Abnormal Obstetrics

Front 1

A 30-year-old G3P2 woman, whose last normal menstrual period was eight weeks ago, began spotting three days ago and developed cramping this morning. She has a history of a chlamydia infection with a previous pregnancy. She smokes one pack of cigarettes per day and denies alcohol or drug use. On physical exam: blood pressure 120/70; pulse 82; respirations 20; and temperature 98.6°F (37.0°C). Abdominal examination is normal. Pelvic examination reveals old blood in the vaginal vault, closed cervix without lesions, slightly enlarged uterus and no adnexal tenderness. Pertinent labs: Quantitative Beta-hCG is 1000 mIU/ml; urinalysis normal; hematocrit = 32%. Transvaginal ultrasound shows no intrauterine pregnancy, no adnexal masses, no free fluid in pelvis. Which of the following is the most appropriate next step in the management of this patient?

Back 1

Repeat Beta-hCG in 48 hours
The patient first needs to have an accurate diagnosis before a treatment plan is entertained. She has risk factors for ectopic pregnancy. Repeating the Beta-hCG is the next step in this patient’s management. Inappropriately rising Beta-hCG levels (less than 50% increase in 48 hours) or levels that either do not fall following diagnostic dilation and curettage would be consistent with the diagnosis of ectopic pregnancy. Alternatively, a fetal pole must be visualized outside the uterus on ultrasound. The patient would need a Beta-hCG level over the discriminatory zone (the level where an intrauterine pregnancy can be seen on ultrasound) with an empty uterus. The level commonly used is 2000 mIU/ml. Treatment with methotrexate may be appropriate, but only after a definitive diagnosis is made.

Front 2

A 28-year-old G0 woman whose last normal menstrual period was four weeks ago presents with a two-day history of spotting. She awoke this morning with left lower quadrant pain of intensity 4/10. She has no urinary complaints, no nausea or vomiting, and the remainder of the review of systems is negative. She has no history of sexually transmitted infections. She smokes one pack of cigarettes per day and denies alcohol or drug use. Her vital signs are: blood pressure 124/68, pulse 76, respirations 18, and temperature 100.2° F (37.9°C). On examination, she has mild left lower quadrant tenderness, with no rebound or guarding. Pelvic exam is normal except for mild tenderness on the left side. Quantitative Beta-hCG is 400 mIU/ml; progesterone 5 ng/ml; hematocrit 34%. Ultrasound shows a fluid collection in the uterus, with no adnexal masses and no free fluid. What is the most likely diagnosis?
A. Ovarian torsion
B. Missed abortion
C. Early intrauterine pregnancy
D. Unable to establish a di

Back 2

Unable to establish a diagnosis
Correct answer is D. It is difficult to establish a definitive diagnosis at this time. When the Beta-hCG level is below the discriminatory zone (2000 mIU/ml), an early intrauterine pregnancy may not be visualized on ultrasound. Missed abortion, early intrauterine pregnancy and ectopic pregnancy could only be confirmed by serial Beta-hCG levels (at least every 48 hours until a trend is established, usually three levels). Ovarian torsion is a possible diagnosis, however, this is more common with an ovarian mass.

Front 3

A 19-year-old G2P1 woman presents with vaginal spotting and uterine cramping. Her last normal menstrual period was six weeks ago and she began spotting three days ago. She has no history of sexually transmitted infections. Her vital signs are: blood pressure 120/70; pulse 78; respirations 20; and temperature 98.6 °F (37.0°C). On pelvic examination, she has no cervical motion tenderness, her uterus is normal size and nontender; no adnexal masses are palpable. Quantitative Beta-hCG 48 hours ago was 1500 mIU/ml; current beta-hCG is 3100 mIU/ml; progesterone 26 ng/ml; hematocrit 38%; and urinalysis is normal. What is the most likely finding on transvaginal ultrasound?
A. Debris in uterus
B. Viable intrauterine pregnancy
C. Adnexal mass, empty uterus
D. No adnexal mass, empty uterus
E. Non-viable intrauterine pregnancy

Back 3

Viable intrauterine pregnancy
Transvaginal ultrasound will most likely show an intrauterine pregnancy. The Beta-hCG level is above the discriminatory zone for ultrasound (2000 mIU/ml), and the level has doubled in 48 hours. Additionally, the progesterone level is within expected range for a normal pregnancy (>25 ng/ml suggests healthy pregnancy) and up to 30% of all normal pregnancies experience first trimester spotting/bleeding. The findings of debris in the uterus, an empty uterus, with or without an adnexal mass, or free fluid (suggesting hemoperitoneum) would not be anticipated.

