LE5 OB Flashcards
A 26-year-old woman with a monochorionic diamniotic (MCDA) twin pregnancy undergoes an ultrasound at 22 weeks. The scan reveals the following:
Twin A: Polyhydramnios, large for gestational age
Twin B: Oligohydramnios, significantly smaller
What is the most likely diagnosis?
A. Selective Intrauterine Growth Restriction (sIUGR)
B. Twin Reversed Arterial Perfusion (TRAP) Syndrome
C. Twin-Twin Transfusion Syndrome (TTTS)
D. Twin Anemia-Polycythemia Sequence (TAPS)
C. Twin-Twin Transfusion Syndrome (TTTS)
Rationale:
TTTS is a complication specific to MCDA twins due to vascular anastomoses in a shared placenta.
Donor Twin (B) → Oligohydramnios, growth restriction, anemia.
Recipient Twin (A) → Polyhydramnios, macrosomia, heart failure risk.
sIUGR does not cause amniotic fluid discordance.
A 28-year-old woman with an MCDA twin pregnancy is diagnosed with Stage III TTTS at 24 weeks. Doppler studies reveal absent or reversed end-diastolic flow in the donor twin. What is the best treatment?
A. Amnioreduction of the recipient twin’s sac
B. Selective fetoscopic laser ablation of placental anastomoses
C. Immediate delivery via C-section
D. Cord ligation of the donor twin
B. Selective fetoscopic laser ablation of placental anastomoses
Rationale:
Laser ablation is the definitive treatment for severe TTTS (Stage II or higher).
Amnioreduction only provides temporary relief but does not correct the underlying issue.
Preterm delivery before viability (<25 weeks) is not ideal unless fetal distress occurs.
A 32-year-old woman with an MCDA twin pregnancy at 30 weeks presents for a routine ultrasound. Doppler studies show the following:
Twin A: Middle cerebral artery (MCA) peak systolic velocity (PSV) is increased
Twin B: MCA PSV is decreased, with signs of polycythemia
Which fetal complication is most likely?
A. Twin-Twin Transfusion Syndrome (TTTS)
B. Selective Intrauterine Growth Restriction (sIUGR)
C. Twin Anemia-Polycythemia Sequence (TAPS)
D. Twin Reversed Arterial Perfusion (TRAP) Syndrome
C. Twin Anemia-Polycythemia Sequence (TAPS)
Rationale:
TAPS is a chronic, slow transfusion imbalance in MCDA twins due to small arterio-venous shunts.
MCA Doppler is key: High PSV (anemia) in one twin, low PSV (polycythemia) in the other.
Unlike TTTS, there is no major amniotic fluid imbalance.
A 29-year-old woman with an MCDA twin pregnancy undergoes an anatomy scan at 22 weeks. Ultrasound reveals:
Twin A: Normal heart function
Twin B: Acardiac, absent cardiac activity, abnormal body development
What is the best next step?
A. Expectant management with serial ultrasound monitoring
B. Fetal echocardiography to assess Twin B’s heart function
C. Fetoscopic laser ablation or radiofrequency ablation (RFA) of Twin B’s cord
D. Immediate delivery regardless of gestational age
C. Fetoscopic laser ablation or radiofrequency ablation (RFA) of Twin B’s cord
Rationale:
TRAP sequence occurs in MCDA twins when one twin (acardiac) receives reversed arterial flow.
Pump twin is at risk of high-output cardiac failure.
Cord occlusion via laser or RFA is required to prevent heart failure in Twin A.
A 30-year-old woman with an MCDA twin pregnancy undergoes ultrasound at 28 weeks. Twin A is growing appropriately, but Twin B is measuring >25% smaller with absent end-diastolic flow in the umbilical artery. What is the best course of action?
A. Expectant management with weekly ultrasound monitoring
B. Immediate delivery via C-section
C. Selective fetoscopic laser ablation
D. Close Doppler monitoring with consideration for early delivery
D. Close Doppler monitoring with consideration for early delivery
Rationale:
sIUGR is diagnosed when one twin is ≥25% smaller.
Absent or reversed umbilical artery end-diastolic flow = High risk of fetal demise.
Management depends on Doppler trends; delivery may be needed if worsening occurs.
A 34-year-old woman with an MCDA twin pregnancy presents for routine ultrasound at 30 weeks. One twin has no cardiac activity, while the other appears viable. What is the next best step?
