, in the context of her age, is most consistent with a benign cyst, which is classically characterized as: smooth, firm, and sometimes tender with sharp borders. Cysts can also present as ill-defined masses with various textures. Ultimately, physical exam cannot distinguish a benign cyst from more worrisome pathology. In this age group (less than 30), the best next step in management is to perform an ultrasound. A woman who is less than 30 years old and presents with a palpable breast mass can be reasonably evaluated with ultrasound as the first step in management after you have performed a thorough history and physical (above she's observed already for 6 months). Observation is also reasonable for 1–2 menstrual cycles with a young patient who presents with a non-concerning mass (based on history and physical exam) that has been present for only a short time. Cysts can be further classified based on ultrasound appearance. Simple cysts are well-circumscribed and anechoic (do not have internal echoes), and do not have solid components or internal vascularization/Doppler flow. Posterior wall enhancement is seen with simple cysts. These simple cysts can either be watched or aspirated if symptomatic. Complex cysts have thick walls and/or septa. Additionally, they may have solid components and do not have posterior wall enhancement. Complicated cysts do not have solid components, thick walls, thick septa, or vascular flow; however, they do have internal echoes due to debris within the cyst. The treatment for complex or complicated cyst is based on its etiology. The basic differential for a complex or complicated cyst includes: abscess hematoma fat necrosis galactocele duct ectasia malignancy

Answer 213

Answer A: Core needle biopsy is a method of acquiring specimen for histologic evaluation. A large-bore (12–16 gauge) needle is used. Palpation or imaging assists the practitioner in placement of the needle in order to sample the lesion. When performing a core needle biopsy, the physician is also able to place a clip by the lesion in order to mark it—this can be helpful in the case of repeat imaging or if further surgery is needed. With the patient above, core needle biopsy may eventually be needed but is not the best next step. Answer B: Fine needle aspiration (FNA) allows for cytologic evaluation. Fine needle aspiration uses a small-bore needle (21–25 gauge). Disadvantages to FNA include: 1) it requires that the pathologist has extensive experience in interpretation of such a specimen; 2) a significant number of specimens will result as "non-diagnostic"; 3) the procedure has a relatively high false negative rate; 4) given that FNA provides a cytologic specimen, it cannot definitely distinguish between in situ and invasive cancer. Some practitioners may argue that an attempt at cyst aspiration is a reasonable first step in management if one suspects a breast cyst; after all, if aspiration yields a fluid that is not bloody and the mass disappears, the fluid may be discarded without need for pathologic evaluation and the issue may be resolved. However, the American Congress of Obstetrics and Gynecology recommends imaging before aspiration. The rationale behind this approach may stem from the fact that it is difficult to distinguish a cystic lesion from a solid mass based on physical exam alone. Aspiration is an invasive procedure relative to ultrasound and in the case of a solid lesion, the sample obtained is often difficult to pathologically interpret, often requiring further evaluation (re-biopsy) with other approaches (such as core needle biopsy). Therefore, an evaluation of the lesion with imaging prior to an invasive procedure is arguably most appropriate.

Answer 214

Due to the increased density of the breast, mammogram is generally less useful for evaluation of breast masses in women less than 30 years old. If the patient had presented at the age of 30 or older, the best next step in management would have been to obtain a diagnostic mammogram with ultrasound to follow (it is also reasonable to order the ultrasound and mammogram at the same time).

Answer 215

The muscles that comprise the levator ani group (pubococcygeus, iliococcygeus, and puborectalis), and possibly others muscles, are likely involved in vaginismus. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), vaginismus is listed as a "genito-pelvic pain/penetration disorder". Traditionally, vaginismus has referred to involuntary contraction of the muscles of the pelvic floor surrounding the vaginal orifice. However, there is no consensus on exactly which muscles are involved in vaginismus and studies that name specific muscle groups as the source of spasm do not describe the method used to arrive at their conclusions. Furthermore, evidence of electromyography (EMG) studies does not definitively support muscle spasms as the etiology of vaginismus.

Answer 216

Vasomotor symptoms are a bothersome component of the postmenopausal changes experienced by women. They can persist for up to 10 years without any relief. Hormonal therapy is an option for managment. Progesterone must be given in conjunction with estrogen in women with an intact uterus. The risk of endometrial hyperplasia increases in women who are placed on unopposed estrogen therapy. Progesterone alone is not indicated for first-line treatment of vasomotor symptoms. Progesterone alone may improve vasomotor symptoms but there are limited data on the safely of progestin alone and in the WHI study there was an increased risk of breast cancer in the progesterone-plus-estrogen arm but not in the estrogen-alone arm.

Answer 217

High-level disinfection is required with vaginal probes, and 70% alcohol or soaking it for 2 minutes in 500 ppm chlorine is an example of a high-level disinfectant. The CDC has approved several different measures for cleaning vaginal probes between uses. They recommend condoms or probe covers for each use, but failure rates have been reported as high as 65–81% and therefore cleaning with high-level disinfectant is important. Cleaning in between is imperative for patient safety. Recommended Regimen for Cleaning Vaginal Probes Wipe gel from the probe Rinse probe with soap and water Soak probe for 2 minutes in 500 ppm chlorine Rinse again Air dry

Answer 218

According to data collected for the National Health and Nutrition Examination Survey (NHANES), between 2017 and March 2020, the prevalence of obesity in adults in the United States is approximately 41.9%.

Answer 219

The biggest patient complaint after IUD placement is heavier, crampier periods the first year after placement. The most common side effects of Paragard use are dysmenorrhea as well as heavier, longer periods with spotting between periods. For most women, these side effects diminish after the first 2 to 3 months. If switching from a hormonal birth control method, periods may seem heavier. Although menstrual blood loss has been noted to increase in copper intrauterine device (IUD) users, the reported decrease in hemoglobin concentration is between 0.36 and 0.94 g/dL over a 12-month period. Nonsteroidal anti-inflammatory medications have been shown to improve the amount of bleeding and cramping in these patients. The copper T380A IUD is a T-shaped device of polyethylene wrapped with copper wire around the stem and arms. Studies indicate that the copper IUD exerts its contraceptive effects primarily by preventing fertilization through inhibition of sperm migration and viability. The U.S. Food and Drug Administration (FDA) has approved use of the copper IUD for up to 10 continuous years, during which time it remains highly effective. It has a reported failure rate at 1 year of 0.8 per 100 women, and a 10-year failure rate comparable with that of female sterilization (1.9 per 100 women over 10 years). Side Effects and Complications of Paragard IUD Placement dysmenorrhea menorrhagia intermenstrual bleeding expulsion perforation failure resulting in pregnancy pelvic inflammatory disease difficult removal

Answer 220

A foreign body is a common cause of acute and chronic recurrent vulvovaginitis and manifests clinically as vaginal discharge, intermittent bleeding or spotting, and/or a foul smelling odor. The most common foreign body that is found is toilet paper, but can also be hair bands, small toys, batteries, etc. The foreign body should be removed which can be accomplished with a swab or irrigation of warm water. It is recommended to apply topical anesthetic agent to the introitus such as viscous xylocaine jelly. Examination under sedation and/or anesthesia may be necessary for extraction of larger foreign bodies and those that cannot be removed with irrigation. Of note, if the patient has pain and a gray watery discharge, an intravaginal battery should be suspected, and emergency removal under general anesthesia is warranted. After removal, the vaginal mucosa should be carefully inspected by vaginoscopy to determine the depth of the burn. Depending upon the depth of the burn, assessment of the bladder or rectal mucosa may also be indicated.

Answer 221

The diagnosis of adenomyosis is made after histologic confirmation of endometrial glands and stroma that are noted to extend into the myometrium, usually on pathologic review of a uterine specimen after hysterectomy. The most common symptoms of adenomyosis include heavy menstrual bleeding and dysmenorrhea. Imaging may be helpful in evaluation for adenomyosis. Ultrasound imaging may demonstrate an enlarged uterus where the posterior wall is thicker than the anterior wall, and multiple bands of alternating bright and dark echoes.

Answer 222

Even in the absence of other risk factors, women who are known to be homozygous for the factor V Leiden mutation or prothrombin gene mutation should receive pharmacologic prophylaxis during pregnancy and the postpartum period, given the high risk of VTE. Current ACOG recommendations regarding thromboprophylaxis for pregnancies complicated by inherited thrombophilias state that low-risk thrombophilias without previous personal history of VTE do NOT require anticoagulation during pregnancy and the postpartum period. All the answer choices listed above are low-risk thrombophilias except for homozygous factor V Leiden mutation. Low-risk thrombophilias without previous VTE: factor V Leiden heterozygous prothrombin G20210A heterozygous protein C deficiency protein S deficiency High-risk thrombophilias without previous VTE: factor V Leiden homozygous prothrombin G20210A homozygous heterozygous for factor V Leiden and prothrombin G20210A mutation antithrombin deficiency The prevalence of the factor V Leiden mutation in European populations is approximately 5%. The mutation renders factor V Leiden refractory to proteolysis by activated protein C. Women who are heterozygous for factor V Leiden have been observed to account for approximately 40% of cases of VTE during pregnancy. The treatment of factor V Leiden thrombophilia has not been shown to decrease the risk of continued recurrent miscarriages. There are inconsistent associations between any inherited thrombophilias and recurrent pregnancy loss or stillbirth. A Cochrane review also concluded that there is insufficient evidence to support the use of anticoagulants (aspirin or low-molecular-weight heparin) in women with recurrent pregnancy loss and an inherited thrombophilia.

Answer 223

More than one-half of all women will have a urinary tract infection (UTI) in their lifetime, and approximately 3%–5% will be diagnosed with "recurrent UTI," defined as ≥2 recurrences in 6 months or ≥3 in 1 year. There are three evidence-based interventions for recurrent UTI: 1. The MOST effective strategy to reduce the incidence of recurrences is prophylactic or intermittent antibiotics, which can reduce the risk by 95%. A culture must be obtained prior to prescribing prophylaxis. Below are options for prophylaxis based on antimicrobial sensitivities. Nitrofurantoin is considered first line based on expert opinion. 2. Proven therapies include hydration with an additional 1.5 L of water daily, which was proven to decrease cystitis occurences in a randomized clinical trial of premenopausal women with at least three UTIs in the past year. 3. Vaginal estrogen for postmenopausal women is proven in small randomized clinical trials to decrease the risk of recurrent UTI. There are varying formulations and dosing schedules that can be prescribed. One trial studied 0.5 mg estriol cream nightly for 2 weeks then twice weekly for 8 months.

Answer 224

Flibanserin is a serotonin receptor agonist/antagonist approved by the FDA as a treatment option for women with female sexual interest and arousal disorder. It can be prescribed to premenopausal women without depression suffering from hypoactive sexual desire. Women must also be counseled appropriately about the risks of concurrent alcohol use during treatment: Alcohol use during treatment leads to an increased risk of hypotension and syncope. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) outlines four classifications of female sexual dysfunction: female sexual interest/arousal disorder female orgasmic disorder genito-pelvic pain and penetration disorder substance/medication-induced sexual dysfunction

Answer 225

Transitional epithelium can be found lining the urinary bladder, ureters, superior aspect of the urethra, and gland ducts of the prostate. It is the layer of the bladder that is exposed to the lumen. Deep to this epithelium is the lamina propria, followed by the submucosa. The transitional epithelium, lamina propria, and submucosa collectively make up the mucosa. Deep to the mucosa is the detrusor muscle, followed by the adventitia, which contains the vessels that feed and drain the bladder.

Answer 226

The lifetime incidence of completed or attempted rape for women in the United States is roughly 1 in 5, or 19% per ACOG and the CDC. Forty-seven percent of sexual assault victims reported the perpetrator was a current or former intimate partner, and 45% reported the perpetrator was an acquaintance. One-third of sexual violence victims seek some sort of medical care as a result of the assault. Knowing the incidence of sexual assault and being aware of the prevalence may help the healthcare provider empower women and provide proper care and support. Knowledge of local laws will also help evaluate a sexual assault victim.

Answer 227

Hirsutism is defined as excessive male-pattern hair and facial and body hair that affects 5%–10% of reproductive-age women. The major circulating hormones in women (in descending order) are: DHEA-S DHEA androstenedione testosterone dihydrotestosterone (DHT) Evaluation of hirsutism includes measurement of total testosterone, DHEA-S, and 17-hydroxyprogesterone. DHEA-S is derived almost exclusively from the adrenal glands, and the upper limit of normal is typically 350 mcg/dL but can vary between laboratories. DHEA-S levels greater than 700 mcg/dL may indicate a rare androgen-secreting adrenal tumor such as an adrenal adenoma or carcinoma. An adrenal CT is the imaging study of choice due to excellent sensitivity and specificity in detecting these tumors. Answer A: Adrenocorticotropic hormone stimulation test would be an appropriate next step in the workup of a patient with an elevated 17-hydroxyprogesterone level and concern for nonclassic congenital adrenal hyperplasia (NCCAH). This test should be performed when the 17-hydroxyprogesterone level is between 200 and 800 ng/dL. An ACTH stimulation test is thus performed, and the 17-hydroxyprogesterone level is rechecked. If it is over 1500 ng/dL, NCCAH is diagnosed. Answer C: Observation is not an appropriate next step because her DHEA-S level is elevated above normal, which may signify a possible androgen-secreting adrenal tumor. Answer D: Evaluating for an adrenal adenoma is best accomplished by an adrenal CT. A pelvic MRI may be useful if evaluating for pelvic pathology, including malignancy or concern for ovarian masses if transvaginal ultrasonography is inconclusive; however, it is not the next best step when assessing adrenal pathology. Answer E: The gold-standard imaging modality for adrenal masses is an adrenal CT. Ultrasonography has unacceptably low sensitivity and specificity in this scenario.

Answer 228

This patient with pain with penetration has genito-pelvic pain and penetration disorder. Vaginismus and dyspareunia are now combined into genito–pelvic pain and penetration disorder. This disorder can be lifelong or acquired. Symptoms of Genito–Pelvic Pain and Penetration Disorder Tightening of the vaginal muscle with decreased ability or inability to accommodate penetration Tension, pain, or burning felt when penetration is attempted Decrease in or no desire to have intercourse; avoidance of sexual activity Intense phobia or fear of pain Symptoms must have persisted for at least 6 months and be distressing to the patient. Pelvic floor physical therapy is recommended for the treatment of genito–pelvic pain and penetration disorders to restore muscle function and decrease pain. Intravaginal prasterone, low-dose vaginal estrogen, and ospemifene can be used in postmenopausal women for the treatment of moderate-to-severe dyspareunia that is due to genitourinary syndrome of menopause. Lubricants, topical anesthesia, and moisturizers may help reduce or alleviate dyspareunia.

Answer 229

Distention fluid used in the expansion of the uterine cavity requires pressure between 45 and 80 mm Hg to be effective. Intrauterine pressure greater than 100 mm Hg increases the risk for intravasation of the distention medium because the average mean arterial pressure for an adult female is typically around 100 mm Hg. Once hypotonic fluid intravasates, it is metabolized and free water is left. This causes dilution of electrolytes that leads to hyponatremia, hypokalemia, etc. Dilution leads to respiratory depression and seizures.

Answer 230

The lifetime incidence of intimate partner violence for women in the United States is estimated at 22%–39%. Intimate partner violence can have several meanings, but it includes actual or threatened harm—psychological, physical, or sexual. It can occur among heterosexual or same-sex couples. The lifetime incidence of intimate partner violence for all women in the world is estimated at 69%.

Answer 231

The 5A's for smoking cessation: Ask, Advise, Assess, Assist, Arrange Cigarette smoking is the leading preventable cause of mortality. Smokers who quit smoking reduce their risk of developing and dying from tobacco-related diseases. There is a simple five-step algorithm called the “5 A’s” (Ask, Advise, Assess, Assist, Arrange) that can be implemented to aid with smoking cessation. Five "A's" for assessing for tobacco use and addressing smoking cessation: Ask: Discussing with the patient if they ever thought about quitting tobacco. This would involve asking every patient that is checked into the office their tobacco-use status and document it. This repeated assessment should be done at each visit. Advise: Tie tobacco use to current health/illness, and/or its social and economic costs, motivation level/readiness to quit, and/or the impact of tobacco use on children and others in the household. Discussing with the patient the benefits of tobacco cessation. Assess: Determine the patient's willingness to quit within the next 30 days. Assist: Providing aid for the patient to quit. Arrange: Schedule follow-up contact, either in person or by telephone. Follow-up contact should occur soon after the quit date, preferably during the first week. A second follow-up contact is recommended within the first month. Schedule further follow-up contacts as indicated. Congratulate success during each follow-up. If tobacco use has occurred, review circumstances and elicit recommitment to total abstinence. Remind the patient that a lapse can be used as a learning experience. Identify problems already encountered and anticipate challenges in the immediate future. Assess pharmacotherapy use and problems. Consider use or referral to more intensive treatment.

Answer 232

The most common type of kidney stone is composed of calcium oxalate, in roughly 70% of cases. Calcium phosphate stones are next, comprising approximately 10%. The calcium-based stones (80% of all stones) are the easiest to see on a non-contrast CT scan—the diagnostic image of choice in this setting. Uric acid stones tend to be more radiolucent and not easily imaged with the other imaging forms, such as abdominal X-ray.

Answer 233

Sexual assault affects one in eight women. Injuries sustained depend on the severity of the attack. The most common injuries associated with sexual assault are abrasions of the head, neck, and arms. Genital injuries accompanied with bleeding and pain also occur. Genital findings are erythema and small tears of the vulva, perineum, and introitus. If there was oral penetration, injuries to the mouth and pharynx, tearing of the frenulum, and broken teeth may be present. All areas penetrated should be thoroughly inspected and samples obtained.

Answer 234

Bartholin gland cysts are rare in postmenopausal women. There is a chance that this lesion could represent a carcinoma, and some pathology should be analyzed. However, the incidence of Bartholin gland carcinoma is still quite low—roughly 0.114 per 100,000 woman-years in postmenopausal women. A biopsy is therefore warranted to avoid a larger procedure. The detection rate from a biopsy seems to be sensitive. If the biopsy is concerning for carcinoma, a referral to gynecology oncology should be made.

Answer 235

In 5-alpha reductase deficiency, the internal structures (epididymis, seminal vesicles, ejaculatory ducts, and vas deferens) form normally, while the external genitalia, prostate, and urethra develop abnormally. When a patient has 5a-reductase deficiency, it is often diagnosed at birth. It is an autosomal recessive disorder with 46, XY karyotype. It is the result of impaired virilization during embryogenesis secondary to defective conversion of testosterone (T) to dihydrotestosterone (DHT). External structures are unable to virilize normally as they require the conversion of T to DHT to form. Classically, there is generally a fusion of the labial folds with or without clitoromegaly. There is usually normal male breast/chest development, helping to distinguish it from androgen insensitivity syndrome. The internal structures are stimulated by testosterone and generally develop normally. These include the epididymis, vas deferens, seminal vesicles, and ejaculatory ducts. External structures develop abnormally, including the external genitalia (penis, scrotum), urethra, and prostate.

Answer 236

Paroxetine is the only FDA-approved nonhormonal treatment for vasomotor symptoms Vasomotor symptoms are a bothersome component of the postmenopausal changes experienced by women. They can persist for up to 10 years without any relief. Hormonal therapy in the form of estrogen is usually indicated to manage these symptoms; however, not everyone is a candidate for hormonal therapy or they do not desire hormonal therapy. Paroxetine and venlafaxine are the best-studied nonhormonal drugs for the treatment of vasomotor symptoms, but the FDA has approved only the 7.5-mg dose of paroxetine for this purpose. Unlike with the larger doses used to treat psychiatric conditions, patients who wish to discontinue the use of paroxetine will not need to taper the dose. Other nonhormonal drugs such as methyldopa, gabapentin, and clonidine have performed successfully in research trials; however, because of the side effect profiles, they are not recommended as first-line treatments.

Answer 237

Lesbian and bisexual women face healthcare disparities that include but are not limited to concerns about confidentiality, discriminatory sentiments, restricted access to care and health insurance, and often an insufficient understanding of the health risks they face. It is the responsibility of the physician to make the office environment welcoming to such patients, to ensure that the best and most efficient healthcare is delivered. Examples of measures that can facilitate this include providing educational materials, making yourself available as a resource, and using neutral language during the history and physical examination. Although the subject of mental health remains a sensitive topic, physicians should include questions concerning it in their history and physical because women who identify as lesbian are more likely to admit to having depression and/or to taking antidepressants.

Answer 238

At approximately 8 weeks of gestation the progesterone production begins to shift from the corpus luteum to the placenta. When a corpus luteum, or ovary that was suspected to have the corpus luteum, is removed progesterone supplementation should continue until approximately 10 weeks. After 10 weeks the progesterone is made at the placental level and supplementation is no longer indicated. Without supplemental progesterone this pregnancy will likely abort. Progesterone supplementation is required to maintain an early pregnancy through 10 weeks when a corpus luteum has been removed. TrueLearn Insight: There are many different uses for progesterone in pregnancy. In the setting of luteal-phase deficiency or removal of a corpus luteum, progesterone supplementation should continue until the time the production of progesterone has shifted to the placenta, approximately 10 weeks. Progesterone supplementation is also used for the prevention of preterm birth in patients with a history of a prior spontaneous preterm birth. When progesterone is used for prevention of preterm birth it is given weekly from weeks 16–36.

Answer 239

the latest USPSTF recommendations 2021 advise that routine screening for all adults begin at age 45 years for colorectal cancer regardless of risk factors, as nearly 94% of all new colorectal cancer cases are occurring in adults 45 years and older. While rates of colorectal cancer are higher in Black adults, the age to begin routine screening is not younger than the general population.

Answer 240

The 1-year failure rate with typical use of the copper IUD is 0.8%. With perfect use, the failure rate in the first year is 0.6%. The copper IUD has the highest failure rate among long-acting reversible contraceptives. Although its 1-year failure rate is higher than that of female sterilization, the 10-year failure rate of the copper IUD is similar to that of female sterilization (1.9 per 100 women over 10 years). The 1-year failure rate for the copper intrauterine device is 0.8% with typical use. This is the highest failure rate among long-acting reversible contraceptives. nexplanon has the lowest failure rate short/long term 0.05%

Answer 241

Patients with alcoholism, chronic lung disease, chronic heart disease, and diabetes mellitus should receive the pneumococcal vaccination between the ages of 19 and 64 years. All other patients, including those with hypertension, should start receiving vaccinations at age 65 years.

Answer 242

A BRCA1 pathogenic variant increases the lifetime risk of breast, ovarian, fallopian tube, peritoneal, pancreatic, and prostate cancers above the baseline population risk -- simliar impact to BRCA2 except it also includes melanoma

Answer 243

For mild disease, nonpharmacologic measures such as education about fibromyalgia, review of sleep hygiene, exercise, and optimization of other medical conditions are the first steps. First-line pharmacotherapy includes amitriptyline, cyclobenzaprine, and certain SSRIs. Pregabalin is recommended for patients with more severe disease that is refractory to first-line nonpharmacologic and pharmacologic therapies.

Answer 244

Irregular cycles are not a hallmark symptom of adenomyosis and are often related to hormonal or ovulatory dysfunction, for example, polycystic ovarian syndrome (PCOS). Adenomyosis is diagnosed on histological review of uterine tissue after hysterectomy. The most common symptoms are heavy and painful menstrual cycles; however, one-third of women with adenomyosis are asymptomatic.

Answer 245

Cyclic mastalgia is a component of fibrocystic changes of the breast and can usually be controlled with oral contraceptive pills (OCPs) or supplemental progestins given during the secretory phase of the cycle. Severe symptoms, as evidenced in the patient above, are best treated with danazol (androgen), which inhibits the release of gonadotropins, leading to a hypoestrogenic, hyperandrogenic state. Danazol relieves symptoms in approximately 90% of patients, but it should not be continued for more than 6 months because of unwanted side effects (i.e., hirsutism). After failing a course of danazol, patients may attempt a course of bromocriptine or tamoxifen. Supplementation with alpha-linoleic acids and evening primrose oil have effects in some women with resistant disease (58% response). When all else fails, GnRH agonists (e.g., leuprolide acetate) may be used for short periods of time. Therapeutic Agents for Mastalgia NSAIDs Combined Hormonal Contraceptive Pills Danazol Bromocriptine Tamoxifen

Answer 246

severe form of premenstrual syndrome. Per DSM-5, five or more symptoms (physical plus behavioral) need to be present for the last week before menses and resolve in the first few days of start of menses, for most of the preceding year. Excluding hypo- or hyperthyroidism, drug use, mood disorders, or medications is important before diagnosis of PMDD. Premenstrual dysphoric disorder (PMDD) is a psychiatric disorder representing a severe form of premenstrual syndrome. It consists of the cyclic recurrence of severe changes in affect such as mood lability, irritability, dysphoria, and anxiety, that occur in the luteal phase of a woman's menstrual cycle 5 or more symptoms must be present during the week prior to menses, resolving within a few days after menses starts. The presence of hypo- or hyperthyroidism, underlying chronic psychiatric disorders, drug use, medications, or hormone treatment such as combined OCPs must be ruled out prior to documenting such a diagnosis. Cyclic symptoms must be present for most of the preceding year. These should be documented using a menstrual diary. Workup includes thyroid function tests, serum electrolytes, liver function tests, urine toxicology screen. Specific serotonin reuptake inhibitors such as sertraline can help relieve symptoms of PMDD.

Answer 247

Mastitis generally occurs after the third to fourth week postpartum. Infection is usually unilateral, and the patient may present with fever, chills, or tachycardia. Staphylococcus aureus is the most common agent and complicates 40% of cases. A culture should be drawn from the affected breast’s milk. Dicloxacillin may be started empirically. Breastfeeding should be continued. If nursing is difficult because of engorgement, pumping should be continued, as abscess formation has been reported to occur in women who stopped breastfeeding.

Answer 248

Answer A: Codeine has been known to cause galactorrhea because it inhibits dopamine release. Answer C: Methyldopa has been known to cause galactorrhea because it depletes dopamine. Answer D: Metoclopramide has been known to cause galactorrhea because it blocks dopamine receptors. Answer E: Risperidone has been known to cause galactorrhea because it blocks dopamine receptors.

Answer 249

The relative risk of developing pelvic inflammatory disease (PID) is increased with intrauterine device (IUD) placement, but the absolute risk of developing PID is <0.5%. Women with an undiagnosed sexually transmitted infection (STI) at the time of IUD insertion are more likely than women without an STI at the time of insertion to develop PID. However, even in women with an STI, the risk of developing PID is low. The greatest risk of IUD-associated PID occurs within the first few weeks to months after insertion, which suggests that bacterial contamination of the endometrial cavity at the time of IUD insertion, rather than the IUD itself, is the cause of PID.

Answer 250

Depression is a common disease in the United States. It is generally diagnosed through a series of questions. Patients often complain of sadness, hopelessness, guilt, moodiness, angry outbursts, and loss of interest. They may complain of difficulty concentrating, making decisions, or remembering things that they should know. If severe enough, it can lead to thoughts of harm to oneself or others, delusions, or hallucinations. Behavior is affected by withdrawing from people, substance abuse, missing time at work or school, or attempts to harm oneself. Finally, physical issues such as tiredness, unexplained aches/pains, changes in appetite and weight, or changes in sleep are possible. When depression is diagnosed, the type of treatment administered is based on the patient's preferences. Psychotherapy helps many patients improve their symptoms. Furthermore, lifestyle changes such as physical activity and stress-reduction exercises may help. Selective serotonin reuptake inhibitors (SSRIs) are generally considered the first-line medication for depression. SSRIs include those listed below, of which escitalopram is among the answer choices. Common SSRI Medications citalopram escitalopram fluoxetine paroxetine sertraline fluvoxamine

Answer 251

Dull/dense white epithelium is a high-grade finding on colposcopy when acetic acid is applied, while normal colposcopic epithelium appears shiny. The margins of these dull white areas may be rolled or peeled or may even have internal borders (a lesion within a lesion). The vessels noted are often coarse and/or dilated in high-grade or cancerous lesions. Colposcopy is a skill that takes time and experience to master. Although pathologic results are necessary for management, the clinician should be able to make an educated diagnosis on the grade of the lesion that is to be biopsied. Adequate visualization of the squamous columnar junction is necessary and sometimes requires the aid of an endocervical speculum. Knowing the grade of a lesion at the time of colposcopy may help determine whether additional procedures are needed at this time, and can help with counseling the patient on future management plans. Colposcopy is a skill that takes time and experience to master. Although pathologic results are necessary for management, the clinician should be able to make an educated diagnosis on the grade of the lesion that is to be biopsied. Adequate visualization of the squamous columnar junction is necessary and sometimes requires the aid of an endocervical speculum. Knowing the grade of a lesion at time of colposcopy may help determine whether additional procedures are needed at this time, as well as help with counseling the patient on future management plans.

Answer 252

Renal artery stenosis should be high on the differential diagnosis for any young, healthy patient with sudden-onset severe hypertension. Renal arteriography is the gold standard for diagnosis of renal artery stenosis. Duplex Doppler ultrasonography, computed tomographic angiography, and magnetic resonance angiography are alternative, less-invasive tests that are appropriate for initial testing. If results of noninvasive testing are inconclusive and/or suspicion for the diagnosis of renal artery stenosis is high, traditional renal arteriography should be performed.

Answer 253

During pregnancy, 16.3% of women admit to continued tobacco use; this percentage is thought to be an underestimate secondary to underreporting by patients. Smoking is the single most important modifiable risk factor associated with poor pregnancy outcomes. Tobacco is the most commonly abused substance among pregnant women; however, it is not uncommon to abuse alcohol, cocaine, marijuana, and opioids as well. During pregnancy, 16.3% of women report continued tobacco use, 10.8% report continued alcohol use, and 4.4% report illicit drug abuse.

Answer 254

The most appropriate age at which to begin osteoporosis screening is 65 years or when the patient is deemed to have the fracture risk of a 65-year-old patient. This can be calculated using the FRAX calculation tool. The risk at this age is approximately 1%. It should be repeated every 15 years if there are no other risk factors or treatments in place. Components of FRAX Score Age Sex Weight (kg) Height (cm) Previous fracture (yes/no) Parent with fractured hip (yes/no) Current smoking (yes/no) Glucocorticoid use (yes/no) Rheumatoid arthritis (yes/no) Secondary osteoporosis (yes/no) 3+ alcoholic drinks/day (yes/no) Femoral neck bone mineral density (BMD)

Answer 255

The classic presentation of a urethral diverticulum consists of the triad of postvoid dribbling, dysuria, and dyspareunia. A urethral diverticulum is a localized outpouching of the urethral mucosa into the surrounding non-urothelial tissues. Urethral diverticula are most often acquired and may result from vaginal, bladder, or urethral surgery or following a vaginal delivery. The diagnosis of urethral diverticulum is made with MRI or ultrasound +/- urethroscopy. Patients with bothersome symptoms may choose to undergo surgical management with a transvaginal diverticulectomy.

Answer 256

Condoms have been shown to be less prone to leakage than commercial use probe barriers. The rate of leakage with condoms is approximately 0.9%–2% versus commercial probe covers, which were noted in recent observational studies to leak 8%–81% of the time. Transvaginal probes should be covered with a single-use barrier, cleaned after use to remove any debris or visible soiling, and then properly sterilized with a high-level disinfectant after cleaning.

Answer 257

APS is a syndrome that has the potential to adversely affect women of reproductive age. Women with a history of recurrent miscarriages may be at risk for APS. If APS is present, they may benefit from treatment to prolong their pregnancy to viability. The recommended tests are all 3 of the tests mentioned above: IgG and IgM anti-β2-glycoprotein antibodies AND IgG and IgM anticardiolipin antibodies AND lupus anticoagulant. Additionally, there must be a positive result on at least 2 occasions, ≥12 weeks apart.

Answer 258

The etonogestrel implant, or Nexplanon, is the most effective birth control on the market. The estimated unintended pregnancy rate is 0.05 per 100 women in the first year of use. A number of variables should be considered when discussing birth control options. One of these variables is the unintended pregnancy rate, as estimated by typical use. Birth control options that require patients to either take a pill, use a barrier, or receive a dose every 3 months have a much higher unintended pregnancy rate than the reversible long-acting methods. A number of variables should be considered when discussing birth control options. One of these variables is the unintended pregnancy rate, as estimated by typical use. The most effective form of birth control available is the Nexplanon implant. The second-most effective female form of contraception is the progestin-containing IUD, followed by the copper IUD. Options that require patients to either take a pill, use a barrier, or receive a dose every 3 months have a much higher unintended pregnancy rate than the reversible long-acting methods.

Answer 259

Lichen sclerosus, on the other hand, is of the chronic variety and typically presents as porcelain-white papules and plaques, often with areas of ecchymosis or purpura. The skin may appear thin, whitened and crinkling, leading to the description of “cigarette paper.” Because other vulvar diseases can mimic lichen sclerosus, a biopsy is necessary to confirm the diagnosis, except in a prepubertal child.

Answer 260

Vaginitis is one of the most common reasons for patient visits to gynecologists. It is defined as abnormal vaginal discharge accompanied by burning, irritation, or itching. Etiologies for vaginitis can differ depending on the age of the patient. In women of reproductive age, 90% of causes are infectious, of which Candida albicans (which causes candidiasis), Gardnerella vaginalis (which causes bacterial vaginosis), and Trichomonas vaginalis are the most common. Other less frequent infectious causes include herpes, gonorrhea, and chlamydia. Before puberty, however, the common causes of vaginitis are different. The most common cause in this demographic is the introduction of bacteria from the anal region to the vaginal region with improper hygiene.

Answer 261

The pudendal nerve provides both sensory and motor innervation to the perineum. It arises from the sacral plexus at S2–S4 and leaves the pelvis through the greater sciatic foramen. It then hooks around the ischial spine and sacrospinous ligament to the enter the pudendal (Alcock's) canal through the lesser sciatic foramen. The branches of the pudendal nerve are: The clitoral branch: supplies the clitoris The perineal branch: supplies the bulbospongiosus, ischiocavernosus, and transverse perineal muscles (motor) as well as the skin of the inner portions of the labia majora, minora, and vestibule (sensory) The inferior hemorrhoidal branch: supplies the external anal sphincter (motor) and perianal skin (sensory)

Answer 262

The Human Papillomavirus vaccination significantly reduces the incidence of anogenital cancer and genital warts. The human HPV vaccine is indicated for males and females age 9–26 for the prevention of diseases caused by HPV. For girls and boys who receive their first dose of HPV vaccine before 15 years of age, only two doses are needed. The timing of the two doses is 0 (baseline) and 6–12 months. If the interval between the two doses is less than 5 months, a third dose is recommended. If females or males receive their first dose at 15 years of age or older, three doses are needed and given at 0 (baseline), 1–2 months after the first dose, and 6 months after the first dose. New FDA and CDC updates on HPV vaccine use in women and men aged 27 through 45 years are under review by ACOG to determine if updates are needed based on this recommendation.

Answer 263

Macroadenomas are defined as pituitary tumors >10 mm. They are often discovered during the workup for neurological and/or visual symptoms. Nonfunctional pituitary macroadenomas that are large enough to cause neurological and/or visual problems require surgery as the initial approach. Medical therapy has not proven effective enough to reduce the size of the tumor to prevent long-term damage. The surgical approach is nearly always transsphenoidal. The transcranial approach may be used as little as 1% of the time. For functional pituitary (prolactinoma), medical therapy is the preferred treatment option.

Answer 264

The Rome criteria for diagnosis of irritable bowel syndrome include abdominal pain or discomfort coupled with altered defecation or bowel habits. Atypical symptoms or symptoms that are not compatible with irritable bowel include progressive or nocturnal abdominal pain, rectal bleeding, weight loss, and laboratory test abnormalities. If any of these symptoms are present, further evaluation should be completed because these are not symptoms attributable to irritable bowel syndrome.

Answer 265

<1% Having an IUD in place is not a risk factor for pelvic inflammatory disease. In fact, many studies show that the risk of pelvic inflammatory disease in women who have an IUD in place is equal to, or maybe even less than, in women who do not have an IUD in place. The Dalkon Shield, which was an IUD used frequently in the 1970s, did have an association with pelvic inflammatory disease. However, the new IUDs have a different construction than the Dalkon Shield, and do not carry that same risk.

Answer 266

Varenicline (most effective), bupropion, and nicotine-replacement products (nicotine patches, gum, and lozenges, as well as nicotine nasal and oral inhalers) are first-line pharmacotherapies for smoking cessation. Varenicline is a partial agonist for the nicotinic acetylcholine receptor (initial dose 0.5 mg daily, increasing to 1 mg twice daily at day 8; treatment duration up to 6 months). Clonidine or nortriptyline may be useful for patients who have failed with first-line pharmacologic treatment or who are unable to use other therapies.

Answer 267

Sexual assault is a crime of violence, conquest, control, and aggression. Sexual assault does not include passion, and has a continuum of sexual activity from sexual coercion to contact abuse, and forcible rape. Sexual assault is common among women. About 1 of 8 women will experience an assault at some time in their life Sexual assault most often affects women, but it can also happen to men. Most women who are raped know their assailant. The assailant is usually a relative or acquaintance of the victim or her friends and family. Only 20%–25% of women do not know their assailant. Many hospitals utilize trained sexual assault nurses for the examination of a rape victim. The examination includes a detailed history and physical exam, gynecologic history, description of assailant, description of type of sexual contact, observation of the survivor's emotional state, collection of vaginal secretions, Gram stain, examination with Woods light, collection of pubic hair, collection of victim's saliva, fingernail scrapings of the victim, wet prep, and a urine specimen. It is important to note if the patient took a bath/shower, used a douche, used a tampon, urinated, defecated, brushed her teeth, used an enema, used mouth wash, or changed clothes because any of those actions can impair collection of the forensic evidence.

Answer 268

The treatment for primary syphilis is benzathine penicillin G 2.4 million units once. When a patient has a painless, nonindurated, singular chancre with raised rounded borders, the most common diagnosis is syphilis. The mean incubation period for these lesions is 3 weeks. Left untreated it will resolve the lesion in up to 6 weeks. The most important aspect once syphilis is diagnosed is determining whether the syphilis is primary, secondary, early latent (< 1 year), late latent, tertiary, or neurosyphilis. Secondary syphilis occurs 6 weeks to 6 months following the initial chancre. It generally leads to a maculopapular rash, which is most commonly associated with lesions on the palms, soles, or mucous membranes. It will actively shed spirochetes and it may produce broad, grayish condylomata lata. Early latent syphilis is the period up to 1 year while late latent syphilis is any period beyond 1 year. This determines whether the patient needs higher dose, more prolonged treatment. Tertiary syphilis can take as long as 20 years to develop and its sequelae can include cardiovascular, CNS, and musculoskeletal involvement. Diagnosis is by dark field examination or direct fluorescent antibody testing. Venereal disease research laboratory/rapid plasma reagin (VDRL/RPR) testing can give a presumptive diagnosis. Fluorescent Treponema antibody absorption may be used as a confirmatory test. Following treatment, VDRL or RPR can be monitored for response to treatment. A fourfold decrease is required by 6 months for primary or secondary syphilis, while it is expected in 12–24 months with latent syphilis. If primary, secondary, or early latent syphilis is diagnosed, treatment is benzathine penicillin G once. If it is late latent or tertiary syphilis, the treatment is at least benzathine penicillin G for 3 weeks.

Answer 269

Oral contraceptive use is associated with a 50% decreased risk of developing ovarian cancer. Oral contraceptive use decreases the risk of ovarian cancer in BRCA1 and 2 carriers who are NOT candidates for or who do not desire prophylactic oophorectomy.

Answer 270

Hunner’s ulcers are pathognomonic for interstitial cystitis (IC). These are described as red lesions on the bladder mucosa with attached fibrin deposits that typically bleed after hydrodistention. Cystoscopy is not necessarily required to diagnose IC, but it is often performed to exclude additional diagnoses.

Answer 271

Trisomy is the presence of three copies of a given chromosome and is the most frequently identified chromosomal anomaly in early pregnancy losses, with an incidence of 22–32%. Of the trisomies, trisomy 16 is the most common detected in first trimester abortions. This is a lethal anomaly and may explain why this anomaly is detected more commonly than the less lethal trisomies listed above. Below is a table on the most common trisomies overall.

Answer 272

When using the FRAX system, treatment should be considered when the hip fracture risk exceeds 3% or the major osteoporotic fracture risk exceeds 20% over the next 10 years. The FRAX system evaluates a patient's risk of fracture. The FRAX calculates risk based on clinical risk factors and bone mineral density.

Answer 273

A 40-year-old obese, nulliparous woman with heavy intermenstrual bleeding should undergo an endometrial biopsy to assess for endometrial hyperplasia or neoplasia. Endometrial biopsy (EMB) is a quick and relatively inexpensive way to sample the endometrial lining and aid in the diagnosis of a number of different disease processes. The mainstay of diagnosing endometrial cancer remains endometrial sampling (either via dilatation and curettage or EMB). A Pipelle® is a common method for sampling the endometrium and it samples 5–15% of the endometrial surface area. This vignette describes a woman with abnormal uterine bleeding; in any woman with these symptoms who is over the age of 35 years, endometrial sampling to rule out endometrial cancer is warranted, particularly before prescribing medications to treat assumed ovulatory dysfunction. In addition, this patient is obese and nulliparous, which increases her chances of having endometrial cancer. Occasionally, patients undergo imaging unrelated to a gynecologic issue and a thickened endometrial stripe is incidentally found. Postmenopausal patients without vaginal bleeding who have an endometrial thickness > 11 mm should undergo endometrial sampling. All patients with atypical endometrial cells on cervical cytology should undergo endometrial and endocervical sampling ± colposcopy. However, this patient has atypical glandular cells (not atypical endometrial cells). Patients with atypical glandular cells (other than atypical endometrial cells) who are ≥ 35 years of age should undergo colposcopy, endocervical sampling, and endometrial sampling; whereas patients < 35 years of age who are not at elevated risk of endometrial neoplasia, such as this patient, only require colposcopy. Tamoxifen is a nonsteroidal antiestrogen agent that is widely used as adjunctive therapy for women with breast cancer. Premenopausal women taking tamoxifen do not have an increased risk of uterine cancer and do not require any additional monitoring beyond routine gynecologic care. However, postmenopausal women taking tamoxifen should be closely monitored for symptoms of endometrial hyperplasia or cancer. This 70yo vaginally bleeding patient's transvaginal ultrasound is reassuring with an endometrial lining measuring 2 mm and she does not need an endometrial biopsy at this time. If her endometrial stripe were > 4 mm, an endometrial biopsy would be indicated. The sensitivity and specificity of transvaginal ultrasound for detection of endometrial cancer at a threshold of 4 mm are 96% and 53%, respectively.

Answer 274

This patient has galactorrhea, which is defined as non-pathologic discharge unrelated to pregnancy or breast-feeding. Galactorrhea typically presents as bilateral, multi-ductal nipple discharge of a white substance. One common cause of galactorrhea is medication-induced hyperprolactinemia. This patient presents with poorly controlled diabetes and subsequent gastroparesis. Nausea and vomiting associated with gastroparesis is commonly treated with metoclopramide. This medication is a prokinetic, antiemetic that works by blocking dopamine receptors in the chemoreceptor trigger zone of the CNS. It also modulates acetylcholine's activity in the GI tract to enhance motility. In some cases, dopamine receptor blockade leads to hyperprolactinemia, which can cause galactorrhea. This patient also suffers from depression. Though many antipsychotic medications cause hyperprolactinemia by dopamine receptor blockade, only a few antidepressant medications such as clomipramine, a tricyclic antidepressant, may cause an increase in prolactin; this is thought to be related to gamma-aminobutyric acid (GABA) stimulation. Antidepressants such as buproprion, mirtazapine, trazodone, and venlafaxine do not cause hyperprolactinemia or galactorrhea.

Answer 275

This patient has galactorrhea, which is defined as non-pathologic discharge unrelated to pregnancy or breast-feeding. Galactorrhea typically presents as bilateral, multi-ductal nipple discharge of a white substance. One common cause of galactorrhea is medication-induced hyperprolactinemia. This patient presents with poorly controlled diabetes and subsequent gastroparesis. Nausea and vomiting associated with gastroparesis is commonly treated with metoclopramide. This medication is a prokinetic, antiemetic that works by blocking dopamine receptors in the chemoreceptor trigger zone of the CNS. It also modulates acetylcholine's activity in the GI tract to enhance motility. In some cases, dopamine receptor blockade leads to hyperprolactinemia, which can cause galactorrhea. This patient also suffers from depression. Though many antipsychotic medications cause hyperprolactinemia by dopamine receptor blockade, only a few antidepressant medications such as clomipramine, a tricyclic antidepressant, may cause an increase in prolactin; this is thought to be related to gamma-aminobutyric acid (GABA) stimulation. Antidepressants such as buproprion, mirtazapine, trazodone, and venlafaxine do not cause hyperprolactinemia or galactorrhea.

Answer 276

This patient fits into NYHA function class II for heart failure. It is not clear exactly how she attained the diagnosis of heart failure. However, she does provide a good description of her functionality. She is able to do a more strenuous task such as walking outside, but it makes her short of breath and tire faster. Although this could simply be deconditioning or secondary to multiple other factors, for that background of this question, it is assumed to be secondary to her heart failure. Because she is not completely functional and without symptoms, she is not class I. Class III describes an inability to do even light activities around the house, which she is perfectly capable of // This class describes difficulty doing daily low-energy tasks. Class IV requires the inability to function normally at rest. Generally, with this class, any activity causes inability to function.

Answer 277

Hidradenitis suppurativa presents with recurrent papular lesions that may lead to abscesses, fistulas, and scarring and can be associated with foul-smelling discharge, primarily in areas of the body with apocrine glands. Crohn's disease of the vulva and hidradenitis suppurativa are difficult to distinguish. Perianal and vulvar manifestations of Crohn's disease include abscesses, rectoperineal and rectovaginal fistulas, sinus tracts, fenestrations, and scarring, as well as classic "knife-cut" ulcers in the inguinal, genitocrural, or interlabial folds. The lack of GI symptoms in this patient supports the diagnosis of hidradenitis suppurativa over Crohn's disease. Folliculitis is simple inflammation of the hair follicle and presents with multiple superficial, inflammatory papules each surrounding a hair follicle, with or without an overlying pustule. Infections can progress if untreated or only partially treated to a nodular abscess which is termed a furuncle. Folliculitis is transient, responds rapidly to appropriate antibiotic therapy, and does not cause the comedones, persistent sinus tracts, or hypertrophic scarring which are common in hydradenitis suppurativa. Granuloma inguinale, also known as Donovanosis, is a sexually transmitted infection caused by Klebsiella granulomatis that usually occurs on the vulva, inguinal folds, or perianal skin. Lesions usually present as enlarging red ulcers with irregular borders and granulation tissue that bleeds easily and with a foul odor. The causative organism cannot be cultured, and diagnosis requires visualization of Donovan bodies on pathology from tissue biopsy. Lymphogranuloma venereum (LGV) is caused by serotypes L1, L2 and L3 of Chlamydia trachomatis, and presents clinically with genital papules and ulcers and painful inguinal adenopathy (buboes).

Answer 278

Long-acting reversible contraceptives (LARC) have higher efficacy, higher continuation rates, and higher satisfaction rates compared with short-acting contraceptives among adolescents who choose to use them.

Answer 279

In premenopausal women with regular cycles, the optimal timing for a diagnostic hysteroscopy is during the follicular phase of the menstrual cycle after menstruation, with reasonable exclusion of pregnancy. At this time, the lining of the endometrium is thin and should not obscure any small fibroids or irregular contours. During the secretory phase, the endometrial lining is thick and it can mimic small polyps and give a false diagnosis. Active bleeding may obscure visualization and therefore hysteroscopy during menstruation is not ideal. Pretreatment with progestins may improve visualization.

Answer 280

Appetite suppressants have a definite association with primary pulmonary artery hypertension. Aminorex, fenfluramine, and dexfenfluramine all increase the risk. The mechanism is unknown, but altered serotonin chemistry likely plays a role. Pulmonary hypertension is separated into 5 groups. The first group is due to pulmonary artery hypertension and is further classified by cause. Causes include: drugs and toxins HIV heart disease connective tissue disorders

Answer 281

Appetite suppressants have a definite association with primary pulmonary artery hypertension. Aminorex, fenfluramine, and dexfenfluramine all increase the risk. The mechanism is unknown, but altered serotonin chemistry likely plays a role. Pulmonary hypertension is separated into 5 groups. The first group is due to pulmonary artery hypertension and is further classified by cause. Causes include: drugs and toxins HIV heart disease connective tissue disorders

Answer 282

A meta-analysis of 13 studies revealed that the prevalence of intimate partner violence in pregnancy is anywhere from 5% to 20%. The table below lists some of the risk factors for intimate partner violence during pregnancy. Risk factors for intimate partner violence in pregnancy history of intimate partner violence age less than 24 years at-risk alcohol or drug use female sex

Answer 283

Lynch syndrome refers to individuals and families with a pathogenic germline mutation in one of the DNA mismatch repair genes (MLH1, MSH2, MSH6, and PMS2) or the EPCAM gene. Screening and Surveillance Recommendations for Women With Lynch Syndrome Colonoscopy every 1–2 years, beginning at age 20–25 years, OR 2–5 years before the earliest cancer diagnosis in the family, whichever is earlier Endometrial biopsy every 1–2 years, beginning at age 30–35 years Keeping a menstrual calendar and evaluating abnormal uterine bleeding For endometrial cancer screening, we perform yearly endometrial sampling starting at age 30–35 or 5–10 years prior to the earliest age of Lynch-associated cancer in the family. For ovarian cancer screening, we perform an annual pelvic examination and transvaginal ultrasound (TVUS) examination, with or without cancer antigen 125 (CA 125), every 6 to 12 months starting at age 30–35 or 5–10 years prior to the earliest age of Lynch-associated cancer of any kind in the family. However, not screening is also reasonable given that no screening strategy (CA 125, TVUS, or multimodal testing) has been shown to reduce mortality, and all surveillance strategies are associated with a high rate of false-positive tests and a risk of harm from invasive testing. For patients with Lynch syndrome who have completed childbearing, we continue to suggest risk-reducing total hysterectomy with bilateral salpingo-oophorectomy (TH-BSO) rather than surveillance and/or chemoprevention. Individuals with Colorectal or Endometrial Cancer for Whom Genetic Risk Assessment is Recommended Patients with endometrial or colorectal cancer diagnosed before age 50 years Patients with endometrial or ovarian cancer with a synchronous or metachronous colon or other Lynch/HNPCC-associated tumor* at any age Patients with colorectal cancer with tumor-infiltrating lymphocytes, peritumoral lymphocytes, Crohn-like lymphocytic reaction, mucinous/signet-ring differentiation, or medullary growth pattern diagnosed before age 60 years Patients with endometrial or colorectal cancer and a first-degree relative† with a Lynch/HNPCC-associated tumor* diagnosed before age 50 years Patients with colorectal or endometrial cancer diagnosed at any age with 2 or more first-degree or second-degree relatives† with Lynch/HNPCC-associated tumors*, regardless of age * = Lynch/HNPCC-related tumors include colorectal, endometrial, stomach, ovarian, pancreas, ureter and renal pelvis, biliary tract, and brain (usually glioblastoma) tumors, sebaceous gland adenomas and keratoacanthomas, and carcinoma of the small bowel † = First-degree relatives are parents, siblings, and children. Second-degree relatives are aunts, uncles, nieces, nephews, grandparents, and grandchildren

Answer 284

Mirena placement is contraindicated in postpartum endometritis, infected abortion, or pelvic inflammatory disease (PID) within the past 3 months. If PID is to occur in the presence of an IUD, do NOT remove the IUD unless 48–72 hours have passed with no clinical improvement despite optimal treatment (possible tubo-ovarian abscess) or if PID is a result of Actinomyces. The levonorgestrel IUD (Mirena) is one of the LARCs. The failure rate is 0.2% with typical use. It works by thickening cervical mucous, causing endometrial decidualization, and glandular atrophy. The levonorgestrel IUD can cause problems with menses. Amenorrhea occurs in up to 20% of users in the first year and rises to 30–50% after 2 years of use. Patients should be counseled that menstrual bleeding patterns may be altered during the first 3–6 months after placement and may result in irregular bleeding, heavy bleeding, or amenorrhea.

Answer 285

If a pregnant woman has no known history of immunization to tetanus and diphtheria, she should receive all 3 Td immunizations at the appropriate intervals. One of the 3 vaccines should be administered as Tdap between 27 and 36 weeks. if a mother does not receive a Tdap vaccine during pregnancy, she can receive it immediately postpartum, even if she is breastfeeding. However, infant immunity through breastfeeding may not occur until approximately 2 weeks after immunization. If a pregnant women lives in an area experiencing a pertussis outbreak, she may receive her Tdap immunization at any time during her pregnancy. The recommended time for a pregnant women to receive a Tdap booster is between 27 and 36 weeks.

Answer 286

Vitiligo is an acquired pigmentary disorder commonly associated with disorders of autoimmune origin, such as hyperthyroidism or hypothyroidism, diabetes mellitus, and pernicious anemia. Additionally, the development of vitiligo may be precipitated by stress. It is characterized by white or hypopigmented lesions that are usually well demarcated and range in size. Treatment is usually with phototherapy, but some forms of the disease are permanent.

Answer 287

In women between the ages of 21 and 24, either reflex human papillomavirus (HPV) testing or repeat cytology in 12 months is acceptable following an atypical squamous cells of undetermined significance (ASCUS) Pap.

Answer 288

An office endometrial biopsy is the first-line procedure for tissue sampling in the evaluation of patients with abnormal uterine bleeding (AUB). The primary role of endometrial sampling in patients with AUB is to determine whether carcinoma or premalignant lesions are present, although other pathology related to bleeding may be found. Endometrial sampling is recommended in many circumstances including in women over the age of 35 who have atypical glandular cells on cervical cytology. It may also be considered for women with atypical glandular cells under 35 years of age if they have risk factors. Endometrial tissue sampling should also be performed in patients with AUB who are older than 45 years as a first-line test. Endometrial sampling also should be performed in patients younger than 45 years with a history of unopposed estrogen exposure (such as seen in obesity or PCOS), failed medical management, or persistent AUB. Answer A: Transvaginal ultrasonography has excellent negative predictive value for endometrial cancer in women with postmenopausal bleeding. When transvaginal ultrasonography is performed for patients with postmenopausal bleeding and an endometrial thickness of 4 mm or less is found, endometrial sampling is not required because of the very low risk of uterine malignancy in these patients . Per ACOG, an endometrial thickness greater than 4 mm in a patient with postmenopausal bleeding should trigger alternative evaluation (such as sonohysterography, office hysteroscopy, or endometrial biopsy). Answer B: Patients with AUB and risk factors above the age of 35 should undergo EMB. Answer C: Screening and surveillance recommendations for women with Lynch Syndrome include endometrial biopsy every 1-2 years, beginning at age 30-35 years. Answer E: In asymptomatic women using tamoxifen, screening for endometrial cancer with routine transvaginal ultrasonography, endometrial biopsy, or both has not been shown to be effective. Bottom Line: Endometrial tissue sampling should be performed in patients with women over the age of 35 who have atypical glandular cells on cervical cytology.

Answer 289

Patients with class 3 obesity treated with a midurethral sling for stress urinary incontinence are 2x more likely to fail treatment when compared with normal-weight women. More than 50% of American women are overweight (BMI 25 to 29.9 kg/m2) or obese (BMI ≥30 kg/m2) and the prevalence of obesity is increasing almost 6% per year. Urinary incontinence affects almost 50% of middle-aged and older women. A retrospective cohort study by Elshatanoufy et al. showed that women with class 3 obesity (BMI ≥40 kg/m2) were 2x more likely to fail treatment with a midurethral sling after controlling for other comorbidities. In this same study, class 3 obesity was the only group that revealed an increased failure rate compared with normal-weight individuals.

Answer 290

Interstitial cystitis is a diagnosis of exclusion and is no longer based on cystoscopic findings Interstitial cystitis (IC), or painful bladder syndrome (PBS), is characterized by chronically occurring suprapubic pain related to bladder filling, usually associated with dysuria, for which acute cystitis can never be diagnosed due to negative urine cultures. Other symptoms include daytime frequency and nocturia in the absence of proven infection or other obvious pathology. The syndrome is midline and, thus, dyspareunia is a common complaint. The pathognomonic finding is Hunner’s ulcers seen on cystoscopy, although these only occur in approximately 5–10% of women with IC. Treatment of IC involves dietary changes (i.e., avoiding acidic, alcoholic, carbonated beverages, spicy foods, and artificial sweeteners) and pentosan polysulfate sodium (Elmiron), which is the only FDA-approved oral drug for IC.

Answer 291

Postpartum blues, which is a transient condition characterized by mild depressive symptoms, develops in 40%–80% of women in the first few days following delivery. Symptoms typically peak over the next few days and resolve within 2 weeks.

Answer 292

Individuals with Lynch syndrome, or mutations of DNA mismatch repair genes associated with Lynch syndrome, are at increased risk of colorectal, endometrial, ovarian, hepatobiliary, stomach, and small bowel cancers, cancers of the renal pelvis, and gliomas in the brain. There may be an increased risk of ureteral cancers and cancers of the renal pelvis. Patients with Lynch syndrome have the highest lifetime risk of colon and endometrial cancers. Lynch syndrome is least likely to be directly associated with breast cancer, although there is a slightly increased risk.

Answer 293

GnRH agonists have proven efficacy in decreasing pelvic pain in women with surgery-diagnosed endometriosis. A maximum of 6 months of treatment with GnRH analogues is currently licensed for ovarian downregulation. Evidence has shown that the add-back therapy does not affect the pain-reducing qualities of the GnRH agonist. However, GnRH agonists in combination with this add-back therapy may make the use of 12-month therapy safer, as opposed to 6 months. The use of GnRH agonists is associated with subsequent hypoestrogenic symptoms. The rate of loss of bone density is in the range of 0.5–1.0% per month, which over time increases the risk of osteoporosis. Restriction of use of GnRHa to 6 months severely limits clinical efficacy: no sooner has the patient derived maximum benefit from the treatment than she is advised to stop. However, several studies have shown the efficacy of hormone replacement “add-back” therapy prescribed in conjunction with GnRHa to reduce the impact of low circulating oestrogens on bone density. Hypoestrogenic state symptoms also include hot flushes, insomnia, and decreased libido; quite concerning is the loss of bone mineral density. This latter point is the main driver limiting the time of treatment with GnRH agonists. This add-back therapy may make the use of 12-month therapy safer. Lupron Depot (3.75 mg leuprolide acetate) is used for management of endometriosis, including pain relief and reduction of endometriotic lesions. It is used monthly with norethindrone acetate (aygestin) 5 mg daily for initial management of endometriosis and for management of recurrence of symptoms. Concomitantly with iron therapy is indicated for the preoperative hematologic improvement of patients with anemia caused by uterine leiomyomata (fibroids).

Answer 294

Treatment for osteoporosis typically starts with lifestyle modifications with first-line medications typically being the bisphosphonates. The main side effect of bisphosphonates is GI irritation and it is recommended that women take this medication with a full glass of water and remain upright for 30 minutes. Osteoporosis is a skeletal disorder characterized by a loss of bone mass. The main determinants of peak bone mass and density are thought to be genetic with many genes identified that are related to bone quality. The diagnosis of osteoporosis is made with a DEXA scan, which all major guidelines recommend be performed at age 65, with earlier screening reserved for women who are postmenopausal with risk factors. Diagnosis of osteoporosis in postmenopausal women is a T-score that is ≤ −2.5. Osteopenia is defined by a T-score between −1.0 and −2.5. Bone health should be addressed at each annual visit, with calcium, vitamin D, and weight-bearing exercises being recommended.

Answer 295

There are generally considered to be 2 types of pessary: support and space-filling. The support pessary exerts its support by using the pubic bone anteriorly and behind the cervix posteriorly. It generally is supported by these harder or more bony structures. A space-filling pessary is used more frequently in severe prolapse or complete procidentia. A Gellhorn pessary is the most commonly used form of space-filling pessary. It is a complete concave disk that sets against the cervix or vaginal cuff and has a stem that points outward. This assists in placement and removal of the device.

Answer 296

According to the CDC, the meningococcal vaccine should be offered to individuals in the following groups: military recruits microbiologists exposed to Neisseria meningitidis individuals with functional or surgical asplenia individuals with complement deficiencies travelers to areas of the world with endemic meningococcal infection.

Answer 297

Adenomyosis is the presence of endometrial glands and stroma in the musculature of the uterus. Heavy menstrual bleeding occurs because of the distortion of the uterine cavity from the displaced endometrial glands. Symptoms of Adenomyosis Heavy menstrual bleeding Dysmenorrhea Enlarged and boggy uterus Dyspareunia Symptoms of adenomyosis often mimic those with endometriosis without adenomyosis. However, of the options, the finding most suggestive of adenomyosis is an enlarged and boggy uterus. Fibroids can form an enlarged uterus, but it usually isn't boggy.

Answer 298

Polymerase chain reaction (PCR) assays have emerged as a sensitive method to confirm HSV infection in clinical specimens from genital ulcers. Although viral culture remains the gold standard, the overall sensitivity is only 50%, and it typically requires at least 5 days.

Answer 299

Initial treatment of a patient with IBS should include dietary modification and increased physical activity. The low FODMAP diet (a diet low in fermentable oligo-, di-, and monosaccharides and polyols) and the strict traditional IBS diet (regular meal pattern; avoidance of large meals; reduced intake of fat, insoluble fibers, caffeine, and gas-producing foods such as beans, cabbage, and onions) have both been shown to reduce symptom severity in patients with IBS. In a randomized trial of 102 patients with IBS, those assigned to the physical activity group showed a trend toward clinical improvement in the severity of IBS symptoms and a reduced likelihood of worsening of their IBS symptoms compared with controls. Food diaries are a helpful tool for any patient with chronic gastrointestinal symptoms, to help identify foods that trigger or are associated with increased symptom frequency and/or severity. If lifestyle and dietary modifications fail to adequately control the patient's IBS symptoms, pharmacologic treatment with fiber supplements, laxatives, antidiarrheal agents, antispasmodic agents, and others may be considered.

Answer 300

TrueLearn Insight: Some commonly tested contraindications to combined hormonal contraceptive use include smoking at age ≥ 35 years, systolic blood pressure greater than 160 mm Hg or diastolic blood pressure greater than 100 mm Hg, high risk of DVT/PE, and migraines with aura. decompensated cirrhosis

Answer 301

When evaluating an infant with ambiguous genitalia, it is imperative to obtain a karyotype to evaluate the sex chromosomes, serum electrolytes, and 17-hydroxyprogesterone levels. Congenital adrenal hyperplasia (CAH) is the most common cause of ambiguous genitalia and is inherited in an autosomal recessive fashion. Ambiguous genitalia arise in 46,XX fetuses who are exposed to excess androgens during the time of external genital differentiation (9–14 weeks). The most common type of congenital adrenal hyperplasia (CAH) is due to a 21-hydroxylase deficiency, which is best assessed by measurement of 17-hydroxyprogesterone, which will be elevated.

Answer 302

The correct regimen is ceftriaxone, doxycycline, metronidazole, and ulipristal acetate. Treatment after sexual assault should include prophylaxis for gonorrhea, chlamydia, trichomonas, and HIV for high-risk encounters within 72 hours of sexual assault. Patients should also be offered emergency contraception. There are currently no recommendations that support treating a victim of sexual assault with prophylaxis for hepatitis C, as it is more commonly associated with dirty needles and transfusions than with sexual contact. For HIV post-exposure prophylaxis, the CDC recommends treatment if the patient presents within 72 hours of assault and there is a substantial exposure risk. For emergency contraception, options include intrauterine device placement or oral medications. This patient does not want to be on long-term contraception. Typically, ulipristal acetate is recommended within 5 days of unprotected intercourse, whereas oral levonorgestrel is only used within 3 days of unprotected intercourse. This patient is outside of this window for treatment with levonorgestrel. A regimen of ceftriaxone, doxycycline, metronidazole, ulipristal acetate, and HIV post-exposure prophylaxis would be the correct option if the patient had presented within 72 hours of assault with a substantial exposure risk to HIV. She could alternatively be offered oral levonorgestrel instead ulipristal acetate. This option has medications for prophylaxis against gonorrhea, chlamydia, trichomoniasis, pregnancy, and HIV.

Answer 303

IV drug abusers are at increased risk of developing infective endocarditis. The most common agent is Staphylococcus aureus, present in more than 50% of cases. The mortality rate overall is approximately 3.6%. However, fungal etiology carries a 67% mortality rate with an odds ratio of 46.2.

Answer 304

Rectovaginal fistulas may be acquired from obstetrical injury during delivery. When the anal sphincter complex is intact, a simple fistulectomy without sphincteroplasty can be performed via a vaginal or rectal route. If the anal sphincter complex has been compromised, a sphincteroplasty should be performed concurrently.

Answer 305

dysmenorrhea and menorrhagia. not irregular bleeding.

Answer 306

During days 14–28 (luteal or secretory phase) of the menstrual cycle, the theca externa produces progesterone. This leads to an increase in progesterone at day 14, after which it becomes the predominant hormone. In the breasts, progesterone stimulates glandular growth; overstimulation of these glands can lead to cyst formation, which in turn leads to fibrocystic change of the breast. The theca interna does not produce progesterone. It produces estrogen during the proliferative phase of the menstrual cycle. Moreover, progesterone is responsible for glandular growth, not ductal growth, in the breasts.

Answer 307

The most effective method for smoking cessation is the combination of behavioral therapy and pharmacologic treatments. Appropriate pharmacologic treatments include buproprion, varenicline, and nicotine replacement therapy. Compared with women who are nonsmokers, women who smoke cigarettes have greater risks of: Reproductive health problems Many forms of gynecologic cancer and other types of cancer Coronary and vascular disease Chronic obstructive lung disease Osteoporosis. Behavioral counseling and the use of evidence-based smoking cessation aids are the most effective strategies for achieving smoking cessation, even for very heavy smokers, with a 6-month abstinence rate of 25–35%. Varenicline is a partial agonist for a subunit of the nicotinic acetylcholine receptor and prevents nicotine stimulation of mesolimbic dopamine system associated with nicotine addiction. this is the most effective med method. Varenicline stimulates dopamine activity but to a much smaller degree than nicotine does, resulting in decreased craving and withdrawal symptoms.

Answer 308

Intrauterine devices (IUDs) are associated with a lower incidence of ectopic pregnancy due to the overall lower incidence of pregnancy. However, if a woman becomes pregnant with an IUD, the risk of ectopic pregnancy is higher than if she had no IUD. One study demonstrated the risk of ectopic pregnancy with copper IUDs (1 in 50 pregnancies) was much lower than with levonorgestrel IUDs (1 in 2 pregnancies). Previous IUD use is associated with a slightly increased risk of ectopic pregnancy compared with the risk in the general population.

Answer 309

Chlamydia trachomatis, herpes simplex, human papillomavirus, and trichomonas vaginalis are all sexually transmitted causes of cervicitis. Although gardnerella vaginalis is known to cause cervicitis as well, it is not currently considered to be sexually transmitted

Answer 310

More than one-third of patients fitting this case will have persistent pelvic pain. In patients with no identifiable pelvic pathology, the rate of persistent pelvic pain following hysterectomy is 40%.

Answer 311

Intimate partner violence (IPV) can include psychological, physical, or sexual abuse; progressive isolation; stalking; deprivation; intimidation; or reproductive coercion. In the United States, women experience 4.8 million incidents of physical or sexual assault annually; however, the true incidence of IPV is unknown. This is most likely because many victims are afraid to disclose their personal experiences of violence. In addition, the severity of IPV can increase during pregnancy and the postpartum period. In fact, homicide is a leading cause of maternal mortality with the majority involving former or current intimate partners. IPV has been associated with poor pregnancy weight gain, infection, anemia, tobacco use, stillbirth, pelvic fracture, placental abruption, fetal injury, preterm delivery, and low birth weight.

Answer 312

Urinary tract infections (UTIs) are exceedingly common, particularly in females. More than half of women will have at least one UTI during their lifetime, and 3%–5% of all women will have multiple recurrences. In fact, an estimated 11% of US women report at least one physician-diagnosed UTI per year, and the lifetime probability that a woman will have a UTI is 60%.

Answer 313

Appendicitis can be caused by gynecological pathology including an ectopic pregnancy, right-sided salpingitis, a tubo-ovarian abscess, PID, and a torsed ovarian cyst. Several gynecologic conditions can mimic appendicitis, and should all be considered in the differential diagnosis. Gynecological Causes of Appendicitis ectopic pregnancy right-sided salpingitis a tubo-ovarian abscess pelvic inflammatory disease torsed ovarian cyst

Answer 314

This patient presents at the appropriate age and with the signs and symptoms of lichen sclerosus. She is having itch-scratch cycles which occur at night and in anal and genital areas. She has failed conservative therapy, which is not uncommon. After 3 weeks, the appropriate next step is a biopsy of the concerning lesion. This patient, having a likely diagnosis of lichen sclerosus, has a 4–6% chance of developing a vulvar cancer, much higher than the general population. The biopsy on that lesion, if lichen sclerosus, often reveals hyperkeratosis with thinning of the rete ridges and plugging of follicular infundibulum. All the other options listed may be options to use, but cancer should be ruled out and a diagnosis made when initial treatment is ineffective and diagnosis is not biopsy-proven.

Answer 315

Kidney stones (also called nephrolithiasis) are a common complaint in the primary care setting. They commonly present with intermittent back/flank pain that waxes and wanes. As the stones move farther down the ureter, the location and nature of the pain can change. Ultimately, the patient may experience pain in the labium. Hematuria in such a patient is very consistent with kidney stones. However, a patient with classic symptoms of kidney stones without hematuria can still have kidney stones.

Answer 316

Obesity is a risk factor for the following cancers more common in women: Endometrial cancer Obese and overweight women are two to about four times as likely as normal-weight women to develop endometrial cancer Liver Kidney Colorectal slightly (about 30%) more likely to develop colorectal cancer Breast among postmenopausal women, those who are obese have a 20% to 40% increase in risk of developing breast cancer compared with normal-weight women Ovarian associated with (10%) increase in the risk in women who have never used HRT Thyroid slight (10%) increase in the risk of thyroid cancer

Answer 317

Endometriosis is a chronic gynecological disorder that can often manifest as pelvic pain, infertility, dyspareunia, or lower back pain. Endometrial lesions can lead to a chronic inflammatory disorder, causing severe pain. Risk factors include early menarche occurring before age 11 years, shorter menstrual cycles occurring less than monthly, and heavy prolonged periods. Incidence of endometriosis in women of reproductive age is 6–10%. There is no evidence to suggest that the incidence is increasing. There has been a familial association for affected patients, specifically with first-degree relatives. There is a nearly 7-fold to 10-fold increased risk of developing endometriosis when this is the case.

Answer 318

Uterine artery embolization (UAE) occludes blood flow to the uterus and subsequently the fibroids. This procedure is typically performed under conscious sedation. The procedure itself is short, and there is a predictable pain pattern afterward. As the blood within the fibroid clots, ischemia occurs, and women develop intense pelvic cramping. This occurs roughly 4–6 hours after the procedure. Given the physiology behind the pain, almost all women experience pelvic pain after a UAE procedure.

Answer 319

Amsterdam II criteria for Lynch syndrome: There should be at least three relatives with any Lynch syndrome-associated cancer (colorectal cancer, cancer of the endometrium, small bowel, ureter, or renal pelvis) One should be a first-degree relative of the other two At least two successive generations should be affected At least one should be diagnosed before age 50 Familial adenomatous polyposis should be excluded in the colorectal cancer case(s), if any Tumors should be verified by pathological examination Screening and Surveillance Recommendations for Women With Lynch Syndrome: Colonoscopy every 1–2 years, beginning at age 20–25 years, OR every 2–5 years before the earliest cancer diagnosis in the family, whichever is earlier Endometrial biopsy every 1–2 years, beginning at age 30–35 years Keeping a menstrual calendar and evaluating abnormal uterine bleeding

Answer 320

This patient is having classic symptoms of premenstrual syndrome. This syndrome presents as affective symptoms (angry outbursts, depression, irritability, confusion, social withdrawal, fatigue) coupled with somatic symptoms (bloating, headache, swollen extremities, breast tenderness) and evidence of dysfunction in social or economic performance in a temporal relationship with menses. Per ACOG, symptoms must start 5 or more days prior to the onset of menstruation and resolve within 4 days after the onset of menses. Diagnoses can be made with a symptom diary detailing daily symptoms for 2–3 menstrual cycles. Other psychiatric disorders can be worsened with premenstrual syndrome and therefore psychiatric screening should be considered. Other systemic medical conditions (hypothyroidism, systemic lupus, chronic fatigue syndrome, etc.) should be considered as well.

Answer 321

Infertility is defined as the inability to achieve pregnancy after 12 months of appropriately timed intercourse. However, in patients older than age 35, workup and treatment may begin after 6 months of appropriately timed intercourse without conception. An evaluation for infertility typically consists of a semen analysis in the male partner. In addition, male partners should have a complete medical, surgical, and reproductive history performed. An endocrine evaluation is recommended when the sperm count is less than 10 million/mL with signs of impaired sexual function or an endocrine abnormality. A basic workup includes FSH and testosterone; if results are abnormal, ordering LH, free testosterone, and prolactin levels is recommended. There are many causes of oligospermia, and assessing laboratory studies as well as physical exam findings can typically clue one in to the diagnosis. A karyotype is indicated in men with severe oligospermia less than 5 million/mL. Microdeletions in the azoospermic factor region (AZF) can lead to oligospermia or azoospermia. Deletions in the AZF a or b region lead to azoospermia, and typically sperm cannot be extracted even with a testicular biopsy. Thus, couples with male partners affected by this diagnosis are advised to use donor sperm to conceive. Although deletions in the AZF c region are associated with severe oligospermia, these men have the ability to have sperm extracted during a testicular biopsy, and their partners can subsequently undergo in-vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI).

Answer 322

Fatigue is the most common symptom noted in women with systemic lupus erythematosus (SLE). Depending on the study, fatigue is present in 74%–100% of women at any given time. Other symptoms suggestive of the disease are arthralgia, fever, photosensitivity, butterfly rash, and alopecia. SLE is a chronic autoimmune disorder affecting multiple organs. It is more prevalent among women than men, especially during their reproductive years. Risk factors associated with the disease include: genetic predisposition long estrogen exposure (early menarche, late menopause, OCPs) exposure to Epstein–Barr virus exposure to ultraviolet light

Answer 323

The quadrivalent human papillomavirus (HPV) vaccine is indicated for use between ages 11–26 (but it may be given from the age of 9 years) as part of the adolescent immunization platform). Dosing schedule varies depending on the age of when the first dose was given: Between 9–14 years old: only two doses of vaccine are sufficient at 0 and 6–12 months Between ages 15–26: includes three doses, separated at 0, 2, and 6 months Recent ACOG recommendations explain the need of a shared-clinical decision with women aged 27–45 years who are previously unvaccinated regarding the HPV vaccination, considering the patient’s risk for acquisition of a new HPV infection and whether the HPV vaccine may provide benefit.

Answer 324

Per Centers for Disease Control and Prevention, the recombinant zoster vaccine Shingrix is recommended for immunocompetent adults aged 50 years and older. Shingles is a painful rash that can develop from herpes zoster and potentially result in long-lasting pain called postherpetic neuralgia (PHN). Shingles is the result of reactivation of varicella zoster virus (VZV). Dosage Adults 50 years and older 2 doses Second dose 2–6 months after the first *It is not necessary to screen (either verbally or via laboratory serology) for a history of varicella. However, if a person is known to be varicella-negative via serologic testing, guidelines for varicella vaccination should be followed.

Answer 325

Women with endometriosis may continue to have symptoms following treatment with hysterectomy with oophorectomy. There has been shown to be a recurrence rate of about 15% following bilateral oophorectomy regardless of whether a woman has hormone replacement after surgery or not. Lesions are most often found on the small and large bowel when repeat surgery is performed as these lesions may have been present but not excised at the initial surgery. Treatment of these lesions with estrogen suppression or aromatase inhibitors has not been shown to be helpful. These lesions likely persist due to local expression of aromatase activity and surgical excision is often required. In general, common findings on laparoscopy in a patient with endometriosis include the following: powder-burn or purplish-blue lesions throughout the peritoneal surfaces old brown scarring lesions red or white lesions Allen-Masters window (a peritoneal defect). Disease is often found where one might expect to see direct spread from retrograde menstruation in the posterior cul-de-sac or at the adnexa. Dense adhesions may be found as well and should be completely resected, as simple lysis often leads to undiagnosed endometriosis in the adhesions, which will return. Peritoneal stripping should be attempted when possible, and removal of an entire cyst should be performed as well to ensure that as little disease as possible is left in the abdomen. Furthermore, a 20% rate of normal-appearing laparoscopy findings is observed in those undergoing diagnostic laparoscopy, and a biopsy should always be taken for tissue diagnosis. Endometrial epithelium, glands, and stroma, as well as hemosiderin-laden macrophages, are common on histopathology.

Answer 326

Levofloxacin 750 mg one tab PO daily for 10 days is an appropriate treatment. Urinary tract infections (UTIs) are exceedingly common, particularly in females. More than one-half of women will have at least one UTI during their lifetime, and 3%–5% of all women will have multiple recurrences. There is some concern regarding multidrug resistant bacteria and fluoroquinolone resistance. Depending on the area you are practicing, this may determine which medications you use. Generally, fluoroquinolones are still first-line treatment for complicated cystitis. Uncomplicated acute bacterial cystitis was previously treated with 7–10 days of antimicrobial therapy, but recent data have shown that 3 days of therapy is equivalent in efficacy. Complicated UTIs, however, require longer durations and higher antimicrobial dosages because of their high risk of failure. Patients with diabetes, renal failure, function or anatomic abnormalities of the urinary tract, renal transplantation and an indwelling catheter stent are more likely to fail more conservative management and are considered to have complicated UTIs. First-Line Treatment for Complicated UTIs Medication Dose Duration Ciprofloxacin 500mg PO BID 7–14 days Levofloxacin 750mg PO Daily 7–14 days Ciprofloxacin extended release 1000mg ER PO Daily 7–14 days *If multidrug-resistant organisms (MDR) are present or the community has >10% known resistance of E. coli to fluoroquinolones, complicated UTIs can be first treated with IV medication and then finish with oral treatment. **Of note, there is a black box warning for fluoroquinolones. Fluoroquinolones are associated with tendinitis/tendon rupture, peripheral neuropathy, and CNS effects. Tendonitis/tendon rupture can occur during treatment or months after. There is increased risk for patients >60 yo, those taking corticosteroids, and patients with kidney/heart/lung transplant.

Answer 327

Cholesterol is the main component of approximately 80% of gallstones, with 10% being purely cholesterol. Pigment stones tend to have calcium bilirubinate as the main component and thus are visible on plain radiographs. However, because only 15%–20% of gallstones are radiopaque, plain radiography is a poor screen examination and has largely been replaced by abdominal ultrasonography, which relies on shadowing and surrounding characteristics to determine the presence of gallstones.

Answer 328

Obesity is a risk factor for the following malignancies: endometrial kidney gastric cardia colon rectal biliary tract pancreatic breast esophageal adenocarcinoma ovarian multiple myeloma hepatocellular carcinoma meningioma

Answer 329

The recommended treatment of lichen sclerosus is a high-potency topical steroid, usually clobetasol propionate. Although there is a lack of randomized controlled clinical trials, a reasonable regimen is: begin with once-daily application for 4 weeks taper to alternate days for 4 weeks followed by 4 weeks of twice-weekly application

Answer 330

Lynch syndrome, otherwise known as hereditary nonpolyposis colorectal cancer, is a hereditary cancer syndrome caused by a defect in mismatched repair genes MLH1 and MSH2, among others. Lynch-related tumors do not include breast cancer, although this does play a major role in another hereditary cancer syndrome, BRCA syndrome. Lynch-related tumors include colorectal, endometrial, stomach, ovarian, pancreatic, ureter and renal pelvis, biliary tract, and brain (usually glioblastoma as seen in Turcot syndrome) tumors, sebaceous gland adenomas and keratoacanthomas in Muir-Torre syndrome, and carcinoma of the small bowel.

Answer 331

Primary syphilis presents with the appearance of a painless vulvar ulcer that contains the spirochete Treponema pallidum. The treatment of primary syphilis is benzathine penicillin G, 2.4 million units IM in 1 dose. Alternative regimens (penicillin-allergic, nonpregnant patients) include doxycycline, 100 mg orally BID for 2 weeks, or tetracycline, 500 mg PO QID for 2 weeks. Aqueous crystalline penicillin via the IV route is the treatment of choice for neurosyphilis. Alternative regimens include procaine penicillin, 2.4 million units IM daily for 10–14 days, plus probenecid, 500 mg PO QID for 10–14 days. Benzathine penicillin G, 2.4 million units IM every week for 3 doses, is the treatment of choice for late latent syphilis, evidenced by >1 year duration, gummas, and cardiovascular syphilis. A total of 7.2 million units should be administered. Alternative regimens include doxycycline, 100 mg PO BID for 2 weeks if <1 year or 4 weeks if unknown duration or >1 year, as well as tetracycline, 500 mg PO QID for 2 weeks if <1 year, otherwise for 4 weeks. Doxycycline, 100 mg PO twice daily for 28 days, is the acceptable alternative regimen for late latent syphilis of >1 year duration. Procaine penicillin and probenecid is the alternative regimen for neurosyphilis if aqueous crystalline penicillin cannot be used.

Answer 332

Uterine sarcomas are significantly rarer than leiomyomas (3 to 7/100,000 in the United States population) and have a poor prognosis. The prevalence of a uterine sarcoma in the setting of surgery for a presumed leiomyoma ranges from 0.05 to 0.28% and is an active area of current investigation. This is a rare but relevant risk. The majority of cases are leiomyosarcoma, a highly aggressive cancer, but there are also reports of cases of endometrial stromal sarcoma, generally a more indolent cancer. Most of these are identified on histology after their removal for presumed benign conditions. A uterine sarcoma is difficult to identify pre-operatively. The sensitivity of an office endometrial biopsy or dilation and curettage (D&C) to detect sarcomatous elements is lower than that for endometrial carcinomas. Specifically, with leiomyosarcoma, symptomatic women receive a correct preoperative diagnosis in only 35–50% of cases. This inability to accurately sample the tumor is probably related to the origin of these neoplasms in the myometrium rather than the endometrium. Preoperative consultation with a gynecologic oncologist is recommended for any patient with a biopsy suggesting uterine sarcoma.

Answer 333

Acetylcholine is the neurotransmitter that is released to cause bladder contraction. This is the neurotransmitter that is targeted by a class of antispasmodics/anticholinergic medications to treat overactive bladder and urge incontinence.

Answer 334

Systemic lupus erythematosus (SLE) is not associated with weight gain. However, patients may report other constitutional symptoms, such as weight loss, fatigue, and lymphadenopathy. Answer A: Patients with SLE may have dyspnea or chest pain associated with serositis, as well as findings that suggest pleural effusion, pneumonitis, or interstitial lung disease. Answer B: Painless mucosal oral or nasal ulcers are a common finding in patients with SLE. Answer C: A pathognomonic finding for SLE is a malar rash, also described as a butterfly rash, associated with skin photosensitivity. Answer D: Raynaud phenomenon refers to the discoloration and decreased blood flow noted at the tips of the fingers and toes in response to cold or emotional stress. Raynaud phenomenon is a common complaint of patients with SLE.

Answer 335

The lifetime incidence of depression is estimated at 17% for women in the United States. This is nearly double the rate for men. Depression is more common in younger women than in older women.