Front 4

A 20-year-old G1P0 woman has vaginal spotting and mild cramping for the last three days. She had her last normal menstrual period approximately seven weeks ago. She had a positive home pregnancy test. Vital signs are: blood pressure 120/72; pulse 64; respirations 18; temperature 98.6°F (37°C). On pelvic exam, she has scant old blood in the vagina, with a normal appearing cervix and no discharge. On bimanual exam, her uterus is nontender and small, and there are no adnexal masses palpable. Quantitative Beta-hCG 48 hours ago was 750 mIU/ml; today, current Beta-hCG 760 mIU/ml; progesterone 3.2 ng/ml; hematocrit 37%. Transvaginal ultrasound shows a fluid collection in the uterus with a yolk sac but no fetal pole. A 3x3 cm cyst is seen on the left ovary. There is no free fluid in the pelvis. Which of the following is the most appropriate next step in the management of this patient?
A. Exploratory laparoscopy
B. Treat with methotrexate
C. Treat with mifepristone
D. Dilation and curettage

Back 4

Dilation and curettage
The pregnancy is abnormal based on the abnormal Beta-hCG levels and the progesterone level. In a normal pregnancy, the level should rise by at least 50% every 48 hours until the pregnancy is 42 days old (after that time, the rise in level may not follow the curve). A progesterone level of <5 ng/ml suggests an abnormal or extrauterine pregnancy. In this instance, the pregnancy is intrauterine because of the presence of a yolk sac. Dilation and curettage is an option for treatment. Other options include expectant management, misoprostol or manual vacuum aspiration. Laparoscopy and methotrexate are not indicated as this is a confirmed intrauterine pregnancy. Mifepristone is a progestin receptor antagonist and can be used as emergency contraception to prevent ovulation and blocks the action of progesterone which is needed to maintain pregnancy. In the US, Mifepristone is also used with misoprostol for pregnancy termination.

Front 5

A 23-year-old G1P0 woman presents with cramping, vaginal bleeding and right lower quadrant pain. Her last normal menstrual period occurred seven weeks ago. On physical exam, vital signs are: blood pressure 110/74; pulse 82; respirations 18; and temperature 98.6°F (37°C). On abdominal exam, she has very mild right lower quadrant tenderness. On pelvic exam, she has scant old blood in the vagina and a normal appearing cervix. Her uterus is normal size and slightly tender. On bimanual exam, there is no cervical motion tenderness, and she has slight tenderness in right lower quadrant. Quantitative Beta-hCG is 2500 mIU/ml; progesterone 6.2 ng/ml; hematocrit 34%. The transvaginal ultrasound shows an empty uterus with endometrial thickening, a mass in the right ovary measuring 3 x 2 cm and a small amount of free fluid in the pelvis. Which of the following is the most appropriate next step in the management of this patient?
A. Methotrexate
B. Antibiotics
C. Observation
D. Dilation and curet

Back 5

A. Methotrexate
The next best step in management is methotrexate administration. Certain conditions must be met prior to initiating methotrexate therapy for treatment of an ectopic pregnancy. These include: hemodynamic stability, nonruptured ectopic pregnancy, size of ectopic mass <4 cm without a fetal heart rate or <3.5 cm in the presence of a fetal heart rate, normal liver enzymes and renal function, normal white cell count, and the ability of the patient to follow up rapidly (reliable transportation, etc.), if her condition changes.

