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18 Cards in this Set
- Front
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A 19-year-old G1P0 woman at 41-weeks gestation with two prior prenatal visits at 35-weeks and 40-weeks, presents in active labor. Review of available maternal labs shows: blood type O+; RPR non-reactive; HBsAg negative; and HIV negative. She delivers a small female infant who cries spontaneously. On examination, you find the infant has a slightly flattened nasal bridge. Her ears are small and slightly rotated. What is the most appropriate next step in the management of this patient?
A. Tell the mother the infant will be fine B. Tell the mother that her newborn has Down syndrome C. Question the patient why an amniocentesis was not performed D. Further examine the infant for wide-spaced nipples and lymphedema E. Further examine the infant for sandal gap toes and hypotonia |
Further examine the infant for sandal gap toes and hypotonia
A flattened nasal bridge, small size and small rotated, cup-shaped ears may be associated with Down syndrome and should prompt a survey looking specifically for other features seen with Down syndrome that include sandal gap toes, hypotonia, a protruding tongue, short broad hands, Simian creases, epicanthic folds, and oblique palpebral fissures |
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A 30-year-old G2P0 woman at 38 weeks gestation has just delivered a male infant. She has a history of type 1 diabetes since age 11. Maternal labs show: blood type B+; RPR non-reactive; HBsAg negative; HIV negative; and GBS negative. She had moderate control of blood sugar during her pregnancy. Which of the following would be the most likely finding in the newborn?
A. Large and hypoglycemic B. Small and hypoglycemic C. Large and hyperglycemic D. Small and hyperglycemic E. Normal size and euglycemic |
Small and hypoglycemic
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A 24-year-old G1P0 woman presents in active labor at 39 weeks gestation. She reports leaking fluid for the last two days. She develops a temperature of 102.0°F (38.9°C) and fetal heart rate is 180 beats/min with minimal variability. Maternal labs show: blood type O+; RPR non-reactive; HBsAg, negative; HIV negative; and GBS unknown. What will be the expected appearance of the baby at delivery?
A. Vigorous, pink with normal temperature B. Vigorous, pale with low temperature C. Lethargic, pink with high temperature D. Lethargic, pale with low temperature E. Lethargic, pale with high temperature |
Lethargic, pale with high temperature
This patient clearly has chorioamnionitis. The fetal tachycardia may be in response to the maternal fever. Fetal tachycardia coupled with minimal variability is a warning sign that the infant can be septic. A septic infant will typically appear pale, lethargic and have a high temperature |
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A 24-year-old G1P0 woman has just delivered 37 week male twins. On your initial assessment, you notice twin A is large and plethoric, and twin B is small and pale. A complete blood count (CBC) is obtained on both twins. What is the most likely finding in this case?
A. Twin A is at high risk for polycythemia B. Twin A is at high risk for thrombocytopenia C. Twin B is at high risk for thrombocytopenia D. Twin B is at high risk for tachycardia E. Twin B is at high risk for hyperbilirubinemia |
This case is suggestive of twin-twin transfusion syndrome (TTTS). Polycythemia is a common complication for the plethoric twin. TTTS is a complication of monochorionic pregnancies. It is characterized by an imbalance in the blood flow through communicating vessels across a shared placenta leading to under perfusion of the donor twin, which becomes anemic and over perfusion of the recipient, which becomes polycythemic. The donor twin often develops IUGR and oligohydramnios, and the recipient experiences volume overload and polyhydramnios that may lead to heart failure and hydrops.
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A 23-year-old G1P0 at 39 weeks gestation presents in spontaneous labor. Pregnancy was complicated by gestational diabetes. She delivers a 4200 gram infant with ruddy color and jitteriness. The infant is at immediate risk for which of the following conditions?
A. Hyperglycemia B. Anemia C. Thrombocytopenia D. Polycythemia E. Hypercalcemia |
Polycythemia.
Infants born to diabetic mothers are at increased risk for developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress. Thrombocytopenia is not a risk. |
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A 25-year-old G6P2 woman in active labor is treated with mepiridine (Demerol). The patient reports the use of marijuana to control nausea during her pregnancy. She quickly progresses from 4 cm to fully dilated in 1 hour and is now pushing. A limp unresponsive infant is delivered. Heart rate is greater than 90 beats/minute. The infant has no respiratory effort. Which of the following is the most appropriate next step in the management of this patient?
A. Give positive pressure ventilation and prepare to intubate B. Give positive pressure ventilation and prepare to give naloxone C. Give stimulation only and continue to monitor heart rate D. Suction thoroughly and check heart rate E. Suction thoroughly and give naloxone |
You should give positive pressure ventilation and prepare to intubate the infant, if necessary. Any history of substance abuse may be a relative contraindication to the use of naloxone (Narcan) because the mother may have used narcotics during the pregnancy and administration of naloxone to the infant can cause life-threatening withdrawal. Stimulation may not be sufficient for this infant. Suction will not necessarily stimulate a respiratory effort.
