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An 18-year-old G1P0 woman is seen in the clinic for a routine prenatal visit at 28 weeks gestation. Her prenatal course has been unremarkable. She has not been taking prenatal vitamins. Her pre- pregnancy weight was 120 pounds. Initial hemoglobin at the first visit at eight weeks gestation was 12.3 g/dL. Current weight is 138 pounds. After performing a screening complete blood count (CBC), the results are notable for a white blood count 9,700/mL, hemoglobin 10.6 g/dL, mean corpuscular volume 88.2 fL (80.8 - 96.4) and platelets 215,000/mcL. The patient denies vaginal or rectal bleeding. Which of the following is the best explanation for this patient's anemia? A. Folate deficiency B. Relative hemodilution of pregnancy C. Iron deficiency D. Beta thalassemia trait E. Alpha thalassemia trait B. There is normally a 36% increase in maternal blood volume; the maximum is reached around 34 weeks. The plasma volume increases 47% and the RBC mass increases only 17%. This relative dilutional effect lowers the hemoglobin, but causes no change in the MCV. Folate deficiency results in a macrocytic anemia. Iron deficiency and thalassemias are associated with microcytic anemia. A 34-year-old G3P1 woman at 26 weeks gestation reports "difficulty catching her breath," especially after exertion for the last two months. She is a non-smoker. She does not have any history of pulmonary or cardiac disease. She denies fever, sputum, cough or any recent illnesses. On physical examination, her vital signs are: blood pressure 108/64, pulse 88, respiratory rate 15, and she is afebrile. Pulse oximeter is 98% on room air. Lungs are clear to auscultation. Heart is regular rate and rhythm with II/VI systolic murmur heard at the upper left sternal border. She has no lower extremity edema. A complete blood count reveals a hemoglobin of 10.0 g/dL. What is the most likely explanation for this woman's symptoms? A. Pulmonary embolism B. Mitral valve stenosis C. Physiologic dyspnea of pregnancy D. Peripartum cardiomyopathy E. Anemia Correct answer is C. Physical examination findings are not consistent with pulmonary embolus (e.g tachycardia, tachypnea, hypoxia, chest pain, signs of a DVT) or mitral stenosis (diastolic murmur, signs of heart failure). Physiologic dyspnea of pregnancy is present in up to 75% of women by the third trimester. Peripartum cardiomyopathy is an idiopathic cardiomyopathy that presents with
heart failure secondary to left ventricular systolic function towards the end of pregnancy or in the several months following delivery. Symptoms include fatigue, shortness of breath, palpitations, and edema. The history and physical do not suggest a pathologic process, nor does her hemoglobin level. A 24-year-old G4P2 woman at 34 weeks gestation complains of a cough and whitish sputum for the last three days. She reports that everyone in the family has been sick. She reports a high fever last night up to 102°F (38.9°C). She denies chest pain. She smokes a half-pack of cigarettes per day. She has a history of asthma with no previous intubations. She uses an albuterol inhaler, although she has not used it this week. Vital signs are: temperature 98.6°F (37°C); respiratory rate 16; pulse 94; blood pressure 114/78; peak expiratory flow rate 430 L/min (baseline documented in the outpatient chart = 425 L/min). On physical examination, pharyngeal mucosa is erythematous and injected. Lungs are clear to auscultation. White blood cell count 8,700; arterial blood gases on room air (normal ranges in parentheses): pH 7.44 (7.36 - 7.44); PO2 103 mm Hg (>100), PCO2 26 mm Hg (28 - 32), HCO3 19 mm Hg (22 - 2 6). Chest x-ray is normal. What is the correct interpretation of this arterial blood gas? A. Acute metabolic acidosis B. Compensated respiratory alkalosis C. Compensated metabolic alkalosis D. Hypoventilation E. Hyperventilation B. The increased minute ventilation during pregnancy causes a compensated respiratory alkalosis. Hypoventilation results in increased PCO2 and the PO2 would be decreased if she was hypoxic. A metabolic acidosis would have a decreased pH and a low HCO3. The patient's symptoms are most consistent with a viral upper respiratory infection A 28-year-old G1P0 internal medicine