Answer 336

Oxybutynin is an anticholinergic that antagonizes acetylcholine at the muscarinic receptor to relax the bladder and inhibit involuntary detrusor contractions. This medication is commonly used for treatment of overactive bladder or urge incontinence, and the side effects are well known and often tested. Side Effects of Anticholinergic Medications Constipation Dry mouth Dizziness Somnolence Confusion Double vision Hyperkalemia Prolonged QTc interval Oxybutynin is an anticholinergic that antagonizes acetylcholine at the muscarinic receptor to relax the bladder and inhibit involuntary detrusor contractions. This medication is commonly used for treatment of overactive bladder or urge incontinence, and the side effects are well known and often tested.

Answer 337

This patient has dysmenorrhea or, more generally, cyclic pelvic pain. When this occurs, multiple etiologies may be possible. However, when the pain is cyclic, menstrual-related disease is most often given credit as the cause of the pain. Whether the pain is simply the result of an amplified pain response or the result of endometriosis, the pathophysiology is essentially the same. Estradiol is produced as a result of increased aromatase activity. In turn, COX-2 is stimulated in uterine endothelial cells. PGE2 production then ensues, leading to a pain response after binding to pain receptors and creating inflammation. These mechanisms are the basis for aromatase inhibitor use in endometriosis.

Answer 338

The main contraceptive efficacy of combined oral contraceptives (COCs) is suppression of ovulation by inhibition of gonadotropin-releasing hormone (GnRH), luteinizing hormone (LH), follicle-stimulating hormone (FSH), and the mid-cycle LH surge. This effect is mediated by both the progestin and estrogen components of the COC working synergistically, but estrogen suppression of FSH, which in turn prevents folliculogenesis, is likely the most important mechanism. Combined hormonal methods have been linked to a small risk of stroke and heart attacks. They are not recommended in patients older than 35 years who smoke; have high blood pressure or a history of stroke, heart attack, or deep vein thrombosis (DVT); have a history of migraine headaches with aura; have certain medical conditions; or have breast cancer or a history of breast cancer. Answer A: Women who smoke >15 cigarettes per day and are over the age of 35 years are at significant risk of a thrombotic event; adding a prothrombotic in hormonal form is contraindicated in these patients. Answer B: Oral contraceptive pills (OCPs) may be considered in healthy, nonsmoking women older than 35 years if there are no other contraindications to combined hormonal contraceptives. Answer C: There is a very small risk that the estrogen in these methods can affect milk supply if a patient is breastfeeding. Patients should avoid these methods for the first 4 to 6 weeks after childbirth, until breastfeeding is established. Answer E: Migraine headaches with aura have been associated with up to a twofold increased risk of stroke in otherwise healthy women taking OCPs. Smoking further increases this risk. For this reason, migraine headache with aura is a contraindication to combined hormonal contraceptives. Stroke risk is not increased in patients with migraine without aura; therefore, combined hormonal contraceptives are not contraindicated unless the patient has other major risk factors for stroke (e.g., smoking, hypertension, diabetes). Bottom Line: Combined hormonal methods have been linked to a small risk of stroke and heart attacks. They are not recommended if you are older than 35 years and smoke; have high blood pressure or a history of stroke, heart attack, or deep vein thrombosis; have a history of migraine headaches with aura; have certain medical conditions; or have breast cancer or a history of breast cancer.

Answer 339

ACOG endorses the American College of Cardiology (ACC) and American Heart Association (AHA)'s 2013 blood cholesterol guidelines, which recommend all adults aged 21 years or older be screened for dyslipidemia with a fasting lipid panel and have their overall cardiovascular disease risk assessed every 4–6 years. Women with a normal lipid screen at age 21 who are not at high risk for cardiovascular disease should have a repeat lipid screen at age 45 years; whereas women with a normal lipid screen at age 21 years who are at high risk for cardiovascular disease should have a repeat lipid screen at age 35.

Answer 340

Recurrent urinary tract infection (UTI) refers to ≥ 2 infections in 6 months or ≥ 3 infections in 1 year. UTI recurrences are typically acute simple cystitis rather than complicated UTI. Most recurrences are thought to represent reinfection rather than relapse (even recurrences caused by the same uropathogenic strain), although occasionally a persistent focus can produce relapsing infection. Recurrent simple cystitis is common among women, even among young, healthy women who have anatomically and physiologically normal urinary tracts. In a study of college women with their first episode of cystitis, 27% experienced at least 1 culture-confirmed recurrence within the 6 months following the initial infection. When the first infection is caused by Escherichia coli, women appear to be more likely to develop a second cystitis episode within 6 months than those with a first infection due to another organism. Patients should be counseled on the risk factors for recurrent simple cystitis and behavioral changes (such as increased fluid intake) that might reduce the risk. For postmenopausal women, vaginal estrogen is recommended. Otherwise healthy women with recurrent cystitis should increase their fluid intake, which can reduce the risk of recurrence. Although the optimal amount of fluid is unknown, a general daily target of 2–3 liters of fluid is encouraged. Answer B: Vaginal estrogen is recommended for postmenopausal women with recurrent cystitis to reduce the incidence of cystitis. Answer C: Clinical studies to date have not definitively demonstrated efficacy in prevention of recurrent simple cystitis with cranberry products. Answer D: It is reasonable to suggest to women that early postcoital voiding might be helpful. However, this has not been shown in controlled studies to result in a reduced risk of recurrent cystitis. Answer E: Clinical trials of oral probiotics have not been encouraging; studies do not suggest probiotics reduce the risk of recurrent cystitis. Given the lack of demonstrated clinical efficacy, providers should not routinely recommend them to their patients.

Answer 341

This is a patient with symptoms of endometriosis but with a goal of fertility. She is presenting to the clinic with the hope of identifying a means to become pregnant. It appears that the cause of her symptoms is endometriosis, and a laparoscopy will be both diagnostic and curative in many cases of endometriosis. The other options listed are commonly used to reduce the symptoms of endometriosis and are reasonably successful. However, none of the other options is faster than diagnostic laparoscopy: the gold standard for endometriosis.

Answer 342

Pelvic inflammatory disease (PID) refers to acute infection of the upper genital tract structures in women, involving any or all of the uterus, fallopian tubes, and ovaries and may involve the neighboring pelvic organs. The 2 most important sexually transmitted organisms associated with acute PID, Chlamydia trachomatis and Neisseria gonorrhoeae, should be the main targets for treatment. There is favor for treatment of possible anaerobic organisms as well. The presumptive clinical diagnosis of PID is made in sexually active young women or women at risk for sexually transmitted infections (STIs) who present with pelvic or lower abdominal pain and have evidence of cervical motion, uterine, or adnexal tenderness on exam. Additional criteria to aid in the diagnosis include fever above 38.3°C (101°F), abnormal cervical or vaginal mucopurulent discharge, presence of abnormal white blood cell count, and recent diagnosis of gonorrhea or chlamydia. There has been a persistent trend towards outpatient treatment of PID with only the minority of women being hospitalized. Outpatient treatment consists of ceftriaxone (500 mg IM x 1 dose if < 150 kg or 1,000 mg IM x 1 dose if > 150 kg), doxycycline 100 mg twice daily for 14 days, and flagyl 500 mg twice a day for 14 days. These treatment regimens cover the most common pathogens responsible for PID, including chlamydia, gonorrhea, and other anaerobic organisms, and cure rates are greater than 90% in studies. Indications for Inpatient Treatment of Pelvic Inflammatory Disease Pregnancy Severe clinical illness Lack of response to oral antibiotics Adnexal abscess (TOA) Persistent nausea and vomiting Inability to adhere to therapy Possible need for surgical intervention Inpatient treatment options are cefoxitin 2 g IV every 6 hours IV and doxycycline 100 mg twice daily (oral and IV have the same bioavailabilty, and oral is preferred if tolerable due to pain associated with IV treatment) until clinical improvement is noted for at least 24 hours followed by transition to oral therapy with doxycycline for a 14-day antibiotic course (+/- metronidazole 500 mg twice daily x 14 days if pelvic abscess or trichomonas present).

Answer 343

Adenomyosis is best characterized as the presence of endometrial tissue within the myometrium. The clinical features of the disease are menorrhagia and dysmenorrhea, especially when there is an enlarged uterus. Imaging studies can assist in the differential, but ultimately, the diagnosis is made at the time of hysterectomy.

Answer 344

Uterine leiomyomas are solid neoplasms composed of smooth muscle cells and fibroblasts. Leiomyomas vary in size and location. Uterine leiomyomas are common and estimated to occur in up to 70% of women by menopause with approximately only 25% being clinically significant enough to require intervention. The prevalence rate of uterine leiomyomas is 2–3 times higher among Black women compared with White women. Prolonged or heavy menstrual bleeding, with or without anemia, and the sequelae of uterine enlargement are the most common presenting symptoms of patients with uterine leiomyomas. Pelvic pressure, urinary frequency, and constipation also can result from the presence of large leiomyomas within the pelvis and are collectively referred to as bulk symptoms. Uterine fibroids are a common cause of AUB and are the leading indication for hysterectomy. Although hysterectomy is a definitive treatment choice, medical therapy and myomectomy are also appropriate. Myomectomy is indicated in patients who want to maintain their fertility, especially when they have bulk symptoms (pelvic pressure, early satiety, and changes in bowel habits). A laparoscopic approach is appropriate when a skilled laparoscopic surgeon is available; however, an abdominal approach is also acceptable. Treatment with GnRH agonists is associated with reduction in leiomyoma size and overall size of the uterus, decreased AUB-L and dysmenorrhea, and improvement in quality-of-life measures (i.e., days of bleeding, pelvic pressure, pelvic pain, urinary frequency, and constipation). Transvaginal ultrasonography is a useful screening test to assess for leiomyomas. Sonohysterography is useful to distinguish between type 0, type 1, and type 2 leiomyomas. Hysteroscopy is useful to distinguish between type 2 and type 3 leiomyomas. Magnetic resonance imaging can be useful in surgical planning, determining vascularity and degeneration, and distinguishing between type 4 and type 5 leiomyomas.

Answer 345

For women with recurrent UTIs (two or more within 6 months), antibiotic prophylaxis can be started. Treatment has been shown to decrease the risk of recurrence by 95%. This treatment may be continued for 6–12 months prior to being reassessed. If recurrent UTIs are associated with sexual activity, the patient may benefit from postcoital prophylaxis. Options for antibiotic prophylaxis include nitrofurantoin, trimethoprim-sulfamethoxazole, trimethoprim, cephalexin, cefaclor, and fosfomycin. These medications are given as once-a-day dosing. Answer B: Nitrofurantoin can be given as urinary tract infection prophylaxis but at the dose of 50–100 mg daily at bedtime. The every 6–12 hour dosing is recommended for a 7-day treatment of an acute urinary tract infection, not for daily prophylaxis.

Answer 346

For women with recurrent UTIs (two or more within 6 months), antibiotic prophylaxis can be started. Treatment has been shown to decrease the risk of recurrence by 95%. This treatment may be continued for 6–12 months prior to being reassessed. If recurrent UTIs are associated with sexual activity, the patient may benefit from postcoital prophylaxis. Options for antibiotic prophylaxis include nitrofurantoin, trimethoprim-sulfamethoxazole, trimethoprim, cephalexin, cefaclor, and fosfomycin. These medications are given as once-a-day dosing. Answer B: Nitrofurantoin can be given as urinary tract infection prophylaxis but at the dose of 50–100 mg daily at bedtime. The every 6–12 hour dosing is recommended for a 7-day treatment of an acute urinary tract infection, not for daily prophylaxis.

Answer 347

Combined oral contraceptives Breastfeeding BSO at the appropriate age Salpingectomy may be considered, however is not currently recommended for risk reduction in those with BRCA mutation

Answer 348

Screening Guidelines Age Breast cancer screening Ovarian cancer screening* 25–30 Breast MRI every 6 months Clinical breast exam every 6 months Not recommended >30 Breast MRI and mammography alternating at 6-month intervals Clinical breast exam every 6 months Can consider annual US with CA-125

Answer 349

The most important modifiable risk factor for stroke in women is hypertension. A gradual increase in blood pressure above 120/80 mm Hg shows a linear increase in risk of stroke. A reduction of blood pressure may reduce the risk of stroke by 25%. All of the listed factors are risk factors associated with stroke. Answer B: Diabetes is associated with stroke. However, glycemic control has not been shown to be a cost-effective method to reduce strokes. Answer C: Statin use decreases the risk of stroke by about 18%. This risk reduction may be appreciated in individuals with normal cholesterol levels as well. Answer E: Smoking cessation is recommended for all women, but has not been shown to decrease the risk of stroke more efficiently than blood pressure.

Answer 350

All adults aged 65 years or older who have not previously received a pneumococcal conjugate vaccine should be vaccinated with either 1 dose of PCV15 followed by PPSV23 at least 1 year later, or 1 dose of PCV20. For patients who receive PCV15 and have an immunocompromising condition, cochlear implant, or cerebrospinal fluid (CSF) leak, PPSV23 can be given as early as 8 weeks after PCV15. Vaccination is indicated in patients aged 19–64 with certain medical conditions. Pneumococcal vaccination is an important preventive health care measure that substantially reduces the burden of pneumococcal disease in vaccinated individuals and in the population.

Answer 351

Resuscitation with IV fluids and early administration of IV fluids are imperative and are the first steps in resuscitation of any patient who is thought to be septic, regardless of the etiology, so long as their respirations and oxygenation are adequate. As such, establishing IV access as soon as possible is important. Septic abortion is a form of spontaneous abortion or early pregnancy loss that is complicated by intrauterine infection. It is more common in women who have medical or surgical management versus spontaneous abortion. Initial resuscitation is as follows: Establish IV access for IV fluids and blood products Obtain blood cultures Initiate broad spectrum antibiotics Evacuate the uterus of any contents Antibiotics are typically given until the patient has been afebrile for 48 hours and has shown clinical improvement. Oral antibiotics are given for a total of 10 to 14 days. If the patient does not respond to antibiotics and uterine evacuation or has clostridial necrotizing myonecrosis, then total hysterectomy and adnexectomy should be performed. There are different types of abortion and if hemodynamically stable, do not necessitate emergent surgery as in the case of a septic abortion.

Answer 352

The primary treatment of urge incontinence is lifestyle changes and bladder training. Urge incontinence can be treated medically with anticholinergic medications or a beta-3 adrenergic agonist. The most common side effect of anticholinergic medications is xerostomia. The most common side effect of Mirabigron (beta-3 adrenergic agonist) is hypertension which occurs in about 11% of patients. All other side effects were reported as <5%.

Answer 353

Turner syndrome is classically associated with the 45,X karyotype but, in fact, can occur with numerous types of chromosomal arrangement, including with a Y chromosome due to mosaicism. Karyotypes with a Y chromosome are important to identify early on, as there is increased risk of malignancy in the streak gonads that are present. The classic phenotype is short stature, a webbed neck, sexual immaturity, wide-spaced nipples, and low-set ears. Typically, this syndrome is recognized early in development, but if it is not, it can present with primary amenorrhea at the time of expected puberty. Sexual immaturity occurs because of failure of normal ovarian development, which is characteristic of hypergonadotrophic hypogonadism, according to WHO criteria. These girls typically have elevated FSH levels and low E2 levels. However, those with mosaicism can also present with partial sexual development, delayed puberty, and irregular menses. Therefore, spontaneous conception can occur, although rarely. Typically, pregnancy can be achieved with oocyte donation; however, patients should be informed that pregnancy in women with Turner syndrome can have a mortality rate almost 100-fold more than that of the general population, typically from aortic dissection or rupture. Thus, extensive counseling is recommended, including strong consideration of a gestational carrier.

Answer 354

Subclinical hypothyroidism is defined as an elevated TSH with a normal free thyroxine level. Because these laboratory findings can frequently revert to normal, the initial managment of these laboratory findings is to repeat the tests. With a mildly elevated TSH, they should be repeated in 1-3 months. If the TSH remains elevated with a normal free T4, the diagnosis of subclinical hypothyroidism is confirmed. With a TSH equal to over 15 μU/mL, the tests should be repeated in 1–2 weeks. Initial evaluation of subclinical hypothyroidism TSH When to repeat test 5–14.9 μU/mL 1–3 months 15 or greater μU/mL 1–2 weeks

Answer 355

Subclinical hypothyroidism is defined as an elevated TSH with a normal free thyroxine level. Because these laboratory findings can frequently revert to normal, the initial managment of these laboratory findings is to repeat the tests. With a mildly elevated TSH, they should be repeated in 1-3 months. If the TSH remains elevated with a normal free T4, the diagnosis of subclinical hypothyroidism is confirmed. With a TSH equal to over 15 μU/mL, the tests should be repeated in 1–2 weeks. Initial evaluation of subclinical hypothyroidism TSH When to repeat test 5–14.9 μU/mL 1–3 months 15 or greater μU/mL 1–2 weeks

Answer 356

Peripartum Management of Women with APS History of thrombotic event Prophylactic heparin while pregnant and for 6 weeks postpartum can be transitioned to warfarin after delivery added benefit of aspirin 81 mg is unknown No history of thrombotic event Prophylactic heparin and aspirin 81 mg while pregnant and for 6 weeks postpartum may reduce pregnancy loss by 50% Other Prednisone IV IG

Answer 357

The common peroneal nerve is one of the most commonly injured nerves during gynecological surgery. This nerve traverses the lateral portion of the calf and is likely to be injured during prolonged surgery and/or incorrect positioning while using stirrups. The abnormal compression causes the injury. Damage to the common peroneal nerve causes footdrop injury. Correct positioning and limited time of surgery are paramount to preventing nerve injuries. Appropriate placement of retractors and judicious surgical dissection may also play a role. Understanding of proper nerve innervation and motor control is essential to properly diagnosing a postoperative nerve injury. Swift diagnosis and treatment are the keys to regaining full function. Conservative therapy is warranted in most cases as injuries caused by compression or stretch due to positioning will resolve spontaneously with supportive care. Tricyclic antidepressants, anticonvulsants, GABA antagonists, serotonin and norepinephrine specific reuptake inhibitors can be effective. Physical therapy and avoiding positions that worsen nerve compression are also helpful. Answer B: The femoral nerve is responsible for flexion of the hip, extension of the knee, and tendon reflexes. This large nerve also carries sensation to the anteromedial thigh, calf, and foot. Deep retractors or excessive hip flexion (such as candy-cane stirrups) can injure the femoral nerve. Answer C: The genitofemoral nerve is responsible for sensation to the mons and labia majora. This nerve may be injured or transected during pelvic sidewall dissection, especially in oncologic lymph node dissection. Answer D: The lateral femoral cutaneous nerve is responsible for sensation to the anteroposterior thigh. Deep retractor use and pressure on the psoas muscle may cause injury. Answer E: The obturator nerve has motor control for adduction as well as sensation to the medial thigh. Retroperitoneal dissection or paravaginal repair surgery may interrupt its route.

Answer 358

Risk Factors for Vaginal Mesh Erosion Poor wound healing (eg, due to vaginal atrophy, smoking, diabetes, history of bariatric surgery, use of immunosuppressive medications) Vaginal dissection that was too superficial Excessive tension on the mesh Contaminated vaginal field during placement of the foreign body

Answer 359

Medications that can lead to elevated prolactin levels include those listed in the table below. Serum prolactin levels secondary to drug-induced causes can elevate prolactin levels to 25–100 ng/mL. Medications That Can Elevate Prolactin Levels Antipsychotics Domperidone Metoclopramide Methyldopa Verapamil Opioids Nipple discharge is a common gynecological complaint, and milky discharge outside of pregnancy, or galactorrhea, is most commonly present. Most cases of galactorrhea are benign and are associated with elevated prolactin levels. Elevated prolactin levels can be caused by medications, pregnancy, trauma, endocrinopathies, hypothyroidism, prolactin-secreting adenomas, and stress. Patients with galactorrhea should have a complete history and physical exam with focused diagnostic imaging as needed, usually reserved for females with pathologic or more concerning nipple discharge.

Answer 360

The corpus luteum provides the necessary progesterone for pregnancy prolongation. The placenta takes over this function at around 10 weeks. If the corpus luteum is removed prior to 10 weeks, then progesterone supplementation is required. There are 3 basic supplementation options. First is weekly 17-hydroxyprogesterone caproate injections through 10 weeks' gestation. The second option is oral micronized progesterone, dosed at 200–300 mg orally through 10 weeks. The last option is 8% progesterone vaginal gel PLUS 100–200 mg of micronized progesterone orally. Any of these 3 regimens is sufficient.

Answer 361

The corpus luteum provides the necessary progesterone for pregnancy prolongation. The placenta takes over this function at around 10 weeks. If the corpus luteum is removed prior to 10 weeks, then progesterone supplementation is required. There are 3 basic supplementation options. First is weekly 17-hydroxyprogesterone caproate injections through 10 weeks' gestation. The second option is oral micronized progesterone, dosed at 200–300 mg orally through 10 weeks. The last option is 8% progesterone vaginal gel PLUS 100–200 mg of micronized progesterone orally. Any of these 3 regimens is sufficient.

Answer 362

The most common female sexual dysfunction is sexual interest/arousal disorder. Overall, 43% of American women report experiencing sexual problems, and 12% report the problem causes personal distress. The prevalence of sexual distress increases from 10% among women aged 18–44 years to 15% among women 45–64 years old and then decreases to 9% in women aged 65–85 years old.

Answer 363

Simple ovarian cysts up to 10 cm can be safely observed and followed in women, given the extremely low risk of malignancy (even postmenopausal women). If there are septations, papillary projections, thick-walled borders, or cystic and solid components, these should be further assessed with tumor markers, and surgical intervention for diagnostic and therapeutic purposes should be considered

Answer 364

There are many known risk factors for developing acute pancreatitis. The most common causes are gallstones and alcohol use. Hyperlipidemia is also a known cause as well, with levels generally above 1,000 mg/dL. Causes of Pancreatitis Gallstones (30-45%) Excessive alcohol use (30%) Hyperlipidemia Medication induced (eg, HIV medications) Mumps infection

Answer 365

Coronary heart disease Personal history of breast cancer History of venous thromboembolic event or stroke Active liver disease Unexplained vaginal bleeding High-risk endometrial cancer

Answer 366

Disulfiram inhibits aldehyde dehydrogenase, causing patients to feel fatigue, nausea, and a headache if they relapse. There are many therapeutic options for patients who suffer from alcohol dependence. Medications to treat alcohol dependence First-line treatment naltrexone acamprosate Second-line treatment disulfiram gabapentin topiramate baclofen

Answer 367

Spontaneous abortion is defined by the loss of a pregnancy prior to 20 weeks gestation, and less than or equal to 500 grams. These definitions are key in defining recurrent risks and help identify the underlying disorder leading to the miscarriage.

Answer 368

Both copper and levonorgestrel IUDs are effective contraception. These IUDs do not increase the risk of ectopic pregnancy because they prevent pregnancy so effectively. The proportion of pregnancies that are ectopic is higher with an IUD in place compared with when there is not an IUD in place. However, because IUDs decrease the pregnancy rate so effectively, the absolute risk of an ectopic pregnancy with an IUD in place is decreased compared with not having an IUD in place. Answer C: The ectopic pregnancy rate of women with an IUD in place is 0–0.5 per 1,000 women-years, compared with the rate of 3.25–5.25 per 1,000 women-years in women without the use of contraception.

Answer 369

Women should be screened for HIV with every pregnancy. Some states mandate screening at the initial visit as well as a repeat test in the third trimester or on presentation to the hospital in labor. Screening in pregnancy allows for the identification of individuals who may benefit from treatment of HIV during pregnancy and labor and to reduce disease morbidity and vertical transmission. Answer A: Homosexual and bisexual men should be considered for HIV screening as frequently as every 3–6 months. Answer B: Patients with high-risk behaviors for the transmission of HIV should be screened every year. Answer D: HIV testing is recommended for unscreened adolescents and adults aged 15–65 years, even in low-risk individuals. Persons outside this age range with high-risk factors for HIV should be considered for screening.

Answer 370

Primary dysmenorrhea is defined as painful menstruation in the absence of pelvic pathology. Secondary dysmenorrhea is defined as painful menstruation with a pathologic cause. Possible causes of secondary dysmenorrhea Endometriosis Obstructive Müllerian anomalies Cervical stenosis Ovarian cysts Uterine polyps Uterine leiomyomata Adenomyosis Pelvic inflammatory disease Pelvic adhesions Symptoms suggestive of secondary dysmenorrhea Failure of empiric therapy Mid-cycle bleeding or pain Heavy menses Severe pain immediately upon menarche Renal anomaly Progressively worsening symptoms Family history of endometriosis When primary dysmenorrhea is suspected, empiric therapy with a nonsteroidal anti-inflammatory drug (NSAID) is the first-line treatment. Often, patients may have tried self-treatment with NSAIDs but with incorrect dosing and timing. Therefore, the first evaluation should include a detailed evaluation of their treatment regimen. Ideally, the treatment should be started 1–2 days prior to menses and then continued through the first 2–3 days of bleeding. Other options include combined oral contraceptive pills or the levonorgestrel IUD.

Answer 371

Endometriosis, a disease characterized by ectopic endometrial implants throughout the pelvis, negatively impacts fertility. Of women who present with infertility, 25–50% are estimated to also have endometriosis. Laparoscopic treatment of minimal and moderate endometriosis improves the pregnancy and live birth rates in couples with otherwise unexplained infertility. In a meta-analysis, it was reported that operative laparoscopy nearly doubled the live birth or ongoing pregnancy rates (57 versus 34 total live births or pregnancies over 382 surgeries, odds ratio [OR] 1.94, 95% CI 1.20–3.16).

Answer 372

Answer A: Sacrocolpopexy is a surgical procedure to treat pelvic organ prolapse, not stress urinary incontinence. Patients who undergo surgical repair of their pelvic organ prolapse may present with postoperative stress urinary incontinence because the prolapse kinks and obstructs the urethra but this obstruction is alleviated when the prolapse is repaired. Answer C: Intradetrusor onabotulinumtoxinA (also known as Botox A) is used for the treatment of overactive bladder, not stress urinary incontinence. Botulinum toxin is a neurotoxin that acts as a muscle paralytic by inhibiting the presynaptic release of acetylcholine from motor neurons at the neuromuscular junction. Answer D: Mirabegron is a beta-agonist that activates the beta-3 adrenergic receptor in the detrusor muscle, causing muscle relaxation and increase bladder capacity. Beta-agonists are used to treat urinary urgency and urge incontinence, not stress incontinence. Answer E: Urethral bulking agents are used to treat stress incontinence with intrinsic sphincter deficiency. The bulking agents are injected transurethrally into the periurethral tissue around the bladder neck and proximal urethra to increase urethral resistance. Urethral bulking agents are less effective than surgical procedures such as midurethral sling placement and are rarely used as a first line treatment for stress urinary incontinence.

Answer 373

Amenorrhea occurs in 12% of women during the first 3 months of use and 46% of women after 1 year of use of DMPA. Despite this, 25% of women discontinue DMPA after the first year because of unscheduled bleeding. Light, unscheduled bleeding after DMPA administration may be treated with 5–7 days of NSAID treatment. Heavy bleeding may be treated with NSAIDs for 5–7 days or hormonal treatment with 1.25 mg of conjugated estrogen for 10–20 days.

Answer 374

A number of conditions lead to the broad diagnosis of female sexual dysfunction, but the key component is that the symptoms must be sufficient to result in personal distress. For female sexual arousal/interest disorder, the symptoms must be present for at least 6 months. The DSM-V re-classifed female sexual dysfunction into five categories. DSM-V Female Sexual Dysfunction Female sexual arousal/interest disorder Female orgasmic disorder Genito-pelvic pain/penetration disorder Substance/medication-induced sexual dysfunction Other specified/unspecified sexual dysfunction

Answer 375

Uterine anomalies are associated with 15% of recurrent pregnancy losses. Anomalies include submucosal leiomyomas, endometrial polyps, intrauterine synechiae, Müllerian anomalies, or cervical insufficiency. Saline infusion sonohysterography is the imaging modality of choice to evaluate uterine anomalies. Recurrent pregnancy loss was previously defined as three or more consecutive pregnancy losses; however, this has recently been redefined as two or more pregnancy losses that need not be consecutive. Pregnancy loss remains defined as a loss <20 weeks' gestation or birth weight <500 g. There are three generally accepted broad causes of recurrent pregnancy loss: parental chromosomal anomalies antiphospholipid antibody syndrome uterine anomalies (detailed in the table below) Other possible causes may include environmental toxins, endocrinopathies, or alloimmunity. Uterine Anomalies Associated with Recurrent Pregnancy Loss Submucosal leiomyomas Endometrial polyps Intrauterine synechiae Müllerian anomalies Cervical insufficiency A positive antinuclear antibody (ANA) has not been clearly associated with an increased risk of recurrent pregnancy loss. Only lupus anticoagulant and anticardiolipin antibody are definitively associated with recurrent pregnancy loss, and therefore routine ANA testing is not recommended.

Answer 376

Lichen planus is an inflammatory disorder of the genital mucosa most likely related to cell-mediated immunity; it can occur on any mucosal surface, including the oral and genital cavities. Approximately 1% of the population has oral lichen planus, and 20%–25% of women with oral lichen planus have genital vulvovaginal disease. The classic presentation is white, reticulate, lacy or fernlike striae (Wickham striae) on mucous membranes along with pruritic, purple, shiny papules on the trunk, buccal mucosa, or flexor surfaces of the extremities. Deep, painful erosions in the posterior vestibule can extend to the labia minora and result in agglutination and distortion of normal labial architecture.

Answer 377

The differential diagnosis of chronic pelvic pain includes disorders of the genitourinary, gastrointestinal, and reproductive tracts. Endometriosis can cause chronic pelvic pain, which usually occurs in a cyclical fashion and is due to the migration of endometrial glands and stroma outside the uterine cavity. NSAIDs are typically first-line therapy, but OCPs are equally efficacious. OCPs' mechanism of action results in a hypoestrogenic environment and lack of proliferation of these ectopic glands. They tend to be well tolerated; however, unfortunately for some, they can lead to rupture of large endometriomas within the first 6 weeks of therapy. The mechanism of this is not clear, particularly because smaller endometriomas (<3 cm) can undergo necrobiosis and resorption. Caution should be used when prescribing OCPs to those with large endometriomas. Answer A: Continuous-dose regimens are aimed at a complete suppression of the hypothalamic-pituitary-ovarian axis for a prolonged period and are well tolerated by patients. Intermittent use is also acceptable, but it may lead to increased dysmenorrhea at the time of menses. Answer B: Historically, when OCPs were first mass-produced, higher estrogen contents were shown to have high efficacy. As techniques and synthesis have improved, lower estrogen formulations are equally as effective and are much better tolerated than those with >20 mcg of estradiol per pill. Answer D: Continuous OCPs have been used successfully and have been shown to decrease symptomatology in approximately 80% of patients. Answer E: The most common side effect with continuous OCP use is amenorrhea and concurrent weight gain and breast tenderness, and approximately 33% of patients discontinue use because of these adverse outcomes. Breakthrough bleeding, however, is more common in the 10-mcg dose pill than in the 20-mcg pill.

Answer 378

Pituitary adenomas are the most common cause of acquired pituitary dysfunction and constitute ~15% of all intracranial tumors. Clinically, symptoms of galactorrhea, menstrual disturbances, or infertility may lead to its diagnosis. Most tumors are benign, and only ~0.1% of adenomas develop into frank carcinoma with metastasis. Tumors are classified by their hormonal expression pattern as determined by immunohistochemistry and then further grouped by size into microadenomas (<10 mm in diameter) OR macroadenomas (>10 mm in diameter). Microadenomas are typically diagnosed during evaluation of an endocrinopathy. Macroadenomas frequently present with patient symptoms from invasion of surrounding structures. The anterior pituitary gland neighbors both the optic chiasm and cavernous sinuses. Disruption of the optic chiasm by suprasellar growth of the pituitary mass may create bitemporal hemianopsia, in which the outer portion of the right and left visual fields is lost. The pituitary gland enlarges during pregnancy, primarily due to hypertrophy and hyperplasia of the lactotropes in response to elevated serum estrogen levels. Tumor growth leading to significant symptoms complicates ~2% of microadenomas and 21% of untreated macroadenomas. However, because significant expansion may lead to headaches or compression of the optic chiasm and blindness, visual field testing is considered in every trimester for women with macroadenomas. In general, first-line treatment is medical for both microadenomas and macroadenomas. Specifically, women should receive a dopamine agonist such as the nonspecific dopamine-receptor agonist bromocriptine, or the dopamine-receptor type 2 agonist cabergoline. Neurosurgical evaluation is mandatory when visual field defects or severe headaches are present. Neurosurgery is required for refractory tumors or those causing acutely worsening symptoms. The pituitary is approached through a transsphenoidal route whenever possible.

Answer 379

Treatment for premenstrual syndrome (PMS) is based on either symptom reduction, or modification of underlying hormonal dysregulation. Mild to moderate symptoms can be relieved by changes in lifestyle and/or diet. However, when symptoms begin to interfere with the patient’s life then medical treatment should be recommended in addition to changes in lifestyle and/or diet. If treatment fails or symptoms are severe then psychiatric referral may be necessary. Well-controlled trials of selective serotonin-reuptake inhibitors (SSRIs) have shown these drugs to be efficacious and well tolerated. Efficacy is highly variable with progesterone and estrogen. Data are limited in support of combination oral contraceptive pills for PMS. Answer A: SNRIs can be used for the treatment of PMS, however SSRIs are the first line. Answer C: Ibuprofen will help her dysmenorrhea, but will not resolve all her symptoms. Answer D: Studies to examine the effects of combined OCP on premenstrual syndrome (PMS) found little difference in PMS symptoms between combined OC users and nonusers. Answer E: GnRH agonists are usually reserved for when other treatment modalities have failed.

Answer 380

Primary dysmenorrhea presents as cramping and pelvic pain at time of menses. It may be associated with heavy menstrual flow. It can be treated empirically with medications as there are no current laboratory or imaging diagnostic criteria. The first-line treatment for primary dysmenorrhea is nonsteroidal anti-inflammatory drugs (NSAIDs). While most NSAIDs inhibit both cyclooxygenase-1 (COX1) and COX2, the primary anti-inflammatory process is through COX2. COX1 is expressed in platelets.

Answer 381

When a patient has chronic vaginitis, vulvar care recommendations are the first treatment to utilize. The measures used in these treatments include avoiding scented products or other chemical wipes or gels on the sensitive areas of the body, using aqueous creams, avoiding washcloth use, gently drying the vulva with dabbing, avoiding tight-fitting pants, using white cotton underwear, avoiding excessive detergents, and wearing skirts or no underwear when at home or in bed to avoid friction. Medicated creams are second line, and surgery should be used only as a last resort.

Answer 382

When a patient presents with prolapse and says she desires surgical management, an obliterative procedure can be performed if she is no longer sexually active. The colpocleisis is an excellent surgical option in patients with multiple comorbidities, and where the concerns of being under anesthesia are great. A colpocleisis can be performed under regional and local anesthesia if necessary. The procedure is as follows: A strip of the anterior and posterior vaginal wall is removed. Purse-string sutures are placed with a delayed absorbable material. The vagina can be divided into quadrants, and the first stitch to be tied is the one placed closest to the cervical os, followed by the second, third, and so on. In the Le Fort partial colpocleisis, the anterior and posterior vaginal walls are again removed. The edge of the anterior vaginal wall is sewn to the cut edge of the posterior vaginal wall. As the edges are sewn to each other, the vagina begins to invert on itself. Answer C: McCall culdoplasty is performed at the time of a vaginal hysterectomy. The uterosacral ligaments are plicated at the midline. Vaginal coitus is still possible. Bottom Line: Colpocleisis is a vaginal obliterative procedure that can be performed when prolapse is present in older women who no longer desire vaginal coitus.

Answer 383

Cerebrovascular accidents are a common form of severe morbidity and even mortality, particularly hemorrhagic strokes. In a study of more than 40,000 patients in Denmark, the 90-day unadjusted case fatality rate was 25% for hemorrhagic strokes compared with 10.9% for ischemic strokes. This is presumably due to the devastating nature of extravasated blood on the brain; and prompt diagnosis and drainage can be life-saving. Answer A: Ischemic strokes were found to be more common in patients with a preexisting diagnosis of diabetes: a finding that has been consistently shown across many studies. Hypertension can be associated with either stroke type, but the cited study claims it was more likely to be associated with the hemorrhagic subtype. Answer B: Hemorrhagic strokes tend to be more severe; in patients presenting with a “severe” stroke based on clinical manifestations, 30% had hemorrhagic stroke compared with 2% of patients with a “less severe” presentation. Answer C: Hemorrhagic strokes are less common than ischemic strokes, with 89.9% of patients presenting with ischemic strokes and 10.1% presenting with hemorrhagic stokes. Answer E: No differences have been found between males and females in terms of propensity to be diagnosed with a stroke, although women tend to be older than men at their diagnosis. This is likely because of the protective effect of endogenous estrogen on the vasculature, a phenomenon that does not translate into exogenous administration.

Answer 384

Prior to October 2020, the U.S. Preventative Services Task Force (USPSTF) had recommended that colorectal cancer screening be initiated at age 50 for all average-risk adults, but begin earlier at age 45 years for Black adults due to the higher rates of cancer. However, the latest USPSTF recommendations advise that routine screening for all adults begin at age 45 years for colorectal cancer regardless of risk factors, as nearly 94% of all new colorectal cancer cases are occurring in adults 45 years and older. While rates of colorectal cancer are higher in Black adults, the age to begin routine screening is not younger than the general population. All women should be screened for colorectal cancer, regardless of family history. For women with an increased risk of colon cancer based on history, in general, screening is recommended to begin 10 years prior to the earliest familial colorectal cancer diagnosis or the routine recommended age, whichever is youngest.

Answer 385

PCS is a disease characterized by pelvic pain for longer than 6 months and is described as a dull ache. The pain has been reported as worsening premenstrually or with periods of prolonged standing, walking, or other activities that may increase intraabdominal pressure. The patient often has generalized tenderness on exam.

Answer 386

Fibroids are the most common indication for hysterectomy in the United States, but surgery may not be feasible for every patient, particularly if multiple medical comorbidities make the patient a poor surgical candidate. A patient with significant medical comorbidities or who is perimenopausal may benefit from gonadotropin-releasing hormone (GnRH) agonist therapy, such as leuprolide acetate. GnRH agonists are primarily used as either preoperative therapy (typically 3–6 months in duration) or as transitional therapy for patients in late perimenopause as they move to menopause. Good quality data exist that GnRH agonists decrease uterine and fibroid volume, increase hemoglobin, and improve perioperative outcomes in patients prior to undergoing hysterectomy and myomectomy. Answer A: Abdominal myomectomy is a risky procedure in this patient given her multiple medical comorbidities. In addition, myomectomy is typically reserved for those who desire future childbearing. Answer C: Observation is not appropriate for this patient who desires definitive therapy and is frustrated by receiving multiple transfusions without a cure being tendered. Although leuprolide acetate is not a cure, it is a better option than watchful waiting. Answer D: A relative contraindication to robotic hysterectomy is elevated BMI (although this is debatable); however, the main reason this is incorrect is that it is a surgical procedure associated with severe morbidity and mortality, and this patient is a poor surgical candidate. Answer E: Uterine artery embolization is an excellent option for women who are poor surgical candidates. Unfortunately, our patient has a severe allergy to iodinated contrast material, which is essential to performing the uterine artery embolization; therefore, it is not recommended.

Answer 387

Vulvar psoriasis usually does not result in the classic scaly appearance, and increased moisture and heat in the region may make it resemble candidiasis. Besides biopsy, the key to diagnosis is that psoriasis does not involve the vagina. Treatment settles around the use of hydrocortisone for mild disease and prolonged topical steroids for moderate disease, with dermatology referral if no improvement is seen. Systemic steroids, although sometimes useful for psoriasis in other body areas, usually result in a rebound flare-up in the vulvar region. Answer A: For moderate to severe disease, dermatology referral is appropriate after failure of prolonged topical steroid treatment, rather than on initial diagnosis. Answer B: Four weeks of topical steroid therapy is the mainstay of treatment for refractory psoriasis that does not respond to conservative hydrocortisone treatment. Answer C: Hydrocortisone 1% cream is used in the initial treatment course, rather than being reserved for refractory cases. Answer D: As previously stated, psoriasis of the vulva does not include the vagina, which is necessary for the distinction between psoriasis and candidiasis.

Answer 388

Metabolic syndrome has been used to describe the coexistence of risk factors for type 2 diabetes and cardiovascular disease, including abdominal obesity, hyperglycemia, dyslipidemia, and hypertension. The prevalence of metabolic syndrome among adolescents is estimated to be approximately 9%. Half of all adolescents initially classified with metabolic syndrome will no longer meet the criteria after 3 years; others will acquire the diagnosis. Awareness of these facts is highly important in order to counsel and motivate your patient to assist in making better, healthier choices associated with more positive outcomes. The recognition of metabolic syndrome as a distinct entity is to draw attention to the vastly increased morbidity associated with it. Criteria for metabolic syndrome: The diagnosis of metabolic syndrome requires 3 out of 5 of the following: female waist circumference over 88 cm elevated blood pressure greater than or equal to 130 systolic; 85 diastolic triglyceride level greater than or equal to 150 HDL level less than or equal to 50 glucose level greater than or equal to 100 or previously established diabetes

Answer 389

Contraceptive Method Typical use % Perfect use % Copper IUD 0.8 0.6 Levonorgestrel IUD 0.2 0.2 Implant 0.05 0.05 Long-acting reversible contraceptives (LARC) are the most effective reversible contraceptive methods. They include intrauterine devices (IUDs) and contraceptive implants. The major advantage of LARC compared with other reversible contraceptive methods is that they do not require ongoing effort on the part of the patient for long-term and effective use. The return of fertility is usually rapid once the device is removed. Typical use failure rate is described as the percentage of women who experience accidental pregnancy during the first year of initiating the use of a method of contraception. However, perfect use failure rate is described as the percentage of women who experience accidental pregnancy during the first year of initiating the use of a method of contraception when this method is used perfectly (consistently and correctly). The failure rate of the ParaGard IUD is approximately 0.6% in the first year of perfect use. It has a reported failure rate of 0.8 per 100 women at 1 year of typical use.

Answer 390

The patient in the question stem has endometriosis. Endometriosis occurs in as many as 32% of patients with pelvic pain and as many as 50% of patients with infertility. Although pain is not directly related to the amount of endometriosis, it is directly related to the depth of endometriosis and the involvement of neurologic structures. Inflammatory cytokines (specifically IL-1, which activates IL-8) are released along with TNF. These cytokines lead to activation of COX and release of prostaglandins, increasing uterine contractions and inflammation of the direct sites of disease. These occur in the background of an estrogen-laden environment. Treatment for Endometriosis NSAIDs are the most common first-line treatment Combined oral contraceptive pills (OCPs) are the 2nd most common treatment, may be taken continuously to create a pseudopregnant state with constant estrogen level GnRH agonist has superior efficacy to OCPs Depot leuprolide may lead to osteoporotic symptoms, hot flashes, or other menopausal symptoms (ie, vaginal dryness, dyspareunia, decreased sexual desire, or pain) To offset these menopausal symptoms, add-back therapy may be used immediately when taken with combined estrogen and progesterone. There is no evidence to support waiting until the patient is symptom-free before starting add-back therapy Add-back therapy reduces or eliminates GnRH agonist-induced bone mineral loss and provides symptomatic relief without reducing the efficacy of pain relief Add-back regimens (using either sex-steroid hormones or other specific bone-sparing agents) have been advocated for use in women undergoing long-term therapy (more than 6 months). Regimens include progestins alone, progestins and bisphosphonates, low-dose progestins, and estrogens. The FDA has approved the daily use of norethindrone 5 mg, as add-back therapy with a GnRH agonist. If women do not tolerate high-dose norethindrone, transdermal estradiol with medroxyprogesterone acetate can be used (transdermal estradiol 25 μg per day plus medroxyprogesterone acetate 2.5 mg orally daily), although this has not been approved by the FDA.

Answer 391

The most common single chromosomal abnormality is monosomy X, or Turner syndrome (also known as absent Barr body, 45,X, or XO), with an approximately 20% incidence. However, as a group, trisomies are the most common chromosomal abnormalities leading to first trimester miscarriage. Trisomies AS A GROUP are the most common chromosomal abnormalities leading to miscarriage, and the most common trisomy is 16; however, this single abnormality accounts for only 13% of first-trimester miscarriages

Answer 392

Lichen simplex chronicus is a dermatologic disorder characterized by a chronic itch-scratch cycle which leads to chronic trauma secondary to rubbing and scratching. This disease is generally started when there is an exposure to a detergent, soap, or other agent such as heat. This irritation secondary to scratching leads to more excoriation within a background of erythema. In return, more scratching causes a lasting trauma to the skin. It can cause sleep disruption and symmetric skin changes. The treatment of this disease involves the halting of the itch-scratch cycle generally eliminating stimuli. Steroid topical cream can be used to decrease inflammation. Lubricants or other oils and baths may be used to help in curing this disease. Oral antihistamines, trimming fingernails, and wearing cotton gloves at night may help as well. If there is no resolution in 1 to 3 weeks, a biopsy may be needed. The usual pathologic finding on biopsy is thickening of the epidermis and stratum corneum.

Answer 393

Hyperandrogenism in PCOS is due to an elevated LH level Polycystic ovary syndrome (PCOS) is characterized by a hyperestrogenic environment causing anovulation, increased androgen production (e.g., acne, hirsutism), and hyperinsulinemia. The pathophysiology is hormonal in nature and relates to an increase in peripheral estrogen production, which leads to decreased FSH production and increased LH production via negative feedback. In a normal ovulatory cycle, the dominant follicle produces the most estrogen and feeds back to the pituitary to decrease FSH (to prevent other follicles from continuing to grow) and increases LH receptors on the dominant follicle. Positive feedback of estrogen on the anterior pituitary increases LH production, thus leading to ovulation. LH is also responsible for androgen production, which is necessary for dominant follicle production. Low levels of androgens increase aromatase activity within the follicle, but levels that are too high lead to follicular atresia, which is why a timed surge of LH is all that is needed to effect ovulation.

Answer 394

DSM-5 Diagnostic Criteria Bulimia Nervosa Recurrent episodes of binge eating which is characterized by both: 1) Eating, in a discrete period of time, an amount of food that is definitely larger than most people would eat in a similar circumstance 2) A feeling of lack of control over eating during the episode Recurrent inappropriate compensatory behavior to prevent weight gain (vomiting, laxatives, excessive exercise, etc) The binge eating and inappropriate compensatory behaviors both occur at least once a week for 3 months Self-evaluation is unduly influenced by body shape and weight The disturbance does not occur exclusively during episodes of anorexia nervosa

Answer 395

Hidradenitis suppurativa (HS) is a chronic, unrelenting, refractory infection of the skin that can be very debilitating. Current theories involve inflammation beginning in the hair follicles. A multifaceted approach to the treatment of HS is necessary. Lesions include both inflammation (early disease amenable to medical treatment) as well as fibrosis (late/chronic disease amenable to surgery only). Early disease can be treated with antibiotics (eg, clindamycin per os [PO]) and anti-inflammatory drugs, but there is often relapse. When chronic disease is encountered (scarring and fistulous tracts), the best treatment option involves wide operative excision. Treatment for Hidradenitis Suppurativa Mild disease (no scarring) Topical clindamycin (first line) Oral tetracyclines (second line) Warm compresses Intralesional corticosteroids Surgically unroofing lesion Moderate to severe disease (scarring present) Oral tetracyclines Oral clindamycin and rifampin Subcutaneous adalimumab (FDA approved for HS) Oral retinoids Wide local excision

Answer 396

Fitz-Hugh–Curtis syndrome is a result of chronic inflammation around the liver capsule, classically from pelvic inflammatory disease, which may include right upper quadrant pain, a friction rub on the right anterior costal margin with auscultation, and scarring in the right upper quadrant visible on laparoscopy. Allen–Masters windows, endometriomas, flat stellate lesions, and hemosiderin deposition can all be seen in endometriosis.

Answer 397

Splinting (This is using a finger to assist in a bowel movement and is a symptom of pelvic organ prolapse), digitation (This is the use of a finger or instrument to manipulate the bladder to better be able to urinate and is a symptom of pelvic organ prolapse), pelvic pressure, and vaginal bulge are the most common symptoms of pelvic organ prolapse. When a patient presents with urinary or gastrointestinal symptoms and you suspect pelvic organ prolapse, it is always important to perform a physical examination. However, prior to this it is important to obtain a full and focused history in order to better determine what you suspect to be the problem. In order to diagnose a pelvic organ prolapse, it is necessary that symptoms should be improved by using surgical or nonsurgical intervention. Potential procedures are vast depending on the type of prolapse, the current state of the patient, previous procedures used to correct the problem, and desires of the patient. These are beyond the scope of this explanation, but the symptoms of bulge, pressure, splinting, and digitation are strong indicators, even prior to performing a physical exam, that the patient may have pelvic organ prolapse.

Answer 398

The use of epinephrine with lidocaine not only causes vasoconstriction and decreases bleeding during vulvar biopsy, but it also increases the duration of the anesthetic effects of lidocaine. Vulvar dermatoses, such as lichen sclerosus in this case, are some of the most common reasons for visits to the gynecologist. Vulvar cancers mimic many of the common dermatoses so a biopsy is often warranted to prevent a delayed or a missed diagnosis of cancer. Lichen Sclerosus One of the most common chronic vulvar dermatoses Occurs in 1 in 60 patients seen in a general gynecology practice Occurs mostly in the menopausal and prepubertal population Causes pruritis and pain of the vulvar and perianal skin, often in an hourglass shape Characterized by thinned, whitened ("cigarette paper") skin; skin tearing; and loss of vulvar architecture Biopsy is indicated if the diagnosis is not readily apparent by examination, if there are elements of the examination/noninvasive testing that are concerning for cancer, if the patient is immunocompromised, if lesions worsen during treatment, or if diagnosis remains uncertain after treatment. In addition, patients with lichen sclerosus are at an increased risk (2–5%) of vulvar squamous cell carcinoma. Diagnostic delays in identifying vulvar cancer are unfortunately quite common. Practitioners should have a low threshold for biopsy to confirm the diagnosis of dermatoses rather than empirically treating patients with steroids under the assumption that a dermatosis exists.

Answer 399

A pituitary microadenoma is usually discovered during a workup on hormonal causes of galactorrhea, amenorrhea, menstrual disturbances, or infertility. A microadenoma is detected by MRI and is defined as <10 mm in size. The risk of growth is low (1–2%) for microadenomas, and may often be treated medically. The resolution of menses allows for healthy pregnancies if desired.

Answer 400

Multiple studies have demonstrated a protective effect against ulcerative colitis for patients who have had an appendectomy; however, the mechanism is not yet understood. In contrast, there is evidence that the risk of Crohn disease may be increased after an appendectomy. Ulcerative colitis and Crohn disease are frequently tested topics and have specific features that differentiate them from each other. Ulcerative colitis and Crohn disease are frequently tested topics and have specific features that differentiate them from each other. Ulcerative colitis is associated with rectal and colon involvement that is linear and mucosal only. Crohn disease can involve any area of the gastrointestinal tract, is transmural, and may appear to have "skip lesions." Although appendectomy and smoking are protective for ulcerative colitis, they are risk factors for Crohn disease.

Answer 401

Pulmonary artery hypertension is due to hereditary, sporadic, or small artery disease. Pulmonary hypertension can be due to secondary causes (e.g., right-sided heart failure, chronic lung disease, chronic thromboembolic pulmonary hypertension, and other multifactorial causes). Several risk factors are associated with this disease, including those listed below. Risk Factors Associated With Pulmonary Hypertension hereditary factors (several genes coding proteins, including BMPR2 protein, are associated with pulmonary artery hypertension) connective tissue disease (autoimmune diseases such as scleroderma, rheumatoid arthritis, and lupus that cause small artery and capillary diseases) drugs and toxins (e.g., appetite suppression, methamphetamine) HIV infection heart disease (other than left-to-right shunt, cardiomyopathy, and obstructive outflow cardiac disease which do not count in this category) schistosomiasis

Answer 402

Uterine artery embolization (UAE) is absolutely contraindicated in the following situations: pregnancy, asymptomatic fibroids, uterine malignancy, and pelvic inflammatory disease. Relative contraindications include postmenopausal status, desire for future pregnancy, contraindications to radiologic contrasts, subserosal or submucosal fibroids with a thin stalk, and potentially large volume fibroids; however, studies are lacking. UAE is a procedure that can be performed to treat heavy uterine bleeding associated with uterine fibroids. It is a minimally invasive, uterine-sparing option that is usually performed by interventional radiologists to embolize the uterine arteries via a transcutaneous femoral artery approach. UAE is recommended in premenopausal women who do not desire childbearing and have symptomatic uterine bleeding. Common complications after UAE include fever, nausea, pain and malaise. Pain after UAE is common due to fibroid tumor necrosis and is typically self-limited; however, pain lasting more than 24 hours may require readmission. Readmission for pain is more common after UAE than after hysterectomy. Another common complication is vaginal discharge after UAE, which can last up to 4 months and is also usually self-limiting. Uterine Artery Embolization Common Complications Following Procedure Fever Nausea Pain (usually self-limiting) If pain exceeds 24 hrs, readmission may be required Malaise Vaginal discharge (usually self-limiting) Absolute Contraindications Pregnancy Asymptomatic fibroids Uterine malignancy Pelvic inflammatory disease Relative Contraindications Postmenopausal status Desire for future pregnancy Contraindications to radiologic contrasts Subserosal or submucosal fibroids with a thin stalk Potentially large volume fibroids

Answer 403

This patient's age is the factor that puts her at the highest risk for osteoporotic fracture. The FRAX® index is a powerful tool that takes risk factors, as well as country, into account to determine fracture risk. Treatment should be considered if there is a 3% risk of hip fracture or 20% risk of a major osteoporotic fracture (spine, arm, shoulder, hip). Predictors of fractures Strongest predictors Age Previous history of low-impact fracture Bone mineral density Other risk factors Smoking history Glucocorticoid history Family history of hip fracture Low body weight Excessive alcohol consumption Rheumatoid arthritis Chronic liver disease Early menopause/surgical menopause

Answer 404

The patient likely has polycystic ovarian syndrome (PCOS) based on her infertility and oligomenorrhea. Although, at this point, there is not enough clinical information provided in the vignette to meet Rotterdam criteria. Patients with PCOS also have an association with endometriosis. The patient's ultrasound findings are consistent with an endometrioma: a cystic mass with low- to medium-level echoes, especially with small echogenic foci in the cyst walls. The foci are endometrial glands, and the low-level echoes correlate with the hemorrhagic component. Answer B: A functional cyst will usually be associated with an ovulating patient with a small cyst. Answer C: A hemorrhagic corpus luteum results from bleeding into the cyst that forms when an oocyte is ovulated from a follicle. On ultrasound, a hemorrhagic corpus luteum appears as a thick-walled cystic lesion with lace-like strands. Answer D: Mucinous cystadenocarcinoma is usually a multilocular, large cyst with echogenic fluid. Answer E: A serous cystadenoma will have clear fluid with or without thin septations. They will generally be smaller than a serous cystadenocarcinoma.

Answer 405

The mucosa is the most interior layer of the bladder. It is lined by transitional epithelium, also referred to as uroepithelium. The muscular central layer is made of the detrusor muscle, and the outermost layer is referred to as the adventitia. Hence, the layers of the bladder from internal to external appear in this order: mucosa, muscle, adventitia.

Answer 406

Cushing disease is an excess of the steroid hormone cortisol in the blood caused by a pituitary tumor secreting adrenocorticotropic hormone (ACTH). While Cushing disease is not a super high yield topic, evaluation, management and the ability to distinguish differential diagnosis of hyperandrogenism are important. Hirsutism affects 5–10% of reproductive-aged females and is defined as excessive terminal hair growth in a distribution typically seen in adult men (face, sternum, lower abdomen, back, and thighs). Acne vulgaris is a multifactorial skin condition of varying severity that affects as many as 90% of all adolescents. Common potential causes of hyperandrogenism include nonclassic congenital adrenal hyperplasia, PCOS, androgen-secreting tumors, hypothyroidism, Cushing disease, and severe hyperprolactinemia. Cushing syndrome is the result of prolonged exposure to glucocorticoids, most notably cortisol. Symptoms include weight gain, central obesity, hyperglycemia, and stretch marks. Cortisol potentiates the effects of epinephrine; thus, vasoconstriction is heightened, which leads to high blood pressure. Cortisol also has mild mineralocorticoid effects, which lead to the reabsorption of sodium in the collecting ducts of the nephron. This leads to hypernatremia. However, water follows suit, which causes a dilutional effect and eventually hyponatremia. The reabsorption of water also increases total volume, which builds upon the already high blood pressure level. Potassium and hydrogen ions are expelled, which leads to a hypokalemic, hyponatremic, metabolic alkalosis. When considering causes of high levels of endogenous cortisol, a myriad of diagnostic tests are at your disposal. Dexamethasone suppression test low-dose (0.5-mg) dexamethasone suppression test administered first dexamethasone, a synthetic steroid, initiates the feedback inhibition that cortisol normally does at the pituitary under normal physiology, ACTH production from the pituitary drops and cortisol levels are suppressed if there is no suppression, however, another etiology is responsible for the hypercortisolism, and further testing must be done high-dose (1-mg) dexamethasone suppression test administered to generate a stronger inhibitory response at the pituitary if there is suppression, this is indicative of a pituitary adenoma, as higher levels of the synthetic steroid inhibit the effects of the tumor at the pituitary

Answer 407

Visual field testing is the first step in determining if imaging is necessary in pregnant women with a macroadenoma Prolactinomas are common and, depending on their size, may enlarge during pregnancy. Microadenomas are defined as being <1 cm in diameter, whereas macroadenomas are >1 cm. Chances of enlargement during pregnancy are 1.4% and 26%, respectively. Visual field testing should be performed every trimester, and imaging should be performed only if symptoms develop. Headaches, unfortunately, are very common findings in pregnancy, and lack of symptoms related to her visual field may still require imaging to rule out more dangerous etiologies. MRI would be the best choice for this patient if visual field testing revealed abnormalities. Answer C: Serum prolactin levels are of no use during pregnancy because the pregnancy itself can confer up to a 300-fold increase in prepregnancy levels. It is a nonspecific test and is not helpful in diagnosing an enlarging tumor. Answer D: As with most answers on tests, surgery is usually the last option. Bromocriptine and cabergoline are so effective at managing prolactinomas that surgery is rarely needed in modern times.

Answer 408

Post-embolization syndrome is an early complication of uterine artery embolization and includes the constellation of fever, nausea, pain, and malaise. These issues are typically self-limited and typically resolve within the first 24 hours. Compared with any type of surgery for uterine leiomyomas, uterine artery embolization is associated with similar rates of major post-procedural complications but is actually associated with a higher rate of minor post-procedural complications. Of these minor complications, post-embolization syndrome is one of the most common. Due to these relatively common early complications, the number of unscheduled visits and readmissions after uterine artery embolization is higher than for myomectomy and hysterectomy. Uterine artery embolization is an option for treatment of symptomatic leiomyomas especially in patients who are otherwise poor surgical candidates. The procedure is done under local anesthesia and involves injecting dye into the hypogastric artery and deploying alcohol beads into the uterine artery to occlude the vessel.

Answer 409

Antiphospholipid syndrome (APS) is an acquired, autoimmune thrombophilia that can lead to recurrent first-trimester or second-trimester miscarriages as well as the early onset of intrauterine growth restriction (IUGR) and severe preeclampsia. Its diagnosis depends on one of these clinical criteria, as well as strict laboratory criteria, for which this patient has been given the diagnosis. APS is the only thrombophilia for which treatment can drastically reduce the risk of recurrent miscarriage, and prophylactic dosing is all that is needed in most cases. Patients with APS who develop blood clots are usually placed on a long-term plan of anticoagulant medications (commonly called “blood thinners”), such as aspirin, warfarin, or heparin. Pregnant women with APS are usually treated with heparin. This treatment gives a fetus an 80% to 90% chance of survival, although it will likely be born several weeks premature. Left untreated, a fetus has only about a 20% chance of survival. Other medications used to treat APS include corticosteroids, such as prednisone. The three antiphospholipid antibodies that contribute to the diagnosis of antiphospholipid syndrome are: lupus anticoagulant anticardiolipin anti-β 2-glycoprotein I. Complications associated with APS include fetal loss, as well as a higher risk of developing preeclampsia and IUGR. In women with APS and a history of stillbirth or recurrent fetal loss but no previous thrombotic history, prophylactic doses of heparin and low-dose aspirin during pregnancy and 6 weeks of postpartum should be considered.

Answer 410

Septic abortion can complicate spontaneous and induced abortions. Presenting signs and symptoms are similar to those of ARDS and other forms of septic shock. Treatment entails immediate resuscitation with IV fluids and the initiation of broad-spectrum antibiotics. Surgical removal of the products of conception (POCs) should be prompt and should occur as soon as the patient is stable. Delay in removal of the POCs may lead to worsening maternal morbidity and could prove fatal. Answer A: Expectant management is not a choice in this setting. A septic abortion requires prompt removal of the POCs. Answer B: Manual evacuation of a septic abortion should take place in the operating room. The opportunity for hemorrhage is great. Even if POCs are visible, exploration under anesthesia is usually warranted in the setting of a septic abortion. Answer C: Misoprostol is very effective in the setting of abortions. However, the onset of action is not quick enough or reliable enough in this setting. Answer D: IV antibiotics may be transitioned to oral antibiotics once the patient is afebrile. This time frame is highly variable, and the fever will likely not abate unless the POCs are removed. Bottom Line: Septic abortion requires prompt diagnosis, fluid resuscitation, broad-spectrum antibiotics, and surgical management once the patient is stable enough to be transferred to the OR. Time is of the essence, and the consequences of delayed removal of the POCs may prove fatal.

Answer 411

Pelvic pain is the most common symptom in women diagnosed with ovarian remnant syndrome (ORS), and is found in over 80% of women with this diagnosis. In premenopausal women the pain is often cyclical. Pathologic inspection of adnexal tissue at time of oophorectomy has shown microscopic ovarian tissue up to 1.5 cm from the gross specimen, in the direction of the pelvic wall. In cases where the surgical specimen is limited to the ovary itself with limited surrounding tissue, some ovarian tissue may still be present in situ. Therefore, some clinicians recommend a margin of at least 2 cm in the direction of the infundibulopelvic ligament to allow for complete resection of ovarian tissue. However, this is not always possible in cases of endometriosis or other adhesive disease and may explain why ORS is more common on the left side, near the sigmoid colon. A high level of suspicion for the diagnosis may help lead to the diagnosis and ultimate treatment of this condition.

Answer 412

Chronic hypertension is common in the general population. According to the American Heart Association, an estimated 39 million American women are hypertensive. More than 65% of women over the age of 60 have elevated blood pressure, but cases of hypertension can occur in younger patients. Usually in this demographic the cause of elevated pressures are due to a secondary cause, such as renal artery stenosis, Cushing syndrome, pheochromocytoma, or Conn syndrome. Regardless, hypertension can be classified according to the criteria below. Hypertension Classification Normal blood pressure <120 mm Hg systolic and 80 mm Hg diastolic Elevated blood pressure 120–129 mm Hg systolic and <80 mm Hg diastolic Stage 1 hypertension 130–139 mm Hg or 80–89 mm Hg diastolic Stage 2 hypertension >140 mm Hg systolic or >90 mm Hg diastolic The staging is based on the highest of the stages (i.e., if systolic is stage 2 and diastolic is stage 1, the patient has stage 2 hypertension).

Answer 413

This patient is presenting with complaints consistent with a cystocele. With no other information provided, it appears that this is the likely cause of her urinary issues. Workup of urinary symptoms generally includes measurement of postvoid residual volume with catheterization or ultrasonography, and a urine culture to rule out infection. Following this, a physical examination is generally performed to assess the severity of the disease. This is a stage 2 pelvic organ prolapse, meaning that the lowest point of the vagina is within 1 cm of the hymenal remnant. The best use of the information at hand at this point is to perform a trial with a pessary to see if it helps her symptoms.

Answer 414

According to ACOG, DXA screening for osteoporosis should be offered to all women starting at age 65 years. Some patients may present with risk factors requiring earlier screening, including those shown in the table below. Risk Factors for Early DXA Screening medical history of a fragility fracture body weight less than 127 lb medical causes of bone loss (medications or diseases) parental medical history of hip fracture current smoker alcoholism rheumatoid arthritis

Answer 415

Endometriosis is a gynecologic condition that occurs in 6–10% of women of reproductive age, with a prevalence of 38% in infertile women and in 71–87% of women with chronic pelvic pain. Endometriosis can cause chronic pelvic pain, which usually occurs in a cyclical fashion and is due to the migration of endometrial glands and stroma outside the uterine cavity. Medications for the Treatment of Endometriosis NSAIDs OCPs Progestins GnRH agonists Elagolix Nonsteroidal anti-inflammatory drugs (NSAIDs) are typically first-line therapy, but hormonal therapy is equally efficacious. Progesterone can be given daily as an oral capsule or every 3 months as an injection. These drugs typically do not get rid of endometriosis tissue that is already there. After an appropriate pretreatment evaluation (to exclude other causes of chronic pelvic pain) and failure of initial treatment with oral contraceptives and nonsteroidal anti-inflammatory drugs, empiric therapy with a 3-month course of a GnRH agonist is appropriate to control endometriosis-related pain. GnRH agonists are highly effective in reducing the pain syndromes associated with endometriosis but may have significant side effects including hot flashes, vaginal dryness, and osteopenia.

Answer 416

Luteinizing hormone (LH) surge can be detected in either urine or serum samples and appears in urine within 12 hours after it appears in the serum. Urine predictor kits are typically positive approximately 36 hours before the oocyte is released. These are available over the counter and do not require invasive ultrasonography or a clinic visit to interpret. Importantly, they are able to PROSPECTIVELY identify ovulation, making them useful for intercourse timing. Women should be counseled that they should begin testing their urine 1 or 2 days before the expected surge. Answer A: Basal body temperature changes show an increase 1–2 days after ovulation and are sufficient to retrospectively identify it, but they occur too late to be useful for timing sexual intercourse for conception. Answer B: Moliminal symptoms, including thin cervical mucus, menstrual cramps, breast tenderness, fluid retention, and appetite or mood changes, can indicate normal cycling but are not a reliable method of predicting ovulation. Answer C: Serum midluteal progesterone levels >6 ng/mL can reliably retrospectively confirm ovulation; however, they will not predict ovulation in order to direct intercourse. Answer D: Ultrasonography can be helpful in determining when a follicle is ready to rupture for ovulation; however, in a healthy young woman without a diagnosis of infertility, this is expensive, invasive, and unwarranted.

Answer 417

Pemphigus vulgaris tends to occur in older patients and is characterized by autoantibodies that are targeted to desmogleins, which are part of the desmosomes that hold cells together. It is clinically manifested as large, flaccid bullae that burst easily given the subcutaneous location of the lesions. They are located on the skin and mucous membranes; this is the distinguishing characteristic between this and bullous pemphigoid. Treatment consists of oral and topical steroids. Answer A: Bullous pemphigoid is similar to pemphigus vulgaris (hence the name), and is due to autoantibodies directed against hemidesmosomes, which hold interstellar junctions to the basement membrane. Thus, these lesions are sub-epidermal and tend to be characterized by bullae that do not rupture with gentle palpation. The treatment consists of high-potency steroids. Answer B: Erosive lichen planus can also involve the skin of the vulva and mucous membranes (particularly in the mouth and vagina). The lesions can be locally destructive and lead to atrophy and scarring but do not tend to form bullae. Answer C: Erythema multiforme is a blistering disease that can be caused by the ingestion of certain drugs, most commonly sulfonamides, beta-lactam antibiotics, and non-steroidal anti-inflammatory drugs. The patient described has been taking glyburide, a sulfonylurea, for some time without any effects. It is unlikely that this would, all of a sudden, cause an outbreak. Answer D: Fixed drug reaction is similar to erythema multiforme in that it can also be caused by non-steroidal anti-inflammatory drugs and sulfonamides. Tetracycline, barbiturates, and fluconazole have also been implicated.

Answer 418

The U.S. Preventive Services Task Force does not recommend or promote screening for thyroid dysfunction in nonpregnant, asymptomatic women because of insufficient evidence to assess the benefit and harm of screening.

Answer 419

Psoriasis of the vulva is generally associated with stress or menses and generally occurs and recurs in the summer months. It can occur simultaneously on the extensor limb surfaces and always appears as silvery plaques with raised edges, sometimes erythematous borders, and scaling-type appearance. All the medications and treatments listed are potential therapies for psoriasis of the vulva; however, high-potency steroids, such as clobetasol, are the treatment of choice for psoriasis. Answer B: cortisone cream Low-potency steroids are rarely helpful for psoriasis.

Answer 420

Cushing syndrome is hypersecretion of cortisol that is persistent. The gold standard for screening for Cushing syndrome is a 24-hour urinary free cortisol. Cushing syndrome is a cause of amenorrhea and hirsutism, although it is rare at an incidence of 10 to 15 per million. When evaluating secondary amenorrhea, the most common cause is pregnancy.

Answer 421

A hypertensive emergency should be treated with antihypertensive medications. The goal reduction of systolic BP is 10–15% over the first 30–60 minutes, with a continued gradual reduction over the next 23 hours. Hypoperfusion may occur in vascular beds, leading to ischemic damage. Goal blood pressure varies greatly if an acute disease process is present, such as an aortic dissection or ischemic stroke. These emergencies must be ruled out to avoid inappropriate treatments. Systolic blood pressures > 180 (or acute significant increase in blood pressure) with evidence of end organ dysfunction should be considered a hypertensive emergency that requires treatment. The goal for blood pressure reduction is 10–15% over the first 30–60 minutes, or 20–30 mm Hg for our patient. This results in a goal of 170–180 mm Hg. A decrease greater than this 10–15% may cause hypoperfusion of vascular beds which are used to the higher pressure. Hypertensive Crisis Hypertensive Emergency Hypertensive Urgency Diagnosed by severe hypertension WITH evidence of end organ damage* Requires hospital admission for monitoring and controlled reduction of BPs† Diagnosed by severe hypertension WITHOUT evidence of end organ damage* Slow reduction of BPs in the outpatient setting *End organ damage includes cerebrovascular disease, hypertensive retinopathy, left ventricular hypertrophy, left ventricular dysfunction, heart failure, coronary artery disease, chronic kidney disease, albuminuria, and peripheral artery disease, among others. †Major Exceptions to Controlled Reduction of BPs Acute phase of an ischemic stroke The blood pressure is usually NOT lowered unless it is ≥185/110 mmHg in patients who are candidates for reperfusion therapy or ≥ 220/120 mm Hg in patients who are not candidates for reperfusion (thrombolytic) therapy Acute aortic dissection The systolic blood pressure should be rapidly lowered to a target of 100–120 mm Hg (to be attained in 20 minutes) to reduce aortic shearing forces Intracerebral hemorrhage Goals of antihypertensive therapy in such patients are variable

Answer 422

Pelvic organ prolapse (POP) can be a cause of distress among patients, especially the elderly. Asymptomatic POP does not necessitate treatment. Management of POP includes non-surgical and surgical modalities. Non-surgical management includes lifestyle modifications, pelvic floor exercises, or pessary placement. Surgical options should account for the patient's health status, POP symptoms and presentation, desire for future sexual activity, patient preference, and surgeon expertise. Uterosacral ligament suspension or sacrospinous ligament suspension with native tissue repair are equally effective for apical repair, and have similar 2-year success rates of 63%–65%. Vaginal hysterectomy with apical suspension is the best option for patients who are otherwise good surgical candidates, would like to maintain the option of sexual activity, and who are no longer childbearing. Sacrocolpopexy with synthetic mesh is a good option for patients at elevated risk of recurrence or who have a shortened vagina. Anterior or posterior repair may be useful for patients with anterior or posterior vaginal wall prolapse. A Le Fort colpocleisis is an obliterative procedure for patients who are either no longer sexually active or poor surgical candidates for a hysterectomy. Additionally, it is important to consider a prophylactic incontinence procedure, as 13%–65% of patients with POP will have incontinence once the POP is corrected.

Answer 423

G—gallstones E—ethanol T—trauma S—steroids M—mumps A—autoimmune pancreatitis S—scorpion sting H—hyperlipidemia, hypothermia, hyperparathyroidism E—endoscopic retrograde cholangiopancreatography D—drugs (commonly azathioprine, valproic acid, liraglutide)

Answer 424

Depressive disorders are exceedingly common and are twice as common in women as in men. They carry significant risks of death and disability. About 15% of patients with mood disorders die by their own hand, and at least 66% of all suicides are preceded by depression. The depressive symptoms also affect everyone in the sufferer's life, not just themselves. Pregnancy and in particular the postpartum period are extremely high times of depression. Mastering the signs and symptoms of this disorder is critical for comprehensive patient care. The mnemonic SIG E CAPS is used here, with 4 or more of the following being diagnostic of depression: sleep disturbances, loss of interest, feelings of guilt, lack of energy, lack of concentration, loss or gain of appetite, psychomotor agitation or retardation, and suicide. Pharmacotherapy is the mainstay of treatment, but St. John’s wort has not been shown to be effective in any US randomized clinical trials. First-line treatment includes counseling and cognitive behavioral therapy. Sometimes this is used in tandem with medication. Medication is not typically the first-line treatment. Counseling is the first-line treatment for depression.

Answer 425

Endometriosis is present in as many as 32% of patients with pelvic pain and as many as 50% of patients with infertility. There are 4 main theories, including retrograde menstruation and coelomic metaplasia. When the tissue is identified in the posterior cul-de-sac it appears to be the result of direct spread, while distant disease appears to be the result of either metaplasia or spread through stem cells in bone marrow. Although the pain is not a direct effect of the amount of endometriosis, it is directly related to the depth of spread and the involvement of neurological structures. It often affects the uterosacral ligaments or causes bowel-related issues when it is on the colon. The mechanism for pain is related to the effect on the structures and on the uterus. When macrophages are activated, generally tissue is removed; however, in the case of endometriosis, inflammatory cytokines (specifically IL-1, which activates IL-8) is released along with TNF. These cytokines lead to activation of COX and the release of prostaglandins, causing increases in uterine contraction and inflammation of the direct sites of disease. NSAIDs are the most common first-line treatment, followed by combined oral contraceptive pills (OCPs), which may be taken continuously, creating a pseudopregnant state with constant estrogen levels. If these do not work, a GnRH agonist may be used. Generally, it removes approximately 90% of the endometriosis. It has superior efficacy to OCPs but equivalent efficacy to danazol. When depot leuprolide is used, osteoporotic symptoms as well as hot flashes may occur. Add-back therapy may be used immediately when on combined estrogen and progesterone to offset these symptoms. Depot leuprolide is a GnRH agonist that acts to mimic the normal structure of GnRH, creating a negative-feedback mechanism and inhibiting release of gonadotropins. When this occurs, the general environment is a hypoestrogenic one.

Answer 426

Endometriosis is a chronic pain disorder in which ectopic endometrial implants outside of the uterus can cause scarring, infertility, and pain. The first-line treatment of endometriosis is medical, with nonsteroidal anti-inflammatory drugs (NSAIDs) and/or oral contraception pills (OCPs). Although the diagnosis of endometriosis can only be made with surgical confirmation of endometriotic lesions, it is reasonable to begin empiric treatment without surgery if endometriosis is suspected based on history and physical exam. Surgical intervention has the advantages of providing a histologic diagnosis, allowing assessment of any lesion concerning for malignancy, and allowing for therapeutic measures such as removal of endometriotic implants. In this patient with refractory, midline, pelvic pain who is young and desires future fertility, and who has already undergone multiple laparoscopies, a presacral neurectomy should be the next option. Resection of the sympathetic nerves over the sacral promontory is thought to block transmission of visceral afferent signals from the pelvic organs and thus reduce pain. It is primarily indicated for treating isolated central dysmenorrhea or chronic midline pelvic pain without associated symptoms of lateralized or pelvic floor pain. Answer C: Laser uterosacral nerve ablation (LUNA), done via laparoscopy, is a historical treatment of endometriosis. Its use has fallen out of favor recently due to multiple randomized controlled trials demonstrating lack of efficacy.

Answer 427

Patients with a 10-year risk of CVE >7.5% should definitely be on statin therapy.

Answer 428

46XY patients with 5α-reductase deficiency have female-appearing external genitalia at birth and during childhood due to the inability to produce dihydrotestosterone (DHT), a hormone responsible for virilizing the external genitalia. 5α-reductase is an enzyme that converts testosterone to the more potent DHT. During normal male embryogenesis, DHT causes lengthening of the anogenital distance, enlargement of the phallus, and fusion of the labioscrotal folds into the scrotum. DHT is also responsible for male-pattern hair, formation of the prostate, and penile enlargement. Absence or reduced levels of this hormone can present with ambiguous genitalia or normal external female anatomy. In 46XY patients with female-appearing genitalia, the condition may present during puberty when the child develops signs of virilization such as male-pattern hair or an enlarging clitoris due to rising testosterone levels. These occur because testosterone can virilize some tissues; it is just not as potent as DHT. The patient described in the question has a 46XY karyotype and produces normal male levels of testosterone and estrogen but is unable to convert testosterone to DHT because of a defective 5α-reductase type 2 enzyme.

Answer 429

Leiomyomas are the most common benign uterine tumors and have a lifetime prevalence of 70%. They tend to occur more frequently as women age and are more common in certain ethnicities (e.g., among Black women) than others. The eventual fate of leiomyomas is determined by their relatively poor vascular supply, which is generally via 1 or 2 large arteries at the base of the myoma and is significantly less than that of a similar-sized portion of myometrium. This compromised vascular supply can lead to several different types of degeneration. The most acute form is red, or carneous, degeneration, which is a form of muscular infarction that causes severe pain and localized peritoneal irritation. It is more common in pregnancy because of shunting of blood toward the placenta and occurs in approximately 5%–10% of pregnant women with myomas. It is best treated with nonsteroidal anti-inflammatory agents (i.e., indomethacin) for no more than 72 hours and as long as the patient is under 32 weeks' gestation (because of danger of closure of the patent ductus arteriosus). Answer A: Calcific degeneration occurs most frequently in postmenopausal women, when hypoestrogenemia drives a decrease in blood flow to all pelvic organs. Answer C: Hyaline degeneration is the mildest form and is grossly described as the surface of the myoma being homogeneous, with loss of the whorled pattern. Cellular detail is lost as smooth muscle cells are replaced by fibrous connective tissue. Answer D: Malignant degeneration is a misnomer, and its use is discouraged. The literature supports a 0.3%–0.7% risk; however, given the high prevalence of benign myomatous uteri, it is thought that malignant sarcomas arise de novo in the background of benign myoma rather than as a consequence of it. The major risk factor for malignant uterine sarcomas is age, and fibroids that continue to grow after menopause should raise concern for possible malignancy. Answer E: Myxomatous degeneration is the most rare form and can be difficult to distinguish from cystic degeneration. The contents of the myoma are replaced by a gelatinous material as the collagen is degraded. Leiomyosarcoma can also undergo myxomatous degeneration and should be considered part of the differential diagnosis.

Answer 430

Interstitial cystitis (IC), or painful bladder syndrome (PBS), is characterized by chronic pelvic pain, usually associated with dysuria, for which acute cystitis can never be diagnosed due to negative urine cultures. Hunner’s ulcers are pathognomonic of the disease, but only occur in 5–10% of patients with IC and, thus, are not necessary for the diagnosis. Hunner’s ulcers are areas of thickened mucosa with a fibrotic center that spontaneously bleed when the bladder is overdistended with media. Treatment of IC involves dietary changes (i.e. avoiding acidic, alcoholic, carbonated beverages, spicy foods, and artificial sweeteners) and pentosan polysulfate sodium (Elmiron), which is the only FDA-approved oral drug for IC.

Answer 431

The most common complication of mesh placement in the form of a midurethral sling as treatment for stress urinary incontinence (SUI) is incomplete bladder emptying/urinary retention. A prospective, randomized controlled trial of 600 women who underwent placement of a midurethral sling demonstrated the frequency of incomplete bladder emptying was 20% on post-op day 1, 6% at 2 weeks post-op, and 2% at 6 weeks post-op. Postoperative urinary retention is typically transient. The patient should be taught intermittent self-catheterization and be seen in a few days for further evaluation. In 2011, the US Food and Drug Administration (FDA) released a safety communication regarding the safety and effectiveness of transvaginal placement of surgical mesh for treatment of pelvic organ prolapse. The resultant media coverage resulted in a negative perception of the midurethral sling as a treatment for SUI. The FDA states, "The safety and effectiveness of multi-incision slings is well-established in clinical trials that followed patients for up to one year." Monofilament polypropylene mesh has demonstrated long-term durability, safety, and efficacy.

Answer 432

The prevalence of coronary artery disease is difficult to estimate due to the absence of symptoms in a lot of patients. The hallmark or most common symptom is chest pain/tightness in both men and women. There are other symptoms that are less common, and some patients are asymptomatic at the time of diagnosis. Abnormal EKGs can be the only abnormal finding. Some patients can present with acute cardiac arrest. While chest pain is the most common presentation, it is not always required to establish a diagnosis, but it highly suggests myocardial ischemia and coronary syndrome, warranting work-up. Typical symptoms of Coronary Artery Disease Chest pain/pressure Acute nausea/Vomiting Indigestion Fatigue Body aches Overall unwell feeling

Answer 433

Pelvic congestion syndrome results from dilated veins in the pelvis and possibly varicose veins. This condition is difficult to diagnose as there are no definitive diagnostic criteria. In general the diagnosis is made once other causes are excluded in a patient with chronic pelvic pain: non cyclic pelvic pain lasting more than 6 months. In women with chronic pelvic pain, there is also found to be tenderness on exam and pelvic vein dilation or incompetence. On initial evaluation, a physical examination and Pap smear should be performed in addition to any laboratory testing that is deemed necessary. If these do not yield positive results, then imaging may be obtained. Ultrasound, MRI, and CT may be used but cannot be used alone to diagnose this condition. Generally, this is a CT scan; however, this patient has a set of symptoms very suggestive of pelvic congestion syndrome. The common symptoms of this disease include pelvic pain symptoms, particularly with standing or sitting. When this is the case, pelvic venography may be the best initial imaging method for making a diagnosis. This is performed by selectively catheterizing specific veins and injecting contrast dye. If varices are found during this procedure, a coil or embolic agent may be injected. In the right physician's hands, this procedure has a success rate as high as 80%. The patient generally has 24 hours of pain control following the procedure and then is sent home on oral pain medication on postoperative day 1. The procedure can be done in 2 parts, a couple of weeks apart, secondary to the limitation on dye and discomfort.

Answer 434

Ovarian torsion is a true gynecological emergency, particularly in the young nulliparous patient. Even with the advent of improved imaging techniques, ovarian torsion remains a clinical diagnosis. Severe onset of lower pelvic pain in the setting of a negative pregnancy test is adnexal torsion until proven otherwise. When it occurs on the right side, it can easily be confused with appendicitis, although CT scans are now >90% sensitive for diagnosis of acute appendicitis. Typical findings (much like acute appendicitis) include, but are not limited to, elevated white blood cell (WBC) count, nausea/vomiting, and mild pyrexia. Ultrasonographic findings are not necessary for the diagnosis, but their presence greatly increases the probability of the diagnosis. The right side is affected more frequently than the left, in a 3:2 ratio, respectively. This is thought to be due to the increased free space from the freely mobile cecum on the right side, as opposed to the fixed sigmoid colon occupying the left adnexal region. Answer B: Ovarian torsion remains a clinical diagnosis, and part of the reason is because ultrasonographic findings of acute interruption of blood flow are not always present. In fact, 50% of women with surgically documented ovarian torsion were retrospectively found to have normal Doppler flow on ultrasonography. If flow is compromised, however, the artery is the last structure to be compromised because of the presence of a muscular intima layer, which resists compression upon twisting.

