Abnormal Obstetrics 2

Front 1

A 27 year-old G1P0 at 14 weeks gestation presents with a 2-month history of insomnia, feeling depressed, and unintentional weight loss. Symptoms began after the unexpected death of her father. She is not excited about this pregnancy and reports no suicidal ideation. Physical examination reveals a woman of stated age with a flat affect. Which of the following therapies is contraindicated in this patient?

A. Paroxetine (Paxil)
B. Sertraline (Zoloft)
C. Fluoxetine (Prozac)
D. Nortriptyline (Norpress)
E. Bupropion (Wellbutrin)

Back 1

Paroxetine (Paxil). The most commonly used antidepressants are the selective serotonin reuptake inhibitors (SSRIs.) One SSRI, Paroxetine (Paxil) has recently been changed to a category D drug because of the increased risk of fetal cardiac malformations and persistent pulmonary hypertension. The older SSRI compounds, fluoxetine and sertraline, have not been reported to cause early pregnancy loss or birth defects in animals or in humans. Because these agents have few side effects compared with other antidepressants, they are a good choice for pregnant women. Tricyclic antidepressants have a long record of use in pregnancy and there is no increase in the rate of fetal malformation. Bupropion is not an MAO inhibitor, nor is it an SSRI and a report by the Bupropion Pregnancy Registry reports no unusual effects in 90 exposed pregnancies.

Front 2

An 18 year-old G1P0 presents at 32 weeks for a routine visit. She complains of intense itching for the past 2 weeks and cannot stop scratching her arms, legs, and soles of her feet. She has tried over the counter lotions and antihistamines with no relief. She also states that her family noticed she is slightly yellow. Her vital signs are normal and there are scattered excoriations over her arms and legs. Which of the following is the best treatment in the management of this patient?

A. Aggressive hydration
B. Antivirals such as Acyclovir
C. Antihistamines
D. Ursodeoxycholic acid
E. Steroids

Back 2

Ursodeoxycholic acid. This patient has pruritus gravidarum, a common pregnancy-related skin condition that is a mild variant of intrahepatic cholestasis of pregnancy. There is retention of bile salt, and as serum levels increase they are deposited in the dermis. This, in turn, causes pruritus. The skin lesions are secondary to scratching and excoriation. Antihistamines and topical emollients may provide some relief and should be used initially. Ursodeoxycholic acid relieves pruritus and lowers serum enzyme levels. Another agent reported to relieve the itching is the opioid antagonist naltrexon. Hydroxychloroquine is used to treat lupus and is not indicated in this patient.

Front 3

A 27 year-old G2P1 at 18 weeks gestation presents to the emergency room complaining of fever, nausea, vomiting, and mid-abdominal pain for the last 24 hours. For the last 12 hours, she has had no appetite. She has been healthy, but reports that her 3 year-old son has had diarrhea for 2 days. Physical examination reveals a blood pressure of 100/60, pulse 88, respiratory rate 18, and temperature 102.0°F (38.9°C). Abdominal examination reveals decreased bowel sounds and tenderness more pronounced on the right than the left. Which of the following is the next best step in the management of this patient?

A. Check a complete blood count
B. Abdominal and pelvic ultrasound
C. Plain abdominal radiograph
D. Helical computed tomography
E. Graded compression ultrasound

Back 3

Graded compression ultrasound. Suspected appendicitis is one of the most common indications for surgical abdominal exploration during pregnancy. The diagnosis of appendicitis is more difficult to make in pregnancy because anorexia, nausea, and vomiting that accompany normal pregnancy are also common symptoms of appendicitis. In addition, the enlarged uterus shifts the appendix upward and outward toward the flank, so that pain and tenderness may not be located in the right lower quadrant. Appendicitis is easily confused with preterm labor, pyelonephritis, renal colic, placental abruption, or degeneration of a uterine myoma. Peritonitis and appendiceal rupture are more common during pregnancy. The diagnosis is made based on clinical findings and graded compression ultrasonography