Front 6

A 32-year-old G5P3 woman presents with left-sided abdominal pain. Her last normal menstrual period was eight weeks ago. She began having pain early this morning and it has increased to a severity of 8/10. She denies nausea or vomiting or vaginal bleeding. Her gynecological history is notable for a history of right-sided ectopic pregnancy four years ago. At that time, she had a right salpingectomy and a left tubal ligation. On physical examination: blood pressure is 90/54; pulse 108; respirations 22; and temperature 98.6°F (37.0°C). On abdominal examination, she has rebound and guarding in all quadrants, and on pelvic exam, her uterus is very tender and there is left adnexal fullness. A transvaginal ultrasound shows an empty uterus, left pelvic mass with a gestational sac and fetal pole, and a large amount of free fluid in the pelvis. Her hematocrit is 26%. What would be the next best step in the management?

Back 6

Perform a laparoscopy
.This scenario is consistent with the patient having a ruptured ectopic pregnancy. Signs of hypovolemia (tachycardia, hypotension) with peritoneal signs (rebound, guarding and severe abdominal tenderness) and a positive pregnancy test lead to the diagnosis of ruptured ectopic pregnancy. Conservative management, with observation and repeating the Beta-hCG level in 48 hours is not indicated since a diagnosis is clear and waiting can potentially be dangerous to the patient. Dilation and curettage would only be considered after laparoscopy, if needed.

Front 7

A 19-year-old G1P0 woman with a desired pregnancy notes vaginal spotting early this morning and it has slightly increased. Her last normal menstrual period occurred six weeks ago. She has no pain or other symptoms. Her medical history is noncontributory. Vital signs are: blood pressure 120/68; pulse 68; respirations 20; and temperature 98.6°F (37.0°C). On pelvic exam, her cervix is normal; her uterus is small and nontender; there are no masses palpable. Labs show Quantitative Beta-hCG 750 mIU/ml; progesterone 3.8 ng/ml; hematocrit 38%. Which of the following is the most appropriate next step in the management of this patient?
A. Order a transvaginal ultrasound
B. Repeat Beta-hCG level in 24 hours
C. Repeat Beta-hCG level in 48 hours
D. Dilation and curettage
E. Bed rest

Back 7

Repeating the Beta-hCG level will show whether the pregnancy is viable or failing. The appropriate time interval for repeating the initial level is 48 hours, since during the first 42 days of gestation levels increase by approximately 50% every 48 hours in most viable pregnancies. Ordering an ultrasound would not be helpful, since the patient’s Beta-hCG level is lower than the discriminatory zone (the level at which an intrauterine pregnancy should be seen on ultrasound, usually 2000 mIU/ml). There is no need to repeat the progesterone level. Dilation and curettage or treatment with methotrexate are both inappropriate without a diagnosis, since both could interrupt a viable pregnancy.

Front 8

A 19-year-old G1P0 woman notes vaginal spotting. Her last normal menstrual period occurred six weeks ago. She began having spotting early this morning and it has increased only slightly. She has no pain and denies other symptoms. Her medical history is noncontributory. Vital signs are: blood pressure 120/68; pulse 68; respirations 20; and temperature 98.6°F (37.0°C). On pelvic exam, her cervix is normal; uterus is small and nontender; and no masses are palpable. Initial labs show quantitative Beta-hCG 2000 mIU/ml and hematocrit 38%. A repeat Beta-hCG level 48 hours later is 2100 mIU/ml. A transvaginal ultrasound shows an empty uterus with a thin endometrial stripe and no adnexal masses. What is the next best step in the management of this patient?
A. Dilation and curettage
B. Treat with methotrexate
C. Exploratory laparotomy
D. Repeat Beta-hCG level in 48 hours
E. Repeat ultrasound in 24 hours

Back 8

The patient clearly has an abnormal pregnancy, as demonstrated by the slowly increasng Beta-hCG levels. Since the Beta-hCG level is above 2000 mIU/ml, and she has a thin endometrial stripe, this rules out an intrauterine pregnancy and the diagnosis is an ectopic pregnancy. She is a good candidate for medical treatment with methotrexate. Dilation and curettage and exploratory laparotomy are invasive procedures that can be avoided in this patient. She does not need another Beta-hCG level because the diagnosis is clear. There is no indication for a repeat ultrasound in this case.