Answer 435

Fibromyalgia is a disease of chronic widespread musculoskeletal pain without another etiology. The first-line treatment is patient education about the disease, beginning a physical exercise program, and drug monotherapy for symptoms that are not relieved by non-pharmacologic means. Medications that have been effective include: SNRIs amitriptyline cyclobenzaprine gabapentin or pregabalin

Answer 436

The primary treatment of urge incontinence is lifestyle changes and bladder training. Urge incontinence can be treated medically with anticholinergic medications or a beta-3 adrenergic agonist. The most common side effect of anticholinergic medications is xerostomia (dry mouth), affecting >30% of patients who take them. The most common side effect of Mirabigron (beta-3 adrenergic agonist) is hypertension which occurs in about 11% of patients. All other side effects were reported as < 5%.

Answer 437

PAH has many causes and is classified into 5 categories. The identification of the underlying cause is paramount to the treatment of this disease. PAH caused by COPD places this patient into group 3. Group 3 pulmonary hypertension is treated with oxygen therapy. Oxygen is the only modality proven to decrease mortality.

Answer 438

According to NHANES (2017–March 2020) data, the prevalence of diabetes among adults in the United States is 14.8%. The prevalence of diabetes increases with age and decreases with a rise in family income and educational attainment. Answer D: 41.9% is the prevalence of obesity among adults in the United States according to NHANES (2017–March 2020) data.

Answer 439

Letrozole is superior to clomiphene citrate for ovulation induction in patients with PCOS. Letrozole is an aromatase inhibitor that blocks peripheral conversion of testosterone and androstenedione to estradiol and estrone, respectively. This results in lower estrogen levels systemically, which causes an increase in FSH secretion from the anterior pituitary. Letrozole should be considered the first-line therapy for ovulation induction in women with PCOS. This recommendation is supported by ACOG and ASRM. It is important to counsel patients that while letrozole has been shown to be superior to clomiphene citrate in increasing live birth rate and cumulative ovulation rates, it is not yet approved by the FDA for this indication. Both clomiphene citrate and letrozole are contraindicated in pregnancy. Pregnancy should be ruled out, preferably with serum hCG, prior to starting ovulation induction agents. Answer A: Clomiphene citrate is a selective estrogen-receptor modulator that competitively inhibits estrogen receptors in the hypothalamus. This disrupts negative feedback from estrogen, resulting in increased release of GnRH from the hypothalamus. This increase in GnRH release stimulates the pituitary to secrete FSH, which causes growth of ovarian follicles. Traditionally, clomiphene was considered the first-line treatment for ovulation induction for women with PCOS. More recent studies and systematic reviews show increased live birth rates and cumulative ovulation rates with letrozole compared with clomiphene citrate. Answer C: Good evidence suggests that metformin alone, versus placebo, increases the ovulation rate in women with PCOS, although it is 3 times less effective than clomiphene citrate. Answer D: Ovarian drilling has not shown a clear advantage with ovulation or pregnancy rates compared with gonadotropins. Ovarian drilling likely reduces secretion of androgens, which results in increased FSH and LH secretion from the pituitary. Following ovarian drilling, the ovary is more responsive to endogenous gonadotropin stimulation. Rotterdam Diagnostic Criteria for Polycystic Ovarian Syndrome (PCOS) 2 out of the following 3 criteria are required to meet diagnostic criteria for PCOS: Oligoovulation or anovulation Clinical and/or biochemical signs of hyperandrogenism ≥ 12 follicles (measuring 2–9 mm) in one ovary or ovarian volume > 10 cc

Answer 440

Letrozole is superior to clomiphene citrate for ovulation induction in patients with PCOS. Letrozole is an aromatase inhibitor that blocks peripheral conversion of testosterone and androstenedione to estradiol and estrone, respectively. This results in lower estrogen levels systemically, which causes an increase in FSH secretion from the anterior pituitary. Letrozole should be considered the first-line therapy for ovulation induction in women with PCOS. This recommendation is supported by ACOG and ASRM. It is important to counsel patients that while letrozole has been shown to be superior to clomiphene citrate in increasing live birth rate and cumulative ovulation rates, it is not yet approved by the FDA for this indication. Both clomiphene citrate and letrozole are contraindicated in pregnancy. Pregnancy should be ruled out, preferably with serum hCG, prior to starting ovulation induction agents. Answer A: Clomiphene citrate is a selective estrogen-receptor modulator that competitively inhibits estrogen receptors in the hypothalamus. This disrupts negative feedback from estrogen, resulting in increased release of GnRH from the hypothalamus. This increase in GnRH release stimulates the pituitary to secrete FSH, which causes growth of ovarian follicles. Traditionally, clomiphene was considered the first-line treatment for ovulation induction for women with PCOS. More recent studies and systematic reviews show increased live birth rates and cumulative ovulation rates with letrozole compared with clomiphene citrate. Answer C: Good evidence suggests that metformin alone, versus placebo, increases the ovulation rate in women with PCOS, although it is 3 times less effective than clomiphene citrate. Answer D: Ovarian drilling has not shown a clear advantage with ovulation or pregnancy rates compared with gonadotropins. Ovarian drilling likely reduces secretion of androgens, which results in increased FSH and LH secretion from the pituitary. Following ovarian drilling, the ovary is more responsive to endogenous gonadotropin stimulation. Rotterdam Diagnostic Criteria for Polycystic Ovarian Syndrome (PCOS) 2 out of the following 3 criteria are required to meet diagnostic criteria for PCOS: Oligoovulation or anovulation Clinical and/or biochemical signs of hyperandrogenism ≥ 12 follicles (measuring 2–9 mm) in one ovary or ovarian volume > 10 cc

Answer 441

Urodynamic testing is useful in diagnosing the underlying cause(s) of urinary incontinence. Detrusor overactivity is characterized by leakage that occurs after a detrusor contraction that the patient cannot suppress.

Answer 442

Hypospadias Undescended testes Micropenis Labial fusion Enlarged clitoris Ovotesticular disorder of sex development (coexistent ovarian and testicular tissue) Partial gonadal dysgenesis (46XY with abnormal gonad development) Abnormal androgen production or action with 46XY genotype Enzyme deficiencies in sex steroid synthesis pathway, including CAH Abnormal 5α-reductase (converts testosterone to dihydrotestosterone) Partial androgen insensitivity syndrome Androgen excess with 46XX genotype Virilizing adrenal or ovarian tumors (luteoma, Sertoli–Leydig cell tumor) Fetal exposure to drugs such as testosterone, danazol, or norethindrone Congenital adrenal hyperplasia Placental aromatase deficiency (leads to virilization of mother and 46XX fetus)

Answer 443

Differential Diagnosis for Ambiguous Genitalia Hypospadias Undescended testes Micropenis Labial fusion Enlarged clitoris Ovotesticular disorder of sex development (coexistent ovarian and testicular tissue) Partial gonadal dysgenesis (46XY with abnormal gonad development) Abnormal androgen production or action with 46XY genotype Enzyme deficiencies in sex steroid synthesis pathway, including CAH Abnormal 5α-reductase (converts testosterone to dihydrotestosterone) Partial androgen insensitivity syndrome Androgen excess with 46XX genotype Virilizing adrenal or ovarian tumors (luteoma, Sertoli–Leydig cell tumor) Fetal exposure to drugs such as testosterone, danazol, or norethindrone Congenital adrenal hyperplasia Placental aromatase deficiency (leads to virilization of mother and 46XX fetus)

Answer 444

Electrolyte testing is the most urgent next step in management in a neonate with ambiguous genitalia. This is because the differential diagnosis includes classic congenital adrenal hyperplasia (CAH), which can result in both ambiguous genitalia and life-threatening electrolyte disturbances and adrenal crisis. The most common form of classic congenital adrenal hyperplasia is 21-hydroxylase deficiency, which accounts for 95% of all cases of CAH. This is included in the newborn screen in the United States. 21-hydroxylase is responsible for the conversion of 17-hydroxyprogesterone to 11-deoxycortisol, which is an important step in the production of both aldosterone and cortisol. 21-hydroxylase deficiency thus leads to reduced production of aldosterone and cortisol, and resultant increased adrenocorticotropic hormone (ACTH) due to loss of negative feedback at the pituitary. This leads to a build-up of adrenal androgens, as precursors are shifted towards androgen production rather than cortisol and aldosterone. Depending on the specific mutations in the 21-hydroxylase gene, patients have varying degrees of aldosterone and cortisol production. In the most severe form of the disease, patients can develop life-threatening adrenal crisis with hyponatremia and hyperkalemia, metabolic acidosis, and hypoglycemia. Several studies should be ordered, but electrolytes are the most urgent.

Answer 445

Ovulation predictor kits (OPKs) are typically simple ways to detect the LH surge prior to ovulation. The tests are sensitive to both fluid and water volume. The best time to check for the surge is in the afternoon because the surge typically happens first in the morning in the blood and then reaches the urine. Ovulation typically occurs 14–26 hours after detecting the LH surge on the OPK and almost always occurs within 48 hours. Peak fertility days are the day the LH surge is detected and the following 2 days.

Answer 446

When diagnosed before age 30 years, aortic stenosis is usually congenital aortic stenosis. Outcomes of pregnancy vary with the degree of severity. Increased cardiac output and increased volume stress the already-overloaded left ventricle, which could lead to heart failure and death. Mortality in patients with unknown disease severity is 8%. Some recommend termination if the ejection fraction is less than 40%.

Answer 447

The incidence of type 2 diabetes mellitus (DM) after the age of 30 years in women with PCOS is 11.9%. Women with PCOS have a 2- to 5-fold increased risk of diabetes. This woman meets diagnostic criteria based on hyperandrogenism (acne), ovulatory dysfunction (abnormal uterine bleeding), and polycystic ovaries (ovarian volume > 10 cm3). Only 2 of the 3 are required for diagnosis. PCOS is characterized by hyperinsulinemia, which decreases sex hormone binding globulin (SHBG) and thus leads to higher bioavailable circulating androgen. Women with PCOS are at increased risk of the conditions shown in the table below. PCOS Leads to Higher Risk of the Following Conditions Insulin resistance Metabolic syndrome Nonalcoholic fatty liver disease Sleep apnea Type 2 diabetes Cardiovascular disease All women with PCOS should be screened for impaired glucose tolerance and diabetes with a 2-hour oral glucose test, which is more sensitive than a fasting glucose test at detecting impaired glucose tolerance. 2-Hour Oral Glucose Tolerance Test Value Interpretation Fasting < 110 mg/dL Normal 110–125 mg/dL Impaired glucose tolerance > 126 mg/dL Type 2 diabetes 2 Hours After 75 g Oral Glucose Load < 140 mg/dL Normal 140–199 mg/dL Impaired glucose tolerance > 200 mg/dL Type 2 diabetes In women with PCOS and impaired glucose tolerance, antidiabetic drugs (insulin-sensitizing agents) are recommended, given the reduced risk of developing diabetes when used. These agents include biguanides (metformin) or thiazolidinediones (pioglitazone and rosiglitazone). Patients with PCOS should also be screened for risk for cardiovascular disease with fasting lipids, which are borderline or high in 70% of patients.

Answer 448

Although androgen excess can manifest in many ways, the most common and recognizable symptoms are hirsutism and acne. Reports of hirsutism and acne should be taken seriously because of their possible association with medical disorders, their substantial effect on self-esteem and quality of life, and the potential for psychosocial morbidity. In patients with symptoms of androgen excess, the differential diagnosis should include physiologic hyperandrogenism of puberty, idiopathic hyperandrogenism, and polycystic ovary syndrome (PCOS). In females, androgens originate from three primary sources: the ovarian theca the adrenal cortex within end organs by peripheral conversion The major androgens include dehydroepiandrosterone, dehydroepiandrosterone sulfate (DHEAS), androstenedione, testosterone, and dihydrotestosterone, with the latter two having the highest affinity for the androgen receptor and the greatest potency. In healthy women, testosterone is largely bound by sex hormone binding globulin and albumin, leaving only approximately 1% freely circulating as bioactive “free testosterone.” Dehydroepiandrosterone sulfate (DHEAS) is produced almost exclusively in the adrenal glands and its elevation requires further investigation. Extremely high levels (>700 or 800 μg/dL) in women are suggestive of a hormone-secreting adrenal tumor. The most likely cause of this patient’s hirsutism and infertility, in light of this markedly elevated value, is an adrenal adenoma. A CT scan of the abdomen will help to identify this lesion and surgical treatment is the preferred course of action. Adrenal carcinoma is a possibility and a full metastatic work-up should also ensue, since metastatic disease carries a poor prognosis.

Answer 449

Uncontrolled diabetes mellitus is a common and well-documented cause of recurrent miscarriages. Although this patient had two previous miscarriages, it is unclear what her glucose load was during those times. Currently, her hemoglobin A1C value is excellent, and she has no blood glucose elevations on diet alone. Women with well-controlled diabetes do not appear to have an increased risk of recurrent miscarriage; if a miscarriage does occur, it is likely due to chromosomal abnormalities. Answer A: Adding metformin has been shown to decrease recurrent miscarriage rates in those with components of polycystic ovary syndrome (i.e., hyperandrogenic findings— acne and hirsutism), but it would not help this patient, who has excellent control of her diabetes. Answer B: Her hemoglobin A1C value represents excellent control of her blood glucose levels over the past 3 months, and patients with well-controlled glucose levels do not appear to be at risk of increased miscarriages. Answer C: It was once thought that diabetes, which causes chronic vascular compromise, always increased the risk of miscarriages. It appears that this patient, whose diabetes is well controlled on diet alone, more likely represents insulin resistance than absolute insulin deficiency. Recent studies have shown that those with well-controlled levels do not have an increased risk of miscarriage in relation to the general population, despite earlier reports to the contrary. Answer E: As with metformin, adding a therapy to a patient with well-controlled diabetes will not decrease her miscarriage rate. She has done all the work herself with lifestyle changes.

Answer 450

Lichen planus is generally associated with a polygonal violaceous plaque on the torso in addition to deep ulcerating vaginal lesions in the posterior vagina. Oral lesions, known as Wickham striae, are also characteristic for lichen planus. Vulvar lichen planus is most commonly treated with a topical steroid. Initial therapy involves nightly application of a super-high-potency topical corticosteroid such as clobetasol propionate 0.05% ointment or halobetasol propionate 0.05% ointment. If there is no improvement after 8 weeks of topical steroid use, treatment with systemic glucocorticoids may be required. Oral lesions, known as Wickham striae, associated with lichen planus

Answer 451

GI: constipation incarcerated hernia infectious colitis inflammatory bowel disease ischemic bowel omental infarction sigmoid diverticulitis GU: ureterolithiasis and urinary tract infection in females GYN: ectopic pregnancy endometriosis hemorrhagic cyst malignancy miscarriage Mittelschmerz ovarian torsion pelvic congestions syndrome ruptured corpus luteum uterine fibroids Vascular: aortitis/vasculitis and dissection aneurysm

Answer 452

A number of medications have side effect profiles that affect the lower urinary tract. Those effects include: incontinence bladder neck obstruction decreased bladder capacity increased intravesical pressure frequency urgency Relaxation of the internal sphincter can lead to incontinence when contraction of the detrusor muscle is not countered by contraction of the internal sphincter to maintain continence. Lisinopril, an angiotensin-converting enzyme (ACE) inhibitor, has a side effect of a cough. Increased coughing can worsen stress incontinence. Medication Effect on Urinary Tract ACE inhibitor Can cause cough, which worsens stress incontinence Haloperidol Dopamine receptor blockade weakens internal urethral sphincter Diuretics Increased urine production

Answer 453

Amitriptyline is a tricyclic antidepressant (TCA), and is one of the most studied antidepressants used for chronic pain. The specific mechanism is unknown, and its use for chronic pain is off-label. Typical doses are lower than those used for depression alone.

Answer 454

Congenital heart disease is a risk factor for pulmonary artery hypertension The Fontan operation is performed as a palliative procedure to improve survival in infants born with a functionally univentricular circulation. The procedure prolongs life and reduces the risk of PAH; however, patients who have undergone the Fontan procedure are still at a much higher risk for PAH than the general population. The World Health Organization (WHO) classifies pulmonary artery hypertension (PAH) into the class 4 risk category for pregnancy. Cardiovascular conditions in this category pose a very high risk of maternal morbidity and mortality, and pregnancy is contraindicated. Pulmonary hypertension specifically carries a 9–28% risk of maternal mortality. If pregnancy occurs in the setting of maternal pulmonary artery hypertension, termination needs to be discussed. PAH is defined as mean pulmonary arterial pressure more that 25 mm Hg at rest. The Pulmonary Hypertension Association identifies the following as risk factor categories for PAH:

Answer 455

Irritable bowel syndrome is a functional bowel disorder characterized by abdominal pain or discomfort with a change in bowel habits. In addition, there are typically alternating bouts of diarrhea and constipation that are usually relieved with defecation. It is a diagnosis of exclusion; thus, other gastrointestinal disorders that can produce similar symptoms (e.g., colon cancer, celiac disease, inflammatory bowel disease, lactose intolerance) must be excluded. Deregulation between the central nervous system and enteric nervous system is thought to be at the center of the disorder. For this reason, the gastrointestinal mucosa is totally normal and devoid of any clear signs of inflammation or infection.

Answer 456

Levator ani syndrome is a type of trigger point pain syndrome. The etiology of these syndromes is not well understood, but involves the hyper-excitability of muscle groups that leads to a sustained contraction and pain. Patients often have a history of perineal trauma from childbirth. A taught or tight rope-like band within the muscle of the perineum can be found on physical examination. Often, these findings will trigger the patient’s pain. Patients often have dyspareunia, pain with sitting, and pain that is relieved with lying down with hips in flexion. Patients can also present with lower back pain from levator ani muscle spasms. The visceral innervation of these muscles is at the sacral spinal cord levels and can converge onto the somatic pain receptors and result in lower back pain.

Answer 457

Hemorrhagic stroke represents only 13% of all strokes in the United States. The other 87% are caused by ischemic strokes. Hemorrhagic stokes are often preceded by the patient's “worst of headache of my life.” The appropriate diagnosis is essential as therapies are drastically different.

Answer 458

Dopamine agonists are discontinued when the patient is found to be pregnant. Pregnant patients are regularly screened for visual changes to monitor for tumor growth Prolactinoma or pituitary adenoma is a known cause of infertility. The prolactin secreted by the adenoma inhibits ovulation and lowers estradiol and progesterone levels. Patients with infertility due to pituitary adenoma are treated with bromocriptine, a dopamine agonist, which inhibits prolactin secretion. After pregnancy is confirmed, bromocriptine is discontinued. The patient must be monitored for signs of tumor growth with visual field testing. Monitoring prolactin levels during pregnancy is not indicated. If tumor growth is suspected, it must be conformed with MRI. Bromocriptine may then be re-initiated. Bromocriptine has not been associated with congenital or structural anomalies. Data from >6,000 pregnancies suggest that administration of bromocriptine during the first month of pregnancy does not harm the fetus and the incidence of spontaneous abortions, multiple births, and fetal malformations is the same as the rates in the general population. Furthermore, a study of children followed for up to 9 years after exposure to bromocriptine in utero showed no harmful effects. Other dopamine agonists, such as quinagolide, cabergoline, and pergolide have been used in pregnancy. However, these medications have not yet been approved for use in pregnancy by the FDA.

Answer 459

Primary pulmonary hypertension is defined as an unexplained elevation in pulmonary artery pressures >25–30 mm Hg. This rise in pressure requires a great deal of preload to maintain perfusion in the lungs. A hypervolemic state will maintain this preload and allow enough oxygenated blood to continue pumping, especially in the third stage of labor. Answer A: One must avoid a drop in vascular resistance, and regional anesthesia should be applied by an experienced anesthesia team to avoid the usual drop in blood pressure. Answer B: Cardiac output is a function of pulse rate and stroke volume. The output needs to be maintained high enough to not drop the systemic pressure. Answer D: The third stage of labor may be quite difficult to manage because great hemodynamic changes occur at this time. A hypervolemic state is desired, and Lasix is not necessarily warranted as an overall recommendation. Answer E: The preload must be maintained to have enough pressure to perfuse the lungs. Bottom Line: Primary pulmonary hypertension is a dangerous lesion. Mortality rates as high as 50% are reported in the literature. The mainstay for this lesion is maintaining a hypervolemic state, thereby maintaining an elevated preload in order to perfuse the lungs.

Answer 460

Treatment of hirsutism is directed at the disruption of the etiology, which is usually excessive androgen production. Combination OCPs are a first-line treatment for hirsutism, particularly for those women who do not wish to conceive currently. By increasing sex-hormone binding globulin (SHBG), circulating, free testosterone is decreased. Response to treatment is slow, however, and may take upwards of 6 months before signs are noticed. This is due, in large part, to the length of the hair growth cycle. Second-line therapies include: spironolactone eflornithine hydrochloride finasteride flutamide Given this patient’s history of untreated hypertension, the best choice for androgen suppression is spironolactone, which is also a potassium-sparing diuretic. Its anti-androgen effects are three-fold: inhibiting steroidogenesis in the ovary and adrenal gland, competing for the androgen receptor in the hair follicle and directly inhibiting 5-alpha-reductase activity.

Answer 461

The New York Heart Association (NYHA) functional classification system was designed to assess the function of individuals with heart disease. The patient described above has NYHA class III symptoms. This is described as a marked limitation in physical activity. She is comfortable at rest but has a marked limitation with ordinary activity. Less-than-normal physical activity causes fatigue, palpitations, dyspnea, or angina. Functional Capacity Classes of the New York Heart Association Class I Patients with cardiac disease but without resulting limitation of physical activity. Ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or anginal pain. Class II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary physical activity results in fatigue, palpitation, dyspnea, or anginal pain. Class III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less than ordinary activity causes fatigue, palpitation, dyspnea, or anginal pain. Class IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of heart failure or the anginal syndrome may be present even at rest. If any physical activity is undertaken, discomfort is increased.

Answer 462

Metabolic syndrome has been used to describe the coexistence of risk factors for type 2 diabetes and cardiovascular disease, including abdominal obesity, hyperglycemia, dyslipidemia, and hypertension. The prevalence of metabolic syndrome among adolescents is estimated to be approximately 9%. Half of all adolescents initially classified with metabolic syndrome will no longer meet the criteria after 3 years; others will acquire the diagnosis. Awareness of these facts is highly important in order to counsel and motivate your patient to assist in making better, healthier choices associated with more positive outcomes. The recognition of metabolic syndrome as a distinct entity is to draw attention to the vastly increased morbidity associated with it. In order to be considered part of the syndrome, a patient must have three out of the following five criteria. Criteria for Metabolic Syndrome (3 must be present) BP > 130/85 mm Hg BG >100 mg/dL HDL <50 mg/dL TG >150 mg/dL Waist circumference >35 inches (88 cm) The only criterion satisfied by the answer choices is HDL <50 mg/dL. About 85% of people who have type 2 diabetes (the most common type of diabetes) also have metabolic syndrome. These people have a much higher risk for heart disease than the 15% who have type 2 diabetes without metabolic syndrome.

Answer 463

Polycystic ovarian syndrome (PCOS) is characterized by anovulation, hyperandrogenism, and some form of insulin resistance. The prevalence of coexistent diabetes is increased in the obese population but is a common staple of all women diagnosed with the syndrome, even if they are thin. ACOG recommends a 2-hour glucose tolerance test for those women diagnosed with PCOS. Overall, a diagnosis of PCOS confers a 2- to 5-fold increased risk of developing diabetes later in life. Undiagnosed diabetes occurs in 3–10% of PCOS patients. Recommended Screening for PCOS Weight Blood pressure 2-hour glucose tolerance test Fasting lipid and lipoprotein levels

Answer 464

When a patient desires relief of pelvic organ prolapse, there are obliterative and reconstructive types of surgeries. Most surgeries are reconstructive or increase the length of the vagina compared to their current length. Obliterative procedures are indicated for elderly women who have no sexual interest with pelvic organ prolapse. An advantage to the technique is that it is almost 100% effective for repair of prolapse. There are 2 types of colpocleisis or vaginal obliterative procedures used: Le Fort and Complete. Complete colpocleisis removes all vaginal epithelium and repairs the defect while LeFort removes only rectangles of tissue anteriorly and posteriorly. These pieces of tissue begin at 2 cm proximal to the urethral meatus and extend to 2 cm above the cervix or vaginal cuff. The tissue is then re-approximated using delayed or permanent suture. There is an increased risk of stress urinary incontinence with these procedures and a SUI procedure (sling, etc.) should be considered at the time of the procedure. The biggest advantage to the procedure is that in frail patients it may be done under local or spinal anesthesia in little time.

Answer 465

The 2017 ACC/AHA guidelines suggest that the best method for diagnosing hypertension involves ambulatory blood pressure monitoring. The home blood pressure measurements should be confirmed with in-office blood pressure measurements. Hypertension is defined by average ambulatory blood pressure readings >130/>80 mm Hg.

Answer 466

There are a number of known risk factors for DM. A prior pregnancy can provide additional information on the risk of developing sequelae later in life. GDM and a child with a birth weight >4 kg are known risks for developing DM later in life.

Answer 467

In younger women (< 45 years old), the most common presenting sign of coronary artery disease (CAD) is an acute myocardial infarction (MI). The most common type of MI in this group is ST-elevation MI. Angina is present in only 14% of these women, whereas an MI is the main sign in 50%–70%, even among the women with angina. Women are less likely than men to suffer from CAD due to the protective effects of estrogen in the premenopausal status. Premature ovarian failure increases the risk by 2- to 3-fold. Oophorectomy prior to 35 years of age increases risk by 7-fold. Most of the women do not notice chest pain or experience minor symptoms prior to the event.

Answer 468

MRI is more sensitive than the other modalities listed above. On MRI, a urethral diverticulum (UD) will show a high-intensity sac. MRI is currently the imaging modality of choice for confirmation of UD, as it is able to delineate the ostium in 85% of cases. UD is a rare condition that affects between 1% and 6% of adult women; however, as many patients are asymptomatic or misdiagnosed, the true incidence is unknown. Most patients with UD present between the third and seventh decade of life, with a median age of 40 years, but the presentation can occur at any age. UD has been reported in 1.4% of women who present for the evaluation of urinary incontinence (UI), with the diagnosis being made in up to 80% of women who present with a periurethral mass. The presentation of UD is variable, ranging from incidental findings on physical examination or cross-sectional imaging to frequent UTIs, dyspareunia, UI, or malignancy. The classic presentation has been historically described as the ‘three Ds’: dysuria, dyspareunia, and dribbling (post-void). When performing a pelvic examination, the anterior vaginal wall should be palpated for masses and associated tenderness. Most UD are located ventrally on the anterior vaginal wall, 1–3 cm inside the introitus, but may extend more proximally toward the bladder neck.

Answer 469

Botulinum toxin, a potent neurotoxin derived from the anaerobic bacterium Clostridium botulinum, acts primarily as a muscle paralytic by inhibiting the presynaptic release of acetylcholine from motor neurons at the neuromuscular junction. Onabotulinumtoxin A is considered a second-line treatment option in appropriate patients with overactive bladder (OAB) and is administered by cystoscopic injection of multiple aliquots into the detrusor muscle. The FDA-approved dosage for the treatment of neurogenic bladder is 200 units, and the FDA-approved dose for overactive bladder is 100 units. The effect of onabotulinumtoxin A is transient and can wear off in 6 to 15 months, with repeat injections needed to maintain effectiveness. Reinjection should be considered when the clinical effect of the previous injection has diminished but no sooner than 12 weeks from the previous injection. In women who received onabotulinumtoxin A injection, the risk of voiding dysfunction that required catheterization and urinary tract infection was 5% and 33%, respectively.

Answer 470

Botulinum toxin, a potent neurotoxin derived from the anaerobic bacterium Clostridium botulinum, acts primarily as a muscle paralytic by inhibiting the presynaptic release of acetylcholine from motor neurons at the neuromuscular junction. Onabotulinumtoxin A is considered a second-line treatment option in appropriate patients with overactive bladder (OAB) and is administered by cystoscopic injection of multiple aliquots into the detrusor muscle. The FDA-approved dosage for the treatment of neurogenic bladder is 200 units, and the FDA-approved dose for overactive bladder is 100 units. The effect of onabotulinumtoxin A is transient and can wear off in 6 to 15 months, with repeat injections needed to maintain effectiveness. Reinjection should be considered when the clinical effect of the previous injection has diminished but no sooner than 12 weeks from the previous injection. In women who received onabotulinumtoxin A injection, the risk of voiding dysfunction that required catheterization and urinary tract infection was 5% and 33%, respectively.

Answer 471

The first-line treatment for stress urinary incontinence includes lifestyle modifications (exercise, weight loss, limiting caffeine) and pelvic floor exercises. The patient described above has a BMI of 22, so weight loss is not indicated in her treatment plan. Kegel exercises can easily be taught to the patient, with instructions to contract the muscles used to stop a urine stream.

Answer 472

Ovarian remnant syndrome is defined as chronic pelvic pain secondary to a small area of functioning ovarian tissue following the intended total removal of both ovaries. Risk factors include endometriosis, history of pelvic inflammatory disease, extensive pelvic adhesions on previous surgery, and more recently described, a laparoscopic oophorectomy. Half of women present with a pelvic mass, and it is usually small and adjacent to either ureter. Premenstrual levels of follicle-stimulating hormone or estradiol can help to establish the diagnosis. This patient, who is young and otherwise healthy, does not likely have an occult cancer or acute appendicitis, but rather ovarian remnant syndrome. Risk Factors for Ovarian Remnant Syndrome Endometriosis History of PID Extensive pelvic adhesions on previous surgery Laparoscopic oophorectomy

Answer 473

Presacral neurectomy is a treatment for patients with chronic pelvic pain. It primarily works for midline pain. The procedure can be done laparoscopically, robotically, and abdominally. Statistically, patients report 90% success with reduction and elimination of pain. The procedure involves identification of the presacral nerve within the hypogastric plexus. This plexus contains sympathetic and parasympathetic innervation to the bowels and bladder, and injury may cause urinary retention and constipation. The effect is usually temporary with resolution of the urinary retention in 1 to 2 weeks and constipation within 6 weeks.

Answer 474

Endometriosis is a chronic pain disorder that responds differently in different people. Some women get by with medication control, whereas others require extensive surgery. An option for a young woman who has completed childbearing but is >10 years from natural menopause (average = 51.2 years) is to remove the uterus and one ovary. The thought process is that in the absence of continued retrograde menstruation, the symptoms are usually controlled, and there is no sacrifice of her bone mineral density or cardiovascular protection. Approximately 1/3 of these women, however, will eventually need a second operation because of continued stimulation of implants that were not visible at the time of the initial surgery. Therefore, her risk of a second operation is approximately 33%.

Answer 475

Pulmonary arterial hypertension is defined as a mean pulmonary arterial pressure more than 25 mm Hg at rest. Primary pulmonary hypertension is one of the few contraindications to pregnancy. The cardiopulmonary physiology changes in pregnancy exacerbate the pulmonary artery hypertension. Despite improved prognosis in women with pulmonary arterial hypertension, the mortality rate during pregnancy is 9–28%. Induced abortion should be discussed if pregnancy occurs.

Answer 476

The prevalence of type 2 diabetes in women with polycystic ovarian syndrome (PCOS) who are over the age of 30 was 11.9% in a prospective cohort study. This number is compared with the baseline risk of diabetes, estimated at 1.4%, a 10-fold increase. The prevalence of glucose intolerance is even higher, estimated at 40% in U.S. women. Type 2 diabetes is much more common in women with PCOS, especially in those who are over 30 years old. PCOS carries a number of physiological changes, including glucose intolerance. Glucose intolerance can often lead to type 2 diabetes. Frequent monitoring with either A1c levels or a 2-hour glucose challenge is recommended for this population given the increased frequency. Effect of PCOS on Diabetes Risk Baseline risk of diabetes in women >30 1.4% Risk of diabetes in women with PCOS >30 11.9% Risk of glucose intolerance in women with PCOS >30 40%

Answer 477

Obesity is the strongest risk factor for urinary incontinence. Women who are obese are approximately 3 times more likely than nonobese women to have urinary incontinence.

Answer 478

Amenorrhea is the most common finding, and hyperprolactinemia is the cause of secondary amenorrhea in up to 30% of women. The amenorrhea is a result of inhibition of hypothalamic gonadotropin releasing hormone (GnRH) secretion with decreased pituitary release of gonadotropin, and therefore anovulation occurs. Answer B: Galactorrhea can occur; however, most women with hyperprolactinemia do not have this finding due to abnormally low estrogen. Answer C: Chronic hypogonadism as a result of GnRH suppression from hyperprolactinemia can cause osteopenia, but this is not the most common finding. Answer D: Recurrent miscarriage is not associated with hyperprolactinemia; however, infertility from anovulation is. Answer E: Visual or neurological disturbances can be seen with large macroadenomas but are not associated with the smaller, microadenoma lesions.

Answer 479

Dysmenorrhea is a common and potentially debilitating condition. When patients initially present with dysmenorrhea, first-line treatments include exercise, NSAIDs, hormonal medications (oral contraceptive pills), diet changes, and heat. If these are attempted and not successful in treating dysmenorrhea, secondary causes of pain need to be evaluated. These include structural abnormalities, ovarian cysts, endometriosis, etc. First-Line Treatments of Primary Dysmenorrhea Heat Exercise Smoking cessation Acupuncture Massage Diet changes NSAIDs Hormonal medication

Answer 480

Women with polycystic ovarian syndrome (PCOS) have an increased risk of developing type 2 diabetes mellitus in their lifetime. Women with PCOS also have a higher incidence of sleep apnea, hyperlipidemia, metabolic syndrome, and non-alcoholic fatty liver disease. Though the aforementioned diseases are all risk factors for coronary artery disease (CAD), an evidence-based link between them has not been established. Chronic Conditions Linked to PCOS Type 2 diabetes Obstructive sleep apnea (OSA) Hyperlipidemia Metabolic syndrome Non-alcoholic fatty liver disease

Answer 481

All patients undergoing major abdominal surgeries have a risk of cardiac complications. However, the incidence is different based on each individual risk factor and patient-specific morbidity. Preoperative evaluation is necessary to identify high-risk patients and those who need further workup preoperatively. In general, patients who have preoperative mortality of 1% should receive a cardiac evaluation. There are a variety of calculators to help stratify this risk. The Revised Cardiac Risk Index (RCRI) is one such tool to monitor cardiac complications among patients undergoing noncardiac procedures. It identifies the risk factors listed in the table below. Six Independent Predictors of Major Cardiac Complications A high-risk type of surgery (vascular surgery, open intraperitoneal, or intrathoracic procedures) History of ischemic heart disease History of heart failure History of cerebrovascular disease Diabetes mellitus requiring treatment with insulin Preoperative serum creatinine > 2.0 mg/dL (177 micromol/L)

Answer 482

Polycystic ovarian syndrome (PCOS) is a very common endocrinopathy that is characterized by hyperandrogenism, anovulation/oligomenorrhea, and polycystic appearing ovaries. The primary pathophysiology and exact cause remain elusive. However, the primary mechanism appears to be two-fold. First, the vast majority of patients have a level of intrinsic functional hyperandrogenism which, in turn, leads to ovarian dysfunction, anovulation/oligomenorrhea, as well as hirsutism. Luteinizing hormone excess plays a role, but is not thought to be a primary cause of the ovarian hyperandrogenism. Second, about half of the patients develop insulin-resistance and subsequent hyperinsulinism. The ovary remains insulin-sensitive despite the liver and skeletal muscle insulin resistance. Hyperinsulinism within the ovary stimulates androgen production within the ovary. Answer A: PCOS is characterized by excess luteinizing hormone. Answer B: PCOS is a risk factor for endometrial hyperplasia, but endometrial hyperplasia is not a causative factor for PCOS. Answer C: Half of PCOS patients have hyperinsulinemia. Answer E: Despite the liver and skeletal muscle insulin resistance found in half of PCOS patients, the ovary remains insulin sensitive.

Answer 483

inguinal ligament, inferior epigastric vessels, rectus sheath

Answer 484

Aortic stenosis found in a pregnant patient is most likely due to a bicuspid valve. This limits the normal 2 to 3 cm2 orifice and creates resistance to ejection. This leads to severe stenosis and left ventricular hypertrophy. One formula to calculate maternal risk of a cardiac complication is the Cardiac Disease in Pregnancy (CARPREG) risk score, developed by Siu et al in 2001. They assign 1 point each to: a history of prior cardiac event or arrhythmia, New York Heart Association (NYHA) class >II or cyanosis, left heart obstruction (aortic valve <1.5 cm2), and a left ventricular ejection fraction <40%. Zero points is equal to a 5% risk. One point is equal to 27%. 2 points or greater is equal to a 62% risk.

Answer 485

The patient described has a ruptured hemorrhagic ovarian cyst, which is leading to a rapid progression of hemoperitoneum. If the patient is stable, close observation is reasonable. However, if she becomes hemodynamically unstable, emergent surgery is warranted. The decision to proceed laparoscopically or via open incision depends on the surgeon, but every attempt should be made to remove as little ovarian tissue as possible, particularly given this patient’s young age and lack of offspring. Although a unilateral oophorectomy is sometimes warranted if the bleeding cannot be controlled, this should not be your first option. Answer B: The decision between laparotomy and laparoscopy depends on the experience of the surgeon, but the decision to outright perform a unilateral adnexectomy on a nulliparous adolescent woman is not warranted. Every attempt should be made to control the bleeding with retention of the affected ovary, although it is understood that this stands as a last resort if all else fails.

Answer 486

The footling breech presentation carries the highest risk for cord prolapse. In this presentation there are no fetal parts obstructing the dilating cervical os to prevent the prolapse of the cord. The frequency of an abnormal presentation is increased greatly in the preterm fetus, as with our patient above. A high degree of suspicion may help diagnose a cord prolapse early enough to intervene successfully.

Answer 487

The first stage of labor encompasses the latent phase (slower cervical change) and the active phase (quicker cervical change). The latent phase of labor begins when the patient starts to perceive regular contractions. The active phase begins when the rate of cervical change increases. Historically, active labor was described at 4 cm or beyond according to published data from Dr. Friedman, known as Friedman's curve. More recently, studies show that a cervical dilation of 6 cm or greater should be considered the threshold of active labor, particularly in those undergoing induction of labor. These definitions play an important role in safe prevention of the primary cesarean section. Cesarean section is indicated when arrest of the first stage of labor is diagnosed by the criteria in the table below. Definition of Arrest of Labor in the First Stage At least 6 cm of cervical dilation with ruptured membranes and one of the following: failure to progress after at least 4 hours of adequate contractions (eg, more than 200 Montevideo units) OR 6 hours or more of inadequate contractions and no cervical change

Answer 488

A prolonged latent phase is defined as >20 hours in a nulliparous patient and >14 hours in a multiparous patient; however, this should not be an indication for a cesarean section. The Consortium on Safe Labor has significantly altered the definitions of labor arrest and protraction disorders. This study involved 19 United States hospitals and retrospectively reviewed the labor course of 62,415 singleton vaginal deliveries. New definitions of arrest and protraction disorders were adopted by the American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine to reduce the number of cesarean sections. The classic definition of a prolonged latent phase is based on the original Friedman curve, which found 95% of nulliparous and multiparous women enter the active phase of labor by 20 and 14 hours, respectively; however, most of the remaining 5% of women enter the active phase with continued expectant management. Thus, the position of the American College of Obstetricians and Gynecologists and the Society of Maternal-Fetal Medicine is that a prolonged latent phase should not be an indication for cesarean delivery.

Answer 489

Gross and microscopic examination of the placenta, umbilical cord, and fetal membranes by a pathologist is the most useful component of the evaluation of a stillbirth. Stillbirth, defined as an in utero death of a fetus at 20 weeks' gestation or greater, complicates 1/160 deliveries in the United States. Essential components to evaluation of stillbirths include a thorough maternal history, fetal autopsy, examination of the placenta/cord/membranes, and fetal karyotype evaluation. Gross evaluation may reveal abruption, umbilical cord thrombosis, velamentous cord insertion, vasa previa, and evidence of infection or genetic abnormalities. Elements of a Stillbirth Evaluation Key Component Details Other Notes Patient history Family history: recurrent spontaneous abortions, venous thromboembolism, congenital or chromosomal abnormalities, hereditary conditions, developmental delay, consanguinity Maternal history: previous venous thromboembolism, diabetes mellitus, chronic hypertension, thrombophilia, systemic lupus erythematosus, autoimmune disease, epilepsy, severe anemia, heart disease, use of tobacco/alcohol/drugs/medications Obstetric history: recurrent miscarriages, previous child with an anomaly/hereditary condition/growth restriction, gestational hypertension or preeclampsia, gestational diabetes mellitus, placental abruption, fetal demise Current pregnancy: maternal age, gestational age at stillbirth, medical conditions complicating pregnancy, BMI, complications of multi-fetal gestation, placental abruption, abdominal trauma, preterm labor or rupture of membranes, gestational age at onset of prenatal care, abnormalities seen on ultrasound, infections or chorioamnionitis Fetal autopsy If patient declines, external evaluation by a trained perinatal pathologist should be performed Other options: photographs, X-ray, ultrasonography, MRI, samples of tissues (ie, blood or skin) Provides important information in 30% of cases Placental examination Includes evaluation for signs of viral or bacterial infection Provides additional information in 30% of cases Fetal karyotype/ microarray Amniocentesis performed prior to delivery provides the greatest yield If amniocentesis is declined, an umbilical cord segment proximal to the placenta provides the 2nd highest yield Abnormalities are found in 8% of cases Maternal evaluation at time of demise Kleihauer–Betke test or flow cytometry for fetal cells in maternal circulation Syphilis Lupus anticoagulant, anticardiolipin antibodies, β2 glycoprotein antibodies Routine testing for inherited thrombophilias is not recommended In selected cases Indirect Coombs test – if not performed previously in pregnancy Glucose screening – in cases of large for gestational age baby Toxicology screen – in cases of placental abruption or when drug use is suspected

Answer 490

The incidence of HIV in pregnancy is increasing. The number of women with HIV giving birth in the United States increased approximately 30%, from 6,000 to 7,000 in 2000 to 8,700 in 2006. Although the actual number of women with HIV is low, it is recommended that all women be screened for HIV as early in pregnancy as possible. Although vertical transmission can occur at any time during gestation, labor and delivery is a high-risk time because of the maternal bodily fluids that the baby is exposed to, although the absolute transmission rates are low. However, depending on the viral load, management differs. Viral load should be assessed at 34–36 weeks' gestation to help determine mode and timing of delivery. Low viral load: HIV RNA <1,000 copies/mL – Proceed with vaginal delivery and deliver only via cesarean section for usual obstetric reasons. There is no correlation with transmission rates and length of membrane rupture. High viral load: HIV RNA >1,000 copies/mL – Delivery by prelabor cesarean section is recommended at 38 weeks' gestation. Women should continue to take their combination antiretrovirals as much as possible during labor and delivery or scheduled cesarean section. Additional IV zidovudine should be given only to those with HIV RNA >1,000 copies/mL, poor adherence to HAART, or unknown HIV RNA levels. If a cesarean section is indicated because of high viral load, IV zidovudine should be given 3 hours prior to scheduled cesarean section. Zidovudine crosses the placenta and acts as a preexposure prophylaxis for the baby. Other labor management should reduce the time that the fetus is exposed to maternal fluids and blood; therefore, invasive fetal monitoring is not recommended.

Answer 491

Neuroimaging plays a very important role in evaluating infants with neonatal encephalopathy. Brain MRI yields the most useful information. A brain MRI is the most sensitive imaging tool for detecting cortical and white matter injury, deep gray matter lesions, arterial infarction, hemorrhage, developmental brain malformations, and other underlying causes of neonatal encephalopathy. Table 1. Patterns suggestive of hypoxic-ischemic brain injury Injury to the deep gray nuclei (especially the posterior putamina and anterolateral thalami): Injury to the deep gray nuclei (especially the posterior putamina and anterolateral thalami). Brainstem injury is also common Parasagittal injury of the cerebral cortex and subcortical white matter in the arterial watershed distribution: this occurs more commonly in the setting of mild hypoxia or ischemia of prolonged or chronic duration. Table 2. Neonatal findings consistent with an acute peripartum or intrapartum event leading to Hypoxic-Ischemic Encephalopathy Apgar score of < 5 at 5 minutes and 10 minutes Fetal umbilical artery acidemia: pH < 7.0, or base deficit ≥ 12 mmol/L, or both Acute brain injury seen on neuroimaging consistent with hypoxia-ischemia, including deep nuclear gray matter or watershed (borderzone) injury Presence of multisystem organ involvement consistent with hypoxic-ischemic encephalopathy (HIE) Additional factors consistent with an acute peripartum or intrapartum hypoxic-ischemic event: A sentinel hypoxic or ischemic event occurring immediately before or during labor and delivery, such as ruptured uterus or severe abruptio placentae Fetal heart rate monitor patterns consistent with an acute peripartum or intrapartum event, such as a category III pattern No evidence of other proximal or distal temporal factors that could be contributing to the encephalopathy Abbreviations: HIE = hypoxic-ischemic encephalopathy

Answer 492

The Bishop score is a tool to predict those patients who will have a successful induction of labor. The components of the Bishop score are cervical dilation, effacement, station, consistency, and position, as seen in the table below. If the total score is more than 8, the probability of vaginal delivery after labor induction is similar to that after spontaneous labor. An unfavorable cervix generally has been defined as a Bishop score of 6 or less in most randomized trials.

Answer 493

A woman with a singleton gestation and a prior spontaneous preterm singleton birth should be offered progesterone supplementation (either intramuscular or vaginal) starting at 16–24 weeks of gestation to reduce the risk of recurrent spontaneous preterm birth. Preterm birth is the leading cause of neonatal mortality in the United States, and preterm labor precedes ~50% of preterm births. One of the strongest clinical risk factors for preterm birth is a prior preterm birth, which confers a 1.5- to 2-fold increased risk in a subsequent pregnancy. Risk Factors for Preterm Birth Prior preterm birth Shortened cervical length < 25 mm Vaginal bleeding Cervical excisional procedures D&C UTIs / Genital tract infections Periodontal disease Low maternal pre-pregnancy weight / BMI < 19.8 Short interval pregnancy Smoking / Substance abuse Although there has been mixed evidence for the use of progesterone supplementation and the prevention of preterm birth, ACOG currently recommends that if a patient has a history of a preterm birth, they be offered either intramuscular or vaginal progesterone. Depending on cervical length or painless cervical dilation, a cerclage can also be considered.

Answer 494

Traditionally, secondary repair of laceration breakdown was deferred for a minimum of two to three months. The purpose for delay was to allow sufficient time for revascularization of the wound edges and formation of scar tissue, which was thought to be of value during reanastomosis of the torn sphincter. However, few data support this approach and it commits the woman to an extended period of physical, social, and sexual disability because of continuous incontinence. Available evidence supports re-repair deep laceration dehiscence within the first two weeks following childbirth, which may result in a reduction in perineal pain during the healing process up to six months postdelivery and a reduction in dyspareunia. For superficial breakdowns that do not involve the rectum or anal sphincter, expectant management with perineal care may allow spontaneous healing to occur over a period of several weeks. For more extensive breakdowns, primary closure of the defect may be attempted. In rare cases, inadequately repaired lacerations may lead to rectovaginal fistula formation. Repair of such defects can be challenging, depending on size and location, and should be repaired by someone familiar with fistula repair techniques, and should be attempted only when there are no signs of infection, or when all signs of infection have resolved. At time of repair, a single preoperative dose of a broad-spectrum antibiotic, such as a cephalosporin, should be given.

Answer 495

Traditionally, secondary repair of laceration breakdown was deferred for a minimum of two to three months. The purpose for delay was to allow sufficient time for revascularization of the wound edges and formation of scar tissue, which was thought to be of value during reanastomosis of the torn sphincter. However, few data support this approach and it commits the woman to an extended period of physical, social, and sexual disability because of continuous incontinence. Available evidence supports re-repair deep laceration dehiscence within the first two weeks following childbirth, which may result in a reduction in perineal pain during the healing process up to six months postdelivery and a reduction in dyspareunia. For superficial breakdowns that do not involve the rectum or anal sphincter, expectant management with perineal care may allow spontaneous healing to occur over a period of several weeks. For more extensive breakdowns, primary closure of the defect may be attempted. In rare cases, inadequately repaired lacerations may lead to rectovaginal fistula formation. Repair of such defects can be challenging, depending on size and location, and should be repaired by someone familiar with fistula repair techniques, and should be attempted only when there are no signs of infection, or when all signs of infection have resolved. At time of repair, a single preoperative dose of a broad-spectrum antibiotic, such as a cephalosporin, should be given.

Answer 496

Patients with a stillbirth < 28 weeks can be given the option for induction, or dilation and evacuation. Patients with a previous hysterotomy can still undergo induction of labor. Classically, misoprostol 400 μg vaginally, every 6 hours, has been used for induction of labor in the setting of a stillbirth between 24–28 weeks' gestation with previous hysterotomy. Based on studies of elective second-trimester abortion, using a single dose of 200 or 600 mg of mifepristone 24–48 hours before misoprostol induction may be helpful. If misoprostol is not available, high-dose oxytocin is also acceptable for induction. Second-Trimester Stillbirth Induction Vaginal misoprostol 400–600 μg every 4–6 hours High-dose oxytocin 200 or 600 mg oral mifepristone 24–48 hours prior to vaginal misoprostol

Answer 497

A fetal weight estimation should be performed and the pelvis should be believed to be adequate for a vaginal delivery before attempting operative delivery. The maternal glucose tolerance status would potentially impact fetal weight and the likelihood of a disproportionate head to abdominal circumference ratio and the potential for a shoulder dystocia; however, it is not directly required for operative vaginal delivery. An estimated fetal weight >4000 g is a risk factor for shoulder dystocia. Suspected macrosomia is NOT a contraindication to operative vaginal delivery as long as it is used judiciously. Other criteria include: cervix fully dilated and retracted engagement of fetal head membranes ruptured known position of the fetal head adequate anesthesia pelvis thought to be adequate maternal bladder has been emptied patient consent

Answer 498

Pulmonary embolism is a serious consequence of the hypercoagulable state in pregnancy. The most common symptom is dyspnea. In an international clinical outcomes registry, the most common symptoms listed in decreasing order were: dyspnea chest pain cough syncope hemoptysis

Answer 499

An epidural should be placed extending to the T10 level, as patients with spinal cord injuries above the T5–T6 level and viable spinal cord segments distal to the lesion are at risk for autonomic dysreflexia. Autonomic dysreflexia (sometimes called autonomic hyperreflexia) is the most serious medical complication that occurs in women with spinal cord injuries and is found in 85% of patients with lesions at or above T6 level. It is a life-threatening complication of spinal cord injuries and is most likely to arise during labor. This condition is thought to be due to a loss of hypothalamic control of sympathetic spinal reflexes and occurs in patients with viable spinal cord segments distal to the level of injury. In susceptible patients, afferent stimuli from a hollow viscus, such as the bladder, bowel, or uterus, and from the skin below the level of the lesion or of the genital areas ascend in the spinothalamic tracts and posterior columns; this causes reflex sympathetic activation that cannot be supressed by the brain as the signals cannot pass through the level of the lesion to suppress the sympathetic excitatory response. The resultant catecholamine release and vasoconstriction lead to hypertension associated with headache, bradycardia, tachycardia, cardiac arrhythmia, sweating, flushing, tingling, nasal congestion, piloerection, and occasionally respiratory distress. Uteroplacental vasoconstriction may result in fetal hypoxemia. Although pain perception is impaired in women with spinal cord injuries at or above T10, neuraxial anesthesia is the treatment of choice to reduce the risk of autonomic dysreflexia because it blocks neurologic stimuli arising from the pelvic organs. In general, complete analgesia for the pain of labor and delivery necessitates block from the T10 to the S5 dermatome. For cesarean delivery, a block extending from the T4 to the S1 dermatome is desired.

Answer 500

Herpes zoster is characterized by fever, malaise, and a vesicular, painful rash that is distributed along a dermatome. It complicates between 0.4 to 0.7 per 1,000 pregnancies. Of these, 10%–20% of patients will develop varicella pneumonia, and the mortality is estimated at 40%. Congenital varicella syndrome, characterized by skin scarring, limb hypoplasia, chorioretinitis, and microcephaly, is rare at 0.4%–2%. The major neonatal morbidity and mortality occurs if the maternal symptoms develop from 5 days before delivery to 48 hours' postpartum. Treatment options include acyclovir and varicella zoster immunoglobulin (VZIG). For patients with uncomplicated varicella infections, monotherapy with oral acyclovir is recommended. Intravenous acyclovir does not improve morbidity or mortality except in patients who develop varicella pneumonia. VZIG is recommended for pregnant patients who are exposed to an infected patient within 14 days of exposure. Intravenous acyclovir plus VZIG is recommended for neonates born to a patient with varicella with symptoms between 5 days before delivery until 48 hours' postpartum.

Answer 501

Reassurance and follow-up is indicated within 1 week. A paradigm shift in postpartum care recommends follow-up within the first 3 weeks' postpartum with assessment of maternal emotional well-being central to this shift. ACOG recommends that providers should screen all patients with a standardized, validated tool at least once antepartum and with each postpartum visit. Perinatal depression is a common complication of pregnancy with potentially devastating consequences if it goes unrecognized and untreated. This patient is likely suffering from postpartum blues; however, it is important to assess for other mood disorders associated with pregnancy such as postpartum depression, postpartum psychosis, major depressive disorder, anxiety disorders, etc. Advocates have emphasized the importance of the 12-week period following delivery by naming this time the "fourth trimester." Previously, women would arbitrarily be have a 6-week postpartum appointment. In order to optimize care, experts recommend women meet with their health care provider within the first 3 weeks postpartum with ongoing follow-up as indicated based on the individual health concerns, and concluding with a comprehensive postpartum visit no later than 12 weeks after delivery. Providers should use these visits to assess physical, social, and psychological well-being such as physical recovery, chronic disease management, mood/emotional well-being, infant care, feeding, sexuality, contraception, birth spacing, and health maintenance.

Answer 502

Endometritis is the most common cause of fever after delivery, occurring in 1–13% of patients depending on risk factors. It is caused by ascending polymicrobial infection. Endometritis is a clinical diagnosis. It consists of a postpartum fever that cannot be related to another etiology (after conducting a thorough history and physical). It may be accompanied by tachycardia, lower abdominal pain and/or uterine tenderness, and leukocytosis. In women with postpartum fever but no uterine tenderness, alternative etiologies should be explored. Risk factors include long labor, cesarean delivery, GBS status, prolonged rupture of membranes, chorioamnionitis, intrauterine monitoring and/or cervical examinations, and bacterial vaginosis. Diagnostic characteristics include: fundal tenderness fever tachycardia elevated WBC and/or foul-smelling lochia Treatment includes antibiotics until 24 hours afebrile. Other causes of fever in the postpartum period include atelectasis, breast engorgement and/or mastitis, urinary tract infections, wound infections, DVTs, and medications. Risk Factors for Endometritis Labor Chorioamnionitis Prolonged labor/rupture of membranes Multiple cervical exams Intrauterine monitoring Large amount of meconium Birth Preterm/postterm birth Operative vaginal delivery/cesarean delivery Manual removal of placenta Maternal HIV, diabetes, severe anemia GBS colonization

Answer 503

Endometritis is the most common cause of fever after delivery, occurring in 1–13% of patients depending on risk factors. It is caused by ascending polymicrobial infection. Endometritis is a clinical diagnosis. It consists of a postpartum fever that cannot be related to another etiology (after conducting a thorough history and physical). It may be accompanied by tachycardia, lower abdominal pain and/or uterine tenderness, and leukocytosis. In women with postpartum fever but no uterine tenderness, alternative etiologies should be explored. Risk factors include long labor, cesarean delivery, GBS status, prolonged rupture of membranes, chorioamnionitis, intrauterine monitoring and/or cervical examinations, and bacterial vaginosis. Diagnostic characteristics include: fundal tenderness fever tachycardia elevated WBC and/or foul-smelling lochia Treatment includes antibiotics until 24 hours afebrile. Other causes of fever in the postpartum period include atelectasis, breast engorgement and/or mastitis, urinary tract infections, wound infections, DVTs, and medications. Risk Factors for Endometritis Labor Chorioamnionitis Prolonged labor/rupture of membranes Multiple cervical exams Intrauterine monitoring Large amount of meconium Birth Preterm/postterm birth Operative vaginal delivery/cesarean delivery Manual removal of placenta Maternal HIV, diabetes, severe anemia GBS colonization

Answer 504

The fetal presentation is a reference to the part of the fetus that is in or over the maternal pelvis. The most common presentation is the cephalic presentation, in which the head is the presenting part. Other presentations commonly seen are breech presentation, funic or umbilical cord presentation, and transverse presentation. Fetal attitude is a reference to the head flexion of the fetus (e.g., flexed or deflexed—think face and brow presentations). Fetal position refers to the orientation of the fetal head (e.g., OP, OA, OT). There are many reasons why a fetus may have a malpresentation, including prematurity, placental location, uterine anomalies, and congenital abnormalities. Any pelvis other than a gynecoid pelvis is at higher risk of a malpositioning, but it does not lead to a malpresented fetus.

Answer 505

Heparin-induced thrombocytopenia can be quite severe, and a hematologist should be consulted immediately. In cases where there is a history of heparin-induced thrombocytopenia, fondaparinux is the best choice. Fondaparinux is a synthetic pentasaccharide. Fondaparinux binds to antithrombin III and accelerates the inhibition of factor Xa. Dabigatran is an oral thrombin inhibitor. Edoxaban, betrixaban, and rivaroxaban are anti-Xa inhibitors. These medications should be avoided in pregnancy because there is inadequate information on safety. These medications cross the placenta and may therefore compromise fetal coagulation.

Answer 506

Herpes simplex virus is not a reportable disease, so the true incidence is not known. Most individuals infected with the herpes virus are completely unaware because infections can occur without having the classic painful ulcers. Approximately 15% of women report recognition of their infection. Of note, this comes from serologic evidence of infection and not necessarily genital ulcers.

Answer 507

Multifetal gestations are associated with an increased risk of almost every pregnancy complication. This includes preterm birth, hypertensive disorders of pregnancy, gestational diabetes, and fetal growth restriction. A large percentage of women with multifetal gestations will give birth before 37 weeks' gestation, and the average gestational age of delivery for women with a twin gestation is 36 weeks. However, in uncomplicated dichorionic/diamniotic twin pregnancies, it is appropriate to deliver at 38 weeks' gestation. The incidence of complications increases after this gestational age. Timing of Delivery Monochorionic-monoamniotic 32–34 weeks Monochorionic-diamniotic 34–37 w6d Dichorionic-diamniotic 38 weeks

Answer 508

Currently, it is recommended that patients in the postpartum period participate in moderate-intensity aerobic exercise for at least 150 minutes per week. Exercise is important as it improves recovery, improves cardiovascular fitness, and facilitates return to pre-pregnancy weight.

Answer 509

In the first trimester, 0 additional calories are recommended. The entirety of pregnancy requires an additional 80,000 calories, however most of this intake should be during the last 20 weeks of pregnancy. The Institute of Medicine has guidelines with recommended dietary allowances in pregnancy. They recommend an additional 0 calories in the first trimester, an additional ~350 calories during the second trimester, and an additional ~450 calories during the third trimester. These recommendations are for normal weight women (BMI 18.5–25) who have a goal weight gain of 25–35 lbs during pregnancy.

Answer 510

Late preterm steroids are recommended in patients between 34 weeks 0 days and 36 weeks 6 days who are at high risk for preterm birth within the next 7 days (but before 37 weeks of gestation). Patients who received a previous course of antenatal corticosteroids are not eligible for late preterm steroids. The Society for Maternal Fetal Medicine (SMFM) recommends against administration in groups not studied in the ALPS trial, including multifetal gestations and patients with pregestational diabetes.

Answer 511

Fetal-maternal hemorrhage of as little as 0.1 mL is enough to cause alloimmunization in pregnancy. There are many different blood group antigens that may cause alloimmunization. Clinically significant alloimmunization in pregnancy is usually the result of Rh D antigen incompatibility. It clinically presents as fetal anemia after fetal-maternal hemorrhage has occurred in a prior pregnancy. Alloimmunization most commonly occurs at the time of delivery, however there are a number of potential scenarios that may result in alloimmunization. Potential causes of fetal-maternal hemorrhage and alloimmunization Delivery (vaginal or cesarean) Antepartum bleeding (all trimesters) First trimester spontaneous abortion Pregnancy termination Ectopic pregnancy External cephalic version Amniocentesis or chorionic villus sampling

Answer 512

Tuberculosis (TB) is an infectious bacterial disease caused by Mycobacterium tuberculosis. Although uncommon in the United States, this illness represents a large disease burden globally during pregnancy. The areas of highest concentration are subsaharan Africa and Southeast Asia. Pregnancy has not been shown to increase the risk of contracting TB or the risk of disease progression. Testing for latent TB during pregnancy should be performed only on patients who would warrant prompt treatment, such as those with a recent exposure or a high risk of disease progression (such as those who are immunocompromised). In patients who are otherwise healthy and do not have risk factors for disease progression, it is preferable to withhold testing and treatment until 3 months postpartum. If testing is obtained and is positive in a patient without major risk factors for progression to active disease, delaying therapy until 3 months postpartum is appropriate. If treatment is indicated, first-line treatment for latent TB during pregnancy is isoniazid monotherapy. Answer A: Streptomycin is a second-line drug used in the treatment of active tuberculosis. However, it causes ototoxicity in the fetus and hence is contraindicated in pregnancy. Isoniazid alone is the preferred treatment for latent tuberculosis during pregnancy. Answer C: Isoniazid alone is the preferred treatment for latent tuberculosis during pregnancy. Answer D: The above four-drug regimen: isoniazid, rifampin, pyrazinamide and ethambutol along with pyridoxine (Vitamin B6) is the recommended initial treatment for active tuberculosis in pregnant patients. The bactericidal phase occurs in the first 2-month phase when all four drugs are given. This is then followed by a 4-month phase of isoniazid and rifampin, called the continuation phase.

Answer 513

1 gm of TXA can be administered IV or orally in the setting of postpartum hemorrhage. The WOMAN trial reported a significant reduction in maternal mortality from obstetric hemorrhage (1.5% vs 1.9%) when tranexamic acid is compared with placebo. ACOG recommends that tranexamic acid be used in the setting of PPH if other medical options fail. Benefits were observed in women receiving tranexamic acid within 3 hours from delivery time. Answer A: Administration of tranexamic acid was not associated with higher incidence of thrombosis compared with the risk in women who did not receive it. Answer B: The WOMAN trial reported a significant reduction in maternal mortality from obstetric hemorrhage (1.5% vs 1.9%) when tranexamic acid is compared to placebo, NOT maternal morbidity. Answer C: 1 gm of TXA can be administered IV or orally in the setting of postpartum hemorrhage; TXA should be considered in addition to uterotonic agents. Answer E: TXA is not meant to replace uterotonic agents. Due to signifcant reduction in mortality rates, TXA should be considered in addition to uterotonic agents.

Answer 514

Mastitis occurs in up to 10% of breastfeeding women and is caused by bacteria entering the milk ducts through cracked nipples. The two most common organisms causing mastitis are Staphylococcus aureus and Streptococcus viridans. Women commonly present with generalized fatigue, fever, and chills. The breast is erythematous and warm to the touch. The treatment is dicloxacillin 500 mg PO QID for 10–14 days. A breast abscess should be suspected when the tissue is fluctuant or if the patient’s symptoms do not improve after 2–3 days of treatment. The treatment for breast abscesses is most commonly incision and drainage, but successful ultrasound-guided drainage of the abscess has been reported. The purulent material from the abscess should be sent for culture, and coverage for methicillin-resistant S. aureus should be given. Some recommend initial intravenous antibiotics with vancomycin 1 g every 12 hours until surgical incision and drainage. An appropriate oral antibiotic regimen that will cover for MRSA is trimethoprim-sulfamethoxazole double-strength BID for 10–14 days. Of note, women with mastitis and breast abscesses should be encouraged to continue breastfeeding during their treatment.

Answer 515

The Consortium on Safe Labor has significantly altered the definitions of labor arrest and protraction disorders. New definitions of arrest and protraction disorders adopted by the American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine were published in an attempt to reduce the number of cesarean sections. A cesarean section for a failed induction of labor should not be performed until the following 3 criteria have been met: Three Criteria for Failed Induction Up to 24 hours or longer of attempts to induce labor Amniotic membranes ruptured 12–18 hours of oxytocin administration after membranes ruptured In addition, a patient should not be considered in the active phase until 6-cm dilation. An active phase arrest is defined as ≥6 cm with membrane rupture and no cervical change after 4 hours of adequate contractions (measured by an intrauterine pressure catheter with Montevideo units >200) or 6 hours of inadequate contractions.

Answer 516

Risk factors for face presentation include prematurity, fetal weight < 2,500 g, fetal macrosomia, anencephaly, and high parity. Face presentation may be suspected by Leopold examination but is usually confirmed during the first or second stage of labor when facial parts are palpated on vaginal examination. The unusual presenting fetal head diameter results in alterations of the cardinal movements of labor and descent. If the face is in the mentum anterior position (chin on the anterior aspect of the maternal pelvis), the diameter of the head is small enough so as to usually allow for vaginal delivery and, therefore, expectant management is the appropriate course of action provided that labor is progressing. Operative vaginal delivery as well as manual rotation are contraindicated. Cesarean delivery should be reserved for usual obstetric indications such as non-reassuring fetal status or labor dystocia.

Answer 517

Prior to 2006, the causes of death related to pregnancy were traditionally hemorrhage, hypertensive disorders of pregnancy, and embolism. From 2011 to 2013, the most common causes of pregnancy-related maternal mortality were cardiovascular conditions, including congenital heart disease, ischemic heart disease, cardiac valvular disease, hypertensive heart disease (NOT pregnancy related), and congestive heart failure. Furthermore, racial disparities still exist, and the rates of death are higher among non-Hispanic Black women.

Answer 518

Late-onset Group B Streptococcus (GBS) disease presents as bacteremia without a focus in about 65% of cases. The most common sign at presentation is a fever consisting of a temperature ≥38°C. The incidence of late-onset disease is 0.3 to 0.4 per 1,000 births. It is not prevented by intrapartum prophylaxis. The incidence of early onset GBS disease is 0.24 per 1,000 births. Risk factors include preterm delivery, premature rupture of membranes (regardless of gestational age), prolonged rupture of membranes for >18 hours before delivery, chorioamnionitis, GBS bacteriuria during the current pregnancy, intrapartum maternal fever, or delivery of a previous infant with GBS disease. Approximately 50% of women colonized with GBS will transmit the disease to their newborn. In absence of antibiotic prophylaxis, 1–2% will develop early onset disease. 72% of cases occur in term infants. Preterm infants are more likely to have apneic episodes, have NICU stays, and require blood pressure support. Late-onset disease mostly occurs in infants born at < 28 weeks' gestation. Most cases present as bacteremia without a focus, but focal sites of infection may be seen (CNS, soft tissue, bones, joints, intravenous catheters). GBS infection after 6 months of age can be the first sign of immunodeficiency (such as HIV infection).

Answer 519

The question describes the area innervated by the pudendal nerve which arises from S2–S4. The pudendal nerve is responsible for transmitting somatic pain signals from the vagina and perineum during the second stage of labor. As the fetal head descends into the pelvis and places pressure on the vagina and perineum, somatic pain is transmitted through the pudendal nerve. A pudendal nerve block is a reasonable option for a patient experiencing pain from the pressure of the fetal head on the vagina and perineum. This involves palpating the sacrospinous ligament on each side and injecting 5–10 mL of lidocaine just inferior to the midsection of the sacrospinous ligament. Although a pudendal block targets the pudendal nerve, a paracervical block does not. The paracervical block targets the T10–L1 nerve roots, which are called the Frankenhäuser plexus. This is rarely used in obstetrics because of postblock fetal bradycardia.

Answer 520

The most common cause of acute pancreatitis during pregnancy is gallstones, whereas outside of pregnancy the most common cause is alcohol. Other possible causes of pancreatitis in pregnancy include alcohol, hyperlipidemia, acute fatty liver of pregnancy, post-ERCP complication, and smoking. Gallstone pancreatitis occurs by blocking the ampulla of Vater, which then causes obstruction of pancreatic enzymes. This leads to significant epigastric and right upper quadrant pain in addition to increased amylase and lipase levels. ERCP can be performed if a stone obstructs the common bile duct, and cholecystectomy is indicated, regardless of trimester, because of the increased recurrence risk of pancreatitis in the postpartum period. Management of pancreatitis in pregnancy is the same as outside of pregnancy. The patient should be kept NPO, intravenous fluid resuscitation should occur, and nasogastric tube placement should be considered. Nearly all cases of acute pancreatitis will resolve with conservative measures, but some may require more intensive therapy. Generally, acute pancreatitis does not increase maternal or neonatal morbidity.

Answer 521

The half-life of oxytocin is approximately 3–5 minutes, therefore, the uterus will start contracting within 3–5 minutes of beginning an oxytocin infusion. Steady-state plasma levels are reached at about 40 minutes. The goal of induction of labor is to stimulate sufficient uterine contractions to elicit cervical change and subsequent fetal descent. Protocols vary greatly among institutions; however, it is agreed that oxytocin should be discontinued with tachysystole or nonreassuring fetal heart rate patterns.

Answer 522

Perineal dehiscence is extremely rare, and almost all cases are caused by infection. In cases of mild cellulitis, antibiotics are usually enough. With a first- or second-degree dehiscence this can usually be allowed to heal by secondary intention. A meta-analysis found that there is no difference in healing versus dyspareunia rates at 4 weeks and 6 months, respectively.

Answer 523

One in 20 monochorionic twins share an amniotic sac. This type of twin pregnancy is associated with a high fetal death rate. In some studies, the death rate has been as high as 17%. Cord entanglement has been associated with up to half of fetal deaths with this amniotic configuration.

Answer 524

Intracranial hemorrhage is the most serious complication of vacuum-assisted delivery, as bleeding into the brain parenchyma may lead to permanent damage or death. The incidence of intracranial hemorrhage varies by method of delivery and is highest with combined vacuum- and forceps-assisted vaginal delivery (1 in 280). One study cites rates of 1 in 860 for vacuum extraction compared with 1 in 1,900 for women who deliver spontaneously. Complications From Vacuum-Assisted Vaginal Delivery (VAVD) Anal sphincter injury 1000–1100 Fetal skin laceration 450–1410 Cephalohematoma 1117 Subgaleal hematoma 260–450 Intracranial hemorrhage 16.2 Retinal hemorrhage 15.7 Skull fracture 235–658 Brachial plexus injury 17.6

Answer 525

Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) is ideally given at 27–36 weeks' gestation. Ideal timing of the vaccination facilitates maximum placental transfer of maternal antibodies to the fetus conferring pertussis immunity to the newborn. Infants are not eligible for vaccination against pertussis until ~2 months of age, which can leave them vulnerable if maternal vaccination is not done. Administration of the Tdap vaccination is indicated in each pregnancy, even if there is a previous history of pertussis or vaccination. If not administered during pregnancy, it can be given immediately postpartum.

Answer 526

The postpartum examination is an opportunity to address potential long-term complications as well as chronic medical conditions. Patients with gestational hypertension or pregnancy-induced hypertension should be advised of their increased lifetime risk of cardiovascular disease. The atherosclerotic cardiovascular (ASCVD) assessment should be conducted, and if the 10-year risk is 10% or greater, 81-mg aspirin should be initiated along with a statin. It would be presumptive to start the patient on a statin and/or aspirin without an increased ASCVD or other major risk factors. An electrocardiogram (ECG) would not likely provide any clinical information and therefore is not indicated.

Answer 527

Mortality in patients with central nervous system (CNS) disease has substantially decreased from 50% to 4% due to appropriate treatment regimens. However, despite this, 20% of survivors of neonatal herpes have long-term neurologic sequelae, including profound neurologic impairment within the first 12 months of life.

Answer 528

Lochia is a normal event after delivery and typically lasts between 4 and 8 weeks. Although women and physicians typically think of this as blood, it is actually a mixture of red blood cells, epithelial cells, bacteria, and fragments of the decidua. In the first few days after delivery, the lochia is called lochia rubra because it is primary mixed with red blood cells, which gives it the characteristic red color. After the first few days, the discharge becomes clear and is termed lochia serosa and then finally, lochia alba, when the composition is predominantly leukocytes. Persistent lochia lasting more than 8 weeks is not normal and should be evaluated. A retained portion of the placenta could be causing the persistent lochia. Although extremely uncommon, placental site trophoblastic tumor (PSTT) can also cause persistent lochia. Both retained placenta and PSTT would cause an elevated beta-hCG level. It is important to remember that PSTT can arise months to years after a normal delivery. Evaluation is warranted for persistent lochia beyond 8 weeks. Noninvasive measures should first be explored, such as a pelvic examination, transvaginal ultrasonography, and beta-hCG measurement.

Answer 529

Cord loops are frequently encountered in labor and delivery and are caused by coiling around various fetal parts during movement. A cord around the neck—a nuchal cord—is common, and is not a contraindication to vaginal delivery. One nuchal cord or loop is reported in 20 to 34 percent of deliveries; two loops in 2.5 to 5 percent; and three loops in 0.2 to 0.5 percent of patients. During labor, up to 20 percent of fetuses with a nuchal cord have moderate to severe variable heart rate decelerations, and these are associated with a lower umbilical artery pH. Cords wrapped around the body can have similar effects. Despite their frequency, nuchal cords are not associated with greater rates of adverse perinatal outcome.

Answer 530

Microcephaly is associated with congenital varicella syndrome. Microcephaly is defined as a head circumference measurement that is smaller than a certain value for babies of the same age and sex. This measurement value for microcephaly is usually more than 2 standard deviations (SDs) below the average. The risk of congenital varicella syndrome is low (0.4–2%); limited to exposure during early pregnancy (first trimester 0.4%, second trimester 2%, third trimester 0%); and characterized by: skin scarring limb hypoplasia chorioretinitis microcephaly Varicella, or chickenpox, usually is diagnosed based on the clinical findings of a classic pruritic, vesicular rash, so laboratory testing is not needed. Once the rash is detected, oral acyclovir should be started within 24 hours, as it is shown to reduce new lesion formation, reduce duration, and also improve symptoms. In the mother, IV acyclovir has been shown to reduce maternal morbidity and mortality associated with varicella pneumonia and can be considered if disseminated infection or encephalitis is present. Varicella pneumonia is the most common cause of mortality. If a pregnant woman denies a history of either varicella vaccination or prior infection, documentation can be accomplished with the use of varicella IgG serology. Neonatal VZV infection is associated with a high neonatal death rate when maternal disease develops from 5 days before delivery to 48 hours postpartum, as a result of the relative immaturity of the neonatal immune system and the lack of protective maternal antibodies. TrueLearn Insight: Oral acyclovir, if started within 24 hours of developing the rash, has been shown to reduce the duration of new lesion formation and the total number of new lesions, and to improve constitutional symptoms.

Answer 531

More than 50% of brachial plexus injuries occur following uncomplicated vaginal deliveries. This is due to the fact that the vast majority of vaginal deliveries are uncomplicated. Brachial plexus injury is associated with the 10%–20% of deliveries that are complicated by shoulder dystocia, making it much more likely to occur during a delivery complicated by shoulder dystocia than during an uncomplicated vaginal delivery. Brachial plexus injury can affect the posterior arm of infants whose anterior shoulder is involved in shoulder dystocia and can occur in association with cesarean delivery for fetal malpresentation.

Answer 532

Septicemia is the most common cause of death following a uterine artery embolization. Septic shock is a form of distributive shock and is marked by an increased cardiac output and a decrease in the system vascular resistance. Uterine fibroids are the most common pelvic tumors and result from an overgrowth of smooth muscle tissue. They can potentially interfere with women’s lifestyles by causing pelvic pressure, urinary incontinence, and abnormal uterine bleeding. There are multiple non-surgical options, including hormones and uterine artery embolization. A uterine artery embolization (UAE) is performed by an interventional radiologist and the procedure involves accessing the uterine artery via the femoral artery and depositing polyvinyl alcohol particles to block the flow of blood to the fibroid. The most life-threatening complication is septic shock from a necrotic fibroid. Leiomyosarcoma is a rare tumor that mimics a fibroid. It is difficult to obtain a sample of this tissue, and there are no distinct characteristics on imaging to distinguish a benign from a malignant mass. Vaginal discharge and some vaginal bleeding are common 24–48 hours after the procedure, but there should not be a large enough amount to cause significant blood loss. There are no reported cases of myocardial infarction following UAE. The rates of venous thromboembolism (VTE) are small following a UAE and are usually treated before they become fatal.

Answer 533

Meconium aspiration syndrome (MAS) entails intrauterine passage of meconium by the fetus, aspiration of meconium, resulting in respiratory distress shortly after birth that is not explained by other reasons. It occurs in approximately 2%–10% of infants born with noted meconium-stained amniotic fluid. Meconium passage can occur in a fetus that is under stress. Stressful states can include intolerance to labor, post-maturity syndrome, placental insufficiency, or other states that can cause fetal hypoxia. Meconium aspiration syndrome has a few other characteristics that can distinguish it from other causes of neonatal respiratory distress. These include a flattening of the diaphragm on chest X-ray, and rales or rhonchi upon auscultation of the lungs. It is also increased in post-term neonates.

Answer 534

In the absence of severe infection or other major complications, a breakdown of an obstetric anal sphincter injury (OASIS) can be managed with outpatient wound care for a brief time prior to surgical repair. In some cases, the breakdown may be too extensive, or the patient may be unable to follow up as frequently as necessary as an outpatient prior to repair. In these instances, primary closure may be the best option. OASIS Management Condition Treatment Breakdown limited to superficial skin Expectant management with perineal care Mild perineal cellulitis without evidence of breakdown 7-day course of cephalosporins Uncomplicated laceration breakdown without infection Outpatient wound care before surgical repair Breakdown with severe infection Emergent surgical debridement

Answer 535

The tuberculin skin test (TST) is used to identify patients who are sensitized to the Mycobacterium antigens. Purified protein derivative is the tuberculin material used in the TST in North America. This material may be different in other areas of the world. Currently, the Mantoux technique is recommended for TST administration. This consists of an intradermal injection of the tuberculin material into the inner surface of the forearm. When the test is read, the transverse diameter of the induration (not the erythema) should be measured 48–72 hours after administration.

Answer 536

Antibiotics given prior to gynecologic surgery or procedures that enter the bowel or vagina tract is one of the most effective strategies to decrease the risk of surgical site infections. When antibiotics are indicated, cefazolin is the preferred drug in most instances; exceptions include patients with allergy or those undergoing uterine evacuation. Answer B: Subcutaneous irrigation has been shown to decrease the risk of wound infection in all patients, regardless of body mass index. Answer C: Subcutaneous drains are not recommended because randomized trials have consistently shown they do not decrease the risk of wound complications in the overall obstetric population or in obese patients. In an observational study of women with ≥ 4 cm of subcutaneous thickness, the use of a drain was associated with an increased risk of wound complications. Answer D: Subcutaneous sutures have been shown to decrease seroma formation and wound disruption, but they have no effect on decreasing postoperative wound infection. Answer E: Negative-pressure wound therapy MAY reduce dehiscence and infection.

Answer 537

Amniotic fluid embolism is an obstetric emergency. The classic clinical triad consists of hypoxia, hypotension, and coagulopathy. Diagnosis is clinical, with many patients losing consciousness and requiring cardiopulmonary resuscitation. There are two phases: the early phase, characterized by right ventricular failure; and the second phase, characterized by left ventricular failure. Hallmarks of management are high-quality CPR, supportive measures, and correction of coagulopathy. One important aspect of management is fluid status. It is important to LIMIT excessive fluid resuscitation, as patients can become easily fluid overloaded and develop pulmonary edema.

Answer 538

Beginning at 36 weeks’ gestation, either acyclovir 400 mg three times daily or valacyclovir 500 mg twice daily should be used to suppress recurrent genital HSV, regardless of the number of prior recurrent outbreaks. Suppression therapy should be continued until delivery.

Answer 539

During pregnancy, there is an increased susceptibility to pyelonephritis. This is in part due to the gravid uterus impinging on the ureters and to urinary stasis from the effect of progesterone. Pyelonephritis is a potentially serious complication, as it can lead to preterm labor, respiratory distress, and septic shock, resulting in death. It is imperative to promptly diagnose and treat the condition when recognized. Most cases of pyelonephritis are due to Escherichia coli, a urinary pathogen, and there are standard antibiotic regimens available. If the patient does not respond to antibiotics within 72 hours after treatment, it is important to consider obtaining a renal ultrasonography to evaluate the kidneys for a renal abscess.

Answer 540

Physical examination–indicated cerclage is newer terminology for a “rescue” or “emergency” cerclage. Patients are candidates if they have cervical dilation (1–4 cm at the internal os) on a digital or speculum exam between 16 0/7 and 23 6/7 weeks' gestation. Of note, signs of labor, placental abruption, and infection must be absent for a patient to be a good cerclage candidate. It is also important to stress that patients do not have to have a history of a prior preterm birth to be a candidate for a physical examination–indicated cerclage (unlike an ultrasound-based cerclage or obstetric history–based cerclage). Patients should be advised that a physical examination–indicated cerclage is a “rescue” attempt to prolong the pregnancy and there is a high risk of membrane rupture at the time of cerclage placement. Studies have shown that women gain, on average, about 34 days after placement of a physical examination–indicated cerclage.

Answer 541

The patient has an intrauterine fetal demise (IUFD) in breech presentation and 1 previous low-transverse uterine incision. The question at hand is mode of delivery: repeat cesarean section or trial of labor after cesarean (TOLAC) with vaginal delivery. Contraindications to TOLAC include a uterine incision other than low transverse or a contraindication to vaginal delivery. Risks and benefits to both modes of delivery exist. The risks of cesarean section include short-term morbidities such as increased pain, increased blood loss, increased risk of infection, and surgical injury. Long-term consequences include abnormal placentation disorders in future pregnancies and increased adhesions, making subsequent abdominal procedures more complicated. TOLAC offers faster recovery and decreased morbidity if vaginal delivery is accomplished; however, it carries a 0.5%–0.7% risk of uterine rupture. Several factors increase the chance of successful TOLAC, including previous vaginal deliveries, normal maternal weight, spontaneous labor, a nonrecurring indication for cesarean section, and maternal age < 35 years. In the case of IUFD of a normal-sized fetus, a vaginal delivery can and should be offered to decrease maternal morbidity. The risk of uterine rupture is thought to be the same as for cephalic fetuses. Induction of labor increases the relative risk of uterine rupture to approximately 1%, though the absolute risk is still low.