A. Immediate C-section to prevent complications in the surviving twin
B. MRI to assess for brain injury in the surviving twin
C. Expectant management without further intervention
D. Umbilical cord coagulation of the deceased twin
B. MRI to assess for brain injury in the surviving twin
Rationale:
In MCDA twins, single intrauterine fetal demise (IUFD) increases the risk of ischemic brain injury in the surviving twin.
MRI is used to detect hypoxic-ischemic injury.
Immediate delivery is not required unless there is fetal distress.
A 30-year-old woman with an MCMA twin pregnancy at 30 weeks is undergoing biweekly ultrasound surveillance. The scan shows intertwined umbilical cords but normal fetal heart rates. What is the best management plan?
A. Continue biweekly monitoring until spontaneous labor occurs
B. Hospital admission for continuous fetal monitoring at 32 weeks
C. Immediate C-section at 30 weeks
D. Induction of labor at 37 weeks if no distress
B. Hospital admission for continuous fetal monitoring at 32 weeks
Rationale:
MCMA twins are at high risk for sudden fetal death due to cord entanglement.
Recommended management = Hospitalization at 32 weeks with continuous monitoring.
Elective delivery at 32-34 weeks via C-section to reduce risk of cord accidents.
A 28-year-old woman with a dichorionic diamniotic (DCDA) twin pregnancy presents for her first prenatal visit at 10 weeks gestation. She asks how often she should have prenatal check-ups compared to a singleton pregnancy. What is the most appropriate response?
A. The same as a singleton pregnancy (every 4 weeks until 28 weeks, then every 2 weeks)
B. More frequent visits (every 2 weeks starting at 16-18 weeks, then weekly after 28 weeks)
C. Monthly visits until 36 weeks, then weekly
D. Weekly visits starting in the second trimester
B. More frequent visits (every 2 weeks starting at 16-18 weeks, then weekly after 28 weeks)
Rationale:
Multifetal pregnancies require more frequent monitoring due to increased risks (e.g., preterm labor, growth restriction).
In twins: Visits should be every 2 weeks starting at 16-18 weeks, then weekly after 28 weeks.
More frequent ultrasounds are needed to monitor fetal growth and complications.
A 27-year-old woman with a dichorionic twin pregnancy at 16 weeks asks about her nutritional needs. How much total weight gain is recommended for a woman with a normal BMI?
A. 11-15 kg (24-32 lbs)
B. 16-24 kg (35-50 lbs)
C. 6-10 kg (13-22 lbs)
D. 25-30 kg (55-66 lbs)
B. 16-24 kg (35-50 lbs)
Rationale:
Weight gain in twins should be higher than in singleton pregnancies (~25-35 lbs).
Higher caloric and protein intake is required to support fetal growth.
A 32-year-old woman with an MCDA twin pregnancy at 20 weeks is found to have a hemoglobin level of 10.5 g/dL. What additional supplementation should she receive?
A. Folic acid only
B. Increased iron and folic acid supplementation
C. Calcium and vitamin D only
D. No additional supplementation is needed
B. Increased iron and folic acid supplementation
Rationale:
Iron-deficiency anemia is more common in multifetal pregnancies due to increased blood volume.
Folic acid helps prevent neural tube defects and supports red blood cell formation.
A 29-year-old woman with a monochorionic twin pregnancy at 30 weeks presents with contractions every 5 minutes and a cervical dilation of 3 cm. What is the most appropriate next step?
A. Administer antenatal corticosteroids and magnesium sulfate
B. Immediate cesarean delivery
C. Bed rest and hydration only
D. Perform emergency cerclage
A. Administer antenatal corticosteroids and magnesium sulfate
Rationale:
Antenatal corticosteroids (betamethasone) reduce neonatal respiratory distress syndrome.
Magnesium sulfate provides neuroprotection if <32 weeks.
Cerclage is contraindicated in active preterm labor.
A 30-year-old woman at 37 weeks with a dichorionic diamniotic (DCDA) twin pregnancy presents in labor. Twin A is cephalic, and Twin B is breech. There are no maternal or fetal complications. What is the best mode of delivery?
A. Elective cesarean section for both twins
B. Attempt vaginal delivery
C. Vaginal delivery for Twin A, followed by external cephalic version (ECV) for Twin B
D. Immediate cesarean section for Twin B only
B. Attempt vaginal delivery
Rationale:
Twin A (first twin) is cephalic, making vaginal delivery possible.
If Twin B is breech, vaginal breech delivery can be attempted in an experienced setting.
External cephalic version (ECV) is not always necessary unless there are delivery difficulties.