Front 9

A 25-year-old G4P1 woman with a previous term delivery presents to the emergency department at 7 1/2 weeks gestation with vaginal bleeding. She has not passed any tissue. On examination, there is blood in the vault and a dilated cervical os. Ultrasound confirms an intrauterine pregnancy and fetal cardiac activity is noted. Which of the following diagnoses most accurately describes her condition?
A. Incomplete abortion
B. Missed abortion
C. Threatened abortion
D. Complete abortion
E. Recurrent abortion

Back 9

Threatened abortion
Threatened abortion refers to vaginal bleeding before 20 weeks without the passage of any products. Incomplete abortions have passed some, but not all, of the products of conception. Missed abortions have experienced fetal demise without cervical dilatation or passage of products of conception. Recurrent abortion refers to three successive spontaneous abortions.

Front 10

A 25-year-old G0 woman presents to the clinic for follow-up after having a first trimester spontaneous abortion. She wants to discuss the cause of this event. Which of the following etiologic categories accounts for the majority of first trimester spontaneous abortions?
A. Immunologic abnormalities
B. Conceptus genetic anomalies
C. Maternal genetic anomalies
D. Structural/uterine anomalies
E. Uterine infections

Back 10

Conceptus genetic anomalies

Front 11

A 35-year-old woman presents to the emergency department with heavy vaginal bleeding at seven weeks gestation. On examination, she has a dilated cervix with blood and tissue present at the cervical os. Which of the following is the most likely chromosomal abnormality to be found in the karyotypic evaluation of the products of conception?
A. Autosomal trisomy
B. Triploidy
C. Tetraploidy
D. Monosomy X (45X,0)
E. Fragile X mutation

Back 11

Autosomal trisomy is the most common abnormal karyotype encountered in spontaneous abortuses, accounting for approximately 40-50% of cases. Triploidy accounts for approximately 15%, tetraploidy 5% of cases, and Monosomy X (45X, 0) identified in 15-25% of losses. The Fragile X mutation involves an expanded number of trinucleotide repeats in the CGG (cytosine-guanine) sequence.

Front 12

A 27-year-old G2P0 woman is diagnosed with an early first trimester spontaneous abortion. She has a history of type I diabetes mellitus, mild chronic hypertension and one prior termination of pregnancy. Which of the following is the most likely cause of this spontaneous abortion?

A. Prior termination of pregnancy
B. Chronic hypertension
C. Diabetes mellitus
D. Intrauterine adhesions
E. Infection

Back 12

Diabetes mellitus. Systemic diseases such as diabetes mellitus, chronic renal disease and lupus are associated with early pregnancy loss. In women with insulin-dependent diabetes, the rates of spontaneous abortion and major congenital malformations are both increased. The risk appears related to the degree of metabolic control in the first trimester

Front 13

A 25-year-old G2P1 woman at eight weeks gestation is diagnosed with a spontaneous abortion. Her husband is 40 years old. The patient’s past medical history is noncontributory. She gets some exercise regularly and smokes two packs of cigarettes a day. Three years ago, she had a full-term delivery that was complicated by mild preeclampsia. Which of the following factors is most likely the cause of this spontaneous abortion?
A. Infection
B. Advanced paternal age
C. Environmental factors
D. Uterine anomaly (i.e. unicornuate uterus)
E. History of preeclampsia

Back 13

Environmental factors. Environmental factors, such as smoking, alcohol and radiation are causes of spontaneous abortion.

Front 14

A 22-year-old G1P0 woman presents to the emergency department at eight weeks gestation experiencing heavy vaginal bleeding. Pelvic examination demonstrates brisk bleeding through a dilated cervical os. The patient’s hemoglobin is 7 g/dL (hematocrit 21%). Which of the following is the most appropriate next step in the management of this patient?
A. Administration of intravaginal misoprostol
B. Administration of oral misoprostol
C. Dilation and suction curettage
D. Endometrial ablation
E. Expectant care to permit spontaneous abortion

Back 14

Dilation and suction curettage
This patient is actively bleeding and is anemic. She, therefore, requires immediate surgical treatment consisting of dilation and suction curettage