Answer 542

In addition to hypotension, neuraxial analgesia may reactivate oral herpes. The most frequently postulated etiology of reactivating oral herpes simplex virus (HSV) is that it is caused by irritation of the trigeminal nerve from facial scratching due to neuraxial opioid-induced pruritus. The likelihood of maternal hypotension depends on the dose of anesthetic administered and the speed of onset of the neuraxial block. Around 10% of women develop hypotension with low-dose neuraxial labor analgesia. Compared with noncatheter pain relief during labor, epidural placement carries an 18.23 RR for the development of hypotension. The hypotension occurs because of sympathetic blockade, dilation of vascular beds, and poor venous return. Prevention of Hypotension After Neuraxial Analgesia Preload or coload the patient with crystalloid Administer vasopressors before, during, or after neuraxial anesthesia: Ephedrine Phenylephrine Table modified from ACOG Practice Bulletin 209: Obstetric Analgesia and Anesthesia. 2020. Answer A: Around 10% of women develop hypotension with low-dose neuraxial labor analgesia. The likelihood of maternal hypotension depends on the dose of anesthetic administered and the speed of onset of the neuraxial block. Answer B: Epidural anesthesia is LESS likely than spinal anesthesia to cause hypotension because epidural anesthesia allows for slow titration of the local anesthetic. Answer C: Hypotension after epidural placement results from SYMPATHETIC blockade and may be partially prevented by preloading the patient with IV fluids. Answer E: Preloading or coloading the patient with crystalloid or small doses of vasopressors (usually ephedrine or phenylephrine) has been shown to decrease hypotension after administration of neuraxial anesthesia. Bottom Line: Postepidural hypotension is a common occurrence. Pretreatment with IV fluids is currently the most common method to prevent hypotension.

Answer 543

A nonstress test is a form of fetal assessment. As with other characteristics of the FHR tracing, baseline variability often changes with fetal sleep or wake state and over the course of labor. Evaluation of minimal FHR variability should include evaluation of potential causes such as maternal medications, fetal sleep cycle, or fetal acidemia. For minimal variability thought to be due to recent maternal opiod administration, FHR variability often improves and returns to moderate variability within 1–2 hours. A fetal sleep cycle generally lasts 20 minutes but can persist up to 60 minutes, and moderate variability should return when the fetal sleep cycle is complete. In these situations, continued observation and expectant management is appropriate. If minimal FHR variability is suspected to be due to decreased fetal oxygenation, then maternal repositioning, administration of oxygen, or intravenous fluid bolus may be considered. If improvement in FHR variability does not occur with these measures and there are no FHR accelerations, additional assessment such as digital scalp or vibroacoustic stimulation should be done. Continued minimal variability (in the absence of accelerations or normal scalp pH) that cannot be explained or resolved with resuscitation should be considered as potentially indicative of fetal acidemia and should be managed accordingly.

Answer 544

Significant changes have occurred in the field of obstetrics in the past several years regarding management of cervical insufficiency and the use of cervical length screening. There are now 3 different terms to define transvaginal cerclage placement: history-indicated physical examination-indicated ultrasound-indicated A history-indicated cerclage is typically placed at 13–14 weeks' gestation and is appropriate in a patient with a clear history of cervical insufficiency (painless cervical dilation in the mid-second trimester) or history of prior cerclage. If a patient has painless cervical dilation in the mid-second trimester (1–4 cm), she is a candidate for a physical examination-indicated cerclage. This is not restricted to women with a history of a prior preterm birth. Evidence in this situation is extremely limited and is based on only one small randomized controlled study and retrospective studies. Thus, this is a “rescue” cerclage in hopes of prolonging the pregnancy. These limited studies suggest that the patient gains, on average, 4 weeks of gestation with a physical examination-indicated cerclage. With an ultrasound-indicated cerclage, the patient has a cerclage placed because of a shortened cervical length discovered on transvaginal ultrasonography. Only patients with a prior preterm delivery at < 34 weeks and a cervical length < 25 mm found on ultrasonography between 16 and 24 weeks are candidates for an ultrasound-indicated cerclage. It is important to remember that medically indicated (eg, preeclampsia) preterm deliveries are excluded.

Answer 545

Starting around 2 days postpartum, the uterus begins to involute. The process is completed around 4 weeks, when the uterus regains its previously nonpregnant state of around 100 g or less. The total number of muscle cells is not believed to decrease; rather, the cell size is believed to decrease along with involution of connective tissue. In some cases, it may take an additional week for the uterine cavity to no longer display sonographic findings of the prepregnant state.

Answer 546

The base excess must be ≥12 mmol/L for diagnosis of neonatal encephalopathy and ≥17 mmol/L to qualify the neonate for hypothermia therapy. The diagnosis is also made with a pH < 7 and 2 MRI or MRS scans, the first obtained between 24 and 96 hours of life and the second at day 10 or later. Well-defined patterns on brain MRI typical of hypoxic–ischemic cerebral injury in the newborn are deep nuclear gray matter (i.e., basal ganglia or thalamus) injury and watershed (borderzone) cortical injury.

Answer 547

Uterine inversion is a rare complication of delivery (1 in 3,700 to 20,000 deliveries). Diagnosis is made after delivery by identifying a firm mass (uterus) below the cervix while the fundus of the uterus cannot be palpated on abdominal examination. Correction of inversion vaginally is usually successful. Manual replacement is achieved by grasping the uterus like a tennis ball and using the fingertips to apply upward pressure circumferentially, with or without administering uterine relaxants.

Answer 548

Gestational thrombocytopenia is a common finding, occurring in up to 8% of pregnancies, and is usually an incidental finding on third-trimester laboratory testing. When evaluating thrombocytopenia, one should first rule out other causes such as: Preeclampsia Thrombotic thrombocytopenic purpura Hemolytic uremic syndromes However, these symptoms relate to the overall constellation of the disease process (e.g., elevated blood pressure levels, neurological symptoms, or significant proteinuria). In contrast, the diagnosis of gestational thrombocytopenia can be made when these criteria are met: Asymptomatic Almost always >70,000/μL (most commonly >100,000/μL). Thrombocytopenia resolves by 2–12 weeks postpartum. There have been case reports of neonatal thrombocytopenia, but overwhelming evidence indicates there is not an increased risk of maternal or neonatal morbidity. The etiology of gestational thrombocytopenia is unknown but is thought possibly to be from the increased plasma volume associated with pregnancy, which causes a hemodilutional effect on the platelet count. Another suggested etiology is increased platelet consumption during pregnancy.

Answer 549

Contributing Factors for Endometritis Cesarean delivery Prolonged rupture of membranes GBS-positive status Young age Prolonged labor duration Multiple vaginal examinations Low socioeconomic status Bacterial vaginosis infections

Answer 550

When a gestation is beyond viability, it is important that external fetal heart rate and contraction monitoring occur for a minimum of 4 hours following blunt trauma to the abdomen because of the increased risk of abruption and preterm labor. Fetal heart rate monitoring combined with uterine tocodynamometry has a very high negative predictive value for placental abruption, up to 100% in the setting of no vaginal bleeding or abdominal pain. Trauma affects 6–8% of pregnancies, and the top causes are assault (domestic violence), motor vehicle crashes, and falls. Anything more than minor trauma requires obstetric evaluation, the components of which may differ based on severity of the trauma and gestational age. After trauma in an obstetric patient, the patient should be stabilized and a fetal heart rate obtained. If there is a fetal heart rate present and the patient has reached a viable gestational age (approximately 24 weeks at many centers, but may be earlier depending on institution), continuous fetal monitoring with uterine tocodynamometry is indicated. Timing of this monitoring is based on factors in the table below. Answer E: A minimum of 24 hours of monitoring is recommended if the patient presents with abdominal bruising or obvious abdominal injury, regular contractions, vaginal bleeding, an abnormal fetal heart tracing, uterine pain, or coagulopathy (for example, low platelets or fibrinogen < 200 mg/dL).

Answer 551

Opioids are a part of the stepwise multimodal approach to postoperative pain management after cesarean delivery. The general risk of opioid-related central nervous system (CNS) depression in a breastfed infant is 2–3%. Opioids are lipophilic drugs, weak bases, and have low molecular weight. These properties facilitate drug transfer into breast milk. Women who are breastfeeding should be counseled regarding the risk of CNS depression in the newborn and should seek immediate medical advice if their child develops any concerning signs. It is also important to know that opioids such as codeine have failed to show superiority in pain relief when compared with various nonsteroidal anti-inflammatory drugs in laparotomy cases in different studies. Signs of CNS Depression in Neonates Decreased feeding, weak suckling reflex Lethargy, decreased response to stimulus Decreased respiratory rate, decreased weight gain

Answer 552

Cardiovascular disease complicates 1%–3% of pregnancies. Heart disease is the leading cause of maternal mortality. The most common etiology of aortic stenosis in reproductive-aged women is a bicuspid aortic valve. Following placement of an epidural, there is a marked decrease in peripheral resistance secondary to partial sympathetic blockade. This in turn decreases the preload to the heart, which can lead to cardiovascular collapse and subsequent maternal death because aortic stenosis is preload dependent.

Answer 553

Breech presentation of a term fetus is unusual and occurs in approximately 2–3% of term pregnancies. This number is significantly higher with earlier gestational age. The 3 categories of breech presentations are frank, complete, and incomplete. Type of Breech Presentation Description Frank Lower extremities are flexed at the hips and extended at the knees, and thus the feet lie close to the head. Complete Both hips are flexed, and one or both knees are also flexed. Incomplete One or both hips are extended and as a result, one or both feet or knees lie below the breech, such that a foot or knee is lowermost in the birth canal. A footling breech is an incomplete breech with one or both feet below the breech. For the fetus, prematurity and its complications are frequently comorbid with breech presentation. Malpresentation may be associated with fundal-cornual placentation, fetal congenital disorders, and uterine abnormalities.

Answer 554

Diabetes mellitus complicates up to 7% of pregnancies. In that 7%, 90% of cases are gestational diabetes mellitus (GDM). This poses a serious risk to women, because each woman stands up to a 70% lifetime chance of developing type 2 diabetes mellitus (T2DM). Routine screening for GDM occurs between 24 and 28 weeks, and early screening is indicated in patients who have a history of GDM in a previous pregnancy, those who are obese (defined as a body mass index ≥30 kg/m2), or those with known impaired glucose metabolism. Screening involves a 2-step process in which patients undergo a 1-hour 50-g glucose challenge. The values that define a positive screen vary from institution to institution and range between 130 and 140 mg/dL. If a patient fails her 1-hour glucose challenge, a 3-hour 100-g oral glucose tolerance test (OGTT) is administered. Diagnostic values also vary depending on the classification system an institution decides to use. In the postpartum period, the carbohydrate intolerance that leads to GDM resolves; however, one-third of women will have impaired glucose metabolism or overt diabetes mellitus. To diagnosis these individuals and treat them accordingly, the Fifth International Workshop on Gestational Diabetes Mellitus recommends that between 6 and 12 weeks' postpartum, all women with a pregnancy complicated by GDM undergo a 75-g OGTT. Normal values for a 2-hr GTT include: Fasting: 60 to 100 mg/dL 1-hr: < 200 mg/dL 2-hr: < 140 mg/dL A 2-hr value between 140 and 200 suggests impaired glucose metabolism. Over 200 mg/dL is diagnostic for type 2 diabetes.

Answer 555

Vaginal and rectal group B Streptococcus (GBS) screening cultures at 36.0–37.6 weeks' gestation are indicated in all pregnant women. In asymptomatic GBS carriers who do not receive intrapartum treatment, 1–2% of infants will develop early onset GBS disease. Early onset GBS disease occurs within the first 7 days of life. Symptoms typically appear within the first 12 hours of life, and almost all affected babies will develop symptoms within 48 hours of birth. If a mother is an asymptomatic carrier of GBS and she is not treated in labor, there is a 50% chance that the neonate will be colonized with GBS and a 1%–2% chance that the baby will go on to develop early onset GBS disease. If she receives appropriate intrapartum antibiotic treatment, the risk of early onset GBS disease in the newborn drops by approximately 80%.

Answer 556

Operative vaginal delivery (which includes forceps and vacuum delivery) may be used to expedite the second stage of labor in certain scenarios. Indications include prolonged second stage of labor, nonreassuring fetal status and maternal cardiac or neurological disease. Operative vaginal delivery may also be considered in the setting of maternal exhaustion. It should only be performed if the cervix is fully dilated, effaced, and the fetal vertex is well engaged in the pelvis. Contraindications include gestational age earlier than 34 weeks, suspected fetal macrosomia and multiple attempts at fetal scalp electrode placement (relative contraindication). This fetus is demonstrating signs of distress and delivery needs to be expedited. Answer B: Cesarean section may be considered in this situation; however, it is prudent to first attempt operative vaginal delivery as the fetus is vertex at +3 station and fetal macrosomia is not suspected. Answer C: While fetal scalp electrode can better characterize fetal heart tracing than external monitoring, there is no difficulty tracing the fetal heart rate in this circumstance. Placement of fetal electrode would be an unnecessary step that may delay delivery. Answer D: IV fluid bolus is one intervention that may improve fetal heart tracing; however, at this point, the most important intervention is delivery. Answer E: Maternal position change is one intervention that may improve fetal heart tracing; however, at this point, the most important intervention is delivery. Bottom Line: The obstetrician should know in which clinical scenarios it would be appropriate to attempt operative vaginal delivery. This could lessen the percentage of cesarean sections performed for prolonged second stage of labor.

Answer 557

Postterm pregnancy is defined as a pregnancy that has gone past 42 weeks, or 294 days of gestation. In the United States, approximately 5.6% of babies are born postterm. The prevalence of postterm pregnancy is influenced by many factors, the most important being the performance of early ultrasound to assess gestational age. Most postterm pregnancies do not have a known etiology. A certain percentage can be attributed to maternal or fetal genetic influence involving initiation of parturition. In some cases, postterm pregnancy can be explained by defects in fetal hormones involved in parturition. Risk Factors for Postterm Pregnancy Adjusted Odds Ratio (aOR) Nulliparity (aOR, 1.46) 1.46 Maternal obesity (aOR 1.26) 1.26 Maternal age 30–39 years (aOR, 1.06) and 40 years or older (aOR, 1.07) 1.06, 1.07 Male fetus is associated with postterm pregnancy with an odds ratio of 1.26; however, the adjusted odds ratio (aOR) is 0.9 0.9 Multiparity is not associated with postterm pregnancy. Therefore, of the choices given, nulliparity is the greatest risk factor for postterm pregnancy.

Answer 558

A personal history of venous thromboembolism (VTE) increases the risk of VTE in pregnancy by 3-fold to 4-fold. Pregnant or postpartum women have a 4-fold to 5-fold increased risk of VTE compared with nonpregnant women. The prevalence of VTE in pregnant women is 0.5–2/1,000. VTE accounts for 9.3% of maternal deaths in the United States. The most important individual risk factor for VTE in pregnancy is a personal history of VTE, which increases the risk of recurrent VTE in pregnancy 3-fold to 4-fold. Other risk factors for VTE include: the presence of a thrombophilia obesity hypertension autoimmune disease heart disease sickle cell disease multiple gestation preeclampsia Medical Conditions and VTE Risk Medical Condition Relative Risk Personal history of VTE 3–4 Obesity (BMI >40) 2.3 Hypertension 1.5 Diabetes mellitus 1.4 Smoking 1.2 Hypercholesterolemia 1.2

Answer 559

Preterm prelabor rupture of membranes complicates approximately 2–3% of all pregnancies in the United States. Term prelabor rupture of membranes occurs in approximately 8% of pregnancies. Periviable prelabor rupture of membranes occurs in less than 1% of pregnancies. The definition of prelabor rupture of membranes is rupture of membranes before the onset of labor. Membrane rupture before labor that occurs before 37 weeks of gestation is referred to as “preterm prelabor rupture of membranes.” Management of preterm and term prelabor rupture of membranes is influenced by gestational age and the presence of complicating factors such as clinical infection, abruptio placentae, labor, or abnormal fetal testing. An accurate assessment of gestational age and knowledge of the maternal, fetal, and neonatal risks are essential to appropriate evaluation, counseling, and care of patients with prelabor rupture of membranes.

Answer 560

The use of HAART can dramatically reduce the risk of vertical transmission of HIV during pregnancy. In a woman with a viral load < 1,000 copies/mL and on HAART, the risk of transmission is estimated at 1%–2%. Current practice dictates continued HAART in labor and prophylaxis in the newborn. Currently, intravenous zidovudine is not recommended for women in labor with a viral load < 1,000 copies per mL who are regularly compliant with HAART therapy. Breastfeeding is not recommended in the United States in HIV positive women. Regardless of the initial viral load or CD4 count, HAART is recommended in resource-rich settings.

Answer 561

The cardinal movements of labor occur in the following order: engagement with the largest diameter of the presenting part (usually the biparietal diameter in an occiput presentation) passing through the pelvic inlet, descent, flexion of the fetal head to fit under the pubic bone, internal rotation to allow for the fetus to pass through the pelvis most easily, extension of the fetal head under the pubic bone, external rotation or restitution, which is a movement of the fetal head when through the perineum, and expulsion or delivery of the shoulders and body.

Answer 562

Polymerase chain reaction (PCR) techniques involve the amplification of particular sequences of DNA and, thus, can detect evidence of viral DNA at low concentrations. In one large study, PCR results were 3 to 5 times more likely to be positive than were cultures. In pregnancy, suspected genital herpes simplex virus (HSV) infections should be confirmed with type-specific laboratory testing, which include viral detection techniques or antibody detection techniques. However, retesting is not warranted in pregnant women with a previous history of laboratory-confirmed genital HSV. Virologic tests are preferred for patients who present with genital vesicles, ulcers, or other mucocutaneous lesions and include viral culture and HSV antigen detection by PCR. For patients who have a clinical history that suggests HSV but who do not present with active lesions or whose lesions have negative culture or PCR test results, type-specific serologic assays that accurately distinguish between HSV-1 and HSV-2 antibodies may be helpful. It also may identify susceptible women (seronegative) whose partners could be offered screening, allowing for counseling of at-risk couples about strategies to reduce the possibility of new maternal infection during pregnancy. Important to note: Routine HSV screening of pregnant women without history of symptoms or lesions is not recommended. In addition, routine antepartum genital HSV cultures in asymptomatic patients with recurrent disease are not recommended.

Answer 563

Subchorionic hematoma is a common cause of first-trimester bleeding. It is often marked by a hypoechoic area behind the gestational sac. Although concerning for patients, the most common outcome is a term delivery. However, there appears to be small but increased risks for miscarriage, stillbirth, and abruption. There is no association between a subchorionic hematoma and preeclampsia. Outcomes if Subchorionic Hematoma Diagnosed in Early Pregnancy Typically will have term delivery Small risk of miscarriage Small risk of stillbirth Small risk of abruption

Answer 564

Parturition involves the orchestration of a complex series of major physiological transitions of the myometrium and cervix during pregnancy. Parturition can be arbitrarily divided into 4 overlapping phases that correspond to the major physiological transitions of the myometrium and cervix during pregnancy: a prelude to parturition, preparation for labor, the labor process itself, and parturient recovery following delivery. Phases of Parturition Phase 1 Quiescence Contractile unresponsiveness Cervical softening Phase 2 Activation Uterine preparedness for labor Cervical ripening Phase 3 Stimulation Uterine contraction Cervical dilation Fetal and placenta expulsion Phase 4 Involution Uterine involution Cervical repair Breastfeeding Answer A: Conception predates the phases of parturition and occurs before phase 1 begins. Answer B: Uterine contractile unresponsiveness and cervical softening is phase 1 of parturition, which corresponds with quiescence. Answer C: Uterine contraction, cervical dilation, fetal and placental expulsion is phase 3 of parturition, which corresponds to the processes of labor. This is the phase in which all of the stages of labor occur. Answer D: Uterine involution, cervical repair, and breastfeeding is phase 4 of parturition, which corresponds to parturient recovery. Bottom Line: There are 4 phases of parturition corresponding to the physiological changes of pregnancy. These must not be confused with the stages of labor, which occur in phase 3 of parturition.

Answer 565

A trial of labor after cesarean section (TOLAC) is an option that allows women with a prior cesarean section to have planned attempt for a vaginal delivery in order to avoid a repeat cesarean section. A successful TOLAC results in a vaginal birth after cesarean (VBAC). A VBAC is associated with decreased maternal morbidity and a decreased risk of future pregnancy complications. It is especially useful for those patients who desire multiple children because it reduces the risks involved with multiple cesarean sections. Uterine rupture is the most significant complication that can occur during a TOLAC and can significantly increase maternal and neonatal morbidity and mortality. The risk of uterine rupture in women with a single prior low transverse hysterotomy is low, approximately 0.5%–0.9%. It is important to monitor for signs/symptoms of uterine rupture throughout the labor course. Typically continuous fetal monitoring is recommended for any patient undergoing TOLAC. Although loss of fetal station, intense abdominal or suprapubic pain, vaginal bleeding, need for frequent epidural dosing and maternal hemodynamic instability are associated with uterine rupture, they are not the most common signs. An abnormal fetal heart rate (commonly fetal bradycardia) is the most common sign and is associated with up to 70% of uterine rupture cases. Answer B: Hemodynamic instability (hypotension, tachycardia) may occur after a uterine rupture due to intraabdominal hemorrhage. This is not the most common finding of a uterine rupture. Answer C: Uterine rupture can be associated with a sudden increase in pain and/or the need for more frequent epidural dosing. Although this can occur, it is not the most common finding. Answer D: Loss of fetal station (as the fetus becomes partially extruded through the rupture site) is the classic answer for uterine rupture. However, with continuous electronic fetal monitoring, fetal heart rate anomalies are now a much more common finding. Answer E: Increased vaginal bleeding may occur, but is not the most common sign of uterine rupture. Bottom Line: Uterine rupture can be a catastrophic complication. However, the overall risk for a patient with one prior low transverse hysterotomy is low. The most common sign associated with uterine rupture is fetal heart rate abnormalities.

Answer 566

Protein S deficiency is not a reliable test during pregnancy due to a normal decrease in pregnancy. If the thrombophilia evaluation must be performed during pregnancy, protein S is not reliable. Protein C and antithrombin deficiency may be performed during pregnancy but are not reliable if there is an active clot. Factor V Leiden and prothrombin G20210A mutations are reliable during pregnancy, as well, if there is an active clot. otehrwise all the other important coag factors increase during pregnancy

Answer 567

Obstetricians, in conjunction with hematologists and maternal–fetal medicine subspecialists, have transitioned pregnant women on anticoagulation from low-molecular-weight heparin (LMWH) regimens to unfractionated heparin (UFH) at or near 36 weeks of gestation, if expecting a standard term delivery. The purpose of conversion to unfractionated heparin is so that patients can more quickly obtain neuraxial anesthesia safely, if desired. Although this practice is not required, it is sometimes used to facilitate the safe use of neuraxial anesthesia, given the long half-life of LMWH compared with UFH and greater ease of reversal of UFH by protamine sulfate, although protamine is uncommonly required. An alternative option for women on either prophylactic or adjusted-dose LMWH may be to stop anticoagulation and induce labor within 12 to 24 hours respectively, if clinically appropriate. Low-molecular-weight heparin is preferentially used during the antepartum period over unfractionated heparin because of its better side-effect profile, which includes fewer bleeding episodes, a more predictable therapeutic response, a lower risk of heparin-induced thrombocytopenia, a longer half-life, and less bone mineral density loss.

Answer 568

Bottom Line: Cryoprecipitate is a concentrated preparation made from FFP and contains factor VIII, factor XIII, fibrinogen, and von Willebrand factor. Factor II is not a component of cryoprecipitate. Disseminated intravascular coagulation (DIC), a systemic disorder of coagulation and fibrinolysis, can be a complication of postpartum hemorrhage. Treatment involves reversing the underlying cause. DIC can additionally be treated by administration of blood products. In addition to fresh frozen plasma and cryoprecipitate (both of which contain blood clotting factors, which are consumed with DIC), packed red blood cells are given to treat a patient with DIC. Fresh frozen plasma is prepared from whole blood using centrifugation techniques. It may be frozen shortly after collection and, if properly handled and stored, may be usable up to 1 year after preparation. Cryoprecipitate is formed when fresh frozen plasma (FFP) is thawed up to 4 degrees Celsius. It is a concentrated preparation made from FFP and contains factor VIII, factor XIII, fibrinogen, and von Willebrand factor.

Answer 569

There are four female bony pelvis types, which were initially characterized by studying radiological images by Caldwell and Moloy in the early 1900s. The gynecoid and anthropoid shapes share characteristics that make them favorable for a vaginal delivery; however, most women fall into an intermediate class, and it is difficult to make distinctions among the four. Because of the broad, flat nature of the platypelloid pelvis, it predisposes the fetus to have a persistent transverse position and to having transverse arrest. The android pelvis is similar in nature to the male pelvis because of its narrow subpubic arch and is most associated with cephalopelvic disproportion. Regardless of the type of pelvis a patient has, a trial of labor is recommended for all women because it is the only method for determining whether a fetus will be able to pass through the birth canal.

Answer 570

Seroprevalence rates of hepatitis C virus (HCV) in pregnant women worldwide are reported to range from 0.6–6.6%. Women infected with HCV have been shown to have vertical HCV transmission rates from 2–8% with maternal viremia. If a patient has a history of HCV but a negative viremia at the time of delivery, vertical transmission is rare, virtually 0%. Therefore, it is unsurprising that studies more consistently report HCV RNA (viremia) and viral load as the most significant risk factors for vertical transmission. The most critical risk factor for vertical transmission of HCV is HCV viremia at the time of delivery. Among women with HCV viremia, the greatest risk factors for vertical transmission include high viral load, membrane rupture > 6 hours before delivery, intrapartum procedures such as internal fetal monitoring devices, and episiotomy. The route of delivery has not been shown to influence the risk of vertical HCV transmission; therefore, cesarean delivery should be reserved for obstetric indications only. In addition, breastfeeding has not been shown to be associated with an increased risk of neonatal HCV infection and is not contraindicated in HCV-infected mothers.

Answer 571

Weak D is the most common variant of the Rh blood types. When receiving blood transfusions, weak D patients should be treated as Rh negative because they might be missing a key part of the antigen, create antibodies against it, and become sensitized. The same consideration should be taken during pregnancy where they should be considered Rh negative to avoid alloimmunization. RhD genotyping has been discussed but is not currently recommended.

Answer 572

Cervical effacement is "obliteration" of the cervix. It is characterized by shortening of the cervical canal, typically from a length of approximately 2 cm, to just a circular orifice. Effacement often begins before labor and causes expulsion of the mucous plug as the canal is shortened. As uterine contractions progress, hydrostatic forces on the amniotic sac dilate the cervical canal similar to a wedge. Following rupture of the membranes, the pressure exerted by the presenting part continues to dilate the cervix. Contraction forces pull smooth muscle fibers from the internal os to the lower uterine segment to create effacement. In addition, effacement occurs by a "funneling" process in which contraction forces dilate the narrow cervical canal into a large funnel, leading to the external os.

Answer 573

The biophysical profile (BPP) consists of fetal breathing movements, gross movements, tone, heart rate reactivity, and amniotic fluid volume assessment. Each component is worth 2 points, and the fetus is assigned “0” points for an absent element and “2” points for each element that is present. The maximum score is 10 (includes a non-stress test), and the minimum is 0. The BPP evaluates the acute and chronic well-being of the fetus, and each component, except amniotic fluid volume, is controlled by a different part of the fetal brain. All elements of the BPP, except amniotic fluid, evaluate the acute status of the fetus. The amniotic fluid volume assessment evaluates the chronic status of a fetus, and, if reduced, represents shunting of fetal blood away from the kidneys and towards vital organs such as the brain. In evaluating the components that represent the acute well-being of the fetus, fetal tone is the first to develop at 8 weeks' gestation. Gross fetal movement is the next to develop at 9 weeks' gestation. Breathing movements develop around 21 weeks' gestation, and fetal heart rate reactivity does not develop until 26 to 32 weeks' gestation. The loss of these components is in the reverse order of their development. Fetal heart rate reactivity and breathing movements are the first to disappear. The loss of these components is then followed by gross fetal movement and then fetal tone. Amniotic fluid is measured in two perpendicular planes and must be at least 2 cm deep in each plane. Studies have investigated the arterial cord pH at which the elements of the BPP are lost. Fetal breathing movements and/or fetal heart rate reactivity exclude fetal acidemia. Gross fetal movements are absent when the arterial cord pH is between 7.1 and 7.2, and fetal tone becomes absent when arterial cord pH is <7.1. Bottom Line: The chronological order of the loss of components of the BPP in fetal distress is: fetal heart rate reactivity and breathing movements, gross fetal movements, tone, and then amniotic fluid.

Answer 574

Currently, it is recommended that patients in the postpartum period participate in moderate-intensity aerobic exercise for at least 150 minutes per week. Patients should be encouraged to exercise because it improves cardiovascular fitness and facilitates return to prepregnancy weight without any effect on milk supply. Patient interest in exercise tends to decrease in the postpartum period.

Answer 575

Magnesium sulfate given before anticipated early preterm birth at less than 32 weeks' gestation significantly reduces the risk of moderate or severe cerebral palsy in surviving infants. No other neurological outcomes have been shown to be improved with use of magnesium sulfate. The medication should be administered in a 6-g bolus followed by a continuous infusion of 2 g per hour until delivery, or the risk of delivery, is no longer considered imminent.

Answer 576

Vaginal delivery of the non-cephalic presenting second twin has not been shown to have worse outcomes than cesarean section. It is recommended that the estimated fetal weights of each baby be greater than 1,500 g and that baby A is larger than baby B. An estimated fetal weight of at least 2,500 g (2,500–4,000 g) is the recommendation for singleton breech deliveries.

Answer 577

Sodium nitroprusside is associated with increased intracranial pressure with potential worsening of cerebral edema in women. Sodium nitroprusside should be used only in extreme emergencies and used for the shortest amount of time due to concern for cyanide and thiocyanate toxicity in the woman and fetus or newborn. Severe range hypertension is defined as a systolic blood pressure > 160 mm Hg or a diastolic blood pressure > 110 mm Hg taken 15 minutes apart. Severe range hypertension places the patient at an increased risk of stroke and necessitates immediate management. IV labetalol, IV hydralazine, and PO nifedipine may be used to acutely lower severe range blood pressures. However, when the IV labetalol, IV hydralazine, or PO nifedipine algorithms are exhausted and a patient's blood pressure remains in the severe range, then anesthesia, maternal-fetal medicine, or critical care should be emergently consulted.

Answer 578

Thrombocytopenia, defined as a platelet count of <150 × 109/L, is common and occurs in 7–12% of pregnancies at the time of delivery. Immune thrombocytopenic purpura (ITP) occurs in approximately 1 in 1,000 pregnancies and is a diagnosis of exclusion. It occurs because of immunoglobulin G (IgG) antiplatelet antibodies that attach to platelets, which mark them for destruction by the reticuloendothelial system, particularly in the spleen. Treatment is recommended if the platelet count is <30,000/μL. Treatment should also be started if the patient is having symptoms, even if the platelet count is >30,000/μL. If the platelet count is <50,000/μL and a surgical procedure is planned, treatment should be initiated. The first-line therapy is prednisone (or an equivalent of prednisone). This should be started at 1–2 mg/kg/day. An initial response should be seen within 3–7 days with a maximal response at 2–3 weeks. Once platelets reach a desirable level, the dose should be decreased by 10–20% per week. The lowest possible dose that maintains platelets ≥50,000/μL should be used. Upwards of 70% of patients will have an increase in platelets, and complete remission has been reported in up to 30% of patients. If the patient is refractory to prednisone, then intravenous immunoglobulin (IVIG) should be started. IVIG should be initiated as first-line therapy if the patient’s platelets are <10,000/μL, <30,000/μL with bleeding symptoms, or if the patient needs an immediate increase in platelets because of a planned surgery. A splenectomy may be required if the patient does not respond to prednisone or IVIG.

Answer 579

Approximately 15% of monochorionic-diamniotic twin gestations are affected by twin-to-twin transfusion syndrome (TTTS). TTTS results from arteriovenous anastomoses in the monochorionic placenta that lead to an unequal sharing of blood from the “donor” twin to the “recipient” twin. Thus, the “donor” twin develops oligohydramnios (maximum vertical pocket [MVP] < 2 cm), while the “recipient” develops polyhydramnios (MVP > 8 cm). Ultimately, hydrops fetalis and/or death can occur in either twin. The advent of fetal surgery has significantly changed management options, and fetal laser therapy of the anastomosis sites is a common treatment. Other options include serial amnio reductions, septostomy of the amniotic membranes to allow the fluid levels to equalize, and selective fetal reductions. Because interventions exist to treat TTTS, all monochorionic-diamniotic twin gestations should be screened for TTTS starting at 16 weeks and then every 2 weeks thereafter. Ultrasonography screening consists of measuring the MVP of each amnion and also confirming that the bladders are filled with urine. Doppler studies should be done only if TTTS is diagnosed or growth restriction exists. Staging for Twin-Twin Transfusion Syndrome Stage 1 Monochorionic-diamniotic gestation with oligohydramnios (MVP < 2 cm) and polyhydramnios (MVP > 8 cm) Stage 2 Absent (empty) bladder in donor Stage 3 Abnormal Doppler ultrasonography findings (one or more of the following): Umbilical artery absent or reversed diastolic flow Ductus venosus absent or reversed diastolic flow Umbilical vein pulsatile flow Stage 4 Hydrops Stage 5 Death of one or both twins

Answer 580

A single randomized controlled trial found that a single dose of a second-generation cephalosporin protects against perineal wound infections. ACOG recommends a single dose of antibiotics at the time of repair of obstetric and anal sphincter injuries (OASIS). OASIS injuries include third- and fourth-degree lacerations. Antibiotic administration has been shown to decrease rates of complications after an OASIS injury from 24% to 8% in a randomized controlled study. This patient has a laceration extending through the rectal mucosa, which categorizes the laceration as 4th degree. Perineal Laceration Grade Description 1st degree Injury to perineal skin only 2nd degree Injury to perineum involving perineal muscles but not involving anal sphincter 3rd degree, a Less than 50% of external anal sphincter thickness disrupted 3rd degree, b More than 50% of external anal sphincter thickness disrupted 4th degree Injury to perineum involving anal sphincter complex (external anal sphincter and internal anal sphincter) and anal epithelium

Answer 581

Growth restriction increases the risk of intrauterine demise. Once the diagnosis of growth restriction is made, further evaluation should be considered, such as amniotic fluid assessment and Doppler blood flow studies of the umbilical artery. Thus, umbilical artery Doppler velocimetry should be performed. This is the only test shown to reduce the risk of intrauterine demise. If umbilical artery Doppler studies are normal, then continued antepartum surveillance may be appropriate. The rate of perinatal death is reduced by as much as 29% when umbilical artery Doppler velocimetry is added to standard antepartum testing in the setting of FGR. Because growth-restricted fetuses have a high incidence of structural and genetic abnormalities, an ultrasonographic examination of fetal anatomy also is recommended if not performed already.

Answer 582

Wound dehiscence refers to separation of all abdominal layers including the fascia. Wound dehiscence is detrimental and leads to prolonged hospital stays, additional procedure(s), and a significantly elevated mortality risk. Thus, prevention is vital. An excellent study performed by Roue et al. reviewed over 2761 patients during a 5-year period and identified 31 patients who had a wound dehiscence. From these patients, they then studied 22 risk factors to determine which were associated with an increased risk of wound dehiscence. Their results found the following to be independent risk factors for wound dehiscence: hypertension, infection, obesity, malignancy, malnutrition, pulmonary disease, age >65 years old, steroid use, and ascites. Interestingly, the type of incision or closure, anemia, and diabetes were not found to be risk factors for developing wound dehiscence. While diabetes mellitus may not be a risk factor for wound dehiscence, it is a risk factor for developing an infection, which is a risk factor for wound dehiscence. Thus, the recommendation is that patients with diabetes have a hemoglobin A1c < 7% prior to surgery. Additionally, glucose should be kept < 200 mg/dL for postoperative days 1 and 2 to decrease the risk of infection. Additionally, patients should cease smoking at least 30 days before the operation to reduce the risk of infection. A pathognomonic sign of a wound dehiscence is a large gush of peritoneal fluid. Wound dehiscence typically occurs 5–10 days after surgery and is a surgical emergency.

Answer 583

One of the ultrasonographic criteria for diagnosing placenta accreta is thinning (< 1 mm) or absence of the hypoechoic myometrial zone in the anterior lower uterine segment between the placenta and the echodense boundary zone representing the uterine serosa and the posterior bladder wall. Other criteria include: - Thinning, irregularity, or focal disruption of the linear, hyperechoic uterine serosa/bladder wall complex - The presence of focal mass-like elevations or extensions of tissue, with the same echogenicity as the placenta, beyond the uterine serosa - The presence of lacunar vascular spaces in the placenta Placental lacunae were found to be the most predictive ultrasonographic finding of an accreta, and the likelihood of accreta increases with an increasing number of placental lacunae. When ultrasonographic findings are ambiguous or the patient has a posterior placenta, an MRI is recommended to further characterize the placenta. This risk of a placenta accreta with cesarean delivery is: Number of previous cesarean deliveries Risk 0 3% 1 11% 2 40% 3 61% 4 67%

Answer 584

The membrane thickness between amniotic sacs is usually less than 2 mm in a monochorionic gestation. Monochorionic gestations have significantly higher risks of neonatal morbidity and mortality. These include an increased risk of preterm birth, stillbirth, fetal growth restriction, twin-to-twin transfusion syndrome, and congenital heart defects, to name a few. Thus, correctly diagnosing chorionicity in a twin gestation is of the utmost importance. This is most accurately done in the late first to early second trimester, and certain ultrasonographic features can be used to distinguish monochorionic from diamniotic gestations. Bottom Line: Ultrasonographic findings of the amniotic membranes meeting the placenta at a 90° angle (T sign), a single placenta, same sex, and a dividing membrane of < 2 mm are all suggestive of a monochorionic gestation.

Answer 585

The postpartum period is an important time during which the groundwork for long-term maternal and fetal well-being is laid. Components for optimal prenatal and postpartum care include: Addressing chronic medical conditions Addressing issues related to sleep and fatigue Addressing the issues related to the physical recovery Assessment of infant feeding and care Assessment of mood and emotional well-being Discussion of sexuality and reproductive planning Discussion of appropriate time off is not a critical component of optimal postpartum care.

Answer 586

The contraction stress test (CST) is interpreted according to the presence or absence of late fetal heart rate (FHR) decelerations. A late deceleration is defined as a visually apparent and usually symmetrical gradual decrease and return to baseline FHR in association with uterine contractions, with the time from onset of the deceleration to the nadir as 30 seconds or longer. The deceleration is delayed in timing, with the nadir of the deceleration occurring after the peak of the contraction. The CST is an antepartum fetal surveillance technique, based on the response of the FHR to uterine contractions. The interpretation is as follows:

Answer 587

Renal infection is the most common serious infection of pregnancy. These infections occur more commonly in the second trimester. Endotoxin from the bacteria can cause severe alveolar injury and lead to acute respiratory distress syndrome (ARDS). In this setting respiratory support is critical. Sometimes intubation is required. The endotoxin-related injury is completely reversible.

Answer 588

Umbilical artery cord values can be used in cases of suspected fetal compromise to assess the degree and the type of acidosis prior to delivery. Normal umbilical artery values are the following: Parameter Normal Value, units pH 7.28 ± 0.05 pCO2 49.2 ± 8.4 mm Hg pO2 18.0 ± 6.2 mm Hg HCO3 22.3 ± 2.5 mEq/L The risk of neonatal morbidity is inversely related to pH, with the highest risks at the lowest pHs. A practical pH threshold for defining pathologic fetal acidemia is umbilical artery pH 7.00, and <7.20 or <7.10 has been proposed as the threshold for identifying fetuses with abnormal fetal heart rate tracings who might benefit from intervention prior to the development of pathologic fetal acidosis and fetal injury. Some degree of respiratory acidosis is common immediately prior to delivery because of cord compression, maternal hypotension, or temporarily reduced placental perfusion with contractions. It represents an acute event and has not been associated with adverse perinatal outcomes. It is reflected by low pH and high pCO2 values with a normal to slightly increased base deficit. The base deficit has a linear relationship with lactic acid accumulation and correlates with the risk of neonatal neurologic morbidity. An umbilical artery base deficit ≥12 mmol/L is commonly accepted as a reasonable threshold for predicting an increased risk of moderate or severe newborn complications. A base deficit of 12 to 16 mmol/L is associated with an increase in infant mortality, moderate to severe neonatal encephalopathy, multiorgan failure, and long-term neurologic dysfunction. Metabolic acidosis, on the other hand, is associated with prolonged hypoxia and ischemia with production of lactate and is associated with neonatal encephalopathy and cerebral palsy. Metabolic acidosis is reflected by a low pH value and an elevated base deficit (>12). The lower the pH and the higher the base deficit, the higher the risk of perinatal morbidity.

Answer 589

B-Lynch sutures may be performed with a number 1 chromic suture. B-Lynch sutures are placed from the cervix to the fundus and provide physical compression of the uterus. Number 1 chromic suture is a common choice because it is a large suture and less likely to break in addition to being rapidly absorbed, which decreases the risk of bowel herniation through a loop of suture after uterine involution. Answer B: In refractory cases, intrauterine tamponade with uterine packing, a Foley catheter, or Bakri balloon, may be used in conjunction with B-Lynch sutures to decrease blood loss. Answer C: Ligation of the internal iliac artery, not the external iliac artery, may decrease blood flow to the uterus. However, this technique is used less frequently than in previous years because practitioners have become less familiar with the technique, which requires a retroperitoneal approach. After performing ligation of the internal iliac artery, it is imperative to check the popliteal pulse to ensure the internal iliac artery, not the external iliac artery, was ligated. Answer D: O'Leary sutures are placed across the uterine arteries bilaterally, not the utero-ovarian ligaments. The goal of O'Leary sutures is to decrease blood flow to the uterus. If O'Leary sutures fail to sufficiently decrease blood flow to the uterus, a next step can be to place sutures across the vessels in the utero-ovarian ligaments. Answer E: Uterine artery embolization (UAE) is an effective management option for PPH in patients with persistent slow bleeding that have failed less invasive therapy. UAE is >80% successful, with 15% of patients subsequently requiring a hysterectomy. The risk of significant harm—uterine necrosis, venous thromboembolism, peripheral neuropathy—is <5%. However, infertility has been reported in up to 43% of women after UAE.

Answer 590

Urinary incontinence dysfunction exists with the use of forceps and vacuum extractors independently. The use of both forceps and a vacuum sequentially at the time of vaginal delivery has not been shown to worsen urinary incontinence. Compared with vacuum extraction alone, the combination of forceps and vacuum is associated with: significantly higher rates of subdural, cerebral, and subarachnoid hemorrhage facial nerve injury brachial plexus injury anal sphincter tears low umbilical artery pH Thus, the sequential use of a vacuum extractor and forceps should NOT be routinely performed.

Answer 591

Romero et al. determined that interleukin-6 (IL-6) concentration in amniotic fluid is the most sensitive test for chorioamnionitis and that it is a better indicator of microbial invasion of the amniotic cavity and neonatal complications than Gram stain, glucose concentration, or white blood cell (WBC) count. The gold standard for the diagnosis of chorioamnionitis in preterm patients is an amniotic fluid culture; however, management decisions often have to be made before the 3–5 days it takes for the amniotic fluid cultures to finalize. Romero et al. compared the diagnostic abilities of Gram stain, WBC, glucose, and IL-6 to accurately diagnose chorioamnionitis in preterm patients. Patients who presented in preterm labor with intact membranes underwent an amniocentesis (N=120). Eleven of the 120 had positive amniotic fluid cultures. Their findings are listed below in the table.

Answer 592

Bottom Line: Maternal cardiac arrest is a rare event that all obstetric providers must be prepared to manage. If spontaneous return of circulation has not been achieved after 4 minutes of cardiopulmonary resuscitation, the provider should proceed with perimortem cesarean delivery to optimize both maternal and neonatal outcomes. Cardiac arrest in pregnancy is a rare complication with limited data to guide management. Current guidelines recommend proceeding with perimortem cesarean delivery (resuscitative hysterotomy) after 4 minutes of cardiopulmonary resuscitation has failed to achieve spontaneous return of circulation, with the goal being a delivery by 5 minutes. Maternal outcomes are not thought to be worsened following perimortem cesarean, and may be improved as evacuation of the gravid uterus can improve venous return to the heart. While neonatal outcomes appear to be best when delivery is accomplished within 5 minutes, normal outcomes have been reported at longer lengths of time to delivery. Answer B: A Pfannenstiel incision is considered acceptable if that's what the obstetric provider is comfortable with, but a vertical incision is preferred in case other interventions are indicated or in case of other potential trauma that may need to be addressed. Answer C: In the perimortem cesarean section, time is of the essence and should not be wasted in transporting the patient to the operating room. Answer D: Traditional cesarean section preparation should be abandoned in the interest of time. A Foley catheter can be placed after the baby has been delivered. A full scrub and pre-incision antibiotics are also not necessary. Antibiotics can also be given later. Time is crucial both for maternal and neonatal outcomes. Answer E: The 5 minute window was first described in 1986 and has since been perpetuated in guidelines. However, there are cases in which the cesarean delivery might be started immediately. For example, if the maternal injury is non-survivable or if there is a very grave prognosis and the fetus is still viable, it makes sense to proceed to delivery without delay.

Answer 593

ACOG endorses paid parental leave as essential, which includes full benefits and 100% of pay for at least 6 weeks postpartum. ACOG also recommends models that facilitate provider reimbursement for evaluation as an ongoing process, rather than a single postpartum visit. Postpartum care should also be tailored to the individual patient. Obstetric care providers should be at the forefront of these policy changes. Postpartum care is important for many reasons: opportunity to ensure maternal and fetal well-being discuss postpartum contraception to reduce the risk of short-interval pregnancies address chronic conditions Up to 40% of women do not attend their postpartum visit, and attendance rates are lower among patients with low resources. Policy changes need to be enacted in order to address healthcare disparities and increase access to postpartum care. Answers A & B: ACOG recommends 100% paid leave for at least 6 weeks postpartum, which includes maintenance of full benefits. Answer C: Infant formula should be covered as failure would increase healthcare disparities. Breastfeeding difficulties and breastfeeding goals should be discussed with the patient. Various programs, such as WIC, have implemented programs to increase the rate of breastfeeding. Answer D: Paid parental leave has been shown to decrease healthcare disparities. Bottom Line: ACOG recommends health policies change to include 100% paid parental leave with benefits for at least 6 weeks, as well as introducing reimbursement models that facilitate ongoing postpartum care.

Answer 594

ACOG considers the periviable period to be from 20 0/7 weeks until 25 6/7 weeks. Infants born during this period have high mortality with high morbidity to survivors. Patients at risk for delivering this period should be counseled by a multidisciplinary team regarding risks and benefits of interventions. Delivery of the infant carries the risks of extreme prematurity to the newborn and cesarean delivery, if undergone, confers significant risks to future pregnancies. Decisions regarding interventions and care should be individualized. ACOG currently recommends consideration of neonatal assessment for resuscitation after 22 weeks and recommends neonatal resuscitation after 24 weeks. Interventions Consider at Recommended at Antenatal corticosteroids 23w 24w Antibiotics to prolong latency (if PPROM) 20w 24w Group B strep prophylaxis 23w 24w Magnesium for neuroprotection 23w 24w–32w Neonatal assessment for resuscitation 22w Neonatal resuscitation 23w 24w

Answer 595

Shoulder dystocia is an unpredictable and unpreventable obstetric emergency, and typically occurs when the descent of the anterior shoulder is obstructed by the symphysis pubis. Shoulder dystocia can also result from impaction of the posterior shoulder on the maternal sacral promontory. It is most commonly diagnosed as failure to deliver the fetal shoulder(s) with gentle downward traction on the fetal head, requiring additional obstetric maneuvers to effect delivery. It can lead to maternal and fetal injury. Although reports indicate that the recurrence rate of shoulder dystocia ranges from 1% to 16.7%, most studies report the incidence of recurrence to be at least 10%. Shoulder dystocia cannot be accurately predicted. However, history of shoulder dystocia, estimated fetal weight, gestational age, maternal glucose intolerance, and prior neonatal outcomes should be considered. As most subsequent deliveries will not be complicated by shoulder dystocia, planned cesarean delivery is not routinely indicated on the basis of a history of prior shoulder dystocia alone. However, careful delivery planning and counseling is recommended, taking into account available clinical information, risk factors, future pregnancy plans, and patient preference.

Answer 596

Face presentation may be suspected by Leopold examination, but it is usually confirmed during the first or second stage of labor when facial parts are palpated on vaginal examination. In these cases the cardinal movements of labor are affected. If the face is in the mentum anterior position, the diameter of the head is small enough to usually allow for vaginal delivery. In contrast, the diameter of the head will not permit delivery in most cases of mentum posterior position. As with simple vertex presentation, internal rotation should occur with descent, bringing the chin anteriorly. If internal rotation to the mentum anterior position does not occur, vaginal delivery is not possible because the neck and head of a normal-sized infant cannot negotiate the space between the pubic symphysis and the sacrum. Risk factors for face presentation include: prematurity fetal weight < 2,500 g fetal macrosomia anencephaly high parity

Answer 597

Women who are pregnant are at 4–5X the risk of the general population for developing a thromboembolism and the greatest per day risk is in the days following delivery. Generally, unfractionated heparin and low-molecular-weight heparin are the preferred medications for prophylaxis and treatment of thromboembolism in pregnancy. LMWH is generally better tolerated due to the more convenient dosing schedule and presents fewer bleeding complications and a decreased risk of HIT. However, heparin holds the advantages of a shorter half-life, pharmacologic reversibility, and the ability to monitor with an aPTT. Prophylactic doses: hold 12 hrs prior to anticipated delivery (unfractionated or low-molecular-weight heparin) Therapeutic doses: hold 24 hrs prior to anticipated delivery (unfractionated or low-molecular-weight heparin) For women with a high risk of thrombosis, anticoagulation should be restarted following delivery. For a vaginal delivery, anticoagulation may be restarted 4–6 hours after delivery. Anticoagulation can be restarted 6–12 hours after a cesarean delivery. These recommendations are complicated in the setting of neuraxial analgesia.

Answer 598

Chorioamnionitis is a serious condition in pregnancy that often warrants delivery of the infant. Chorioamnionitis is generally a polymicrobial bacterial infection of the chorion, amnion, and/or the amniotic fluid. The infection can become systemic in the mother and fetus; thus, delivery is usually indicated as soon as possible. Infection can be managed with antibiotics, but it is not considered cured until after delivery of the infected products of conception. In a term pregnancy in which a patient is already in labor, diagnosis can often be made clinically using the criteria of maternal fever plus maternal leukocytosis, maternal tachycardia, fetal tachycardia, uterine tenderness, or malodorous amniotic fluid. A culture of the amniotic fluid is the most reliable finding in diagnosing chorioamnionitis but its use is limited. If amniocentesis is used, elevated leukocyte count, low glucose concentration, high interleukin (IL)-6, and positive Gram stain are indicative of chorioamnionitis. A negative Gram stain is 99% specific for absence of infection. Laboratory tests may be useful when clinical signs are equivocal, but routine use is not recommended.

Answer 599

Bottom Line: Intravenous drug users, persons with more than one sexual partner in the past 3 months or those with a recent diagnosis of a sexually transmitted infection, or persons with a history of organ transplantation or on long-term hemodialysis are at increased risk for hepatitis C infection.

Answer 600

Pyelonephritis is a common complication in pregnancy. The diagnosis can be suspected based on clinical presentation of fever, flank pain, and pyuria; however, the diagnosis is ultimately confirmed by a positive urine culture which also guides appropriate antibiotic selection. If the diagnosis is suspected on presentation, the patient should have a urinalysis and complete blood count, frequent monitoring of vital signs, and intake and output monitoring. The complications of pyelonephritis are severe for both the mother and the fetus. Women are at an increased risk of preterm labor as well as acute respiratory distress syndrome (ARDS). For that reason, any clinical suspicion of pyelonephritis must be managed aggressively. Patients who show signs of respiratory insufficiency require hospitalization. Intravenous (IV) regimens of antimicrobial therapy include cephalosporins (2nd–4th generation), gentamicin, aminopenicillins (ampicillin-sulbactam), and extended spectrum penicillins (piperacillin-tazobactam). Following IV therapy, patients need to be continued on oral therapy for a total of 14 days. Patients diagnosed with acute pyelonephritis will require suppression throughout pregnancy. The most commonly used regimen is nitrofurantoin 100 mg at bedtime.

Answer 601

The risk of uterine rupture in a woman with any prior uterine surgery is related to the location of the prior incision. A prior incision through the fundus represents the highest risk of uterine rupture. The reported risk of uterine rupture during labor in a woman with a prior classical hysterotomy is 1%–12% (~5% avg). This is a wide range, but it is substantially higher than the risk in a woman with a prior low-transverse or even low-vertical incision. Even history of a fundal myomectomy or other procedure carries a lower risk of rupture than a classical incision. These patients should be counseled strictly on the risk of rupture and early indicated delivery.

Answer 602

The Consortium on Safe Labor has significantly altered the definitions of labor arrest and protraction disorders. This study involved 19 United States hospitals and retrospectively reviewed the labor course of 62,415 singleton vaginal deliveries. New definitions of arrest and protraction disorders, adopted by The American Congress of Obstetricians and Gynecologists and The Society for Maternal-Fetal Medicine, were made in an attempt to reduce the number of cesarean sections. The most up-to-date definition of an active phase arrest is the patient must be at least 6 cm dilated and membranes ruptured. Furthermore, either the contractions must be adequate for greater than 4 hours, as measured by an intrauterine pressure catheter showing Montevideo units >200, or greater than 6 hours of inadequate contractions without cervical change. Active Phase Arrest of Labor ≥6 cm dilated + rupture of membranes AND >4 hours of adequate contractions (Montevideo units >200) without cervical change OR >6 hours of inadequate contractions (Montevideo units <200) without cervical change

Answer 603

During pregnancy, it is important for HIV-infected women to be treated with a combination drug regimen to prevent vertical transmission to the fetus and to treat their disease. The following measures should be taken: CD4 count and viral load are checked at least every trimester for monitoring. 34 to 36 weeks of gestation, it is important to obtain a CD4 count and viral load, as this will help plan the mode of delivery. If the viral load is greater than 1,000 copies/mL at this time, a cesarean delivery is recommended at 38 weeks of gestation to decrease the risk of transmission to the fetus. Performing a cesarean section at 38 weeks of gestation is also recommended to decrease the likelihood of membrane rupture and onset of labor. If the viral load is less than 1,000 copies/mL, the patient may be allowed a trial of labor and cesarean delivery reserved for standard obstetric indications.

Answer 604

Alloimmunization occurs when a mother is rhesus-negative and is exposed to red blood cells from a rhesus-positive fetus. This most commonly occurs at the time of delivery, with about 45% of women experiencing a fetal-maternal hemorrhage. Other events that can result in fetal-maternal hemorrhage include: spontaneous miscarriage threatened abortion, or abortion bleeding placenta previa placental abruption amniocentesis, or chorionic villus sampling ectopic pregnancy evacuation of molar pregnancy abdominal trauma intrauterine fetal demise external cephalic version Therefore, administration of anti-D immune globulin is recommended within 72 hours of any of these events, for women who have rhesus-negative blood type. Operative delivery may occur during some of the above scenarios but is not a risk factor.

Answer 605

The carrier frequency of the factor V Leiden mutation in White patients is 5.27%. In the normal physiologic state, factor V Leiden is inactivated by protein C; however, a factor V Leiden mutation prevents this, making a person more prone to clots. Factor V Leiden mutation is the most common thrombophilia. Women who are heterozygous for this mutation account for approximately 40% of venous thromboembolisms in pregnancy.

Answer 606

Neonatal alloimmune thrombocytopenia is the most common cause of severe thrombocytopenia among term newborns. The cause is maternal alloimmunization to paternal inherited platelet antigens. The mother's platelet count is normal, and unlike Rh-D alloimmunization, the first pregnancy is at risk.

Answer 607

Epidural analgesia is the most effective form of pain relief in labor and is used by the majority of women in the United States. A 16- to 18-gauge needle is placed in the epidural space, and local anesthetic is given. The most common placement for the epidural is at the level of the iliac crest, which correlates with L4–L5. Epidurals are placed at this level in approximately 90% of cases.

Answer 608

Shoulder dystocia is diagnosed as failure to deliver the fetal shoulders with gentle downward traction of the fetal head and requiring additional maneuvers to deliver the infant. The incidence of shoulder dystocia in vaginal deliveries of cephalic fetuses is 0.2–3%, and the incidence of recurrent shoulder dystocia in subsequent pregnancies is at least 10%. The consequences of shoulder dystocia are significant, with a 10–20% brachial plexus injury rate, 11% rate of postpartum hemorrhage, and 3.8% rate of fourth-degree laceration. Management of Shoulder Dystocia Step Action/Maneuver Comments 1 Note the time the shoulder dystocia is diagnosed 2 Request additional nursing, obstetric, and anesthesia assistance 3 Instruct the patient to stop pushing 4 Position the patient so the health care provider has sufficient access to perform the maneuvers Remove the bottom of the labor bed, position the patient at the edge of the bed. 5 McRoberts maneuver Two assistants each grasp a maternal leg and sharply flex the thigh back against the abdomen. This causes cephalad rotation of the symphysis pubis and flattening of the lumbar lordosis, which can free the impacted shoulder. 6 Suprapubic pressure An assistant applies pressure above the pubic bone both downward (to below the pubic bone) and laterally (toward the fetus's face or sternum) to abduct and rotate the anterior shoulder. May be performed at the same time as McRoberts maneuver. Fundal pressure should be avoided because it may worsen shoulder impaction or cause uterine rupture. 7 Delivery of the posterior arm This maneuver, along with McRoberts and suprapubic pressure, has been shown to relieve 95% of shoulder dystocias within 4 minutes. 8 Rubin maneuver Place a hand in the vagina and on the back surface of the posterior fetal shoulder, then rotate the shoulder anteriorly towards the fetal face. This may be used instead of delivery of the posterior arm or after failure to deliver the posterior arm. 9 Wood's screw maneuver Place a hand in the vagina and on the anterior, clavicular surface of the posterior shoulder to rotate the fetus until the anterior shoulder is disimpacted from behind the maternal symphysis. This may be used instead of delivery of the posterior arm or after failure to deliver the posterior arm. 10 Gaskin maneuver The patient is placed on her hands and knees (works best for patients without anesthesia). Gentle downward traction is then applied on the posterior shoulder or upward traction on the anterior shoulder. 11 Zavanelli maneuver Replacement of the fetus into the uterus and emergent cesarean delivery. This is associated with significant fetal and maternal morbidity and mortality.

Answer 609

Compared with vacuum extraction alone, the combination of forceps and vacuum is associated with: significantly higher rates of subdural, cerebral, and subarachnoid hemorrhage facial nerve injury brachial plexus injury anal sphincter tears low umbilical artery pH Sequential use of both forceps and a vacuum at the time of vaginal delivery has not been shown to worsen urinary incontinence above the baseline risk associated with either individual operative delivery method. It is not associated with retinal hemorrhage any more than vacuum delivery is on its own, nor is it associated with shoulder dystocia or trigeminal nerve injury. Because sequential use of a vacuum extractor and forceps has been associated with increased rates of neonatal complications, it should NOT be routinely performed. When one method fails, the patient should undergo cesarean delivery.

Answer 610

Females at increased risk of neural tube defects (NTDs) should take 4 mg (4000 mcg) of folic acid daily before conception and through the first trimester. Open NTDs include anencephaly, spina bifida, cephalocele, and schisis abnormalities. These defects affect 1–2% of pregnancies and are the second most common birth defect following cardiac anomalies. Increased risks include having had a prior affected child or if the patient or her partner has an NTD.

Answer 611

Multifetal gestation is an absolute contraindication to external cephalic version (ECV). ECV is also contraindicated in all circumstances where vaginal delivery is not recommended, such as placenta previa and vasa previa. According to the updated ACOG Practice Bulletin 221 there are not current adequate data to establish absolute or relative contraindications to ECV and each scenario should be managed accordingly. Currently the only absolute contraindication to ECV is anything that would preclude a patient from a vaginal delivery. External cephalic version (ECV) is the process of converting a fetus from any malpresentation to cephalic presentation by applying pressure to the maternal abdomen; it is a relatively safe alternative to cesarean delivery and is associated with a reduction in cesarean rate. It is typically performed after 37 weeks' gestation and has a pooled success rate of 58%. All women at or near term without contraindications should be offered an ECV attempt. Nulliparity, advanced cervical dilation, fetal weight < 2500 g, and low station are related to lower success rates. There are some studies that suggest that oligohydramnios, maternal obesity, and anterior placenta decrease the success rate of ECV; however, other studies failed to show these associations. Transverse or oblique presentations and tocolytic use are associated with higher success rate. Also a recent study showed that there is a higher incidence of successful ECV with the use of neuraxial analgesia plus a tocolytic. Data are limited looking at each of these alone. Women who underwent a successful ECV have lower hospital charges, reduced total length of stay, and a lower odds ratio of developing endometritis, sepsis, and length of stay greater than 7 days. Answer A: Some studies suggest that anterior placenta may be associated with decreased success rate; however, this is not an absolute contraindication. Answer B: Although fetuses with fetal growth restriction are at higher risk for intolerance of external cephalic version, this is not an absolute contraindication. Answer C: Some studies suggest that maternal obesity may be associated with decreased success rate of ECV; however, this is not an absolute contraindication. Answer D: Some studies suggest that normal or elevated amniotic fluid level may be associated with increased success rate of ECV; however, this is not an absolute contraindication. Bottom Line: ECV is only contraindicated in all circumstances where vaginal delivery is not recommended, such as placenta previa and vasa previa.

Answer 612

Physiologic and anatomic changes of pregnancy increase the risk of thromboembolism. These changes include: hypercoagulability increased venous stasis decreased venous outflow compression of the inferior vena cava by the uterus decreased mobility Changes in the expression levels of coagulation factors contribute to the hypercoagulable state of pregnancy. Procoagulants such as fibrinogen, factor VII, factor VIII, factor X, von Willebrand factor, plasminogen activator inhibitor-1, and plasminogen activator inhibitor-2 are increased, whereas the anticoagulant protein S is decreased. These factors together contribute to an overall thrombogenic state.

Answer 613

Progesterone inhibits completion of Stage I of lactogenesis, thereby inhibiting alpha-lactalbumin which is the main stimulator of lactose synthase. Progesterone also inhibits prolactin; and when progesterone levels decrease after delivery of the placenta, prolactin can act unopposed which allows for uninhibited stimulation of alpha-lactalbumin.

Answer 614

Bottom Line: There are very few absolute contraindications to breastfeeding. Women with HIV infection, active or untreated tuberculosis, or human T-cell lymphotropic virus type I or type II; women undergoing treatment for breast cancer; or women currently using chemotherapy should not breastfeed. Breastfeeding is recognized as a mode of HIV transmission. The use of a breast milk substitute prevents 44% of infant HIV infections during the first 2 years of life, a finding that has been well studied. It is recommended that mothers with HIV infection and access to formula use formula substitutes to feed their infants in order to reduce the risk of transmission. Answer A: Hepatitis B virus is excreted in breast milk; however, breastfeeding is not contraindicated if hepatitis B immune globulin is given to infants of seropositive mothers. Answer C: It is possible to spread herpes to any part of the breast, including the nipple and areola. If there are no lesions on the breast, women with active herpes simplex virus may breastfeed their infants. Particular care should be directed to handwashing before nursing. Answer D: Gonorrhea is not a contraindication to breastfeeding. Answer E: If there are no sores on the breast, women with syphilis may breastfeed their infants.

Answer 615

Permanent sterilization protects against ovarian cancer (complete salpingectomy) and pelvic inflammatory disease Permanent contraception with tubal occlusion can be completed via electrocoagulation, mechanical devices, or tubal excision. Studies have shown that sterilization via complete salpingectomy reduces the risk of ovarian cancer. This beneficial effect remains even in those at risk of ovarian cancer due to BRCA1 and BRCA2 mutations. This protective effect has not been shown to extend to endometrial cancer. Tubal occlusion does not protect against sexually transmitted infections; however, it does reduce the risk of pelvic inflammatory disease by preventing the spread of organisms from the lower genital tract.

Answer 616

Numerous studies have established that women with an incidentally discovered shortened cervix (< 25 mm) are at increased risk of delivering preterm, but management strategies depend on patients’ obstetrical history, as shown in the table below. Obstetric history of preterm birth < 34 weeks Management recommendation No Nightly vaginal progesterone alone for women with cervical length < 20 mm – this is based on a meta-analysis which showed that cerclage placement did not reduce the risk of preterm birth < 35 weeks An incidentally found shortened cervix between 20 and 25 mm does not require intervention Yes Ultrasound-indicated cerclage for women with cervical length < 25 mm – this is based on a meta-analysis which showed cerclage placement reduces the risk of preterm delivery < 35 weeks as well as neonatal morbidity and mortality

Answer 617

High-dose oxytocin may cause profound hypotension due to relaxation of vascular smooth muscle. This may be well tolerated by most patients. However, patients who are already hypovolemic may not tolerate this drop in blood pressure. As a result, tachycardia, not bradycardia, would be seen. The exact mechanism is not well understood. Oxytocin does have an antidiuretic action and may cause water intoxication as well, which would be seen with a slow infusion over a long time such as 24 hours. This can result in profound hyponatremia. To avoid this, oxytocin should be given in a dilute solution. More common side effects of oxytocin are nausea and vomiting.

Answer 618

Breech presentation complicates 3–4% of deliveries. The greatest risk factor for breech presentation is preterm gestation. The extremes of the AFI put the fetus at risk of malpresentation as does a cornual-fundal placental location. Uterine malformations predispose patients to fetal malpresentation, but they are also associated with an increase in early pregnancy loss. Overall, the greatest risk of breech presentation and the factor that places this patient at an increased risk is her gestational age. Risks Associated with Fetal Malpresentation Preterm gestation Uterine anomalies Extremes of MVP Multiparity Cornual-fundal placenta

Answer 619

Either IV calcium chloride or calcium gluconate is the appropriate treatment for hypocalcemia secondary to transfusion-associated citrate toxicity. As sodium citrate and citric acid are used to prevent products from coagulating, large amounts of citrate are given with massive blood transfusions. Citrate binds with ionized calcium, which can lead to a decline in plasma free calcium resulting in hypocalcemia. Signs/symptoms of citrate toxicity include those listed below. IV calcium administration is the appropriate treatment. Signs and Symptoms of Citrate Toxicity Prolonged QT intervals on ECG Circulatory depression due to decreased ventricular contractility Hypotension due to decreased peripheral vascular resistance Muscle tremors Cardiac arrhythmias In addition, as citrate is metabolized to bicarbonate, blood pH increases resulting in a metabolic alkalosis.

Answer 620

Vitamin D is a fat-soluble vitamin obtained largely from consuming fortified milk or juice, fish oils, and dietary supplements. It also is produced endogenously in the skin with exposure to sunlight. The active form of Vitamin D is essential to promote absorption of calcium from the gut and enables normal bone mineralization and growth. During pregnancy, severe maternal vitamin D deficiency has been associated with biochemical evidence of disordered skeletal homeostasis, congenital rickets, and fractures in the newborn. At this time, there is insufficient evidence to support a recommendation for screening all pregnant women for vitamin D deficiency. For pregnant women thought to be at increased risk of vitamin D deficiency, maternal serum 25-hydroxyvitamin D levels can be considered and should be interpreted in the context of the individual clinical circumstance. Women at increased risk of vitamin D deficiency include women with malabsorption disorders. When vitamin D deficiency is identified during pregnancy, most experts agree that 1,000–2,000 international units per day of vitamin D is safe. The recommended intake of vitamin D is 600 international units daily. The typical prenatal vitamin has 400 international units of vitamin D.

Answer 621

Infectious endocarditis (IE) is a rare but life-threatening complication in women with congenital heart disease. IE results from a complex interaction between bloodstream pathogens and matrix molecules and platelets at sites of endocardial cell damage. Unlike older guidelines, the most recent American Heart Association guidelines are less conservative in their recommendations for prophylaxis based on the following evidence: IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than with dental, GI, or GU procedures Antibacterial prophylaxis may prevent an exceedingly small number of cases of IE in individuals who undergo a dental, GI, or GU procedure The risk of adverse events from antibiotics exceeds the benefit Only those at highest risk for IE should be considered for prophylaxis during dental procedures and vaginal deliveries. Highest risk individuals include those with: A prosthetic cardiac valve A previous episode of IE Unrepaired cyanotic heart disease with palliate shunts or conduits Completely repaired heart defect with prosthetic material within 6 months Repaired congenital heart defect with residual defects at or near the site of prosthetic material that inhibits endothelialization A cardiac transplant recipient with valve regurgitation due to a structurally abnormal valve Single dose antibiotic prophylaxis should be given 30–60 minutes prior to anticipated delivery.

Answer 622

Uncontrolled hyperthyroidism increases the risk of the development of preeclampsia with severe features. Hyperthyroidism is characterized by low thyroid-stimulating hormone (TSH) and elevated free T4 levels. Hyperthyroidism complicates 0.2% of pregnancies, and the majority are associated with Graves disease. Impaired neonatal neurological development is associated with poorly controlled hypothyroidism. Signs/Symptoms of Hyperthyroidism Nervousness Heat intolerance Frequent stools Ophthalmopathy Dermopathy Risks of Uncontrolled Hyperthyroidism in Pregnancy Preeclampsia with severe features Maternal heart failure Preterm delivery Low birth weight

Answer 623

Hepatitis B virus is a small DNA virus. It is transmitted through parenteral and sexual contact. Mortality from an acute hepatitis B infection is about 1%. Of all adults infected, 85% will have complete resolution, whereas 15% will go on to develop chronic disease. In the United States, hepatitis C is the leading cause of liver disease; however, worldwide it is hepatitis B. During an acute infection, most patients are asymptomatic. However, they may present with fatigue, temperature, fever, right upper quadrant pain, jaundice, nausea, and vomiting. Lab values during an acute infection reflect a positive hepatitis B surface antigen and a positive anti-hepatitis B core antibody. Currently, there are no treatments for an acute infection. Most infections are self-limited and require only supportive measures such as electrolyte replacement. During an acute infection, preterm delivery risk does increase. The course of the disease is unaltered by pregnancy. Transplacental viral infection is quite uncommon. Viral DNA can rarely be found in amniotic fluid or cord blood. The highest risk to the fetus is during labor; however, there is no evidence that cesarean section lowers this risk.

Answer 624

Sustained fetal tachyarrhythmia with ventricular rates exceeding 200 bpm impairs ventricular filling and increases the risk for fetal hydrops. Maternal administration of antiarrhythmic agents that cross the placenta may convert the rhythm to normal or lower the baseline heart rate to forestall heart failure. Digoxin is the preferred first-line treatment for fetal supraventricular tachycardia (SVT) given its favorable side effect profile and its relative success. In non-hydropic fetuses, digoxin will successfully convert more than 50% of fetuses back to sinus rhythm over the course of a week. Treatment should be initiated in a hospital setting, with close fetal monitoring until the arrhythmia resolves. Maternal drug levels should also be drawn to ensure accurate dosing. If the case remains refractory despite digoxin, alternative medications should be used in addition to consideration of a medically indicated preterm delivery.

Answer 625

Leukorrhea, or vaginal discharge, in pregnancy is usually a thick white discharge and is significantly increased during pregnancy because of the elevated estrogen levels. Hyperestrogenemia stimulates cervical gland hypertrophy, which produces copious amounts of thick white discharge. The endocervical mucosal cells produce significant amounts of mucus that obstruct the cervical canal soon after conception. This mucus is rich in immunoglobulins and cytokines and may act as an immunological barrier to protect the uterine contents against infection. By the end of pregnancy, cervical glands occupy up to one half of the entire cervical mass. This is a normal physiologic response during pregnancy due to estrogen, and women should be counseled during their initial prenatal visit that increased leukorrhea is normal. Similarly, they should also be counseled that infection can also cause increased amounts of leukorrhea, and they should notify their physician if they develop vaginal irritation, change in color, or an odor as this can indicate bacterial vaginosis, vaginal candidiasis, or trichomonas. Hormone Role in Pregnancy hCG corpus luteum rescue, maintains early pregnancy FSH development of ovarian follicle LH ovulation Progesterone physiologic changes of pregnancy (cardiac, respiratory, gastrointestinal, renal) Estrogen maintains uterine lining, cervical gland hypertrophy, leukorrhea, breast growth, milk duct development

Answer 626

Appendicitis is the most common nonobstetric indication for surgery in pregnancy and affects 1 in 500 pregnancies. Women with appendicitis have an increased risk for preterm birth and even fetal loss. Diagnostic evaluation in pregnancy differs in several ways from evaluation in nonpregnant patients. First, the appendix is not reliably at McBurney point and can migrate to the right upper quadrant near the gallbladder. Second, CT of the abdomen and pelvis, which is considered the gold standard for evaluation in the nonpregnant patient, is typically avoided in pregnancy to reduce fetal exposure to radiation. MRI has emerged as a sensitive and specific imaging tool to exclude appendicitis in pregnancy with 90%–100% sensitivity and specificity. Once appendicitis is confirmed, if the patient is at 24–36 weeks 6 days' gestation, betamethasone should be administered for fetal lung maturity given the increased risk of preterm birth in the setting of infection and abdominal surgery; however, surgery should not be delayed to administer the full course of betamethasone. Delaying appendectomy in cases of acute appendicitis increases morbidity and mortality.

Answer 627

labor arrest (most common), nonreassuring fetal heart rate tracing, and fetal malpresentation Arrest of First Stage of Labor Adequate Contractions Inadequate Contractions (with Pitocin) Spontaneous or Artificial Rupture of Membranes PLUS Cervical Dilation ≥6 cm ≥4 hours with no progress ≥6 hours with no progress Arrest of Second Stage of Labor Without Epidural With Epidural Primipara >3 hours of pushing with no progress >4 hours of pushing with no progress Multipara >2 hours of pushing with no progress >3 hours of pushing with no progress

Answer 628

Bottom Line: CT causes the highest radiation exposure to the fetus. MRI and ultrasonography should be utilized if possible. However, if medically necessary, a CT scan should be performed because it is still below the safety threshold for radiation exposure.

Answer 629

The frequency of third- or fourth-degree perineal lacerations is more common with forceps. Forceps deliveries are classified as outlet, low, or mid, depending on the fetal station and degree of head rotation. Avoid midforceps delivery (fetal station is above +2 station) as it comprises a higher rate of severe perinatal morbidity/mortality compared with cesarean deliveries performed in the second stage. Operative vaginal delivery is often a safe and necessary procedure, occurring in 10%–15% of deliveries in the United States. Both forceps and vacuum extractors are safe instruments for operative vaginal delivery. The choice of instrument is greatly attributed to provider preference of use. The procedure should be abandoned if good instrument placement and adequate traction are followed by no descent with three attempts. If descent has occurred and delivery is clearly imminent, then proceeding with instrumental delivery after three pulls or a longer duration may be appropriate and less morbid than a cesarean delivery of an infant with its head on the perineum. ACOG recommends against routinely performing sequential attempts at operative vaginal delivery using different instruments (both forceps and vacuum) to avoid increased maternal and fetal harm. Although short-term neonatal morbidity varies between procedures, the developmental outcome appears to be equivalent for both forceps and vacuum.

Answer 630

Most women who require anticoagulation therapy before pregnancy will need to continue this therapy during pregnancy and the postpartum period. Common anticoagulation medications include low-molecular-weight heparin, unfractionated heparin, and warfarin. Warfarin, a vitamin K antagonist commonly used for long-term anticoagulation therapy outside of pregnancy, has been associated with potentially harmful fetal effects, especially with first-trimester exposure. Warfarin embryopathy has been linked with exposure at 6–12 weeks of gestation, highlighting the importance of prepregnancy and early pregnancy care in patients using warfarin. Therefore, for most women receiving prolonged anticoagulation therapy who become pregnant, it is recommended that low-molecular-weight heparin be used in place of warfarin. Neither unfractionated heparin nor low-molecular-weight heparin crosses the placenta and both are considered safe in pregnancy. Unique considerations regarding the use of anticoagulation therapy in pregnancy include a 40–50% increase in maternal blood volume; an increase in GFR, which results in increased renal excretion of heparin compounds; and an increase in protein binding of heparin. Because of its greater reliability and ease of administration, low-molecular-weight heparin is recommended rather than unfractionated heparin for prevention and treatment of VTE within and outside of pregnancy. Potential short- and long-term advantages of low-molecular-weight heparin include fewer bleeding episodes, a more predictable therapeutic response, a lower risk of heparin-induced thrombocytopenia, a longer half-life, and less bone mineral density loss. Relative disadvantages of low-molecular-weight heparin surrounding the time of delivery include its longer half-life, the inability to rapidly assess current effect with standard laboratory studies (e.g., aPTT), and the inability to pharmacologically reverse its effect, which are important considerations for neuraxial anesthesia and peripartum bleeding risk.

Answer 631

Non-stress tests (NSTs), contraction stress tests (CSTs), and biophysical profile (BPP) assessments all have a high negative predictive value (NPV) and low positive predictive value (PPV). A high NPV would indicate that a negative test has a high likelihood of being truly negative, which provides reassurance to patients and providers. A low positive predictive value in relation to this testing would indicate that there may be false positives screened in by this type of testing. The negative predictive value is 99.8% for the NST and is greater than 99.9% for the CST, BPP, and modified BPP.

Answer 632

Determining chorionicity early in gestation is extremely important in twin pregnancies because of the increased fetal morbidity and mortality associated with monochorionic gestations. Chorionicity is best determined by late first-trimester or early second-trimester ultrasonography, but definitive diagnosis is with pathologic evaluation of the placenta. Studies have shown ultrasonography has 96% accuracy in correctly determining chorionicity when done in the second trimester. When 2 placentas are clearly identified or opposite sexes are visualized, a dichorionic twin gestation is easily diagnosed. It is more difficult, though, when just 1 placental mass is seen on ultrasonography. In this situation, ultrasonographers look for a “twin-peak” sign, which is the upward or downward projection of placental tissue into the area where the amnion and chorion interface between the 2 amniotic sacs. Because this often looks like the Greek symbol lambda, this is described as the lambda sign. If the twin-peak sign is present, a dichorionic twin pregnancy is highly likely. In addition, the dividing membrane between the 2 amniotic sacs is usually at least 2 mm thick in dichorionic gestations. Dichorionic Two placentas and two amniotic sacs Can either be monozygotic (1 egg that separates during the first 2 days after fertilization) or dizygotic (2 eggs) Two placentas Differing fetal sex Twin peak sign/lambda sign Monochorionic One placenta Can either have one amniotic sac (monoamniotic) or 2 amniotic sacs (diamniotic) Monochorionicity confirms monozygosity (1 egg); therefore, the twins are identical One placenta Thin dividing membrane (maximum 2 mm) Membrane insertion to placenta is at a right angle --------- If diamniotic, can have findings of twin to twin transfusion syndrome including oligohydramnios (MVP < 2 cm) in one twin and polyhydramnios (MVP > 8 cm) in the other absence of fetal bladder in donor twin abnormal umbilical artery Dopplers in either twin hydrops death

Answer 633

It is recommended that patients with hypothyroidism have their thyroid tested at least once per trimester, with some recommending testing every 4–6 weeks. Antithyroid peroxidase and antithyroglobulin antibodies, most common in Hashimoto thyroiditis, rarely cross the placenta and thus only cause fetal hypothyroidism in 1 in 180,000 cases. Despite these, adverse effects can occur as a result of inadequate maternal levels due to the fact that 30% of T4 found in umbilical cord sampling is maternal in origin.

Answer 634

Listeriosis is an infection caused by Listeria monocytogenes; a motile, gram-positive bacillus. L. monocytogenes is the principal human pathogen. Pregnant women and their newborns are particularly susceptible to infection with L. monocytogenes. High perinatal morbidity and mortality rates have been reported for listerial infection in pregnancy. Although listeriosis has an extremely low incidence in the non-pregnant US population, pregnant women, particularly of Hispanic ethnicity, are at a much higher risk. The most common route of infection is unpasteurized cheeses and processed foods. Many infected women are asymptomatic, but some do experience flu-like symptoms that may present with symptoms such as headache, fatigue, myalgias, backache, and gastrointestinal symptoms. Infections are most common in the third trimester. Listeriosis spreads hematogenously. It classically causes abscess development of the fetus and placenta.

Answer 635

Answer A: Infants born with congenital cytomegalovirus may have jaundice, hepatosplenomegaly, nonimmune hydrops, or thrombocytopenia; however, most are asymptomatic. Answer C: “Slapped-face” in a question stem should tip you off to parvovirus B19. Hydrops fetalis is the most serious sequelae of fetal parvovirus B19. Answer D: Toxoplasmosis is often associated with undercooked meat or oocysts from infected cats. Chorioretinitis that causes severe vision problems is a possible manifestation of congenital toxoplasmosis. Answer E: Congenital varicella syndrome is transmitted through the placenta and presents with skin scarring, limb hypoplasia, or chorioretinitis. Bottom Line: Suspect listeriosis when a stillbirth occurs, and the placenta and/or neonate has multiple abscesses. The source of infection is unpasteurized cheeses and processed meats, and the mode of transmission is hematogenous spread to the placenta.

Answer 636

Premature atrial contractions are the most common fetal arrhythmia. They occur in 1% to 2% of pregnancies and are generally benign. Patients should be given reassurance. Approximately 2% of patients will progress to tachycardia. Because of this, it seems prudent to follow up every couple of weeks to ensure that the arrhythmia has resolved.

Answer 637

pulm edema

Answer 638

The risk of vertical transmission of HIV in a mother without any HAART medications either antenatally or intrapartum is estimated at 25%. In a woman with a viral load >1,000 copies/mL, a scheduled cesarean delivery at 38 weeks prior to the onset of labor is indicated. Intravenous zidovudine started at least 3 hours prior to the surgery is also indicated. The patient above presented without time for HAART intrapartum. The protective effects of a planned cesarean delivery do not apply for an emergent delivery as would be the case above.

Answer 639

The risk of vertical transmission of HIV in a mother without any HAART medications either antenatally or intrapartum is estimated at 25%. In a woman with a viral load >1,000 copies/mL, a scheduled cesarean delivery at 38 weeks prior to the onset of labor is indicated. Intravenous zidovudine started at least 3 hours prior to the surgery is also indicated. The patient above presented without time for HAART intrapartum. The protective effects of a planned cesarean delivery do not apply for an emergent delivery as would be the case above.

Answer 640

Infectious mastitis is the most likely cause of this constellation of findings. Women presenting with signs and symptoms of breast inflammation, including breast erythema, warmth, pain, and fever, should be evaluated with a detailed history that notes the time, course, and duration of symptoms and breast history, including lactation, recent trauma, and any prior treatment for these symptoms. Mastitis complicates the lactating course for 5%–10% of patients. Puerperal infectious mastitis most commonly is caused by infection with Staphylococcus aureus (40%). Other organisms that can cause infectious mastitis include Streptococcus and Staphylococcus epidermidis, Enterococcus, and anaerobes. The immediate source of organisms that cause mastitis is almost always the infant's nose and throat. Most recommend that milk be expressed from the affected breast onto a swab and cultured before therapy is begun for bacterial identification and antimicrobial sensitivities. Dicloxacillin, 500 mg orally four times daily, may be started empirically. If the infection is caused by resistant, penicillinase-producing staphylococci or if resistant organisms are suspected while awaiting the culture results, then vancomycin, clindamycin, or trimethoprim-sulfamethoxazole can be given. Treatment is recommended for 10 to 14 days. Clinical response is usually prompt. Breast ultrasound can be helpful to evaluate for abscess if unresponsive after 48–72 hours of supportive care and antibiotics Antibiotic Regimen: 1. Empiric treatment with dicloxacillin 500 mg PO QID for 10–14 days 2. If risk factors for MRSA, consider clindamycin 450 mg PO TID for 10–14 days 3. If severe infection (hemodynamic instability, failed outpatient management), inpatient management with parenteral vancomycin 15–20 mg/kg q 8–12 hours not to exceed 2 g per dose

Answer 641

Twenty-four hours is the minimum time that the patient should wait from her last dose of LMWH. The risk of spinal hematoma is estimated to be 1 in 18,000 for epidurals if the minimum amount of time has elapsed. Patients having epidural anesthesia who have received LMWH need scheduled neurological exams, particularly noting motor and sensory functions at and below the level of the neuraxial intervention. The epidural should be placed as low as possible in these patients.