Cesarean is only required if there are fetal distress or delivery complications.
Indications for Cesarean in Twin Pregnancies
A 35-year-old woman at 36 weeks with an MCDA twin pregnancy is admitted for delivery planning. Twin A is breech, and Twin B is transverse. What is the best mode of delivery?
A. Vaginal delivery
B. External cephalic version (ECV) of Twin A followed by vaginal delivery
C. Cesarean section
D. Induction of labor with oxytocin
C. Cesarean section
Rationale:
Non-cephalic presentation of Twin A is an indication for cesarean delivery.
Twin B in transverse lie further supports the need for C-section.
ECV is not performed on Twin A before delivery.
A 28-year-old woman at 37 weeks with a DCDA twin pregnancy presents in active labor. Twin A delivers vaginally, but Twin B remains in transverse lie. What is the best immediate management?
A. Wait for spontaneous repositioning of Twin B
B. Perform external cephalic version (ECV) for Twin B
C. Perform internal podalic version for breech extraction of Twin B
D. Perform emergency cesarean section for Twin B
C. Perform internal podalic version for breech extraction of Twin B
Rationale:
If Twin B is in transverse lie after Twin A is delivered, repositioning is needed.
Internal podalic version allows for controlled breech extraction of Twin B.
Emergency C-section is not necessary unless there is fetal distress.
🔹
A 30-year-old woman delivers twins vaginally at 37 weeks. After placental delivery, she develops heavy vaginal bleeding and a boggy uterus. What is the most likely cause?
A. Uterine rupture
B. Retained placenta
C. Uterine atony due to overdistension
D. Vaginal laceration
C. Uterine atony due to overdistension
Rationale:
Multifetal pregnancy increases the risk of PPH due to an overdistended uterus.
Uterotonics (oxytocin), uterine massage, and fluid resuscitation are first-line treatments.
A 33-year-old woman is in labor with a DCDA twin pregnancy. Twin A delivers vaginally at 10:15 AM, but Twin B remains intrauterine with normal heart tones. What is the recommended management?
A. Perform immediate cesarean section
B. Allow up to 30 minutes for spontaneous delivery of Twin B
C. Induce contractions with oxytocin if labor stalls
D. Perform external cephalic version (ECV) for Twin B
B. Allow up to 30 minutes for spontaneous delivery of Twin B
Rationale:
Twin B usually delivers within 30 minutes of Twin A.
If labor stalls or there is fetal distress, oxytocin can be used.
C-section is only necessary for complications.
A 30-year-old woman with a trichorionic triamniotic (TCTA) triplet pregnancy at 9 weeks is considering selective reduction. What is the best gestational age for this procedure?
A. Before 8 weeks
B. Between 10-14 weeks
C. At 16-20 weeks
D. After 24 weeks
B. Between 10-14 weeks
Rationale:
Selective reduction is ideally performed in the late first trimester (10-14 weeks).
Early reduction ensures better placental adaptation and reduces risks of miscarriage.
After 14 weeks, risks of preterm labor and pregnancy loss increase.
A 32-year-old woman at 12 weeks gestation with a trichorionic triplet pregnancy opts for selective reduction. What is the preferred method for reducing the number of fetuses?
A. Intracardiac potassium chloride (KCl) injection
B. Fetoscopic laser ablation of placental vessels
C. Radiofrequency ablation (RFA)
D. Cord occlusion with umbilical clips
A. Intracardiac potassium chloride (KCl) injection
Rationale:
For triplets or higher-order pregnancies, KCl injection into the fetal heart is the standard method.
Laser ablation and RFA are typically used in monochorionic pregnancies with TTTS or TRAP.
Umbilical cord occlusion is used in later gestations (>16 weeks).
Twins with monochorionic placentation should be delivered when there are signs of maturity due to the risk of:
A. Cord entanglement
B. Twin-Twin Transfusion Syndrome (TTTS)
C. Preterm premature rupture of membranes (PPROM)
D. Intrauterine Growth Restriction (IUGR)
B. Twin-Twin Transfusion Syndrome (TTTS)
📌 Rationale:
MC twins are at risk for TTTS, which can occur at any point in pregnancy.
Prolonging pregnancy increases the risk of sudden fetal deterioration.
Delivery is typically planned between 34-36 weeks if there are no complications.
Cord entanglement is a risk only in monoamniotic (MCMA) twins, not all MC twins.
What is the recommended schedule for monitoring fetal weight estimate in twins?