Front 15

A 34-year-old G1P0 woman presents with vaginal spotting. An ultrasound confirms a non-viable intrauterine pregnancy. She is otherwise healthy. Her partner accompanies her and is supportive. The patient wishes to avoid any unnecessary medical interventions and asks whether she can safely let nature take its course. What is the best next step in the management of this patient?
A. Immediate dilation and suction curettage
B. Dilation and suction curettage in one week
C. Immediate treatment with misoprostol
D. Treatment with misoprostol in one week
E. Expectant management

Back 15

Expectant management.
Patients experiencing early pregnancy loss can safely consider several different treatments, including expectant management, medical treatment to assist with expulsion of the pregnancy or surgical evacuation. Provided the patient is hemodynamically stable and reliable for follow-up, expectant management is appropriate therapy. At the gestational age described, expectant management portends no increase in risk of either hemorrhage or infection compared with surgical or medical evacuation. Regardless of method chosen, the patient’s blood type should be checked and rhogam administered as indicated.

Front 16

A 29-year-old G3P0 woman presents for prenatal care at eight weeks gestation. Her two prior pregnancies ended in spontaneous losses at 19 and 18 weeks, respectively. Records corroborate the patient’s history of an uncomplicated gestation until the evening of the losses, when she experienced a pink-tinged discharge that prompted her to call her obstetrician. In both cases, the obstetrician noted that her cervix had dilated completely with the amnionic sac bulging into the vagina to the level of the introitus. The patient was afebrile without other complaints and there was no uterine tenderness on exam. She spontaneously delivered the fetus and placenta in both cases. A sonohysterogram confirmed normal uterine anatomy several weeks later. What is the most appropriate next step in the management of this patient?
A. Begin weekly fetal fibronectin testing
B. Placement of a cervical cerclage at approximately 14 weeks gestation
C. Immediate placement of a cervical cerclage

Back 16

Placement of a cervical cerclage at approximately 14 weeks gestation. This patient has an incompetent cervix and should have a cervical cerclage at 14 weeks. A positive fetal fibronectin does not indicate incompetent cervix and is used later in pregnancy as a negative predictor of preterm delivery. Pregnancy loss in the late second trimester is not usually related to genetic abnormality of the conceptus and most clinicians delay placement of a cerclage until after the first trimester, given the high background prevalence of first trimester pregnancy wastage.

Front 17

Question 9 of 10Point value 0 - 1
A 32-year-old G3P0 woman presents to the clinic for preconception counseling. Her prior three pregnancies resulted in first trimester losses. Which of the following tests should be ordered for this patient?
A. Adrenal stimulation test
B. Clomiphene citrate-FSH challenge test
C. Lupus anticoagulant test
D. Pelvic MRI
E. CT scan of the pelvis

Back 17

. Lupus anticoagulant test. It is important to rule out systemic disease in a patient with recurrent abortion (three successive first trimester losses). Testing for lupus anticoagulant, diabetes mellitus and thyroid disease are commonly performed. Maternal and paternal karyotypes should also be obtained.

Front 18

A 26-year-old G2P0 woman presents for counseling following manual vacuum aspiration of an eight-week missed abortion. The patient asks whether an uncomplicated first trimester pregnancy termination three years ago might have predisposed her to the subsequent spontaneous abortion. What are the patient’s risks associated with the prior surgical abortion in the first trimester?
A. Does not predispose the patient to subsequent spontaneous abortion
B. Increases the risk of spontaneous abortion two-fold
C. Predisposes the patient to primary infertility
D. Increases the likelihood of subsequent pregnancy loss in both the first and second trimesters
E. Increases the likelihood of spontaneous abortion and future delivery complications

Back 18

Does not predispose the patient to subsequent spontaneous abortion

Front 19

A 28-year-old G0 woman presents to your office for preconception counseling. She has a history of type 1 diabetes, diagnosed at age six, and uses an insulin pump for glycemic control. She has a history of proliferative retinopathy treated with laser. Her last ophthalmologic examination was three months ago. Her last hemoglobin A1C (glycosylated hemoglobin level) six months ago was 9.2%. Which of the following complications is of most concern for her planned pregnancy?
A. Fetal growth restriction
B. Fetal cardiac arrhythmia
C. Group B Streptococcal infection
D. Oligohydramnios
E. Macrosomia