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A 32-year-old G3P1 woman at 37 weeks gestation is admitted to labor and delivery for a scheduled repeat Cesarean delivery. Maternal labs show: HIV positive; blood type B+; RPR non-reactive; HBsAg negative; GBS negative; PPD positive; CXR negative. She received adequate antiretroviral therapy prior to and during the pregnancy. A live male infant is delivered with Apgar scores of 9 and 9 at 1 and 5 minutes, respectively. Which of the following is the most appropriate next step in the management of the newborn?
A. Order HIV testing on the infant immediately on admission to the nursery B. Treat the infant with zidovudine (AZT) immediately after delivery C. Encourage breastfeeding D. Start zidovudine at 24 hours of life E. Isolate the infant from the other infants in the nursery |
Treat the infant with zidovudine (AZT) immediately after delivery.
A usual protocol is to start AZT immediately after delivery. HIV testing begins at 24 hours. There is no reason to isolate the infant even though the mother is PPD positive, because her CXR is negative. Breastfeeding would not be encouraged in a mother with HIV. |
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A 33-year-old G2P1 woman delivered a male infant after a precipitous second stage. On initial assessment, the infant has no respiratory effort. You decide to proceed with positive pressure ventilation. Which of the following techniques will impede positive pressure ventilation on this newborn?
A. Adjusting head position to modified flex position B. Adjusting the head to sniffing position C. Securing mask for a good seal D. Compressing the bag just until chest rise is seen E. Having the oxygen flow at minimum 10 L/minute |
Adjusting head position to modified flex position
Adjusting the head to a modified flex position is typically used in adult CPR. The sniffing position (tilting the neonate’s head back and lifting the chin) is the correct position for application of positive pressure ventilation in a newborn infant. It is important to also secure the mask to the infant’s face and to observe an initial chest rise. A recommended rate of oxygen flow is 10 L/minute. |
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At one minute of life, an infant has a heart rate greater than 120 beats/minute, is crying, has acrocyanosis, gags when suctioned and is vigorously moving all four extremities. What is the APGAR score for this infant?
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9
Heart rate= 2, Respiratory rate= 2, Reflex = 2, Activity =2, Color =1. Therefore, the one-minute APGAR score is 9. |
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A 28-year-old G3P3 woman status post an uncomplicated spontaneous vaginal delivery of 4150 gram infant experiences profuse vaginal bleeding of 700 cc. Prior obstetric history was notable for a previous low uterine segment transverse Cesarean section, secondary to transverse fetal lie. The patient had no antenatal problems. The placenta delivered spontaneously without difficulty. Which of the following is the most likely cause of this patient’s hemorrhage?
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Postpartum hemorrhage (PPH) is an obstetrical emergency that can follow vaginal or Cesarean delivery. Uterine atony is the most common cause of PPH and occurs in one in every twenty deliveries. It is important to detect excessive bleeding quickly and determine an etiology and initiate the appropriate treatment as excessive bleeding may result in hypovolemia, with associated hypotension, tachycardia or oliguria. The most common definition of PPH is an estimated blood loss of greater than or equal to 500 ml after vaginal birth, or greater than or equal to 1000 ml after Cesarean delivery.
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A 21-year-old G1P1 woman presents to the office with amenorrhea since the birth of her one-year old daughter. She reports extreme fatigue, forgetfulness, and depression. She was unable to breastfeed because her milk never came in. She notes hair loss including under her arms and in her pubic area. Her delivery was complicated by a postpartum hemorrhage, hypovolemic shock, requiring aggressive resuscitation. She is afebrile. Vital signs are: blood pressure 90/50; pulse 84. The patient appears tired. Her exam is normal but she is noted to have dry skin. A urine pregnancy test is negative. Which of the following is the most likely diagnosis in this patient?
A. Hyperprolactinemia B. Hyperthyroidism C. Sheehan Syndrome D. Asherman Syndrome E. Major depressive disorder |
Sheehan Syndrome is a rare occurrence. When a patient experiences a significant blood loss, this can result in anterior pituitary necrosis, which may lead to loss of gonadotropin, thyroid-stimulating hormone (TSH) and adrenocorticotropic hormone (ACTH) production, as they are all produced by the anterior pituitary. Signs and symptoms of Sheehan syndrome may include slow mental function, weight gain, fatigue, difficulty staying warm, no milk production, hypotension and amenorrhea. Sheehan’s syndrome frequently goes unnoticed for many years after the inciting delivery. Treatment includes estrogen and progesterone replacement and supplementation with thyroid and adrenal hormones.
