LE4 - Antepartum

Question 1

A 32 y/o G2P2 at 35 weeks gestation presents with painful vaginal bleeding, uterine tenderness, and a rigid abdomen. The fetal heart rate is 100 bpm, and the mother is hypotensive.

Questions:

What is the most likely diagnosis?
A. Placenta previa
B. Abruptio placenta
C. Uterine rupture
D. Vasa previa

What is the appropriate management for this patient?
A. Vaginal delivery with expectant management
B. Emergency cesarean delivery
C. Administer tocolytics and observe
D. Administer corticosteroids and delay delivery

Answer 1

B. Abruptio placenta
Rationale: Painful vaginal bleeding, uterine tenderness, and fetal distress are hallmark features of abruptio placenta.

B. Emergency cesarean delivery
Rationale: An emergency cesarean delivery is indicated in severe abruptio placenta with fetal distress to improve maternal and fetal outcomes.

Question 2

A 29 y/o G1P0 at 30 weeks gestation presents with mild vaginal bleeding and a stable maternal and fetal condition. Ultrasound shows a retroplacental hematoma.

Questions:

What is the most appropriate management in this case?
A. Immediate cesarean delivery
B. Expectant management with close monitoring
C. Administer uterotonics to expedite delivery
D. Perform emergency vaginal delivery

What laboratory test is most critical in monitoring this patient?
A. Complete blood count (CBC)
B. Coagulation studies (PT, PTT, fibrinogen)
C. Renal function tests
D. Liver enzymes

Answer 2

B. Expectant management with close monitoring
Rationale: In stable maternal and fetal conditions before 34 weeks, expectant management aims to prolong pregnancy while closely monitoring for signs of deterioration.

B. Coagulation studies (PT, PTT, fibrinogen)
Rationale: Abruptio placenta increases the risk of consumptive coagulopathy (DIC); coagulation studies are essential for early detection.

Question 3

A 40 y/o G5P4 with chronic hypertension and a history of placental abruption presents at 28 weeks with recurrent vaginal bleeding and reduced amniotic fluid on ultrasound.

Questions:

What is the term for the co-occurrence of placental abruption and oligohydramnios?
A. Chronic abruption-oligohydramnios sequence
B. Preterm premature rupture of membranes
C. Hydramnios syndrome
D. Fetal growth restriction

What is the recommended management for this patient?
A. Immediate delivery regardless of gestational age
B. Expectant management with corticosteroids for fetal lung maturity
C. Uterine artery embolization
D. Administer tocolytics and continue monitoring

Answer 3

A. Chronic abruption-oligohydramnios sequence
Rationale: This condition occurs when chronic abruption leads to reduced amniotic fluid due to poor placental function.

B. Expectant management with corticosteroids for fetal lung maturity
Rationale: In stable conditions, expectant management with corticosteroids improves fetal outcomes by enhancing lung maturity.

Question 4

A 35 y/o G3P2 at 37 weeks presents with sudden painful vaginal bleeding and a non-reassuring fetal heart rate. She reports a history of cocaine use during pregnancy.

Questions:

What is the most likely cause of her placental abruption?
A. Hypertension
B. Cocaine use
C. Trauma
D. Placenta previa

What complication is most associated with concealed hemorrhage in abruptio placenta?
A. Uterine rupture
B. Disseminated intravascular coagulation (DIC)
C. Preterm labor
D. Maternal fever

Answer 4

B. Cocaine use
Rationale: Cocaine use causes vasoconstriction, increasing the risk of placental abruption.

B. Disseminated intravascular coagulation (DIC)
Rationale: Concealed hemorrhage increases the risk of DIC due to placental thromboplastin entering the maternal circulation.

Question 5

A 38 y/o G4P3 with preeclampsia presents at 34 weeks gestation with vaginal bleeding and abdominal pain. The fetus has died in utero.

Questions:

What is the preferred mode of delivery in this case?
A. Emergency cesarean delivery
B. Vaginal delivery with uterotonics
C. Hysterectomy
D. Expectant management

What is the major risk during delivery in this scenario?
A. Fetal distress
B. Maternal coagulopathy
C. Premature rupture of membranes
D. Infection

Answer 5

B. Vaginal delivery with uterotonics
Rationale: Vaginal delivery is preferred in cases of fetal demise as it reduces maternal morbidity compared to cesarean delivery.

B. Maternal coagulopathy
Rationale: Placental abruption increases the risk of DIC, especially in cases of fetal death, necessitating careful monitoring of coagulation status.

Question 6

A 28 y/o G1P0 at 32 weeks gestation presents with mild vaginal bleeding, stable vital signs, and a reactive fetal heart rate tracing. The ultrasound shows a retroplacental hematoma.

Questions:

What is the most appropriate management for this patient?
A. Immediate cesarean delivery
B. Induction of labor
C. Expectant management
D. Uterine artery embolization

Why is expectant management appropriate in this scenario?
A. The fetus is preterm, and delaying delivery may benefit fetal outcomes
B. The retroplacental hematoma will resolve without intervention
C. Delivery is contraindicated in cases of stable placental abruption
D. Tocolytics can prevent further abruption

Answer 6

C. Expectant management
Rationale: For stable maternal and fetal conditions before 34 weeks, expectant management aims to prolong pregnancy while monitoring closely for deterioration.

A. The fetus is preterm, and delaying delivery may benefit fetal outcomes
Rationale: Expectant management allows for fetal lung maturation, particularly when corticosteroids are administered, improving neonatal outcomes.

Question 7

A 35 y/o G3P2 at 35 weeks gestation presents with painful vaginal bleeding, uterine contractions, and a category II fetal heart rate tracing. The mother is hemodynamically stable.

