LE 6 OB Flashcards

Question

15. A 34-year-old Jewish woman at 36 weeks AOG with Crohn’s disease presents with severe abdominal pain and perianal fistulas. Which of the following is NOT included in her management? a. Corticosteroids b. Methotrexate c. Biologic therapy d. Nutritional support

Answer 1

b. Methotrexate Rationale: Methotrexate is contraindicated in pregnancy due to its teratogenic effects. Corticosteroids and biologic therapy can be used to manage Crohn’s disease flares.

Answer 2

c. Congenital anal atresia Rationale: Crohn’s disease is associated with fetal growth restriction, preterm birth, and miscarriage. Congenital anal atresia is not a known complication.

Answer 3

a. Vaginal delivery at the onset of labor Rationale: Cesarean section is not routinely indicated in Crohn’s disease unless there is severe perianal disease or obstetric indications.

Answer 4

b. Intrahepatic cholestasis of pregnancy Rationale: Intrahepatic cholestasis of pregnancy (ICP) presents with pruritus and elevated bile acids. It is associated with an increased risk of fetal complications.

Answer 5

d. Liver transplant Rationale: Liver transplant is reserved for severe liver failure, which is rare in ICP. Ursodeoxycholic acid is the treatment of choice.

Answer 6

d. Induction of labor at 37 weeks AOG Rationale: Induction at 37 weeks is recommended to reduce the risk of stillbirth associated with intrahepatic cholestasis of pregnancy.

Answer 7

d. AFLP causes hepatic function to return to normal postpartum Rationale: AFLP is a severe but reversible condition. Liver function usually normalizes postpartum, but immediate delivery is required to prevent maternal and fetal complications.

Answer 8

b. Pregnant women have a higher risk of fulminant hepatitis, particularly with hepatitis E Rationale: Hepatitis E infection in pregnancy has a high risk of fulminant hepatic failure, particularly in the third trimester.

Answer 9

a. HBsAg Rationale: The presence of HBsAg indicates ongoing infection (acute or chronic). Chronic hepatitis B infection, particularly with persistent HBsAg and high viral loads, increases the risk of hepatocellular carcinoma (HCC). HBeAg indicates high infectivity, while Anti-HBs suggests immunity.

Answer 10

d. A and B only Rationale: Infants born to mothers with hepatitis B should receive both Hepatitis B immunoglobulin (HBIG) and the Hepatitis B vaccine within the first 24 hours of life to prevent vertical transmission. Breastfeeding is not contraindicated as long as the neonate is immunized.

Answer 11

d. Passive immunization with hepatitis A immunoglobulin (HAV Ig) Rationale: Pregnant women exposed to hepatitis A, especially those unvaccinated, should receive HAV Ig for immediate passive immunity. The hepatitis A vaccine can also be given but does not provide immediate protection. Breastfeeding is not contraindicated.

Answer 12

b. Varicella Rationale: Varicella (chickenpox) in pregnancy presents with flu-like symptoms followed by vesicular lesions that crust over in a week.

Answer 13

b. Pneumonia Rationale: Varicella pneumonia is a severe complication in adults, particularly in pregnant women, leading to significant morbidity and mortality.

Answer 14

b. One day before the onset of the rash until the lesions crust over Rationale: Varicella is highly contagious from one day before rash onset until all lesions are crusted.

Answer 15

b. Asymptomatic bacteriuria Rationale: Asymptomatic bacteriuria is defined as significant bacteriuria (>100,000 CFU/mL) without symptoms. It requires treatment in pregnancy to prevent pyelonephritis.

Answer 16

d. AOTA (All of the Above) Rationale: Urinalysis detects leukocytes and nitrites, urine culture confirms the causative organism, and CBC assesses systemic infection.

Answer 17

b. Between 13 and 20 weeks AOG Rationale: The highest risk for congenital varicella syndrome occurs between 13-20 weeks AOG, leading to limb hypoplasia, skin scarring, and neurologic defects.

Answer 18

a. RNA paramyxovirus Rationale: Mumps is caused by an RNA paramyxovirus, which primarily affects the parotid glands and may lead to complications like orchitis.