Answer 642

With increasing gestational age, fetal arterial PO2 and pH decrease and PCO2 increases because of increased oxygen consumption; however, base deficit does not change with gestational age. The relative hypoxic state of the fetus is compensated by increased fetal hemoglobin, efficient placental oxygen transfer, and a relatively slow fetal metabolism rate. Both respiratory and metabolic acidosis can influence cord arterial pH. Respiratory acidosis (reflected by low pH and high PCO2 values) is associated with an acute, short-lasting hypoxic event and is not associated with neonatal morbidity; whereas metabolic acidosis (reflected by a low pH value and a high base deficit) is associated with lactate production and relatively long-standing hypoxia and with neonatal morbidity, such as neonatal encephalopathy and cerebral palsy.

Answer 643

Vitamin D is a fat-soluble vitamin that is critical for calcium absorption from the gut. Evidence suggests that vitamin D deficiency is common during pregnancy especially among high-risk groups, including vegetarians, women with limited sun exposure and ethnic minorities with darker skin. Newborn vitamin D levels are largely dependent on maternal vitamin D status. Consequently, infants of mothers with or at high risk of vitamin D deficiency are also at risk of vitamin D deficiency. For pregnant women thought to be at increased risk of vitamin D deficiency, maternal serum 25-OH-D levels can be considered and should be interpreted in the context of the individual clinical circumstance. When vitamin D deficiency is identified during pregnancy, most experts agree that 1,000–2,000 international units per day of vitamin D is safe. During pregnancy, severe maternal vitamin D deficiency has been associated with biochemical evidence of disordered skeletal homeostasis, congenital rickets, and fractures in the newborn. At this time, there is insufficient evidence to support a recommendation for screening all pregnant women for vitamin D deficiency. For pregnant women thought to be at increased risk of vitamin D deficiency, maternal serum 25-OH-D levels can be considered and should be interpreted in the context of the individual clinical circumstance.

Answer 644

A history of placental abruption is the greatest risk factor for a subsequent placental abruption. Placental abruption occurs in approximately 2–10/1,000 births. The pathophysiology of placental abruption involves rupture of maternal vessels in the decidua basalis. The accumulating blood splits the decidua, separating off a thin layer of decidua attached to the placenta. Placental abruptions caused by high pressure arterial hemorrhage in the central area of the placenta extensively dissect through the placental-decidual interface and often result in complete or nearly complete abruptions. In contrast, low pressure venous hemorrhage, which often occurs at the periphery of the placenta, tends to be self-limited and to cause a small area of placental separation. Answer B: Chronic hypertension increases the risk of placental abruption 1.8–5.1 fold. Answer C: Cigarette smoking during pregnancy increases the risk of placental abruption 1.4–2.5 fold. Answer D: Preeclampsia increases the risk of placental abruption 0.4–4.5 fold. Answer E: Maternal age increases the risk of placental abruption 1.1–1.3 fold.

Answer 645

Cesarean Delivery Risk of Accreta First (primary) 3.3% Second 11% Third 40% Fourth 61% Fifth 67% Sixth or greater 67% Placenta accreta develops when there is an abnormal adherence of the placenta to the myometrium. It occurs when there is a defect in the decidua basalis, which leads to abnormal placental implantation. It is associated with significant morbidity and mortality secondary to catastrophic maternal hemorrhage during labor and delivery. Antenatal diagnosis can lead to improved intrapartum care and allow for coordination of appropriate consultations with a surgical team experienced in managing placenta accreta and with anesthesiology. It also allows for the anticipation of possible significant blood loss requiring transfusion. Risk factors for placenta accreta placenta previa previous cesarean delivery previous myomectomy advanced maternal age grand multiparity Asherman syndrome submucous myoma One of the greatest risk factors is history of prior cesarean delivery. The risk increases with each subsequent cesarean delivery. The risk is even greater if placenta previa is present. The risk for placenta accreta in the setting of known placenta previa is 3%, 11%, 40%, 61%, and 67% for first (PRIMARY), second, third, fourth, and fifth or more cesarean deliveries, respectively. This will be the patient’s fourth cesarean section and she has a placenta previa, making her risk of placenta accreta 61%. Confusion is often generated by the term "repeat" cesarean section in terms of which cesarean section is being referred to and its associated risk of accreta (i.e., people often argue if the 3.3% risk is associated with the first cesarean section with previa or the first repeat cesarean section, and so on...). This can be clarified by referring to Table 4 in the referenced Silver et al. paper. In this table, there is a superscript next to "First" cesarean section, which denotes it as the PRIMARY cesarean section. Therefore, in a patient with placenta previa and NO prior cesarean sections, her risk for placenta accreta is 3.3%. The following table is adapted from the Silver et al. prospective observational cohort study of maternal morbidity associated with multiple repeat cesarean deliveries and helps to clarify the risk of accreta associated with previous cesarean section and placenta previa in the current pregnancy.

Answer 646

Sterilization is the most common method of contraception; it is used by 47% of married couples, with 30% of these related to some form of female tubal occlusion or destruction. Immediate postpartum partial salpingectomy may have the lowest failure rate in actual practice—6.3 per 1,000 procedures at 5 years and 7.5 per 1,000 procedures at 10 years. A note about Essure: Questions about Essure are unlikely to be on the exam. However, in practice, it is worth knowing about it as you will see patients who have had Essure coils placed. The device has 1.64 failures over 1,000 procedures at the 5-year mark when a confirmatory hysterosalpingogram is completed. Unfortunately, data do not exist to prove long-term efficacy of the device at the 10-year mark. Furthermore, the 5-year failure rate of the Essure device does not take into account failures due to improper coil placement, expulsion of the device, failure to adhere to appropriate alternative contraceptive methods for the 3 months prior to the hysterosalpingogram, or actually completing the hysterosalpingogram.

Answer 647

Parturition is a complicated process that is believed to occur with the interplay of maternal and fetal factors. The endocrinological signaling that occurs is complex and is still not completely understood. It is known that expression of certain proteins before and at term plays a role in the initiation of labor. Myometrial contractions of labor result from an increase in myometrial activation and stimulation. Activation develops through the expression of contraction-associated proteins, sometimes referred to as “CAPs.” These include oxytocin receptors, connexin 43 (a component of gap junctions), prostaglandin F2 alpha receptors, and calcium channels. Its activation induces inflammatory genes, which are believed to induce functional progesterone withdrawal and play a role in parturition.

Answer 648

Pyelonephritis is a potentially serious complication of pregnancy. When recognized, it must be promptly treated inpatient with IV antibiotics and IV hydration. Close monitoring for improvement must be done as well. If left untreated, there are a number of complications that can occur, which can be life-threatening to the mother and fetus. Possible complications include sepsis, acute respiratory distress syndrome (ARDS), anemia, acute kidney injury (AKI), renal abscess, maternal death, preterm delivery, intrauterine fetal demise, and spontaneous abortion. Patients must be appropriately counseled on these risks and be treated as an inpatient until symptoms improve. Patients who develop pyelonephritis in pregnancy are at risk for recurrence. It is therefore recommended that they be treated with prophylactic antibiotics against urinary tract infections for the remainder of the pregnancy. Sepsis is the most common complication of pyelonephritis as it occurs in up to 49% of cases. Complications of Pyelonephritis Rate Sepsis 49% Acute respiratory distress syndrome 47% Anemia 33% Preterm delivery 23% Acute kidney injury 10% Renal abscess 6%

Answer 649

Postoperative pain management after cesarean delivery should follow a stepwise approach using a multimodal combination of agents. Always start with oral/parenteral nonsteroidal anti-inflammatory drugs (NSAIDs) and/or acetaminophen. Add oral opioids for treating breakthrough pain when analgesia from the combination of neuraxial opioids and nonopioid adjuncts becomes inadequate. It is important when prescribing postcesarean opioids to counsel patients regarding the risks of addiction and dependence. The risk of persistent opioid use/dependence in the opioid-naive patient after cesarean delivery was 1 in 300 or 0.3%, as noted in a recent study. The following table represents risk factors and incidence rates of opioid dependence in the opioid-naive population. Risk Factors for Opioid Dependence Incidence Rate History of illicit substance abuse, such as cocaine 7% History of tobacco, antidepressants, benzodiazepines use 1–3% History of chronic medical conditions, such as back pain or migraines < 1%

Answer 650

Forceps-assisted vaginal delivery is the best option. Vacuum-assisted vaginal deliveries are contraindicated prior to 34 weeks' gestation because of the increased risk of neonatal complications, including neonatal cephalohematoma, retinal hemorrhage, and intracranial hemorrhage. Forceps carry a lower risk to the fetus but greater maternal risk, including third- and fourth-degree lacerations with long-term sphincter incontinence, and are the preferred method for operative vaginal delivery below 34 weeks' gestation. Answer A: Fetal heart tones may not return to baseline level even after cessation of pushing efforts. Five minutes of fetal bradycardia at +4 station requires expedited delivery. Answer B: This is not the best option. Five minutes of fetal bradycardia at +4 station requires an operative delivery intervention rather than continuation of regular pushing efforts. Answer D: Immediate cesarean delivery is not indicated because the fetus is at an outlet position and is easily instrumented, with minimal potential risk to the fetus. The maternal morbidity of crash cesarean delivery is much greater than the morbidity of outlet forceps use. Answer E: Vacuum-assisted vaginal delivery is contraindicated prior to 34 weeks' gestational age.

Answer 651

Febrile episodes following a cesarean delivery are common. It is important to perform a through physical examination and take an appropriate history. Initiation of broad-spectrum antibiotics is warranted until cultures and other laboratory tests return. However, in the face of negative cultures and persistent fevers despite appropriate antibiotic therapy, consider ovarian vein thrombosis, also known as septic pelvis thrombophlebitis. The treatment is therapeutic intravenous heparin.

Answer 652

To date, there is no evidence to adequately support the treatment of subclinical hypothyroidism for the prevention of poor obstetric outcomes, making expectant management the appropriate choice. Treatment of overt hypothyroidism is associated with improved maternal and fetal outcomes. Subclinical hypothyroidism has garnered more attention as there have been several mixed studies on the risks of subclinical hypothyroidism and poor obstetric outcomes (e.g., placental abruption, preeclampsia, gestational diabetes). Answer A: Checking for thyroid antibodies may help identify women at long-term risk of developing hypothyroidism but is not helpful for the management of pregnancy. Answer C: Levothyroxine does not need to be started as there is no evidence of improved outcomes. Answer D: TRH stimulation was used to identify abnormal pituitary responses; however, this practice is out of date. Answer E: Propylthiouracil is used for treatment of hyperthyroidism and would be inappropriate.

Answer 653

Kell alloimmunization due to the presence of the K1 antigen is associated with hydrops fetalis. Exposure to the Kell antigen is usually the result of blood transfusions, given that Kell compatibility is not a part of routine screening. Although analysis of amniotic fluid is important in the evaluation of RhD alloimmunization, it is not useful in the evaluation and management of Kell antibodies. Amniotic fluid evaluations have resulted in poor correlation with fetal anemia. Prior to initiating any workup, it is important to determine the paternal status. If the father is K1 antigen negative, and it is certain that he is the father of the baby, no additional evaluation is needed. If it is proven that the father is antigen positive, the fetus should be monitored with middle cerebral artery Doppler every 2 weeks starting at 18 weeks, and it should be continued up until 35 weeks gestational age. After 35 weeks, Doppler is not accurate. If the multiples of the median (MoM) on the Doppler are greater than 1.5 MoM, intrauterine transfusion should be initiated. Fetal hematocrit is irrelevant in this scenario given the severity of anemia associated with Kell alloimmunization. Repeating the antibody screen should also be avoided. The best step in the initial management of Kell alloimmunization is paternal testing followed by MCA Doppler studies if the father is Kell positive. Answer B: Doppler studies are initiated at 18 weeks' gestation and continued every 1 to 2 weeks up until 35 weeks' gestation. Answer C: Cordocentesis is not a part of the management of Kell alloimmunization. Answer D: Analysis of amniotic fluid does not correlate with the severity of fetal anemia in Kell alloimmunization. Answer E: Repeating the antibody screen is not indicated in this circumstance.

Answer 654

The most recent statistics from the CDC showed that 50% of pregnant women received the vaccine. The U.S. Health and Human Services Healthy People goal was to have 80% of pregnant women receive the influenza vaccine by 2020.

Answer 655

Folic acid supplementation reduces the risk of fetal neural tube defects when used before pregnancy and throughout the first trimester. Women at high risk should supplement with 4 mg (4000 mcg) of folic acid compared with the 400 mcg recommended in low-risk women. High-risk women include those with a prior pregnancy affected by a fetal neural tube defect, those with a personal history of neural tube defect, those with a partner who is affected, and those with a partner with an affected child. Supplementation in low-risk women should begin 1 month prior to pregnancy. In high-risk women, supplementation should begin 3 months prior to pregnancy. In both groups, supplementation should be continued until 12 weeks' gestation. Folic Acid Supplementation Recommendation Low Risk High Risk Folic Acid Recommendation 400 mcg daily 4 mg daily Supplementation with folic acid timing 1 month prior to pregnancy 3 months prior to pregnancy Length of supplementation with folic acid until 12 weeks gestation until 12 weeks gestation

Answer 656

Low forceps deliveries are described as the leading point of the fetal skull at station greater than +2 cm and not on the pelvic floor, with rotation <45 degrees. Given the left occiput anterior (LOA) position, rotation will be <45 degrees with an attempt at an occiput anterior delivery. Types of Forcep Deliveries Outlet Fetal scalp is visible at the introitus without separating the labia Fetal skull has reached the pelvic floor Fetal head is at, or on, perineum Sagittal suture is in an anteroposterior diameter, or right or left occiput anterior, or posterior position Rotation does not exceed 45 degrees Low Leading point of the fetal skull is at station +2 cm or more and not on the pelvic floor Without rotation: Rotation is 45 degrees or less (right or left occiput anterior to occiput anterior, or right or left occiput posterior to occiput posterior) With rotation: Rotation is greater than 45 degrees Mid Station is above +2 cm but head is engaged Prerequisites for Operative Vaginal Birth Cervix fully dilated and retracted Membranes ruptured Engagement of the fetal head Position of the fetal head has been determined Fetal weight estimation performed Pelvis thought to be adequate for vaginal birth Adequate anesthesia Maternal bladder has been emptied Patient has agreed after being informed of the risks and benefits of the procedure Willingness to abandon trial of operative vaginal birth and back-up plan in place in case of failure to deliver Answer A: High forceps are no longer included in the current approved categories of forceps deliveries because they cannot be safely performed. Answer C: Low-rotational forceps are low forceps and involve rotation >45 degrees (e.g., rotating a transverse head into the occiput anterior or posterior position). Answer D: Midforceps are defined as fetal station above +2 cm, but the head is engaged.

Answer 657

Cervical insufficiency is defined as painless cervical dilation in the second trimester. Various diagnostic tests in the nonpregnant woman have been suggested to confirm the presence of cervical insufficiency, including hysterosalpingography and radiographic imaging of balloon traction on the cervix, assessment of the patulous cervix with Hegar or Pratt dilators, the use of a balloon elastance test, and use of graduated cervical dilators to calculate a cervical resistance index. However, none of these tests has been validated in rigorous scientific studies, and they should not be used to diagnose cervical insufficiency. Risk factors include previous trauma to the cervix, congenital defects, biological shortened cervix, uterine anomalies, collagen disorders such as Ehlers–Danlos syndrome, in utero diethylstilbestrol (DES) exposure, and increased cervical inflammatory factors such as interleukin (IL)-8. Cryotherapy and laser ablation independently have not been associated with an increased risk of cervical insufficiency, possibly because of less damage to the cervix caused by these techniques. Risk Factors for Cervical Insufficiency Previous cervical trauma/cervical procedures Dilation and curettage Loop electrosurgical excisional procedure (LEEP) Cold knife conization (CKC) Congenital cervical defects/uterine anomalies Collagen disorders DES exposure Increased cervical inflammatory factors (IL-8)

Answer 658

A contraction stress test (CST) can be used to assess the status of the fetus. It is performed by either administering pitocin or nipple stimulation to induce contractions. At least 3 contractions are necessary in a 10-minute window, each lasting 40 seconds. The fetal heart rate is evaluated during the contractions. A "negative" CST is defined as having no late or significant variable decelerations. A CST is positive if late decelerations occur in greater or equal to 50% of the contractions. CST Interpretation Negative No late decelerations Positive Late decelerations with > or = 50% of contractions Equivocal–suspicious Intermittent late decelerations or significant variable decelerations Equivocal Decelerations that occur in the presence of contractions every 2 minutes or lasting longer than 90 seconds Unsatisfactory Fewer than 3 contractions in 10 minutes or uninterpretable tracing

Answer 659

Endometritis is an infection of the placental implantation site, uterine decidua, and myometrium that is polymicrobial in nature. If left untreated, in can progress to peritonitis, sepsis, and even death. Thus, broad-spectrum antibiotics are indicated. The intravenous antibiotics of choice are gentamicin and clindamycin. Ampicillin is added for coverage of Enterococcus species if the patient remains febrile 48–72 hours after initiation of treatment; however, 95% of patients are cured with gentamicin and clindamycin alone. Antibiotics can be discontinued after the patient has been afebrile for at least 24 hours; however, most guidelines allow up to 48 hours of inpatient treatment after the last fever, per provider discretion and local practice. Oral antibiotic treatment after initial IV treatment is not indicated unless the patient had blood culture–proven bacteremia. Routine blood cultures or vaginal cultures, however, are not routinely recommended. Inpatient Treatment of Postpartum Endometritis Preferred initial regimen (GBS negative) Clindamycin 900 mg IV Q8h AND Gentamicin 5 mg/kg IV Q24h Preferred initial regimen (GBS positive) Clindamycin 900 mg IV Q8h AND Gentamicin 5 mg/kg IV Q24h AND Ampicillin 2 g IV Q6h Alternative regimen Ampicillin-sulbactam 3 g IV Q6h

Answer 660

External cephalic version is a procedure by which fetal presentation is altered from breech to cephalic by manipulation of the abdomen. It is performed in an attempt to help the patient have a successful vaginal delivery. The recommendation is for the procedure to be performed after 36 completed weeks of gestation, as most breech presentations should have spontaneously converted by this time. There is a higher likelihood of spontaneous reversion if the procedure is done on a preterm fetus. It must also be done in a facility where emergent delivery can be performed if complications arise. There are a number of variables to consider when counseling a patient about external cephalic version. Some studies have shown that an anterior placenta is associated with a decreased chance for success with the procedure.

Answer 661

When a fetal heart rate tracing is Umbilical artery cord gases are typically obtained when a fetal metabolic abnormality is suspected based on fetal heart rate tracing intrapartum. Normal umbilical artery values are the following: pH, 7.28 ± 0.05 Pco2, 49.2 ± 8.4 mm Hg Po2, 18.0 ± 6.2 mm Hg HCO3, 22.3 ± 2.5 mEq/L Respiratory acidosis Some degree of respiratory acidosis is common immediately prior to delivery because of cord compression, maternal hypotension, or temporarily reduced placental perfusion with contractions. It represents an acute event and has not been associated with adverse perinatal outcomes. It is reflected by a low pH value and a high Pco2 value with a normal to slightly increased base deficit. Metabolic acidosis, on the other hand, is associated with prolonged hypoxia and ischemia with production of lactate and is associated with neonatal encephalopathy and cerebral palsy. Metabolic acidosis is reflected by a low pH value and an elevated base deficit (>12). The lower the pH and the higher the base deficit, the higher the risk of perinatal morbidity. Answer A: The base deficit is normal. This value would be elevated in metabolic acidosis. Answer B: The pH value is low and the HCO3 value is normal. In metabolic alkalosis, the pH and HCO3 are elevated. Answer C: The pH value is low and the Pco2 value is elevated. These are not normal values for an umbilical artery cord gas. Answer D: Alkalosis would have a higher pH.

Answer 662

Management of Severe Range Blood Pressures in Pregnancy Hydralazine Notify physician if BP ≥ 160/110 Start fetal surveillance if the patient is undelivered and the fetus is viable If severe range BP persists for 15 minutes, administer hydralazine 5 mg or 10 mg IV over 2 minutes Repeat BP in 20 minutes If BP ≥ 160/110, administer hydralazine 10 mg IV over 2 minutes. If BP is below the threshold, continue to monitor BP closely Repeat BP in 20 minutes If BP ≥ 160/110, administer labetalol 20 mg IV over 2 minutes. If BP is below the threshold, continue to monitor BP closely Repeat BP in 10 minutes If BP ≥ 160/110, administer labetalol 40 mg IV over 2 minutes and consult maternal-fetal medicine, internal medicine, anesthesia, or critical care emergently. If BP is below the threshold, continue to monitor BP closely Once BP thresholds are achieved (BP < 160/110), repeat BP measurement every 10 minutes ×1 hour, then every 15 minutes ×1 hour, then every 30 minutes ×1 hour, then every hour ×4 hours MAX DOSE of hydralazine IV: 20 mg IV Labetalol Notify physician if BP ≥ 160/110 Start fetal surveillance if the patient is undelivered and the fetus is viable If severe range BP persists for 15 minutes, administer labetalol 20 mg IV over 2 minutes Repeat BP in 10 minutes If BP ≥ 160/110, administer labetalol 40 mg IV over 2 minutes. If BP is below the threshold, continue to monitor BP closely Repeat BP in 10 minutes If BP ≥ 160/110, administer labetalol 80 mg IV over 2 minutes. If BP is below the threshold, continue to monitor BP closely Repeat BP in 10 minutes If BP ≥ 160/110, administer hydralazine 10 mg IV over 2 minutes. If BP is below the threshold, continue to monitor BP closely Repeat BP in 20 minutes If BP ≥ 160/110, consult maternal-fetal medicine, internal medicine, anesthesia, or critical care emergently. If BP is below the threshold, continue to monitor BP closely Once BP thresholds are achieved (BP < 160/110), repeat BP measurement every 10 minutes ×1 hour, then every 15 minutes ×1 hour, then every 30 minutes ×1 hour, then every hour ×4 hours MAX DOSE of labetalol IV: 300 mg Nifedipine Notify physician if BP ≥ 160/110 Start fetal surveillance if the patient is undelivered and the fetus is viable If severe range BP persists for 15 minutes, administer nifedipine 10 mg PO immediate release Repeat BP in 20 minutes If BP ≥ 160/110, administer nifedipine 20 mg PO immediate release. If BP is below the threshold, continue to monitor BP closely Repeat BP in 20 minutes If BP ≥ 160/110, administer nifedipine 20 mg PO immediate release. If BP is below the threshold, continue to monitor BP closely Repeat BP in 20 minutes If BP ≥ 160/110, administer labetalol 20 mg IV over 2 minutes and consult maternal-fetal medicine, internal medicine, anesthesia, or critical care emergently. If BP is below the threshold, continue to monitor BP closely Once BP thresholds are achieved (BP < 160/110), repeat BP measurement every 10 minutes ×1 hour, then every 15 minutes ×1 hour, then every 30 minutes ×1 hour, then every hour ×4 hours MAX DOSE of nifedipine IR PO: 180 mg/day

Answer 663

Bispinous diameter is the most accurate way to predict cephalopelvic disproportion (CPD). Cephalopelvic disproportion is when the fetal head is too large, the pelvis is too small, or the head is malpositioned as it enters the birth canal. The 3 "Ps" of labor are: 1) Passage: maternal bony pelvis and tissues 2) Passenger: fetus 3) Power: strength of contractions CPD occurs when the "passage" or "passenger" inhibit continuation of labor. The ischial spines can be found by following the sacrospinous ligaments to their lateral insertions. The ischial spines should be palpated to determine if they are particularly prominent. The interspinous diameter is the smallest dimension in the pelvis and is assessed by touching both ischial spines simultaneously with the index and middle fingers of the examining hand. The interspinous diameter should be ≥10 cm to be considered adequate. While assessing the ischial spines, the thumb of the other hand should be placed on the ischial tuberosity on the same side and if the thumb is medial to the examining fingers, the side wall is convergent; whereas if the thumb is lateral to the examining fingers, the side wall is divergent. The sacrum can also be palpated for its curve, shape, and length. The sacrospinous notch can also be palpated and if it accommodates 2.5 fingerbreadths, it is considered adequate. Findings Expected in an Adequate Pelvis Assessment Finding Pelvic brim Round Symphysis Average thickness, parallel to sacrum Sacrum Hollow, average inclination Ischial spines Blunt Interspinous diameter ≥10.0 cm Sacrosciatic notch 2.5–3 fingerbreadths Subpubic angle >90 degrees (2 fingerbreadths) Bi-tuberous diameter >8.0 cm (4 knuckles) Coccyx Mobile Anteroposterior diameter of outlet ≥11.0 cm

Answer 664

Uterine inversion occurs in 1 in every 2,000 to 1 in every 20,000 deliveries. It is considered one of the classic hemorrhagic disasters. This condition must be recognized quickly to avoid massive hemorrhage. The uterus must be replaced to stop the bleeding. Oftentimes, the first sign is hemorrhage because the uterus does not always protrude out of the vagina. Answer A: Complete protrusion may occur; however, oftentimes there is only partial inversion, and this cannot be seen. Answer B: Fever usually does not occur. Answer C: Pain can occur, but profuse bleeding is much more common. Answer E: It was once thought that shock symptoms developed from parasympathetic tone on the stretched uterus. However, this has been found to be false.

Answer 665

Ectopic pregnancy affects approximately 0.5–1.5% of all pregnancies, but accounts for 3% of pregnancy-related deaths. With more-sensitive hCG sampling and better quality ultrasonography, maternal deaths are becoming less common due to earlier detection and management. However, ectopic pregnancy remains the most common cause of maternal death in the first trimester. Risk factors for ectopic pregnancy include the following: Risk factors for ectopic pregnancy Prior tubal surgery Prior ectopic pregnancy Sexually transmitted infection Pelvic inflammatory disease History of endometriosis, appendicitis Congenital fallopian tube anomalies Infertility treatment Smoking Failure of tubal sterilization, IUD* *Absolute risk of ectopic pregnancy is greatly decreased, however the relative risk of having ectopic pregnancy after contraception failure is elevated. Answer A: Surgical abortions have generally low complication rates and even lower mortality rates, compared with the 3% mortality rate associated with ectopic pregnancy. The overall mortality rate for legal, induced abortions is 0.6 per 100,000. The mortality rate increases with gestational age, with a rate of 0.1 per 100,000 at 8 weeks' gestation or less, increasing to a rate of 8.9 per 100,000 at 21 weeks' gestation or greater. Answer C: Medical comorbidities are not typically exacerbated in the first trimester and would not be responsible for a mortality rate higher than the 3% mortality rate seen with ectopic pregnancy in the first trimester. Generally, physiologic alterations that would be affected by comorbid conditions become more pronounced later in pregnancy. Answer D: Molar pregnancies occur about 1% of the time. In today’s obstetrics, they have a very low mortality rate, even in the setting of gestational trophoblastic disease. Molar pregnancy would not be responsible for a mortality rate higher than ectopic pregnancy in the first trimester. Answer E: Preeclampsia may be diagnosed after 20 weeks, except in rare cases of preeclampsia caused by molar pregnancy. Preeclampsia associated mortality in the setting of a first trimester molar pregnancy is rare. It would not be responsible for a mortality rate higher than ectopic pregnancy in the first trimester.

Answer 666

Vaginal lacerations and hematomas are complications of operative deliveries. In the case of hematomas, they are managed according to size and rate of expansion. Small hematomas may be managed expectantly. However, rapidly expanding hematomas are best managed with surgical exploration or angiographic embolization. Surgical exploration is done by making an incision over the hematoma. Blood clots are evacuated, and any bleeding vessels are ligated. Mattress sutures are then used to close the space. This patient has an allergy to contrast and, therefore, the best choice for this patient is surgical exploration.

Answer 667

Twin-to-twin transfusion syndrome (TTTS) is a serious threat to the well-being of monochorionic-diamniotic twin gestations and occurs in approximately 15% of these pregnancies. Thus, all monochorionic-diamniotic twin gestations should start twin-to-twin transfusion screening at 16 weeks and then every 2 weeks thereafter. Quintero et al. proposed a sonographic staging classification of TTTS as shown below. Staging Classification of Twin–Twin Transfusion Syndrome Stage 1 Oligohydramnios and polyhydramnios sequence Stage 2 Oligohydramnios and polyhydramnios sequence, but the bladder of the donor is not visualized Stage 3 Oligohydramnios and polyhydramnios sequence, nonvisualized bladder, and abnormal Dopplers There is absent/reversed end diastolic velocity in the umbilical artery, reversed flow in a-wave of the ductus venosus, or pulsatile flow in the umbilical vein in either fetus Stage 4 Hydrops in either twin Stage 5 Demise of either fetus The current mainstay of treatment for twin-to-twin transfusion syndrome is either amnioreduction of the amnion with polyhydramnios or laser therapy of the arteriovenous anastomoses in the placenta. Patients with twin-to-twin syndrome should immediately be referred to specialists who regularly care for patients with this condition.

Answer 668

The low-molecular-weight heparin (LMWH) dose should be titrated to reach a goal anti-Xa level of 0.6–1.0 units/mL measured 4 hours after dosing. When monitoring continuous intravenous administration of unfractionated heparin, anti-factor Xa activity can be measured at any time. For LMWH, therapeutic dosing is based on weight and anti-factor Xa levels. For unfractionated heparin, therapeutic dosing is titrated to keep the activated partial thromboplastin time in the therapeutic range. Often, LMWH does not require anti-Xa testing because it is given in a fixed dose once or twice daily (weight based only); however, if a patient has altered metabolism, including morbid obesity or renal disease, more attentive dose titration is warranted. In these cases, a sample should be drawn 4 hours after the last dose.

Answer 669

The latent phase of labor is defined as beginning with maternal perception of regular contractions. On the basis of the 95th percentile threshold, historically, the latent phase has been defined as prolonged when it exceeds 20 hours in nulliparous women and 14 hours in multiparous women. The active phase of labor has been defined as the point at which the rate of change of cervical dilation significantly increases. Answer A: Based on Friedman’s work, the traditional definition of a protracted active phase (based on the 95th percentile) has been cervical dilatation in the active phase of <1.2 cm/hr for nulliparous women and <1.5 cm/hr for multiparous women. The determination of latent versus active phase is based upon cervical dilation. Answer B: Labor in which the rate of change of cervical dilation significantly increases is the definition of the active phase. Answer C: Latent labor that exceeds 20 hours of labor for nulliparous women and 14 hours of labor for multiparous women is the definition of a prolonged latent phase. Answer E: Active phase arrest traditionally has been defined as the absence of cervical change for 2 hours or more in the presence of adequate uterine contractions and cervical dilation of at least 4 cm. Latent phase is the maternal perception of contractions with cervical dilation less than 6 cm. Bottom Line: It is important to distinguish active phase from latent phase of labor. Definitions for the latent phase of labor have not changed as dramatically as those for the active phase of labor. Loosely, latent labor is believed to begin at maternal perception of regular contractions. Active labor begins after latent labor, when cervical dilation reaches 6 cm. TrueLearn Insight: Studies support that a substantial proportion of women undergoing induction who remain in the latent phase of labor for 12–18 hours with oxytocin administration and ruptured membranes will give birth vaginally if induction is continued.

Answer 670

Alpha-fetoprotein (AFP) is a glycoprotein that is secreted by the yolk sac and liver of the fetus and is 150–200 times higher in fetal serum than amniotic fluid. Levels of maternal serum alpha-fetoprotein (MSAFP) increase early in pregnancy. MSAFP levels are reported in multiples of the median (MoM) using unaffected pregnancies of the same gestational age as the reference group. When MSAFP is elevated to 2.5 MoM or greater, the detection rate is expected to be greater than 95% for anencephaly and 65-80% for open neural tube defects (NTDs). An elevated level of MSAFP is not diagnostic of an open NTD because it also can also be explained by inaccurate gestational dating and can be found in association with multiple gestation, fetal abdominal wall defects, fetal nephrosis, fetal demise, and placental conditions that increase risk of adverse events later in pregnancy. Also, MSAFP is not usually increased with closed NTDs, which limits the value of MSAFP screening for NTD.

Answer 671

Cesarean delivery is not recommended for women with nongenital lesions, such as lesions on back, thigh, buttock. These lesions may be covered with an occlusive dressing and the patient can give birth vaginally. However, women with nongenital lesions should be examined carefully for herpetic lesions of the genital region. Herpes simplex virus (HSV) infection during pregnancy carries the potential for transmission to the fetus, which can cause severe neonatal morbidity and mortality in the form of neonatal encephalitis. Obstetricians must be familiar with the management of different presentations of HSV.

Answer 672

Breastfeeding has been shown to have a multitude of maternal and neonatal benefits. One of the most common maternal benefit that appeals to postpartum women is that breastfeeding helps women lose weight more quickly than nonbreastfeeding women. It is important, though, that patients are counseled on the additional nutritional requirements for adequate milk production. At least 1,800 kcal must be consumed daily to meet the demands of milk production. An important counseling point to patients should be that an additional 500 kcal are required daily for women who are breastfeeding; however, just like during pregnancy, these increased caloric requirements should consist of healthy food options. Women should also be encouraged to adopt healthy weight loss strategies to allow for continued adequate breast milk production. Thus, weight loss greater than 2 lb per month will decrease milk supply.

Answer 673

There are four components of the Amsel criteria for bacterial vaginosis. The first is a thin, gray-white vaginal wall discharge. The second is a vaginal pH greater than 4.5. The third is a positive whiff amine test, which is a fishy odor noted when a drop of 10% potassium hydroxide is added to a sample of vaginal discharge. The fourth is clue cells (>20% of the vaginal epithelial cells) noted in microscopy of the vaginal smear. Clue cells are vaginal epithelial cells with a distinctive stippled appearance secondary to bacteria adherent to the cell membrane. Amsel Criteria Vaginal Discharge Thin, gray Vaginal ph >4.5 Whiff test Positive (fishy odor) Clue cells >20% of cells

Answer 674

Varicella zoster virus is highly contagious and is transmitted by respiratory droplets or close contact. During pregnancy, varicella virus can be transmitted across the placenta. This can result in either congenital or neonatal chicken pox. The risk of congenital varicella syndrome is greatest when exposure occurs before 20 weeks' gestation.

Answer 675

There are 2 common causes of subinvolution of the placental site: infection and retained fragments of placenta. Most patients present with prolonged lochia or secondary hemorrhage. On examination, the uterus is larger than expected and is soft. Other causes include failure of the vessels to remodel. Cesarean section is not a cause of subinvolution. Uterine anomalies and uterine inversion do not cause subinvolution.

Answer 676

Placenta accreta is defined as abnormal trophoblast invasion of part or all of the placenta into the myometrium and is most commonly treated with hysterectomy. Answer A: Dilation and curettage may remove the placenta; however, this can lead to massive hemorrhage and is not the treatment of choice. Answer B: Expectant management has been attempted with some success; however, several patients require hysterectomy later for bleeding or infection. Answer D: Methotrexate therapy is not recommended by ACOG because there is little evidence to support it. The biologic plausibility of methotrexate therapy for placenta left in situ is questionable because methotrexate targets rapidly dividing cells and there is little cell division in third trimester placentas. Additionally, methotrexate is contraindicated with breastfeeding. Answer E: Uterine artery embolization may be beneficial in reducing blood loss during hysterectomy, but it should not be the sole therapy. Bottom Line: The most accepted approach to placenta accreta spectrum is cesarean hysterectomy with the placenta left in situ after delivery of the fetus. Attempts at placental removal are associated with significant risk of hemorrhage.

Answer 677

Signs of placental separation include the following: small gush of blood uterus rises in the abdomen and becomes more anterior the uterus becomes globular and firmer the umbilical cord lengthens Of these, umbilical cord lengthening is the most reliable sign of placental separation. Placental traction that causes large-volume hemorrhage, particularly after 30 minutes of expectant management, may actually indicate a placental accreta. Most of the above other signs of normal placental separation appear within 1–5 minutes of delivery of the newborn.

Answer 678

Pain and swelling are the most common presenting symptoms of a deep vein thrombosis (DVT). They are present in more than 80% of cases. A difference in calf circumference is helpful in making the diagnosis, but it is not the most common presentation. Leg cramping with movement is more common with an arterial clot and is much less common. Shortness of breath occurs when a deep vein thrombosis leads to a pulmonary embolism; this is not the most common symptom of a deep vein thrombosis. When a deep vein thrombosis is suspected, the initial test should be compression ultrasonography of the proximal veins. In contrast to the nonpregnant population, in which DVT is most commonly distal, a systematic review found a high frequency of ileofemoral (64%) and iliac (17%) thromboses in pregnant women with confirmed DVT. When results are negative or equivocal and iliac vein thrombosis is suspected (based upon swelling of the entire leg, with or without flank, buttock, or back pain), additional imaging with Doppler ultrasonography of the iliac vein, venography, or magnetic resonance imaging is recommended. If DVT remains a primary diagnosis due to symptoms, consider empiric anticoagulation even if imaging is negative. May consider repeat imaging in 3–7 days.

Answer 679

The most common cause of ambiguous genitalia is congenital adrenal hyperplasia (CAH), and more than 90% of these cases have a 46,XX karyotype. CAH is due to inadequate production of cortisol by the adrenal gland. It is an autosomal recessive condition and, in most cases, is caused by 21-hydroxylase deficiency. This deficiency causes an accumulation of 17α-hydroxyprogesterone, which has a mild androgenic effect resulting in ambiguous genitalia and virilization.

Answer 680

Spiral CT is the diagnostic gold standard for pulmonary embolus (PE), regardless of pregnancy. The radiation exposure is well within safe limits for pregnancy. Pregnancy should not delay obtaining the scan if clinical suspicion is high. The embolus is directly visualized in this modality, as the demonstration of a filling defect in any branch of the pulmonary artery is considered diagnostic of PE. It is highly sensitive and specific and has a high negative predictive value. Answer E: V-Q scan, or ventilation-perfusion scanning, measures mismatch between ventilation and perfusion images of the lung. Although a positive V-Q scan would make a provider very suspicious of PE, it is not a diagnostic test. The embolus is not visualized on this scan.

Answer 681

In 2011, the FDA issued a black box warning on the use of terbutaline for tocolysis because there was a high rate of cardiac events. Other side effects include tachycardia and higher blood glucose levels in people with diabetes. Terbutaline is FDA approved for the treatment of asthma. Hypotension, platelet dysfunction, and preeclampsia are not contraindications to the use of terbutaline.

Answer 682

Hepatitis B is a viral disease that is spread both perinatally and sexually; however, the majority of chronic hepatitis B infections worldwide are the result of perinatal transmission. Routine prenatal lab tests include hepatitis B surface antigen, which is positive in both acutely and chronically infected patients. Without intervention, 10%–20% of mothers seropositive for hepatitis B will pass the infection on to their newborns. This transmission rate increases to almost 90% if the mother is also positive for hepatitis B e antigen.

Answer 683

Glyburide is a sulfonylurea that binds to beta-islet cells of the pancreas to stimulate secretion of insulin. Several studies have evaluated its efficacy compared with that of insulin as well as metformin. Meta-analyses of these studies have consistently shown higher rates of neonatal hypoglycemia with use of glyburide compared to insulin. Some meta-analyses also demonstrated increased risk of macrosomia. Some observational studies also reported an often statistically insignificant higher rate of preeclampsia, hyperbilirubinemia and stillbirth with use of glyburide.

Answer 684

Maternal varicella zoster infection is becoming less common with vaccination; however, when it occurs, there is potential for transplacental passage of the virus to the fetus. Rates of congenital varicella syndrome may reach 1%–2%. Ultrasound findings suggestive of congenital varicella include: fetal hydrops hyperechogenic foci in the liver and bowel cardiac malformations limb deformities microcephaly fetal growth restriction Fetal varicella can be indicated by the presence of ultrasonographic abnormalities after documented acute maternal infection. Ultrasonographic findings that suggest congenital varicella syndrome include hydrops, hyperechogenic foci in the liver and bowel, cardiac malformations, fetal growth restriction, microcephaly, and limb deformities. Neonates with congenital varicella syndrome have a spectrum of outcomes, from a good prognosis to death. Answer A: Ultrasonographic findings that suggest congenital varicella syndrome include hydrops, hyperechogenic foci in the liver and bowel, cardiac malformations, fetal growth restriction, microcephaly, and limb deformities. Congenital hearing loss is more associated with congenital CMV. Answer C: Ultrasonographic findings that suggest congenital varicella syndrome include hydrops, hyperechogenic foci in the liver and bowel, cardiac malformations, fetal growth restriction, microcephaly, and limb deformities. Potentially, up to 18–27% of cases of non-immune hydrops fetalis are associated with parvovirus B19 infection. Answer D: Ultrasonographic findings that suggest congenital varicella syndrome include hydrops, hyperechogenic foci in the liver and bowel, cardiac malformations, fetal growth restriction, microcephaly, and limb deformities. Periventricular calcifications are more associated with toxoplasmosis. Answer E: Ultrasonographic findings that suggest congenital varicella syndrome include hydrops, hyperechogenic foci in the liver and bowel, cardiac malformations, fetal growth restriction, microcephaly, and limb deformities. Placentomegaly is more associated with toxoplasmosis. Bottom Line: Ultrasonographic findings that suggest congenital varicella syndrome include hydrops, hyperechogenic foci in the liver and bowel, cardiac malformations, fetal growth restriction, microcephaly, and limb deformities.

Answer 685

Preeclampsia, HELLP syndrome and acute fatty liver of pregnancy (AFLP) can be difficult to distinguish as their lab values are often similar. AFLP is more likely to be normotensive than the preeclampsia syndromes. The most helpful lab value to help distinguish AFLP from HELLP is the hypoglycemia, which is unlikely to occur with preeclampsia. Acute fatty liver of pregnancy (AFLP) is associated with deficiency of long-chain 3-hydroxyacyl-CoA dehydrogenase (LCHAD). This may lead to an increase in maternal fatty acid levels, resulting in the hepatic toxicity seen in AFLP. Screening for the genetic variants of LCHAD in women who have had AFLP and their newborns can allow for assessment of risk to neonates and in future pregnancies.

Answer 686

To date, no maintenance tocolytic therapy has been proven to be effective in reducing the risk of preterm birth or improving neonatal outcomes when compared with placebo. This includes oral nifedipine. Its use is not recommended for this purpose. In a multi-center RCT, tocolysis with maintenance oral nifedipine showed no reduction in spontaneous preterm birth or improvement in neonatal outcomes. Recommendations for Preterm Labor Course of corticosteroids at 24–34 weeks' gestation for those at risk of delivery within 7 days Magnesium for neuroprotection <32 weeks' gestation Tocolytic therapy to prolong pregnancy for only up to 48 hours in order to give steroids

Answer 687

Maternal age < 15 years old and > 35 years old is an independent risk factor for stillbirth. In older women, perinatal death is largely attributed to lethal congenital and chromosomal anomalies. Additionally, there appears to be an even higher risk for stillbirth if the woman is of advanced age and nulliparous compared with if she was multiparous and of the same age. There are a variety of comorbidities that can increase the risk of stillbirth as shown in the below table.

Answer 688

In this question, the patient has the presence of accelerations. The presence of accelerations are highly predictive of normal fetal acid-base status. Fetal heart rate (FHR) interpretation is critically important to an obstetrician. Intrapartum electronic fetal monitoring (EFM) is used for most women who give birth in the United States. A standardized categorization of the characteristics of fetal heart tracings provides obstetric care providers with a framework for evaluating fetal well-being during labor. After delivery, blood from the umbilical cord (cord gases) can be used to assess the metabolic status of the neonate.

Answer 689

Pregnancy places a woman in a hypercoagulable state and increases the risk of venous thromboembolism. This state is the result in several coagulation factor changes. During pregnancy there is NO change to the levels of factor II, factor V, factor IX, and protein C. Free protein S does, however, decrease; as this is an anticoagulant, this increases the risk of venous thromboembolism in pregnancy. Deciding the type of skin incision can be difficult in obstetrical and gynecologic surgeries, and the benefits of each type of skin incision must be considered. Obstetrics and gynecology surgeons use the Pfannenstiel skin incision more than any other surgeons. The benefits of a Pfannenstiel skin incision are multifold. First, the incision is made in a transverse curvilinear fashion 2 cm above the pubic symphysis, which follows Langer lines of skin tension. Thus, this allows for excellent healing and isn’t even noticeable in many cases. Next, it is associated with lower postoperative incisional hernias and wound dehiscence rates. Lastly, patients with a Pfannenstiel skin incision usually require less pain control than those with a vertical skin incision. Vertical skin incisions do carry benefits, though. For example, vertical skin incisions are associated with less blood loss compared with Pfannenstiel skin incisions. Secondly, entry into the abdominal cavity is often faster with a vertical skin incision compared with a Pfannenstiel skin incision. Lastly, vertical skin incisions allow for improved visualization and ability to extend the incision upwards if additional room is needed.

Answer 690

Contractions on tocometer are frequently seen even with small abruptions, as the formation of thrombin in the area of bleeding is a direct uterotonic. For this reason, women should have fetal monitoring for at least 4 hours after abdominal trauma to monitor for uterine contractions. If contractions are noted, further fetal monitoring for at least 24 hours is indicated, as contractions can be indicative of a concealed placental abruption. Motor vehicle crashes are the most common cause of serious injury in pregnancy. Pregnant women who incur serious injuries are more likely not to have been wearing their seat belt. Placental abruption is the leading cause of fetal death in trauma. Patients may have a concealed abruption at relatively low speeds. They may or may not have abdominal pain or vaginal bleeding.

Answer 691

The ultrasonographic finding of a double-bubble sign is consistent with duodenal atresia. Although most automatically think of Down syndrome when they hear the double-bubble term, Down syndrome is present in only 30% of duodenal atresia cases. When duodenal atresia is diagnosed, genetic testing and a detailed ultrasonography should ensue because half the time there are other abnormalities. For example, there is an increased risk of congenital heart defects, ventral wall defects, and skeletal dysplasias. Massive polyhydramnios is universally found in the second and third trimesters because of the blind duodenal pouch preventing absorption of the amniotic fluid by the intestinal tract. The image below demonstrates the double-bubble sign. This sign represents distension of the stomach (S) and the first part of the duodenum (D), as seen on this axial abdominal image. Demonstrating continuity between the stomach and proximal duodenum confirms that the second “bubble” is the proximal duodenum.

Answer 692

The correct treatment for gastroesophageal reflux disease (GERD) refractory to lifestyle changes, antacids, and H2 receptor antagonists, is a proton pump inhibitor (PPI), such as esomeprazole. Up to 80% of females experience heartburn or GERD throughout their pregnancy. Pregnant patients are at increased risk of developing GERD because of decreased lower esophageal sphincter resting tone in pregnancy. This physiologic alteration appears to be mediated by progesterone. Other factors may include increased intraabdominal pressure and decreased gastric emptying (causing gastric fluid reflux), and ineffective esophageal motility to clear the esophageal acid. The symptoms of GERD in pregnancy are the same as in the general adult population and patients may also experience extraesophageal manifestations, as shown in the table below.

Answer 693

During the first 2 weeks after conception (0–4 weeks of gestational age), exposure from ionizing radiation is an all-or-nothing phenomenon. If exposed, the developing embryo either is unharmed and survives, or dies. During organogenesis, the fetus is more likely to be damaged as a result of radiation-induced injury, and teratogenicity can be noted depending on which developing organ system is disrupted. Multiple, long-term studies that evaluated the effects of atomic bomb survivors have been used to extrapolate teratogenicity risks. Using data from animals, and outcomes from reported human exposures at various times during pregnancy, subsequent studies demonstrated that the period between 4 and 11 weeks' gestation is most sensitive in terms of multiple organ system effects, and from 12 to 15 weeks' gestation the CNS is most sensitive. Effects of Radiation Exposure 0–4 weeks gestational age All or nothing 4–11 weeks gestational age Multi-organ systems 12–15 weeks gestational age CNS

Answer 694

No immediate intervention is indicated. Since there is an overall theoretical risk of about 1%, and no evidence that the vaccine induces malformation, the patient should undergo routine second trimester anatomy ultrasound to assess if there are any congenital signs of rubella.

Answer 695

Helicobacter pylori infection is the most common cause of peptic ulcer disease in a reproductive age female patient. All patients with a diagnosis of peptic ulcer disease should be tested for H. pylori, keeping in mind that false-negative results may come from proton pump inhibitors, bismuth, many antibiotics, and upper GI bleeding. If 2 tests in the absence of these factors are negative, the patient is declared negative for H. pylori. If positive, the patient can be treated with a proton pump inhibitor given along with an antibiotic regimen, which includes amoxicillin and clarithromycin for 10–14 days.

Answer 696

A biophysical profile (BPP) score of 6/10 is considered equivocal, and fetal asphyxia cannot be excluded. In a patient who is less than 37 weeks' gestation with normal amniotic fluid volume and equivocal results, repeated testing is warranted. The timing of repeated testing is controversial, with some experts recommending immediately repeating the BPP and others recommending repeating it in 24 hours. ACOG currently recommends repeated testing in 24 hours. Prolonged fetal monitoring in the interim is also advisable. If the second test score is greater than 6/10, the fetus should be managed according to the results of the repeated test (eg, if a repeated test score is 10/10, manage as a 10/10). A score of 4/10 calls for delivery by the most appropriate method, whereas scores of 2/10 and 0/10 require immediate delivery, usually via cesarean birth. Answer A: A contraction stress test is not indicated at this time because the biophysical profile (BPP) has already been completed to evaluate fetal status.

Answer 697

Breast cancer, although uncommon, is the most prevalent malignancy encountered in pregnancy and the postpartum period. It affects about 1 in 3,000 women who are pregnant. Other cancers that tend to occur during pregnancy are also generally more common in younger people who are not pregnant, including cervical cancer. The difficulty and delay in diagnosis may be attributed to pregnancy-related changes in the breast and diagnostic challenges that allow these cancers to go undetected until the first postpartum year. Breast cancers in pregnancy usually have the following characteristics: larger in size node positive Stage II or III high-grade invasive ductal cancer, and ER/PR/HER2/neu-negative. Prognosis is related to tumor characteristics and delay in starting treatment, and not to pregnancy alone. When breast cancer is suspected in pregnancy, delay in diagnosis should be avoided. Mammography and ultrasound are the best imaging modalities; mammography has a sensitivity of more than 80% despite pregnancy-associated breast changes. Ultrasound can be used to assess the extent of the disease in breast and lymph nodes and for guiding biopsies. Core needle biopsy is the preferred modality. Experience with MRI in pregnancy is limited and gadolinium-enhanced contrast is contraindicated in the first trimester because it crosses the placenta. A recent study of breast MRI showed 98% sensitivity in diagnosis of pregnancy-associated breast cancer and changed treatment modality in 28% of women. Comprehensive staging studies are needed because breast cancer in pregnancy may present in advanced stage. Chest X-ray with abdominal shielding to evaluate the lungs and ultrasound for liver involvement are safe in pregnancy. Bone scans can be performed postpartum, but if a woman is symptomatic, noncontrast skeletal MRI is safe. Treatment is as for nonpregnant women with the goal of achieving local control and preventing distant metastases. Modified radical mastectomy with axillary staging is the treatment of choice in the first trimester. Adjuvant chemotherapy can be started in the second trimester and radiation therapy given postpartum. Adjuvant chemotherapy with anthracycline-based regimes, such as various combinations of cyclophosphamide, doxorubicin, and fluorouracil, can be started in the second and third trimester. There are insufficient data to recommend taxanes, but paclitaxel can be used after the first trimester if indicated by disease status. Trastuzumab is contraindicated and oligohydramnios/anhydramnios have been reported. Endocrine treatments including tamoxifen, aromatase inhibitors, and LHRH analogues are contraindicated in pregnancy due to the high risk of birth defects. If a woman becomes pregnant while on tamoxifen, pregnancy termination should be advised.

Answer 698

The most common indication for primary cesarean delivery in the United States is failure to progress, also known as labor dystocia or arrest of labor. In a 2013 review, labor dystocia represented 35.4% of all primary cesarean sections. In an attempt to decrease the number of primary cesarean deliveries, ACOG has revised the definition of failure to progress. Arrest of Labor in the First Stage More than or equal to 6 cm dilation with membrane rupture and one of the following: 4 hours or more of adequate contractions (more than 200 Montevideo units) 6 hours or more of inadequate contractions and no cervical change

Answer 699

Fetal demise complicates approximately 5.96 per 1,000 live births in the United States. Laboratory and pathological examination can occasionally determine a cause of the fetal death. IUFD Evaluation CBC Syphilis serology Fasting glucose or HbA1c Urine drug screen Fetomaternal hemorrhage evaluation In addition, all patients should be offered fetal karyotype and autopsy as these will often elucidate the cause of death. An abnormal fetal karyotype is found in 6–13% of stillbirths. Amniocentesis yields the greatest percentage of viable cells for culture at 80–100%. Microarray analysis increases the rate of detecting genetic anomalies, but is logistically and financially difficult.

Answer 700

Fetal fibronectin (fFN) has a positive predictive value of approximately 30% for preterm delivery within 7 days in symptomatic women between 24 and 34 weeks' gestation. This is greater than the positive predictive value of cervical dilation of greater than 1 cm (11%) and 8 or more contractions per hour (9%).

Answer 701

Postpartum thyroiditis is a destructive thyroiditis induced by an autoimmune mechanism within 1 year after childbirth or even abortion. It leads to transient destruction of thyroid tissue and release of thyroid hormone. It usually presents in one of three ways: either transient hyperthyroidism alone, transient hypothyroidism alone, or transient hyperthyroidism followed by hypothyroidism and then complete recovery in most cases. This state lasts only until depletion of thyroglobulin stores as new hormone synthesis ceases, not only because of damage to the thyroid follicular cells but also because of inhibition of thyroid-stimulating hormone (TSH) secretion by elevated serum T4 and T3. As the inflammation subsides, the thyroid follicles regenerate, and thyroid hormone synthesis and secretion resume. There may be a transient period of hypothyroidism and increased TSH secretion before thyroid secretion becomes normal again. Some cases develop persistence hypothyroidism later on. It usually resolves spontaneously, but if hyperthyroid symptoms are severe, patients can take beta-blockers to alleviate symptoms. Thioamides (methimazole and propylthiouracil) will not help as the release of thyroid hormone is from destruction of thyroid tissue and is not from overproduction of thyroid hormones. The incidence rate of postpartum thyroiditis estimated at 7–8% of women. It has no specific risk factors, but incidence increases if patient has a history of type 1 diabetes mellitus (DM) or postpartum thyroiditis in a previous pregnancy. Thus, assessment of thyroid function should be performed at 3 and 6 months' postpartum in women at high risk for developing postpartum thyroiditis, women with history of high serum antithyroid peroxidase antibody concentrations prior to pregnancy, and in postpartum depression because hypothyroidism can be a reversible cause of depression. Work-up to exclude women with Graves disease should be done if there are clinical manifestations of Graves disease (ophthalmopathy), persistent hyperthyroidism for >1 month, or severe hyperthyroidism (markedly elevated T3 >T4). Work-up includes radioiodine uptake (if not contraindicated due to recent or active breastfeeding, or the patient being pregnant) and serum thyrotropin receptor antibodies levels.

Answer 702

Hydroxychloroquine (Plaquenil) is safe for patients with SLE to continue throughout their pregnancy. The risk of discontinuing the medication outweighs the benefits of it being discontinued. Per ACOG, "continued treatment with hydroxychloroquine also helps prevent SLE from affecting other organ systems, such as the renal system or the central nervous system." Fetal exposure to lupus-associated antibodies predisposes the fetus to neonatal lupus. Neonatal lupus syndrome includes the presence of a rash, thrombocytopenia, hepatitis, congenital heart block, and hemolytic anemia. Except for congenital heart block, these are transient in nature. Congenital heart block can be diagnosed in utero with the use of fetal echocardiography and is a severe complication related to maternal SLE. Renal disease is a severe complication associated with SLE, and up to 70% of those with severe disease will have a fetal loss. Mycophenolate is used daily in these settings. It is recommended that women with SLE have a 6-month period without flare-ups before attempting pregnancy. Prednisone can be given in conjunction with hydroxychloroquine, but this patient’s disease is under control without it; therefore, there is no reason to add it to her current regimen. The nonsteroidal anti-inflammatory drug (NSAID) class of medications should be avoided in pregnancy because of the side-effect profile; they can cause oligohydramnios or injure the fetal kidneys and possibly induce premature closure of the patent ductus arteriosus. The exception to this is the use of indomethacin as a tocolytic agent in preterm labor. Diagnosing SLE is very challenging and often requires the expertise of a specialist (nephrology, rheumatology, dermatology). For reference, there are 3 sets of classification criteria as shown in the table below. Answer A: Mycophenolate is used daily to treat lupus nephritis. This drug is not recommended in pregnancy due to teratogenicity and increased risk of pregnancy loss. Answer B: Prednisone is inactivated by placental hydroxylase; as a result, it does not reach the fetus in significant concentrations. However, this patient can continue her hydroxychloroquine throughout her pregnancy. Answer D: NSAIDs can result in oligohydramnios or can injure the fetal kidneys and possibly induce premature closure of the patent ductus arteriosus; thus, they should be avoided. Answer E: Hydroxychloroquine is safe throughout the entire pregnancy. It does cross the placenta but is not associated with fetal toxicity. Hydroxychloroquine may actually reduce the risk of congenital heart block and neonatal lupus rash.

Answer 703

Exercise affects neither pain related to lactation nor the patient's ability to lactate and has no effect on the milk supply. Exercise also has no effect on the growth of a breastfed infant. Exercise in the postpartum period improves cardiovascular fitness and facilitates return to prepregnancy weight, and therefore should be encouraged. Currently, it is recommended that patients in the postpartum period participate in moderate-intensity aerobic exercise for at least 150 minutes per week.

Answer 704

Recent use of methylprednisolone for 7 days does not require use of stress-dose steroids during labor. Patients who do not require stress-dose steroids because they are not considered to have suppression of their hypothalamus-pituitary-adrenal (HPA) axis Patients who have been taking any dose of glucocorticoid for < 3 weeks Patients who have received morning doses of < 5 mg/day of prednisone or its equivalent for any length of time Patients who have received < 10 mg of prednisone or its equivalent every other day Table modified from UpToDate: The management of the surgical patient taking glucocorticoids. 2019. If a patient does require stress-dose steroids in labor, she should receive hydrocortisone 25 mg IV every 6 hours. At the time of delivery, she should receive hydrocortisone 100 mg IV. Taper the glucocorticoid dose to her baseline regimen over 3 days. Answer A: Women who exhibit a cushingoid appearance (moon facies, red cheeks, excessive striae) should be assumed to have HPA-axis suppression, and stress-dose steroids are indicated. Answer C: The dose of dexamethasone 0.75 mg twice a day is equivalent to 10 mg of prednisone daily. Because the patient has been taking more than the equivalent of 5 mg of prednisone daily and for longer than 3 weeks, stress-dose steroids are indicated. Answer D: The dose of hydrocortisone 40 mg/day is equivalent to 10 mg of prednisone daily. Because the patient has been taking more than the equivalent of 5 mg of prednisone daily and for longer than 3 weeks, stress-dose steroids are indicated. Answer E: Because the patient has been taking more than the equivalent of 5 mg of prednisone daily and for longer than 3 weeks, stress-dose steroids are indicated. However, if she had been taking prednisone 10 mg every other day, she would not require stress-dose steroids in labor. Bottom Line: Patients who have been taking any dose of glucocorticoid for < 3 weeks, have received morning doses of < 5 mg/day of prednisone or its equivalent for any length of time, or who have received < 10 mg of prednisone or its equivalent every other day do not require stress-dose steroids in labor.

Answer 705

Alpha-thalassemia trait is caused by 2 alpha-globin gene deletions or mutations on the same or different chromosomes. It is most common in individuals of African, West Indian, Mediterranean, and Southeast Asian ancestries. Unlike other hemoglobinopathies, alpha-thalassemia cannot be identified with hemoglobin electrophoresis. For women with a low mean corpuscular volume (MCV), no evidence of iron deficiency anemia, and hemoglobin electrophoresis not consistent with beta-thalassemia trait, DNA-based testing is recommended to detect alpha-globin deletions or mutations consistent with alpha-thalassemia. Importantly, individuals of Southeast Asian ancestry are more likely to carry two gene deletions in CIS (same chromosome) and therefore there is a higher prevalence of Hb Bart (i.e., hydrops fetalis) in this patient group than in Africans who are more likely to carry the mutations in TRANS.

Answer 706

Bilateral renal agenesis is a genetic disorder characterized by the absence of both fetal kidneys. The fetal kidneys start producing urine at 12 weeks, and by 18 weeks they are producing 7–10 mL per day, which increases to 650 mL per day at term. Absence of fetal kidneys leads to an empty- or absent-appearing bladder. The source of amniotic fluid varies greatly throughout the gestational period. Amniotic fluid is an ultrafiltrate of maternal plasma in early pregnancy. In the second trimester, it is formed from extracellular fluid that diffuses through the fetal skin and is reflective of fetal plasma. After 20 weeks, when the skin becomes less permeable, fluid is composed mostly of fetal urine.

Answer 707

stepwise sequential screening

Answer 708

Hepatitis B virus (HBV) infection affects more than 240 million people worldwide. It is estimated that 0.7%–0.9% of chronic hepatitis B in the United States is found among pregnant women, putting approximately 25,000 infants at risk annually for perinatal/neonatal hepatitis B infection. HBV acquired during the perinatal/neonatal period is more likely than that acquired during adulthood to progress to chronic infection and carry long-term health risks. HBV acquired during adulthood is more likely to resolve after the acute infection has passed and immunity has been established. Complications of chronic HBV infection include cirrhosis, end-stage liver disease, and liver cancer. Answers B & C & D & E: HBV acquired during the perinatal/neonatal period is more likely than that acquired during adulthood to progress to chronic infection and carry long-term health risks.

Answer 709

About 75% of females with recurrent genital HSV (herpes simplex virus) will have at least one recurrence during pregnancy. 14% of patients with recurrent HSV will have either clinical recurrence or prodromal symptoms at the time of delivery. The risk of transmission to the neonate is greatest (40–80%) with a primary genital HSV infection acquired close to the time of delivery. Transmission rates are much lower (1–3%) for patients with recurrent HSV but positive cultures are collected at the time of delivery. Primary HSV has also been demonstrated to cause poor fetal outcomes through transplacental or transcervical transmission.

Answer 710

The most frequently encountered non-Rhesus antibodies in pregnancy are the Lewis antibody and the I antibody. These antibodies do not cause hemolytic anemia because the immunoglobulin is type M (IgM), which does not cross the placenta. Duffy Can cause severe hemolytic anemia Kell Can cause severe hemolytic anemia Antibody titer does not correspond to fetal risk Kidd Can cause severe hemolytic anemia Lewis Most frequently encountered non-Rhesus IgM Does not cross the placenta Does not cause hemolytic anemia Lutheran Can cause mild hemolytic anemia I Most frequently encountered non-Rhesus IgM Does not cross the placenta Does not cause hemolytic anemia

Answer 711

The fetal fibronectin test has a 99.5% negative predictive value for delivery within 7 days and 99.2% negative predictive value for delivery within 14 days. Interpretation of Fetal Fibronectin Testing Negative Predictive Value Positive Predictive Value 7 days 99.5% 12.7% 14 days 99.2% 16.7% Table Modified From: Rapid fFN, Sample collection and interpreting results. Fetal fibronectin (fFN) is an extracellular matrix protein at the decidual-chorionic interface. Disruption of this interface due to subclinical infection, inflammation, abruption, or uterine contractions leads to the release of fFN into cervicovaginal secretions. Measurement of fFN is used to determine which women are in true preterm labor versus those in false labor. By identifying patients with preterm labor, interventions that improve neonatal outcomes can be implemented, such as corticosteroids, prophylaxis for group B strep, magnesium sulfate for neuroprotection, and transfer to a facility with an appropriate level nursery. Notably, fFN can also be used for asymptomatic women from 22w0d–30w6d in routine prenatal care.

Answer 712

In the first trimester, the crown rump length should be measured to determine the gestational age of a pregnancy. In the second and third trimesters, multiple parameters should be used to determine the gestational age. These include: the biparietal diameter the abdominal circumference, and the femoral diaphysis length

Answer 713

Endometritis is a polymicrobial infection caused by normal vaginal flora that enters the uterine cavity. The risk of developing endometritis after an uncomplicated vaginal delivery is only 1%, but it increases to nearly 10% after a cesarean section. The most common organisms are gram-positive cocci, such as S. aureus and Group B Streptococcus, and gram-negative organisms, such as E. coli, K. pneumoniae, and Proteus species. Treatment is broad spectrum and is aimed at treating these common organisms. The recommended treatment is intravenous clindamycin and gentamicin until the patient is afebrile for 24 hours. If the patient continues to be febrile after 48–72 hours, ampicillin should be added for coverage of Enterococcus species. Addition of ampicillin is needed in only approximately 5% of cases, however, and other causes of persistent fever should be explored. Oral antibiotics after intravenous antibiotics are not indicated after an uncomplicated case of endometritis.

Answer 714

Asthma may get worse, improve, or stay the same during pregnancy. It is a common medical condition affecting 4% to 8% of pregnancies. It is recommended that pulmonary function tests be followed throughout pregnancy. This is best done by looking at peak expiratory flow rate (PEFR) or forced vital capacity over 1 second. PEFR is technically easier to perform and is not affected by the pregnancy. A PEFR below 80% of personal best indicates a poor response to therapy. In the case of uncontrolled asthma, we would expect a PEFR that would be below 80% of her personal best. Severe and poorly controlled asthma may be associated with increased risk of premature birth, fetal growth restriction, cesarean birth rate, hypertensive disorders, and other perinatal complications that may affect fetal and maternal morbidity and mortality.

Answer 715

The FDA has approved oseltamivir for the treatment and prophylaxis of influenza A and B. Treatment is recommended within 48 hours of symptom onset and should be continued for 5 days.

Answer 716

Down syndrome is the most common chromosomal aneuploidy seen in liveborn neonates, and the most common cause of intellectual disabilities due to a chromosomal anomaly. It can be screened for prenatally by blood tests, such as a quad screen or non-invasive perinatal testing. Amniocentesis can be used to diagnose chromosomal abnormalities in pregnancy if screening tests show an increased risk. There are a number of features on ultrasound that can possibly point to a diagnosis of Down syndrome. However, it should be stressed to the patient that these findings do not definitively diagnose Down syndrome. Ultrasound Findings for Down Syndrome Thickened nuchal fold Echogenic cardiac foci Echogenic bowel Short humerus and/or femur Absent nasal bone In the second trimester, the most sensitive and specific finding for Down syndrome is a thickened nuchal fold. Bottom Line: There are a number of features on ultrasound that can possibly point to a diagnosis of Down syndrome. Ultrasound findings that are considered soft markers for Down syndrome include echogenic cardiac foci, echogenic bowel, a short humerus and/or femur, and absent nasal bone. In the second trimester, the most sensitive and specific finding for Down syndrome is a thickened nuchal fold.

Answer 717

Corticosteroids are administered during this time. They have been the most beneficial intervention for neonates born preterm. A course of corticosteroids is recommended for women who are between 24 and 36 weeks of gestation and with suspected preterm delivery in 1 week. This has been shown to reduce neonatal morbidity and mortality. Benefits of Corticosteroid Therapy Lower severity, frequency, or both of respiratory distress syndrome Lower severity, frequency, or both of intracranial hemorrhage Lower severity, frequency, or both of necrotizing enterocolitis Lower frequency of death

Answer 718

Herpes simplex virus (HSV) is a double-stranded DNA virus. Although HSV-1 has traditionally been associated with oral outbreaks and HSV-2 has been associated with genital outbreaks, the incidence of HSV-1 in the genital area is increasing. Approximately 26% of the female population is seropositive for HSV-2, one of the most common sexually transmitted infections. HSV is spread by direct contact, with abrasions of the vaginal mucosa increasing the likelihood of transmission. Treatment is acyclovir or valacyclovir. Pregnant patients with a history of HSV should be placed on suppression from 36 weeks until delivery.

Answer 719

Increased risk of development of urinary incontinence exists with the use of forceps and vacuum extractors independently. The use of both forceps and vacuum used sequentially at the time of vaginal delivery has not been shown to worsen urinary incontinence at this time. Sequential use of vacuum extractor and forceps has been associated with increased rates of neonatal complications and should NOT routinely be performed. Answer A: In a study of nulliparous women undergoing operative vaginal delivery, use of sequential instruments was associated with increased anal sphincter tears (not anal incontinence) and low umbilical artery pH compared with patients undergoing single instrument vaginal delivery.

Answer 720

Molar pregnancies typically arise from chromosomally abnormal fertilizations. Complete moles most often have a diploid chromosomal composition. These usually are 46,XX and result from androgenesis, meaning both sets of chromosomes are paternal in origin. The chromosomes of the ovum are either absent or inactivated. The ovum is fertilized by a haploid sperm, which then duplicates its own chromosomes after meiosis. Less commonly, the chromosomal pattern may be 46,XY or 46,XX and due to fertilization by two sperm, i.e., dispermic fertilization or dispermy. Partial moles usually have a triploid karyotype—69,XXX, 69,XXY—or much less commonly, 69,XYY. These are each composed of two paternal haploid sets of chromosomes contributed by dispermy and one maternal haploid set. Less frequently, a similar haploid egg may be fertilized by an unreduced diploid 46,XY sperm. These triploid zygotes result in some embryonic development; however, ultimately it is a lethal fetal condition. Fetuses that reach advanced ages have severe growth restriction, multiple congenital anomalies, or both. The presentation of molar pregnancies has drastically changed as ultrasound and early prenatal care have become almost universal. Classic symptoms such as preeclampsia, anemia, severe nausea and vomiting, and hyperthyroidism are much less common now. Untreated molar pregnancies will almost always cause vaginal bleeding that varies from spotting to profuse hemorrhage. Bleeding may presage spontaneous molar abortion, but more often, it follows an intermittent course for weeks to months. In more advanced moles with considerable concealed uterine hemorrhage, moderate iron-deficiency anemia develops.

Answer 721

Major congenital malformations occur in approximately 3%–4% of live births, and cardiac anomalies are the most common type of congenital malformations. Of the different types of cardiac malformations that have been noted, ventricular septal defects account for approximately 50%. The presence of a ventricular septal defect at times may have little effect on cardiac flow in the fetus while in utero. Because there is equal pressure in the left and right ventricles antenatally, small to moderate ventricular septal defects can be missed. However, large ventricular septal defects can be detected via fetal echocardiogram. Detection of a large ventricular septal defect in addition to other cardiac defects should prompt evaluation for possible fetal chromosomal abnormalities.

Answer 722

A patient with an unknown HIV status who presents in labor should undergo a rapid HIV test to screen for HIV, which should result within 20 minutes. If a rapid HIV test results as positive during labor, antiviral prophylaxis should be immediately started. It is recommended that all women undergo HIV screening early in pregnancy or when they enter into prenatal care. In high-risk populations, or in women from high prevalence areas, it is recommended that repeat HIV testing be performed in the third trimester. Women who present in labor with unknown HIV status should have a rapid HIV test performed. If the rapid HIV is positive, the patient in labor should be managed as if HIV positive in order to prevent fetal transmission. In a non-laboring patient, the CDC recommends a fourth-generation immunoassay, which detects the HIV p24 antigen and HIV antibody. This is not possible in a laboring patient in which a result would be required sooner.

Answer 723

Demise of one twin but survival of the co-twin is not an uncommon occurrence, especially in the first trimester. Thus, the phrase “vanishing twin” is a common layperson term to describe when twins are initially visualized during the first trimester but only one is identified in the second trimester. Second-trimester demise of one twin is less common but can have detrimental effects on the surviving twin. The prognosis for the surviving twin hinges on the chorionicity of the twin gestation. Monochorionic surviving twins have a much higher risk of experiencing a sudden neurological injury and even death after in utero demise of their co-twin because of shared placental anastomoses. In a monochorionic twin gestation, the risk of neurological injury in the surviving twin after demise of the other twin is 18%. On the contrary, this risk of neurological injury is only 1% in dichorionic twin gestations because they do not share placental anastomoses; thus, profound hypotension does not occur in the surviving twin. The risk of demise of the second twin in a monochorionic twin pregnancy after intrauterine fetal demise of the first twin is 15%, compared with 3% in dichorionic pregnancy. Despite the high risk of morbidity and mortality, immediate delivery should not occur unless the gestation is greater than 34 weeks and the surviving twin shows signs of distress. Chorionicity Risks Surviving Monochorionic Twin Neurological injury: 18% Death: 15% Surviving Dichorionic Twin Neurological injury: 1% Death: 3%

Answer 724

Uterine inversion is a rare event but can lead to catastrophic bleeding. Uterine inversion often presents as a postpartum hemorrhage. On exam, it is common to palpate a bulge at the cervix or inside the vagina. Complete prolapse of the uterus is also possible. When inversion is diagnosed it is important to make sure adequate help is available; therefore, it is important to activate a massive transfusion protocol and get anesthesia involved. If the uterus is still relaxed then immediate replacement is the best step. If the uterus has started to retract, then often anesthesia and uterine relaxant is needed to replace the uterus. Surgical intervention is the last option. Risk Factors for Uterine Inversion Fundal placental implantation Delayed or inadequate uterine contractility after delivery of fetus Traction on cord PRIOR to placental separation Abnormally adhered placenta (such as accreta) The Huntington procedure consists of application of atraumatic clamps to the round ligaments and pulling the uterus up. This is one of the options for reduction of the inversion following a laparotomy. haultain incision is verticial incision on posterior uterine wall through myometrial contraction ring to pull out the uterus . after this fails it's hysterectomy

Answer 725

Various tests exist to screen for Down syndrome, trisomy 18, and trisomy 13 by measuring specific maternal serum analyte levels. These should be offered to all pregnant women at <20 weeks' gestation. Several of these tests can be performed in the first trimester, some in the second trimester, and some use combined results from the first and second trimesters. The integrated screen (nuchal translucency, PAPP-A, and quadruple screen) has the highest sensitivity for detecting Down syndrome at 94%–96% sensitivity, with the lowest false-positive rate, whereas nuchal translucency measurement alone has the lowest detection rate at 64%–70%. The stepwise sequential screen is a combined first- and second-trimester screen and offers the advantage of obtaining results after the first portion is completed, thereby allowing the patient to make a decision about diagnostic testing or completing the second portion of the test. Noninvasive prenatal testing (NIPT) using cell-free fetal DNA in maternal serum is a new method of aneuploidy screening that is approved for use after 10 weeks' gestational age. It is 99% sensitive with a 0.05% false-positive rate for cases of Down syndrome. Of note, unlike invasive diagnostic testing such as amniocentesis or chorionic villus sampling (CVS), these screening tests do not test for all aneuploidies. Another disadvantage is that sensitivity in twin and triplet gestations is significantly lower because expected analyte levels are not well known in this population; therefore, levels must be estimated by mathematical modeling. Answer A: NIPT can be offered to all pregnant women but only after 10 weeks. Fetal fraction increases with gestational age, but it decreases in obese patients. If patients are obese, consider waiting even longer because a minimum of 4% of fetal fraction is required to report an adequate result. Answer C: Serum screening is less sensitive in multiple gestations because the exact levels are unknown and are based on mathematical models. One twin could have an elevated AFP while the other had a decreased AFP, but overall the exact number could appear normal. Answer D: The integrated screen is a test for nuchal translucency and PAPP-A and a quad screen. Detection rate for Down syndrome is 96%. The integrated screen also detects trisomies 13 and 18. Answer E: The quadruple screen detects only 81% of fetuses with Down syndrome. Bottom Line: Aneuploidy screening tests are designed to screen only for Down syndrome, trisomy 18, and trisomy 13. The integrated screen (nuchal translucency, PAPP-A, and quadruple screen) has the highest sensitivity for detecting Down syndrome at 94%–96% sensitivity. Noninvasive prenatal testing has a sensitivity of 98% for Down syndrome.

Answer 726

Adequate iodine intake is important for the maternal and fetal synthesis of T4. In the thyroid gland, the cells convert thyroglobulin into T4 through several steps, most importantly by adding 4 iodine atoms to the molecule. This is the reason it is called T4 due to its 4 iodine atoms. It then undergoes deiodination to become T3 with 3 iodine atoms. Iodine - Recommended Doses Population Recommended Dose (mcg) Reproductive-aged women 150 Pregnant women 220 Breastfeeding women 290 Untreated hypothyroidism leads to an increased risk of spontaneous miscarriage, preterm birth, stillbirth, and anemia. Approximately 30% of fetal thyroid hormone at birth is actually of maternal origin. Severe iodine deficiency can lead to fetal hypothyroid that in severe cases can lead to cretinism, a condition that is characterized by learning disabilities and physical deformities.

Answer 727

Gastroschisis and omphalocele are the two most common types of fetal abdominal wall defects. Bottom Line: It is important to distinguish between gastroschisis and omphalocele. Gastroschisis is a right paraumbilical, full-thickness defect that is not usually associated with another anomalies, whereas omphalocele is a midline defect covered by a sac that is often associated with aneuploidy and cardiac defects. TrueLearn Insight: Mnemonic: Gastroschisis starts with G, which looks like an open sac that allows bowel to herniate through. Omphalocele starts with O, which looks like a closed sac that covers the bowel.

Answer 728

Preterm contractions that are not accompanied by cervical change are common in pregnancy. In the absence of other complicating factors, these patients can be reassured and discharged home, especially if the cervix is less than 2 cm dilated. There is no indication for tocolytic therapy to prevent preterm birth as an outpatient.

Answer 729

Of all infectious diseases listed, human immunodeficiency virus (HIV) is the only absolute contraindication to breastfeeding in the United States. Even in the setting of appropriate antiretroviral therapy and viral suppression, breast milk transmission rate is 0.7–1% per week in the first 4–6 weeks of life but continues to be present as time progresses. If all HIV-infected women are included, the overall risk of transmission is about 14%. Therefore, in a resource-rich country where alternatives to breastfeeding are available and risk of diarrheal illness and malnutrition is low, breastfeeding is contraindicated. However in other countries where resources are fewer, the risk/benefit balance may be different. Answer A: Though active hepatitis B infection has not been well studied, chronic hepatitis B, as in the majority of pregnant women, does not confer a high risk for transmission by breast milk. Answer B: Though hepatitis C virus has been detected in colostrum, acquisition of hepatitis C by breast milk has never been reported and is not a contraindication to breastfeeding. Answer D: This indicates a recent infection with herpes simplex virus (HSV). Unless there is an active lesion on the breast, HSV infection is not a contraindication to breastfeeding. Answer E: This indicates a lack of maternal immunity to rubella. Though this indicates that the woman should receive the MMR vaccine after delivery, there is no risk to the infant with breastfeeding.

Answer 730

Maternal age greater than 35 is a known risk factor for fetal chromosomal abnormalities including trisomy 21 (Down syndrome). However, all pregnant patients should be offered prenatal screening for fetal chromosomal abnormalities. Several screening methods have been developed for fetal chromosomal fetal abnormalities. Noninvasive prenatal screening with cell-free fetal DNA from maternal serum has been shown to have a sensitivity of 98–99% for detecting Down syndrome in both high-risk and low-risk patients. All available options should be discussed with patients and the most appropriate screening method selected for each patient. Patients with a positive screening result should be offered diagnostic testing with either chorionic villus sampling or amniocentesis depending upon their gestational age.

Answer 731

Ionizing radiation can have different effects on the developing fetus depending on when the fetus is exposed. For the first 2 weeks after conception, the fetus undergoes an all-or-nothing phenomenon when exposed to radiation. This means that the fetus either survives after exposure or dies, which is related to the pluripotent capability of each cell during this stage of development.

Answer 732

The uterus undergoes tremendous architectural changes and remodeling nearly immediately after delivery, and this continues up to 6 weeks postpartum. Involution, or shrinkage of the uterus, begins immediately after delivery. The uterus weighs 1 kg following delivery of the placenta, and this decreases to 300 g by 2 weeks postpartum. At 2 weeks postpartum, the uterus has descended into the pelvis, and it is no longer palpable on abdominal examination. The uterus returns to the prepregnancy size and weight by 4 weeks postpartum. It is not uncommon for the uterus to contain fluid or gas within the endometrial cavity in the days to weeks after delivery. This is a common incidental radiological finding but should be noted as normal when no other concerning signs or symptoms of infection are present. The cervix also undergoes profound architectural changes after delivery, and it is not uncommon for abnormal cervical pathology to no longer be present after a delivery.

Answer 733

Fetal death is a risk factor of postpartum hemorrhage secondary to coagulopathy. Maternal hemorrhage, defined as a cumulative blood loss of greater than or equal to 1,000 mL, or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process, remains the leading cause of maternal mortality worldwide. When evaluating a patient who is bleeding, it may be helpful to consider “the 4 Ts” mnemonic device: Tone Trauma Tissue Thrombin Abnormal uterine tone (uterine atony) is estimated to cause 70–80% of postpartum hemorrhage and usually should be suspected first as the etiology of postpartum hemorrhage. Maternal trauma is indicated by lacerations, expanding hematomas, or uterine rupture. Retention of placental tissue can be readily diagnosed with manual examination or bedside ultrasonography of the uterine cavity and is addressed with manual removal or uterine curettage. Thrombin is a reminder to evaluate the patient’s coagulation status and, if abnormal, to correct with replacement of clotting factors, fibrinogen, or other factor replacement sources. A number of well-established risk factors such as prolonged labor or chorioamnionitis are associated with postpartum hemorrhage:

Answer 734

Group B Streptococcus (GBS) is a hemolytic streptococci that colonizes the rectovaginal area in 10%–30% of pregnant women. It is an asymptomatic infection but is an important cause of perinatal morbidity and mortality in newborns. Approximately 50% of women colonized with GBS will transmit the bacteria to their newborns. It is routine to screen all pregnant women at 35–37 weeks for colonization. Women who test positive should receive intrapartum antibiotic prophylaxis. GBS-Related Problems Percentage Affected GBS colonization in pregnancy 10–30% Vertical neonatal GBS transmission 50% Neonatal meningitis due to GBS sepsis 1% Urinary tract infections (UTIs) in pregnancy caused by GBS 5%

Answer 735

Fetomaternal hemorrhage can happen after any event that causes trauma to the maternal-fetal interface. It is pertinent to recognize the maternal blood group and provide anti-D to rhesus (Rh) negative women who could be potentially exposed to Rh-positive fetal blood to prevent alloimmunization and subsequent pregnancy complications. Fetomaternal hemorrhage is most likely to occur at the time of delivery. Nearly one-half of women show evidence of fetal blood in their circulation after delivery if their fetus is Rh positive. The ideal time to administer anti-D immune globulin is within 72 hours of a potentially sensitizing event; however, patients may still receive some benefit from anti-D immune globulin as late as 28 days postpartum. It is also important to estimate the amount of fetomaternal hemorrhage using quantitative testing (such as the Kleihauer–Betke test) to determine the number of doses of Rh D immune globulin required, especially in patients who are at high risk of excessive fetal–maternal hemorrhage, including cases of abruptio placentae, placenta previa, intrauterine manipulation, or fetal death. The standard 300-microgram dose of anti-D immune globulin covers about 30 mL of fetal whole blood or 15 mL of fetal RBCs. If a patient has received anti-D after undergoing external cervical version (ECV) or amniocentesis, or for third-trimester bleeding and delivery occurs within 3 weeks of administration, the postnatal dose may be withheld in the absence of excessive fetal–maternal hemorrhage. The only 3 situations where anti-D should not be given is if paternity is certain and the biological father is Rh-ve, cell-free DNA testing confirmed the fetal Rh D negative status, or in Rh-negative women who are already sensitized to D. Indications of Anti-D (RhIG) in Rh-ve Pregnant Women Abdominal trauma Abortion: threatened, incomplete, or missed abortion Amniocentesis and chorionic villus sampling (CVS) Abruptio placenta or Antepartum hemorrhage Antenatal routinely at 28 weeks After vaginal delivery, cesarean section, or manual removal of placenta ECV Ectopic pregnancy Evacuation of molar pregnancy Ending (terminating pregnancy) or in intrauterine fetal demise (IUFD) Sensitizing Event Risk of Fetomaternal Hemorrhage Spontaneous miscarriage 2% Dilatation and curettage 4% Amniocentesis < 6% ECV < 6% CVS 14% Delivery Almost 50% TrueLearn Insight: It is important to be familiar with indications for RhIG and how much one vial of RhIG covers (30 mL of fetal blood).