Questions:

What is the recommended management for this patient?
A. Administer tocolytics and delay delivery
B. Vaginal delivery if imminent
C. Emergent cesarean delivery
D. Expectant management with corticosteroids

Why is emergent delivery indicated at this gestational age?
A. The fetus is preterm, and expectant management is contraindicated
B. Late preterm infants have outcomes similar to term infants
C. Tocolysis is contraindicated in placental abruption
D. Vaginal delivery is always contraindicated in placental abruption

Answer 7

C. Emergent cesarean delivery
Rationale: At 35 weeks with fetal compromise, emergent delivery ensures the best outcomes for both the mother and fetus.

B. Late preterm infants have outcomes similar to term infants
Rationale: At 34–36 weeks, late preterm infants have survival rates nearly identical to term infants, especially with antenatal corticosteroids for lung maturity.

Question 8

A 40 y/o G5P4 at 28 weeks gestation presents with painful vaginal bleeding and uterine tenderness. Fetal monitoring shows a non-reassuring heart rate pattern.

Questions:

What is the next best step in management?
A. Expectant management with close monitoring
B. Administer corticosteroids and delay delivery
C. Emergency cesarean delivery
D. Tocolysis to prolong pregnancy

Why is expectant management not appropriate in this case?
A. The fetus is preterm, and delivery will worsen outcomes
B. Severe abruption requires immediate intervention regardless of gestational age
C. Corticosteroids are contraindicated in preterm pregnancies with bleeding
D. Tocolysis is the only option for prolonging pregnancy

Answer 8

C. Emergency cesarean delivery
Rationale: Non-reassuring fetal status in the context of placental abruption necessitates emergent delivery to prevent further fetal compromise.

B. Severe abruption requires immediate intervention regardless of gestational age
Rationale: Severe placental abruption mandates immediate delivery to address both maternal and fetal risks.

Question 9

A 25 y/o G2P1 at 30 weeks gestation presents with recurrent vaginal bleeding and reduced amniotic fluid. Both the mother and fetus are stable.

Questions:

What term describes the combination of placental abruption and oligohydramnios in this patient?
A. Chronic abruption-oligohydramnios sequence
B. Preterm premature rupture of membranes (PPROM)
C. Severe placental abruption
D. Hydramnios syndrome

What is the recommended management for this condition?
A. Immediate cesarean delivery
B. Induction of labor
C. Expectant management with corticosteroids
D. Uterine artery embolization

Answer 9

A. Chronic abruption-oligohydramnios sequence
Rationale: This sequence occurs when chronic abruption leads to reduced amniotic fluid due to impaired placental function.

C. Expectant management with corticosteroids
Rationale: In stable maternal and fetal conditions, expectant management allows time for fetal lung maturity while monitoring for complications.

Question 10

A 38 y/o G4P3 presents at 29 weeks with placental abruption and painful contractions. Fetal monitoring shows a stable heart rate pattern, but the mother develops tachycardia and hypotension.

Questions:

What is the primary indication for expeditious delivery in this patient?
A. Preterm labor
B. Maternal hemodynamic instability
C. Oligohydramnios
D. Stable fetal heart rate

What is the recommended delivery mode in this situation?
A. Expectant management to stabilize maternal condition
B. Vaginal delivery if possible
C. Emergency cesarean delivery
D. Uterine artery embolization

Answer 10

B. Maternal hemodynamic instability
Rationale: Maternal instability is a critical indication for expeditious delivery to prevent further deterioration.

C. Emergency cesarean delivery
Rationale: In the presence of maternal instability, cesarean delivery is preferred for rapid intervention and improved outcomes.

Question 11

A 29 y/o G2P1 at 32 weeks gestation presents with painless vaginal bleeding. Ultrasound reveals a placenta completely covering the internal cervical os. The mother is stable, and the fetal heart rate is normal.

Questions:

What is the most likely diagnosis?
A. Placenta previa (total)
B. Placental abruption
C. Vasa previa
D. Marginal placenta previa

What is the appropriate next step in management for this patient?
A. Emergency cesarean delivery
B. Hospital admission with close monitoring
C. Vaginal delivery with oxytocin augmentation
D. Expectant management at home

Answer 11

A. Placenta previa (total)
Rationale: Total placenta previa is diagnosed when the placenta completely covers the internal os, causing painless bleeding and precluding vaginal delivery.

B. Hospital admission with close monitoring
Rationale: For stable patients with placenta previa, hospital admission and close monitoring are indicated to prolong pregnancy while preparing for delivery in case of severe bleeding.

Question 12

A 34 y/o G3P2 at 36 weeks gestation with a history of previous cesarean section presents with painless vaginal bleeding. Ultrasound reveals an anterior placenta previa.

Questions:

What is the greatest risk associated with this condition?
A. Preterm labor
B. Placenta accreta spectrum (PAS)
C. Postpartum hemorrhage
D. Coagulopathy

What is the recommended delivery approach for this patient?
A. Vaginal delivery under close observation
B. Elective cesarean delivery at 37 weeks
C. Expectant management until spontaneous labor
D. Vertical laparotomy and hysterectomy

Answer 12

B. Placenta accreta spectrum (PAS)
Rationale: Anterior placenta previa in women with a history of cesarean section significantly increases the risk of PAS, which involves abnormal placental invasion.

B. Elective cesarean delivery at 37 weeks
Rationale: Cesarean delivery at 37 weeks is recommended to minimize risks of hemorrhage and preterm complications while ensuring maternal and fetal safety.

Question 13

A 30 y/o G4P3 at 28 weeks gestation presents with painless vaginal bleeding. Ultrasound reveals a low-lying placenta 1.5 cm from the internal os.

Questions:

How is this condition classified?
A. Complete placenta previa
B. Partial placenta previa
C. Low-lying placenta
D. Marginal previa

What is the best course of action for this patient?
A. Immediate cesarean delivery
B. Expectant management with follow-up ultrasound
C. Induction of labor at 32 weeks
D. Administration of uterotonics

Answer 13

C. Low-lying placenta
Rationale: A low-lying placenta is defined as a placental edge within 2 cm of the internal os but not covering it, as seen in this case.