Answer 19

a. Adynamic colon Rationale: Colonic pseudo-obstruction (Ogilvie syndrome) results from an adynamic colon, often following surgery or trauma, leading to functional bowel obstruction.

Answer 20

d. H. pylori infection Rationale: H. pylori is the most common cause of gastroduodenal ulcers. It is associated with peptic ulcer disease and can impact pregnancy outcomes.

Answer 21

c. It is safe to administer during pregnancy Rationale: Live vaccines like MMR are contraindicated in pregnancy due to the risk of fetal infection.

Answer 22

c. Rubeola (Measles) Rationale: Measles presents with the classic 3 Cs (cough, coryza, conjunctivitis) and fever, followed by a maculopapular rash.

Answer 23

d. Rubella Rationale: Rubella is highly teratogenic, particularly in the first trimester, causing congenital rubella syndrome with deafness, heart defects, and cataracts.

Answer 24

a. < 12 weeks Rationale: The risk of fetal rubella infection is highest in the first trimester, especially before 12 weeks, leading to severe congenital abnormalities.

Answer 25

a. Staphylococcus aureus Rationale: S. aureus produces TSST-1, leading to toxic shock syndrome, characterized by fever, hypotension, and multi-organ failure.

Answer 26

d. Streptococcus agalactiae Rationale: Group B streptococcus (GBS) is the leading cause of early-onset neonatal sepsis, typically transmitted during birth.

Answer 27

c. 35-37 weeks Rationale: GBS screening is done at 35-37 weeks AOG to identify carriers and determine the need for intrapartum antibiotic prophylaxis to prevent neonatal sepsis.

Answer 28

c. 30-50% Rationale: Cardiac output increases by 30-50% due to an increase in stroke volume and heart rate. This supports the increased metabolic demands of pregnancy.

Answer 29

b. Increase in estrogen and progesterone Rationale: Estrogen and progesterone act as vasodilators, reducing systemic vascular resistance and leading to a decrease in mean arterial pressure, reaching its lowest point in the second trimester.

Answer 30

b. Second trimester Rationale: Systemic vascular resistance decreases due to vasodilation from progesterone, estrogen, and nitric oxide, reaching its lowest point in the second trimester.

Answer 31

c. Compression of the aorta & vena cava Rationale: The gravid uterus compresses the aorta and inferior vena cava in the supine position, reducing venous return and cardiac output, which can cause supine hypotensive syndrome.

Answer 32

c. Left lateral decubitus Rationale: The left lateral decubitus position relieves aortocaval compression, improving venous return and cardiac output.

Answer 33

b. Structural modification of the trophoblast on the maternal artery Rationale: The trophoblast invades and remodels maternal spiral arteries, reducing resistance and facilitating increased placental blood flow.

Answer 34

b. Decreases Rationale: FRC decreases by 10-25% due to the enlarged uterus elevating the diaphragm, reducing lung volumes.

Answer 35

c. 40% Rationale: GFR increases by 40% to accommodate fetal metabolic waste removal and maintain maternal fluid balance.

Answer 36

b. Hormonal changes, particularly progesterone Rationale: Progesterone relaxes the lower esophageal sphincter, increasing reflux and contributing to GERD symptoms.

Answer 37

d. All of the above Rationale: Surgical emergencies such as ectopic pregnancy, appendicitis, and cholecystitis are common indications for abdominal exploration in pregnancy.

Answer 38

a. Right upper quadrant

Answer 39

b. Cholecystitis Rationale: While cholecystitis is common in pregnancy, appendicitis is the most likely diagnosis for right lower quadrant pain.

Answer 40

a. Appendicitis Rationale: Appendicitis is the most common non-obstetric surgical emergency in pregnancy, often presenting with atypical pain due to uterine displacement.

Answer 41

b. Surgery Rationale: Surgical intervention (appendectomy) is the standard treatment to prevent perforation and sepsis.

Answer 42

c. Ultrasound

Answer 43

b. Poor Rationale: Appendicitis increases the likelihood of abortion or preterm labor, especially if peritonitis develops. Without peritonitis, the prognosis is excellent.