Answer 736

Anti-Lewis antibodies most characteristically produce the M type immunoglobulin (IgM), preventing them from crossing the placenta. There are numerous antibodies that may present themselves during pregnancy. The antibodies may pose no to severe risk of hemolytic disease in the fetus. The most common are described in the table below. The anti-Lewis antibody is the most frequently encountered non-Rhesus antibody in pregnancy. It is detected on a routine type and screen. Like most cold agglutinins, anti-Lewis antibodies do not cause erythroblastosis fetalis because they are predominantly of the immunoglobulin M type, therefore unable to cross the placenta, and the antigens are poorly expressed on fetal and newborn erythrocytes.

Answer 737

Factor V Leiden (FVL) is a low-risk thrombophilia that does not require antepartum therapy unless the patient has a personal history of a venous thromboembolism (VTE).

Answer 738

Prothrombin G20210A mutation is tested by DNA analysis and is reliable during pregnancy, an acute thrombosis, and on anti-coagulation. Venous thromboembolisms are more common in pregnancy due to increased venous stasis and increased clotting potential, decreased anticoagulant activity, and decreased fibrinolysis.

Answer 739

If testing is necessary, different cut off values for the second and third trimester should be used. Outside of pregnancy, free protein S antigen <55% is consistent with protein S deficiency. In the 2nd trimester, a cutoff of <30% should be used In the 3rd trimester, a cutoff of <24% should be used. Protein S deficiency is the only thrombophilia that is not reliable to test during pregnancy. It is also not reliable to test during an acute thrombosis event or while on anti-coagulation.

Answer 740

Neonatal Risks Associated with Intraamniotic Infection Acute morbidity Pneumonia Meningitis Sepsis Bronchopulmonary dysplasia Cerebral palsy Death Answer C: Maternal tachycardia is no longer included in the list of clinical features associated with chorioamnionitis. The clinical features are maternal leukocytosis, fetal tachycardia, and cervical purulent discharge.

Answer 741

Intrapartum antimicrobial agents administered for suspected or confirmed intraamniotic infection should not be continued automatically postpartum. Rather, extension of antimicrobial therapy should be based on risk factors for postpartum endometritis. Data suggest that women who have vaginal deliveries are less likely to have endometritis and therefore post-delivery antibiotics are not required. For women undergoing cesarean deliveries, at least one additional dose of antimicrobial agents after delivery is recommended. However, the presence of other maternal risk factors such as bacteremia or persistent fever in the postpartum period may be used to guide continuation of antimicrobial therapy, duration of antimicrobial therapy, or both in vaginal and cesarean deliveries.

Answer 742

Women with a history of spontaneous preterm birth are at risk for recurrence. Management of subsequent pregnancies includes serial cervical length measurements by transvaginal ultrasound. If short cervix is detected in the 2nd trimester prior to fetal viability, cervical cerclage (ultrasound-indicated cerclage) should be offered as it decreases the risk of recurrent preterm birth and perinatal morbidity and mortality. Therefore, women with a prior spontaneous preterm birth at < 34 weeks' gestation and a short cervical length (< 2.5 cm) detected on transvaginal ultrasound in the 2nd trimester prior to fetal viability are candidates for cerclage. If the patient had a preterm birth preceded by painless cervical dilation, it is possible she has a diagnosis of cervical insufficiency, in which case the patient might be a candidate for a prophylactic cerclage.

Answer 743

There are several consequences to the fetus when Graves disease is poorly controlled. Women with Graves disease can have both stimulatory and inhibitory thyroid antibodies that cross the placenta. Uncontrolled Graves disease is associated with low birth weight neonates and medically indicated preterm delivery. As a consequence of the antibodies crossing the placenta, a newborn may present with either hyperthyroidism or hypothyroidism. Mothers who have been treated for Graves disease with thyroidectomy or radiation are at a higher risk of fetal complications because they are not on thioamide medications, which suppress thyroid production and function.

Answer 744

Women at greatest risk of placenta accreta are those who have myometrial damage caused by an earlier cesarean delivery, with either an anterior or posterior placenta previa overlying the uterine scar. A hypoechoic boundary between the placenta and the bladder is a normal ultrasonographic finding and is least indicative of an accreta.

Answer 745

Peripartum cardiomyopathy is the leading cause of maternal deaths and accounts for 23% of deaths in the late postpartum period. It most commonly affects women after 36 weeks of gestation to the first month postpartum, although it can be seen outside this time frame. Risk factors for postpartum cardiomyopathy include age > 30 years, multiple gestation, Black descent, and a history of preeclampsia, eclampsia, or postpartum hypertension. Patients can present with shortness of breath, fatigue, palpitations, edema, nocturia, etc. This patient is presenting with classic signs and symptoms of peripartum cardiomyopathy. The diagnostic test of choice is echocardiography, and generally reveals a left ventricular ejection fraction < 45%. The left ventricle is also frequently dilated. Answer D: Measurement of plasma BNP may be considered in the evaluation of patients with suspected heart failure when the diagnosis is uncertain. In pregnancy and in peripartum cardiomyopathy, BNP is expected to be elevated and is not the most useful test available.

Answer 746

An estimated fetal weight of greater than 4,000–4,500 g at any gestational age is consistent with a diagnosis of macrosomia. Macrosomia corresponds to an estimated fetal weight greater than an absolute value (4,000–4,500 g) Large for gestational age (LGA) corresponds to a birth weight ≥90th percentile for that gestational age Macrosomia increases the risk of shoulder dystocia in addition to other complications (see table below). Overall, shoulder dystocia occurs in 0.2–3% of vaginal deliveries, but the risk increases to 9–14% with a birth weight >4,500 g. ACOG suggests prophylactic cesarean section be considered when the estimated fetal weight is >5,000 g in a nondiabetic mother and >4,500 g in a diabetic mother. However, studies have shown upwards of 1,000 cesarean sections would need to be performed to prevent one permanent neurological injury. It is imperative to pay particular attention to the labor curve of the patient because labor dystocias are exceedingly more common in pregnancies affected by macrosomia, and the risk of cesarean section is double in those fetuses with an estimated fetal weight >4,500 g. The degree of fetal macrosomia corresponds to a continuum of risk: Birth Weight Complications 4,000–4,499 g Cephalopelvic disproportion, birth injuries 4,500–4,999 g The above risks plus dysfunctional labor, cesarean section, Apgar < 4, assisted ventilation >30 minutes ≥5,000 g The above risks plus infant mortality

Answer 747

Bacterial vaginosis occurs when there is an alteration in the vaginal pH because of the lack of hydrogen peroxide-producing lactobacilli, allowing facultative anaerobes, such as Gardnerella vaginalis, to become the dominant species in the vagina. Bacterial vaginosis is classically diagnosed on the basis of Amsel’s criteria, and 3 of the 4 criteria must be present. A meta-analysis found bacterial vaginosis was associated with low birth weight, preterm premature rupture of membranes, and prematurity. The National Institute of Child Health and Human Development Maternal-Fetal Medicine Units performed a randomized controlled trial in the late 1990s investigating whether treatment of bacterial vaginosis in asymptomatic women reduced the preterm birth rate in pregnant women. Of note, the study found that treatment of asymptomatic women with bacterial vaginosis did not reduce their risk of preterm birth. Thus, asymptomatic women should NOT be screened and treatment is NOT RECOMMENDED in patients without a history of preterm birth, but they should be counseled on the increased risk of preterm birth. Amsel's Criteria Grayish vaginal discharge pH > 4.5 Positive whiff test > 20% clue cells on wet mount TrueLearn Insight: Symptomatic women or women with a history of preterm birth MAY benefit from treatment of BV in pregnancy, but data do not show a benefit for asymptomatic women without a history of preterm birth.

Answer 748

Active management of the third stage of labor has been shown to reduce the incidence of postpartum hemorrhage (PPH). The 3 components of active management are: oxytocin administration uterine massage umbilical cord traction ACOG recommends administering uterotonics, specifically oxytocin, after all deliveries for the prevention of postpartum hemorrhage. Prophylactic oxytocin may be administered as a dilute 10 unit IV infusion or 10 units intramuscularly. Timing of oxytocin administration has not been adequately studied nor found to be associated with a difference in the risk of hemorrhage. Bottom Line: The 3 components of active management are 1) oxytocin administration, 2) uterine massage, and 3) umbilical cord traction. ACOG recommends administering uterotonics, specifically oxytocin, after all deliveries for the prevention of postpartum hemorrhage.

Answer 749

Parvovirus B19 is an infection with potential for transplacental passage to the fetus. Pregnant women who are exposed to parvovirus should be tested via serology as soon as possible after exposure. Any woman with a positive IgM should be monitored for fetal infection. Possible fetal effects include fetal anemia with subsequent development of fetal hydrops. Serial ultrasonography to assess for hydrops and to measure the middle cerebral artery peak systolic velocity (to assess for fetal anemia) should be performed every 1–2 weeks for 8–12 weeks after exposure. If no fetal sequelae have developed by 8–12 weeks after exposure, they are unlikely to develop at all.

Answer 750

Predicting the outcome of neonates born at the limits of viability is a difficult task. Studies have recently described general improvements in rates of neonatal survival without impairment, though rates of neonatal survival are not universal and instead may vary by hospital and treatment received. In a 2017 study of periviable outcomes in the National Institute of Child Health and Human Development Neonatal Research Network (NICHD NRN), during the time period 2008–2011, 13% of neonates born between 23 weeks 0 days and 23 weeks 6 days gestation survived without neurodevelopmental impairment to 18–22 months' corrected age, while 11% survived with neurodevelopmental impairment, and 76% died. Importantly, children born in the periviable period without prior neurodevelopmental impairment may have some cognitive impairments noted at school age, and additional studies are needed.A pregnant patient who had a stillbirth 18 months ago presents with concerns about risk of stillbirth recurrence. Which of the following is the greatest risk factor for stillbirth?

Answer 751

Of the options listed, the greatest risk factor for stillbirth is systemic lupus erythematosis, with rates ranging from 40–150/1,000 births. Stillbirth occurs in about 1 per 160 pregnancies overall, or about 6/1,000 births. Patients who have previously had a stillbirth are understandably concerned about risk of recurrence in future pregnancies, but may not realize that a history of stillbirth is actually not as a strong a risk factor as conditions like lupus or fetal growth restriction. Females who have had a stillbirth have an increased risk (odds ratio 4.8) of having another stillbirth compared with a patient with no history of stillbirth.

Answer 752

Neonatal lupus is an autoimmune disease that occurs from passive transfer of maternal autoantibodies to the fetus. Neonatal lupus syndrome primarily occurs in fetuses whose mothers are positive for anti-Ro/SSA (Sjögren syndrome type A antigen) and/or anti-La/SSB (Sjögren syndrome type B antigen) antibodies. It may occur in women with a history of systemic lupus erythematosus, or other autoimmune disorders, such as Sjogren syndrome. The major manifestations are cardiac and cutaneous findings. Cutaneous findings include an erythematous rash, which may be confused for tinea or dermatitis. Cardiac findings usually manifest as first- or second-degree heart block, which is present in 2%–5% of fetuses with mothers who are anti-SSA/SSB positive. Mothers who are positive should have a fetal echocardiogram weekly from 16–26 weeks' gestation and then every other week from 26–34 weeks to evaluate for signs of fetal heart block. Answer A: Anti-centromere antibodies are most commonly associated with CREST (calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome. Answer B: Anti-Jo 1 antibodies are most commonly associated with polymyositis. Answer C: Anti-mitochondrial antibodies are most commonly associated with primary biliary cirrhosis. Answer D: Antiphospholipid antibodies can be associated with lupus or antiphospholipid syndrome. However, they are not associated with neonatal lupus.

Answer 753

Preterm birth is defined as a delivery between 20 0/7 and 36 6/7 weeks of gestation. Early preterm birth is defined as a birth before 34 weeks of gestation, whereas a late preterm birth is between 34 0/7 and 36 6/7 weeks of gestation. Preterm birth can be spontaneous or indicated (for either a maternal or fetal indication). In 2019, the rate of live preterm births in the United States was 10.2%. Preterm birth is a major factor in perinatal morbidity and mortality and accounts for approximately 70% of neonatal deaths and 36% of infant deaths, as well as 25%–50% of cases of long-term neurological impairment in children.

Answer 754

The incidence of Rhesus incompatibility varies with race and ethnicity. White people have the highest incidence of Rhesus-negative blood type, at 15%.

Answer 755

In a symptomatic patient, the recommended method for diagnosing bacterial vaginosis (BV) is the Amsel criteria or Gram stain with Nugent scoring. Gram stain is considered the gold standard in a research setting, but is not typically performed in clinical practice because it takes more time and resources than using Amsel criteria. In practice, the diagnosis of bacterial vaginosis is made by observing at least 2 of the Amsel criteria. These are as follows: The Amsel criteria have a sensitivity of 92% and a specificity of 77% compared with Gram stain with Nugent scoring.

Answer 756

Fundal height measurements at routine prenatal visits can screen for both fetal growth restriction (FGR) and macrosomia. FGR is defined as a fetus having an estimated fetal weight (EFW) or abdominal circumference (AC) less than the 10th percentile for its gestational age. All pregnancies should be screened starting at 24 weeks by performing fundal heights. If discrepancy between EFW and fundal height is >3 cm, an ultrasound is indicated to assess for FGR. There are many causes of FGR, including chromosomal abnormalities, infections, maternal comorbidities, tobacco and substance use, and placental abnormalities. A fetus with FGR and EFW < 10% has a 1.5% risk of stillbirth while severe FGR < 5% carries a stillbirth rate of 2.5%. Once FGR has been diagnosed, the amniotic fluid levels should be evaluated and umbilical artery (UA) Doppler velocimetry should be performed. UA Doppler velocimetry evaluates the blood flow to the fetus, and absent or reversed end-diastolic flow (EDF) in the umbilical arteries is associated with a higher risk of perinatal mortality. The rate of perinatal death is reduced by as much as 29% when UA Doppler velocimetry is added to standard antepartum testing in the setting of fetal growth restriction. Antepartum Care of FGR Recommendations Growth ultrasound Every 3–4 weeks Anatomy scan To be done if not already done before suspecting FGR Genetic testing and TORCH panel To be done in cases of early onset FGR for suspected aneuploidy Fetal surveillance (start when fetus is at a gestational for possible delivery) 32 weeks or earlier if high risk Serial UA Dopplers, amniotic fluid assessment or biophysical profile nonstress test (BPP NST) every week or more often if high risk Middle cerebral artery and ductus venosus Doppler No evidence to support improved outcomes with these interventions Additional nutrient intake in the absence of true maternal malnutrition No evidence to support improved outcomes with these interventions Antepartum steroids Recommended if delivery is anticipated before 33 6/7 weeks or delivery is anticipated between 34 0/7 and 36 6/7 weeks of gestation and did not receive a previous course of antenatal corticosteroids Magnesium sulfate For neuroprotection if delivery is planned before 32 weeks Delivery time Isolated FGR < 10%tile: deliver at 38 0/7–39 6/7 weeks Isolated FGR < 3%tile: deliver at 37 0/7 weeks Abnormal UA Dopplers: absent EDF deliver at 34 weeks, reversed EDF at 32 weeks FGR with other comorbidities: delivery plan is individualized Delivery method FGR by itself is not an indication for a cesarean section

Answer 757

Hemodynamic stability along with persistent slow bleeding and failure of less invasive therapy to improve bleeding are the three criteria for a patient to be a candidate for uterine artery embolization (UAE). The median success rate for UAE is 89%. The risk of harm is low and includes risk of uterine necrosis, deep vein thrombosis, or peripheral neuropathy. Infertility has been reported in up to 43% of patients who undergo UAE for management of postpartum hemorrhage (PPH) and future pregnancy complications including preterm birth and fetal growth restriction occur at the same rate as the general obstetric population.

Answer 758

Varicella zoster virus (VZV) is a single-stranded DNA herpesvirus that has become exceedingly uncommon during pregnancy because of a vaccination introduced in 1995. Even prior to the vaccine, the prevalence of maternal infection with VZV during pregnancy was 0.4–0.7 per 1,000 pregnant women; however, maternal VZV infection carries an exceedingly high mortality rate because nearly 20% develop pneumonia. The highest risk to the fetus/neonate of having detrimental sequelae from a primary maternal VZV infection is when the primary maternal infection occurs between 5 days pre-delivery or within 48 hours' postpartum. A primary maternal infection occurring during this time period translates to a very high mortality rate. Any neonate born within this time period is immediately started on intravenous acyclovir to reduce the risk of transmission and disease severity if transmission does occur. Congenital varicella syndrome is also a serious consequence of primary maternal infection during pregnancy, but the transmission rate is much lower (first trimester 0.4%, second trimester 2%, and third trimester 0%). Congenital varicella syndrome manifests as short limbs, skin scarring, microcephaly, and chorioretinitis. Any non-immune pregnant patient exposed to a person with active varicella zoster virus should immediately receive varicella zoster immune-globulin to reduce the risk of VZV infection and to reduce the severity if infection does occur.

Answer 759

Nuchal translucency (NT) is the primary ultrasound marker for risk of chromosomal abnormality in the first trimester. Increased NT is associated with genetic syndromes and anomalies. Anomalies associated with increased NT Congenital heart defects Abdominal wall defects Diaphragmatic hernias Increased nuchal translucency in a euploid fetus is associated with increased risks of structural abnormalities. Of these, cardiac malformations are the most common structural malformation associated with increased nuchal translucency. Although a wide spectrum of cardiac malformations are observed, septal defects are the most common in fetuses with increased nuchal translucency. Complex congenital heart disease may occur in fetuses that have increased nuchal translucency combined with fetal bradycardia. A fetus identified as having an increased nuchal translucency and possible cardiac defect should be assessed with first-trimester Doppler of the ductus venosus and a second-trimester echocardiogram.

Answer 760

Women who have risk factors for early delivery may be monitored with serial ultrasonography between weeks 16 and 24 to assess for changes that are consistent with a short cervical length, with or without the presence of funneling. Patients may be a candidate for a cerclage. Indications for a cerclage: History 1 or more 2nd trimester losses due to painless cervical dilation AND absence of abruption OR prior 2nd trimester cerclage due to painless cervical dilation Exam Finding of dilated cervix in the 2nd trimester Ultrasound Current singleton pregnancy with a short cervical length (less than 25 mm) before 24 weeks of gestation in addition to a prior spontaneous preterm birth at less than 34 weeks of gestation Shortened cervical length on ultrasound in the absence of a history of preterm birth (incidentally found shortened cervix) is NOT an indication for cerclage. Cerclages are contraindicated in multi-fetal gestation.

Answer 761

Women who have risk factors for early delivery may be monitored with serial ultrasonography between weeks 16 and 24 to assess for changes that are consistent with a short cervical length, with or without the presence of funneling. Patients may be a candidate for a cerclage. Indications for a cerclage: History 1 or more 2nd trimester losses due to painless cervical dilation AND absence of abruption OR prior 2nd trimester cerclage due to painless cervical dilation Exam Finding of dilated cervix in the 2nd trimester Ultrasound Current singleton pregnancy with a short cervical length (less than 25 mm) before 24 weeks of gestation in addition to a prior spontaneous preterm birth at less than 34 weeks of gestation Shortened cervical length on ultrasound in the absence of a history of preterm birth (incidentally found shortened cervix) is NOT an indication for cerclage. Cerclages are contraindicated in multi-fetal gestation.

Answer 762

Bottom Line: The top 3 vaginal infections associated with preterm birth are bacterial vaginosis (stronger when detected early in pregnancy, before 16 weeks), Neisseria gonorrhoeae, and asymptomatic bacteriuria. There is an association between bacterial vaginosis and preterm labor due to chorioamnionitis. Treatment of asymptomatic bacterial vaginosis does NOT decrease the risk of preterm birth in the general obstetric population. Treatment should be given to patients diagnosed with symptomatic or asymptomatic STDs and bacteriuria. The top 3 vaginal infections associated with preterm birth are bacterial vaginosis before 16 weeks > Neisseria gonorrhoeae > asymptomatic bacteriuria. Pregnant women with symptomatic bacterial vaginosis should receive treatment to relieve symptoms. As many as 1/3 of pregnant women in the US have bacterial vaginosis. There has been some association with bacterial vaginosis and preterm labor due to chorioamnionitis. Other complications of bacterial vaginosis include: postpartum endometritis (OR 2.53, 95% CI 1.25–5.08) increased risk of late miscarriage (OR 6.32, 95% CI 3.65–10.90). Although there has been an association between bacterial vaginosis and adverse outcomes, data have shown that treatment of asymptomatic infection does NOT decrease the risk of preterm birth in the general obstetric population. Therefore, all pregnant women should not be routinely screened and treated for asymptomatic bacterial vaginosis.

Answer 763

Between 1 million and 1.2 million individuals in the United States are estimated to be living with HIV or AIDS. Because HIV infection often is detected through prenatal and STD screening, it is not uncommon for an obstetrician–gynecologist to be the first health professional to provide care for an infected woman. With the advent of highly active antiretrovirals there is an increasing number of people living with chronic HIV infections. This therapy has also reduced the number of perinatal HIV transmissions. Pregnancy does not accelerate the disease process, nor does it decrease the viral load. Some medical therapies used to treat HIV can increase glucose intolerance, however there is no evidence that shows women are at increased risk of gestational diabetes while taking antiretrovirals.

Answer 764

Primary immune thrombocytopenic purpura (ITP) is a rare condition that occurs in only 1 in 1,000 to 10,000 pregnancies. It is a diagnosis of exclusion, and all other maternal conditions and medications associated with thrombocytopenia need to be explored prior to assigning the diagnosis. Common medications that can cause thrombocytopenia are zidovudine, heparin, and sulfonamides. Some conditions that can cause thrombocytopenia are systemic lupus erythematous, preeclampsia, and antiphospholipid antibody syndrome. Criteria for a diagnosis of primary ITP include the following: 1) Platelet counts are <100,000/μL. 2) All other medications and medical conditions that can cause thrombocytopenia have been excluded. 3) Bone marrow biopsy shows normal or increased amounts of megakaryocytes (immature platelets). A bone marrow biopsy is rarely needed for the diagnosis. 4) A splenectomy has not been performed.

Answer 765

Condition Recommended Weight Gain (lb) Underweight (BMI < 20) 28–40 Ideal weight (BMI 20–25) 25–35 Overweight (BMI 25–30) 15–25 Obese (BMI > 30) 11–20

Answer 766

Ask for help, Assess vitals, Anticipate possible need of blood products Wide-bore IV lines x 2 Empty the bladder Check for lacerations and repair them if present Bimanual massage and removal of clots Uterotonic drugs Tamponade techniques Surgical intervention (exploratory laparotomy)

Answer 767

Contraindications to Breastfeeding in the United States Infant galactosemia – infants lack enzyme to metabolize galactose Human immunodeficiency virus* Human T-cell lymphoblastic virus types I and II – risk of transmission Current illegal drug use or alcohol use (amount of alcohol can be controversial) Active untreated tuberculosis – due to risk of airborne transmission to infant associated with close contact needed for breastfeeding Methotrexate and other antimetabolites – drug transmission *HIV is not a contraindication in developing nations where the benefits of breast milk outweight the risk of transmission. Answer A: Supervised methadone use with no illicit substance use is not a contraindication to breastfeeding. These patients should be encouraged to breastfeed. Answer C: An active genital or oral herpes infection is not a contraindication to breastfeeding, as long as there are no open herpes lesions on the nipples. Lesions that the infant could be exposed to during feeding should be covered. Answer D: Although hepatitis C virus has been detected in colostrum and breast milk, a well-designed review of 3 studies found transmission rates were not statistically different among those who were breastfeeding and those who were not breastfeeding. Thus, hepatitis C is not a contraindication to breastfeeding with any viral load. However, women should avoid breastfeeding if open lesions or cracked nipples are present because this could expose the infant to blood, which could transmit the virus. Answer E: Although hepatitis B virus has been detected in colostrum and breast milk, a well-designed review of 3 studies found transmission rates were not statistically different among those who were breastfeeding and those who were not breastfeeding. Thus, hepatitis B is not a contraindication to breastfeeding with any viral load. However, women should avoid breastfeeding if open lesions or cracked nipples are present because this could expose the infant to blood, which could transmit the virus. Bottom Line: Hepatitis B and C are not contraindications to breastfeeding in the United States. HIV is a contraindication in the United States, but not in developing nations due to benefits of breastmilk outweighing the risk of HIV transmission through breastmilk. Supervised methadone use is not a contraindication to breastfeeding, but illicit substance use is a contraindication.

Answer 768

Immediate postpartum IUD insertion is defined as occurring within 10 minutes of delivery of the placenta. Timing of IUD Insertion After Delivery Postplacental (immediate postpartum) Insertion within 10 minutes of delivery of the placenta Early postpartum Insertion > 10 minutes and < 1 week postpartum Delayed postpartum Insertion 1 week to 6–8 weeks postpartum Interval Insertion unrelated to timing of delivery (beyond postpartum period) Immediate postpartum IUD insertion should not be performed in patients with ongoing postpartum hemorrhage or uterine infection. Postpartum contraception is an important component of postpartum care and counseling should begin during pregnancy. Initiation of contraception helps reduce short-interval pregnancy, defined as an interval between birth and conception of the subsequent pregnancy that is less than 18 months. The provider is the expert regarding the efficacy and medical eligibility for various forms of contraception and the patient is the expert on their life experiences and desire for future pregnancies. During these discussions the provider should describe all the suitable methods of contraception and then engage in shared decision-making with the patient to find the most appropriate contraception method. Answer A: For women who are not lactating, the average time to ovulate is 45–94 days after delivery. The earliest reported cases of ovulation occur 25–27 days postpartum. It is important to counsel patients about when they may begin ovulating again. Many patients do not attend a postpartum follow-up appointment, and many patients who do have already resumed sexual activity prior to the appointment. For patients who breastfeed, resumption of ovulation is unpredictable and is partially dependent on the frequency and exclusiveness of breastfeeding. Around 20–56% of fully breastfeeding women begin ovulating prior to 6 months postpartum, and many women stop exclusively breastfeeding prior to 6 months. Answer B: Estrogen-containing methods of contraception should be avoided for at least 21 days postpartum due to the increased risk of venous thromboembolism (VTE) in the postpartum period, which is compounded by estrogen-containing contraception. Many women will have additional risk factors for VTE (advanced maternal age, elevated BMI, cesarean delivery, preeclampsia, postpartum hemorrhage, etc) and for these patients estrogen-containing contraceptives are considered category 3–4 (risks outweight the benefits or contraindicated) by the CDC for 3–6 weeks following delivery. Answer C: While progestin-only pills do not affect breastfeeding, they are not the most effective contraceptive method, with a failure rate of 9% in the first year of use. The subdermal implant and intrauterine device are also progesterone-only containing methods of contraception that do not affect breastfeeding and have a failure rate < 1% in the first year of use. The "best method" will vary depending on a patient's comorbidities and preferences. Answer E: Data have shown that postplacental levonorgestrel IUDs have a 2-fold increased rate of expulsion compared with copper IUDs. This is important to include when counseling patients about postplacental IUD insertion.

Answer 769

Answer A: 17-hydroxyprogesterone caproate is indicated in women with a history of prior preterm birth at 20–36 weeks' gestation. The pregnancy losses in this case occurred at <20 weeks' gestation. -- makena now is off shelves per FDA Answer E: Vaginal progesterone has been shown to be beneficial in women with a short cervix in the 2nd trimester and NO history of preterm birth

Answer 770

In the United States, the rate of postpartum hemorrhage (PPH) increased 26% between 1994 and 2006 primarily because of increased rates of atony. Although a PPH is about 4% of all vaginal deliveries and 6% of cesarean sections with the vast majority (>80%) related to atony, there are risk factors that can make a patient more susceptible to a hemorrhage and should be identified as soon as possible. Maternal hemorrhage is defined as a cumulative blood loss of greater than or equal to 1,000 mL, or blood loss accompanied by signs or symptoms of hypovolemia within 24 hours after the birth process. Maternal hemorrhage remains the leading cause of maternal mortality worldwide. Primary PPH occurs within the first 24 hours of birth, whereas secondary PPH is defined as excessive bleeding that occurs more than 24 hours after delivery and up to 12 weeks postpartum. According to the latest CDC data, the rate of PPH with procedures to control hemorrhage (per 10,000 delivery hospitalizations) increased from 4.3 in 1993 to 21.2 in 2014, with sharper increases in later years. The rate of PPH with blood transfusions also increased noticeably over time, from 7.9 in 1993 to 39.7 in 2014. The incidence of PPH is 4% for vaginal delivery and 6% for cesarean delivery. Bottom Line: In the United States, the rate of postpartum hemorrhage (PPH) increased 26% between 1994 and 2006 primarily because of increased rates of atony. The rate of PPH is about 4% of all vaginal deliveries and 6% of cesarean sections, with the vast majority (>80%) related to atony. TrueLearn Insight: When evaluating a patient who is bleeding, it may be helpful to consider “the 4 Ts” mnemonic device—tone, trauma, tissue, and thrombin. Postpartum hemorrhage is common and highly tested. Know your patient's risk factors and know your unit's protocols for management. Risk assessment tools are readily available and have been shown to identify 60–85% of patients who will experience a significant obstetric hemorrhage.

Answer 771

Postpartum hemorrhage is classified as primary or secondary. Primary hemorrhage occurs in the first 24 hours after delivery, while secondary hemorrhage occurs after 24 hours and up to 12 weeks' postpartum. There are multiple etiologies for both types of hemorrhage. The most common reason for secondary hemorrhage is retained products of conception (POCs). Treatment should be focused on the etiology of the hemorrhage and may include uterotonic agents and antibiotics, but if these fail to resolve the problem or if retained products of conception are suspected, uterine curettage may be necessary.

Answer 772

Gastroschisis risk is actually decreased in neonates born to obese mothers, with an odds ratio of 0.17. During prenatal counseling of obese women, it is important to discuss the increased risk of fetal structural congenital anomalies as well as diagnostic challenges. This includes a decrease in the detection rate of fetal anomalies by at least 20%. Maternal obesity also increases plasma volume, and this alters interpretation of serum analytes. Weight adjustment does improve detection of neural tube defects and trisomy 18, but does not improve the detection of Down syndrome. Bottom Line: The risk of fetal structural congenital anomalies increases among obese women with the exception of risk of gastroschisis, which is actually decreased. Diagnostic challenges include lower detection rates by second-trimester ultrasonography, serum analytes, and cell-free fetal DNA compared with rates in nonobese women. MRI is not recommended for routine screening in obese pregnant women. TrueLearn Insight: In addition to increased risk of congenital anomalies, obesity also increases the risk of spontaneous abortion and stillbirth.

Answer 773

Maternal T4 is transferred to the fetus throughout the entire pregnancy and is important for normal fetal brain development. It is especially important before the fetal thyroid gland begins concentrating iodine and synthesizing thyroid hormone at approximately 12 weeks of gestation. This patient has hypothyroidism in pregnancy and the most common cause is Hashimoto thyroiditis. Adverse effects of hypothyroidism include spontaneous abortion, preeclampsia, preterm birth, abruptio placentae, low birth weight, impaired neuropsychologic development of the offspring and fetal death; these are all associated with untreated overt hypothyroidism. Levothyroxine is a synthetic form of T4 that is commonly used to treat individuals with hypothyroidism. The usual dose is 1.6 mcg/kg, with dose adjustments being made on the basis of repeated lab tests 6 weeks later. Treatment is usually lifelong, and the goal is a euthyroid state as indicated by normal laboratory values.

Answer 774

Although rare, congenital rubella syndrome (CRS) has multiple anomalies. If exposure is suspected during the prenatal course, one should expect to see evidence of cardiac abnormalities, defects involving the central nervous system and its development, evidence of growth restriction, and hepatosplenomegaly, to name just a few. Following delivery, the findings include deafness, glaucoma as evident by corneal clouding, and possibly respiratory distress. To prevent CRS, it is important that individuals who do not test positive for immunity receive the vaccination in the postpartum period. Pregnant women are not allowed to receive the rubella vaccine because it is a live attenuated vaccination.

Answer 775

All pregnant women are offered screening for Down syndrome with a quadruple screen, which is performed at approximately 14–21 weeks of gestation. Some centers may offer first-trimester screening as well, which includes ultrasonography measuring nuchal translucency (done at 10–4/7 to 13–6/7 weeks gestation) along with serum markers for PAPP-A (pregnancy-associated plasma protein A) and hCG. If the screening test is positive, the patient can be counseled to have further diagnostic testing done, which entails an amniocentesis. Focused ultrasonography is also performed, which can look for soft markers for Down syndrome. These markers are not diagnostic of Down syndrome; however, their presence may further aid in diagnosis. Soft markers for Down syndrome on second-trimester ultrasonography include echogenic cardiac foci, pyelectasis, echogenic bowel, thickened nuchal fold, mild ventriculomegaly, choroid plexus cysts, and shortened femur length.

Answer 776

Determining chorionicity is vital once a twin gestation is diagnosed because of the increased morbidity and mortality associated with monochorionic gestations. Further, 15% of monochorionic gestations will develop twin-to-twin transfusion syndrome; thus, all monochorionic twin gestations need screening initiated at 16 weeks and every 2 weeks thereafter. Ultrasonography is incredibly accurate (96%) at correctly diagnosing the chorionicity, but all twin gestation placentas should be sent to pathology because chorionicity can be definitively diagnosed only on placental pathology. The late first or early second trimester is the best time to determine chorionicity. If the twins are opposite sexes, then the chorionicity is dichorionic. When they are not the same sex or sex cannot be determined because of gestational age or position, other ultrasonographic findings can be used. Dichorionic twin gestations typically have a dividing membrane that is ≥ 2 mm. Also, dichorionic twin gestations have a twin-peak sign (also called a lambda sign). This is the upward or downward projection of placental tissue into the amnion and chorion interface between the 2 amniotic sacs.

Answer 777

This patient has a molar pregnancy, and the safest way to manage her disease is with suction curettage. Before performing the procedure, a chest X-ray and labs (CBC with platelets, PT, PTT, type and screen) are indicated to rule out metastatic disease. Pelvic ultrasonography is also warranted to exclude the presence of a theca lutein cyst. If a patient is Rh negative, RhoGAM should be administered. Infusion of oxytocin should begin once in the operating suite. Following the procedure, the patient should be started on contraception to prevent pregnancy, and her beta human chorionic gonadotropin (βhCG) levels require monitoring on a weekly basis until they are negative for 3 consecutive values. Once negative values are obtained, her levels should be drawn every 2 months for 6 months, followed by every 2–3 months for 6 months. In subsequent pregnancies, early ultrasonography is indicated to exclude the presence of a molar pregnancy, and the βhCG level test will need to be repeated at the 6-week postpartum visit. Molar pregnancies occur at a rate of 1 in 1,000–1,500. Risk factors for a molar pregnancy include the extremes of the reproductive age and a previous molar pregnancy. The risk of recurrence is 1%–2% after 1 molar pregnancy, and the risk increases to 25% after 2 previous molar pregnancies. Vaginal bleeding, an enlarged uterus, and an elevated βhCG level (greater than 100,000 mIU/mL) are some of the initial signs and symptoms of a molar pregnancy. Suction curettage is the preferred treatment modality, followed by chemotherapy with methotrexate. Definitive therapy, such as hysterectomy, is indicated in older patient populations or in patients with evidence of metastatic disease who have completed their childbearing years.

Answer 778

Theca lutein cysts are a common finding in patients with molar pregnancies (ranging from 25% to 60%). It is thought to be due to stimulation of the theca cells by large concentrations of hCG. Theca lutein cysts can be quite large, growing up to 20 cm. These cysts are benign; however, the presence of large cysts is a risk factor for the development of gestational trophoblastic disease. The best management is observation, as they will spontaneously regress after evacuation of the molar pregnancy. This can take up to 6 weeks. Occasionally, these cysts may cause torsion; however, this is not an indication for an oophorectomy. Most ovaries can be preserved with a detorsion.

Answer 779

Mechanism of Action Inhibits prostaglandin synthesis, leading to anti-inflammatory, antipyretic, analgesic, antiplatelets, and spasmolytic effect Nonsteroidal anti-inflammatory drugs (NSAIDs) are appropriate pharmacologic therapy in the postpartum patient. NSAIDs are excreted in the breast milk at low levels as opposed to opiates which appear in higher levels in breastmilk and can be associated with central nervous system depression in nursing neonates. Ibuprofen is considered first line because prior studies have shown levels in breastmilk are < 1% of accepted infant dosing. Injectable and oral forms of ketorolac are used to treat moderate pain in the immediate postpartum period in women for whom multimodal analgesia is indicated. The relative infant dose after IV administration is not known but is likely low in the first 24–72 hours postpartum before the onset of copious milk production. Given its strong antiplatelet activity, the manufacturers of ketorolac caution use in breastfeeding women (although the risk in the first 72 hours when levels in colostrum are anticipated to be low is likely outweighed by possible benefits in terms of maternal pain control). Therefore, based on the effectiveness and minimal breast milk concentration of ketorolac, it can be used in the immediate postpartum period, especially after cesarean deliveries. One less common exception to the use of NSAIDs in breastfeeding mothers is when the feeding neonate has a ductal-dependent lesion due to the hypothetical risk of premature closure of the ductus arteriosus (in which case holding NSAIDs may be reasonable). The table below summarizes the most important points about NSAIDs in obstetrics and gynecology, as well as where to use them with caution.

Answer 780

The use of assisted reproductive technology (ART) increases the risk of cesarean hysterectomy. It is not certain why use of ART increases the risk of peripartum hysterectomy. It is theorized that the risk of hemorrhage leading to peripartum hysterectomy is related to suboptimal endometrium at the time of implantation. Implantation issues can lead to either complete or focal placenta accreta, leading to hemorrhage and ultimately hysterectomy. Peripartum hysterectomy is most commonly performed to arrest or prevent hemorrhage from intractable uterine atony or abnormal placentation, and most commonly at the time of cesarean section, but it may also occur following vaginal delivery. The rate of peripartum hysterectomy in the United States approximates 1 per 1000 births. In a study by Cromi et al., published in Fertility and Sterility in 2016, data suggest that history of ART leads to a greater than fivefold increase in the odds of having a peripartum hysterectomy to control hemorrhage. Several other studies have also shown an increased association between peripartum hysterectomy and use of ART. This patient has many risk factors that predispose to peripartum hysterectomy including age (AMA, 36 years old), multiparity, obesity (BMI 30), and multifetal gestation (Di-Di twins).

Answer 781

Approximately 1000 mg of iron is required for normal pregnancy. Iron requirements are greater in pregnancy than in the nonpregnant state. Although iron requirements are reduced in the first trimester because of the absence of menstruation, they rise steadily thereafter. In most women, this amount is usually not available from iron stores or diet. Thus, without supplemental iron, the optimal rise in maternal erythrocyte volume will not develop, and the hemoglobin concentration and hematocrit will fall appreciably as plasma volume rises. Bottom Line: Approximately 1000 mg of iron is required for normal pregnancy. In most women, this amount is usually not available from iron stores or diet. Therefore, iron supplementation is important, and can be accomplished with prenatal vitamins, or at least 27 mg daily. Answer A: 27 mg is the recommended intake of iron daily, which is found in most prenatal vitamins.

Answer 782

Uterine atony is the most common cause of postpartum hemorrhage (PPH), causing 70%–80% of cases, and the incidence appears to be increasing. Identification of a soft, poorly contracted, or boggy uterus suggests atony as the causative factor. There are occasions when the fundus is firm and contracted down, but the lower uterine segment is dilated and atonic, which can also contribute to postpartum hemorrhage. Causes of PPH Percentage of cases of PPH (approximate) Uterine atony 70–80% Obstetric trauma/laceration 13% Retained products/placenta 5% Coagulopathy, DIC 2%

Answer 783

If patients present for care with elevated glucose levels >200 mg/dL, check urine for ketones. There should be concerns for greater than or equal to 3+ ketones. Once diabetic ketoacidosis (DKA) is diagnosed, continuous fetal heart rate monitoring commonly demonstrates minimal variability and may have late decelerations in the setting of contractions. Once the diagnosis for DKA is made, the next best step is to place IV catheters and start administering normal saline to dilute blood glucose levels and improve fluid volume and tissue perfusion, unless serum sodium levels are elevated, in which case administer half-normal saline. DKA is a life-threatening emergency observed in 5–10% of all pregnancies complicated by pregestational diabetes mellitus. Because DKA is caused by an absolute or relative insulin deficiency, it is most commonly observed in women with type 1 pregestational diabetes mellitus. Maternal glucose control should be maintained near physiologic levels before and throughout pregnancy to decrease the likelihood of complications of hyperglycemia, including spontaneous abortion, fetal malformation, fetal macrosomia, fetal death, and neonatal morbidity. Bottom Line: Once the diagnosis for diabetic ketoacidosis is made, the next best step is to place IVs and start administering normal saline to dilute blood glucose levels and improve fluid volume and tissue perfusion. If serum sodium levels are elevated, then administer half-normal saline. TrueLearn Insight: Because pregestational diabetes is considered a high-risk factor for the development of preeclampsia, the American College of Obstetricians and Gynecologists recommends that low-dose aspirin (81 mg/day) prophylaxis should be initiated between 12 weeks and 28 weeks of gestation (optimally before 16 weeks of gestation) and be continued until delivery.

Answer 784

In obstetrics, transfusing platelets (PLT) is recommended if cesarean delivery is required and the platelet count is less than 50,000/μL. Immune thrombocytopenic purpura (ITP) is a diagnosis of exclusion after thorough workup for all other causes of thrombocytopenia. It is an acquired thrombocytopenia caused by autoantibodies against platelet antigens. When to treat ITP? Symptomatic patient irrespective of platelet count (such as epistaxis or bruising) Platelet count is <30,000/μL even if asymptomatic Prior to epidural or spinal anesthesia (requires PLT >70,000/μL) Prior to cesarean delivery or any surgical procedure (requires PLT >50,000/μL) Management of ITP First line Glucocorticoids Prednisone 10–20 mg/day for at least 21 days then tapered Dexamethasone 40 mg daily for 4 days then stopped IV immunoglobulin (IVIG, if steroids are contraindicated or not effective) 1 g/kg for 1 or 2 days Second line Rituximab Thrombopoietin receptor agonists Immunosuppressive therapy Anti-D immunoglobulin Refractory cases Splenectomy Emergency situation Platelet transfusion

Answer 785

Consuming undercooked pork and lamb products is the most likely cause of maternal toxoplasmosis infection. The meat can contain oocysts, which can withstand temperatures of up to 160 degrees, so it is recommended that these meats be cooked at 160 degrees for at least 20 minutes prior to serving. Maternal toxoplasmosis infection is typically silent, although patients can present with symptoms of fatigue, fever, muscle pain, and a maculopapular rash. Maternal infection is associated with a fourfold increased preterm delivery rate. Fetal effects include low birthweight, hepatosplenomegaly, jaundice, anemia, intracranial calcifications, hydrocephalus, and chorioretinitis. The severity of the disease is much greater if contracted prior to 20 weeks.

Answer 786

According to the American College of Obstetricians and Gynecologists (ACOG), massive transfusion is defined as a transfusion of 10 or more units of packed red blood cells within 24 hours, or 4 units of packed red blood cells within 1 hour while more blood transfusion is still anticipated, or replacement of a complete blood volume. Massive transfusion is associated with risks such as hyperkalemia due to tissue damage or hemolysis, hypocalcemia due to citrate toxicity, metabolic acidosis due to production of lactic acid and decreased removal of citrate, hypothermia which reduces platelet and enzymatic activity, transfusion reactions (TRALI), and transfusion-associated infections. TrueLearn Insight: The lethal triad of acidosis, hypothermia, and coagulopathy associated with MT is associated with a high mortality rate.

Answer 787

According to the American College of Obstetricians and Gynecologists (ACOG), massive transfusion is defined as a transfusion of 10 or more units of packed red blood cells within 24 hours, or 4 units of packed red blood cells within 1 hour while more blood transfusion is still anticipated, or replacement of a complete blood volume. Massive transfusion is associated with risks such as hyperkalemia due to tissue damage or hemolysis, hypocalcemia due to citrate toxicity, metabolic acidosis due to production of lactic acid and decreased removal of citrate, hypothermia which reduces platelet and enzymatic activity, transfusion reactions (TRALI), and transfusion-associated infections. TrueLearn Insight: The lethal triad of acidosis, hypothermia, and coagulopathy associated with MT is associated with a high mortality rate.

Answer 788

This woman developed HELLP (hemolysis, elevated liver enzymes, low platelets) syndrome in the second trimester. This is a severe form of preeclampsia manifested by elevated blood pressure levels (>140/90 mm Hg) in addition to laboratory findings consistent with hemolysis and elevated liver enzyme levels and thrombocytopenia. Several risk factors for development of preeclampsia have been identified, including obesity, chronic hypertension, autoimmune disorders, acquired thrombophilias, renal disease, diabetes, and a history of preeclampsia. The gestational age at which preeclampsia develops is inversely proportional to the risk of recurrence. If preeclampsia develops at term, 31–36 weeks, 27–30 weeks, and <27 weeks, the risk of recurrence is 20%, 30%, 40%, and 50%, respectively. This patient developed preeclampsia at 26 weeks' gestation, conferring about a 50% risk of recurrence.

Answer 789

Accommodations are work modifications that allow a person to continue to safely perform the essential functions (primary duties) of the job, thereby allowing continued pay and benefits. Requests for accommodation should be specific in their requests. They should also state that the patient has a specific condition that requires the request. Accommodation letters should only be written to suggest work modifications or restrictions that are medically necessary. Bottom Line: If it is necessary to write a request for accommodations, it should be limited to a specific request that is absolutely medically necessary and should be for a specific time period. Federal law does not require complete compliance and does not guarantee pay.

Answer 790

Parvovirus B19 is a single stranded DNA virus that causes the classic childhood illness of fifth disease. This illness is characterized by flu-like symptoms, accompanied by reddened cheeks (“slapped cheeks”), and typically resolves without permanent sequelae in children. In utero, however, the disease has potential for serious fetal effects. Rates of in utero infection range from 17%–33%. Potential sequelae of in utero fetal infection include hydrops fetalis and fetal death. Hydrops fetalis may occur from aplastic anemia due to suppression of erythroid precursors (most common) or from myocarditis or chronic fetal hepatitis. These severe effects are most common when maternal infection occurs before 20 weeks' gestation. In most patients, however, the infection resolves spontaneously with no adverse fetal outcomes.

Answer 791

All twin gestations should have serial growth measurements every 4–6 weeks because fundal height measurements are not a reliable screening test for appropriate interval growth. Singleton and twin gestations grow at similar rates until 28–32 weeks gestation, at which point twins grow at a slower rate. Thus, twin growth curves can be used to avoid misdiagnosing a twin gestation with growth restriction on the basis of a singleton growth curve. Recommended delivery timing in uncomplicated twin gestation depends on the type of twins. Dichorionic twins should be delivered at 38 weeks gestation. Monochorionic diamniotic twin gestations should be delivered at 34–37+6 weeks gestation, and monoamniotic twin gestations should be delivered between 32 and 34 weeks. Provided the twins are at least 32 weeks gestation and the presenting twin is vertex, dichorionic and monochorionic diamniotic twin gestations can be delivered vaginally. Monoamniotic twin gestations should be delivered by cesarean section because of the high risk of cord entanglement during labor and delivery. Timing of Twin Deliveries Dichorionic 38 weeks Monochorionic 34 to 37w6d Monoamniotic 32 to 34 weeks

Answer 792

The etiology for isolated neural tube defects is typically multifactorial. Factors in the United States that increase risk include Hispanic race, obesity, pregestational diabetes, and medications that lower the amount of available folic acid. The baseline prevalence of spina bifida the United States is 4.41 per 10,000 live births, stillbirths, or terminations. The neural tube closes between 25 and 28 days after conception. This is earlier than the time at which most women realize they are pregnant and highlights the importance of initiating folic acid supplementation prior to pregnancy. Fortification of wheat flour with folic acid in the United States has led to a 19% decrease in all neural tube defects.

Answer 793

The American College of Obstetricians and Gynecologists (ACOG) defines delayed, or secondary, postpartum hemorrhage as excessive bleeding that occurs any time after 24 hours following delivery and up to 12 weeks postpartum. This occurs in approximately 1% of pregnancies. Any occurrence of delayed postpartum hemorrhage places the patient at greater risk of another hemorrhage in her next delivery. Consider the following etiologies in patients with delayed postpartum hemorrhage. Etiologies of Postpartum Hemorrhage Most Common Uterine atony (secondary to retained products of conception) Subinvolution of the placental bed Infection, especially in patients with fever and uterine tenderness More Rare Inherited or acquired bleeding disorders (such as von Willebrand disease) Pseudoaneurysm of the uterine artery, internal pudendal artery, vaginal artery, or vulvar labial artery Arteriovenous malformations Choriocarcinoma Undiagnosed carcinoma of the cervix Adenomyosis Infected intrauterine masses, such as polyps or submucosal fibroids Uterine diverticulum Resumption of menses with excessive bleeding Dehiscence of a cesarean section scar

Answer 794

Group prenatal care models are designed to improve patient education and include opportunities for social support while maintaining the risk screening and physical assessment of individual prenatal care. Studies appear to demonstrate high levels of patient satisfaction, obstetric outcomes equally efficacious as individual prenatal care, and improved outcomes for some populations. Evidence suggests patients who participate in group prenatal care have better prenatal knowledge, feel more ready for labor and delivery, are more satisfied with overall care, and initiate breastfeeding more often. In theory, the expanded visit time and opportunity for in-depth peer-to-peer personal discussion facilitates learning opportunities and social support. Prenatal educational information is reliably communicated to the patients in a manner that avoids repetition for patients and obstetricians and other obstetric care providers. Some patients appreciate the ease of long-term scheduling, avoidance of wait times, and the unique and long-term social bonds that develop within the group, sustaining patients through unforeseen outcomes and into the postpartum period. The existing literature on group prenatal care is relatively small and limited to primarily observational studies, however the research is growing. Racial and ethnic disparities persist in the prevalence of preterm birth and infant mortality, and group prenatal care may be particularly useful in addressing disparities in perinatal outcomes such as preterm birth among Black women. A meta-analysis reported similar rates of preterm birth, overall, in the individual and group prenatal care arms, and outcomes in low-income Black women suggest reduced risk of preterm birth with group care. The largest RCT also found that Black women as a group had the greatest reduction in preterm birth, with a rate of 10.0% in group care compared with 15.8% among those who received traditional prenatal care.

Answer 795

Middle cerebral artery Doppler values that are elevated indicate fetal anemia may be present. One cause of fetal anemia is alloimmunization. Severe fetal anemia can lead to fetal hydrops and ultimately death. This occurs when the mother is exposed to an antigen that is foreign to her, either from a previous pregnancy or blood transfusions. The maternal antibodies that form in response to the antigen can cross the placenta and destroy fetal red blood cells. Several antigens may cause this alloimmunization, including c, C, D, E, K, and e. Typically the critical titer is 1:8 for which middle cerebral artery screening is indicated. However, some antibodies such as Kell is titer independent. Lewis and I antigens are predominantly immunoglobulin M (IgM) and cannot cross the placenta to cause alloimmunization. If titers are present of these antibodies, the patient will require frequent evaluation of the fetus via ultrasound and MCA Dopplers. Maternal Antibodies That Can Cause Fetal Hydrops c C D E e K Bottom Line: Common antigens capable of causing alloimmunization include: C, c, D, E, K, and e.

Answer 796

Numerous studies have linked poor glucose control to poor neonatal outcomes including congenital anomalies. Hyperglycemia during organogenesis (week 5 to 8 after LMP) is suspected to be the cause. HbA1C levels near 10% is associated with a fetal anomaly rate of 20–25%. The most common malformations from hyperglycemia include: complex cardiac defects central nervous system anomalies (spina bifida and anencephaly) skeletal abnormalities (sacral agenesis) Omphaloceles are not commonly associated with hyperglycemia but are associated with aneuploidy.

Answer 797

Asthma during pregnancy is associated with an increased risk of premature delivery. Asthma affects approximately 4%–8% of pregnancies and is characterized by chronic inflammatory disease of the lungs. Poorly controlled asthma or severe asthma exacerbations can be associated with growth restriction, cesarean delivery, premature delivery, preeclampsia, and increased morbidity and mortality to the mother and fetus. One of the primary concerns during an asthma exacerbation is fetal hypoxia. Optimization of maternal oxygenation status is of paramount importance. The course of asthma during pregnancy is variable. A study by Shatz et al. showed that during pregnancy, 23% of women had improved symptoms versus 30% of women who had worsening of symptoms. Those with asthma should be monitored throughout their pregnancy using peak expiratory flow rate or forced expiratory volume in 1 second. Initial pulmonary function tests are useful when attempting to establish the diagnosis of asthma, and ideally baseline pulmonary function should be assessed early on in gestation. Patients should be counseled regarding avoidance of triggers, use of pharmacological therapies, and the importance of maintaining good control of asthmatic symptoms.

Answer 798

Clinically significant discordant fetal growth in women with multifetal gestations is most commonly defined as a 20% difference in estimated fetal weight between the larger and smaller fetus. This growth discordance is calculated by determining the difference in the estimated fetal weight between the two fetuses, divided by the weight of the larger fetus. Growth discordance may contribute to fetal or neonatal morbidity and mortality; while multifetal gestations with discordant but appropriate-for-gestational-age growth are not at increased risk, multifetal gestations with discordant growth and at least one growth-restricted fetus have been observed to be associated with a 7.7-fold increased risk of major neonatal morbidity. Bottom Line: Twenty percent is the minimum percentage for clinically significant discordant growth in multifetal gestations. While discordance alone in appropriate-for gestational-age gestation may not increase the risk of fetal or neonatal morbidity and mortality, discordance in conjunction with at least one growth-restricted fetus is associated with increased risk of major neonatal morbidity or mortality.

Answer 799

Immediate postpartum long-acting reversible contraception (LARC) methods are becoming increasingly popular. It is important to counsel patients about the following contraindications to an IUD: puerperal sepsis intrauterine infection postpartum hemorrhage Expulsion rate with immediate post-placental IUDs is estimated to be between 10%–27%, which is higher when compared with interval placement. This, however, is mitigated by the high no-show rate at the postpartum visit. Several studies have shown that patients who receive an immediate postpartum IUD are more likely to have an IUD in place than those who wait until their postpartum visit to get an IUD.

Answer 800

Hypothyroidism is defined as elevated thyroid-stimulating hormone (TSH) and decreased free thyroxine (T4) levels. Symptoms of hypothyroidism include fatigue, cold intolerance, weight gain, hair loss, and dry skin. To decrease the risks of these adverse maternal and neonatal outcomes, treatment of hypothyroidism should be initiated as soon as possible, ideally prior to conception. Risks of Untreated Hypothyroidism Maternal Fetal Spontaneous abortion Spontaneous abortion Preterm delivery Preterm delivery Placental abruption Fetal demise Preeclampsia Low birth weight Gestational hypertension Neurodevelopmental delays

Answer 801

Current available evidence suggests that marijuana use is associated with low birth weight. While some evidence states that marijuana use alone is not associated with increased risk for low birth weight, stratification of marijuana use demonstrated that at-least-weekly users were at significantly increased risk of giving birth to a neonate weighing less than 2500 g. Marijuana use in pregnancy also increases the risk for stillbirth, cognitive dysfunction, and behavioral changes. Marijuana use alone is not associated with an increased risk of preterm birth, as tobacco use is a confounding factor for preterm birth in marijuana users. Available evidence does not consistently suggest an association between prenatal marijuana use and birth defects. Marijuana Use in Pregnancy Increases risk for: Low birth weight Stillbirth Cognitive dysfunction Behavioral changes

Answer 802

For a pregnant patient with no history of thrombophilia, the greatest time of risk for venous thromboembolism is in the postpartum period. The same is true for patients with heterozygous Factor V Leiden with no personal history of venous thromboembolism, as the increased risk of thrombotic episode above the baseline pregnancy risk is estimated to be very low. There are several physiologic and anatomic changes that occur during pregnancy that increase the risk of blood clot formation. These include: hypercoagulability increased venous stasis compression of pelvic vessels by the growing uterus decreased mobility. While there may be a greater risk for thrombus formation in the third trimester compared with the first trimester, the increased risk begins in the first trimester. However, the time of greatest risk is in the postpartum period, with the highest being the first week after delivery.

Answer 803

Omphalocele is a type of abdominal wall defect in which the intestines and occasionally other organs remain outside the body after 12 weeks of gestation. The defect is the result of the persistence of the body stalk. Omphalocele and gastroschisis occur in 1 in 2,500 deliveries, and they can often be distinguished from one another on the basis of the location of the defect, with the omphalocele occurring in the midline. The mode of delivery for fetuses with omphalocele is controversial; however, vaginal delivery tends to be preferred when the herniated viscera is small and the liver is not included in the defect.

Answer 804

An easy way to understand neonatal alloimmune thrombocytopenia (NAIT) is to think about the etiology of hemolytic (Rh) disease of the fetus and newborn (HDFN). HDFN is the result of maternal alloimmunization to fetal red blood cell antigens. Similarly, NAIT is a result of maternal alloimmunization to fetal platelets. The antigen most commonly involved is HPA-1a. NAIT results in severe thrombocytopenia in the fetus (often < 20,000/μL) and can cause intracranial hemorrhage while in utero and in the neonatal period. NAIT is often diagnosed in retrospect after a child is born with severe thrombocytopenia. Unlike immune thrombocytopenic purpura, maternal platelet count is not affected in NAIT, and the pregnancy and delivery are uncomplicated. The first presenting sign in the neonate can be generalized petechiae or ecchymosis, continued bleeding after a circumcision, or in worst case scenarios, seizures from an intracranial hemorrhage. Nearly 100% of all future pregnancies between the couple will be affected. Management strategies are aimed at increasing fetal platelet counts with weekly IVIG with prednisone sometimes added to the regimen. Depending on the severity of the previously affected child, IVIG is either started at 12 or 20 weeks. Ultrasound monitoring can be done to look for signs of an intracranial hemorrhage such as intracranial hematoma or porencephalic cyst formation.

Answer 805

Initiation of transfusion therapy is indicated if the patient has abnormal vital signs or there is estimated blood loss of 1500 mL or more with ongoing bleeding. According to ACOG guidelines, massive transfusion is defined as transfusion of 10 or more units of packed red blood cells within 24 hours, 4 units of packed red blood cells within 1 hour if ongoing need of transfusion is anticipated, or replacement of the whole blood volume of the patient. When a massive transfusion protocol is needed, fixed ratios of packed red blood cells, fresh frozen plasma, and platelets should be used. The recommended initial transfusion ratio for packed red blood cells:fresh frozen plasma:platelets has been in the range of 1:1:1 and is designed to mimic replacement of whole blood. In a recent survey, more than 80% of institutions reported using the 1:1 red blood cell:plasma ratio.

Answer 806

Vitamin D levels should be maintained above 20 ng/mL to avoid problems with neonatal bone density. Women who are deficient should take 1,000–2,000 international units a day. Women who are vitamin D replete need a daily intake of 600 international units. A general prenatal vitamin typically contains 400 international units. Bottom Line: Pregnant women should have a daily intake of 600 international units of vitamin D.

Answer 807

Certain autosomal recessive diseases are more prevalent in individuals of Eastern European Jewish (Ashkenazi) descent. Individuals of Eastern European Jewish ancestry should be offered carrier screening for Tay–Sachs disease, Canavan disease, cystic fibrosis, and familial dysautonomia as part of routine obstetrical care. Other autosomal recessive conditions are also more prevalent in this population, including Gaucher disease, Fanconi anemia, Bloom syndrome, and Niemann-Pick disease type A. Screening is available for these disorders as well. If only 1 partner is of Ashkenazi Jewish descent, that individual should be screened first. If this individual is determined to be a carrier, the partner should then be screened. However, the frequency and detection rate in non-Jewish individuals is unknown for all of these disorders with the exception of Tay-Sachs disease and cystic fibrosis. Diseases increased in Ashkenazi Jewish descent Carrier Frequency Cystic fibrosis 1 in 29 Tay-Sachs 1 in 30 Familial dysautonomia 1 in 32 Canavan disease 1 in 40

Answer 808

The postpartum period is an important time for laying the groundwork for long-term maternal and fetal well-being. This process should begin during pregnancy with anticipatory guidance regarding the postpartum transition. These prenatal discussions should include postpartum contraception and long-term reproductive plans. Postpartum care should be an ongoing process and should NOT be limited to a single postpartum visit. The "fourth trimester" can be a very challenging period for postpartum women, and early contact may help reduce maternal morbidity and mortality. Patients should be contacted by a maternal care provider no later than 3 weeks postpartum to discuss ongoing needs. These conversations facilitate individualization of this process, as some patients may require closer observations and frequent office visits and others may desire to return to work after only a couple of weeks. The patient should have ongoing care as needed and a comprehensive visit no later than 12 weeks postpartum.

Answer 809

Vegetarians are at increased risk of vitamin D deficiency. The typical recommended dose for replacement is 1,000–2,000 international units. While adequate data are lacking, most experts suggest up to 4,000 international units may be considered safe in pregnancy.

Answer 810

First-line treatment of immune thrombocytopenic purpura (ITP) is glucocorticoids or IV immunoglobulin (IVIG) if steroids are contraindicated or not effective. Platelet (PLT) count starts increasing 4–14 days after initiating prednisone or dexamethasone with a maximal effect seen at 2–3 weeks after initiation of treatment. When to treat ITP? Symptomatic patient irrespective of PLT count (such as epistaxis or bruising) If PLT count is < 30,000/μL even if asymptomatic Prior to epidural or spinal anesthesia (requires PLT >70,000/μL) Prior to cesarean delivery or any surgical procedure (requires PLT >50,000/μL) Answer A: Initial response to IVIG usually occurs within 1–3 days, and a peak response usually is reached within 2–7 days. IVIG is appropriate therapy for cases of immune thrombocytopenia refractory to corticosteroids when significant adverse effects occur with corticosteroids or a more rapid platelet increase is necessary. IVIG should be given initially at 1 g/kg as a one-time dose but may be repeated if necessary. Anti-D immunoglobulin also leads to an initial response in 1–3 days. Answer B: Platelet levels should begin to increase 1–56 days after splenectomy for treatment of refractory cases of ITP. It is safe to perform splenectomy in pregnancy in the second trimester. Answer D: Platelet levels should begin to increase 7–14 days after initiating romiplostim for ITP treatment. Romiplostin is a thrombopoietin receptor agonist that can be used as a second-line drug if steroids and IVIG are contraindicated or ineffective. Answer E: Platelet levels should begin to increase 30–90 days after initiating azathioprine (immunosuppressive agent) for ITP treatment. The maximum peak in platelets is seen at 30–180 days after treatment. It is a second-line drug that is used if steroids and IVIG are contraindicated or ineffective.

Answer 811

Alpha-fetoprotein (AFP) is a glycoprotein initially produced by the yolk sac and later by the fetal GI tract and liver. Defects in the skin (neural tube defects or ventral wall defects) cause a rise in AFP level in the maternal serum.

Answer 812

Angiotensin-converting enzyme inhibitor (ACEI) use during pregnancy is associated with fetal hypotension and renal hypoperfusion. As a result the fetus is anuric. As a result of the hypoperfusion, oligohydramnios and calvarium maldevelopment may ensue. Fetal Exposure to Teratogens Drug Potential Fetal Effects ACEI Oligohydramnios Calvarium maldevelopment Danazol Androgenic effects (Virilization of female fetus) Isotretinoin Early pregnancy loss Cardiac abnormalities CNS anomalies Lithium Ebstein anomaly (Apical displacement of the tricuspid valve) Thalidomide Phocomelia

Answer 813

Postterm pregnancy is defined as gestation of 42 0/7 weeks or beyond. Postterm pregnancy is associated with the following maternal and fetal outcomes: Postterm Pregnancy Associated Outcomes Maternal Fetal Oligohydramnios Convulsions Increased perineal laceration Meconium aspiration Increased operative delivery NICU admission Increased cesarean sections Macrosomia Postpartum hemorrhage Low 5-minute APGAR Infection Postmaturity syndrome

Answer 814

Antiphospholipid antibody syndrome (APAS) is an autoimmune disorder that is characterized by clinical criteria and laboratory criteria. In order to make the diagnosis, a patient must have one from each category. Clinical criteria include a vascular thrombosis, a demise of a morphologically normal fetus after 10 weeks, 3 or more early miscarriages, or delivery before 34 weeks due to preeclampsia with severe features or eclampsia. Term deliveries that are complicated by preeclampsia without severe features do not qualify as clinical criteria and do not meet criteria to evaluate for APAS. Diagnosis of Antiphospholipid Antibody Syndrome One of the following clinical events: Arterial or venous thrombotic event ≥1 unexplained deaths of morphologically normal fetuses after the 10th week of gestation by ultrasound or direct examination of the fetus ≥1 premature births of a morphologically normal neonate < 34 weeks gestation because of eclampsia or severe preeclampsia or recognized features of placental insufficiency ≥3 unexplained consecutive spontaneous abortions < 10 weeks gestation with maternal anatomic or hormonal abnormalities and paternal and maternal chromosomal causes excluded Presence of antiphospholipid antibodies on 2 occasions, at least 12 weeks apart Lupus anticoagulant present in plasma Anticardiolipin IgM or IgG in serum or plasmia present in medium or high titer (>99th percentile) β-2 glycoprotein I IgM or IgG in serum or plasma in titer >99th percentile

Answer 815

Beta-human chorionic gonadotropin is approximately 100 mU/mL at time of missed menses, but this can have a wide normal range, with some studies citing median values between 49 and 239 mU/mL. The b-hCG level may be lower in in vitro fertilization (IVF) pregnancies when compared with spontaneous conception. The b-hCG concentration doubles every 29–53 hours during the first 30 days after implantation of a viable, intrauterine pregnancy; a slower rise is suggestive of an abnormal pregnancy (e.g., ectopic, early embryonic death, blighted ovum). While serial b-hCG can show a pregnancy is likely normal or likely abnormal (spontaneous abortion or ectopic), an isolated b-hCG level is rarely useful aside from confirming a home pregnancy test. Of the answer choices, the most one can infer base on this lab is the pregnancy is likely <5 weeks.

Answer 816

One of the leading causes of death for pregnant women in the United States is venous thromboembolism (VTE). The physiologic and anatomic changes of pregnancy put pregnant women at an increased risk. Fifty percent of VTEs occur in the postpartum period and the risk is higher during this time; therefore, measures must be taken to prevent the development of blood clots during this period. The patient in the question stem developed her VTE because of injuries sustained during trauma—a transient event—and as a result her risk of developing a VTE during pregnancy is the same as a patient without a previous history. She will not require anticoagulation therapy throughout the antepartum period of her pregnancy. However, in the postpartum period, she will need anticoagulation therapy. This can be in the form of UFH or low molecular weight heparin (LMWH) for 4–6 weeks. It can also be given in the form of warfarin for 4–6 weeks with a target INR of 2.0–3.0. The initiation of warfarin also requires overlapping therapy with UFH or LMWH until the INR is 2.0 or more for 2 days. Bottom Line: Patients with a history of a single, provoked VTE (unrelated to estrogen) as the result of a transient event do not require heparin therapy during the antepartum period.

Answer 817

Regular aerobic exercise in lactating women has been shown to improve maternal cardiovascular fitness without affecting milk production, composition, or infant growth. Women who are lactating should consider feeding their infants or expressing milk before exercising to avoid discomfort of engorged breasts. They also should ensure adequate hydration before commencing physical activity. Several reports indicate that women’s level of participation in exercise programs diminishes after childbirth, frequently leading to overweight and obesity. The postpartum period is an opportune time for obstetric care providers to recommend and reinforce a healthy lifestyle. Some women are capable of resuming physical activities within days of delivery. Pelvic floor exercises can be initiated in the immediate postpartum period. Concerns that regular physical activity during pregnancy may cause miscarriage, poor fetal growth, musculoskeletal injury, or premature delivery have not been substantiated for women with uncomplicated pregnancies. In the absence of obstetric or medical complications or contraindications, physical activity in pregnancy is safe and desirable, and pregnant women should be encouraged to continue or to initiate safe physical activities.

Answer 818

This fetus has alobar holoprosencephaly. Holoprosencephaly is a complex malformation of the brain and ranges in severity from alobar holoprosencephaly to lobar holoprosencephaly. It occurs in 1:15,000 births and is associated with aneuploidy in 20%–50% of cases, with trisomy 13 being most common. Classic features on fetal ultrasound include fused thalami, single crescent-shaped midline ventricle, absent midline structures such as the cavum septi pellucidi, corpus callosum, and falx cerebri, as well as facial abnormalities such as cyclopia, median clefts, proboscis between the eyes, and nasal agenesis. With alobar holoprosencephaly, prognosis is poor with a high intrauterine demise rate and 80% of children born alive die within 1 year of age. If this diagnosis is made, women should be offered karyotype analysis and termination of pregnancy.

Answer 819

In a high-risk population, neural tube defects can be prevented in up to 70% of cases with appropriate folic acid supplementation of 4 mg daily, beginning at least 3 months prior to pregnancy. Neural tube defects are structural defects of the central nervous system and spinal column. While inheritance is multifactorial, recurrence risk is 3% with one affected sibling. Prepregnancy folic acid supplementation with 400 mcg daily has been shown to decrease risk of neural tube defects in the general population. In patients with high risk of developing neural tube defects, 4 mg folic acid daily decreases risk of neural tube defects by 70%. Approximately 30% of neural tube defects are not preventable with folic acid. Folic acid supplementation should begin at least 1 month prior to pregnancy in low-risk populations and at least 3 months prior to pregnancy in high-risk populations and continue through at least the first 12 weeks of gestation.

Answer 820

Metoprolol is the most likely medication to reduce mortality when managing peripartum cardiomyopathy. Peripartum cardiomyopathy is a serious complication of pregnancy. The etiology is still unknown. Peripartum cardiomyopathy is defined as heart failure in the last month of pregnancy, or within the 5 months after delivery. For true peripartum cardiomyopathy, there should be no history of prior heart disease, and abnormal left ventricular systolic dysfunction should be demonstrated on echocardiogram. Management is similar to that for other causes of systolic heart failure in nonpregnant patients. Medications that help reduce the preload and afterload are helpful in avoiding pulmonary failure from edema. Left ventricular thrombi are common for ejection fractions less than 35%. These patients should be started on anticoagulation for this reason. Beta-blocking agents are critical in the management of heart failure because they have been demonstrated to reduce mortality.

Answer 821

Three millimeters is the 95th percentile for nuchal translucency measurements and generally is the accepted level for offering invasive testing. Accurate testing may be limited by the sonographer's experience and by the position of the fetus. In addition, nuchal translucency measurements vary from week to week, and abnormal nuchal measurements can quickly revert to normal, even in fetuses with Down syndrome. The outcomes associated with nuchal translucency >3 mm include: Normal outcomes in 70% to 90% Miscarriage in 2.2% to 10.6% Perinatal death in 0.5% to 15.8% Increased nuchal translucency is associated with aneuploidy, most commonly trisomy 21 (Down syndrome). It is also associated with trisomy 13 (Patau syndrome), trisomy 18 (Edward syndrome), monosomy X (Turner syndrome), and triploidy.

Answer 822

Domestic violence during pregnancy is common, with abuse rates ranging from 1% to 20% during pregnancy. Women who are abused are more likely to present late or not at all for prenatal care. Preterm delivery is increased 3–5 times in abused women, and this is not related to the severity of the abuse. Other less common sequelae of abuse include placental abruption, uterine rupture, maternal death, and fetal death.

Answer 823

Acute fatty liver of pregnancy (AFLP) is a rare disorder with an incidence of 1 in 10,000 to 1 in 15,000. Onset is typically in the third trimester, though it can arise in the second trimester or postpartum. Common symptoms include nausea, vomiting, anorexia, epigastric or right upper quadrant pain, and jaundice. Hepatic encephalopathy may also be present. Hypertension occurs in about 50% of cases. Proteinuria and low-grade fever may also be present. Impaired renal function and elevated bilirubin, elevated ammonia, low glucose, and elevated transaminase levels are common laboratory findings. Reduced production of coagulation factors by the liver can lead to disseminated intravascular coagulation. Liver biopsy is the gold standard for diagnosis of AFLP. This patient presents with jaundice; elevated bilirubin, low serum glucose, and elevated transaminase levels; and impaired renal function without hypertension, making AFLP the most likely diagnosis.

Answer 824

Oral acyclovir can reduce the duration and number of new varicella lesions formed if started within 24 hours of developing a rash. Furthermore, oral acyclovir has been shown to reduce nonspecific symptoms associated with varicella infection. Intravenous acyclovir should be used in the case of varicella pneumonia because it may decrease associated maternal morbidity and mortality. Maternal varicella-zoster immune globulin (VZIG) is appropriate for prophylaxis against potential infection following exposure to someone with a primary active infection. Ideally, it should be given within 96 hours of exposure; however, it may be efficacious if administered up to 10 days following exposure. VZIG should also be given to neonates of women who develop varicella between 5 days before and 2 days after delivery.

Answer 825

The goal of prepregnancy care is to reduce the risk of adverse health effects for the woman, fetus, and neonate by working with the patient to optimize her health, address modifiable risk factors, and provide education about healthy pregnancy. Many chronic medical conditions such as lupus have implications for pregnancy outcomes and should be optimally managed before pregnancy. Contraception and family planning are important considerations for patients with systemic lupus erythematosus (SLE), as they will need to plan pregnancies around times when the disease is quiescent. For improved pregnancy outcomes, it is recommended that the disease should be quiescent for at least 6 months prior to conception. Strong predictors of adverse maternal and obstetrical outcomes include active disease at the time of conception and history of lupus nephritis or lupus pneumonitis. Patients should also be counseled that all patients with SLE are at increased risk of developing preeclampsia, preterm birth, fetal demise, intrauterine growth restriction, and neonatal lupus.

Answer 826

Bottom Line: At 38 weeks' gestation, patients without an indication for early delivery can be managed expectantly until labor ensues or an indication for delivery arises. Well-controlled gestational diabetes alone is not an indication for delivery before 39 weeks. Suspected large-for-gestational-age fetus is not an indication for delivery prior to 39 weeks.

Answer 827

Approximately 5–10% of women with pregestational diabetes also have chronic hypertension. Long-term complications from diabetes include vasculopathies and renal disease. These predispose diabetic women to hypertension, which subsequently increases their risk for preeclampsia substantially. Hypertension, especially in the presence of nephropathy, increases the risk of preeclampsia, uteroplacental insufficiency, and stillbirth. Ideally, hypertension should be controlled before pregnancy. In nonpregnant patients, treatment is likely to include an angiotensin-converting enzyme inhibitor or an angiotensin II receptor blocker. Because of their adverse fetal effects, these medications should be discontinued before becoming pregnant and should not be used during pregnancy. Appropriate antihypertensives for use in pregnancy are listed below.

Answer 828

Adnexal masses are not uncommon in pregnancy. Most masses are benign, but there is a small risk of malignancy. The risk of torsion also exists, and that risk is greater in the first trimester before adnexa move upwards towards the abdominal cavity. Adnexal masses that do not have concerning features (e.g., persistence into the second trimester, large size, or solid components) are likely to be physiologic cysts and can be managed expectantly and often resolve during pregnancy. Expectant management is also appropriate for cysts with benign features suggestive of a follicular or corpus luteal cyst, endometrioma, or mature teratoma (dermoid cyst). The most commonly reported pathologic diagnoses are mature teratomas and paraovarian or corpus luteum cysts. MRI is the modality of choice if additional imaging is needed for better visualization of deep soft tissue structures. Elevation of CA-125 levels may occur in premenopausal women with endometriosis, early pregnancy, and pelvic inflammatory disease without evidence of malignancy. If intervention is warranted based on symptoms, laparoscopic approaches and laparotomy may be considered. Data support the relative safety and efficacy of laparoscopic management of persistent adnexal masses in the second trimester. Avoid surgery in the first trimester due to increased risk of miscarriage and in the third trimester due to increased risk of preterm labor. Continued surveillance of adnexal mass is NOT appropriate in the following findings: Patient is symptomatic with a concern for adnexal torsion Mass >10 cm in diameter even if asymptomatic Presence of solid or contain solid and cystic areas or have papillary areas or septae even if asymptomatic Presence of ascites Mass showing high color Doppler flow Nodular or fixed pelvic mass on examination, or evidence of abdominal or distant metastasis

Answer 829

The birth of the first set of octuplets in 2009 led to a widespread campaign to encourage reproductive endocrinologists to limit the number of embryos transferred during in vitro fertilization. The physician who performed the in vitro fertilization on the patient transferred 12 embryos; his medical license was subsequently revoked. The American Society of Reproductive Medicine and the Society of Assisted Reproductive Medicine jointly published a committee opinion in 2013 encouraging physicians to reasonably select the number of embryos to transfer to reduce the number of multifetal gestations. Their joint efforts have led to the first reduction in multifetal gestations since the advent of in vitro fertilization. Despite the strides made, 25% of in vitro fertilization cycles results in twin gestations. Thankfully, though, higher-order multiples are much less common. FYI Older patients are actually more likely to have a twin gestation because of the peaking follicular stimulating hormone levels around 37 years of age.

Answer 830

Hyperthyroidism is defined as a low TSH and elevated free T4. Treatment is important to reduce maternal and fetal effects such as preeclampsia, heart failure, miscarriage, preterm birth, intrauterine growth restriction, and stillbirth. The treatment for hyperthyroidism drastically changed in 2009 when the FDA issued an alert that propylthiouracil was associated with hepatotoxicity. Methimazole is not without risks either, and it is associated with esophageal or choanal atresia (embryopathy) and aplasia cutis. Thus, as ACOG weighed the risks versus benefits, the new recommendation was to use propylthiouracil during the first trimester when embryogenesis occurs, and then switch to methimazole for the second and third trimester.

Answer 831

Bottom Line: Polyhydramnios in a twin gestation is defined as a maximum vertical pocket greater than 8 cm. Amniotic fluid index is not calculated in multiple gestation pregnancies given the inability to reliably divide the amnion into four separate quadrants. Polyhydramnios and oligohydramnios are defined similarly in singleton and twin gestations. However, the maximum vertical pocket, rather than amniotic fluid index, is used the define fluid parameters. The definition of polyhydramnios in a twin gestation is a maximum vertical pocket greater than 8 cm, and oligohydramnios is defined as a maximum vertical pocket less than 2 cm. AFI is calculated by summing the deepest, unobstructed, vertical pocket of fluid, in each of the four abdominal quadrants. This is NOT used in twin gestation because it is impossible to reliably break each amnion into four even quadrants, as calculated in singleton gestations. Possible etiologies of polyhydramnios are uncontrolled maternal diabetes mellitus, fetal gastrointestinal tract atresias such as esophageal or duodenal atresias, neck masses inhibiting fetal swallowing, twin-to-twin transfusion syndrome, or unknown reasons. When twin-to-twin transfusion is ruled out because of either dichorionicity or a normal amniotic fluid volume in the other fetus, half of the cases are idiopathic in nature. In twin gestations, though, polyhydramnios should immediately prompt evaluation of the other fetus’s amniotic fluid volume, especially in cases of monochorionic twin gestations in which the pregnancy is at risk of twin-to-twin transfusion syndrome. Fetuses affected by polyhydramnios have an increased risk of intrauterine fetal demise. Thus, antenatal fetal testing should be initiated when diagnosed if the fetus is at least 32 weeks gestation.

Answer 832

Toxoplasmosis infection is caused by the intracellular parasite Toxoplasma gondii. There are four main ways a pregnant patient can become infected with T. gondii. The most common way is through undercooked meat from infected animals Consuming insect-contaminated foods Contact with insects in soil Least commonly (but the cause that receives the greatest publicity) is infection through handling cat litter that contains oocysts from infected cats. Toxoplasmosis is usually asymptomatic in immunocompetent adults and can present with just asymptomatic cervical lymphadenopathy. In pregnant women, the parasitemia can infect the placenta. If this occurs, the risk of congenital toxoplasmosis is 20%–50%, depending on the trimester of pregnancy. The chances of the fetus becoming infected increase as the gestational age increases; however, the infection is more severe when the fetus is infected earlier in gestation. Most infants with congenital toxoplasmosis are asymptomatic at birth, but upward of 90% will have hearing and vision damage later in childhood. Thus, diagnosis and treatment are essential to lower this risk. If a pregnant patient is exposed to toxoplasmosis, regardless of trimester, she should undergo serologic testing for the toxoplasmosis IgM and IgG antibodies. Contrary to other infections, IgM can remain positive from months to years after an infection. Thus, just because a patient has a positive IgM doesn’t mean she definitively has an acute infection. An IgM negative and IgG positive result would indicate a previous infection, and the fetus is not at risk of congenital toxoplasmosis. A positive IgM, with or without a positive IgG, should prompt confirmation of an acute infection by a reference laboratory because this serologic testing has a high false-negative and false-positive rate. If the infection is confirmed, spiramycin should be started. This is a macrolide antibiotic, but it is not approved for use in the United States. Thus, acquisition and treatment with the drug requires U.S. Food and Drug Administration approval. Bottom Line: The initial test for a patient exposed to toxoplasmosis during pregnancy is toxoplasmosis IgM and IgG. If IgM is positive, then a reference laboratory should be contacted to confirm the infection.

Answer 833

There is no evidence-based data to guide resumption of coitus after delivery, and practices are individualized. The earliest time at which coitus may be resumed safely after childbirth is unknown. The risks of infection and hemorrhage diminish significantly after 2 weeks. After 2 weeks, coitus may be resumed based on patient desire and comfort. The joint American College of Obstetricians and Gynecologists and American Academy of Pediatrics Guidelines for Perinatal Care state that intercourse can resume after delivery when the perineum has healed, bleeding has decreased, reliable contraception is being used, and the patient does not have discomfort with coitus. Although a common recommendation has been that sexual activity should be delayed until 6 weeks postpartum, there are no data to direct or support this statement. It likely mirrors the previous arbitrary recommendation for postpartum appointment at 6–8 weeks. With the paradigm shift to include the 12 weeks postpartum as the "fourth trimester," ACOG recommends a postpartum visit within the first 3 weeks postpartum. While postpartum contraception should be discussed throughout antenatal care with a plan prior to delivery, this 3-week postpartum appointment also provides an opportunity to once more discuss contraceptive options to help patients decide on an option appropriate for their lifestyle and reproductive plans for the future.