B. Expectant management with follow-up ultrasound
Rationale: Low-lying placentas may resolve as pregnancy progresses. Follow-up ultrasound at 32 weeks is recommended to reassess placental location.

Question 14

A 37 y/o G5P4 at 38 weeks gestation presents with profuse painless vaginal bleeding. Ultrasound confirms placenta previa, and the fetus is in cephalic presentation.

Questions:

What is the immediate management for this patient?
A. Attempt vaginal delivery
B. Emergency cesarean delivery
C. Expectant management with corticosteroids
D. Uterine artery embolization

What is the main complication during cesarean delivery in this condition?
A. Uterine rupture
B. Coagulopathy
C. Severe hemorrhage requiring hysterectomy
D. Preterm labor

Answer 14

B. Emergency cesarean delivery
Rationale: In cases of placenta previa with active bleeding near term, cesarean delivery is the safest option for both mother and fetus.

C. Severe hemorrhage requiring hysterectomy
Rationale: Placenta previa significantly increases the risk of severe hemorrhage during cesarean delivery, especially when associated with placenta accreta spectrum.

Question 15

A 28 y/o G2P1 at 20 weeks gestation is diagnosed with a placenta previa on routine ultrasound. She is asymptomatic and has no bleeding.

Questions:

What is the likelihood that the placenta previa will resolve by term?
A. 10%
B. 30%
C. 50%
D. >90%

What is the next step in monitoring this patient?
A. Reassess at 32 weeks with ultrasound
B. Perform transvaginal ultrasound immediately
C. Plan for cesarean delivery at 37 weeks
D. No further monitoring is needed

Answer 15

D. >90%
Rationale: Most cases of placenta previa diagnosed early in pregnancy resolve due to placental “migration” as the lower uterine segment develops.

A. Reassess at 32 weeks with ultrasound
Rationale: Follow-up ultrasound at 32 weeks is the standard approach to monitor placental position and plan delivery accordingly.

Question 16

A 35 y/o G4P3 at 36 weeks gestation presents with painless vaginal bleeding. Ultrasound reveals a placenta completely covering the internal cervical os.

Questions:

How is this condition classified?
A. Low-lying placenta
B. Marginal placenta previa
C. Partial placenta previa
D. Complete placenta previa

What is the recommended mode of delivery for this patient?
A. Vaginal delivery with close monitoring
B. Elective cesarean delivery at 37 weeks
C. Expectant management until labor begins
D. Emergency cesarean hysterectomy

Answer 16

D. Complete placenta previa
Rationale: Complete placenta previa is diagnosed when the placenta entirely covers the internal cervical os, preventing vaginal delivery.

B. Elective cesarean delivery at 37 weeks
Rationale: Cesarean delivery is recommended to prevent complications such as severe bleeding during labor, especially for complete placenta previa.

Question 17

A 28 y/o G2P1 at 34 weeks gestation is diagnosed with a placenta partially covering the internal os. The mother is stable, and the fetal heart rate is reassuring.

Questions:

What is the classification of this condition?
A. Complete placenta previa
B. Partial placenta previa
C. Low-lying placenta
D. Marginal placenta previa

What surgical approach is preferred if cesarean delivery is needed in this patient?
A. Low transverse hysterotomy
B. Vertical uterine incision
C. Vertical laparotomy incision
D. Uterine artery embolization

Answer 17

B. Partial placenta previa
Rationale: Partial placenta previa occurs when the placenta partially covers the internal cervical os, posing complications for vaginal delivery.

A. Low transverse hysterotomy
Rationale: A low transverse hysterotomy is typically the preferred surgical approach unless the placenta is anterior, requiring alternative incisions.

Question 18

A 30 y/o G1P0 at 29 weeks gestation is diagnosed with a placenta located 1.8 cm from the internal cervical os. She has had no bleeding episodes so far.

Questions:

How is this condition classified?
A. Complete placenta previa
B. Partial placenta previa
C. Low-lying placenta
D. Marginal placenta previa

What is the next step in managing this patient?
A. Expectant management with follow-up ultrasound at 32 weeks
B. Immediate cesarean delivery
C. Induction of labor at 34 weeks
D. Administer uterotonics to expedite delivery

Answer 18

C. Low-lying placenta
Rationale: A low-lying placenta is defined as a placental edge within 2 cm of the internal cervical os but not covering it, as seen in this case.

A. Expectant management with follow-up ultrasound at 32 weeks
Rationale: Low-lying placentas may resolve due to placental “migration.” Ultrasound at 32 weeks can re-evaluate placental position.

Question 19

A 38 y/o G5P4 presents at 37 weeks with significant painless vaginal bleeding. Ultrasound reveals an anterior placenta previa completely covering the internal os.

Questions:

What is a major surgical risk if a cesarean delivery is performed?
A. Uterine rupture
B. Fetal distress
C. Severe hemorrhage requiring hysterectomy
D. Preterm labor

What surgical incision is preferred to minimize complications if the placenta is anterior?
A. Vertical laparotomy incision
B. Vertical uterine incision
C. Low transverse hysterotomy
D. Midline episiotomy

Answer 19

C. Severe hemorrhage requiring hysterectomy
Rationale: Placenta previa, particularly with an anterior location, increases the risk of severe bleeding during cesarean delivery, sometimes requiring hysterectomy.

B. Vertical uterine incision
Rationale: A vertical uterine incision avoids cutting through the anterior placenta, reducing the risk of excessive bleeding and fetal complications.

Question 20

A 25 y/o G3P2 at 20 weeks gestation is diagnosed with a low-lying placenta on routine ultrasound. She has no symptoms or risk factors for placental abnormalities.