Answer 44

b. Peritonitis Rationale: Appendicitis is a common indication for abdominal surgery in pregnancy. Peritonitis significantly increases the risk of abortion or preterm labor.

Answer 45

c. Acute cholecystitis Rationale: Acute cholecystitis commonly presents with RUQ pain, nausea, and vomiting. Pregnancy-related hormonal changes increase the risk of gallstone formation.

Answer 46

c. Fat/Cholesterol Rationale: Gallbladder stasis and increased cholesterol secretion in pregnancy contribute to gallstone formation, the leading cause of acute cholecystitis.

Answer 47

d. All of the above Rationale: Initial management of acute cholecystitis includes antibiotics and analgesics. If symptoms persist or complications arise, surgery (cholecystectomy) is indicated.

Answer 48

d. None of the above (AOTA) Rationale: All listed factors, including age, multiparity, and dietary habits, increase the risk of gallstone formation and acute cholecystitis in pregnancy.

Answer 49

c. Placenta abruptio Rationale: The presence of tetanic uterine contractions suggests placental abruption, a life-threatening complication often triggered by trauma.

Answer 50

c. Placental abruption Explanation: Placental abruption is the most common maternal injury in motor vehicle accidents (MVAs), occurring in 1–5% of minor crashes and 20–50% of major crashes. The sudden deceleration forces in an MVA can shear the placenta away from the uterine wall, leading to bleeding, fetal distress, or even fetal loss.

Answer 51

a. Upper belt above, lower belt below the uterus Rationale: Proper seatbelt positioning minimizes uterine compression and protects both the mother and fetus in case of an accident.

Answer 52

b. Left lateral decubitus, ~30° angle Rationale: Placing the patient at a 30° left lateral tilt reduces aortocaval compression and improves maternal circulation during CPR.

Answer 53

c. Increased serum creatinine Rationale: Serum creatinine usually decreases due to increased renal clearance and hemodilution in pregnancy.

Answer 54

a. Renal plasma flow increases by 40% Rationale: Renal plasma flow increases by 40% to accommodate fetal waste removal and maintain maternal fluid balance.

Answer 55

b. Increased ureteral reflux Rationale: Ureteral reflux increases due to progesterone-induced smooth muscle relaxation, leading to urinary stasis and increased UTI risk.

Answer 56

c. Asymptomatic bacteriuria Rationale: Asymptomatic bacteriuria (ASB) is defined as ≥10,000–100,000 CFU/mL of a single bacterial species in a clean-catch urine sample without symptoms of UTI.

Answer 57

c. Pregnancy itself Rationale: Pregnancy increases the risk of ASB due to hormonal and anatomical changes, leading to urinary stasis and vesicoureteral reflux.

Answer 58

a. Yes Rationale: ASB in pregnancy should always be treated to prevent progression to pyelonephritis, which can lead to maternal and fetal complications.

Answer 59

b. Cephalexin Rationale: Cephalexin is a first-line antibiotic for UTIs in pregnancy due to its safety profile and effectiveness against E. coli. Nitrofurantoin is also used but is avoided near term.

Answer 60

c. 30% Rationale: Pregnant women with ASB have a 30% risk of developing recurrent UTIs or pyelonephritis if left untreated.

Answer 61

c. Two weeks Rationale: A test for cure (repeat urine culture) is recommended two weeks after completing antibiotics to ensure eradication of bacteria and prevent recurrence.

Answer 62

a. Acute pyelonephritis Rationale: Acute pyelonephritis in pregnancy presents with fever, flank pain, nausea, vomiting, and costovertebral angle tenderness. It is more common on the right side.

Answer 63

d. All of the above Rationale: Acute pyelonephritis in pregnancy requires IV antibiotics (e.g., cephalosporins), IV fluids for hydration, and pain control. Severe cases may require hospitalization.

Answer 64

c. Admit the patient Rationale: Pyelonephritis in pregnancy can rapidly progress to sepsis, requiring hospital admission for IV antibiotics, fluids, and close monitoring.