resident at 34 weeks gestation wants to discuss the values on her pulmonary function tests performed two days ago because she was feeling slightly short of breath. She is a non-smoker, and has no personal or family history of cardiac or respiratory disease. Vital signs are: respiratory rate 16; pulse 90, blood pressure 112/70; oxygen saturation is 99% on room air. On physical examination: lungs are clear; abdomen non-tender; fundal height is 34 cm. The results of the pulmonary function tests are: Inspiratory Capacity (IC) increased Tidal volume (TV) increased Minute ventilation increased Functional reserve capacity (FRC) decreased Expiratory reserve capacity (ERC) decreased Residual volume (RV) decreased
limitations on her activity. Vital signs are: respiratory rate 12; heart rate 88; blood pressure 112/68. On physical examination: her skin appears normal; lungs are clear to auscultation; heart is a regular rate and rhythm. There is a grade IV/VI coarse pansystolic murmur at the left sternal border, with a thrill. Chest x-ray and ECG are normal. Which of the following is the correct statement regarding cardiovascular adaptation in this patient? A. Approximately 2% of women will normally have a diastolic murmur B. Maternal pulmonary vascular resistance is normally less than systemic vascular resistance C. The maternal cardiac output will increase up to 33% during pregnancy D. Maternal systemic vascular resistance increases throughout pregnancy E. The increase in cardiac output is only due to the increase in the maternal stroke volume C. The cardiac output increases up to 33% due to increases in both the heart rate and stroke volume. The SVR falls during pregnancy. Up to 95% of women will have a systolic murmur due to the increased volume. Diastolic murmurs are always abnormal. The systemic vascular resistance (SVR) is normally greater than the pulmonary vascular resistance. If the pulmonary vascular resistance exceeds the SVR, right to left shunt will develop in the setting of a VSD, and cyanosis will develop. A 1 7 - year-old G1P0 woman at 32 weeks gestation complains of right flank pain that is "colicky" in nature and has been present for two weeks. She denies fever, dysuria and hematuria. Physical examination is notable for moderate right costovertebral angle tenderness. White blood cell count 8,800/mL, urine analysis negative. A renal ultrasound reveals no signs of urinary calculi, but there is moderate (15 mm) right hydronephrosis. Which of the following is the most likely cause of these findings? A. Smooth muscle relaxation due to declining levels of progesterone B. Smooth muscle relaxation due to increasing levels of estrogen C. Compression by the uterus and right ovarian vein D. Elevation of the bladder in the second trimester E. Iliac artery compression of the ureter C. Some degree of dilation in the ureters and renal pelvis occurs in the majority of pregnant women. The dilation is unequal (R > L) due to cushioning provided by the sigmoid colon to the left ureter and from greater compression of the right ureter due to dextrorotation of the uterus. The right ovarian vein complex, which is remarkably dilated during pregnancy, lies obliquely over the right ureter and may contribute significantly to right ureteral dilatation. High levels of progesterone likely have some effect but estrogen has no effect on the smooth muscle of the ureter. A 34-year-old G4P2 woman at 18 weeks gestation presents with fatigue and occasional headache. She has a sister with Grave's disease. On physical exam, vital signs are normal. BMI is 27. Thyroid is
difficult to palpate due to her body habitus. The remainder of her exam is unremarkable. Thyroid function studies show: Results Reference Range TSH 1.8 mU/L 0.30 - 5.5 mU/L Free T4 1.22 ng/dL 0.76 - 1.70 ng/dL Total T4 14.2 ng /dL 4.9 - 12.0 ng /dL Free T3 3.4 ng/dL 2.8 - 4.2 ng/dL Total T3 200 ng/dL 80 - 175 ng/dL What is the next best step in the management of this patient? A. Continue routine prenatal care B. Check anti-thyroid antibody levels C. Obtain a thyroid ultrasound D. Initiate propylthiouracil E. Initiate methimazole A. Thyroid binding globulin (TBG) is increased due to increased circulating estrogens with a concomitant increase in the total thyroxine. Free