Questions:

What is the likelihood that this condition will resolve by term?
A. 10%
B. 30%
C. 50%
D. >90%

When should the next ultrasound assessment be performed?
A. At 24 weeks
B. At 28 weeks
C. At 32 weeks
D. No further ultrasound is needed

Answer 20

D. >90%
Rationale: Most cases of low-lying placenta diagnosed early in pregnancy resolve due to placental “migration” as the lower uterine segment develops.

C. At 32 weeks
Rationale: Follow-up ultrasound at 32 weeks is recommended to assess whether the placenta has moved away from the internal cervical os.

Question 21

A 34 y/o G3P2 at 36 weeks gestation presents with a history of multiple prior cesarean deliveries and placenta previa diagnosed on ultrasound. The ultrasound shows a loss of the hypoechoic retroplacental zone and multiple placental vascular lacunae.

Questions:

What is the most likely diagnosis?
A. Placenta previa
B. Placental abruption
C. Placenta accreta
D. Placenta percreta

What is the recommended management for this condition?
A. Vaginal delivery with close monitoring
B. Cesarean delivery at 39 weeks
C. Planned cesarean hysterectomy at a tertiary care center
D. Conservative management with methotrexate

Answer 21

C. Placenta accreta
Rationale: The loss of the hypoechoic retroplacental zone and presence of vascular lacunae are characteristic findings of placenta accreta on ultrasound.

C. Planned cesarean hysterectomy at a tertiary care center
Rationale: Cesarean hysterectomy is the definitive treatment for placenta accreta, especially in cases with significant risk of hemorrhage. It should be performed at a specialized center with advanced resources.

Question 22

A 28 y/o G4P3 with no prior uterine surgeries presents with vaginal bleeding at 32 weeks. Ultrasound shows a placenta invading through the uterine serosa into the bladder.

Questions:

How is this condition classified?
A. Placenta accreta
B. Placenta increta
C. Placenta percreta
D. Chronic placental abruption

What is the preferred surgical approach for this patient?
A. Low transverse hysterotomy
B. Classical hysterotomy with placenta removal
C. Hysterectomy leaving the placenta in situ
D. Conservative management with uterine artery embolization

Answer 22

C. Placenta percreta
Rationale: Placenta percreta occurs when placental villi penetrate through the uterine wall and invade adjacent structures, such as the bladder.

C. Hysterectomy leaving the placenta in situ
Rationale: For placenta percreta, the safest approach is to leave the placenta in situ and proceed with hysterectomy to prevent life-threatening hemorrhage.

Question 23

A 30 y/o G2P1 at 28 weeks gestation with a history of cesarean delivery is diagnosed with placenta previa. Ultrasound and MRI findings show a placenta invading the myometrium without reaching the serosa.

Questions:

What is the classification of this condition?
A. Placenta previa
B. Placenta accreta
C. Placenta increta
D. Placenta percreta

What is the next step in managing this patient?
A. Schedule delivery at 34–36 weeks in a tertiary care center
B. Immediate cesarean hysterectomy
C. Vaginal delivery at term
D. Conservative management with methotrexate

Answer 23

C. Placenta increta
Rationale: Placenta increta involves the invasion of placental villi into the myometrium without reaching the uterine serosa.

A. Schedule delivery at 34–36 weeks in a tertiary care center
Rationale: Planned delivery at a specialized center allows for optimal preparation to manage potential hemorrhage and complications.

Question 24

A 40 y/o G5P4 presents at 35 weeks with recurrent painless bleeding and a history of two prior cesarean sections. Ultrasound shows an anterior placenta with evidence of myometrial invasion and loss of the retroplacental hypoechoic zone.

Questions:

Which imaging modality can provide additional information about the extent of invasion?
A. Transvaginal ultrasound
B. Magnetic resonance imaging (MRI)
C. Transabdominal ultrasound
D. Doppler echocardiography

What is the most appropriate delivery plan?
A. Induction of labor at 37 weeks
B. Vaginal delivery with oxytocin augmentation
C. Cesarean hysterectomy at 34–36 weeks
D. Expectant management until term

Answer 24

B. Magnetic resonance imaging (MRI)
Rationale: MRI provides detailed information about the depth of placental invasion and involvement of adjacent structures.

C. Cesarean hysterectomy at 34–36 weeks
Rationale: Cesarean hysterectomy is the standard management for high-risk cases of placenta accreta syndrome, especially with prior cesarean deliveries.

Question 25

A 36 y/o G3P2 at 37 weeks gestation with placenta previa and suspected accreta is scheduled for cesarean delivery. The surgical team identifies significant placental invasion extending into the bladder.

Questions:

What is the most common maternal complication associated with placenta accreta syndrome?
A. Coagulopathy
B. Hemorrhage
C. Uterine rupture
D. Infection

Which specialists should be included in the multidisciplinary team for this case?
A. Urologist and interventional radiologist
B. Neonatologist and anesthesiologist
C. Gynecological oncologist and critical care specialist
D. All of the above

Answer 25

B. Hemorrhage
Rationale: Hemorrhage is the most common and life-threatening complication of placenta accreta syndrome, requiring prompt management.

D. All of the above
Rationale: Managing placenta accreta requires a multidisciplinary approach involving surgical, radiological, neonatal, and critical care expertise to optimize outcomes.

Question 26

1 & 2:
A 32 y/o G3P2 at 36 weeks presents with sudden onset of painful vaginal bleeding and severe abdominal pain. The uterus is rigid and tender to palpation. Fetal heart rate monitoring shows late decelerations.

Questions:

What is the most likely diagnosis?
A. Placenta previa
B. Placental abruption (revealed type)
C. Uterine rupture
D. Vasa previa

What is the most appropriate management for this patient?
A. Expectant management with corticosteroids
B. Immediate cesarean delivery
C. Trial of labor with close monitoring
D. Emergency hysterectomy

Answer 26

B. Placental abruption (revealed type)
Rationale: Painful vaginal bleeding, abdominal pain, and a rigid, tender uterus are classic findings of placental abruption. Late decelerations indicate fetal hypoxia.