Answer 65

a. Hydration Rationale: IV fluid hydration is crucial to maintain renal perfusion, prevent preterm labor, and promote bacterial clearance.

Answer 66

c. 3 days Rationale: Most pregnant women with pyelonephritis become afebrile within 72 hours of IV antibiotic therapy. Persistent fever suggests an abscess or resistant infection.

Answer 67

b. Nitrofurantoin Rationale: Nitrofurantoin is used for prophylaxis in pregnant women with recurrent pyelonephritis. It is given as a daily suppressive therapy until delivery.

Answer 68

c. Serial ultrasound Rationale: Serial ultrasound biometry is the gold standard for diagnosing IUGR, tracking fetal growth and estimating fetal weight.

Answer 69

a. Circumvallate placenta Rationale: Circumvallate placenta is linked to placental insufficiency, which can lead to IUGR due to restricted nutrient and oxygen exchange.

Answer 70

a. Hypertension Rationale: Hypertension (chronic or gestational) leads to placental insufficiency, restricting fetal growth.

Answer 71

b. Multiple pregnancy Rationale: Twin-to-twin transfusion syndrome (TTTS) and unequal placental sharing in multiple pregnancies can cause growth restriction in one or more fetuses.

Answer 72

b. Assesses adequate uteroplacental perfusion Rationale: Umbilical artery Doppler velocimetry evaluates blood flow resistance. Absent or reversed end-diastolic flow suggests severe placental insufficiency.

Answer 73

b. Brain-sparing phenomenon Rationale: MCA Doppler detects brain-sparing, a compensatory response where blood is preferentially shunted to the fetal brain due to placental insufficiency.

Answer 74

a. Gender Rationale: Male fetuses tend to be larger than female fetuses due to genetic and hormonal differences.

Answer 75

c. Watery vaginal discharge Rationale: Oligohydramnios may result from rupture of membranes, causing watery vaginal discharge due to amniotic fluid leakage.

Answer 76

a. Contraction stress test (CST) Rationale: CST evaluates fetal well-being by assessing fetal heart rate response to uterine contractions in suspected IUGR at term.

Answer 77

b. Serial ultrasound Rationale: Serial ultrasound biometry is the most accurate method for diagnosing and monitoring IUGR.

Answer 78

b. Fetal ultrasound growth estimates plateau Rationale: Failure of fetal growth progression on serial ultrasounds is a defining feature of IUGR.

Answer 79

d. Quadruplet pregnancy Rationale: Higher-order multiple pre

Answer 80

a. Early onset of growth restriction Rationale: Congenital anomalies often cause early-onset IUGR due to structural or metabolic defects affecting fetal growth.

Answer 81

b. Fetal growth restriction Rationale: Brain-sparing redistributes blood flow to the brain at the expense of other organs, leading to asymmetric IUGR with a smaller abdominal circumference.

Answer 82

b. Abdominal circumference Rationale: Abdominal circumference is the most sensitive parameter for detecting brain-sparing because it reflects reduced liver perfusion and fetal malnutrition.

Answer 83

b. Cytolysis and loss of functioning cells Rationale: CMV is a lytic virus that causes cytopathic effects, leading to cellular destruction and dysfunction, which contributes to IUGR.

Answer 84

a. It is most commonly seen among preeclamptic patients with severe features Rationale: Preeclampsia causes placental insufficiency, leading to asymmetrical IUGR, where the brain is spared but the abdomen and liver are disproportionately small.

Answer 85

b. Do direct laryngeal suctioning on resuscitation Rationale: Direct laryngeal suctioning during resuscitation removes thick meconium from the airway, preventing meconium aspiration syndrome (MAS).

Answer 86

a. Birth weight > 4,500 g ⸻ Explanation: Macrosomia is precisely defined as a birth weight greater than 4,500 grams (4.5 kg) regardless of gestational age. This is the most widely accepted clinical definition, especially in the context of increased risk for delivery complications (e.g., shoulder dystocia, birth trauma, cesarean delivery).

Answer 87

b. Arrest of descent Rationale: Failure of fetal descent in active labor can indicate cephalopelvic disproportion (CPD) or inadequate uterine contractions, requiring further evaluation.