A. Ultrasound every 3-4 weeks
B. Weekly ultrasounds from 16 weeks
C. Ultrasound only if fundal height is abnormal
D. Growth scans every 6 weeks
A. Ultrasound every 3-4 weeks
📌 Rationale:
Twins require regular ultrasound monitoring to assess growth discordance.
DC twins → Ultrasound every 4 weeks from 20 weeks onward.
MC twins → Ultrasound every 2 weeks from 16 weeks to check for TTTS.
What is the recommended maternal weight gain for a woman with a twin pregnancy and normal BMI?
A. 37 lbs (16-24 kg)
B. 25 lbs (11-12 kg)
C. 45 lbs (20 kg)
D. 50 lbs (23 kg)
A. 37 lbs (16-24 kg)
📌 Rationale:
Twin pregnancies require more weight gain than singletons for optimal fetal growth.
Recommended range: 16-24 kg (35-50 lbs), depending on pre-pregnancy BMI.
Underweight mothers may require even higher weight gain.
What does the lambda (λ) sign on ultrasound in the second trimester indicate?
A. Diamniotic dichorionic (DCDA) twins
B. Monochorionic diamniotic (MCDA) twins
C. Monochorionic monoamniotic (MCMA) twins
D. Conjoined twins
A. Diamniotic dichorionic (DCDA) twins
📌 Rationale:
Lambda (λ) sign = Thick dividing membrane → Suggests DCDA twins (each has its own placenta and amniotic sac).
T-sign = Thin dividing membrane → Suggests MCDA twins.
MCMA twins have no separating membrane.
Twins and other multiples are usually born preterm before 37 weeks. What is the average length of pregnancy for twin births?
A. 35 weeks
B. 37 weeks
C. 33 weeks
D. 38 weeks
A. 35 weeks
📌 Rationale:
Twins typically deliver at ~35-36 weeks, earlier than singletons (~40 weeks).
Monochorionic twins are delivered between 34-36 weeks.
Higher-order multiples (triplets, quadruplets) deliver even earlier.
Which of these nutrients is most important for mothers with twin pregnancies?
A. Iron and folate
B. Vitamin D and calcium
C. Protein and omega-3 fatty acids
D. Magnesium and zinc
A. Iron and folate
📌 Rationale:
Iron is needed to prevent anemia (higher risk in twin pregnancies).
Folic acid reduces neural tube defects and supports increased fetal demands.
Calcium and protein are also important, but iron and folate are most critical.
🔹 Which statement is TRUE about Twin Anemia-Polycythemia Sequence (TAPS)?
A. It is a chronic form of Twin-Twin Transfusion Syndrome (TTTS).
B. It is seen only in dichorionic twins.
C. It is diagnosed by abnormal amniotic fluid levels.
D. It does not require treatment.
A. It is a chronic form of Twin-Twin Transfusion Syndrome (TTTS).
📌 Rationale:
TAPS is a slow, imbalanced transfusion of blood between monochorionic twins.
Unlike TTTS, there is no major amniotic fluid discordance.
Diagnosed by Doppler ultrasound (MCA PSV)—one twin has anemia, the other polycythemia.
Treatment depends on severity; severe cases require laser therapy or early delivery.
What is the mechanism behind the production of fraternal (dizygotic) twins?
A. Two eggs fertilized by different sperm
B. One egg splitting into two embryos
C. A single sperm fertilizing two eggs
D. A single zygote dividing after fertilization
A. Two eggs fertilized by different sperm
📌 Rationale:
Fraternal (dizygotic) twins = Two separate eggs fertilized by two different sperm.
Identical (monozygotic) twins = One fertilized egg splitting into two embryos.
A woman was diagnosed with a twin pregnancy on early ultrasound, but later scans show a singleton pregnancy. What most likely happened?
A. One twin died and was reabsorbed (Vanishing Twin Syndrome)
B. The ultrasound was incorrect initially
C. The second twin is hidden behind the first twin
D. The mother passed tissue from a miscarriage
A. One twin died and was reabsorbed (Vanishing Twin Syndrome)
📌 Rationale:
Vanishing Twin Syndrome occurs when one twin dies early and is absorbed by the body.
Usually detected in the first trimester.
Which maternal condition is more common in twin pregnancies compared to singletons?
A. Hypertension
B. Post-term pregnancy
C. Uterine rupture
D. Cord prolapse
A. Hypertension
📌 Rationale:
Hypertensive disorders (gestational hypertension, preeclampsia) are 2-3× more common in twins.
Increased placental mass leads to higher vascular resistance.