B. Immediate cesarean delivery
Rationale: Fetal distress and maternal symptoms necessitate emergency cesarean delivery to prevent further complications for both mother and fetus.

Question 27

A 28 y/o G2P1 at 32 weeks presents with mild abdominal pain and no vaginal bleeding. Ultrasound reveals a retroplacental hematoma. The fetus is viable, and maternal vitals are stable.

Questions:

What is the most likely type of abruption?
A. Revealed abruption
B. Concealed abruption
C. Mixed abruption
D. Chronic abruption

What is the next step in management?
A. Emergency cesarean delivery
B. Expectant management with close monitoring
C. Immediate induction of labor
D. Uterine artery embolization

Answer 27

B. Concealed abruption
Rationale: A retroplacental hematoma without vaginal bleeding is characteristic of concealed abruption.

B. Expectant management with close monitoring
Rationale: Stable maternal and fetal conditions with a preterm fetus allow for expectant management, aiming to prolong pregnancy while monitoring for signs of deterioration.

Question 28

A 30 y/o G5P4 at 37 weeks presents with vaginal bleeding, abdominal pain, and hypotension. Her uterus is firm and tender. Labs show thrombocytopenia, prolonged PT/PTT, and low fibrinogen.

Questions:

What maternal complication is most likely in this patient?
A. Acute kidney injury
B. Disseminated intravascular coagulation (DIC)
C. Sheehan syndrome
D. HELLP syndrome

What is the definitive treatment for this complication?
A. Transfusion of fresh frozen plasma (FFP)
B. Administration of corticosteroids
C. Uterine artery embolization
D. Immediate delivery

Answer 28

B. Disseminated intravascular coagulation (DIC)
Rationale: Thrombocytopenia, prolonged PT/PTT, and low fibrinogen are hallmarks of DIC, a severe complication of placental abruption.

D. Immediate delivery
Rationale: Delivery is essential to stop the source of thromboplastin release from the placenta, which drives the DIC process. Blood products like FFP may be administered as supportive therapy.

Question 29

A 26 y/o G2P1 at 30 weeks presents with sudden vaginal bleeding and abdominal pain after a motor vehicle accident. Fetal heart rate shows bradycardia.

Questions:

What is the most likely underlying cause of the patient’s condition?
A. Placenta previa
B. Trauma-induced placental abruption
C. Uterine rupture
D. Preterm labor

What is the best next step in management?
A. Immediate cesarean delivery
B. Vaginal delivery with oxytocin augmentation
C. Transfusion of packed red blood cells
D. Expectant management

Answer 29

B. Trauma-induced placental abruption
Rationale: Trauma is a known cause of abruptio placenta, leading to vaginal bleeding, abdominal pain, and fetal bradycardia.

A. Immediate cesarean delivery
Rationale: Fetal bradycardia indicates significant compromise, necessitating emergency cesarean delivery to save the fetus.

Question 30

A 38 y/o G4P3 with chronic hypertension and a history of placental abruption presents at 33 weeks with painful contractions, vaginal bleeding, and uterine tenderness. Fetal heart tracing is reassuring.

Questions:

Which risk factor is most likely associated with her condition?
A. History of prior cesarean section
B. Chronic hypertension
C. Polyhydramnios
D. Gestational diabetes

What is the most appropriate management for this patient?
A. Immediate cesarean delivery
B. Induction of labor with oxytocin
C. Expectant management with corticosteroids
D. Uterine artery ligation

Answer 30

B. Chronic hypertension
Rationale: Chronic hypertension is a significant risk factor for placental abruption.

C. Expectant management with corticosteroids
Rationale: Stable maternal and fetal conditions allow for expectant management to improve fetal lung maturity with corticosteroids while monitoring for worsening symptoms.

Question 31

A 34-year-old G3P2 at 28 weeks presents with sudden, painless vaginal bleeding. She denies abdominal pain or contractions. Fetal heart tracing is normal. Transabdominal ultrasound reveals the placenta covering the internal os.

Questions:

What is the most likely diagnosis?
A. Placental abruption
B. Placenta previa
C. Vasa previa
D. Uterine rupture

What is the most appropriate next step in management?
A. Perform digital cervical examination to assess dilation
B. Admit for observation and administer corticosteroids
C. Immediate cesarean delivery
D. Discharge with instructions for pelvic rest

Answer 31

B. Placenta previa
Rationale: Painless vaginal bleeding after 20 weeks, combined with ultrasound findings of the placenta covering the os, is diagnostic of placenta previa.

B. Admit for observation and administer corticosteroids
Rationale: Observation in a hospital setting is necessary to monitor for further bleeding. Corticosteroids are given to enhance fetal lung maturity in case of preterm delivery. Digital examination is contraindicated as it may worsen bleeding.

Question 32

A 29-year-old G4P3 at 36 weeks with a history of placenta previa presents with heavy vaginal bleeding. The fetus is in a vertex position with normal heart tracings.

Questions:

What is the most appropriate mode of delivery?
A. Vaginal delivery with close monitoring
B. Scheduled cesarean delivery
C. Expectant management and pelvic rest
D. Emergent cesarean delivery

If the placenta is found to be anterior and the patient has a history of two prior cesarean deliveries, what is the most likely complication?
A. Uterine rupture
B. Placenta accreta spectrum (PAS)
C. Retained placenta
D. Umbilical cord prolapse

Answer 32

D. Emergent cesarean delivery
Rationale: Active heavy bleeding at 36 weeks with placenta previa necessitates an emergent cesarean delivery to prevent maternal hemorrhage and fetal compromise.

B. Placenta accreta spectrum (PAS)
Rationale: A history of cesarean deliveries with an anterior placenta increases the risk of PAS, where the placenta abnormally adheres to the uterine wall.