Front 4

A 36-year-old G5P4 woman with no prenatal care presented in active labor with a blood pressure of 170/105 and 3+ proteinuria. Fundal height is 28 cm. Fetal heart tones were found to be in the 170s with decreased variability and a sinusoidal pattern. Resting uterine tone was noted to be increased and she was having frequent contractions (every 1-2 minutes). The patient complained of bright red vaginal bleeding for the past hour. Based on this history, what is the most likely etiology of her vaginal bleeding?
A. Uterine rupture
B. Placenta previa
C. Bloody show
D. Abruption placenta
E. Cervical trauma

Back 4

Abruption placenta. Although all the options above can result in third trimester vaginal bleeding, the most likely cause in this patient is placental abruption. This diagnosis goes along with the tachysystole on tocometer and evidence of fetal anemia (tachycardia and sinusoidal heart rate pattern) on the heart rate tracing. Hypertension and preeclampsia are risk factors for abruption. She has no history of cervical trauma.

Front 5

A 28-year-old G2P1 woman presents at 20 weeks gestation for a routine prenatal care visit. This pregnancy has been complicated by scant vaginal bleeding at seven weeks and an abnormal maternal serum alpha fetoprotein (MSAFP), with increased risk for Down syndrome, but had a normal amniocentesis: 46, XX. Her previous obstetric history is significant for a Cesarean delivery at 34 weeks due to placental abruption and fetal distress. Prenatal labs at six weeks showed blood type A negative, antibody screen positive: anti-D 1:64. Which of the following is the most likely cause of the Rh sensitization?
A. ABO incompatibility
B. Placental abruption
C. Amniocentesis
D. Abnormal maternal serum alpha fetoprotein (MSAFP)
E. First trimester bleeding

Back 5

Placental abruption
his patient was sensitized during her first pregnancy that was complicated by abruption and required Cesarean delivery. Transplacental hemorrhage of fetal Rh-positive red blood cells into the circulation of the Rh-negative mother may occur following a number of obstetric procedures and complications, such as amniocentesis, chorionic villus sampling, spontaneous/threatened abortion, ectopic pregnancy, dilation and evacuation, placental abruption, antepartum hemorrhage, preeclampsia, cesarean section, manual removal of the placenta and external version.

Front 6

A 24-year-old Rh-negative G1P1 woman just delivered a healthy term infant who is Rh-positive. You recommend RhoGAM administration but she declines because she does not desire any blood products. What is her approximate risk of isoimmunization if she does not receive the RhoGAM?
A. Less than 20%
B. 40%
C. 60%
D. 80%
E. 100%

Back 6

Less than 20%

Front 7

A 24-year-old Rh-negative G2P1 woman is found at 10 weeks gestation to have anti-D antibodies. You follow her closely during this pregnancy and order serial ultrasound examinations. Which of the following fetal ultrasound findings would be most explained by the presence of Rh disease?
A. Meconium
B. Fetal bladder obstruction
C. Oligohydramnios
D. Pericardial effusion
E. Placenta previa

Back 7

Pericardial effusion. Fetal hydrops is easily diagnosed on ultrasound. It develops in the presence of decreased hepatic protein production. It is defined as a collection of fluid in two or more body cavities, such as ascites, pericardial and/or pleural fluid and scalp edema. On occasion, when extramedullary hematopoiesis is extensive, there will be evidence of hepatosplenomegaly. Placentomegaly (placental edema) and polyhydramnios are also seen on ultrasound. Meconium, fetal bladder obstruction, oligohydramnios and placenta previa do not fit the clinical scenario.