What is the most feared complication in multiple pregnancy, and how is it managed?
A. Preterm birth → Administer corticosteroids
B. Cord prolapse → Perform emergency C-section
C. Postpartum hemorrhage → Give oxytocin
D. Fetal growth restriction → Perform fetal transfusion
A. Preterm birth → Administer corticosteroids
📌 Rationale:
Preterm birth is the most feared complication in twins (~50% deliver before 37 weeks).
Corticosteroids (betamethasone) reduce neonatal respiratory distress.
How is birth order assigned in twin pregnancies?
A. Twin A is the fetus nearest to the pelvic inlet
B. Twin A is the fetus on the mother’s left side
C. Twin A is determined by estimated fetal weight
D. The first twin to move into the birth canal is Twin A
A. Twin A is the fetus nearest to the pelvic inlet
📌 Rationale:
Twin A is closest to the cervix and is expected to be delivered first.
Twin B is the second-born twin.
Which is a common postpartum complication in multiple pregnancy?
A. Immediate postpartum hemorrhage (PPH)
B. Shoulder dystocia
C. Uterine rupture
D. Retained placenta
A. Immediate postpartum hemorrhage (PPH)
📌 Rationale:
PPH is common due to uterine overdistension.
Uterotonic agents (oxytocin) and uterine massage are first-line treatments.
What is the main distinguishing feature between Twin-Twin Transfusion Syndrome (TTTS) and Twin Anemia-Polycythemia Sequence (TAPS)?
A. Amniotic fluid volume
B. Fetal heart rate
C. Placental position
D. Cervical length
A. Amniotic fluid volume
📌 Rationale:
TTTS = Large amniotic fluid discordance (polyhydramnios in one twin, oligohydramnios in the other).
TAPS = No significant fluid discordance, but anemia/polycythemia detected via MCA Doppler.
A 39-year-old primigravida is 2 weeks pregnant and experiencing severe vomiting. What is the next best step?
A. Perform a transvaginal ultrasound
B. Start IV hydration and antiemetics
C. Check serum β-hCG levels
D. Prescribe vitamin B6 and discharge home
A. Perform a transvaginal ultrasound
📌 Rationale:
Hyperemesis gravidarum is more common in multiple pregnancies due to high β-hCG levels.
Ultrasound confirms multiple gestations or molar pregnancy (which also causes severe vomiting).
A 38-year-old multigravida comes to the clinic with 5 months of amenorrhea. On Leopold’s Maneuver:
LM1: Hard ballotable mass
LM3: Hard ballotable mass
What is the most likely diagnosis?
A. Multiple pregnancy
B. Hydatidiform mole
C. Polyhydramnios
D. Macrosomic fetus
A. Multiple pregnancy
📌 Rationale:
Multiple ballotable masses suggest two fetal heads → Twin pregnancy.
Hydatidiform mole presents with a large-for-gestational-age uterus but no ballotable masses.
In dichorionic placentation, what is the most common cause of intrauterine growth restriction (IUGR)?
A. Uteroplacental insufficiency
B. Twin-Twin Transfusion Syndrome (TTTS)
C. Selective intrauterine growth restriction (sIUGR)
D. Placental abruption
A. Uteroplacental insufficiency
📌 Rationale:
DC twins have independent placentas → IUGR is often due to poor placental function.
TTTS and sIUGR occur in MC twins, not DC twins.
For further study of the hemodynamic capacity of a pregnant woman, what is the best position to assess cardiovascular function?
A. Left lateral decubitus
B. Supine
C. Semi-Fowler’s
D. Trendelenburg
A. Left lateral decubitus
📌 Rationale:
Left lateral position reduces compression of the inferior vena cava by the gravid uterus.
Improves venous return, cardiac output, and placental perfusion.
Supine position can cause supine hypotensive syndrome (IVC compression).
By what percentage does GFR increase during pregnancy?
A. 20%
B. 30%
C. 40%
D. 50%
C. 40%
📌 Rationale:
GFR increases by ~40-50% due to increased renal plasma flow.
This enhances clearance of creatinine, urea, and uric acid.
Pregnancy is a state of physiologic hyperfiltration.
- Which of the following statements regarding the physiologic changes of pregnancy is true?
A. Glomerular filtration rate (GFR) increases.
B. Renal plasma flow decreases.
C. Serum creatinine and urea levels increase.
D. Renal tubular reabsorption decreases.
A. GFR increases
- Which of the following statements regarding the physiologic changes of pregnancy is true?