Question 33

A 26-year-old G2P1 at 30 weeks presents with a history of placenta previa diagnosed at 20 weeks. She has had no further bleeding episodes. The fetus is growing appropriately, and maternal vitals are stable.

Questions:

What is the most appropriate management at this stage?
A. Immediate delivery at 30 weeks
B. Expectant management with serial ultrasounds
C. Induction of labor at 34 weeks
D. Perform a trial of labor

If bleeding resumes and becomes profuse, what is the definitive treatment?
A. Uterine artery embolization
B. Cesarean delivery
C. Balloon tamponade
D. Blood transfusion

Answer 33

B. Expectant management with serial ultrasounds
Rationale: For stable patients without active bleeding and an immature fetus, expectant management with serial ultrasounds to monitor placental position is appropriate.

B. Cesarean delivery
Rationale: Profuse bleeding in the setting of placenta previa requires definitive delivery via cesarean to prevent maternal and fetal complications.

Question 34

A 40-year-old G5P4 at 38 weeks presents with painless vaginal bleeding and a diagnosis of low-lying placenta on prior ultrasound. She is in labor with ruptured membranes.

Questions:

What is the most appropriate next step in management?
A. Vaginal delivery
B. Trial of labor with close monitoring
C. Emergency cesarean delivery
D. Administration of tocolytics

What complication is the patient most at risk for during delivery?
A. Postpartum hemorrhage
B. Fetal hypoxia
C. Cord prolapse
D. Shoulder dystocia

Answer 34

C. Emergency cesarean delivery
Rationale: Low-lying placenta at term with active labor poses a high risk of bleeding, necessitating cesarean delivery for both maternal and fetal safety.

A. Postpartum hemorrhage
Rationale: Placenta previa increases the risk of postpartum hemorrhage due to impaired uterine contraction at the lower segment where the placenta is implanted.

Question 35

A 35-year-old G3P2 with a history of placenta previa and two prior cesarean sections is scheduled for an elective cesarean at 36 weeks.

Questions:

What is the most critical preparation before surgery?
A. Administration of oxytocin
B. Placement of large-bore IV catheters for potential transfusion
C. Induction of labor to minimize surgical risk
D. Use of epidural anesthesia

If the placenta is found to have invaded the bladder during surgery, what is the most appropriate management?
A. Attempt manual removal of the placenta
B. Perform a cesarean hysterectomy
C. Administer methotrexate postpartum
D. Leave the placenta in situ

Answer 35

B. Placement of large-bore IV catheters for potential transfusion
Rationale: Placenta previa with a history of cesarean delivery increases the risk of massive hemorrhage, requiring preoperative preparation for transfusion.

B. Perform a cesarean hysterectomy
Rationale: Placenta percreta with bladder invasion requires cesarean hysterectomy to control bleeding and prevent further complications.

Question 36

A 32-year-old G4P3 at 35 weeks presents for a routine ultrasound. She has a history of two prior cesarean deliveries and is now diagnosed with anterior placenta previa. Ultrasound shows multiple placental lacunae and loss of the retroplacental hypoechoic zone.

Questions:

What is the most likely diagnosis?
A. Placenta previa
B. Placenta increta
C. Placenta accreta spectrum (PAS)
D. Placental abruption

What is the most appropriate next step in management?
A. Schedule delivery at 37 weeks in a tertiary-care facility
B. Attempt a trial of labor at term
C. Perform an emergency hysterectomy immediately
D. Administer methotrexate to aid placental resorption

Answer 36

C. Placenta accreta spectrum (PAS)
Rationale: Risk factors such as placenta previa and prior cesarean deliveries, combined with ultrasound findings of placental lacunae and loss of the retroplacental hypoechoic zone, are characteristic of PAS.

A. Schedule delivery at 37 weeks in a tertiary-care facility
Rationale: Planned cesarean delivery in a tertiary-care center is the safest approach to manage PAS, ensuring access to surgical expertise and resources for managing complications.

Question 37

38-year-old G3P2 at 36 weeks presents with painless vaginal bleeding. She has a history of placenta previa and one prior cesarean section. Ultrasound reveals a placenta invading the bladder wall.

Questions:

What is the most likely diagnosis?
A. Placenta accreta
B. Placenta increta
C. Placenta percreta
D. Vasa previa

What is the definitive management for this condition?
A. Planned vaginal delivery with close monitoring
B. Cesarean hysterectomy
C. Leave the placenta in situ for resorption
D. Uterine artery embolization

Answer 37

C. Placenta percreta
Rationale: Placenta percreta is characterized by villi penetrating through the uterine wall into adjacent structures, such as the bladder.

B. Cesarean hysterectomy
Rationale: Placenta percreta with bladder invasion requires cesarean hysterectomy to control bleeding and prevent life-threatening complications.

Question 38

A 40-year-old G5P4 with a history of three prior cesarean sections presents at 34 weeks for evaluation. MRI confirms placenta increta.

Questions:

What is the most critical preoperative preparation?
A. Administering corticosteroids for fetal lung maturity
B. Placement of balloon-tipped intra-arterial catheters
C. Administering methotrexate postpartum
D. Planning a vaginal delivery at term

What is a potential complication if the placenta is removed manually during surgery?
A. Severe postpartum hemorrhage
B. Retained placenta
C. Uterine rupture
D. Postpartum endometritis

Answer 38

A. Administering corticosteroids for fetal lung maturity
Rationale: Delivery at 34–37 weeks is recommended for PAS. Corticosteroids should be administered to prepare the fetus for preterm delivery. Balloon-tipped catheters may be considered but are not universally recommended.

A. Severe postpartum hemorrhage
Rationale: Manual removal of the placenta in PAS increases the risk of severe hemorrhage due to abnormal adherence and invasion of placental tissue.