Front 8

A 28-year-old Rh negative G1P0 woman at eight weeks gestation presents to the clinic for a first prenatal visit. Which of the following is the current recommendation for RhoGAM administration to prevent Rh isoimmunization?
A. Routine administration for every Rh-sensitized woman at term
B. Administration for Rh-negative patients with no Rh antibodies at 28 weeks
C. Administration for every Rh-negative woman who delivers an Rh-negative infant
D. Routine administration for all Rh-negative patients during first trimester
E. Routine administration for all Rh-negative patients during each trimester

Back 8

Administration for Rh-negative patients with no Rh antibodies at 28 weeks. The current recommendations for Rh-negative women without evidence of Rh immunization is prophylactically at 28-weeks gestation (after an indirect Coombs’ test) and within 72 hours of delivering an Rh-positive baby, following spontaneous or induced abortion, following antepartum hemorrhage and following amniocentesis or chorionic villus sampling. If the father of the fetus is known to be Rh-negative, RhoGAM is not necessary, since the fetus will be Rh-negative and not at risk for hemolytic disease.

Front 9

A 24-year-old G2P1 woman has a fetus that is affected by Rh disease. At 30 weeks gestation, the delta OD450 (optical density deviation at 450 nm) results plot on the Liley curve in Zone 3 indicating severe hemolytic disease. Which of the following is the most appropriate next step in the management of this patient?
A. Immediate Cesarean delivery
B. Induction of labor
C. Intrauterine intravascular fetal transfusion
D. Umbilical blood sampling
E. Maternal plasmapheresis

Back 9

Intrauterine intravascular fetal transfusion. Correct! Values in Zone 3 of the Liley curve indicate the presence of severe hemolytic disease, with hydrops and fetal death likely within 7-10 days, thus demanding immediate delivery or fetal transfusion. At 30 weeks gestation, the fetus would benefit from more time in utero. An attempt should be made to correct the underlying anemia. Intravascular transfusion into the umbilical vein is the preferred method

Front 10

A 24-year-old G2P1 woman at 30 weeks gestation is sensitized to the D antigen. She is Rh negative and received RhoGAM during her first delivery one year ago. Which of the following statements best explains these findings?
A. The patient initiated her prenatal care late during the present pregnancy
B. The patient was sensitized during the previous pregnancy by receiving the RhoGAM
C. Current pregnancy is too close to the first pregnancy
D. The amount of fetal maternal hemorrhage was more than previously estimated
E. The cause is most likely idiopathic in this case

Back 10

The protection afforded by a standard RhoGAM administration is dose-dependent. One dose will prevent Rh sensitization to an exposure of as much as 30 cc of Rh-positive red blood cells. With greater exposure, there is only partial protection and Rh sensitization may occur as a result of failure to diagnose massive transplacental hemorrhage. Alternatively, an Rh-negative woman may be sensitized in the latter part of pregnancy or soon after delivery before the post-delivery prophylaxis dose is given. Inadvertent maternal transfusion of Rh-positive blood may result in Rh sensitization to the D or another red blood cell antigen. Patients may become sensitized if they do not receive RhoGAM following an episode of antenatal bleeding or after an invasive procedure, such as amniocentesis or chorionic villus sampling. In addition, RhoGAM only confers protection against the D antigen. Therefore, despite administration of RhoGAM to Rh-negative patients, they may still become sensitized

Front 11

A 25-year-old G2P1 woman states her gestational age by sure LMP is 16 weeks, 3 days. She reports no complaints and is not yet feeling fetal movement. Her fundal height is 22 cm. The MSAFP (maternal serum alpha fetoprotein) result is elevated. Which of the following is the most likely cause for the abnormal MSAFP result?
A. Fetal trisomy
B. Polyhydramnios
C. Twin gestation
D. Fetal abdominal wall defect
E. Fetal neural tube defects

Back 11

Alpha fetoprotein (AFP) levels in twin gestations are elevated and should be roughly twice that seen in singleton pregnancies. An additional clue to a possible diagnosis of twin gestation is the fundal height exceeding gestational age in weeks. Other causes of elevated maternal serum AFP include neural tube defects, pilonidal cysts, cystic hygroma, sacrococcygeal teratoma, fetal abdominal wall defects, and fetal death. Polyhydramnios is not by itself associated with abnormal MSAFP levels.