thyroxine (T4) remains relatively constant. Total triiodothyroxine (T3) levels also increase in pregnancy while free T3 levels do not change. In a pregnant patient without iodine deficiency, the thyroid gland may increase in size up to 10%. This patient's thyroid function is normal for pregnancy, and her symptoms of fatigue can be explained by other physiologic changes in pregnancy, including anemia, difficulty with sleep, and increase metabolic demand. An 18 - year-old G1P0 woman at 12 weeks gestation reports nausea, vomiting, scant vaginal bleeding and a "racing heart." These symptoms have been present on and off for the past four weeks. The patient has no significant past medical, surgical or family history. Vital signs are: temperature 98.6°F (37°C); heart rate 120; blood pressure 128/78. On physical examination: uterine fundus is 4 cm below the umbilicus; no fetal heart tones obtained by fetal Doppler device; cervix is 1 cm dilated with pinkish/purple "fleshy" tissue protruding through the os. Labs show: hemoglobin 8.2 gm/dL, quantitative Beta-hCG 1.0 Million IU/mL; thyroid-stimulating hormone (TSH) undetectable; free T 3.2 (normal 0.7 - 2.5). An ultrasound reveals heterogeneous cystic tissue in the uterus (snowstorm pattern). Which of the following is the most appropriate next step in the management of this patient? A. Repeat quantitative Beta-hCG
C. Quantitative Beta-hCG D. Obstetrical ultrasound E. Quadruple screen D. The patient's gestational age based on her LMP and the findings on physical exam are discordant. In this case, the most reliable method of confirming gestational age is a dating ultrasound. A quantitative Beta-hCG will not reliably predict the gestational age. The uterine size on physical exam is not the most accurate way to date a pregnancy. An ultrasound performed between 14 and 20 weeks gestation should be used to date the pregnancy if there is greater than a 10 day discrepancy from the menstrual dates. First trimester ultrasound provides the most accurate assessment of gestational age and can give an accurate estimated date of confinement (EDC) to within 3-5 days. A 34-year-old G2P1 woman presents at 13 weeks gestation. She did not seek preconception counseling and is worried about delivering a child with Down syndrome, given her maternal age. She has no significant medical, surgical, family or social history. Which of the following tests is most effective in screening for Down syndrome in the second trimester? A. Quadruple screen B. Triple screen C. Amniotic fluid for alpha fetoprotein level D. Maternal serum alpha fetoprotein level E. Nuchal translucency measurement with serum PAPP-A (pregnancy associated plasma protein-A) and free Beta-hCG level A. The quadruple test (maternal serum alpha fetoprotein, unconjugated estriol, human chorionic gonadotropin, and inhibin A) is the most effective screening test for Down syndrome in the second trimester. Down syndrome occurs in about 1 in 800 births in the absence of prenatal intervention. The efficacy of screening for Down syndrome is improved when additional components are added to the maternal serum alpha fetoprotein screening. The addition of unconjugated estriol and human chronic gonadotropin (the Triple Screen) results in a 69% detection rate for Down syndrome. Adding inhibin A to produce a quadruple screen achieves a detection rate of 80 - 85%. An amniotic fluid alpha fetoprotein level is unnecessary. Nuchal translucency measurement with maternal serum PAPP-A and free Beta-hCG (known as the combined test) is a first trimester screen for Down syndrome. It detects approximately 85% of cases of Down syndrome at a 5% false positive rate. A 26 - year-old G2P1 woman at 26 weeks gestation presents for a routine 50 - gram glucose challenge test. After receiving a one-hour blood glucose value of 148 mg/dl, the patient has a follow up 100- gram three-hour oral glucose tolerance test with the following plasma values:
Fasting 102 mg/dl (normal ≤95 mg/dl) 1 - hour 181 mg/dl (normal ≤180 mg/dl) 2 - hour 162 mg/dl (normal ≤155 mg/dl) 3 - hour 139 mg/dl (normal ≤140 mg/dl) B. This patient has three values on the three-hour glucose tolerance test that were abnormal. Initial management should include teaching the patient how to monitor her blood glucose levels at home on a schedule that would include a fasting blood sugar and one- or two-hour post-prandial values after all three meals, daily. Goals for blood sugar management would be to maintain blood sugars when fasting below 90 and one- and two-hour post-meal values below 120. A repeat glucose tolerance test would not add any value, as an abnormal test has already been documented. Oral hypoglycemic agents and insulin are not indicated at this time, as the patient may achieve adequate glucose levels with diet modification alone. Gestational diabetes varies in prevalence. The prevalence rate in the United States has varied from 1.4 to 14% in various studies. Risk factors for gestational diabetes include: a previous large baby (greater than 9 lb), a history of abnormal glucose tolerance, pre-pregnancy weight of 110% or more of ideal body weight, and member of an ethnic group with a higher than normal rate of type 2 diabetes, such as American Indian or Hispanic descent. A 29-year-old G2P1 woman at 36 weeks gestation is seen for management of her gestational diabetes. Despite diet modification, the patient has required insulin to control her serum glucose levels. She has gained 25 pounds with the pregnancy. She is at risk for all the following complications, except: A. Polyhydramnios B. Neonatal hypoglycemia C. Intrauterine growth restriction D. Preeclampsia E. Fetal macrosomia C. Intrauterine growth restriction is typically seen in women with pre-existing diabetes and not with gestational diabetes. Shoulder dystocia, metabolic disturbances, preeclampsia, polyhydramnios and fetal macrosomia are all associated risks of gestational diabetes. A 32 - year-old G3P2 woman has delivered a previous child with anencephaly. What is the appropriate recommended dose of folic acid for this woman? A. 0.4 mg
temperature 98.6°F (37.0°C); blood pressure 100/60; pulse 79; respiratory rate 14; fetal heart rate 140s, reactive, with no decelerations; tocometer shows irregular contractions every 2-8 minutes; fundal height 36 cm; cervix is firm, long, closed and posterior. A urine dipstick is notable for 1+ glucose with negative ketones. Which of the following is the most likely diagnosis in this patient? A. Appendicitis B. Gestational diabetes C. Braxton-Hicks contractions D. First stage of labor E. Dehydration C. Braxton Hicks contractions are characterized as short in duration, less intense than true labor, and the discomfort as being in the lower abdomen and groin areas. True labor is defined by strong, regular uterine contractions that result in progressive cervical dilation and effacement. This patient's history does not suggest she is in the first stage of labor. Patients with appendicitis usually present with fever, decreased appetite, nausea and vomiting. Gestational diabetes is diagnosed based on glucose challenge tests. The first test with a 50 gram load is typically performed at 24-28 weeks gestation. It is not abnormal for patients to have glucosuria. This finding is not diagnostic for gestational diabetes. Patients with dehydration frequently present with maternal tachycardia and have ketonuria. A 22-year-old G3P0 woman at 37 weeks gestation with an uncomplicated pregnancy presents to labor and delivery with decreased fetal movements for one day. She denies contractions, loss of fluid, or bleeding. Vital signs are temperature 98.6°F (37.0°C); blood pressure 100/60; pulse 79; respiratory rate 13; fetal heart rate 140s, reactive, with no decelerations. Tocometer reveals one contraction every eight minutes. Fundal height 36 cm, amniotic fluid index is 9. Cervix is firm, long, closed and posterior. What is the next best step in the management of this patient? A. Discharge home with labor warnings B. 24 hour observation C. Biophysical profile D. Contraction stress test E. Induction of labor A. The patient has reassuring fetal testing and may be discharged home with labor warnings: contractions every five minutes for one hour, rupture of membranes, fetal movement less than 10 per two hours or vaginal bleeding. A reactive non-stress test and normal AFI (modified biophysical profile) are sufficient to assess fetal well being at this time. Additional testing and interventions are not indicated at this time.