Question 39

A 35-year-old G3P2 with a diagnosis of placenta accreta spectrum (PAS) undergoes cesarean delivery at 36 weeks. During the procedure, the placenta is noted to be abnormally adherent to the uterine wall, but there is no evidence of invasion beyond the myometrium.

Questions:

What is the most likely type of PAS in this patient?
A. Placenta accreta
B. Placenta increta
C. Placenta percreta
D. Placental abruption

If the patient desires fertility preservation, what management option may be considered?
A. Manual removal of the placenta
B. Conservative management with placenta left in situ
C. Immediate hysterectomy
D. Methotrexate therapy to aid placental resorption

Answer 39

A. Placenta accreta
Rationale: Placenta accreta is characterized by villi attaching to but not invading the myometrium, which fits the description of abnormal adherence without deeper invasion.

B. Conservative management with placenta left in situ
Rationale: Leaving the placenta in situ may preserve fertility but requires close monitoring for complications like infection or hemorrhage. Methotrexate is not proven effective in this scenario.

Question 40

A 37-year-old G6P5 with a history of placenta previa and multiple cesarean sections presents with suspected placenta percreta at 33 weeks.

Questions:

What facility is most appropriate for delivery?
A. A community hospital with basic obstetric care
B. A tertiary-care center with multidisciplinary surgical teams
C. A birthing center focused on low-intervention deliveries
D. An outpatient surgical center

What is the most likely long-term complication after surgery for placenta percreta?
A. Uterine rupture in subsequent pregnancies
B. Chronic pelvic pain
C. Bladder injury requiring surgical repair
D. Recurrent placenta previa

Answer 40

B. A tertiary-care center with multidisciplinary surgical teams
Rationale: PAS cases require specialized care, including access to advanced surgical and anesthetic teams, blood banking, and critical care resources.

C. Bladder injury requiring surgical repair
Rationale: Bladder injury is a common complication in cases of placenta percreta due to its invasive nature.

Question 41

A 28-year-old G2P1 at 30 weeks presents with painless vaginal bleeding. Transabdominal ultrasound suggests placenta previa but has limited visualization due to maternal obesity.

Questions:

What is the next best imaging modality to confirm the diagnosis?
A. Repeat transabdominal ultrasound after bladder filling
B. Magnetic resonance imaging (MRI)
C. Transvaginal ultrasound
D. Color Doppler ultrasound

If placenta accreta is suspected, what sonographic finding is most indicative of PAS?
A. Hyperechoic retroplacental zone
B. Retroplacental hematoma
C. Loss of retroplacental hypoechoic zone
D. Placental calcifications

Answer 41

C. Transvaginal ultrasound
Rationale: Transvaginal ultrasound is the most accurate and safe method for confirming placental localization, particularly in cases of limited transabdominal visualization.

C. Loss of retroplacental hypoechoic zone
Rationale: The absence of the hypoechoic zone, along with other findings like placental lacunae, suggests abnormal placental invasion characteristic of PAS.

Question 42

A 34-year-old G3P2 with a history of placenta previa and two prior cesarean deliveries undergoes ultrasound at 32 weeks. Sonographic findings include multiple placental lacunae and bulging into the bladder wall.

Questions:

What imaging modality would further clarify the extent of placental invasion?
A. Power Doppler ultrasound
B. MRI with gadolinium contrast
C. Transperineal ultrasound
D. CT scan of the pelvis

What is the most likely maternal complication in this patient?
A. Postpartum endometritis
B. Uterine rupture
C. Massive postpartum hemorrhage
D. Cervical incompetence

Answer 42

B. MRI with gadolinium contrast
Rationale: MRI provides detailed imaging of placental invasion, especially for posterior placenta previa or suspected PAS with bladder involvement.

C. Massive postpartum hemorrhage
Rationale: PAS significantly increases the risk of massive hemorrhage due to abnormal placental attachment and difficulty in separation.

Question 43

A 36-year-old G5P4 at 34 weeks presents with heavy vaginal bleeding. She is diagnosed with placenta previa. Fetal heart rate monitoring shows repetitive late decelerations.

Questions:

What fetal complication is most likely?
A. Preterm labor
B. Intrauterine growth restriction
C. Fetal hypoxia
D. Amniotic band syndrome

What is the immediate next step in management?
A. Administer betamethasone and continue monitoring
B. Perform emergency cesarean delivery
C. Induce labor with oxytocin
D. Perform uterine artery embolization

Answer 43

C. Fetal hypoxia
Rationale: Late decelerations indicate uteroplacental insufficiency and fetal hypoxia, which are common in placenta previa with active bleeding.

B. Perform emergency cesarean delivery
Rationale: Fetal distress and active bleeding in placenta previa necessitate immediate cesarean delivery to prevent fetal and maternal complications.

Question 44

A 30-year-old G3P2 at 33 weeks presents with painless vaginal bleeding and is diagnosed with placenta previa. After stabilization, the patient inquires about long-term risks associated with this condition.

Questions:

What is a potential maternal complication in future pregnancies?
A. Preterm labor
B. Uterine rupture
C. Gestational diabetes
D. Pre-eclampsia

What fetal complication is most likely in the current pregnancy?
A. Fetal macrosomia
B. Intrauterine growth restriction
C. Neural tube defect
D. Polyhydramnios

Answer 44

B. Uterine rupture
Rationale: Women with prior PAS or placenta previa are at increased risk for uterine rupture in subsequent pregnancies, especially after cesarean deliveries.

B. Intrauterine growth restriction
Rationale: Placenta previa and associated conditions, like PAS, often lead to fetal growth restriction due to compromised uteroplacental blood flow.

Question 45

A 38-year-old G4P3 with placenta accreta is scheduled for delivery at a tertiary-care center. During surgery, significant hemorrhage occurs, and the placenta cannot be separated from the uterine wall.