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A 21-year-old G1P0 woman delivered a 4000 gram infant by a low-forceps delivery after a protracted labor course that included a three-hour second stage. Her prenatal course was notable for development of anemia, poor weight gain and maternal obesity. Following the delivery, the patient was noted to have a vaginal sulcus laceration and a third-degree perineal laceration, which required extensive repair. Her hematocrit was noted to be 30% on postpartum day one. Which of the following factors places this patient at greatest risk for developing a puerperal infection?
A. Third-degree perineal laceration B. Poor nutrition C. Obesity D. Anemia E. Protracted labor |
Protracted labor.
Endometritis in the postpartum period is most closely related to the mode of delivery. Endometritis can be found in less than 3% of vaginal births and this is contrasted by a 5-10 times higher incidence after Cesarean deliveries. Factors related to increased rates of infection with a vaginal birth include prolonged labor, prolonged rupture of membranes, multiple vaginal examinations, internal fetal monitoring, removal of the placenta manually and low socioeconomic status. |
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A 23-year-old G1P1 woman develops a fever on the third day after an uncomplicated Cesarean delivery that was performed secondary to arrest of descent. The only significant finding on physical exam is moderate breast engorgement and mild uterine fundal tenderness. What is the most likely diagnosis in this patient?
A. Urinary tract infection B. Mastitis C. Endometritis D. Wound cellulitis E. Septic pelvic thrombophlebitis |
Endometritis. The most common cause of postpartum fever is endometritis.
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A 34-year-old G4P4 woman is diagnosed with endometritis following a Cesarean delivery three days ago. Which of the following is the most likely causative agent(s) of endometritis in this patient?
A. Aerobic streptococcus B. Anaerobic streptococcus C. Aerobic staphylococcus D. Anaerobic staphylococcus E. Aerobic and anaerobic bacteria |
Bacterial isolates related to postpartum endometritis are usually polymicrobial resulting in a mix of aerobes and anaerobes in the genital tract. The most causative agents are Staphylococcus aureus and Streptococcus.
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A 45-year-old G2P2 woman presents for a six-week post partum check. She reports crying spells, loss of appetite, difficulty sleeping and a feeling of low self-worth that began one week after her delivery. She denies any suicidal or homicidal ideations. She is frustrated because she has not been able to breastfeed and feels that she is a bad mother. She has a previous history of anxiety. Which of the following is the most likely diagnosis in this patient?
A. Normal puerperium B. Postpartum blues C. Postpartum depression D. Anxiety disorder E. Bipolar disorder |
Postpartum depression is a common condition estimated to affect approximately 10-15% of women and often begins within two weeks to six months after delivery. Signs and symptoms of depression which last for less than two weeks are called postpartum blues. It occurs in 40-85% of women in the immediate postpartum period. It is a mild disorder that is usually self-limited. This patient does not have signs/symptoms of anxiety disorder or bipolar disorder.
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A 35-year-old G4P3 woman comes in for a postpartum visit. She had a normal uncomplicated vaginal delivery two weeks ago. She has a history of postpartum depression, which required treatment with antidepressants with her last pregnancy. Which of the following signs or symptoms of postpartum depression are most useful to distinguish it from postpartum blues and normal changes that occur after delivery?
A. Anhedonia B. Crying spells C. Ambivalence toward the newborn D. Sleeplessness E. Weight loss |
Ambivalence toward the newborn
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A 17-year-old G1P1 woman delivered a term infant two days ago. She is not interested in breastfeeding and she asks for something to suppress lactation. Which of the following is the safest method of lactation suppression in this patient?
A. Bromocriptine B. Breast binding, ice packs and analgesics C. Medroxyprogesterone acetate D. Oral contraceptives E. Manual milk expression |
Breast binding, ice packs and analgesics.
Hormonal interventions for preventing lactation appear to predispose to thromboembolic events, as well as a significant risk of rebound engorgement. Bromocriptine, in particular, is associated with hypertension, stroke and seizures. The safest method to suppress lactation is breast binding, ice packs and analgesics. The patient should avoid breast stimulation or other means of milk expression, so that the natural inhibition of prolactin secretion will result in breast involution. |
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A 23-year-old G1P1 woman delivered a healthy infant two days ago. She has had difficulty breastfeeding despite multiple attempts. Her nipples are sore and cracked and she is thinking about exclusively bottlefeeding. The patient’s pregnancy was complicated by gestational diabetes and the patient has chronic hypertension and a history of an abnormal Pap. She had a cone biopsy two years ago and had a normal Pap with the current pregnancy. The patient’s mother has a history of endometrial and colon cancer and her maternal grandmother and grandfather both had fatal heart attacks in their early sixties. Breastfeeding decreases the risk of which of the following for this patient?
A. Type 2 diabetes B. Coronary artery disease C. Cervical cancer D. Ovarian cancer E. Colon cancer |
Ovarian cancer
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