Front 12

A 29-year-old G0 woman presents to your office for a routine visit. She has been trying to conceive for the last six months unsuccessfully. She requests fertility medications and hopes to get pregnant with twins. What counseling do you tell her regarding the risks of multifetal gestation?
A. The morbidity with twin gestations is similar to triplet pregnancies
B. The twin infant death rate is five times higher than that of singletons
C. The rate of cerebral palsy is double in twin infants
D. The incidence of abnormal fetal growth is similar to singleton pregnancies
E. The incidence of prematurity is similar to singleton pregnancies

Back 12

. The twin infant death rate is five times higher than that of singletons

Front 13

A 30-year-old G2P1 woman with last menstrual period 10 weeks ago presents for her first prenatal care visit. She is healthy and takes no medications. Her previous pregnancy was an uncomplicated vaginal delivery at 39 weeks. On examination, her vital signs are normal. Her exam is notable for a uterus measuring 14 weeks gestation. Ultrasound shows a diamniotic monochorionic twin gestation at 10 weeks. Which of the following obstetrical complications is more likely in this pregnancy compared to her previous pregnancy?
A. Low maternal weight gain
B. Congenital anomalies
C. Induction after 40 weeks
D. Macrosomia
E. Rh isoimmunization

Back 13

Congenital anomalies

Front 14

A 32-year-old G1P0 woman at 10 weeks gestation presents to your office after an ultrasound evaluation has revealed a diamniotic, dichorionic twin gestation. She is very concerned about the risk for preterm delivery. Which intervention would you recommend as a possible means to reduce the risk of a preterm, low-birthweight infant?
A. Bed rest
B. Cervical cerclage
C. Tocolytics starting at 24 weeks
D. Home uterine monitoring
E. Early, good weight gain

Back 14

Early, good weight gain.
Studies show that an adequate weight gain in the first 20 to 24 weeks of pregnancy is especially important for women carrying multiples and may help to reduce the risk of having preterm and low-birth weight babies.

Front 15

A 29-year-old G4P2 woman with no previous prenatal care presents at 24 weeks gestation with signs and symptoms of preterm labor. Her cervix is 3 cm dilated and 80% effaced. Fundal height is 30 cm and an ultrasound examination reveals a twin gestation. Estimated fetal weights on the twins are 850 gm and 430 gm. The maximum vertical amniotic fluid pocket around the smaller twin is 1 cm; the maximum vertical amniotic fluid pocket around the larger twin is 8 cm. Which of the following is the most likely associated with these ultrasound findings?

A. Dichorionic diamniotic twins
B. Monochorionic monoamniotic twins
C. Monochorionic diamniotic twins
D. Superfecundation
E. Rh-isoimmunization

Back 15

. Monochorionic diamniotic twins
Twin-twin transfusion syndrome is the result of an intrauterine blood transfusion from one twin to the other. It most commonly occurs in monochorionic, diamniotic twins. The donor twin is often smaller and anemic at birth. The recipient twin is usually larger and plethoric at birth. Clues to the presence of the twin-twin transfusion syndrome include the large weight discordance (although this is not necessary for diagnosis), polyhydramnios around the larger (recipient) twin, and oligohydramnios around the smaller (pump) twin. The two different placental types in twin gestation are monochorionic and dichorionic.

Front 16

A 29-year-old G4P2 woman was diagnosed with twin-twin transfusion syndrome when an ultrasound was performed at 24 weeks gestational age. Which of the following is a complication of twin-twin transfusion syndrome?