Back 19

Fetal cardiac arrhythmia

Front 20

A 36-year-old G2P1 woman presents for her first prenatal visit at 11 weeks gestation. She has a two-year history of chronic hypertension treated with lisinopril and labetalol. In addition, she has hypothyroidism treated with levothyroxine, and recurrent herpes, for which she is on chronic acyclovir suppressive therapy. She takes amitriptyline for migraine headaches. Which of her medications is contraindicated in pregnancy?
A. Levothyroxine
B. Labetalol
C. Acyclovir
D. Lisinopril
E. Amitriptyline

Back 20

Lisinopril

Front 21

A 24-year-old G3P0 woman at 26 weeks gestation was brought to the hospital by paramedics. Her husband found her shivering and barely responsive. Two days prior, the patient noted that she was feeling sick, with a slight cough. She was having back pain at the time, but thought it was probably normal for pregnancy. Her pregnancy has been uncomplicated except for the recent diagnosis of gestational diabetes. On exam, vital signs are: temperature 100.2°F (37.9°C); pulse 160; and blood pressure 68/32; respiratory rate 32. Oxygen saturation is 82% on room air. There is no apparent fundal tenderness, although the patient exhibits pain with percussion of the right back. Fetal heart tones are not audible. There is no evidence of vaginal bleeding. Extremities are cool to touch. White blood cell count 24,000; hemoglobin 9.5; hematocrit 27%. Urine microscopic analysis shows many white blood cells. What is the most likely etiology for this patient’s disease?

Back 21

This is a patient in septic shock. The most common cause of sepsis in pregnancy is acute pyelonephritis. Given the absence of bleeding, the clinical picture is not suggestive of placental abruption. Diabetic ketoacidosis is unusual in gestational diabetic patients. Chorioamnionitis and pneumonia may both lead to sepsis, but are less important causes than is pyelonephritis, and are not suggested by the clinical picture.

Front 22

A 24-year-old G2P1 woman at 18 weeks gestation with a history of asthma presents to the office with worsening symptoms, needing to use her inhaler more frequently. The symptoms began with the pregnancy and have gradually increased. She is using her albuterol inhaler as needed, recently three times a day. She denies any illness or fever. She has had asthma since she was a child. On exam, the patient appears comfortable. Her temperature is 100.2°F (37.9°C) and respiratory rate is 18. Auscultation of the lungs shows good air movement with mild scattered end expiratory wheezes. There are no rales or bronchial breath sounds. Which of the following is the most appropriate next step in the management of this patient?
A. Oral theophylline
B. Subcutaneous terbutaline
C. Inhaled corticosteroids
D. Oral zafirlukast (leukotriene inhibitor)
E. Antibiotic treatment

Back 22

Inhaled corticosteroids
Asthma generally worsens in 40% of pregnant patients. One of the indications for moving to the next line of treatment includes the need to use beta agonists more than twice a week. The appropriate choice for her treatment would be inhaled corticosteroids or cromolyn sodium. Theophylline would be used in more refractory patients. Subcutaneous terbutaline and systemic corticosteroids would be used in acute cases. Zafirlukast, a leukotriene receptor antagonist, is not effective for acute disease. There is little experience with their use in pregnancy, thus the safety of zafirlukast in pregnancy is not well established. Antibiotic treatment is only used when a pulmonary infection is diagnosed.