Answer 88

a. Fetal macrosomia secondary to gestational diabetes mellitus (GDM) Rationale: A fetus weighing 3.4 kg at 37 weeks is large for gestational age (LGA), commonly associated with GDM-induced fetal overgrowth.

Answer 89

b. Maternal weight gain Rationale: Excessive maternal weight gain increases the risk of fetal macrosomia, particularly in pregnancies complicated by GDM or obesity.

Answer 90

a. Postpartum hemorrhage Rationale: Macrosomia increases the risk of uterine atony, postpartum hemorrhage, and birth canal trauma due to the large fetal size.

Answer 91

b. Brachial plexus palsy Rationale: Shoulder dystocia in macrosomic fetuses increases the risk of brachial plexus injury, particularly Erb’s palsy due to excessive traction on the shoulder during delivery.

Answer 92

c. 30-50% Rationale: Cardiac output increases by 30-50% due to increased blood volume and stroke volume, ensuring adequate perfusion to the placenta and fetus.

Answer 93

b. Increased progesterone and estrogen Rationale: Estrogen and progesterone induce vasodilation, reducing systemic vascular resistance and lowering blood pressure in early pregnancy.

Answer 94

c. Compression of the aorta & the vena cava Rationale: The gravid uterus compresses the inferior vena cava and aorta, reducing venous return and leading to supine hypotensive syndrome.

Answer 95

c. Structural modification of the trophoblast on maternal arteries Rationale: The trophoblast remodels spiral arteries, reducing vascular resistance and increasing blood flow to the placenta.

Answer 96

c. Left lateral decubitus Rationale: The left lateral decubitus position relieves aortocaval compression, improving venous return and cardiac output.

Answer 97

b. Decreases Rationale: FRC decreases by 10-25% due to diaphragmatic elevation from the expanding uterus, leading to reduced lung volume.

Answer 98

b. 40% Rationale: GFR increases by 40% due to renal hyperfiltration required for fetal metabolic waste clearance and maternal fluid balance.

Answer 99

c. Increased hormonal progesterone Rationale: Progesterone relaxes the lower esophageal sphincter, increasing the risk of acid reflux (GERD), especially in the supine position.

Answer 100

e. All of the above Rationale: Ectopic pregnancy, appendicitis, and cholecystitis are leading causes of surgical intervention during pregnancy.

Answer 101

c. Right subchondral area Rationale: In pregnancy, the gallbladder is displaced upward by the uterus, making Murphy’s sign palpable in the right subchondral area.

Answer 102

b. Decreases Rationale: FRC declines due to the upward displacement of the diaphragm, reducing lung volumes and increasing the risk of dyspnea.

Answer 103

a. Increased progesterone Rationale: Progesterone stimulates the respiratory center, increasing tidal volume and minute ventilation, leading to mild respiratory alkalosis.

Answer 104

d. Acute cholecystitis Rationale: Acute cholecystitis typically presents with RUQ pain, fever, and nausea, whereas RLQ pain is more suggestive of appendicitis, ectopic pregnancy, or ovarian pathology.

Answer 105

a. Acute appendicitis Rationale: Appendicitis is the most common non-obstetric surgical emergency in pregnancy. Classic presentation includes RLQ pain, nausea, and rebound tenderness.

Answer 106

b. Surgical exploration Rationale: Appendectomy is the definitive treatment to prevent perforation, sepsis, and fetal complications.

Answer 107

d. A and B (CT Scan and MRI) Rationale: MRI is preferred over CT to avoid radiation exposure, but CT is more sensitive when ultrasound is inconclusive.

Answer 108

b. Poor Rationale: Generalized peritonitis significantly increases the risk of sepsis, preterm labor, and maternal morbidity. Immediate surgical intervention is required.

Answer 109

a. Increased Rationale: Peritonitis increases uterine irritability and inflammatory cytokines, which can trigger preterm labor or spontaneous abortion.

Answer 110

b. Acute cholecystitis Rationale: Acute cholecystitis is common in pregnancy, especially in multiparous women and those >40 years old, due to hormonal effects on gallbladder motility.