A. Fetal macrosomia in the donor twin
B. Neurologic sequelae in the surviving twin
C. Tricuspid regurgitation in the donor twin
D. Heart failure in the donor twin only
E. High perinatal mortality for donor twin only

Back 16

. Fetal macrosomia in the donor twin

Front 17

A 34-year-old G4P3 woman at 36 weeks with a twin gestation presents in labor. She has three prior normal spontaneous vaginal deliveries at term, with the largest infant weighing 3400 grams. Twin A is breech with an estimated fetal weight of 2800 gm and twin B is vertex, with an estimated fetal weight of 3200 gm. Which of the following is an appropriate delivery option for this patient?
A. Total breech extraction of twin A, vaginal delivery of twin B
B. External cephalic version for twin A, vaginal delivery twin of B
C. Operative vaginal delivery for twin A and vaginal delivery for twin B
D. Cesarean delivery
E. Vaginal delivery for twin A and Cesarean delivery for twin B

Back 17

The optimal mode of delivery for twins in which the first twin is in the breech presentation is by Cesarean section

Front 18

A 24-year-old G4P0 presents to your office at seven weeks gestation after two days of bleeding and cramping. She thinks that she miscarried at home and did not bring in the tissue for pathologic evaluation. What is the karyotype most likely to be found on chromosomal analysis?
A. Turner Syndrome (45, X)
B. Autosomal Trisomy
C. Monoploidy
D. Triploidy
E. Tetraploidy

Back 18

Autosomal Trisomy

Front 19

A 34-year-old G1 is in a motor vehicle accident. While in the emergency department, the doctors order multiple x-rays to evaluate her injuries. At what gestational age would the fetus be most susceptible to developing mental retardation with sufficient doses of radiation?

Back 19

. 8-15 weeks

Front 20

A 21-year-old G1 presents to labor and delivery at 39 weeks gestation with a chief complaint of decreased fetal movement over the last two days. An ultrasound shows a fetus with biometry consistent with 34 weeks gestation with no cardiac activity. The head circumference and biparietal diameter are consistent with 37 weeks and the abdominal circumference, femur and humerus lengths are all lagging by approximately five weeks. The amniotic fluid volume is slightly decreased. No other abnormalities are identified. The patient’s medical history is notable for a deep venous thrombosis which she had three years ago while she was using oral contraceptives. She had a reassuring quad screen. She denies any history of fever or viral illnesses during the pregnancy. She works as a preschool teacher. The patient had a fetal ultrasound at 20 weeks gestation. At that time all of the fetal anatomy was well-visualized and no abnormalities were identified. Which of the following is the most likely explan

Back 20

his patient is most likely to have the autosomal dominant Factor V Leiden (FVL) mutation based on her history.

Front 21

A 33-year-old G1 at 22 weeks gestation presents to the office with a complaint of pelvic pressure. She reports that she had intercourse the night prior to presentation and noted some mucous mixed with blood this morning. Her history is significant for type 1 diabetes and she is on an insulin pump. She also has a history of obesity but reports that she lost about 30 pounds in the last two years prior to getting pregnant. Her current BMI is 26. Her surgical history is significant for a history of cone biopsy for treatment of abnormal Pap smear three years ago. On examination, she is noted to have a 2 cm dilated cervix with bulging membranes that break upon placing the speculum. Fetal parts are noted in the vagina. What is the most likely cause of this finding?
A. Uncontrolled diabetes
B. Cervical incompetence/insufficiency
C. Preterm labor
D. History of obesity
E. Infection

Back 21

Cervical incompetence/insufficiency
he most likely cause of painless cervical dilation which leads to pelvic pressure, bulging membranes and fetal loss is cervical incompetence or insufficiency. This patient has a history of cone biopsy which can lead to cervical incompetence

Front 22

A 26-year-old G1 with last menstrual period 10 weeks ago presents to your office for her first prenatal visit. She reports vaginal spotting for the last two days. You perform an ultrasound that shows an intrauterine pregnancy consistent with nine weeks gestation with no cardiac activity. She denies cramping or abdominal pain. What is the most important laboratory test to check for this patient?
A. Quantitative beta-hCG
B. Maternal blood type
C. Hemoglobin and hematocrit
D. Platelet count
E. Progesterone