Front 23

An 18-year-old G1 woman presents for prenatal care at 16 weeks gestation without complaints. The patient denies any history of sexually transmitted disease, although admits to a history of multiple sex partners, with irregular use of condoms. She is allergic to penicillin, which causes anaphylaxis. Physical exam is unremarkable. Pertinent labs: rapid plasma reagin test (RPR) positive (titer = 32); fluorescent treponemal antibody absorption test (FTA-ABS) is positive. Which of the following is the best treatment for this patient?
A. Oral erythromycin
B. Oral doxycycline
C. Desensitization and penicillin
D. Intravenous erythromycin
E. Intravenous cefazolin

Back 23

. Desensitization and penicillin. There are no proven alternatives to penicillin therapy during pregnancy and penicillin G is the therapy of choice to treat syphilis in pregnancy. Women with a history of penicillin allergy can be skin tested to confirm the risk of immunoglobulin E (IgE)-mediated anaphylaxis. If skin tests are reactive, penicillin desensitization is recommended and is followed by intramuscular benzathine penicillin G treatment.

Front 24

A 34-year-old G1 woman at eight weeks gestation presents for prenatal care. She is healthy and takes no medications. Family history reveals type 2 diabetes in her parents and brothers. She is 5 feet 2 inches tall and weighs 220 pounds (BMI 40.2 kg/m2). Which of the following is the best recommendation to screen her for gestational diabetes?
A. No screening required
B. Screen at 24 – 28 weeks with a 50-g oral glucose challenge test
C. Screen at 16 – 20 weeks with a 50-g oral glucose challenge test
D. Screen now with a 50-g oral glucose challenge test
E. Begin an oral hypoglycemic agent now

Back 24

Screen now with a 50-g oral glucose challenge test.
Screening should be performed between 24 and 28 weeks in those women not known to have glucose intolerance earlier in pregnancy. This evaluation can be done in two steps: a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral glucose tolerance test (OGTT) if initial results exceed a predetermined plasma glucose concentration. Patients at low risk are not routinely screened. For those patients of average risk screening is performed at 24 – 28 weeks while those at high risk (severe obesity and strong family history) screening should be done as soon as feasible.

Front 25

A 22-year-old G4P1 woman at 26 weeks gestation presents with a postcoital musty odor and increased milky, gray-white discharge for the last week. This was an unplanned pregnancy. She had her first pregnancy at age 15. She reports that she has no new sex partners, but the father of the baby may not be monogamous. On examination, there is a profuse discharge in the vaginal vault, which covers the cervix. Pertinent labs: wet mount pH >4.5 and whiff test positive. Microscopic exam reveals clue cells, but no trichomonads or hyphae. Which of the following is the most appropriate next step in the management of this patient?
A. Delay treatment until postpartum
B. Treat her now and again during labor
C. Treat her now
D. Treat her and her partner
E. No treatment necessary

Back 25

Treat her now. The patient has bacterial vaginosis. All symptomatic pregnant women should be tested and treatment should be not be delayed because treatment has reduced the incidence of preterm delivery. The optimal regimen for women during pregnancy is not known, but the oral metronidazole regimens are probably equally effective. Once treated antepartum, there is no need to treat during labor unless she is reinfected.

Front 26

A 33-year-old G2P1 woman at eight weeks presents to the clinic. This is an unplanned pregnancy. She had planned a tubal ligation six years ago when she was diagnosed with pulmonary hypertension, but was unable to have the procedure. She states her pulmonary hypertension has been stable, but she gets short of breath when climbing stairs. She sleeps on one pillow at night. What is the concern for her during this pregnancy?
A. There are no additional concerns compared to a normal pregnancy
B. She will need a Cesarean section at delivery
C. Her baby is at increased risk for pulmonary hypoplasia
D. The mother’s mortality rate is above 25%
E. Epidural analgesia is contraindicated

Back 26

The mother’s mortality rate is above 25%
Among women with cardiac disease, patients with pulmonary hypertension are among the highest risk for mortality during pregnancy, a 25-50% risk for death. Management of labor and delivery is particularly problematic. These women are at greatest risk when there is diminished venous return and right ventricular filling which is associated with most maternal deaths

Front 27

A 19 year-old G1P0 woman at 18 weeks gestation presents with a 3-month history of palpitations and intermittent chest pain. Physical examination reveals a pulse of 96 and grade II/VI systolic ejection murmur with a click. The ECG shows normal rate and rhythm and an echocardiogram is ordered. Which of the following is the best treatment in the management of this patient?