Answer 834

Universal screening for hemoglobinopathies at the first prenatal visit is recommended for all patients who have not previously had screening. It is also acceptable to offer screening to patients who are not yet pregnant but planning to conceive. It is estimated that about 1 in 66 people in the United States is a carrier of a hemoglobinopathy trait. The frequency of these genes varies by ethnicity, and screening previously was recommended only for certain ethnic groups. The acceptable screening methods are either hemoglobin electrophoresis or molecular genetic testing through expanded carrier screening. Solubility tests are not recommended. The hemoglobinopathies are single gene disorders. Mutations in these genes can result in thalassemias or alterations in the structure of hemoglobin. Patients who have a positive screening test should be offered genetic counseling and the other parent should also have testing performed to assess risk to the fetus. The fetal genetic makeup is determined through diagnostic testing via amniocentesis or chorionic villus sampling (CVS).

Answer 835

Twins account for approximately 2%–3% of live births in the United States. Dizygotic twins (coming from 2 fertilized eggs) are more common than monozygotic twins (arising from 1 fertilized egg). Many factors can increase a patient's chance for having a twin gestation. They include increasing maternal age, increasing parity, obesity, and being in a certain ethnic group (certain groups have an increased incidence of dizygotic twins, although the incidence of monozygotic twins remains stable among different groups). A major factor causing an increase in the incidence in dizygotic twinning in recent years is the increasing use of reproductive technology and ovulation-inducing drugs. Some of the drugs (including Clomid) cause ovulation of multiple eggs, increasing the chance of multiple fertilized eggs.

Answer 836

The timing of the comprehensive postpartum visit has typically been scheduled between 4 and 6 weeks' postpartum, which represents cultural traditions rather than evidence-based medicine. Many women return to work as soon as 10 days' postpartum and therefore may need a postpartum visit sooner. The postpartum visit should be individualized and patient centered. Patients should be contacted by a maternal care provider no later than 3 weeks' postpartum, to discuss ongoing needs. The comprehensive exam should occur no later than 12 weeks after delivery. Patients with complicated pregnancy including preterm delivery, gestational diabetes, or hypertensive disorders related to pregnancy should obtain follow-up sooner in the postpartum period than those with uncomplicated pregnancy. Those patients with chronic medical comorbidities may require coordination of care. Examples include chronic hypertension, obesity, diabetes, mood disorders, substance abuse, thyroid and/or renal disease.

Answer 837

Universal screening for thyroid disease in pregnancy is not recommended by ACOG. This is because treatment of maternal subclinical hypothyroidism has not been found to be beneficial for fetal neurodevelopment or have any improved pregnancy outcomes. Thyroid function should be tested only in indicated women (see table below). Indications for Thyroid Function Testing in Pregnancy Personal history of thyroid disease Family history of thyroid disease Type 1 diabetes mellitus Clinical suspicion of thyroid disease* *This may include a significant goiter or distinct thyroid nodules, but not mild enlargement of the thyroid The first-line screening test to assess thyroid function is a TSH level. When the TSH is abnormally high or low, follow-up measurement of free T4 can be obtained to determine if there is overt thyroid dysfunction.

Answer 838

Obesity during pregnancy is associated with increased risk of fetal birth defects, with the greatest increased risk being for neural tube defects. There is greater increased risk for fetal spina bifida specifically (odds ratio [OR] of 2.24) than all neural tube defects (OR 1.87) in pregnant patients with obesity compared with pregnant patients of normal BMI. Obesity also reduces the sensitivity of ultrasound in being able to detect fetal anomalies. Obesity is defined as a BMI of 30 or greater. Compared with pregnant patients of normal BMI, obese females are at increased risk of cardiac dysfunction, proteinuria, sleep apnea, nonalcoholic fatty liver disease, gestational diabetes, and preeclampsia. Unfortunately, obese patients also have an increased risk of stillbirth compared with their normal-weight counterparts, and the risk increases with increasing BMI. Maternal Obesity Increased risk to fetus Neural tube defects Cleft palate Cleft lip and palate Hydrocephaly Cardiovascular anomalies Septal anomalies Anorectal atresia Limb reduction anomalies Decreased risk to fetus Gastroschisis

Answer 839

Noninvasive prenatal testing with cell-free DNA has the highest detection rate for Trisomy 21 (Down syndrome). Maternal age greater than 35 is a known risk factor for fetal chromosomal abnormalities. Other factors that increase the likelihood of chromosomal abnormalities are: paternal translocation (or other chromosomal abnormalities) having a previous pregnancy with a chromosomal abnormality prenatal ultrasonographic abnormalities a screen positive test result All pregnant patients should be offered prenatal screening for fetal chromosomal abnormalities, regardless of age or risk factors. Several different screening methods have been developed and were all originally designed to detect Down syndrome. One of the first screening methods developed was the triple screen, which measures maternal serum MSAFP, hCG, and unconjugated estriol during the second trimester. The triple screen has a detection rate of 69%. By adding an inhibin A measurement to the triple screen, the quadruple screen was developed and has a detection rate of 81%. A first-trimester screen was then developed that combines measurement of the nuchal translucency, maternal serum PAPP-A, and free or total B-hCG, which has a detection rate of 82–87%. An integrated screening method that incorporates both a first-trimester screen and a quadruple screen has a detection rate of 94–96%. The newest screening method, noninvasive prenatal screening with cell-free fetal DNA from maternal serum, has been shown to have the highest detection rate of 99% for Down syndrome. The test can be used starting from 9–10 weeks of gestation. The fetal component of cell-free DNA is derived from placental trophoblasts that are released into maternal circulation from cells undergoing programmed cell death. This component is known as fetal fraction. Fetal fraction concentration can be affected by gestational age, maternal BMI, maternal medication exposure, maternal race, aneuploidy status (if present), fetal or maternal mosaicism, and singleton or multiple gestation. This test is the only screening test to identify fetal sex and chromosome aneuploidies. Uninterpretable (no-call) results are at increased risk for chromosomal abnormalities. All available options should be discussed with patients and the most appropriate screening method selected for each patient. Patients with a positive screening result should be offered diagnostic testing with either chorionic villus sampling or amniocentesis depending upon their gestational age. A patient should not have multiple screening tests performed simultaneously.

Answer 840

Advantages of insulin pump use include higher patient satisfaction, less severe hypoglycemia, and better control of hyperglycemia. However, it is associated with higher costs and risk of rapidly developing diabetic ketoacidosis following battery failure, pump malfunction or infection. Overall, there is no indication to stop using the pump during pregnancy. Studies show no significant change in outcome when patients are switched to insulin pumps; however, patients already using a pump should continue during the pregnancy.

Answer 841

Adult hemoglobins consist of 2 α-chains and either 2 β-chains (hemoglobin A), 2 γ-chains (hemoglobin F), or 2 δ-chains (hemoglobin A2). The sickle-cell disorders are caused by a substitution of thymine for adenine in the β-globin gene (resulting in valine-to-glutamic acid substitution at that codon), which leads to the production of hemoglobin S. Because one normal chromosome produces enough hemoglobin A to result in a normal phenotype (sickle-cell trait), sickle-cell disorder is thus an autosomal recessive disorder. The most common forms of sickle-cell disease are hemoglobin SS, SC, S beta-thalassemia, and S beta-zero thalassemia.

Answer 842

Hepatitis C is now routinely screened for at the first prenatal visit per ACOG and CDC since 2021 Historically, only patients with HIV, history of intravenous drug use, hemodialysis patients, patients with unexplained elevations in aminotransferase values, and anyone who received a blood transfusion before 1992, were tested for HCV in pregnancy. Prenatal Screening Routine Testing at First Prenatal Visit Complete blood count Blood type / Rh factor Urine dipstick / urinalysis Urine culture Infectious diseases (rubella, hep B/C, HIV, syphilis) Testing Based on Risk Factors* Glucose tolerance STIs (chlamydia, gonorrhea) Tuberculosis

Answer 843

Measurement at 13 weeks' gestation is the most accurate for diagnosis of aneuploidy. Nuchal translucency measurements vary from week to week, and abnormal nuchal measurements can quickly revert to normal, even in fetuses with aneuploidy. However, a cutoff at the 99th percentile of 3.5 mm is sensitive for aneuploidy regardless of gestational age from 10–14 weeks.

Answer 844

Most experts agree on the following definitions: MVP* AFI** Mild 8.0–11.9 cm 24–29.9 cm Moderate 12–15.9 cm 30–34.9 cm Severe ≥16 cm ≥35 cm *maximum vertical pocket **amniotic fluid index Most cases of polyhydramnios are mild, and the majority of mild cases are due to maternal diabetes, multiple gestation, or idiopathic factors. However, an etiology can be identified in >90% of cases of SEVERE polyhydramnios, and more than half of severe cases are due to fetal anomalies, also often associated with a genetic abnormality. TrueLearn Insight: Polyhydramnios is associated with an increased risk of various adverse pregnancy outcomes, including preterm birth, placental abruption, and fetal anomalies.

Answer 845

Laparoscopic tubal occlusion is a safe and effective contraceptive method with an estimated major complication rate of 0.1–3.5%. This complication rate does not vary significantly with type of tubal occlusion method used (electrocoagulation, mechanical, or excisional). The major complication rate of vasectomy is extremely rare. Vasectomy minor complications that include incision site infection, bleeding, hematoma or granuloma formation, or epididymitis have a reported 0.4–10% complication rate. Compared with female abdominal sterilization, vasectomy is a safer, more effective at a 0.15% annual failure rate, and less expensive option. However, it is not immediately effective, and an alternative method of contraception should be used for at least 3 months. Annual failure rates of contraceptive methods Male sterilization 0.15% Female sterilization 0.5% Levonorgestrel IUD 0.2% Copper IUD 0.8% Etonogestrel implant 0.05% Injectable 3% Oral contraceptive, patch, ring 9% Male condom 18% Fertility-based awareness 24%

Answer 846

Vasa previa is defined as fetal vessels without cord or placental coverage that are located near the cervical os. The majority of cases are associated with a low-lying placenta, and many are seen with a velamentous (membranous) cord insertion near the cervix. Some cases are associated with a succenturiate lobe, in which vessels travel between the primary and secondary lobes and cross near the cervix. Because the fetal vessels are exposed near the cervix, membrane rupture—either spontaneous or artificial—is also likely to cause damage to the fetal vessels, resulting in fetal exsanguination. Perinatal mortality is 56% in cases that are not diagnosed prenatally, whereas it is 3% in cases that are diagnosed prenatally. This rate is higher than that in any other placental abnormalities. Cesarean delivery is typically performed by 34 weeks' gestation.

Answer 847

Bottom Line: Early pregnancy screening for undiagnosed type 2 diabetes, preferably at the initiation of prenatal care, is suggested in overweight and obese women with additional risk factors, including physical inactivity. Of the choices given, physical inactivity is a risk factor that should prompt performing early glucose screening in an overweight pregnant patient. All pregnant women should be screened for gestational diabetes (GDM) with a laboratory-based screening test(s) using blood glucose levels. Screening for GDM generally is performed at 24–28 weeks of gestation. Early pregnancy screening for undiagnosed type 2 diabetes, preferably at the initiation of prenatal care, is suggested in overweight and obese women (BMI greater than 25, or 23 in Asian-Americans) with at least one of the following additional risk factors: Screening Strategy for Detecting Pregestational Diabetes or Early Gestational Diabetes Mellitus Physical inactivity First-degree relative with diabetes High-risk race or ethnicity (e.g., Black, Hispanic, Native-American, Asian-American, Pacific Islander) Have previously given birth to an infant weighing 4,000 g (approximately 9 lb) or more Previous gestational diabetes mellitus Hypertension (140/90 mm Hg or on therapy for hypertension) High-density lipoprotein cholesterol level <35 mg/dL (0.90 mmol/L), a triglyceride level >250 mg/dL (2.82 mmol/L) Women with polycystic ovarian syndrome A1C greater than or equal to 5.7%, impaired glucose tolerance, or impaired fasting glucose on previous testing Other clinical conditions associated with insulin resistance (e.g., prepregnancy BMI >40 kg/m2, acanthosis nigricans) History of cardiovascular disease

Answer 848

Thrombocytopenia is defined as platelets less than 150,000. Gestational thrombocytopenia is typically mild and is self-limited. It affects 5–11% of pregnant women. It is a diagnosis of exclusion after ruling out all other potential causes (same as immune thrombocytopenic purpura [ITP]). Platelet count is usually more than 75,000 in such cases. It is important to repeat platelet count every 3 to 4 weeks in order to intervene appropriately. If platelets continue to drop significantly, ITP is then considered the most probable diagnosis. Treatment by prednisone or IV immunoglobulin (IVIG) should be initiated when the patient has symptomatic bleeding, when platelet counts fall below 30,000, or to increase platelet counts to a level considered safe for procedures. Epidural anesthesia requires platelet count to be above 70,000 to avoid hematoma formation, which can have detrimental neurological effects. Gestational Thrombocytopenia New onset of low platelet count in pregnancy most commonly in the mid-second to third trimester Platelet count is usually more than 75,000 Patient is asymptomatic with no history of bleeding No history of thrombocytopenia outside of pregnancy Platelets return to normal 1–2 months after delivery Incidence of fetal or neonatal thrombocytopenia (NAIT) is very low in such cases (0.1–2.3%) Platelets return to normal 1–2 months after delivery

Answer 849

Intrauterine growth restriction (IUGR) is diagnosed when the estimated fetal weight or the abdominal circumference is less than the 10th percentile for gestational age. IUGR is the only indication for umbilical artery Doppler evaluation, which should be initiated at the time of the diagnosis, but not before a gestational age where delivery would be considered for perinatal benefit. Doppler measurement of the umbilical artery can detect downstream impedance to flow from the placenta, which can signify placental insufficiency. Any fetus that is measuring at < 10th percentile for estimated fetal weight should prompt further assessment, either with amniotic fluid measurement or umbilical artery Doppler studies. A full anatomy scan should be performed if not yet done, as growth restricted fetuses have a higher incidence of structural and genetic abnormalities. Optimal intervals for screening after diagnosis have not yet been established. Most growth restricted fetuses can undergo ultrasound evaluation for growth every 3–4 weeks, but not more frequently than every 2 weeks. Fetuses with IUGR are at an increased risk of intrauterine demise, neonatal morbidity and neonatal death. The risk of fetal death is approximately 1.5% in fetuses with estimated weights less than the 10th percentile, increasing to 2.5% at weights less than the 5th percentile. Growth restricted fetuses that have absent or reversed end-diastolic flow in the umbilical artery have a higher frequency of neonatal morbidity and mortality. Fetuses with IUGR are also predisposed to developing cognitive delay during childhood as well as obesity, type 2 diabetes mellitus, coronary artery disease, and stroke in adulthood. With the appropriate incorporation of umbilical artery Doppler coupled with antenatal testing, perinatal mortality can be reduced by 29%. Small fetuses with normal Dopplers provide evidence of fetal well-being, especially if the growth velocity is normal. Thus, providers are able to identify those infants at risk of adverse events in utero and act clinically.

Answer 850

Turner syndrome, or monosomy X (45X), is the most common cause of cystic hygroma findings in the second trimester. Other findings associated with Turner syndrome include: coarctation of the aorta a shield-shaped chest short stature The hygroma may give way to a webbing of the neck after birth, and the child could also be noted to have generalized lymphedema. Answer B: Edwards syndrome, or trisomy 18, would not present with cystic hygroma. Instead, the fetus would exhibit microcephaly and micrognathia, and short, overlapping digits. Answer C: Noonan syndrome is a less common etiology of cystic hygroma seen in the second trimester. It may be associated with findings including pectus excavatum, pulmonary artery stenosis, and short limbs. Answer D: Patau syndrome, or trisomy 13, would not present with cystic hygroma. Instead, the fetus would be noted to have microphthalmia, microcephaly, cardiac defects, and cleft lip and palate.

Answer 851

The incidence of placenta previa is around 1 in 300 births. Prior cesarean section is one of the strongest risk factors for placenta previa. Multi-fetal gestation is associated with an increased risk for placenta previa as there is more placental volume. Other risk factors for placenta previa include: previous placenta previa, multiparity (not nulliparity), advanced maternal age, infertility treatment, previous abortion, previous intrauterine surgical procedure, maternal smoking, cocaine use, and male fetus. Answer A: Cigarette use is associated with double the risk for placenta previa, but previous cesarean section is the strongest of these risk factors.. Answer B: Fertility treatments do increase the risk of placenta previa, but previous cesarean section is the strongest of these risk factors. Answer C: As maternal age increases the risk of placenta previa also increases, but previous cesarean section is the strongest of these risk factors.. Answer D: Multi-fetal gestation increase the risk for placenta previa, but previous cesarean section is the strongest of these risk factors..

Answer 852

Echogenic fetal bowel is associated with approximately sixfold increased risk of fetal trisomy 21. Echogenic fetal bowel is defined as bowel that is sonographically as bright as fetal bone. Echogenic bowel is also associated with fetal cytomegalovirus infection and cystic fibrosis. Follow-up ultrasound evaluation is suggested at 32 weeks’ gestation to evaluate fetal growth. Etiologies of fetal echogenic bowel and related disorders are summarized in the table below. Bowel echogenicity is not evaluable in the first trimester. Additionally, echogenic bowel is a normal finding in the third trimester and reflects normal fetal physiology since meconium is present in the colon at this time and can be echogenic.

Answer 853

Initial response to IV immunoglobulin (IVIG) usually occurs within 1–3 days, and a peak response usually is reached within 2–7 days. IVIG is appropriate therapy for cases of immune thrombocytopenia refractory to corticosteroids when significant adverse effects occur with corticosteroids or a more rapid platelet (PLT) increase is necessary. IVIG should be given initially at 1 g/kg as a one-time dose but may be repeated if necessary. Anti-D immunoglobulin also leads to an initial response in 1–3 days. When to treat ITP? Symptomatic patient irrespective of PLT count (such as epistaxis or bruising) If PLT count is less than 30,000/μL even if asymptomatic Prior to epidural or spinal anesthesia (requires PLT >70,000/μL) Prior to cesarean delivery or any surgical procedure (requires PLT >50,000/μL)

Answer 854

Congenital hydrocele, defined as serous fluid in the scrotal sac, is seen in approximately 15% of male fetuses after 27 weeks' gestation. Its etiology is unknown. Rarely, the fluid communicates between the scrotum and peritoneal cavity through a patent processus vaginalis, forming an abdominoscrotal hydrocele, which is a giant hydrocele that extends into the abdomen. It is most often physiologic and transient. Approximately 50% resolve by term gestation, and the remainder resolve within 12–18 months of life. The majority are unilateral.

Answer 855

Postnatal growth delay is an extremely common occurrence among very low birth weight infants. The fetus typically undergoes a large acceleration in growth in the second trimester. Due to the stresses of the external environment among those born prematurely, this growth acceleration is often not met in the postnatal period. While infants that are born in the second trimester are typically very low birth weight by virtue of their gestational age, very few of them are small for their actual gestational age (16%).

Answer 856

1%–12% is the estimated risk of uterine rupture in a subsequent pregnancy after having had a previous classical cesarean section. Most cesarean sections in the United States are performed via a low-transverse uterine incision. There are certain circumstances, most commonly extreme prematurity, that require the surgeon to make a vertical incision on the uterus, called a classical incision. Patients must be counseled properly on their risk of uterine rupture after having had a classical cesarean section if they are considering a vaginal delivery for a subsequent pregnancy. Generally, patients with a prior classical incision are not candidates for trial of labor after cesarean section. Answer A: 0.7–0.9% is the risk of rupture after 1 low-transverse cesarean section. Answer B: 0.9–1.8% is the risk of rupture after 2 previous low-transverse cesarean sections. Answer D: 2% is the risk of rupture after a low-vertical cesarean section. Answer E: 32% is the risk of rupture after a previous rupture of a vertical uterine incision. Bottom Line: According to ACOG guidelines, patients with a prior classical cesarean section are not candidates for trial of labor after cesarean delivery. Patients must be properly counseled on this issue.

Answer 857

Anti-D immune globulin is routinely administered to reduce the risk of Rh alloimmunization in susceptible individuals. It is created by cold alcohol fractionation performed on plasma donated by individuals with high-titer anti-D immune globulin G antibodies. The typical dose of 300 mcg may prevent alloimmunization against exposure of up to 30 mL of fetal whole blood.

Answer 858

Angiotensin-converting enzyme (ACE) inhibitors such as captopril and enalapril are well-known teratogens in pregnancy, classified as Category D. When used in pregnancy, they are known to disrupt the fetal renin-angiotensinogen system, resulting in renin-angiotensin-aldosterone system (RAAS) inhibitor fetopathy (oligohydramnios, pulmonary hypoplasia, and renal disease). Thrombosis and blinding retinopathy have also been reported. In lactation, these medications are considered to be relatively safe due to low levels excreted in breast milk. Limited information has shown no to minimal risk of adverse affects to breastfeeding infants. There is no information on the use of angiotensin receptor blockers (ARBs) during breastfeeding. Answer A: Bromocriptine and cabergoline are both dopamine agonists, which are used to treated hyperprolactinemia by inhibition of anterior pituitary prolactin secretion, resulting in suppressed lactation. Bromocriptine and carbergoline are contraindicated in patients wishing to breastfeed. Answer C: Lithium should be avoided in breastfeeding mothers because it crosses into breast milk. Lithium is highly lipophilic by nature and has been found to accumulate in breast milk at such high amounts that infant serum concentrations can be 10% to 50% of maternal serum concentrations. If it is absolutely necessary for the mother to be on lithium, as in she has severe bipolar disorder that is well-controlled solely on lithium monotherapy after failing other treatment regimens, then consider lithium therapy on a case-by-case basis. However, neonates need to be monitored for lithium toxicity because it may cause feeding difficulties, mild hypotonia, cyanosis, heart murmur, and ECG abnormalities. Answer D: Breastfeeding is an absolute contraindication to the use of methotrexate (MTX) in treatment of tubal ectopic pregnancy due to antineoplastic effects. MTX is excreted in breast milk in low concentrations and may accumulate in neonatal tissues. Answer E: Isotretinoin is Category X in pregnancy. Major fetal abnormalities resulting in fatal birth defects and spontaneous abortion have been reported. Specific birth defects associated with tretinoin include: facial dysmorphia, cleft palate, and eye and central nervous system abnormalities. The medication is strictly contraindicated or requires cessation of breastfeeding. It is not known if it is present in breast milk; however, it should be discontinued due to the potential for serious adverse effects in the nursing infant.

Answer 859

The incidence of twin, triplet, and higher-order multifetal gestations has dramatically increased over the past 30 years. The rate of twin gestations in 1980 was only 18.9 per 1,000 births. It increased steadily for three decades. It declined 4% from 2014–2018 to 32.6 per 1,000 births. The rates of triplet and higher-order multifetal gestations are even more staggering, increasing more than 400% since the 1980s. The trend in delaying conception to an older age is partly to blame for the increased incidence because twins are more likely to naturally occur in an older population; however, the major reason is assisted reproductive technology. The American Society for Reproductive Medicine (ASRM) has led a major effort over the past decade to decrease the multifetal gestation rate and was successful in lowering the triplet and higher-order multifetal gestation rates by 4% from 2012 to 2013. The major complication of multifetal gestations is preterm birth, which leads to neonatal morbidity and mortality.

Answer 860

Cytomegalovirus (CMV) is the most common perinatal viral infection that can lead to neonatal and childhood sequelae. It is a herpesvirus and is the leading cause of nongenetic congenital deafness. Approximately 30%–50% of reproductive-age women are susceptible to a primary CMV infection. About 40% of pregnancies complicated by a primary CMV infection will develop fetal infection. The frequency of congenital infection actually increases with gestational age, with the highest risk of congenital infection in the third trimester.

Answer 861

Ultrasounds performed at ≤ 14 weeks are most likely to correctly identify chorionicity. Ultrasound is used to determine chorionicity by evaluating the separating membrane and the number of placentas present. Correctly assigning chorionicity is vital to the counseling, surveillance, and management of twin gestations. Although all types of twin pregnancies can be more complicated and have increased surveillance compared with singleton pregnancies, monochorionic twin gestations are at a much higher risk. The risk of twin-to-twin transfusion only occurs in monochorionic gestations and can be devastating. For this reason, increased ultrasounds/NSTs/evaluations occur during these pregnancies to maintain maternal and fetal health. The twin peak sign, or lambda sign, is a wedge-shaped projection of tissue at the dividing membrane that suggests a dichorionic pregnancy.

Answer 862

Low-dose aspirin is recommended to reduce the risk of preeclampsia in women with high or moderate risk. Some evidence suggests that preeclampsia may result from an imbalance of low prostacyclin (a vasodilator) and high thromboxane A2 (a vasoconstrictor). At low doses, aspirin inhibits the production of thromboxane A2. ACOG recommends starting aspirin between 12 and 28 weeks of gestation. Evidence suggests that for maximum benefit, aspirin should be started before 16 weeks. Aspirin is indicated for those with 1 high-risk factor and should be considered for those with at least 2 moderate-risk factors.

Answer 863

The normal fetal heart rate ranges from 110–160 beats per minute (bpm). Baseline rate above 160 bpm is used to define fetal tachycardia, for which there are many attributable causes. Atrial flutter is one of the more rare causes of tachycardia but can often lead to a fetal heart rate >300 bpm due to the varying degrees of block at the AV node. It is difficult to treat in utero and often requires multiple antiarrhythmic medications to help prevent fetal hydrops. Even if no hydrops develops in utero, once delivered, most of these infants will have relapse of the atrial flutter requiring medications throughout their first few years of life. Answer B: Isolated extrasystolic beats such as preatrial contractions (PACs) are the most common arrhythmias and can usually be attributed to maternal use of caffeine or tobacco. These are rarely serious (<1% of the time) and usually resolve spontaneously. Answer C: Sinus tachycardia is most often associated with maternal tachycardia. When the mother’s heart rate is improved the fetal heart rate is improved and there are rarely long-term consequences. Answer D: Supraventricular tachycardia (SVT) is more common than atrial flutter. If intermittent SVT is present it is of minimal clinical significance, but if sustained and untreated it can lead to fetal hydrops. Answer E: Ventricular tachycardia is a rare arrhythmia most commonly due to a re-entry mechanism. Due to its rarity there are very few cases on long-term prognosis, but given its comparatively low rate of <200 bpm, there is a decreased incidence of fetal hydrops, which improves prognosis compared with other tachyarrhythmias.

Answer 864

Nausea and vomiting affects 80% of pregnant women, but the diagnosis of hyperemesis gravidarum affects only 0.5% of all live births. The reason for this low incidence is that the diagnostic criteria most commonly used for diagnosing hyperemesis gravidarum are quite stringent; nevertheless, many patients are incorrectly assigned this diagnosis. The stringent criteria require the patient to have dehydration, electrolyte abnormalities, intractable vomiting, and weight loss totaling at least 5% of the prepregnancy weight. Diagnostic Criteria for Hyperemesis Gravidarum Dehydration Electrolyte abnormalities Intractable vomiting Weight loss ≥5% of prepregnancy weight Hyperemesis gravidarum is more commonly seen in multiple gestations, molar pregnancies, gestational trophoblastic disease, and triploidy. The patient does not have to have a documented intrauterine pregnancy to receive the diagnosis of hyperemesis gravidarum.

Answer 865

Neural tube defects (NTDs) result from failure of the neuropores to close during the third to fourth week of gestation. The most common forms of NTDs are anencephaly and spina bifida. Risk factors include: family history of NTD poorly controlled diabetes seizure medications poor nutritional status or low folate stores Diagnosis is made by maternal serum alpha-fetoprotein screening and prenatal ultrasonography. Prevention with preconception folate supplementation (0.4 mg/d) significantly reduces the incidence of NTDs and is recommended for all women of reproductive age. For women with a previously affected pregnancy, a higher dose of 4 mg of folic acid is recommended.

Answer 866

Growth discordance is calculated by determining the difference in the estimated fetal weight between the two fetuses, divided by the weight of the larger fetus. In this case, % growth discordance = (2000 − 1500) / (2000) x 100 = 25% The American College of Obstetricians and Gynecologists defines discordance as greater than 20%. Several studies that examined this population have shown that multifetal gestations with discordant but appropriate-for-gestational-age growth are not at increased risk of fetal or neonatal morbidity and mortality. However, multifetal gestations with discordant growth and pregnancies with at least one growth-restricted fetus have been observed to be associated with a 7.7-fold increased risk of major neonatal morbidity. Moreover, growth-restricted twins have higher perinatal mortality and morbidity rates when compared with age-matched singletons. Thus, although there is no clear evidence of increased neonatal morbidity or mortality with twin discordance alone, fetal growth restriction (or other abnormalities, such as fetal anomalies or oligohydramnios) in the setting of discordance may be a risk factor for adverse perinatal outcomes.

Answer 867

Treatment of hyperthyroidism with propylthiouracil (PTU) is associated with hepatotoxicity. Thus, its treatment in pregnancy is generally limited to the first trimester. Untreated hyperthyroidism increases the risk of heart failure, hydrops, and risk of preeclampsia with severe features among others. Treatment generally involves PTU in the first trimester followed by methimazole in the latter trimesters due to the risk of embryopathy of methimazole and risk of hepatotoxicity (rare but can be life-threatening). Both medications work by inhibiting thyroid peroxidase. PTU also inhibits the conversion of T4 to T3. Associated Medication Risks Methimazole PTU Aplasia cutis Esophageal atresia Choanal atresia Hepatotoxicity Both drugs may cause transient leukopenia in up to 10% of patients. This can rarely lead to acute onset agranulocytosis. Patients on these medications should be instructed that if they develop fever or sore throat they should immediately stop the medication and obtain a CBC.

Answer 868

Patients who have pregnancies complicated by gestational diabetes should be screened for type 2 diabetes mellitus. The preferred method is a 75-g glucose tolerance test (2-hour GTT) in the postpartum period. The fasting component should be < 100 mg/dL, and the 2-hour level should be less than 140 mg/dL. If the fasting level is higher than 126 mg/dL or the 2-hour glucose level is higher than 200 md/dL, then the patient has diabetes. Fasting levels between 100 and 125 mg/dL or 2-hour levels between 140 and 199 mg/dL are considered insulin resistant. Although a glycosylated hemoglobin A1C level may be helpful outside of pregnancy, it is usually not helpful during pregnancy because it may be falsely lowered. This is because the increased hematopoiesis in pregnancy leads to a larger volume of new red blood cells. These new red blood cells may not be old enough to have been exposed to glucose in order to become glycosylated.

Answer 869

Shoulder dystocia is an event that all obstetricians attempt to avoid because of the significant neonatal morbidity and even mortality associated with this event. Further, a large portion of obstetrical litigation stems from neurological injuries as a result of shoulder dystocias. The most commonly accepted definition of macrosomia is an estimated fetal weight >4,500 grams, regardless of gestational age. Macrosomia significantly increases the risk of shoulder dystocia. Further, maternal diabetes is an independent risk factor for shoulder dystocia, brachial plexus injury, and clavicle fracture. The overall incidence of shoulder dystocias including all deliveries is 1.4%. This increases to 9.2–24% in those pregnancies not affected by diabetes and live birth weight of 4,500 grams. The incidence of shoulder dystocia skyrockets to 20–50% when maternal diabetes and macrosomia (>4,500 grams) is present. This high incidence is the reason ACOG states a prophylactic cesarean section to reduce the risk of shoulder dystocia can be considered in diabetic patients when the estimated fetal weight is >4,500 grams. This estimated fetal weight threshold increases to 5,000 grams if the pregnancy is not complicated by diabetes.

Answer 870

This patient's estimated due date (EDD) based on last menstrual period (LMP) differed by 15 days compared with the EDD based on the earliest sonography at 23 weeks gestation. Given this is more than 14 days, the best EDD is February 17, based on the 23-week ultrasonography. Assigning an EDD for a pregnancy can be challenging for a provider, especially if the patient doesn’t have her first ultrasonography until the second trimester. The earliest ultrasonography is the best to use when considering redating a pregnancy on the basis of ultrasonography, and once an EDD is determined after comparing the first ultrasonography with the LMP, it should not be reassigned on the basis of future ultrasonography results. The American College of Obstetricians published guidelines as below on redating a pregnancy. Prior to 14 weeks gestation, a crown-rump length (CRL) is used to measure the fetus, and after 14 weeks, a combination of the biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) is used. Before 9 weeks gestation, the ultrasonography and LMP EDDs must differ by >5 days before the pregnancy should be redated using the ultrasonography EDD. Between 9 weeks' and 13+6/7 weeks gestation, more than 7 days must exist between the LMP and ultrasonography EDDs before reassigning the gestational age. In the second trimester between 14 and 15+6/7 weeks gestation, the ultrasonography and LMP EDDs must differ by more than 7 days before the EDD should be reassigned. Between 16 and 21 +6/7 weeks gestation, the EDDs of the LMP and ultrasonography must differ by more than 10 days before reassigning the EDD. Between 22 and 27+6 weeks gestation, the LMP and ultrasonography EDDs must differ by more than 14 days before reassigning the EDD. After 28 weeks gestation, the ultrasonography and LMP must differ by more than 21 days before reassigning the EDD.

Answer 871

The absence of an embryo with a heartbeat 11 days or more after a scan that showed a gestational sac with a yolk sac is diagnostic of pregnancy failure. All of the other choices describe findings that are suspicious for, but not diagnostic of, pregnancy failure. When findings suspicious for pregnancy failure are present, a follow-up ultrasound scan is generally recommended in 7–10 days. The criteria outlined below are from the Society of Radiologists in Ultrasound and are accepted by the American College of Obstetricians and Gynecologists.

Answer 872

Postmaturity syndrome affects 10%–20% of postterm pregnancies. Postmaturity Syndrome Findings Decreased subcutaneous fat Lack of vernix Lack of lanugo Meconium staining Oligohydramnios The risk of stillbirth has been shown to increase with each week of pregnancy beyond 41 weeks and NICU admissions in postterm infants are double those of term infants.

Answer 873

Alpha-fetoprotein (AFP) is a glycoprotein synthesized by the fetus and is analogous to albumin. Fetal body wall defects uncovered by skin will permit AFP to leak into the amniotic fluid and subsequently maternal serum. Valproic acid is believed to disrupt embryonic folate metabolism, leading to an increased risk of neural tube defects (NTD) in 1%–2% of women using monotherapy and 9%–12% of women using polytherapy to manage seizure disorders. Ultrasound and AFP measurements would be most appropriate to screen for the teratogenic effects of valproic acid, which include not only neural tube defects, but also cleft lip and palate and other skeletal abnormalities.

Answer 874

Similar to generalized edema in preeclamptic patients, brain edema is also common. While neuroimaging is not part of routine eclampsia workup, it is commonly performed during workup for seizure activity. On MRI T2 signals are hyperintense because of the water (edema) in the brain, and T1 signals are hypointense. The most common location of edema in the brain after an eclamptic seizure is the occipital lobe, and the least common area is the temporal lobes. MRI Findings after Eclampsia Most Common Location of Edema Least Common Location of Edema Occipital Lobe Temporal Lobes

Answer 875

Most cesarean sections in the United States are completed via a low-transverse incision. However, there are some instances in which a classic incision may be preferred. If there is difficulty in safely accessing the lower uterine segment, a classic cesarean section may be done. Instances in which this may occur are scarring from multiple previous cesarean sections, a bladder that is densely adhered to the lower uterine segment, cervical cancer that extends to the lower uterine segment, and fibroids in the lower uterine segment. This patient has large uterine fibroids that are located in the lower uterine segment. This will cause difficulty in making a low-transverse incision, and the patient will have a greater risk of bleeding from the fibroids if they are incised. Thus, a classical incision is preferred because of the fibroids. Bottom Line: There are times when it is difficult for the obstetrician to access the lower uterine segment during a cesarean section. Thus, it is important to be familiar with indications for a classic cesarean section.

Answer 876

The diagnosis of ICP is based on symptoms of pruritus that typically include the palms and soles, as well as elevated bile acid levels. Other liver function tests such as alanine aminotransferase and aspartate aminotransferase are also frequently elevated, and other causes of liver dysfunction should be ruled out. Fetal risks of ICP include increased risk of preterm birth, meconium-stained amniotic fluid, respiratory distress syndrome, or stillbirth. Fetal risks of ICP include: increased risk of preterm birth meconium-stained amniotic fluid respiratory distress syndrome stillbirth The risk of stillbirth associated with intrahepatic cholestasis of pregnancy has been estimated at 12–30 deaths per 1,000 births. There appears to be a positive correlation between maternal levels of bile acids and the risk of stillbirth, particularly with total bile acid levels greater than 40 mmol/L or, in more recent studies, greater than 100 mmol/L. For singleton pregnancies with intrahepatic cholestasis, the prevalence of stillbirth was 1.3 per 1,000 births with total bile acids less than 40 micromole/L; 2.8 per 1,000 births with total bile acids of 40–99 micromole/L; and 34.4 per 1,000 births with total bile acids of 100 micromole/L or greater. The mechanism of fetal death in individuals with intrahepatic cholestasis of pregnancy has been hypothesized in some cases to be related to sudden fetal cardiac arrhythmia, a phenomenon that would not be expected to be predicted by traditional methods of antenatal fetal surveillance and, indeed, there are reports of stillbirths quite proximal to a normal test result.

Answer 877

The American College of Obstetricians and Gynecologists (ACOG) recommends waiting 4–6 weeks after delivery to start estrogen-containing contraception, such as combined oral contraceptives, because of estrogen's effects on milk supply and the increased risk of venous thromboembolism. Estrogen has been shown to decrease both the quality and quantity of human milk production. In addition, a patient’s risk of forming a blood clot is greatest in the postpartum period, and estrogen increases the risk of blood clots. Progestin-containing contraceptives can be started immediately postpartum, even though most package inserts recommend waiting 6 weeks after delivery to start the contraceptive. A very good resource regarding appropriate choices of contraceptive options is the United States Medical Eligibility Criteria for Contraceptive Use published by the Centers for Disease Control and Prevention. According to this document, estrogen-containing contraception may be started 4 weeks after delivery, as this category receives a designation of 2, defined as “a condition for which the advantages of using the method generally outweigh the theoretical or proven risk.”

Answer 878

Severe range hypertension places the patient at an increased risk of stroke and therefore necessitates immediate management. Severe hypertension should be initially managed by IV hydralazine, IV labetalol, or oral immediate-release nifedipine. While IV medications are generally preferred, oral nifedipine can be utilized when IV access is not functioning or available. None of these medications requires maternal continuous cardiac monitoring. Pulse monitoring is warranted which can be accomplished with a simple pulse oximetry monitor (especially for hydralazine and nifedipine which can be associated with reflex tachycardia). Of note, labetalol, while less commonly associated with tachycardia, should be used with caution in women with pre-existing myocardial disease, decompensated cardiac function, heart block, or bradycardia.

Answer 879

Epulis of pregnancy (otherwise known as granuloma gravidarum, pyogenic granuloma, or epulis gravidarum) occurs in a small number of pregnancies, most commonly in the third trimester. It is a highly vascular, hyperplastic, sometimes pedunculated lesion often up to 2 cm in size, usually in the anterior gingiva. Epulis of pregnancy results from vascular swelling of the gums, usually a heightened inflammatory response from oral pathogens. It is treated with proper dental hygiene and avoidance of trauma, as it will typically regress following delivery. It is not associated with permanent changes in the gum line or an increased risk of oral cancer. Pregnancy may lead to dental caries or increased tooth decay due to increased exposure to gastric acid from vomiting.

Answer 880

Poorly controlled Graves disease is associated with maternal heart failure and severe preeclampsia. Treatment with thioamide medications is warranted. Use of methimazole in the first trimester is associated with aplasia cutis. Therefore, propylthiouracil is recommended in the first trimester followed by methimazole for the rest of the pregnancy, as propylthiouracil carries a risk of hepatotoxicity. Methimazole works through the inhibition of thyroid peroxidase, preventing the synthesis of thyroid hormone. Aplasia cutis is a congenital syndrome characterized by the absence of skin on various areas of the body. Answer A: Methimazole does not prevent the absorption of iodine. Answer B: Propylthiouracil inhibits the conversion of T4 to T3.

Answer 881

Hemolytic disease of the fetus and newborn (HDFN) can occur earlier and be more severe with Kell sensitization than in cases of alloimmunization with other antibodies. This is because Kell antibodies cross the placenta earlier in pregnancy. Kell antibodies cause fetal hemolysis and also suppress fetal red cell production, causing earlier and more severe fetal anemia. After a positive antibody screen, paternal Kell antigen status should be assessed. If he is negative for Kell antigen, no further workup or monitoring of the pregnancy is necessary. However, if he is positive, additional workup is needed. Pregnancies affected by alloimmunization with anti-Kell antibodies are managed differently than pregnancies affected by other antibodies. Antibody titers are not a reliable means of determining when to initiate middle cerebral artery (MCA) Dopplers to evaluate for fetal anemia because anti-Kell titers correlate poorly with the risk of severe HDFN. Therefore, some recommend initiating MCA Dopplers at a lower critical titer threshold, and others recommend forgoing titers and initiating monitoring MCA Dopplers on all Kell-sensitized patients. Bottom Line: In Kell-sensitized patients, middle cerebral artery (MCA) Doppler studies correlate well with fetal status and are used for fetal anemia screening. TrueLearn Insight: Remember "Kell Kills, Duffy Dies, and Lewis Lives" – The Duffy and Kell antigens can cause significant hemolysis, while the Lewy antigen leads to a mild hemolysis that is not usually fatal.

Answer 882

Untreated hyperthyroidism can lead to spontaneous abortion and hydrops. Hyperthyroidism affects 0.2% of pregnancies and is diagnosed by having low thyroid-stimulating hormone (TSH) and elevated free T4 levels. Treatment of hyperthyroidism should start upon diagnosis and varies by trimester. Treatment options in pregnancy include propylthiouracil (PTU) and methimazole. PTU is linked to hepatotoxicity, and methimazole is linked to aplasia cutis and esophageal/choanal atresia. Due to these warnings, your patient should initially be treated with PTU in the first trimester and then switch to methimazole beginning in the second trimester.

Answer 883

Women who suffer third- or fourth-degree perineal trauma were 270% more likely to report dyspareunia at 3 months postpartum than women who delivered over an intact perineum. Of the choices listed, this is the patient's greatest risk factor for dyspareunia at this time. Postpartum dyspareunia is common and can be a significant source of difficulty in the months after delivery. In many cases, it can be due to a combination of medical and psychosocial factors. The greatest risk factors that occur at the time of delivery are episiotomy, operative vaginal delivery, and extent of perineal trauma. It is an underdetected problem and deserves more attention. Answer A: Dyspareunia in the postpartum period has been 2 to 4 times higher in lactating women than in their nonlactating counterparts. This is believed to be due to low estrogen levels. Similar to lactation, there is an association between progestogen-only pills for contraception and postpartum dyspareunia. Answer B: Episiotomy has been proven to cause more dyspareunia than spontaneous perineal tears. It is an important risk factor for short-term sexual dysfunction; however, there is little evidence to support a possible long-term effect, especially if other complications to episiotomy occurred later, such as infection or poor wound healing. Answer C: At 6 months postpartum, the use of vacuum extraction or forceps was significantly associated with dyspareunia (odds ratio, 2.5; 95% confidence interval, 1.3–4.8). Answer E: The risk of postpartum dyspareunia after vaginal delivery is not higher with the first child compared with subsequent children. Bottom Line: Women who suffer third- or fourth-degree perineal trauma were 270% more likely to report dyspareunia at 3 months postpartum than women who delivered over an intact perineum.

Answer 884

Currently, ACOG recommends controlling postoperative pain with scheduled acetaminophen and an NSAID, then using as-needed oxycodone. Patients should be counselled that all opioids appear in the breast milk and increase the risk of neonatal sedation and toxicity, and that neonatal deaths also have been reported. The risk of opioid-related central nervous system (CNS) depression in a breastfed baby is 2–3%. This risk appears to worsen after 4 days; therefore, ACOG currently recommends that opioids be limited to 4 days postpartum.

Answer 885

Fetal–neonatal alloimmune thrombocytopenia (NAIT) can be considered the platelet equivalent of hemolytic (Rh) disease of the newborn. Unlike red cell alloimmunization however, fetal–neonatal alloimmune thrombocytopenia can affect a first pregnancy. It occurs as a result of maternal alloimmunization to fetal platelet antigens with transplacental transfer of platelet-specific antibody and subsequent platelet destruction. The antigen most commonly involved is HPA-1a. NAIT is not routinely screened for because of the rarity of this condition (1 in 1,000 live births), and it most commonly is diagnosed in retrospect after a newborn is found to have severe thrombocytopenia. Presenting symptoms can be bruising on the presenting fetal part, continued oozing after a circumcision, or neonatal seizures from an intracranial hemorrhage which is the most serious complication. Assuming the same paternity, nearly 100% of all future pregnancies will be affected. The management of pregnancies affected by NAIT depends on the severity of the previous child’s presenting condition and platelet count. The mainstay of treatment is raising the fetal platelet level, and this is done with weekly IVIG. Prednisone is sometimes added to this regimen. This is initiated at either 12 or 20 weeks’ gestation depending on the severity of the previous NAIT. Ultrasonography monitoring can be done to look for signs of an intracranial hemorrhage, such as hematoma or porencephalic cyst formation. NAIT has no maternal impact, and the maternal platelet count is almost always normal. If it is low, other etiologies for maternal thrombocytopenia need to be explored. Bottom Line: Maternal platelet counts are almost always normal in fetuses/newborns affected by neonatal alloimmune thrombocytopenia (NAIT). When maternal thrombocytopenia is present, it is from a source other than NAIT, and other etiologies for maternal thrombocytopenia need to be explored. TrueLearn Insight: Fetal–neonatal alloimmune thrombocytopenia should be suspected in cases of otherwise unexplained fetal or neonatal thrombocytopenia, hemorrhage, or ultrasonographic findings consistent with intracranial bleeding.

Answer 886

The first-trimester screen is a 2-part screening test, which involves maternal serum labs and ultrasonography to measure nuchal translucency. The first-trimester screen has an 82%–87% detection rate for trisomy 21 (Down syndrome.) The maternal labs for a first-trimester screen are PAPP-A and free or total β-hCG. Aneuploidy screening or diagnostic testing should be discussed and offered to all women early in pregnancy, ideally at the first prenatal visit. The choice of whether to perform screening or diagnostic testing for aneuploidy depends on the woman’s goals and values. The incidence of fetal aneuploidy increases as a woman ages but can affect any woman regardless of age and is not related to race or ethnicity.

Answer 887

This patient has an abnormal nuchal translucency. Patients with nuchal translucency of 3.0 mm or greater should be offered diagnostic testing or cell-free fetal DNA screening if they choose to avoid an invasive procedure. This patient would like diagnostic testing, so cell-free fetal DNA screening is not an option. At this gestational age, chorionic villus sampling (CVS) is recommended. This is the modality of invasive genetic testing that is immediately available to the patient. It is typically performed at 10 to 14 weeks' gestation. The procedure is performed under direct ultrasound guidance and collects chorionic villi, which consist of outer syncytiotrophoblast cells, a middle layer of cytotrophoblast cells, and an inner mesenchymal cell core. Karyotype is available within 24–48 hours. A systematic review of 16 cohort studies on procedure-related complications of CVS calculated pregnancy loss rates of 0.7% within 14 days of a transabdominal CVS procedure, 1.3% within 30 days, and 2% for loss anytime during pregnancy, which approaches risks similar to those of amniocentesis. According to the latest practice bulletin, positive aneuploidy screening results (ultrasonography or serum analyte) may be followed by cell-free fetal DNA screening. It is important to remember that cell-free fetal DNA screening is NOT a diagnostic test but is in fact a parallel screening method, and it may further delay definitive diagnosis. The practice bulletin also states that parallel or simultaneous screening methods are not cost-effective and should not be offered (of course, with the caveat of cell-free fetal DNA screening, as noted above, in those who would like to avoid invasive procedures). In any case, the question states that the patient would like diagnostic testing; therefore, cell-free fetal DNA is not an option in this scenario. Answer A: The patient should be offered immediate invasive testing. Amniocentesis cannot be performed for another 4 weeks.

Answer 888

The nuchal translucency refers to the fluid-filled space measured on the dorsal aspect of the fetal neck. An enlarged nuchal translucency (often defined as 3.0 mm or more or above the 99th percentile for the crown–rump length) is independently associated with fetal aneuploidy and structural malformations. Typically performed when the crown–rump length measures between 38–45 mm and 84 mm (generally between 10 0/7 weeks and 13 6/7 weeks of gestation), first-trimester screening includes a nuchal translucency measurement, serum free β-hCG, or total human chorionic gonadotropin (hCG) along with pregnancy-associated plasma protein A analyte levels. The finding of an increased nuchal translucency extending along the length of the fetus is associated with a 50% likelihood of fetal aneuploidy (most commonly Down syndrome, 45,X, and trisomy 18). Of the remaining euploid fetuses, one-half will have a major structural malformation, such as congenital heart defects, diaphragmatic hernia, or skeletal dysplasia, or other genetic syndromes. Less than 20% of pregnancies will result in a healthy live-born infant at term. Patients with an enlarged nuchal translucency or cystic hygroma and normal fetal karyotype should be offered an anatomic evaluation in the second trimester, fetal cardiac ultrasonography, and further counseling regarding the potential for genetic syndromes not detected by aneuploidy screening.

Answer 889

Demise of one twin but survival of the co-twin is not an uncommon occurrence, especially in the first trimester. Commonly referred to as a “vanishing twin,” this term refers to a twin gestation that is initially identified during the first trimester but one of the fetuses “vanishes” and only a singleton gestation persists. After 14 weeks' gestation, intrauterine demise of one twin can cause detrimental sequelae in the surviving twin. The single most important prognostic factor for the other twin is the chorionicity of the twin gestation. A surviving monochorionic twin has a higher risk of experiencing a neurological injury or death than a dichorionic twin because of shared placental anastomoses between the monochorionic twins. Death of one twin can lead to immediate hypotension in the other twin, causing neurological injury or death. A surviving monochorionic twin has an 18% risk of a neurological abnormality if its co-twin dies in utero after 14 weeks' gestation. In contrast, there is only a 1% risk of neurological injury to a surviving dichorionic co-twin if the other fetus dies in utero after 14 weeks' gestation.

Answer 890

Kallmann syndrome is hypothalamic-hypogonadism associated with anosmia that has been associated with several gene mutations. All of the remaining above syndromes are imprinting disorders. Imprinting disorders occur when a maternal or paternal gene is silenced. A gene may be inherited in a transcriptionally silent state, meaning there is no mutation, but the gene is silent because of epigenetic changes. These epigenetic changes work through methylation of the gene, which silences it. The phenotype depends on the gene location and whether the silence is of maternal or paternal origin. Bottom Line: Kallmann syndrome is hypothalamic-hypogonadism associated with anosmia that has been associated with several gene mutations. Prader–Willi, Beckwith–Wiedemann, Russell–Silver, and Angelman syndromes are all disorders of imprinting. Imprinting acts through epigenetic modifications and is not genotypic change.

Answer 891

Valproic acid is associated with an increased risk of neural tube defects (NTDs); as a result, women who must be on this medication need to take 4 mg of folic acid each day. The effects of angiotensin-converting enzyme (ACE) inhibitors and tetracyclines are seen in the second and third trimesters, whereas the risk with warfarin is greatest at 6–9 weeks. Answer A: Doxycycline can lead to discoloration of teeth and enamel hypoplasia. Answer B: Lisinopril is associated with an increased risk of renal dysgenesis. Answer C: Lithium carries an increased risk of Ebstein cardiac anomaly. Answer E: Warfarin is associated with an increased risk of nasal hypoplasia, stippled epiphyses, and growth restriction.

Answer 892

Approximately 10% of patients who are heterozygous for factor V Leiden mutation with a personal history of VTE go on to develop a VTE during pregnancy or in the postpartum period. Those without a personal history of VTE have a 0.5%–1.2% risk of developing a VTE during pregnancy. Factor V Leiden mutation is the most common of the thrombophilias, affecting 3%–15% of the population depending on race, with White Europeans being at highest risk and the risk being virtually absent in Asians and Black Africans. Universal screening is not recommended. Chemical prophylaxis is indicated in the postpartum period for this patient and should be strongly considered for antepartum management as well. Bottom Line: Factor V Leiden is the most common of the inherited thrombophilias. Antithrombin III deficiency is the most thrombogenic of the thrombophilias among pregnant patients.

Answer 893

The relative infant dose, defined as the weight-adjusted maximum percentage of maternal dose in milligrams per kilogram (assuming that the maternal dosage is a standard therapeutic dose), is the measure most often used to assess drug safety during lactation. A relative infant dose greater than 10% of the maternal dose is generally concerning and indicates a potential risk of neonatal central nervous system (CNS) depression. Pain is the most common problem reported by patients in the early postpartum period. Pain may interfere with a woman's ability to care for herself and her newborn infant. Additionally, untreated pain is associated with a risk of greater opioid use, postpartum depression, and developing persistent pain. One in 300 opioid-naive patients exposed to opioids after cesarean birth will become persistent users of opioids. In the United States, 81% of women breastfeed; providers should be aware of drug effects for both mother and infant in order to thoroughly counsel patients regarding potential risks of prescribed opioid analgesics, specifically, the risk of CNS depression in the woman and the breastfed infant. Factors that affect drug transfer into breast milk include: Lipophilic nature of the drug Degree to which the drug binds to protein Bioavailability of the drug pKa (acidity) and milk pH Molecular weight of the drug Amount of breast milk consumed by infant Timing of medication administration relative to breastfeeding episodes Opioids are lipophilic, have a low molecular weight, and are generally weak bases, which are all properties that facilitate transfer into breast milk.

Answer 894

This patient has a complete placenta previa. Placenta previa is a disorder of abnormal placentation in which the placenta implants in the lower uterine segment and either completely (complete previa) or partially (marginal previa) covers the internal cervical os. Risk factors include prior cesarean delivery, prior placenta previa, in vitro fertilization, advanced maternal age, multiparty, and smoking. The majority (>90%) of cases diagnosed in the second trimester resolve by the time of delivery, affecting about 0.5% of pregnancies at term. Because the majority resolve by the time of delivery, a repeat ultrasonography should be performed at 32 weeks' gestation to assess placental location. If unresolved by the third trimester, pregnancies complicated by placenta previa are at risk for vaginal bleeding secondary to contractions, development of the lower uterine segment, and cervical effacement. Bleeding can also be triggered by intercourse or digital vaginal examination. If the previa is unresolved in the third trimester, delivery should be accomplished by cesarean section at 37 weeks' gestation to avoid labor and subsequent bleeding.

Answer 895

The most common presenting symptom in intrahepatic cholestasis of pregnancy (ICP) is pruritis. The etiology is poorly understood. Pruritis is common and affects 23% of pregnant women. The most frequent causes of pruritis in pregnancy are atopic eruption of pregnancy, polymorphic eruption of pregnancy, pemphigoid gestations, and ICP. In ICP, women typically present with generalized pruritis that predominantly affects the palms and soles and is worse at night. A rash suggests another etiology; however, patients may present with excoriations. Lab evaluation includes bile acids and liver transaminases. Bile acids take up to two weeks to return, thus the diagnosis can made with clinical criteria. A total serum bile acid level of > 10 μmol/L is diagnostic of ICP. Increases in transaminases can occur but are not necessary for diagnosis and may suggest another etiology such as a hepatobiliary condition. While pruritis can be extremely bothersome for patients, ICP poses little maternal risk. In contrast, risks to the fetus include preterm delivery, meconium-stained amniotic fluid, and stillbirth. The incidence of stillbirth after 37 weeks attributable to ICP is estimated to be 1.2%. This risk increases 2.5 fold in women with bile acids > 40 μmol/L. Ursodeoxycholic acid (UDCA) is the first-line treatment for ICP. UDCA can improve maternal symptoms and lab abnormalities; however, it is unknown if it improves perinatal outcomes. Pruritis can improve in 1–2 weeks, and biochemical improvement can be seen in 3–4 weeks. Antihistamines and topical antipruritics are of limited use. Due to risk of stillbirth, delivery is recommended at 36 0/7 weeks in patients with bile acids > 100 μmol/L. Delivery timing otherwise is individualized between 36 weeks and 39 0/7 weeks. If bile acids are 40–100 μmol/L, it is reasonable to consider delivery on the earlier end and the later end for patients with bile acids < 40 μmol/L. For those diagnosed based on clinical criteria, preterm delivery is not recommended. Antenatal fetal surveillance is recommended to begin at a gestational age at which delivery would be performed if abnormal fetal testing indicated delivery. Antenatal steroids are recommended when delivery occurs prior to 37 0/7 weeks. ICP is self-limited and resolves after delivery; however, it can be a sign of underlying hepatic disease. If pruritis or symptoms of hepatobiliary disease persist more than a few days following delivery, liver function tests should be repeated. If abnormal, the patient should be referred to a liver specialist to exclude another underlying condition.

Answer 896

Antithrombin III is a rare deficiency, but it is the most thrombogenic of the thrombophilias. Antithrombin functions as a natural anticoagulant by inactivating thrombin and coagulation factors IXa, Xa, XIa, and XIIa. Bottom Line: Antithrombin III deficiency is the most thrombogenic of all the thrombophilias, with a thrombosis risk of 11%–40% per pregnancy. Given this risk, most recommend that these patients be treated with heparin throughout pregnancy, regardless of whether they have had a thrombotic event in the past.

Answer 897

Subclinical hypothyroidism is a diagnosis based on laboratory findings, defined as an increased TSH level with normal free T4 level. Nearly 5% of pregnant women would fulfill this diagnosis if universal thyroid screening was completed in pregnancy. Universal screening was in vogue for a short time in the late 1990s after a couple of observational studies found offspring of women with subclinical hypothyroidism had neurodevelopmental delays; however, a well-designed, randomized, controlled trial compared treatment versus no treatment in pregnant women with subclinical hypothyroidism and found no difference in neurodevelopmental milestones between the 2 groups. Therefore, the American College of Obstetricians and Gynecologists recommends against universal screening for thyroid disorders in pregnancy. Further, a patient with subclinical hypothyroidism should not receive treatment.

Answer 898

Mild pulmonary stenosis is an example of a low risk maternal cardiac lesion. The World Health Organization (WHO) has classified maternal cardiac lesions by risk in pregnancy (classes I–IV). Class I confers no detectable risk of maternal mortality. Class II confers a small increased risk of maternal mortality or a moderate increase in morbidity. Class III confers a significantly increased risk of maternal mortality or severe morbidity. Class IV confers an extremely high risk of maternal mortality or severe morbidity and pregnancy is contraindicated. Bottom Line: Maternal cardiac lesions that are considered WHO Class I (low risk) include: uncomplicated, small, or mild pulmonary stenosis, patent ductus arteriosus, mitral valve prolapse; successfully repaired simple lesions (atrial or ventricular septal defects, patent ductus arteriosus, anomalous pulmonary venous drainage); and isolated atrial or ventricular ectopic beats.

Answer 899

Peripartum cardiomyopathy is a potential serious complication of pregnancy. The etiology is still unknown. For true peripartum cardiomyopathy, there should be no history of heart disease. There should be no preeclampsia during the pregnancy, and abnormal left ventricular systolic dysfunction should be documented. All other causes of heart disease should be ruled out. The diagnosis of peripartum cardiomyopathy is a diagnosis of exclusion. The diagnostic criteria are as follows: Development of cardiac failure in the last month of pregnancy or within the last 5 months after delivery Absence of an identifiable cause for cardiac failure No preexisting heart condition prior to last month of pregnancy Left ventricular systolic dysfunction on echocardiogram

Answer 900

There is a genetic contribution to neural tube defects (NTDs) as can be seen in the association between family history and increased NTD risk. The increased NTD risk for relatives of an affected individual has been well documented, and parents who have had one child with an NTD are at significantly increased risk of having another child with the same or a similar defect. Women with a prior child affected with a neural tube defect are at increased risk for recurrence in a subsequent pregnancy. Compared with a baseline risk of approximately 0.04 percent in the United States, the risk of having a fetus with a neural tube defect is approximately 3.2 percent when there is an affected sibling. With two affected siblings, the risk is 10%.

Answer 901

Decisions regarding the timing of delivery in pregnancies complicated by pregestational diabetes depend on weighing the risk of prematurity against the risk of fetal demise and maternal complications. Indications for early delivery include: vasculopathy nephropathy difficult glucose control history of stillbirth If diabetes is well controlled and there are no medical complications, pregnancy can advance up to 39 weeks and 6 days. Expectant management beyond 40 weeks is generally not recommended. Delivery Considerations in Pregnancies Complicated by Pregestational Diabetes If estimated fetal weight is 4,500 g or greater, consider cesarean delivery Without vascular complications and with well-controlled blood glucose levels, deliver at 39 0/7 weeks to 39 6/7 weeks of gestation In women with vascular complications or poorly controlled blood glucose, consider delivery at 36 0/7 weeks to 38 6/7 weeks of gestation, and in rare cases, even earlier

Answer 902

Among women undergoing in vitro fertilization, the rates of singleton, twin, and triplets-or-more pregnancies were 61.7%, 28.5%, and 3.1%, respectively. Multi-fetal gestations are much lower in spontaneous pregnancies. While some families may find an IVF twin pregnancy to be desirable, the goal of IVF should always be a singleton pregnancy. However, with many patients desiring as few cycles as possible due to lack of insurance coverage or other factors, there is often pressure to implant more than one embryo. The most effective method of avoiding high-order multiple pregnancy is single embryo transfer. IVF Pregnancy Rates Singleton 61.7% Twins 28.5% Triplets or more 3.1% Answer A: Adnexal torsion may be a complication of the egg retrieval portion of the in vitro fertilization procedure as the ovary is enlarged with follicles, but it is not the most common complication. Answer B: Women who conceive after in vitro fertilization have been observed to have an increased risk of venous thromboembolism during pregnancy, with an increased risk of up to 3/10,000 with a baseline risk of 0.4/10,000. However, this is not the most common complication of in vitro pregnancy. Answer D: While the use of fertility drugs has been associated with ovarian cancer, infertility is an important risk factor for ovarian cancer. Infertility treatment does not independently increase the risk for ovarian cancer. Overall, in vitro fertilization may lower the risk of ovarian cancer based on increased rates of pregnancy. Answer E: Clinically significant ovarian hyperstimulation syndrome occurs in 0.1%–0.2% of all IVF cycles. While an important adverse effect to be aware of, it is not the most common complication.

Answer 903

Antiphospholipid antibodies are a diverse group that share specificity for binding to negatively charged phospholipids on cell surfaces. This syndrome is associated with several medical complications. The most common and serious complication is venous and arterial thrombosis. This risk increases significantly during pregnancy. Experts recommend prophylaxis during pregnancy and 6 weeks postpartum. Antiphospholipid syndrome also is associated with several obstetric complications including: fetal loss preeclampsia intrauterine growth restriction placental insufficiency preterm delivery A meta-analysis that evaluated heparin and aspirin versus aspirin alone found an increase in live births in the heparin and aspirin group.

Answer 904

Pregnant women chronically infected with hepatitis C virus (HCV) can have uneventful pregnancies; however, there are some adverse maternal outcomes to watch for. Pregnant women with asymptomatic chronic hepatitis C have a 20-fold increased incidence of cholestasis. Several studies have shown improved serum aminotransferase concentrations during pregnancy. One study observed declining serum alanine aminotransferase levels despite rising HCV RNA titers during the third trimester. Studies have had conflicting results regarding the effect of pregnancy on histologic progression in women with chronic HCV, with some showing histologic deterioration, whereas others showed improvement in long-term progression of fibrosis. Pregnant women who are chronically infected with HCV are eligible for either vaginal or cesarean deliveries as indicated by routine obstetric management.

Answer 905

With the advent of rhesus immune globulin, red cell alloimmunization in pregnancy has become a rare entity. Improved ultrasonography and genetic technologies have changed contemporary management of sensitized patients. The first step in managing a patient with a previous hydropic fetus is to look for causes that increase the risk in a subsequent pregnancy, such as alloimmunization. Given maternal Rh-negative status and positive titers, there is a high likelihood that the cause of hydrops in her previous pregnancy was secondary to Rh D alloimmunization. The first step in management of this pregnancy is to obtain the paternal Rh status; if the father is the same father from the alloimmunized pregnancy, we can assume he is Rh positive and that this pregnancy also has a risk of alloimmunization and subsequent fetal anemia. If paternity is different, and he is Rh negative, then no further testing is indicated. If he is Rh positive, then zygosity must be assessed. If paternal status is heterozygous or unknown for Rh type, then an amniocentesis is recommended to confirm the fetal Rh status.

Answer 906

Warfarin is an anticoagulant commonly used to treat deep venous thrombosis or pulmonary embolism when the patient is stable for outpatient therapy. It is not recommended for use during pregnancy because it readily crosses the placenta and can cause a number of teratogenic effects. If the fetus is exposed around 6 to 12 weeks' gestation, a phenomenon called warfarin embryopathy can result. This includes nasal and midline facial hypoplasia and stippling of the vertebral and femoral epiphyses, which are rings noted near the epiphyseal plates on ultrasonography. If a patient requires anticoagulation during pregnancy, unfractionated or low-molecular-weight heparin can be used. Answer A: Lithium is associated with Ebstein anomaly, which is a downward displacement of the tricuspid valve. Answer B: Methamphetamine has been associated with symmetrical fetal growth restriction. Answer C: First-trimester exposure is associated with spontaneous abortion and with microtia and anotia. Answer D: Exposure to thalidomide is associated with limb abnormalities.

Answer 907

Folic acid 4 mg daily is recommended in patients who are taking antiseizure medication to reduce the risk of neural tube defects. A deficiency in folate can lead to the development of neural tube defects. It is recommended that women at increased risk for neural tube defects receive an increased daily amount of folic acid. This dose is higher than the recommended daily dose of 400 mcg for low-risk women. Bottom Line: Folic acid 4 mg daily is recommended in patients who are taking antiseizure medication to reduce the risk of neural tube defects.

Answer 908

The most appropriate first treatment in the setting of thyroid storm (thyrotoxicosis) is PO prophylthiouracil. Thyroid storm is an extremely dangerous complication secondary to poorly controlled hyperthyroidism. The risk of heart failure is higher in pregnancy with thyroid storm than in the nonpregnant state. Fortunately, this occurs in only 1% of pregnancies complicated by hyperthyroidism. Because of the urgency of the situation, when thyroid storm is suspected, treatment should begin before blood chemistry results have been obtained. Treatment should include medicines that block the release of T3 and T4, medicines that inhibit peripheral conversion of T4 to T3, and those that control heart rate. *Beta blockers should be used with caution in patients with signs of heart failure.

Answer 909

Studies performed in the 1960s measured neonatal blood volumes directly after cord clamping. These numbers have provided estimates for circulating fetal blood volume at term. A fetus at term has approximately 78 mL/kg of blood volume. When the placental blood volume is added to the fetal blood volume, this number increases to about 125 mL/kg of feto-placental blood volume. Fetal Blood Volume at Term Fetus Alone 78 mL/kg Fetus + Placental Blood Volume 125 mL/kg

Answer 910

Multifetal, or selective, reduction refers to the elective reduction of a multifetal gestation to a lower order. The procedure involves injecting potassium chloride (or another substance) into the fetal thorax of the selected fetus(es). Prior to the procedure being performed, crown–rump lengths and nuchal translucencies of all fetuses should be performed. If these measurements are normal, the safest and easiest fetus to reduce is the one closest to the anterior uterine wall or fundus. The most commonly reported benefit of reducing from a triplet to a twin gestation is the reduced risk of preterm delivery before 32 weeks' gestation. However, these patients are at a 50% increased risk of having a spontaneous abortion leading to a loss of all fetuses. Other studies have reported a decreased incidence of gestational diabetes, preeclampsia, low birth weights, and neonatal death in those patients who undergo multifetal reduction from a triplet to twin gestation.

Answer 911

Justice is the principle of ethics that refers to patient equality and fairness. Although there are different types of justice, it is the driving principle in resource allocation. By denying one patient access to the clinic above other patients merely because of her celebrity, this ensures that all patients have an equal opportunity for treatment. Answer A: Autonomy ensures the rights of a patient to make her own decisions without interference from other health care staff or family (e.g., ensuring that patients have a translator available if needed so they fully understand any risks and benefits from a procedure). Answer B: Beneficence is an action done in the best interests of the patient (e.g., providing the best treatment for a patient regardless of her ability to pay). Answer D: Nonmaleficence refers to “doing no harm” (e.g., stopping a medication that has been shown to be harmful, such as ACE inhibitors in pregnancy). Answer E: Paternalism is displayed when a health care staff member makes a decision, acting as if he or she knows what is best for the patient rather than allowing that patient to decide her own course of action (e.g., not providing the patient with all the available choices for treatment of her gynecological cancer and proceeding with surgery because you think that is the best course of action). Bottom Line: Justice refers to maintaining equality between patients.

Answer 912

Informed consent is a concept that is integral to modern medical ethics and practice. This ethical concept expresses respect for the patient as a person and guards against unwanted medical treatment. Informed consent has two parts: comprehension and free consent. These two parts ensure that the patient’s autonomy is protected throughout medical treatment.

Answer 913

Risk factors for stillbirth are numerous and include prior stillbirth, fetal conditions such as anomalies and aneuploidy, maternal chronic medical conditions, pregnancy conditions such as placental abruption and preeclampsia, and congenital infections. Large studies on stillbirth have shown that the 3 evaluations that are most likely to yield an explanation in an otherwise unexplained stillbirth are fetal autopsy, fetal cytogenetic analysis, and placental pathology examination. About 30% of stillbirths have abnormal autopsy findings, 50% have abnormal placental pathology findings, and 9–30% have abnormal cytogenetic analysis. Other diagnostic studies are indicated if suspicion for causation is high. This can include hemoglobin A1C to screen for diabetes, thyroid stimulating hormone to test for thyroid disease, congenital infection studies, antiphospholipid antibodies, maternal toxicology screen, and hemoglobin electrophoresis.

Answer 914

Immunizations have decreased the incidence of a number of diseases in both children and adults. A recommended immunization schedule for children has been approved by the American Academy of Pediatrics and the Centers for Disease Control and Prevention (CDC). Several vaccinations provide lifelong immunity. One exception is tetanus. It has been found that immunity to tetanus and diphtheria wanes among adults in the United States. This waning of immunity has resulted in a recommendation for universal administration of tetanus-diphtheria boosters every 10 years for adults. Answer A: Varicella (chicken pox) booster is currently not required in adulthood. Answer B: Measles booster is currently not required in adulthood. Answer C: Polio booster is currently not required in adulthood. Answer D: Rubella booster is currently not required in adulthood.

Answer 915

Thromboembolism during pregnancy is one of the major causes of maternal morbidity and mortality in the United States. If there is a medical history of thromboembolism outside of pregnancy or a disorder of the blood that renders one at high risk of forming a blood clot (such as homozygosity for factor V Leiden mutation, homozygous for G20210A mutation, antithrombin III deficiency), it is necessary to use anticoagulation during pregnancy. Usually, low-molecular-weight heparin (Lovenox) is given for treatment. Transitioning to unfractionated heparin is recommended at approximately 36–37 weeks of gestation. This is necessary because as the patient approaches her delivery date, she is at increased risk of hemorrhage, especially at the time of delivery. Typically, therapy is stopped prior to planned delivery; however, in the event of labor and delivery prior to cessation of therapy, the effects of unfractionated heparin can be reversed with protamine sulfate. No effective reversal agent is available for low-molecular-weight heparin. Vitamin K, and in emergency conditions, PCC, or FFP can be used for warfarin reversal, whereas protamine sulfate reverses the effects of heparin completely.

Answer 916

Thromboembolism during pregnancy is one of the major causes of maternal morbidity and mortality in the United States. If there is a medical history of thromboembolism outside of pregnancy or a disorder of the blood that renders one at high risk of forming a blood clot (such as homozygosity for factor V Leiden mutation, homozygous for G20210A mutation, antithrombin III deficiency), it is necessary to use anticoagulation during pregnancy. Usually, low-molecular-weight heparin (Lovenox) is given for treatment. Transitioning to unfractionated heparin is recommended at approximately 36–37 weeks of gestation. This is necessary because as the patient approaches her delivery date, she is at increased risk of hemorrhage, especially at the time of delivery. Typically, therapy is stopped prior to planned delivery; however, in the event of labor and delivery prior to cessation of therapy, the effects of unfractionated heparin can be reversed with protamine sulfate. No effective reversal agent is available for low-molecular-weight heparin. Vitamin K, and in emergency conditions, PCC, or FFP can be used for warfarin reversal, whereas protamine sulfate reverses the effects of heparin completely.

Answer 917

Von Willebrand disease is a disorder that affects 1–2% of the population. Von Willebrand factor is a protein that adheres to damaged vessels, which leads to platelet activation and adhesion. In addition to platelet adhesion signaling, von Willebrand factor also binds factor VIII and prevents its degradation. Women are often diagnosed with the disease when they start menstruating as they often have very heavy bleeding. Bleeding time is the least useful test as its sensitivity and specificity for the disease are quite poor.

Answer 918

S. aureus is the most common foodborne pathogen listed. It is associated with vomiting and diarrhea and occasionally fever, usually within 6 hours of ingestion. It typically results from cross contamination between an infected food worker and leaving food out at room temperature for the organism to multiply. It can occur in raw produce, raw egg products, and meats. Patients should receive supportive care with anticipation of full resolution.

Answer 919

Steps of Embryo Implantation Step Description Apposition Blastocyst hatches from zona pellucida Blastocyst aligns itself adjacent to the endometrium usually in the upper posterior wall of the uterus in the midsagittal plane Endometrium produces colony-stimulating factor-1 (CSF-1), leukemia-inhibitory factor (LIF), and interleukin-1 (IL-1) Adhesion Expression of adhesion molecules including integrins, selectins, and trophinin Decidualized endometrium and embryo express extracellular matrix proteins (ie, laminin and fibronectin) which mediate cell adhesion by binding to adhesion molecules Invasion Trophoblasts at the implantation site have formed masses of cytotrophoblasts and syncytiotrophoblasts Walls of maternal spiral arteries are destroyed and sinusoidal sacs are formed Sinusoidal sacs are lined with endovascular trophoblast Answer B: Blastulation is formation of the blastocyst (ranging from 32 to 250 cells) and occurs prior to implantation. Answer C: Capacitation describes the necessary changes a sperm must undergo to fertilize an oocyte and involves 3 accomplishments: 1) The ability to bind to the zone pellucida 2) The ability to undergo the acrosome reaction 3) The acquisition of hypermotility. Answer D: The initial process of cell division in the zygote is called cleavage. Answer E: Zona reaction is the hardening of the zona pellucida in response to fusion of the sperm and oocyte membranes to prevent fertilization by further sperm.

Answer 920

The medical director should be one of the group’s partners. The role of the medical director is to encourage a culture of safety, create a learning and non-punitive learning environment, and develop policies for practice. This is best accomplished by one of the partners because they are able to make policies and can relate to the other physicians when reviewing cases of medical errors. Roles of Medical Director Coordinate medical care in the facility Collaborate with facility leadership, practitioners and staff to help develop, implement, and evaluate policies and procedures that reflect current standards of practice Help the facility identify, evaluate, and resolve medical and clinical concerns

Answer 921

Screening for diabetes is an important concept to understand because nearly 10% of the US population has diabetes mellitus. The American Diabetes Association recommends that all patients with a BMI ≥25 kg/m2 with a risk factor (such as hypertension, hyperlipidemia, or sedentary lifestyle) be screened every 3 years. Those without a risk factor but with a BMI ≥25 kg/m2 should commence screening at age 45 years. Screening test Diagnostic criteria Hemoglobin A1C ≥6.5% Fasting blood sugar ≥126 mg/dL Blood sugar evaluation 2 hours after a 75-g oral glucose tolerance test ≥200 mg/dL A random blood sugar level can be tested if a patient is having classic signs of hyperglycemia, such as polydipsia or polyuria. ≥200 mg/dL Answer C: This is considered prediabetes. Lab values for a1c: Normal: less than 5.7% Prediabetes: 5.7–6.4% Diabetes: 6.5% or higher Answer D: This is considered prediabetes. Lab values for a 75-g oral glucose tolerance test: Normal: Less than 140 mg/dL Prediabetes: 140–199 mg/dL Diabetes: 200 mg/dL or more

Answer 922

TrueLearn Insight: Key points of fragile X syndromes are 1) anticipation of the CGG trinucleotide repeat occurs in subsequent generations; 2) women with the premutation (55 to 200 CGG trinucleotide repeats) are at increased risk of premature ovarian failure; and 3) FMR1 protein is decreased in individuals with fragile X because of methylation of the FMR1 gene. Carriers of the FMR1 gene premutation with CGG repeat lengths 55 to 200 were originally thought to be unaffected; however, it is now recognized that this was incorrect. Premutation carriers are at an increased risk of premature ovarian insufficiency (POI), which affects ~15% of women who carry the premutation. While the mechanism by which the premutation causes ovarian failure is not known, women with premutations appear to have a gain-of-function mutation resulting in increased FMR1 mRNA expression and decreased but not absent FMR1 protein. This is in contrast to affected women with full mutation (>200), which results in hypermethylation and inactivation (silencing) of the FMR1 gene and lack of transcription and protein production (loss-of-function mutation). Women with the full mutation do not present with premature ovarian insufficiency in the disease spectrum. In other words, there is no association between POI and full FMR1 mutations. Therefore, since premutation carriers have a normal amount of protein, the increased levels of mRNA are hypothesized to cause a toxic effect.

Answer 923

Agent Maximum dose with epinephrine (mg/kg) Maximum dose without epinephrine (mg/kg) Bupivacaine 3 3 Lidocaine 7 5 Ropivacaine 2 2 2-Chloroprocaine 14 11

Answer 924

Occiput posterior (OP) position is associated with an anthropoid pelvis shape. OP is also the most common fetal malposition. Prior to labor, 15–20% of term fetuses in cephalic presentation are OP, but only 5% remain OP at the time of vaginal delivery because most OP fetuses spontaneously rotate to an anterior position during labor. Pelvic Shape and Fetal Head Position Pelvic Shape Fetal Position Android (narrow arch) Occiput posterior, occiput transverse Anthropoid (narrow transverse diameter) Occiput posterior Platypoid (wide transverse diameter) Occiput transverse Gynecoid Occiput anterior, occiput transverse

Answer 925

Of the options listed, rhinovirus is the most common etiology of acute bronchitis. Other common causes include adenovirus, parainfluenza viruses, and coronavirus. These viral illnesses are self-limited and do not require antibiotics for treatment. Antibiotics should be considered if the patient is febrile (>38°C) because this can be a sign of bacterial infection, or if the patient has other signs/symptoms of pneumonia, including tachypnea and tachycardia. Pneumonia should be ruled out with a chest X-ray as well as a physical exam.

Answer 926

Tamoxifen is a nonsteroidal antiestrogen that acts as a selective estrogen receptor modulator (SERM). Its antiestrogen effects are what makes it useful in the treatment of breast cancer; on the other hand, its estrogenic effects on the uterus are what can cause adverse gynecological effects. Tamoxifen increases the risks of endometrial proliferation, hyperplasia, polyps, invasive adenocarcinoma, and sarcoma. The risk of developing invasive adenocarcinoma is 2–3 times higher in those taking tamoxifen than in matched controls, but this risk is relatively small (1.6 per 1,000 patient-years compared with 0.2 per 1,000 patient-years, respectively). The benefit of a 38% higher 5-year survival rate in those taking tamoxifen generally outweighs the small risk of endometrial cancer; however, all patients should be counseled to seek immediate gynecological evaluation if they have abnormal uterine bleeding or abnormal discharge. Screening asymptomatic women who are on tamoxifen for endometrial hyperplasia or cancer is not recommended because standard screening techniques, such as ultrasonography and biopsy, are not effective in this population. This is partly because tamoxifen causes subepithelial stromal hypertrophy, which gives a thickened endometrial appearance in nearly all patients. Thus, the standard “less than or equal to 4 mm” rule of endometrial thickness in postmenopausal women cannot be applied to women on tamoxifen.

Answer 927

Fabry disease is a the most prevalent lysosomal storage disorder; pattern of inheritance is X-linked. The prevalence of classic Fabry disease is estimated to range from 1:8454 to 1:117,000 males and the disease is seen across all ethnic and racial groups. Patients with Fabry disease have a deficiency of α-galactosidase A, leading to the accumulation of glycosphingolipid in the vasculature of the brain, kidneys, and heart. The classic presenting symptom is significant pain in the palms and soles, and it typically presents in the teenage years. Features of classic Fabry disease Most severe clinical phenotype occurs predominantly in males Severe neuropathic or limb pain (acroparesthesias) Telangiectasias and angiokeratomas Corneal opacities (cornea verticillata) Kidney manifestations such as proteinuria, isosthenuria, polyuria, and polydipsia Hearing loss Tremors Treatment options include medications. Before the advent of the enzyme-replacement drug Fabrazyme (agalsidase beta), most patients died in their fourth or fifth decade from heart disease or renal failure.

Answer 928

Bottom Line: The fetal thyroid begins producing thyroid hormone at 12 weeks' gestation. Fetal thyroid tissue begins to concentrate iodine and synthesize thyroid hormone by 12 weeks' gestation. Therefore, exposure to radioiodine at 6 weeks' gestation is unlikely to have an effect on the fetal thyroid gland as the radioiodine will not be processed by the fetal thyroid tissue. Maternal T4 is transferred to the fetus throughout pregnancy and is essential for normal fetal brain development. This is especially important before 12 weeks' gestation, which is when the fetal thyroid gland begins functioning.

Answer 929

A case series discusses interesting features in a series of patients and is useful when a disease is rare. This allows information about the clinical care aspects of the disease to be distributed. Case Series Series of patients Good for rare diseases Case Report Only discusses 1 patient Cohort Studies Observational Follows natural course of events following an exposure Useful for large numbers of patients Randomized Controlled Trials Comparing a test/treatment group with a control group Requires a large number of patients

Answer 930

Beneficence refers to an action that is done in the best interests of the patient (e.g., providing the best treatment for a patient regardless of her ability to pay). Answer A: Autonomy ensures the rights of a patient to make her own decisions without interference from other health care staff or family (e.g., ensuring that patients have a translator available if needed so they fully understand any risks and benefits from a procedure). Answer C: Justice is the ethical principle that refers to patient equality and fairness. Although there are different types of justice, it is the driving principle in resource allocation. Answer D: Nonmaleficence means “doing no harm” (e.g., stopping a medication that has been shown to be harmful, such as ACE inhibitors in pregnancy). Answer E: Paternalism occurs when a health care staff member makes a decision, acting as if he or she knows what is best for the patient rather than allowing that patient to decide her own course of action (e.g., not providing the patient with all the available choices for treatment of her gynecological cancer and proceeding with surgery because you think that is the best course of action). Bottom Line: Beneficence is an action that is done in the best interests of the patient. At the heart of our fundamental principles of medical ethics are both beneficence and respect for autonomy (i.e., treating patients well and allowing them to be partners in their health care).