A 38 - year-old G1P0 woman presents to the hospital at 39 weeks in early labor. She has had routine prenatal care and no antepartum complications to date. She reports good fetal movement and denies vaginal bleeding and leakage of fluid. What is the next best step in the initial assessment of this patient? A. Physical examination B. Nitrazine test C. Fetal ultrasound D. Biophysical profile E. Contraction stress test A. The initial evaluation of patients presenting to the hospital for labor includes a review of the prenatal records with special focus on the antenatal complications and dating criteria, a focused history and a targeted physical examination to include maternal vital signs and fetal heart rate, and abdominal and pelvic examination. A speculum exam with a nitrazine test to confirm rupture of membranes is indicated if the patient's history suggests this, or if a patient is uncertain as to whether she has experienced leakage of amniotic fluid. Performing a fetal ultrasound is not a routine part of an assessment in a patient who may be in early labor. A prenatal ultrasound may be used in cases to determine fetal presentation, estimated fetal weight, placental location or amniotic fluid volume. A 16-year-old G1P0 woman at 39 weeks gestation presents to labor and delivery reporting a gush of blood-tinged fluid approximately five hours ago and the onset of uterine contractions shortly thereafter. She reports contractions have become stronger and closer together over the past hour. The fetal heart rate is 140 to 150 with accelerations and no decelerations. Uterine contractions are recorded every 2-3 minutes. A pelvic exam reveals that the cervix is 4 cm dilated and 100 percent effaced. Fetal station is 0. After walking around for 30 minutes the patient is put back in bed after complaining of further discomfort. She requests an epidural. However, obtaining the fetal heart rate externally has become difficult because the patient cannot lie still. What is the most appropriate next step in the management of this patient? A. Place the epidural B. Apply a fetal scalp electrode C. Perform a fetal ultrasound to assess the fetal heart rate D. Place an intrauterine pressure catheter (IUPC) E. Recommend a Cesarean delivery B. If the fetal heart rate cannot be confirmed using external methods, then the most reliable way to document fetal well-being is to apply a fetal scalp electrode. Putting in an epidural without
D. Begin Pitocin augmentation E. Keep IUPC in position and connect to tocometer B. If an intrauterine pressure catheter is placed, and a significant amount of vaginal bleeding is noted, the possibility of placenta separation or uterine perforation should be considered. In this case, withdrawing the catheter, monitoring the fetus and observing for any signs of fetal compromise would be the most appropriate management. If the fetal status is found to be reassuring, then another attempt at placing the catheter may be undertaken. A 19-year-old G1P0 woman at 39 weeks gestation presents in labor. She denies ruptured membranes. Her prenatal course was uncomplicated and ultrasound at 18 weeks revealed no fetal abnormalities. Her vital signs are: blood pressure 120/70; pulse 72; temperature 101.0° F (38.3° C); fundal height 36 cm; and estimated fetal weight of 2900 gm. Cervix is dilated to 4 cm, 100% effaced and at +1 station. She receives 10 mg of morphine intramuscularly for pain and soon after has spontaneous rupture of the membranes. Light meconium-stained fluid was noted and, five minutes later, the fetal heart rate tracing revealed variable decelerations with good variability. What is the most likely cause for the variable decelerations? A. Umbilical cord compression B. Meconium C. Maternal fever D. Uteroplacental insufficiency E. Umbilical cord prolapse A. Variable decelerations are typically caused by cord compression and are the most common decelerations seen in labor. Placental insufficiency is usually associated with late decelerations. Head compression typically causes early decelerations. Oligohydramnios can increase a patient's risk of having umbilical cord compression; however, it does not directly cause variable decelerations. Umbilical cord prolapse occurs in 0.2 to 0.6% of births. Sustained fetal bradycardia is usually observed. A 34 - year-old G1P0 woman at 39 weeks gestation presents in active labor. Her cervical examination an hour ago was 5 cm dilated, 90 percent effaced and 0 station. The baseline is 140 beats/minute. There is a deceleration after the onset of each of the last four contractions. She just had spontaneous rupture of membranes and is found to be completely dilated with the fetal head is at +3 station. What is the most likely etiology for these decelerations? A. Oligohydramnios B. Rapid change in descent