A. Anxiolytics
B. β-blockers
C. Calcium-channel blockers
D. Digitalis
E. No treatment needed at this time

Back 27

β-blockers
The correct answer is B. Most women with mitral valve prolapse are asymptomatic and diagnosed by routine physical examination or as an incidental finding at echocardiography. A small percentage of women with symptoms have anxiety, palpitations, atypical chest pain, and syncope. For women who are symptomatic, -blocking drugs are given to decrease sympathetic tone, relieve chest pain and palpitations, and reduce the risk of life-threatening arrhythmias. Because she is symptomatic, the option of no treatment is not correct.

Front 28

An 18 year-old G1P0 at 16 weeks gestation was admitted 4 days ago because of back pain, chills and fever. She has been receiving aggressive hydration and taking broad-spectrum antibiotics but continues to have spiking fever up to 102.0°F (38.9°C). Work-up reveals a right ureteral obstruction secondary to calculi. Which of the following is the most appropriate next step in the management of this patient?

A. Aggressive hydration
B. Change antibiotics
C. Continue present antibiotics
D. Pass a double-J ureteral stent
E. Perform percutaneous nephrostomy

Back 28

Pass a double-J ureteral stent.
The correct answer is D. Renal infection is the most common serious medical complication of pregnancy. Initially aggressive intravenous hydration is given to ensure adequate urinary output. Antimicrobials are begun promptly after diagnosis. The majority of patients are afebrile by 72 hours. If there is no clinical improvement by 72 hours, further evaluation is warranted including sonography to look for urinary tract obstruction (abnormal ureteral or pyelocaliceal dilatation) or calculi. Obstruction can be relieved by cystoscopic placement of a double-J ureteral stent unless long-term stenting is foreseen, then percutaneous nephrostomy is indicated. Surgical exploration is required in up to 2% of women if other conservative therapies are not successful.

Front 29

A 24 year-old G1P0 at 12 weeks gestation presents for prenatal care. She is 5 feet 4 inches tall and weighs 220 pounds (BMI: 37.8 kg/m2). She wants to know if there is an increased risk on her pregnancy because of her size. Which of the following is the most common complication in this patient?

A. Hypertension
B. Preterm labor
C. Post-term pregnancy
D. Small for gestational age
E. Shoulder dystocia

Back 29

Hypertension

Front 30

A 16 year-old G1P0 African-American woman presents at 8 weeks gestation for prenatal care. She reports occasional spotting but denies pain or fever. The laboratory reports hemoglobin of 8 g/dL and a peripheral smear reveals hypochromia and microcytosis. Which of the following is the most likely diagnosis for this patient?

A. sickle cell anemia
B. folate deficiency
C. iron deficiency
D. β-thalassemia
E. acute blood loss

Back 30

iron deficiency. The two most common causes of anemia during pregnancy and the puerperium are iron deficiency and acute blood loss. Classical morphological evidence of iron-deficiency anemia is erythrocyte hypochromia and microcytosis. Serum ferritin levels are lower than normal and there is no stainable bone marrow iron on examination of a bone marrow aspirate. The spotting she reports would not lead to anemia due to blood loss.

Front 31

A 27 year-old G1P0 at 22 weeks gestation with systemic lupus erythematosus (SLE) presents complaining of malaise, joint aches, and fever. Physical examination reveals the following: pulse 88, temperature 98.6°F (37.0°C), respiratory rate of 22, and BP 150/110 (baseline is 100/70.) Laboratory analysis reveals 1 + proteinuria, AST 35, and ALT 28. Which of the following is the most appropriate initial therapy for the treatment of this patient?

A. steroids
B. nonsteroidal anti-inflammatory drugs (NSAIDs)
C. azathioprine
D. cyclophosphamide
E. magnesium sulfate

Back 31

steroids

Front 32

A 34 year-old G2P1 at 18 weeks gestation presents with a newly discovered lump in her left breast. Fine needle aspiration reveals adenocarcinoma. Which of the following is NOT a recommended therapy for breast cancer during pregnancy?

A. Wide local excision biopsy
B. Modified radical mastectomy
C. Total mastectomy and node dissection
D. Chemotherapy
E. Radiotherapy

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Radiotherapy