Answer 931

Although not available in all locations, three vaccines have been developed for the human papillomavirus, and they are the 9-valent, quadrivalent, and bivalent vaccines for human papillomavirus. The natural human papillomavirus capsid is composed of two coat proteins, L1 and L2, but the vaccines utilize the L1 capsid proteins of each type. These capsid proteins are highly immunogenic. HPV Vaccines HPV Types 9-valent vaccine (Gardasil 9) 6, 11, 16, 18, 31, 33, 45, 52, and 58 Quadrivalent HPV vaccine (Gardasil) 6, 11, 16, and 18 Bivalent vaccine (Cervarix) 16 and 18

Answer 932

Iron deficiency anemia accounts for 75% of all cases of anemia during pregnancy. There is an increased iron requirement during pregnancy because blood volume expands by approximately 50% (1,000 mL), and total red blood cell mass expands by approximately 25% (300 mL) during a singleton gestation. The daily requirement for iron in a singleton gestation is 1,000 mg. Half of this is for maternal hemoglobin mass expansion. The fetus and placenta require 300 mg daily. 200 mg is lost each day through the intestines, urine, and skin. The two most common reasons for iron deficiency anemia are due to physiologic volume and red blood cell mass expansion. Other causes are short-interval pregnancy and not eating foods rich in iron or foods that enhance iron absorption. Foods such as dairy and soy products reduce iron absorption in the gut. A less common reason during pregnancy is blood loss. Iron deficiency is associated with an increased risk of low birth weight, preterm birth, perinatal mortality, and postpartum depression.

Answer 933

“Kell kills” is the mnemonic commonly taught in obstetrics regarding a positive anti-Kell antibody screen. The reason such extreme surveillance is needed after diagnosis of the Kell antibody is because of the severe hemolytic disease of the fetus and newborn (HDFN) that can develop if the fetus has the Kell antigen. There are 23 different members of the Kell red cell antigen system, and 9 of these have been shown to cause HDFN. The most common are the K1 and K2 (Cellano) antigens. K1 carries the highest risk of HDFN, but K2 is also associated with HDFN. If paternity can be assured, the most appropriate step after identifying a Kell antibody in a pregnant patient is to test the father of the fetus for the Kell antigen. This is a vital step to determine whether the fetus is at risk of HDFN and may prevent unnecessary ultrasonography and interventions if the father is found to be Kell antigen negative (kk). If the patient cannot guarantee paternity, this step should be skipped. Testing the father of the fetus is important because only 9% of White patients and 3% of Black patients carry the K1 antigen, and if they do, nearly 100% are heterozygotes. Thus, if the father is found to be kk and paternity is assured, no further testing of the fetus is necessary because there is no way the fetus can be affected. If the father is found to be K1 antigen positive (assumed heterozygous), then interrogation of the fetal middle-cerebral artery (MCA) for fetal anemia should be performed. If the MCA Doppler becomes > 1.5 MoM, then fetal anemia is suspected, and an intrauterine fetal transfusion is the next step in management and treatment.

Answer 934

In the setting of latent tuberculosis and with risk factors for more rapid progression (HIV infection, immunosuppression, recent exposure <2 years), initiating treatment after the first trimester is appropriate. Isoniazid for 9 months is the treatment and duration of choice for latent tuberculosis in pregnancy with risk factors for progression. There is an increased risk for hepatotoxicity with isoniazid treatment during pregnancy and for the first 2–3 months postpartum. Therefore, if a patient does not have risk factors for progression, it would be appropriate to wait until after 2–3 months postpartum to initiate treatment. While latent tuberculosis has the potential to develop into active tuberculosis, pregnancy itself does not alter the pathogenesis of tuberculosis. Risk factors Treatment Latent tuberculosis Average progression risk Isoniazid with B6 for 9 months, 2–3 months after delivery Latent tuberculosis Elevated progression risk Isoniazid with B6 for 9 months, after the first trimester Active tuberculosis Isoniazid with B6 and rifampin for 9 months, +/- ethambutol Bottom Line: In a pregnant patient with risk factors for rapid progression, tuberculosis treatment with isoniazid should start after the first trimester and continue for 9 months.

Answer 935

Of the choices listed, pregestational diabetes is associated with the highest risk of an NTD. NTDs are the second most common major congenital malformation after cardiac malformations. The neural tube forms from the neural plate, which folds in the midline to form the neural tube at 3–4 weeks after fertilization. Closure of the neural tube begins in the cervical region and extends cranially and caudally. Failure of the neural tube to close at the cranial end results in anencephaly, and failure of the tube to close at the caudal end results in myelomeningocele or spina bifida. Development of an NTD is multifactorial and involves environmental exposures, maternal medical conditions, and family history. To produce an NTD, these factors must be present during the first 28 days of development, when the neural tube is forming. NTDs account for as many as 29% of neonatal deaths associated with congenital abnormalities in low-income settings. Isolated or nonsyndromic NTDs are generally multifactorial, or attributed to a complex combination of genetic and environmental factors.

Answer 936

The patient should continue watchful waiting of symptoms of rubella infection and seek serum testing if she experiences these. Rubella, also called German measles, is one of the most teratogenic agents known. As the duration of the pregnancy increases, fetal effects decrease. An affected fetus will demonstrate eye lesions, including cataracts and microphthalmia, sensorineural deafness, fetal growth restriction, hepatosplenomegaly, jaundice, anemia, and heart defects, including patent ductus arteriosus and pulmonary artery stenosis.

Answer 937

The intrauterine device (IUD) should be removed today. Removal confers the lowest risk of miscarriage, as the miscarriage rate is approximately 50% if the IUD is left in place. This rate is more than twofold the risk of women who have the IUD removed. Antibiotics should not be routinely given for this procedure. Under ultrasound guidance, the strings should be grasped and the IUD removed. When instrumentation is used, prophylactic antibiotics should be given. If the IUD is difficult to remove, the provider must weigh the risks of pregnancy loss with aggressive removal versus the maternal/fetal risks later in the pregnancy. Answer A: Although having an IUD in place increases the patient's risk of miscarriage, infection, and preterm delivery, it is NOT recommended that the pregnancy be terminated or termination be offered based on the presence of the IUD. There are no proven risks of birth defects with an IUD concurrent with a pregnancy. Answer B: Having the IUD in place increases this patient's risk of miscarriage, infection, and preterm delivery. The IUD should be removed as soon as possible. The removal process does increase the patient's risk of miscarriage, but the risk is less than leaving the IUD in place throughout the pregnancy.

Answer 938

FAS is characterized by facial dysmorphisms, including short palpebral fissures, thin vermillion border, and smooth philtrum, as well as growth restriction (both in utero and as children) and central nervous system abnormalities including abnormal reflexes and tone with poor coordination and balance. A neonate with fetal alcohol syndrome (FAS) does not necessarily exhibit microcephaly. The neonate will have overall growth restriction, but s/he is generally symmetric and does not reflect microcephaly. Children may have additional features common to the syndrome, such as micrognathia, "railroad track" ears, clinodactyly, hockey stick crease, and ptosis; however, these are not diagnostic features. Parents should be counseled that no amount of alcohol is safe during pregnancy. Characteristics of FAS Growth restriction Central nervous system abnormalities: Abnormal reflexes and tone Poor coordination and balance Facial dysmorphisms: Short palpebral fissures Thin vermillion border Smooth philtrum

Answer 939

The management of a twin gestation with a shortened cervix is an exceedingly hot topic in the field of obstetrics and gynecology at this point. Berghella et al. recently published a meta-analysis analyzing four randomized-controlled trials with the purpose of determining whether an ultrasound-indicated vaginal cerclage decreased the risk of preterm birth. They found a decreased incidence of preterm birth in those with a singleton gestation who underwent a cerclage placed for a cervical length <25 mm. Surprisingly, women with twin gestations who had an ultrasound-indicated cerclage were twice as likely to deliver preterm. A pitfall of this study is that it only included 49 women with twins. Similarly, there has been conflicting evidence on whether progesterone, either 17-OHP intramuscular injections or vaginal progesterone, prolongs twin pregnancies with a short cervix. Thus, the Eunice Kennedy Shriver National Institute of Child Health and Development Maternal-Fetal Medicine Units Network is conducting a multi-center randomized-controlled trial studying placebo versus pessary versus expectant management in twin gestations complicated by a short cervix (<25 mm). Until this trial is complete, the recommendation from the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) is that twin gestations with a short cervix be managed conservatively.

Answer 940

Thrombotic thrombocytopenic purpura (TTP) is a rare but fatal microangiopathic disease and requires urgent and aggressive plasma-based treatment, such as plasmapheresis. Untreated TTP is associated with > 90% mortality. TTP is characterized by the pentad of thrombocytopenia, microangiopathic hemolytic anemia, renal abnormalities, fever, and neurologic symptoms such as headache, lethargy, confusion, and seizures. TTP is caused by a congenital or acquired deficiency of, or antibody against, ADAMTS-13 which is a metalloprotease that cleaves von Willebrand factor multimers (vWF cleaving protease). Depletion of ADAMTS-13 results in ultralarge vWF multimers which lead to microangiopathic thromboses and severe thrombocytopenia which can manifest as hemolytic anemia with thrombotic sequelae. ADAMTS-13 is lowered in normal pregnancy and thus is thought to be why TTP is more common in pregnancy. Furthermore, placental proteins may trigger maternal antibody production against ADAMTS-13. Mean gestational age of onset is in the 23rd week of pregnancy. Diagnosis is based on clinical signs and symptoms with supporting laboratory evidence of microangiopathic hemolytic anemia (low hemoglobin, schistocytes), low platelets (often < 20,000/mL), very elevated LDH, mildly elevated AST, and ADAMTS-13 levels lower than 25% normal. Hemolytic anemia associated with ITP is diagnosed by a negative indirect (Coombs) test. The gold standard treatment is plasmapheresis to remove antibodies to ADAMTS-13 and replenish the depleted protease. No well-defined cutoff exists for when to initiate plasmapheresis, however levels from < 2.5% to < 10% have been proposed. Plasmapheresis should be continued for 2 days following remission as defined by normalizing labs. Severe TTP may also require high-dose corticosteroids or immunosuppressant, but this is not the primary treatment. Low-dose aspirin is also recommended to prevent recurrence.

Answer 941

Systemic lupus erythematosus (SLE) is an autoimmune disorder that affects multiple organ systems. It has a myriad of symptoms, and is a chronic, lifelong condition. It affects women of reproductive age, and thus women with this condition need to be monitored closely during pregnancy. Women with SLE are 20 times more likely to die during their pregnancy than women without the disease. There are a number of lupus-associated complications specific to pregnancy. These complications are more prevalent in women who have experienced an exacerbation of the disease within the 6 months prior to conception or if severe renal disease is present prior to conception. In women with SLE, hypertensive disorders of pregnancy are more common, such as gestational hypertension, preeclampsia, and eclampsia. Other complications of pregnancy associated with lupus include spontaneous abortion prior to 10 weeks (controversial), intrauterine fetal demise, fetal growth restriction, preterm labor, and preterm delivery. An association between SLE in pregnancy and gestational diabetes has not been demonstrated. Complications in Pregnancy Associated with SLE Intrauterine fetal growth restriction Intrauterine fetal demise Preterm labor Preterm delivery Spontaneous abortion less than 10 weeks Somewhat controversial finding Hypertensive disorders of pregnancy Gestational hypertension Preeclampsia Eclampsia

Answer 942

ACOG recommends insulin as the first-line therapy for the treatment of gestational diabetes. Metformin is a reasonable alternative if: there are safety or compliance issues the patient refuses insulin the patient cannot afford insulin Metformin crosses the placenta and there are few safety data on the long-term use of this medication for the developing fetus. Obesity is certainly not a contraindication to use of metformin; however, it is not a reason to use metformin preferably over insulin.

Answer 943

Pain is the most common complication of leiomyomas in pregnancy. The pain from the leiomyomas is due to a process known as red degeneration. The degeneration is due to necrosis, and there are a number of theories related to how the necrosis occurs. One theory is that the necrosis is due to the leiomyoma outgrowing its own blood supply, which leads to tissue anoxia and necrosis, resulting in infarction. A second theory is that the blood supply is obstructed by the structure of the uterus, and the decrease in blood flow leads to ischemia. An additional theory is that the pain is secondary to the increase in prostaglandins.

Answer 944

Transfusion for pregnant sickle cell patients can be performed as a standard or prophylactic exchange transfusion. There is no consensus regarding the exact thresholds for transfusion in sickle cell patients. Patients with crisis, acute chest syndrome, and Hb less than 6.0 g/dL clearly need blood transfusions. Blood transfusions should also be given when clinically indicated, such as in anticipation of blood loss during delivery. Once a transfusion becomes clinically indicated, most experts agree that the objective is to lower the percentage of Hb S to 40% and increase hemoglobin concentration to about 10 g/dL. In a randomized controlled trial, prophylactic transfusions aimed at maintaining similar goals significantly reduced incidence of sickle cell crisis but did not improve rates of pregnancy complications such as preeclampsia, IUGR, etc. TrueLearn Insight: Some patients with sickle cell anemia receive prophylactic exchange transfusions to prevent stroke due to occlusive disease or frequent sickle cell crises prior to pregnancy. These exchange transfusions should be continued during pregnancy under the guidance of the patient's hematologist.

Answer 945

The majority of adnexal masses found during pregnancy are benign and less than 5cm in diameter. Benign masses can be simple or complex appearing. Simple appearing masses include follicular cysts, hydrosalpinx, or cystadenomas. Complex appearing cysts include mature teratomas, corpus luteum cysts, endometriomas, theca lutein cysts, and multilocular cystadenomas. The majority of masses that are greater than 6 cm in diameter are mature teratomas, also known as dermoid cysts. Answer A: Corpus luteum cysts are functional cysts that can appear complex on ultrasound. These can enlarge, become hemorrhagic, rupture, or even undergo torsion. Answer B: Theca lutein cysts form as a result of overstimulation from hCG and present as bilateral multi-septated cystic adnexal masses. They can appear in patients with multiple gestation, gestational trophoblastic disease, or with pregnancies complicated by fetal hydrops. Answer C: About 1/3 of malignant ovarian neoplasms in pregnancy are of germ cell origin and dysgerminoma is the most common of the germ cell tumors. Dysgerminomas can be bilateral in 10–15% of cases. Answer E: A luteoma is a benign solid mass associated with pregnancy. Patients will show signs of virilization.

Answer 946

The risk of gastroschisis in obese females is reduced compared with normal-weight females. The prevalence of obesity in females of reproductive age continues to increase. Compared with those of normal weight, obese patients are at increased risk for numerous pregnancy complications. In addition to increased risk of fetal complications such as miscarriage, congenital anomalies, and stillbirth, maternal complications are also increased. These include cesarean delivery, wound infections, endometritis, gestational diabetes, preeclampsia, venous thromboembolism, postpartum depression, and excess maternal weight gain, among others. Fetal Conditions Increased by Obesity Miscarriage Neural tube defects Cardiac anomalies Limb reduction anomalies Septal defects Hydrocephaly Cleft lip/palate Stillbirth Maternal Conditions Increased by Obesity Gestational diabetes Preeclampsia Cesarean delivery Endometritis Wound infections Venous thromboembolism Excess weight gain Postpartum depression *This is not an exhaustive list.

Answer 947

In the United States, the preterm delivery rate in twins is 60.3% before 37 completed weeks of gestation and 19.5% before 34 completed weeks. The mean birthweight for twins is 2,345 g. The mean gestational age for twins at delivery is 35.0 weeks. Multifetal gestations are associated with increased risk of fetal and infant morbidity and mortality. Perinatal complications that are increased with multiple gestations include fetal anomalies, preeclampsia, and gestational diabetes. One of the most consequential complications encountered with multifetal gestations is preterm birth, which affects infant morbidity and mortality. Women with multifetal gestations are 6 times more likely to give birth preterm. There is an increase in short-term and long-term neonatal and infant morbidity associated with multifetal gestations. For example, twins born less than 32 weeks are twice as likely to have a high-grade intraventricular hemorrhage and periventricular leukomalacia when compared with singletons of the same gestational age. Interventions such as prophylactic cerclage, prophylactic tocolytics, prophylactic pessary, routine hospitalization, and bed rest have not been proven to decrease neonatal morbidity or mortality and, therefore, should not be used in women with multifetal gestations.

Answer 948

Stillbirth is a devastating obstetric complication. One in 160 deliveries in the United States is a stillbirth (0.4%). Several causes of stillbirth can be identified. However, the most common cause is unknown. Recurrence rate in subsequent pregnancies is 2.5%. Stillbirth is defined as fetal death at 20 weeks or greater of gestation (if the gestational age is known), or a weight greater than or equal to 350 grams if the gestational age is not known. The cutoff of 350 grams is the 50th percentile for weight at 20 weeks of gestation. Fetal mortality rates are widely calculated using a birth-based approach: the number of stillbirths per 1,000 live births and stillbirths.

Answer 949

Non-immune hydrops is characterized by the presence of 2 or greater abnormal fetal fluid collections in the absence of red cell alloimmunization. The fluid collections include ascites, pleural effusions, pericardial effusion, and generalized skin edema. The most common etiologies include cardiovascular, chromosomal, and hematologic abnormalities. Parvovirus is the MOST commonly reported infectious cause of non-immune hydrops. In addition to causing fetal loss, parvovirus B19 is cytotoxic to fetal red blood cell precursors, resulting in anemia and subsequent hydrops. Maternal immunoglobulin M (IgM) and immunoglobulin G (IgG) serologies are obtained for the most common infectious causes of non-immune hydrops fetalis, with parvovirus B19 being the most common viral cause of fetal anemia and myocardial dysfunction.

Answer 950

Syphilis can have detrimental effects on the fetus beginning at 16 weeks' gestation, and thus, rigorous screening protocols have been instituted by the Centers for Disease Control and Prevention (CDC). ACOG recommends screening for syphilis infection in pregnant women as early as possible in pregnancy; ACOG also recommends repeat screening at 28 weeks of gestation and again at delivery in high-risk women. Diagnostic evaluation for syphilis is the same in pregnant and non-pregnant women. Initial screening serologic test is determined by each laboratory. Traditional or reverse screening can be used. Traditional: non-treponemal tests (Venereal Disease Research Laboratory [VDRL]) rapid plasma reagin [RPR] Reverse: treponemal tests are initially performed (Fluorescent treponemal antibody absorption [FTA-ABS], Treponema pallidum particle agglutination [TP-PA]) It is more difficult to establish whether a patient who has previously had a treated syphilis infection has a recurrent infection or just has a positive screening test. Treponemal tests are often positive for life in patients with a history of syphilis. A diagnosis of syphilis is therefore made when both non-treponemal and treponemal tests are reactive. The combination of both types of tests can aid with the differentiation. Since non-treponemal tests such as VDRL or RPR are reported in titers they can be followed, trended and compared. If the titer is higher than the previous titer collected after successful treatment, the patient is considered to have reinfection. Bottom Line: A rising quantitative Venereal Disease Research Laboratory or rapid plasma reagin titer indicates a recurrent or persistent active syphilis infection.

Answer 951

During pregnancy, there is an increased need for thyroxine. This increase in demand is likely due to estrogenic effects leading to increased levels of thyroxine-binding globulin. In women who do not have any thyroid reserve, such as patients with iodine ablation or thyroidectomy, symptomatic hypothyroidism can occur. To decrease this risk, the levothyroxine dose should be increased by 25% when pregnancy is confirmed. The risk of hypothyroidism is increased in patients who have had thyroid radiation or thyroidectomy. After this initial increase, TSH levels can be followed every 4–6 weeks and medication adjustments can be made accordingly. TrueLearn Insight: For hypothyroidism in pregnancy, TSH levels are followed. For hyperthyroidism in pregnancy, free T4 levels are followed.

Answer 952

The patient described in the scenario has had an eclamptic seizure, which is the convulsive manifestation of the hypertensive disorders of pregnancy. Women are particularly at risk of posterior reversible encephalopathy syndrome (PRES) in the settings of eclampsia. PRES is almost a universal finding in women with eclampsia. The hallmark finding is hyperintense T2 lesions representing edema in the subcortical and cortical regions of the parietal and occipital lobes, that is, edema at the white and gray matter junction. These findings are reversible. PRES is a constellation of a range of clinical neurologic signs and symptoms such as vision loss or deficit, seizure, headache, and altered sensorium or confusion. Although suspicion for PRES is increased in the setting of these clinical features, the diagnosis of PRES is made by the presence of vasogenic edema and hyperintensities in the posterior aspects of the brain on magnetic resonance imaging. Treatment of women with PRES may include medical control of hypertension, antiepileptic medication, and long-term neurologic follow-up.

Answer 953

Thrombocytopenia is a common finding in pregnancy and affects 7%–12% of pregnancies (according to the Thrombocytopenia in Pregnancy practice bulletin). This number includes all causes such as gestational thrombocytopenia, immune thrombocytopenic purpura, HELLP syndrome, and medication related thrombocytopenia. A normal platelet count, >150,000/μL, is based on nonpregnant individuals and is rather arbitrary. Gestational thrombocytopenia, the most common cause of thrombocytopenia in pregnancy, is a diagnosis of exclusion and platelet counts are almost always >70,000/μL.

Answer 954

Deletion of all 4 copies of the alpha-globin gene results in alpha-thalassemia major (hemoglobin Bart's disease) which presents with fetal hydrops and often leads to intrauterine fetal demise. In this case, the hydrops is a result of high-output heart failure secondary to severe anemia. The increased peripheral demand leads to diastolic heart failure and widespread edema. Preeclampsia is also more common in patients who have a fetus with alpha-thalassemia major. Alpha-thalassemia trait (α-thalassemia minor) is common among those of Southeast Asian, African, West Indian, and Mediterranean ancestry. Individuals of Southeast Asian descent are more likely to carry two gene deletions on the same chromosome (cis) and are therefore at increased risk of having offspring with Hb Bart's or Hb H disease.

Answer 955

Topical vaginal estrogen has been shown to improve urinary incontinence by increasing α-adrenergic receptor sensitivity. Local estrogen replacement therapy improves both stress and urgency urinary incontinence in peri- or postmenopausal women with vaginal atrophy due to genitourinary syndrome of menopause (see table below). Local Estrogen Replacement Therapy for Female Urinary Incontinence Enhances urethral blood flow and increases α-adrenergic receptor sensitivity Improves urethral closure pressure Increases collagen deposition and promotes vascularity of the periurethral capillary plexus Improves urethral coaptation In contrast, evidence suggests that systemic (oral) estrogen therapy may worsen urinary incontinence. Some medications, such as oral estrogens, diuretics, and caffeine may worsen urinary incontinence (see table below).

Answer 956

After implementation of the childhood varicella vaccine, disease incidence decreased by 82% from 2000 to 2010 (previously 4 million infections per year). Symptoms of varicella infection include fever, malaise, and a maculopapular pruritic rash. The maculopapular rash then becomes vesicular. Varicella pneumonia is an uncommon, yet very serious and potentially deadly, complication of varicella infection. The treatment of choice for varicella pneumonia during pregnancy is intravenous (IV) acyclovir. Although no randomized controlled trials have established the efficacy of IV acyclovir, it is thought to decrease disease severity and risk of mortality.

Answer 957

History What medications is the patient taking? Heparin, NSAIDs, anticonvulsants, antibiotics such as penicillins Any infections? Viral: HIV, Hep C, Hep B, ZIKA virus, CMV Bacterial: Helicobacter pylori, Escherichia coli gastroenteritis (hemolytic uremic syndrome) Any autoimmune disorders? SLE, antiphospholipid syndrome Any associated neurological symptoms? Possible TTP Any chronic medical problems? Chronic liver or kidney disorders, bone marrow depression, or myeloproliferative disorders Is it a new onset in pregnancy? If new onset, think of HELLP syndrome, acute fatty liver of pregnancy, DIC in the setting of suspected placental abruption If all the above is negative Think of gestational thrombocytopenia or immune thrombocytopenic purpura Workup (if PLT <100,000) Normotensive patients: CBC, peripheral blood smear PT/aPTT/fibrinogen Hypertensive patients, as above, PLUS: CMP including liver enzymes, creatinine Protein: creatinine ratio in urine In selected cases: ANA, Anti-dsDNA for SLE Antiphospholipid antibodies ADAMTS13 activity for TTP

Answer 958

Ferritin levels have the highest sensitivity and specificity for the diagnosis of iron deficiency anemia. Levels should be less than 10–15 mcg/L in the setting of this diagnosis. Hemoglobin electrophoresis is used to diagnose hemoglobinopathies and is reserved for ethnic groups with an increased risk of anemia because of inherited disorders.

Answer 959

Inadequately treated hyperthyroidism in pregnancy is associated with preeclampsia and heart failure. Hyperthyroidism is defined as decreased TSH and increased free T4 levels. Only 0.2% of pregnancies are affected by hyperthyroidism. Graves' disease accounts for 95% of hyperthyroidism cases. Classic symptoms of hyperthyroidism are palpitations, tremors, tachycardia, insomnia, diarrhea, and nervousness, among many other symptoms. Universal thyroid function screening is not recommended by ACOG for the general pregnant population and should be reserved for those with symptoms. Treatment consists of propylthiouracil in the first trimester and then methimazole thereafter. Table 1. Complications of hyperthyroidism in pregnancy Maternal Neonatal Preeclampsia Low birth weight Heart failure Iatrogenic preterm birth Intrauterine fetal demise

Answer 960

The patient has primary varicella infection and varicella pneumonia. Her history and physical exam findings are consistent with chicken pox, caused by varicella zoster virus (VZV). VZV is a highly contagious DNA herpesvirus that is transmitted by respiratory droplets or close contact. The disease is most common in childhood and is usually self-limited. Clinical features include fever, malaise, and a pruritic maculopapular rash that becomes vesicular. Prior infection confers lifelong immunity. Severe complications, such as pneumonia and encephalitis, are more common in adults who develop primary infection. Diagnosis is usually based on clinical findings, particularly if a rash is present after a known exposure. Varicella infection also can be documented by the detection of the fluorescent antibody to the membrane antigen or of the VZV antibody by ELISA. Varicella in pregnant women can result in VZV transmission to the fetus or newborn, causing congenital varicella syndrome or neonatal varicella. Congenital varicella syndrome can manifest in growth restriction, cutaneous scarring, limb hypoplasia, microcephaly, chorioretinitis, and cataracts. It occurs in 1.5% of infants born to women who contract VZV in the first 28 weeks of gestation. Fetuses infected by VZV during the second half of gestation can develop zoster early in life without having had extrauterine chicken pox. The onset of varicella in pregnant women around the time of delivery may result in severe varicella in newborns, which has a high mortality rate if untreated.

Answer 961

Rh D alloimmunization occurs when an Rh-negative woman is exposed to red blood cells expressing the Rh D antigen. As little as 0.1 mL of fetal-maternal hemorrhage has been reported to cause alloimmunization. Bottom Line: 0.1 mL is the minimum volume of fetal-maternal hemorrhage that can cause alloimmunization. A 300 mcg dose of RhoGAM is enough to protect against exposure to 30 ml of fetal whole blood or 15 ml of fetal red blood cells.

Answer 962

In the setting of latent tuberculosis and in the absence of risk factors for progression (HIV infection, immunosuppression, recent exposure <2 years), it is appropriate to wait until 2–3 months postpartum to initiate treatment in order to avoid administering unnecessary medication during pregnancy. Isoniazid would be the treatment of choice for 9 months if the patient was deemed high risk for tuberculosis progression in pregnancy. Rifampin may also be used but is considered second-line therapy. While latent tuberculosis has the potential to develop into active tuberculosis, pregnancy itself does not alter the pathogenesis of tuberculosis. Risk factors Treatment Latent tuberculosis Average progression risk Isoniazid with B6 for 9 months, 2–3 months after delivery Latent tuberculosis Elevated progression risk Isoniazid with B6 for 9 months, after the first trimester Active tuberculosis Isoniazid with B6 and rifampin for 9 months, +/- ethambutol

Answer 963

This patient has rhesus alloimmunization. In an Rh(D) negative woman, she does not have a D antigen on her red blood cells. The presence of anti-D antibodies usually occurs during a prior pregnancy with an Rh(D) positive fetus and a large fetomaternal hemorrhage most commonly from delivery. Alloimmunization has also been reported after first-trimester spontaneous and induced abortion, threatened abortion, ectopic pregnancy, and after several obstetric procedures including chorionic villus sampling, amniocentesis, and external cephalic version. The initial management of a pregnancy involving an alloimmunized patient is determination of the paternal erythrocyte antigen status. If the father is negative for the erythrocyte antigen in question (and it is certain that he is the father of the fetus), further assessment and intervention are unnecessary. If the father is Rh(D) positive, then red cell antigen genotyping should be performed to determine zygosity. If the father is homozygous, there should be no further work-up as the fetus must be Rh(D) positive by serology and should be monitored closely. If the father is heterozygous, there is a 50% likelihood of a Rh(D) negative fetus that is at risk of anemia. If the paternal genotype is heterozygous or unknown, fetal antigen type should be assessed through amniocentesis. Answer A: The patient is already alloimmunized. Rhogam is administered to prevent alloimmunization and is therefore not indicated. Answer B: Middle cerebral arterial (MCA) Doppler measurement of the peak systolic velocity is a non-invasive method to assess for fetal anemia. This should only begin when the fetus is known to be Rh(D) positive and at risk of subsequent anemia. Specifically, MCA Doppler studies are recommended once critical titers are reached (1:16 or 1:32, depending on the laboratory). A titer in this patient of 1:4 is considered not critical and therefore followed monthly if stable. Answer D: Hemolysis of fetal red cells causes a rise in indirect bilirubin, which can be measured in amniotic fluid by delta optical density 450 (ΔOD450) assessment via amniocentesis. This is an invasive method and is not as accurate as MCA Doppler assessment and is no longer recommended, especially with a low titer of 1:4. Answer E: Percutaneous umbilical cord sampling is the most invasive but most accurate way to assess for fetal anemia. Fetal hematocrit is assessed once critical titers are reached and the MCA Doppler studies are abnormal (usually middle cerebral artery peak systolic velocity [MCA-PSV] greater than 1.5 MoMs). TrueLearn Insight: The initial management of a pregnancy involving an alloimmunized patient is determination of the paternal erythrocyte antigen status. If the paternal genotype is heterozygous or unknown, fetal antigen type should be assessed through amniocentesis.

Answer 964

Immediate management of a patient with eclampsia includes administration of supplemental oxygen (8–10 L/min) via a nonrebreather face mask to treat hypoxia from hypoventilation during the seizure. Eclampsia is the development of new-onset, generalized, tonic-clonic seizures or coma in a woman with preeclampsia. Eclamptic seizures can occur before diagnosis of the underlying disorder. The incidence of eclampsia in high resource countries is 1.5–10/10,000 deliveries.

Answer 965

Particularly for abdominal procedures or those dependent upon positioning during surgery, continuous fetal monitoring may not be possible. If the fetus is viable, discussion of the need for fetal monitoring should be individualized between all providers involved in the patient's care. If continuous monitoring is undertaken, the pediatrics team should be aware and possibly present in the operating room if the risk of needing delivery is considered high. Answer A: Considerations should be given to medications that are safe for both mother and fetus in this type of patient. This includes consideration of medications that may be necessary if delivery is indicated, such as administration of antenatal corticosteroids prior to proceeding to the OR. Answer B: Pediatric personnel should be aware of the case before the patient goes to the OR, in case emergent delivery is necessary. Answer D: If risk of delivery is considered high, it is reasonable to have obstetric and pediatric personnel present in the operating room should delivery be undertaken. Answer E: Checklists and guidelines for obstetric hemorrhage, including massive transfusion protocol, should be adhered to even when undergoing non-obstetric surgery in pregnancy. Bottom Line: Several additional considerations are necessary in the pregnant patient undergoing non-obstetric surgery, to include medication administered, communication among and presence of appropriate personnel, and use of fetal monitoring.

Answer 966

Neisseria meningitidis bacteria are spread through respiratory and throat secretions; therefore, transmission occurs more frequently in those who share close quarters with others. It is responsible for about 50% of meningitis cases around the world. The meningococcal vaccine is indicated in those with functional or anatomic asplenia, those who are known to be exposed to meningococcus, and first-year college students up through age 21 years who reside in residence halls. It is safe to administer in pregnancy because it is not a live attenuated vaccine. Answer A: Hepatitis A vaccine is indicated only in those with risk factors for infection, such as travel to endemic areas, working with infected persons, or having a chronic liver disease. Answer C: Pneumococcal vaccine is indicated in persons aged 19–64 years with an immunocompromising disease or asplenia and persons aged ≥65 years. Answer D: The tDAP is indicated in the third trimester of pregnancy. Answer E: Varicella vaccine is a live attenuated vaccine that is contraindicated in pregnancy.

Answer 967

Vancomycin remains the first-line choice for the treatment of methicillin-resistant Staphylococcus aureus (MRSA). IV antibiotics should be reserved for patients with evidence of soft-tissue involvement, multiple infections, fevers, or signs of systemic illness. Individuals who are immunocompromised or those with diabetes mellitus all warrant treatment with parenteral therapy. Intravenous antibiotic therapy is the appropriate choice in this patient. Vancomycin remains the first-line therapy for treatment of MRSA in patients requiring parenteral therapy. MRSA Antibiotic Choices Bactrim Taken orally For outpatient use Is a sulfonamide Clindamycin Can be used orally For outpatient use Is NOT a sulfonamide Vancomycin IV drug of choice for MRSA Linezolid Second-line choice if other treatments not working Limited by toxicity and cost

Answer 968

The internal iliac arteries give rise to the umbilical arteries. To be specific, the umbilical arteries arise from the anterior branch of the internal iliac arteries. They represent the dominant outflow of the distal aortic circulation. There are no somatic branches after their origin and, as such, they purely mirror the downstream resistance of the placental circulation. Normal umbilical artery resistance falls progressively through pregnancy, reflecting the increased numbers of tertiary stem villous vessels. During the early stages of embryological development, the umbilical cord develops. It consists of two umbilical arteries and one umbilical vein. It is enclosed inside a tubular sheath of amnion. The umbilical arteries carry deoxygenated blood away from the fetus toward the placenta. After birth, a significant distal portion of the umbilical artery degenerates and later obliterates and eventually becomes a solid fibrous cord, which are termed the medial umbilical ligaments. The proximal portions of the umbilical arteries are the superior vesical arteries. The internal iliac arteries later give rise to the superior vesical arteries that supply the urinary bladder and ureters, as well as the ductus deferens and seminal vesicles in males. The umbilical cord is a vital structure for the entire period of development since it functions to tether the fetus to the placenta and the uterine wall while also acting as the primary route to enable blood to circulate between the fetus and placenta.

Answer 969

A surrogate decision is a decision made for an incapacitated patient by a family member or close friend who knows the patient well but has not been legally appointed by the court. In order for a patient to make a decision on her own behalf, she must have capacity. Capacity is the ability to understand the information provided, express a preference, and evaluate the consequences of either accepting or refusing treatment in a rational manner. In this case, the patient does not have capacity, as she is unconscious and unable to express a preference. For patients who are incapacitated, different types of decisions can be made on their behalf. A health care agent, also referred to as a durable power of attorney, is someone legally appointed to make medical decisions on behalf of a patient. Patients can also create a living will, a document that gives specific instructions regarding the medical care, or treatments, that they would or would not want. Surrogate Decision Decision made for incapacitated patient by family/friend who knows patient but has not legally been appointed Durable Power of Attorney Someone legally appointed to make medical decisions on behalf of a patient Living Will Document providing specific instructions regarding medical care/treatment desired by patient

Answer 970

Most of the oxygenated blood in the fetal circulation comes from the umbilical vein, which receives oxygenated blood directly from the placenta (see the illustration below). The umbilical vein then distributes this highly oxygenated blood evenly (50/50) between the ductus venosus and the hepatic-portal venous system that supplies the liver. The ductus venosus then connects directly to the inferior vena cava, which carries deoxygenated blood from the inferior portion of the fetus. The vena cava then delivers this mix of oxygenated and deoxygenated blood to the right atrium.

Answer 971

Wrong-site surgery refers to any surgical procedure performed on the wrong patient, wrong body part, or wrong side of the body,or at the wrong level of the correctly identified anatomic site. The following terms can be used to describe the various errors: Wrong-patient surgery describes a surgical procedure performed on a different patient than the one intended to receive the operation. Wrong-side surgery indicates a surgical procedure performed on the wrong extremity or side of the patient's body (e.g., the left ovary rather than the right ovary). Wrong-level surgery and wrong-part surgery indicate surgical procedures that are performed at the correct operative site but at the wrong level or part of the operative field or patient's anatomy. The Joint Commission has identified the following factors as contributing to an increased risk of wrong-site surgery: Multiple surgeons involved in the case Multiple procedures during a single surgical visit Unusual time pressures to start or complete the procedure Unusual physical characteristics, including morbid obesity or physical deformity

Answer 972

The branches of the abdominal aorta in descending order are: celiac trunk, superior mesenteric artery, ovarian arteries, and inferior mesenteric artery. The abdominal aorta begins as it enters the abdomen at the T12 level and ends at the bifurcation into the common iliac arteries at the L4 level. The azygos vein and thoracic duct accompany the aorta through the diaphragm. The major branches of the abdominal aorta as it descends are the celiac trunk, superior mesenteric artery, renal arteries, ovarian arteries, and then the inferior mesenteric artery. When discussing venous return, it is important to remember the right ovarian vein drains into the inferior vena cava, and the left ovarian vein drains into the left renal vein.

Answer 973

The urogenital sinus gives rise to the bladder (except the trigone), bulbourethral glands, urethra, and lower two-thirds of the vagina. Answer A: The bulbourethral glands are formed from the urogenital sinus, along with the distal two-thirds of the vagina. Answer B: The mesonephric duct regresses in the female fetus, and the paramesonephric ducts persist, giving rise to the oviducts, uterus, and upper one-third of the vagina. Answer C: The paramesonephric ducts persist to give rise to the oviducts, uterus, and upper one-third of the vagina. They do not contribute to the lower two-thirds of the vagina. Answer D: The urethra is not involved with the formation of the distal two-thirds of the vagina.

Answer 974

A number of physiologic changes occur in the respiratory tract during pregnancy, in order to accommodate the growing fetus and provide an adequate amount of oxygen. The subcostal angle increases and the diaphragm rises about 4 cm, starting in the first trimester. Progesterone is a central stimulant of respiratory drive, and most likely changes the homeostatic set points in the brainstem during pregnancy. There is an increase in tidal volume and respiratory rate, which results in an increase in minute ventilation and respiratory alkalosis. There is an increase in inspiratory capacity, likely a compensatory mechanism in order to meet increasing oxygen demands. Oxygen consumption increases by approximately 20% during pregnancy, in order to provide for the growing fetus and placenta. PaO2 during pregnancy increases from 100 to 110 mm Hg as more oxygen is required. A respiratory parameter that decreases during pregnancy is functional residual capacity, in part due to the upward shift in the diaphragm. Answer B: Inspiratory capacity increases with normal pregnancy. Answer C: Minute ventilation increases with normal pregnancy. Answer D: PaO2 increases with normal pregnancy. Answer E: Tidal volume increases with normal pregnancy.

Answer 975

Sepsis is currently understood as a “life-threatening organ dysfunction caused by a dysregulated host response to infection” and remains a leading cause of maternal mortality. Gram-positive bacteria, including Streptococcus, Pneumococcus, and Staphylococcus, are the most common causes of sepsis in the United States. Methicillin-resistant Staphylococcus aureus (MRSA) is not a common etiology of gram-positive bacteria leading to sepsis, although it may continue to increase in prevalence. Sepsis is defined as the presence (probable or documented) of infection together with systemic manifestations of infection. These may include fever, altered mental status, tachypnea, tachycardia, leukocytosis, end-organ dysfunction, hyperglycemia, and hypotension. In the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) from the Society of Critical Care Medicine and the Society of European Intensive Care Medicine, the terms systemic inflammatory response syndrome and severe sepsis were abandoned in favor of simply using the following categories of infection, sepsis, and septic shock: Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) Infection Infection + lack of organ dysfunction Sepsis Infection + organ dysfunction Septic Shock Infection + vasopressor support to maintain mean arterial pressure >65 mmHg, serum lactate >2 mmol/L The above changes in terminology should not delay treatment for pregnant women who have infections as they still require prompt attention, broad-spectrum antibiotic therapy, and fluid resuscitation.

Answer 976

Cystic fibrosis is an autosomal recessive disorder caused by a mutation in the chloride channel on the epithelial cell membrane. This channel is called the cystic fibrosis transmembrane conductance regulator (CFTR), and when the long arm of chromosome 7 undergoes a frameshift mutation in cases of cystic fibrosis, chloride can no longer be transported across this altered channel. Thus, thick mucous secretions build up in the affected organs. There are hundreds of mutations on the long arm of chromosome 7 that can lead to cystic fibrosis, but the most common is ΔF508. Of note, the carrier rate in the Caucasian and Ashkenazi Jewish populations is 1:25. Cystic fibrosis is uncommon in African and Asian American populations, with a carrier rate of 1:65 and 1:94, respectively. All patients pregnant or thinking about becoming pregnant, regardless of their ethnicity, should be told about cystic fibrosis screening. Patients who should be strongly encouraged to undergo carrier testing are those with a family history of cystic fibrosis and partners of those with cystic fibrosis. In addition, anyone with a family history of congenital absence of the vas deferens should be encouraged to undergo carrier screening because 50% of those with congenital absence of the vas deferens have cystic fibrosis. Screening can be done via 2 different strategies. One option is to first test the mother of the child, and if she screens positive, then test the father. Another option is to test both the mother and father at the same time. Regardless, all patients should be aware that cystic fibrosis carrier screening is available.

Answer 977

ACE inhibitors should be used for patients with hypertension and diabetes because they may protect against the progression of albuminuria and may protect against diabetic nephropathy.

Answer 978

In pregnancy some women may complain of physiologic dyspnea, which is an increased awareness of a desire to breathe. The mechanism is thought to be increased tidal volume that lowers the blood PCO2 slightly (respiratory alkalosis), which paradoxically causes dyspnea. This increased respiratory effort is thought to be induced in large part by progesterone, which directly stimulates the respiratory center in the central nervous system. Several cardiopulmonary changes occur with pregnancy. These include: increased cardiac output (+45%) increased heart rate (+17%) decreased systemic vascular resistance (-21%) decreased pulmonary vascular resistance (-34%) Specifically, several changes in the respiratory system occur mainly due to rising of the diaphragm, effects of progesterone, and decreased arterial oxygen content. These pulmonary changes include: decreased functional residual capacity (responsible for more shallow breathing) decreased total lung capacity decreased residual volume decreased expiratory reserve volume increased inspiratory capacity increased tidal volume The respiratory rate, mean arterial pressure, and lung compliance do not change significantly with pregnancy. Answer A: Cardiac output increases in pregnancy by approximately 45%. Answer B: Minute ventilatory volume increases in pregnancy. Answer D: Tidal volume increases in pregnancy. Answer E: Respiratory rate does not change with pregnancy.

Answer 979

Mitral valve stenosis impedes blood flow from the left atrium to the left ventricle. The most common complaint is dyspnea from pulmonary hypertension and edema. Labor is a particularly stressful time for patients with these cardiac lesions because an increase in heart rate decreases diastolic filling times. It is best to prevent these patients from having a tachycardic rhythm. Diuretics should be given if fluid overload is suspected. Oftentimes, epidural anesthesia is recommended to decrease pain and keep the heart rate lower. Induction of labor is recommended so that care can be coordinated among an experienced multidisciplinary team. Avoiding an increase in preload is absolutely the most important factor, so fluid restriction is key to proper management.

Answer 980

The endometrium prepares for the implantation of the blastocyst under the influence of estrogen and progesterone. It develops large stromal cells with edema and glands filled with glycogen. This endometrium is called the decidua and is shed at the end of pregnancy with delivery of the fetus. There are three types of decidua. The decidua the blastocyst implants into is the decidua basalis. The decidua that covers the blastocyst is the decidua capsularis. The rest of the decidua is the decidua parietalis. When the embryo reaches about the 3rd to 4th month of pregnancy and fills the uterine cavity, then the capsularis and parietalis fuse, essentially sealing off the endometrial cavity.

Answer 981

The perineal body is composed of interlacing fibers of the superficial transverse perineal muscles, bulbocavernosus, and fibers of the external anal sphincter. The perineal body is the central point of the perineum and separates the urogenital triangle from the anogenital triangle.

Answer 982

The superficial epigastric artery is a small branch that crosses the inguinal ligament and runs to the region of the umbilicus. The superficial circumflex iliac artery is a small branch that runs up to the region of the anterior superior iliac spine.

Answer 983

The intricacies of fertilization and implantation are complex and require multiple events to occur in a defined timeline. First, ovulation must occur, and the secondary oocyte must be picked up by the fimbria of a fallopian tube. Next, spermatozoa must be present in the fallopian tube at the time the oocyte is picked up by the fimbria. Fertilization typically then occurs in the isthmus-ampulla junction portion of the fallopian tube. The fertilized oocyte, now called a zygote, consists of 2 cells and a polar body. The 2 cells are called blastomeres. Cell division of the blastomeres continues slowly as the cell mass travels down the fallopian tube. The cell mass is called a morula when it enters the uterine cavity. At approximately the 50- to 60-cell stage, the cell mass is now termed a blastocyst, which consists of an inner cell mass surrounded by cells called trophoblasts. The blastocyst secretes interleukins and human chorionic gonadotropin (hCG) to assist in preparing the endometrium for successful implantation of the blastocyst. The blastocyst then implants at approximately day 7–9 after fertilization. Implantation is divided into 3 stages: apposition, adhesion, and invasion. The blastocyst is between 100 and 250 cells at the time of uterine wall invasion. Answer A: Fertilization occurs at the isthmus-ampulla junction. About 1 day after fertilization, the embryo starts to produce hCG. Answer B: Two days after fertilization, the embryo, called a cleavage-stage embryo, is traveling down the fallopian tube toward the uterus. Answer C: Four days after fertilization, the embryo, called a morula at this stage, is traveling down the fallopian tube toward the uterus. Answer E: 10 days after fertilization, the embryo, called a blastocyst at this stage, is already implanted in the uterus.

Answer 984

Early pregnancy loss is defined as a nonviable, intrauterine pregnancy with either an empty gestational sac or a gestational sac containing an embryo or fetus without fetal heart activity within the first 12 6/7 weeks of gestation. The most common cause of first trimester spontaneous loss is sporadic chromosomal error. Most pregnancy losses after 8 weeks occur in the following 2 gestational months. This can be deduced from loss rates being only 1% in women confirmed by ultrasound to have viable pregnancies at 16 weeks. Early pregnancy loss is common, occurring in 10% of all clinically recognized pregnancies. Approximately 80% of all cases of pregnancy loss occur within the first trimester. Approximately 50% of all cases of early pregnancy loss are due to fetal chromosomal abnormalities. The frequency is probably higher because if one analyzes the chorionic villi recovered by chorionic villus sampling immediately after ultrasound diagnosis of fetal demise (rather than culturing spontaneously expelled products) the chromosomal abnormalities are detected 75–90%. A recent article analyzed cytogenetics of over 100 embryos and found that 50.1% of first-trimester miscarriages in the studied group had chromosomal abnormalities: 59.7% of trisomies, 22% of poliploidies, 7.5% of monosomies, 7% of unbalanced structural abnormalities, and 3.8% of multiple aneuploidies. Chromosome 16 is the most common trisomy in spontaneous first trimester abortion, occurring in more than 7% of cases. Trisomy 22 is the next most common. Trisomy 21 is only slightly less common. Most commonly identified chromosomal abnormalities in first-trimester miscarriages Trisomies 59.7% Poliploidies 22% Monosomies 7.5% Unbalanced structural abnormalities 7% Multiple aneuploidies 3.8% The most common risk factors identified among women who have experienced early pregnancy loss are advanced maternal age and a prior early pregnancy loss. The frequency of clinically recognized early pregnancy loss for women aged 20–30 years is 9–17%, and this rate increases sharply from 20% at age 35 years, to 40% at age 40 years, and 80% at age 45 years.

Answer 985

The contents of the superficial perineal space are as follows: the corpora cavernosa of the clitoris, the corpus spongiosum of the vestibular tissue, ischiocavernosus, bulbospongiosus, superficial transverse perinei, branches of the pudendal vessels and nerves, as well as the urethra and vagina. The levator ani are made up of the pubococcygeus, iliococcygeus, and puborectalis muscles. They are part of the pelvic floor and are not part of the superficial perineal space. Answer A: The ischiococcygeus (or coccygeus) is located posterior to the levator ani and therefore is not within the superficial perineal space. Answer B: The deep transverse perinei are located in the deep perineal space, not the superficial perineal space. Answer C: The pubococcygeus is part of the levator ani and is therefore not located within the superficial perineal space. Answer D: The pudendal nerves and vessels, not the obturator nerve, is located within the superficial perineal space. Bottom Line: The contents of the superficial perineal space are as follows: the corpora cavernosa of the clitoris, the corpus spongiosum of the vestibular tissue, ischiocavernosus, bulbospongiosus, superficial transverse perinei, branches of the pudendal vessels and nerves, as well as the urethra and vagina.

Answer 986

A discrete variable is a variable that can take on only finite, distinct values. Examples include counts of things, such as number of children, number of units in an apartment building, and parity. Parity cannot take on values such as 1.2 or 1.3 but rather only distinct and finite values such as 1, 2, and 3. Continuous variables can have an infinite number of possible values and are usually measurements. Examples include height, weight, age and, in this case, bile acid level.

Answer 987

The fetus begins synthesizing thyroid hormone at 12 weeks' gestation. During the 10th–12th weeks of gestation, fetal TSH is first released, and the fetal thyroid is capable of concentrating iodine and synthesizing iodothyronines. However, fetal thyroid hormone synthesis does not increase dramatically until the 18th–20th weeks of gestation. Maternal T4 is transferred to the fetus throughout pregnancy, which is especially important for normal fetal brain development before the fetal thyroid gland begins producing thyroid hormone. At delivery, approximately 30% of the T4 in umbilical cord serum is maternal in origin.

Answer 988

Marfan syndrome is inherited by an autosomal dominant mode of inheritance. This child's father would need to have genetic testing or pedigree to determine the risk of the baby having Marfan syndrome. If he is homozygous for the allele, the child would have a 100% likelihood of having the disease. If he is heterozygous, meaning with one recessive allele, his child would have a 50% chance of having the disease.

Answer 989

Metabolic syndrome describes a set of risk factors for both cardiovascular disease and type 2 diabetes mellitus. The Adult Treatment Panel III (ATP III) criteria are the most widely used. The presence of any 3 of the following 5 traits defines metabolic syndrome in women: 1. Abdominal obesity, defined as a waist circumference ≥88 cm (35 in.) 2. Serum triglycerides ≥150 mg/dL (1.7 mmol/L) or drug treatment for elevated triglycerides 3. Serum high-density lipoprotein (HDL) cholesterol <50 mg/dL (1.3 mmol/L) or drug treatment for low HDL cholesterol 4. Blood pressure ≥130/85 mm Hg or drug treatment for elevated blood pressure 5. Fasting plasma glucose ≥100 mg/dL (5.6 mmol/L) or drug treatment for elevated blood glucose The purpose of identifying individuals with metabolic syndrome is to target them for aggressive lifestyle modifications to prevent the sequelae of type 2 diabetes mellitus and cardiovascular disease.

Answer 990

Neural tube defects are a prime example of a genetic condition that has been significantly decreased with fortification of commonly consumed foods. The inheritance pattern of neural tube defects is considered multifactorial, meaning the environment, genetics, ethnicity, family history, etc., all play a role in inheritance. The neural plate first forms during the third week of gestation. The neural plate gives rise to the neural folds, which fuse at 6 weeks' gestation (after the last menstrual period) to close the neural tube. Public health initiatives, including the fortification of cereal and recommending prenatal vitamins with folic acid, have drastically reduced the incidence of neural tube defects. The Food and Drug Administration began mandating grain cereals be fortified with folic acid in 1998. This is an effort to ensure reproductive-aged women consume an additional 200 μg per day of folic acid. Also, all reproductive-aged women should take a prenatal vitamin with at least 400 μg to reduce the risk of having a child with a neural tube defect.

Answer 991

The interspinous diameter is the smallest dimension of the female pelvis. It is measured between the ischial spines and is located in the midpelvis.

Answer 992

Methyldopa, or Aldomet, is an older medicine used in the pregnant population. Methyldopa has a known toxicity, in that extended use can lead to a positive Coombs test. Methyldopa requires multiple doses per day, and a large number of women will require additional medications because methyldopa alone is not effective in controlling hypertension during pregnancy. The Coombs reaction is caused by an anti-gamma reaction, leading to a false-positive result.

Answer 993

ACOG recommends against using magnesium sulfate for more than 48 hours in women between 24 and 34 weeks' gestation. Common side effects from magnesium sulfate include diaphoresis, nausea, vomiting, flushing, and benign fetal heart rate changes such as decreased variability and a lower heart rate baseline. Magnesium sulfate is exclusively excreted by the kidney, and levels are typically followed clinically by evaluating urine output (surrogate measure of glomerular filtration rate) and deep tendon reflexes. The first sign of magnesium sulfate toxicity is loss of deep tendon reflexes. This tends to occur at serum concentrations of 7–10 mEq/L. At this same level, breathing often becomes labored, and above 10 mEq/L, respiratory paralysis ensues. Cardiac arrest occurs at serum levels >25 mEq/L. The antidote for magnesium toxicity is 1 g of calcium gluconate or calcium chloride administered intravenously. Signs of Magnesium Toxicity Serum Magnesium Levels Loss of deep tendon reflexes 7–10 mEq/L Respiratory depression >12 mEq/L Cardiac arrest >25 mEq/L

Answer 994

Patients infected with acute hepatitis B, C, or D may have resolution of their symptomatic infection or become lifelong chronic carriers of viral infection. In the United States, hepatitis C is the leading cause of chronic liver disease. At least 50% of individuals infected with hepatitis C virus (HCV) progress to a chronic infection, whereas only 10%–15% of patients with hepatitis B infection become chronically infected. Hepatitis D is a chronic infection; however, the hepatitis D virus is an incomplete viral particle and causes disease only in the presence of HBV, making it much less prevalent. Hepatitis A and E do not lead to chronic infections. Chronic HCV infection is associated with an increased risk of developing both B-cell lymphomas and cryoglobulinemia. Although at least 20% of HCV infections will result in liver cirrhosis, it is unclear if HCV has any association with the development of hepatocellular carcinoma.

Answer 995

The Rh D antigen has been reported as early as 38 days after conception. This corresponds to 7w3d (52 days pregnant). Fetal blood cells are first made in the yolk sac. Later on, they are made in the liver, spleen, and finally the bone marrow. For this reason, ACOG says that the administration of Rh D immune globulin should be considered for women with 1st trimester miscarriage.

Answer 996

Infectious endocarditis (IE) is a rare but life-threatening complication in women with congenital heart disease. IE results from a complex interaction between bloodstream pathogens and matrix molecules and platelets at sites of endocardial cell damage. In patients at highest risk for IE, antibiotic prophylaxis is recommended. This patient is at high risk for IE due to her prosthetic pulmonary valve. Viridans group streptococcus is the most common pathogen associated with infectious endocarditis after invasive dental procedures. Though resistance rates can be as high as 30%, oral amoxicillin (2 grams for adults) is the antibiotic of choice for dental procedures because it is well absorbed in the GI tract, it provides high and sustained serum concentrations, and it is impractical to recommend prophylaxis with only those antibiotics, such as vancomycin or a fluoroquinolone, that are highly active in vitro against viridans group streptococcus. Indications for Endocarditis Prophylaxis Patients with prosthetic cardiac valve or prosthetic material used for cardiac valve repair Patients with previous infective endocarditis Patients with congenital heart disease (CHD) Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (both of which inhibit endothelialization) Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve Bottom Line: Amoxicillin is the antibiotic of choice for infectious endocarditis prophylaxis during dental procedures. In those with a non-anaphylactic allergy to penicillins, cephalosporins can be used. In those with anaphylactic reactions to penicillins or an allergy to cephalosporins, clindamycin can be used.

Answer 997

New surgical equipment and techniques are constantly developed to improve the quality of care. It is important to remember patient safety when new surgeons would like to implement new techniques. An applicant who desires to implement a new surgical procedure should be proctored by a more experienced surgeon in their own facility. If this is not available, then arrangements should be made for the applicant to go to another hospital and be proctored, or temporary privileges be granted to a surgeon at another facility to visit and provide supervision.

Answer 998

Progesterone causes relaxation of smooth muscle which leads to relaxation of the bladder wall, dilation of the ureters, and urinary stasis. These changes in the urinary system place pregnant patients at increased risk of developing urinary tract infections. Hydroureter and hydronephrosis also occur in pregnancy, and are attributed to hormonal effects as well as mechanical compression of the ureters by the growing uterus.

Answer 999

Cardiac output (heart rate x stroke volume) and plasma volume increase during pregnancy as a result of increases in estrogen and progesterone and the activation of the renin-angiotensin-aldosterone system. Pregnancy is associated with decreased systemic vascular resistance and lower blood pressure readings when compared with prepregnancy state. The increase in cardiac output, along with the increase in uterine artery diameter, leads to increased uterine artery blood flow to reach up to 750 mL/minute at term which represents approximately 15% of the cardiac output. Bottom Line: Pregnancy is associated with increased cardiac output and plasma volume, and decreased systemic vascular resistance. The increase in cardiac output, along with the increase in uterine artery diameter, leads to increased uterine artery blood flow to reach up to 750 mL/minute at term which represents approximately 15% of the cardiac output.

Answer 1000

Combined estrogen-progestin oral contraceptives (COCs) are the first-line option in the treatment of hirsutism. Additional therapy is often needed. Other therapies such as finasteride, flutamide, and spironolactone involve inhibition of the testosterone receptor or the formation of testosterone. Because these drugs are teratogenic, they should be given with adequate contraception. Answer A: Finasteride has a well-documented risk of teratogenicity in male fetuses; therefore, adequate contraception should be used. Finasteride inhibits 5-alpha-reductase type 2, the enzyme that converts testosterone to dihydrotestosterone (DHT). If inadvertently used in early pregnancy, there is a substantial risk of preventing the development of normal male external genitalia given the essential role of DHT in the development of male external genitalia. Answer E: Spironolactone can bind to the androgen receptor as an antagonist and can prevent steroidogenesis in the adrenal gland and ovary, resulting in reducing unwanted hair growth. Because spironolactone is a potassium-sparing diuretic, it should be used cautiously in patients with renal impairment due to the risk of hyperkalemia. Answer D: Topical eflornithine is FDA-approved for the treatment of female facial hirsutism. Eflornithine in combination with laser hair removal is superior to laser hair removal alone in the reduction of unwanted facial hair. Topical eflornithine is an inhibitor of hair growth, not a depilatory, and it must be used indefinitely to prevent regrowth. Local burning and erythema are potential side effects.

Answer 1001

The best next step in the evaluation of this patient of Southeast Asian descent with evidence of microcytic anemia and normal iron studies is to perform a hemoglobin electrophoresis. The first step is to perform a complete blood count (CBC) with red blood cell (RBC) indices. Patients of African descent should then obtain a hemoglobin electrophoresis to assess for sickle cell anemia. Meanwhile, patients of Southeast Asian or Mediterranean descent with evidence of anemia (reduced mean corpuscular volume [MCV] and normal iron studies) should undergo a hemoglobin electrophoresis. The hemoglobin electrophoresis will either show evidence of a hemoglobinopathy (Hb AS, SS, SC, elevated A2) or will be normal. If the patient is of Southeast Asian descent and the hemoglobin electrophoresis results as normal, the patient should be evaluated for α-thalassemia via molecular genetic testing.

Answer 1002

Magnesium sulfate is administered to patients with preeclampsia for prophylaxis against associated seizures. It is also administered for fetal neuroprotection in a patient who is preterm labor prior to 32 weeks gestation. It is thought that seizure prophylaxis is achieved by membrane stabilization in the central nervous system. There are a number of side effects of the drug, which can occur depending on the drug level in the system. Therefore, it is important to carefully monitor a patient's magnesium level while they are being treated. A common side effect when it is initially given, if given as a rapid infusion, is flushing. Other side effects, such as loss of deep tendon reflexes, can occur at higher blood serum levels. At critically high levels of the drug, cardiovascular collapse can occur. Answer A: Drowsiness is a side effect of magnesium sulfate; however, it is not a result of rapid infusion. Answer B: Dyspnea can be related to pulmonary edema, a rare side effect of magnesium sulfate. It is not related to rapid infusion. Answer D: Loss of reflexes are a side effect of magnesium sulfate, but are not a result of rapid infusion. Answer E: Pulmonary edema is a rare side effect of magnesium sulfate, but is not usually related to rapid infusion.

Answer 1003

A midline episiotomy is sometimes required to expedite delivery. Understanding pelvic floor anatomy is critical for ensuring an appropriate episiotomy and repair. Underlying the skin are the muscle and fascial supports of the perineum. A midline episiotomy extends from the vaginal orifice caudad toward the anus, in the central point of the perineum and extending to the transverse perineal muscles (superficial and deep). The two muscles are in close approximation and are usually not identifiable as 2 separate entities. The perineal body is a strong, fibrous connection of several muscles and is superficial to both transverse perineal muscles. In a mediolateral episiotomy, the bulbospongiosus muscle is incised as well.

Answer 1004

The internal iliac artery is one of the major branches that supply the pelvis. It has anterior and posterior divisions. The branches of the anterior division in the female are the superior vesical, middle vesical, inferior vesical, middle hemorrhoidal, obturator, internal pudendal, sciatic, uterine, and vaginal arteries. The vaginal artery can also branch from the uterine artery, and some textbook illustrations show the vaginal artery branching off the uterine artery.

Answer 1005

The exact prevalence of domestic violence is difficult to know because many victims are afraid to disclose their personal experiences of violence. However, more than 1 in 3, or approximately 30%, of women in the United States report experiencing rape, physical violence, or stalking by a partner during their lifetime. More than 4.8 million incidents of physical or sexual assault are reported annually, and more than 250,000 hospital visits occur each year as a result of domestic violence. In 2007, domestic violence resulted in the deaths of 1,640 females and 700 males.

Answer 1006

Increased estrogen production during pregnancy contributes to the rise in angiotensinogen, a renin substrate, which is important for maintaining blood pressure, particularly during the first trimester. Angiotensinogen is produced by the maternal and fetal livers. The renin-angiotensin-aldosterone system is crucial for maintaining blood pressure, in both the pregnant and nonpregnant state. During pregnancy, all components of this system are increased. Renin levels are increased, as renin is produced by both the maternal kidneys and placenta.

Answer 1007

15-methyl prostaglandin F2-alpha was approved more than 25 years ago for uterine atony. It is given intramuscularly. The dose may be repeated up to 8 times every 15–90 minutes if needed. It is very effective at controlling bleeding from uterine atony. Side effects include diarrhea, flushing, hypertension, tachycardia, nausea, or vomiting. Additionally, bronchospasm may occur, so this medication is contraindicated in patients with a history of asthma.

Answer 1008

The fetus is in a persistent occiput transverse position. This occurs when flexion is not maintained and the occipitofrontal diameter becomes caught at the narrow bispinous diameter of the outlet. This phenomenon is associated with a platypelloid pelvis. With a platypelloid pelvis, the wide transverse axis of the pelvic inlet readily accommodates the occipitofrontal diameter of the fetal head as it descends in the pelvis, resulting in occiput transverse position. Answer A: In an android pelvis, the forepelvis is narrow and the occiput tends to occupy the roomier hindpelvis. Right or left occipitoposterior presentations are more common with this pelvic shape. Answer B: The oval shape of the anthropoid pelvis, with its narrow transverse diameter, favors a direct occipitoposterior position. Answer C: This is not one of the four pelvic types based on Caldwell-Moloy classification. Answer D: A gynecoid pelvis has rounded anterior and posterior segment and is the classic female pelvis type; it is most favorable for vaginal birth.

Answer 1009

Myasthenia gravis is an autoimmune phenomenon that results in weakness of the skeletal muscles. The weakness is due to dysfunction at the neuromuscular junction, secondary to autoantibodies binding postsynaptic acetylcholine receptors. This results in an intermittent weakness of the limb, respiratory, and other skeletal muscles. In females, development is predominant in the second and third decades of life. Magnesium sulfate interferes with neuromuscular transmission by inhibiting the release of acetylcholine from the presynaptic membrane. Patients with underlying disorders at the synaptic junction, such as myasthenia gravis, are very sensitive to magnesium-induced muscular weakness. Magnesium sulfate infusion in patients with myasthenia gravis can lead to myasthenia crisis and is therefore contraindicated.

Answer 1010

Wrong-site surgery refers to any procedure performed on the wrong patient, wrong body part, wrong area of the body, wrong side, or at the wrong level of an anatomic site. The Joint Commission identified the following risk factors for wrong-site surgery. Risk Factors for Wrong-Site Surgery Multiple surgeons involved in a case Multiple procedures during a single surgical visit Unusual time pressures to start or complete a case Unusual surgical characteristics such as deformity or morbid obesity

Answer 1011

Uterine blood flow increases during pregnancy with an estimated 500 to 750 mL/min of blood delivered to the uterus at term, which is up to 10–15% of maternal cardiac output. Adequate perfusion of the placental villous interspace is necessary to support the growth and metabolism of both the infant and placenta. To achieve this increased perfusion, the vessels that supply the uterus widen and elongate yet preserve their contractile function, and the spiral arteries, which directly supply the placenta, vasodilate but lose contractility. Given that blood flow increases proportionally to the fourth power of the radius of a vessel, it is this vasodilation that allows such enormous increases in uterine blood flow during gestation. Anatomical Changes in the Uterus During Pregnancy Increase in uterine weight: 70 g prepregnancy to 1100 g at term Increase in uterine capacity: 10 mL prepregnancy to 5+ L at term Hypertrophy of uterine myocytes Uterine ascent with dextrorotation (likely due to rectosigmoid on the left) Cervical softening and bluish color Hypertrophy and hyperplasia of the cervical glands Increase in uteroplacental blood flow largely due to vasodilation

Answer 1012

The most common side effects of lisinopril use in the 1st and 2nd trimester are related to the renal system. Renal failure with resulting anuria and oligohydramnios may be present in approximately 50% of cases. These findings can then lead to pulmonary hypoplasia and respiratory disease at birth. These are the reasons all angiotensin-converting enzyme (ACE) inhibitors are contraindicated in pregnancy. Lisinopril is known to cross the placenta. Fetal circulation has low perfusion pressure, requiring high levels of angiotensin II levels to maintain a proper glomerular filtration rate (GFR). Lisinopril rapidly reduces angiotensin II levels, thereby reducing GFR. This reduced renal flow then leads to the findings explained above. These changes have led to chronic kidney disease in infants who have survived to adulthood.

Answer 1013

Low-molecular-weight heparin (LMWH) is generally the anticoagulant of choice during pregnancy if the patient has a history of a high-risk thrombotic disorder (antithrombin III deficiency, homozygous for factor V Leiden, homozygous for G20210a mutation, etc.). It is easier to administer than unfractionated heparin, as it is mainly given subcutaneously. It does not cross the placenta and thus does not result in fetal anticoagulation. LMWH is not recommended for use in patients with renal insufficiency, as clearance of the drug is mainly renal. Unfractionated heparin may be given in this case, as clearance is renal and hepatic. LMWH is preferred over unfractionated heparin in the early weeks of pregnancy because it results in a predictable anticoagulant response. Answer A: LMWH does not cross the placenta. Answer B: LMWH is easily administered subcutaneously. Answer C: LMWH is not recommended for patients with renal insufficiency. Answer E: LMWH does not result in fetal anticoagulation.

Answer 1014

Maternal thyroid abnormalities can be confused with physiologic thyroid changes during pregnancy. Maternal thyroid volume increases 10% to 30% during the third trimester and this is attributable to increases in extracellular fluid and blood volume during pregnancy. In addition, there are changes to thyroid hormone levels and thyroid function throughout pregnancy. Thyroid-stimulating hormone (TSH) decreases in the first 12 weeks of pregnancy. This is because human chorionic gonadotropin (hCG) weakly stimulates TSH receptors → increased thyroid hormone secretion → increased serum free thyroxine (T4) → suppressed hypothalamic thyrotropin-releasing hormone (TRH) secretion → decreased pituitary TSH secretion. After the first trimester, TSH levels return to baseline values and progressively increase in the third trimester. This pattern of TSH levels is related to placental growth and production of placental deiodinase. Thyroid-binding globulin increases, which leads to an increase in maternal total (bound) thyroid hormone levels. Total T3 and T4 levels are markedly increased during pregnancy because of increased serum thyroid-binding globulin levels. Free T3 does not substantially change during pregnancy.

Answer 1015

Patients with hypercalcemia and elevated serum parathyroid hormone levels should undergo thyroid ultrasonography to look for a parathyroid adenoma. Parathyroid adenomas are the most common cause of hyperparathyroidism. Multiple endocrine neoplasias (MENs) should be investigated when a parathyroid adenoma is present. Imaging to evaluate these other tumors is important to patient outcome. Thyroid-stimulating hormone level would not be helpful in this instance because it is often normal, even with medullary thyroid cancer.

Answer 1016

Hemoglobin electrophoresis in a woman without a heterozygous or homozygous hemoglobinopathy will appear as mostly hemoglobin A (>95%) with a small fraction of hemoglobins A2 (2%–3%) and F (1%–2%).

Answer 1017

In recent years (since 2019), falls have been the most commonly reported sentinel event. In 2022, falls were 42% of the total reviewed events. Per the Joint Commission, a sentinel event is “a patient safety event that reaches a patient and results in death, permanent harm, or severe harm”. Each year, causes and outcomes of sentinel events are reviewed and analyzed in order to help organizations gain insight into causes of these events and to help develop strategies to reduce these risks.

Answer 1018

Heparin is an indirect thrombin inhibitor. Heparin binds to antithrombin III, converting this circulating cofactor from a slow to a rapid inactivator of thrombin and factor Xa. The binding of heparin to antithrombin III and thrombin forms a large molecule. This large molecule does not form when low-molecular-weight heparin is used. Low-molecular-weight heparin has a lesser effect on thrombin because most of the molecules are not long enough to simultaneously bind to thrombin and antithrombin III.

Answer 1019

Pulmonary arterial hypertension is associated with an extremely high maternal mortality risk. Pregnancy should be avoided or terminated in these patients. Maternal cardiac disease is now the leading case of death in pregnant and postpartum women and accounts for 4.23 deaths/100,000 live births. In the United States, cardiac disease is responsible for 26.5% of pregnancy-related deaths.

Answer 1020

In normal pregnancy, important physiologic changes are paramount for the obstetrician to understand. There is a physiologic mild respiratory alkalosis in normal pregnancy. This is due to the increased minute ventilation and blowing off of carbon dioxide. The increased minute ventilation occurs because of increased progesterone of pregnancy. Remember, it is increased minute ventilation and not tachypnea that drives this decreased carbon dioxide level. This chronic compensated respiratory alkalosis is reflected in the maternal pH (7.4–7.47 is normal in pregnancy compared with 7.35–7.43 outside of pregnancy). It is importation to understand the pregnancy-induced changes to blood gas values so that interpretation of results is accurate.

Answer 1021

The use of statin drugs with any inhibitor of the P450 isoenzyme 3A4 will increase the concentration of statin drugs that are also metabolized by CYP3A4. This increase in statin drug levels can result in myolysis, rhabdomyolysis, and acute kidney injury. Clarithromycin is one of the antibiotic medications that inhibits the 3A4 isoenzyme and, as a result, should not be used in combination with statin medications. The macrolide class of antibiotics (azithromycin and erythromycin) are all inhibitors of the CYP450 enzyme; however, the isoenzyme has not been identified with azithromycin. The manufacturers of simvastatin warn against the use of their drug with other strong CY3A4 inhibitors such as azoles, HIV protease inhibitors, danazol, cyclosporine, and gemfibrozil. Metformin, levothyroxine, and ibandronate either have no effect on the CYP450 enzyme or their interaction is unknown. Nifedipine is metabolized by the CYP450 enzyme, but the manufacturer of nifedipine recommends using the lowest dose possible when it is given in conjunction with clarithromycin; however, no dosage adjustments are recommended when used with a statin.

Answer 1022

Thyroid-stimulating hormone (TSH) plays a central role in screening for and diagnosing many thyroid disorders. During early pregnancy, TSH level decreases. Human chorionic gonadotropin (hCG) and TSH share identical alpha-subunits with different beta-subunits. As a result of their structural similarity, substantial quantities of hCG during the first 12 weeks of gestation lead to TSH receptor stimulation. Thyroid hormone secretion is thus stimulated, and the resulting increased serum free thyroxine (T4) levels suppress hypothalamic thyrotropin-releasing hormone, which in turn limits pituitary TSH secretion. After the first trimester, TSH levels return to baseline values. During the third trimester, TSH levels progressively increase secondary to placental growth and production of placental deiodinase. Answer A: TSH levels are decreased from baseline during the first 12 weeks of gestation due to the stimulation from high levels of beta hCG. They return to normal in the early second trimester. Answer C: TSH levels start to increase from baseline during the third trimester which is normal process in pregnancy. Answer D: By the third trimester, the thyroid's volume may be 10–15% greater and this coincides with a rise in TSH. Answer E: The TSH increases normally during the third trimester with the enlargement of the thyroid gland and growth of the placenta with increased thyroid hormone production. Bottom Line: Substantial quantities of hCG during the first 12 weeks of gestation lead to thyroid-stimulating hormone receptor stimulation, which results in downregulation of TSH levels from baseline. This effect usually resolves during the second trimester.

Answer 1023

The increase in blood volume in pregnancy is well described. Plasma volume typically peaks at 45% above baseline at term. The average amount is approximately 1,500 to 2,000 mL. This expansion of volume serves many roles, including supporting the growing uterus and fetus as well as protecting the mother during parturition.

Answer 1024

Fever is an uncommon side effect that occurs later in withdrawal, at approximately 48–96 hours after the last drink. It is less common than any of the other side effects of alcohol withdrawal. It can occur along with delirium tremens or on its own. Typically, the fever is a low-grade temperature and is accompanied by hypertension, tachypnea, and diaphoresis. Generally, these symptoms require hospitalization for monitoring and treatment. Expected resolution is in 1–5 days. Answer A: Gastrointestinal distress is a common early symptom of alcohol withdrawal, typically occurring within 6 hours of withdrawal in severe cases. The patient may experience nausea, vomiting, and anorexia. It may occur while the patient still has a significant blood alcohol concentration. Answer B: Hallucinations are a common symptom of withdrawal that develop within 12 to 24 hours of abstinence and typically resolve within 24 to 48 hours. Hallucinations are usually visual, although auditory and tactile phenomena may also occur. A patient may have hallucinations as part of delirium tremens, but this is distinguishable from alcoholic hallucinations by the time frame in which they occur. Answers C & D: Fever often occurs at 48–96 hours after the last drink. Bottom Line: Fever is an uncommon side effect that occurs later in withdrawal, at approximately 48–96 hours after the last drink.

Answer 1025

Approximately 324,000 pregnant women are abused each year in the United States. The severity of violence may also escalate during pregnancy or during the postpartum period. The highest prevalence of domestic violence is seen particularly in the third trimester of pregnancy. In fact, homicide has been reported as a leading cause of maternal mortality, with the majority of perpetrators being current or former intimate partners. Negative consequences attributed to domestic violence in pregnancy poor pregnancy weight gain infection anemia tobacco use stillbirth pelvic fracture placental abruption fetal injury preterm delivery low birth weight Answer A: History of abortion is not a known risk factor for increasing the prevalence of domestic violence in pregnant women. Answer B: History of sexually transmitted infections is not a known risk factor for increasing the prevalence of domestic violence in pregnant women. Answer C: Living with an intimate partner is not known to increase the risk of domestic violence for pregnant women. Answer D: Pregnant women in general are known to experience an increased prevalence of domestic violence; however, because domestic violence commonly escalates during pregnancy, women in the first trimester experience less violence than women in the third trimester.

Answer 1026

Bottom Line: Acute respiratory failure occurs in fewer than 0.1% of pregnancies but is an obstetric emergency with potentially serious maternal and fetal consequences. Knowing when to intubate a patient to maintain appropriate oxygen saturation levels is important to maternal and fetal well-being. Arterial PCO2, as a result of progesterone-induced increased alveolar ventilation, falls from a partial pressure of carbon dioxide and drops from a range of about 36–44 mm Hg to a range of 28–32 mm Hg in pregnancy. Maternal compensation of this respiratory alkalosis is done via renal excretion of bicarbonate; as such, resultant bicarbonate levels are lower in pregnancy. Maternal arterial pH is normal to slightly alkalotic (usually between 7.40 and 7.45). In asthma attacks, hypercapnia is a later finding, typically secondary to increased airway obstruction and fatigue due to increased work of breathing. Pulse oximetry provides no information on the patient's ability to clear CO2, and thus cannot substitute for arterial blood gas evaluation. She is a candidate for intubation to protect both her and the fetus. Clues to the need for an urgent evaluation include those listed below. Signs and Symptoms Indicating Urgent Evaluation heart rate > 120/min respiratory rate > 24/min pulse oxygen saturation (SpO2) < 95% use of accessory respiratory muscles difficulty speaking in full sentences stridor asymmetric breath sounds or percussion diffuse crackles (also known as rales) diaphoresis neck or substernal chest pain cyanosis, hemoptysis depressed or agitated mental status oropharyngeal swelling Answer A: An arterial bicarbonate value of 30 mmol/L is slightly abnormal, and indicative of maternal compensation, but this is not the most indicative of need for intubation and mechanical intubation. In hypercarbic respiratory failure, the primary goal of treatment is to maintain arterial pH at greater than 7.30 with a PaCO2 < 45 mm Hg in the gravid patient. Answer C: A PaO2 of 92 is normal, while a PaO2 < 70 mm Hg would indicate respiratory failure. Answer D: Arterial pH of 7.47 is alkalotic. Pregnancy is a state of slightly respiratory alkalosis and while this value is slightly abnormal, it does not necessitate intubation. Answer E: A sustained respiratory rate of 24 necessitates urgent evaluation, but does not necessarily require intubation.

Answer 1027

Lidocaine toxicity is a rare event, but something that should be carefully monitored in any patient receiving local anesthesia. Systemic toxicity may occur if the recommended dose is exceeded, or if a major vessel is inadvertently injected when administering the medication. The earliest signs of lidocaine toxicity are circumoral numbness and tongue paresthesia. Maximum dose of lidocaine WITHOUT epinephrine: 4 mg/kg Maximum dose of lidocaine WITH epinephrine: 7 mg/kg

Answer 1028

During pregnancy, the diaphragm is displaced superiorly approximately 4 cm. Tidal volume, minute ventilation, and inspiratory capacity all increase in pregnancy. Functional residual capacity decreases in pregnancy. Vital lung capacity is the total lung volume and is composed of the functional residual capacity plus the inspiratory capacity. Although the individual components change, the overall vital lung capacity is unchanged in pregnancy. Answer A: Functional residual capacity is the amount of air remaining after a normal exhalation. This decreases in pregnancy. Answer B: Inspiratory capacity is the maximum amount of air that can be inhaled. This increases in pregnancy. Answer C: Minute ventilation is the amount of gas inhaled in 1 minute. This increases in pregnancy. Answer D: Tidal volume is the amount of air inhaled with a normal respiration. This increases in pregnancy.

Answer 1029

Eisenmenger syndrome is a congenital heart defect with communication between the systemic and pulmonary circulations, eventually resulting in secondary pulmonary hypertension. The most common congenital heart defects that lead to Eisenmenger syndrome are a large ventricular septal defect or an unrepaired patent ductus arteriosus. Increased pulmonary vascular resistance and architectural changes of the right side of the heart make Eisenmenger syndrome dangerous in pregnancy. Eisenmenger syndrome in pregnancy is a serious medical condition that requires a multidisciplinary team approach to reduce the risk of cardiopulmonary arrest and death. Once Eisenmenger syndrome is diagnosed, severe pulmonary vascular damage has already occurred, and corrective surgery of the underlying congenital defect almost uniformly results in the death of the patient. Pregnancy is strongly discouraged because of the extremely high mortality rate for the patient and her fetus. Both the patient and the fetus face a 50% mortality rate. Compression on the inferior vena cava (IVC) from the gravid uterus and hypotension resulting from neuraxial anesthesia are the two most likely obstetrical issues that can lead to a sudden decrease in preload and then cardiopulmonary arrest. Bottom Line: Patients with Eisenmenger syndrome have a 50% risk of dying during their pregnancy and puerperium period. Furthermore, there is a 50% fetal mortality rate. Patients face the highest risk of cardiopulmonary arrest (and death) from any event that causes a reduction in preload.

Answer 1030

The most commonly injured vessels are branches of the pudendal artery, including the inferior rectal, transverse perineal, and posterior labial arteries. Prompt diagnosis, evaluation, and management of a patient with a puerperal hematoma after a delivery is vital to prevent massive blood loss and subsequent coagulopathy. There are 4 different locations of puerperal hematomas: vulvar vulvovaginal paravaginal retroperitoneal Risk factors for the development of puerperal hematomas include: nulliparity episiotomy forceps delivery an underlying coagulopathy Vulvar hematomas are the most common, and the hallmark symptom is incredibly intense pain of the perineum rapidly developing after a vaginal delivery. Other possible symptoms include urinary retention or discolored tense bulging of the vulva. Very small hematomas can be conservatively managed, but surgical exploration may be required for enlarging or unrelenting painful vulvar hematomas. Surgery involves incision and drainage over the tensest area, and then after evacuation of the blood clot, oversewing of the tissue with mattress sutures. The vagina should then be packed for 12 to 24 hours. One-half of those requiring incision and drainage will need a blood transfusion during their postpartum course. Bottom Line: Branches of the pudendal artery (inferior rectal, transverse perineal, and posterior labial) are the most commonly injured blood vessels in a vulvar hematoma.

Answer 1031

The corpus luteum is responsible for progesterone production to support the pregnancy until 10 weeks of gestation. After ovulation, the ruptured follicle collapses and fills with a blood clot, and then forms the corpus luteum. The surrounding granulosa cells enlarge and are now called granulosa-lutein cells. Theca-lutein cells are located between granulosa-lutein cells. Under the control of LH, the corpus luteum produces progesterone. Following LH, hCG begins to be produced, which maintains the health of the corpus luteum and continued progesterone production. On ultrasound, the corpus luteum is often < 2.5 cm and has an echogenic border referred to as "the ring of fire". Grossly, the corpus luteum appears yellow. The corpus luteum is responsible for early first-trimester progesterone production

Answer 1032

The superior border of the femoral triangle is formed by the inguinal ligament, a ligament that runs from the anterior superior iliac spine to the pubis tubercle. The lateral border is formed by the medial border of the sartorius muscle. The medial border is formed by the medial border of the adductor longus muscle. The rest of this muscle forms part of the floor of the triangle. The inguinal ligament acts as a flexor retinaculum, supporting the contents of the femoral triangle during flexion at the hip. The contents of the femoral triangle (lateral to medial) are the femoral nerve, which innervates the anterior compartment of the thigh, and provides sensory branches for the leg and foot; the femoral artery; and the femoral vein.

Answer 1033

Serum potassium is generally decreased in the setting of nausea, vomiting, and dehydration due to decreased intake combined with ongoing potassium excretion. Antidiuretic hormone (ADH) is released from the posterior pituitary in response to dehydration. Serum sodium is conserved via reuptake in the kidneys, and in combination with increased serum osmolality, hypernatremia results. Urine output is decreased due to increased ADH, resulting in increased urine osmolality.

Answer 1034

Defects as a result of isotretinoin use include external ear malformations, cleft palate, micrognathia, conotruncal heart defects, ventricular septal defects, aortic-arch malformations, and certain brain malformations. Even short-term exposure to the drug has the potential to cause these fetal consequences. Isotretinoin is a known teratogen and has been disclosed as such since 1983. It is now categorized as FDA Category X. Early pregnancy loss is also a potential consequence of exposure. Women on this medication are required to use two forms of contraception.

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