Back 22

Maternal blood type
A maternal blood type should be checked on all women with vaginal bleeding during pregnancy, unless it was documented earlier in the pregnancy. If the patient’s blood type is Rh-negative, RhoGAM would be indicated to prevent Rh sensitization

Front 23

A 27-year-old G1 presents to labor and delivery and is found to have a fetal demise at 34 weeks gestation. She did not have access to prenatal care during the pregnancy. Her vital signs are normal and she is not in labor. Her uterus is non-tender and she does not have any vaginal bleeding or ruptured membranes on exam. Which untreated condition is the most likely cause?
A. Diabetes
B. Anemia
C. Hypothyroidism
D. Herpes
E. Rh-isoimmunization

Back 23

Diabetes. Uncontrolled glucose is associated with adverse fetal outcome. A patient with type 1 diabetes is at risk for many pregnancy complications, including fetal death and fetal macrosomia, although fetal growth restriction may also occur.

Front 24

A 22-year-old G1 currently at eight weeks gestation is noted to have a missed abortion on ultrasound, along with a sharply retroverted uterus. She elects to undergo suction dilation and curettage. During the procedure, “fatty appearing tissue” is noted to be coming through the curette. What is the next best step in the management of this patient?
A. Continuing with the suction curettage
B. Remove the tissue from the curette and replace it into the uterus
C. Cut the tissue off at the cervical os
D. Proceed with laparoscopy
E. Stop the procedure and observe her the hospital for 48-hours

Back 24

Proceed with laparoscopy. The tissue is consistent with omental tissue and may include segments of bowel. The suction should be turned off and the tissue gently removed from the curette. Laparoscopy will allow closer examination and should bowel appear to be involved

Front 25

A 33-year-old G2P1 with a known twin gestation presents to your office at 23 weeks gestation and notes that two days prior she had a nosebleed. She has not been seen in your office for the last seven weeks. Ultrasound today shows a demise of one twin that has measurements consistent with 21 weeks gestation. What is the next step in the management of this patient?
A. Immediate delivery of the surviving twin
B. Continued management as a singleton pregnancy
C. Maternal fibrinogen level
D. Abdominal x-ray to assess for Spalding's sign
E. Nonstress test of the surviving twin

Back 25

The incidence of the death of one twin in-utero is 2-7%. When a dead fetus has been in utero for three to four weeks, fibrinogen levels may decrease, leading to a coagulopathy. The patient’s nosebleed may be a common pregnancy finding or be related to the demise, and a coagulopathy must be ruled out. Induction should be considered, but may be delayed after the death of a twin in order to allow the viable twin to mature. In these cases, fibrinogen levels should be monitored to detect a progressive coagulopathy. Usually this is performed weekly or biweekly, depending on the levels obtained. Spalding sign is an overlapping of fetal skull bones suggesting a fetal demise. It is not necessary to do an x-ray, since the diagnosis was confirmed on ultrasound and it would give unnecessary radiation exposure to the surviving twin. Although an ultrasound to assess fetal well-being of the surviving twin would be very helpful, at this gestational age and in a twin pregnancy a non-stress notneeded

Front 26

A 32-year-old G1P0 woman comes to your office for her first prenatal care visit. She has recently read an article about the rising Cesarean section rate in the United States and asks you about the rate in your hospital. What do you explain as the major cause of higher Cesarean delivery rates?

A. The rate of breech presentations has increased
B. Less women are having vaginal births after Cesarean
C. Obstetricians’ reluctance to perform forceps delivery
D. Increased rate of fetal macrosomia due to uncontrolled gestational diabetes
E. Rate of twins has increased

Back 26

Less women are having vaginal births after
The rate of vaginal birth after Cesarean (VBAC) has decreased in recent years due to studies that showed an increased risk of complications, especially uterine rupture