Questions:

What maternal complication is most likely associated with this scenario?
A. Sheehan syndrome
B. Hemorrhagic shock
C. Amniotic fluid embolism
D. Postpartum cardiomyopathy

What is the definitive treatment for this condition?
A. Conservative management with placenta left in situ
B. Uterine artery embolization
C. Cesarean hysterectomy
D. Bilateral tubal ligation

Answer 45

B. Hemorrhagic shock
Rationale: Massive blood loss due to failure of placental separation in PAS can lead to hemorrhagic shock, requiring urgent intervention.

C. Cesarean hysterectomy
Rationale: In cases of placenta accreta with significant hemorrhage, hysterectomy is often necessary to control bleeding and prevent further complications.

Question 46

A 29-year-old G2P1 at 32 weeks is diagnosed with placenta previa after an episode of painless vaginal bleeding. She is hemodynamically stable, and fetal heart monitoring is reassuring.

Questions:

What is the most appropriate management at this time?
A. Immediate cesarean delivery
B. Expectant management with pelvic rest
C. Induction of labor at 34 weeks
D. Uterine artery embolization

When should delivery be planned in this patient?
A. At 34 weeks regardless of fetal condition
B. At 36 weeks if no further complications occur
C. At term unless active bleeding resumes
D. Immediate delivery if the patient has no complications

Answer 46

B. Expectant management with pelvic rest
Rationale: In stable patients with placenta previa and no active bleeding, expectant management and pelvic rest are appropriate to prolong the pregnancy and reduce risks to the fetus.

B. At 36 weeks if no further complications occur
Rationale: Elective delivery at 36 weeks is recommended for placenta previa to reduce the risk of hemorrhage while minimizing prematurity-related complications.

Question 47

A 35-year-old G4P3 presents at 30 weeks with abdominal pain and painful vaginal bleeding. She is diagnosed with abruptio placenta. The patient is hypotensive with a blood pressure of 90/60 mmHg and fetal heart rate showing late decelerations.

Questions:

What is the most critical next step in management?
A. Administer IV fluids and monitor vitals
B. Perform emergency cesarean delivery
C. Administer corticosteroids and tocolytics
D. Monitor fetal heart rate and continue expectant management

If the patient stabilizes and the fetus is immature, what is the appropriate management strategy?
A. Perform immediate cesarean delivery
B. Administer corticosteroids and observe closely
C. Induce labor
D. Perform uterine artery embolization

Answer 47

B. Perform emergency cesarean delivery
Rationale: Maternal hypotension and fetal distress in abruptio placenta require immediate cesarean delivery to prevent maternal and fetal complications.

B. Administer corticosteroids and observe closely
Rationale: In stable cases of abruptio placenta with an immature fetus, corticosteroids are administered to promote fetal lung maturity, and the patient is monitored closely for signs of worsening condition.

Question 48

A 40-year-old G5P4 at 34 weeks with a history of two prior cesarean sections is diagnosed with placenta accreta spectrum (PAS). The multidisciplinary team decides to schedule an elective cesarean delivery.

Questions:

What is the primary goal of the multidisciplinary team in managing this patient?
A. Prevent fetal distress
B. Minimize intraoperative blood loss and complications
C. Preserve fertility at all costs
D. Expedite delivery regardless of maternal risks

If there is heavy bleeding during surgery, what is the definitive management?
A. Manual removal of the placenta
B. Cesarean hysterectomy
C. Use of methotrexate
D. Bilateral tubal ligation

Answer 48

B. Minimize intraoperative blood loss and complications
Rationale: The primary goal in PAS management is to minimize blood loss and complications during surgery, as these are the leading causes of maternal morbidity and mortality.

B. Cesarean hysterectomy
Rationale: Hysterectomy is the definitive treatment for PAS with heavy bleeding, as attempts to remove the placenta manually can exacerbate hemorrhage.

Question 49

A 28-year-old G3P2 presents at 33 weeks with a diagnosis of placenta previa and expresses a strong desire for future pregnancies.

Questions:

What management strategy should be considered for this patient?
A. Leave the placenta in situ during cesarean delivery
B. Perform a cesarean hysterectomy to prevent complications
C. Deliver at term to maximize fetal maturity
D. Attempt vaginal delivery with close monitoring

What are the risks associated with conservative management (leaving the placenta in situ)?
A. DIC, sepsis, and subsequent hysterectomy
B. Uterine rupture and bladder injury
C. Fetal hypoxia and prematurity
D. Placenta accreta recurrence in future pregnancies

Answer 49

A. Leave the placenta in situ during cesarean delivery
Rationale: For patients with a strong desire for future pregnancies, leaving the placenta in situ may be considered to preserve fertility, though it carries significant risks.

A. DIC, sepsis, and subsequent hysterectomy
Rationale: Conservative management carries risks like sepsis, disseminated intravascular coagulation (DIC), and the need for hysterectomy due to bleeding or infection.

Question 50

A 33-year-old G2P1 with placenta accreta is undergoing cesarean delivery at 35 weeks in a tertiary-care center. The surgical team faces difficulty controlling intraoperative bleeding.

Questions:

What intraoperative intervention can help minimize blood loss?
A. Uterine artery embolization
B. Bilateral uterine artery ligation
C. Manual compression of the uterus
D. Leaving the placenta in situ

If the patient stabilizes postoperatively, what long-term complication is she at increased risk for?
A. Chronic pelvic pain
B. Recurrence of placenta accreta in future pregnancies
C. Endometrial cancer
D. Preterm labor

Answer 50

B. Bilateral uterine artery ligation
Rationale: Uterine artery ligation reduces blood supply to the uterus and is an effective measure to control bleeding during PAS-related surgeries.

B. Recurrence of placenta accreta in future pregnancies
Rationale: Patients with a history of PAS are at significantly increased risk of recurrence in future pregnancies, especially with placenta previa.