Answer 111

b. Cholesterol stones Rationale: Pregnancy increases gallbladder stasis and cholesterol saturation, leading to cholesterol gallstone formation, the primary cause of acute cholecystitis.

Answer 112

d. All of the above Rationale: Mild cases may be managed with IV antibiotics and analgesics, but surgery (cholecystectomy) is required if symptoms persist or complications develop.

Answer 113

NOTA (None of the Above) Rationale: Advanced maternal age, female gender, and multiparity are all risk factors for gallbladder disease in pregnancy due to hormonal effects on gallbladder motility and bile composition.

Answer 114

d. B and C Rationale: Placental abruption presents with sudden-onset abdominal pain, uterine tenderness, and fetal distress. Placenta previa should also be considered in cases of painless vaginal bleeding.

Answer 115

a. Placental abruption

Answer 116

b. Upper belt is above the uterus, and the lower belt fits snugly across the upper thighs and well below the uterus Rationale: Proper seatbelt use prevents direct uterine trauma and reduces the risk of placental abruption and fetal injury in a crash.

Answer 117

a. 1 mg epinephrine IV/IO every 3 to 5 minutes Rationale: According to Advanced Cardiac Life Support (ACLS) guidelines, 1 mg epinephrine IV/IO is administered every 3 to 5 minutes during cardiac arrest to enhance myocardial perfusion and increase chances of return of spontaneous circulation (ROSC).

Answer 118

b. FALSE Rationale: Pregnancy alters drug pharmacokinetics due to increased plasma volume, renal clearance, and hepatic metabolism. Some drugs require dose adjustments to maintain therapeutic levels while avoiding fetal risks.

Answer 119

a. TRUE Rationale: Cardiac output increases by 30-50% during pregnancy due to increased stroke volume and heart rate, ensuring adequate perfusion to the placenta and fetus.

Answer 120

b. 32 weeks Rationale: At 32 weeks AOG, cardiac output is near its peak, and the left lateral position optimizes venous return by reducing aortocaval compression by the gravid uterus.

Answer 121

b. Suspicion of IUGR is in order. Rationale: An SDP of 1.3 cm suggests oligohydramnios, which is associated with intrauterine growth restriction (IUGR). Further evaluation with Doppler velocimetry and biophysical profile (BPS) is warranted.

Answer 122

d. Ruptured membranes Rationale: Premature rupture of membranes (PROM) is the most common cause of oligohydramnios, leading to decreased amniotic fluid levels and increased risk of fetal complications.

Answer 123

b. Circumvallate placenta Rationale: Circumvallate placenta is associated with placental insufficiency, which can restrict fetal growth and lead to IUGR.

Answer 124

b. Contraction stress test (CST) Rationale: CST assesses fetal well-being by monitoring fetal heart rate (FHR) response to contractions, helping determine fetal reserve and placental function in term IUGR cases.

Answer 125

c. Increased cesarean section (CS) rates Rationale: Macrosomia increases the likelihood of labor complications, including cephalopelvic disproportion (CPD), prolonged labor, and increased need for cesarean delivery.

Answer 126

a. Arrest of descent of the presenting part Rationale: Macrosomia increases the risk of cephalopelvic disproportion (CPD), leading to prolonged labor and arrest of descent.

Answer 127

d. Perform a lower transverse cesarean section (LTCS) and offer bilateral tubal ligation (BTL) Rationale: The combination of macrosomia (EFW 4 kg), insulin-dependent diabetes, and thick meconium-stained fluid increases the risk of shoulder dystocia and birth complications, warranting an elective cesarean delivery.

Answer 128

b. Strong suprapubic pressure by an assistant Rationale: Suprapubic pressure helps dislodge the anterior shoulder from the pubic symphysis, reducing the risk of brachial plexus injury. Fundal pressure should be avoided as it worsens impaction.

Answer 129

c. Diabetes mellitus Rationale: Gestational diabetes and poorly controlled diabetes mellitus (DM) are strong risk factors for fetal macrosomia, leading to complications such as shoulder dystocia and birth trauma.