C. Umbilical cord compression D. Uteroplacental insufficiency E. Head compression D. This patient is having late decelerations. Late decelerations are associated with uterine contractions. The onset, nadir, and recovery of the decelerations occur, respectively, after the beginning, peak and end of the contraction. Late decelerations are associated with uteroplacental insufficiency. A rapid change in cervical dilation and descent are not associated with late decelerations. Umbilical cord compression is associated with variable decelerations. Oligohydramnios can increase a patient's risk of having umbilical cord compression; however, it does not cause late decelerations. Head compression is associated with early decelerations. A 34-year-old G2P1 woman is 40 weeks gestation. She was admitted to labor and delivery in active labor 2 hours ago. Her cervix was 6 cm dilated and 100% effaced on admission. Her fetus was vertex and - 3 station. You are called to examine the patient after she experiences spontaneous rupture of membranes. The cervix is completely dilated and the fetal head is occiput anterior (OA) at +1 station. You palpate a 5 cm long section of umbilical cord in the patient's vagina. The fetal heart tracing is reassuring. The baseline is 130 beats per minute. There are multiple accelerations and no decelerations. The patient is having regular uterine contractions every 2-3 minutes. She has an epidural and is not feeling the contractions. What is the most appropriate next step in the management of this patient? A. Allow for passive descent of the fetal head with continuous fetal monitoring B. Have the patient start pushing with the contractions C. Gently attempt to replace the umbilical cord segment back up into the uterus D. Perform a forceps assisted vaginal delivery E. Elevate the fetal head with a vaginal hand and perform a Cesarean delivery E. This patient has an umbilical cord prolapse. Although fetal surveillance is reassuring, the most appropriate management is to continue to elevate the fetal head with a hand in the patient's vagina and call for assistance to perform a Cesarean delivery. It is important to elevate the fetal head in an attempt to avoid compression of the umbilical cord. Once an umbilical cord prolapse is diagnosed, expeditious arrangements should be made to perform a cesarean section. It is not appropriate to replace the umbilical cord into the uterus or allow the patient to continue to labor or perform a forceps-assisted vaginal delivery. 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
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 B. Small babies are more common with type 1 diabetes than with gestational diabetes, and the blood sugar level of all newborns of diabetic mothers should be monitored closely after delivery, as they are at increased risk for developing hypoglycemia. Macrosomic (large) infants are typically associated with gestational diabetes. 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 E. 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. 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 A. 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. 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 D. Infants born to diabetic mothers are at increased risk for developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress. Thrombocytopenia is not a risk. 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
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? A. Vaginal lacerations B. Cervical lacerations C. Uterine atony D. Uterine dehiscence E. Uterine rupture C. 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. 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 C. 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. 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 E. 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. 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 The most common cause of postpartum fever is endometritis. The differential diagnosis includes urinary tract infection, lower genital tract infection, wound infections, pulmonary infections, thrombophlebitis, and mastitis. Endometritis appearing in a postpartum period is most closely related to the mode of delivery and occurs after vaginal delivery in approximately 2 percent of patients and after Cesarean delivery in about 10 to 15 percent. Factors related to increased rates of