Front 27

A 23-year-old G1P0 woman at 40 weeks gestation presents to labor and delivery with contractions. At 10:00 am, her cervical exam is 2 centimeters dilated, 70% effaced and the vertex at 0 station. Clinical pelvimetry reveals an adequate pelvis and membranes are intact. The fetus is in a cephalic presentation and EFW is 3500 gms. Contractions are occurring every 3-4 minutes, based on the external monitor. Her labor slowly progresses and, at 1:00 pm, the patient has spontaneous rupture of membranes. Fetal surveillance remains reassuring. Her cervical exam is 5 centimeters dilated, 100% effaced, and 0 station. At 4:00 pm, the patient’s cervical exam is unchanged. Contractions are occurring every 5-6 minutes. Which of the following is the most appropriate next step in the management of this patient?
A. Perform a biophysical profile
B. Have the patient ambulate
C. Consent the patient for a Cesarean section secondary to failure to progress
E. Begin oxytocin augmentation

Back 27

E. Begin oxytocin augmentation. he patient has an arrest of dilatation in the active phase of labor. She is only having contractions every 5-6 minutes, so it is reasonable to start oxytocin to increase the frequency and strength of this patient’s contractions. If the patient does not have cervical change once she is having more frequent contractions on oxytocin, it would be reasonable to place an IUPC (intrauterine pressure catheter) to assess the strength of the contractions. It is not yet necessary to perform a Cesarean delivery. Further observation and having the patient ambulate do not facilitate delivery

Front 28

A 34-year-old G2P1 woman at 40 weeks gestation, with a history of one prior vaginal delivery, strongly desires an induction of labor, as she is unable to sleep secondary to severe back pain. Her cervical exam is closed, 20% effaced and -2 station. The cervix is firm and posterior. Which of the following is the most appropriate next step in the management of this patient?
A. Wait until 42 weeks for induction
B. Administer cytotec
C. Insert a foley bulb in the cervix
D. Perform artificial rupture of membranes
E. Perform a Cesarean delivery

Back 28

Administer cytotec. The patient is multiparous at term and waiting until she reaches 42 weeks may increase the risk of perinatal mortality. Since she is uncomfortable with back pain, it is reasonable to induce labor. Her cervix is unfavorable; therefore, cytotec administration is appropriate prior to pitocin induction. A foley bulb or artificial rupture of membranes cannot be achieved in a patient with a closed cervix. At this time, there are no indications to perform a Cesarean delivery in this patient.

Front 29

A 22-year-old G1P0 woman at 39-weeks gestation presents in active labor. Her pregnancy is complicated by diet controlled gestational diabetes. She has a history of uterine fibroids. On examination, she is found to be 4 cm dilated in breech presentation. An ultrasound confirms the breech presentation, amniotic fluid index is 5, and the estimated fetal weight is 3900 g. Which of the following is the most likely cause of the breech presentation in this patient?
A. Gestational diabetes
B. Uterine fibroids
C. Oligohydramnios
D. Macrosomia
E. Gravidity

Back 29

Prematurity, multiple gestation, genetic disorders, polyhydramnios, hydrocephaly, anencephaly, placenta previa, uterine anomalies and uterine fibroids are all associated with breech presentation

Front 30

A 20-year-old G1 woman at 40 weeks gestation presents to labor and delivery complaining of painful contractions every 3-4 minutes since midnight. Her examination on admission was 2 centimeters dilated, 90% effaced and 0 station. Three hours later, her exam is unchanged. The patient is still having contractions every 3-4 minutes. She is discouraged about her lack of progress. Which of the following is the most appropriate next step in the management of this patient?
A. Laminaria placement
B. Artificial rupture of membranes
C. Counseling about latent phase of labor and rest
D. Manual cervical dilation
E. Cesarean section for arrest of labor

Back 30

Counseling about latent phase of labor and rest. The patient is in the latent phase of labor and has not yet reached the active phase (more than 4 cm). A prolonged latent phase is defined as >20 hours for nulliparas and >14 hours for multiparas, and may be treated with rest or augmentation of labor. Artificial rupture of membranes is not recommended in the latent phase as it places the patient at increased risk of infection. Cervical dilation or laminaria placement are not indicated.