A. Intrarenal vasodilation occurs.
B. Renal plasma flow decreases.
C. Glomerular filtration rate (GFR) decreases.
D. Creatinine clearance is reduced.
A. Intrarenal vasodilation
- An asymptomatic primigravid patient comes in for her first prenatal visit. During routine laboratory workup, her urine culture is positive for gram-negative rods >70,000 CFU/mL. What is the diagnosis?
A. Asymptomatic bacteriuria
B. Acute cystitis
C. Pyelonephritis
D. Physiologic glycosuria
A. Asymptomatic bacteriuria
- An asymptomatic primigravid patient comes in for her first prenatal visit. Her urine culture reveals gram-negative rods >60,000 CFU/mL. What is the appropriate management?
A. Prescribe antibiotics
B. Observe and repeat culture in 1 week
C. No treatment is needed unless symptoms develop
D. Increase fluid intake only
A. Prescribe antibiotics
- A 28-year-old, G2P1 (1001), showgirl presents with dysuria, urinary frequency, and fever. What laboratory test should you order for diagnosis?
A. Complete blood count (CBC)
B. Urine culture
C. Renal ultrasound
D. All of the above (AOTA)
D. All of the above (AOTA)
- A 28-year-old, G2P1, showgirl presents with terminal dysuria and sterile urine culture. What is the most likely diagnosis?
A. Urethritis (possibly due to Chlamydia trachomatis)
B. Acute cystitis
C. Pyelonephritis
D. Nephrolithiasis
A. Urethritis (possibly due to Chlamydia trachomatis)
- What is the best treatment for asymptomatic bacteriuria in pregnancy?
A. Clindamycin
B. Cephalexin
C. Cefixime
D. Ampicillin
E. Nitrofurantoin
E. Nitrofurantoin
- What percentage of untreated asymptomatic bacteriuria develops into symptomatic infection in pregnancy?
A. 25%
B. 10%
C. 50%
D. 5%
E. 75%
A. 25%
- A patient presents with lower urinary tract symptoms, but her urine culture is sterile. What is the most likely causative agent?
A. Chlamydia trachomatis
B. Escherichia coli
C. Klebsiella pneumoniae
D. Enterococcus faecalis
E. Proteus mirabilis
A. Chlamydia trachomatis
- What is the drug of choice for urethritis caused by Chlamydia trachomatis?
A. Azithromycin
B. Amoxicillin
C. Cephalexin
D. Nitrofurantoin
E. Doxycycline
A. Azithromycin
- A multigravid patient presents with dysuria, fever, chills, vomiting, and costovertebral angle tenderness. Urinalysis shows pyuria. What is the most likely diagnosis?
A. Acute Cystitis
B. Asymptomatic Bacteriuria
C. Pyelonephritis
D. Urethritis
E. Nephrolithiasis
C. Pyelonephritis
- What is the most common site of pyelonephritis in pregnancy?
A. Bilateral kidneys
B. Unilateral right kidney
C. Unilateral left kidney
D. Bladder
E. Urethra
B. Unilateral right kidney
- Which of the following is a consequence of untreated pyelonephritis?
A. All of the above
B. Death
C. Sepsis
D. Respiratory failure
A. All of the above
- What is the most common infection in pregnancy?
A. Renal infection (Urinary tract infection)
B. Pulmonary infection
C. Meningitis
D. Endocarditis
E. None of the above
A. Renal infection (Urinary tract infection)
- What is the cornerstone of treatment for acute pyelonephritis?
A. IV hydration
B. Oral antibiotics
C. Pain management
D. Observation without treatment
A. IV hydration
- How do you confirm the cure of asymptomatic bacteriuria after treatment?
A. Repeat urinalysis 1-3 weeks after therapy completion
B. Immediate repeat urine culture after last antibiotic dose
C. No follow-up required if patient is asymptomatic
D. Blood culture to confirm clearance
A. Repeat urinalysis 1-3 weeks after therapy completion
- How do you confirm the cure of pyelonephritis after treatment?
A. Repeat urine culture 1-2 weeks after therapy completion
B. Blood culture to confirm eradication
C. Repeat urinalysis only if symptoms recur
D. Imaging studies to rule out kidney damage
A. Repeat urine culture 1-2 weeks after therapy completion
- What is the appropriate management for pyelonephritis in pregnancy?
A. AOTA (Hospitalization, IV antibiotics, urine culture monitoring)
B. Oral antibiotics at home
C. Increased hydration only
D. Immediate delivery of the fetus
A. AOTA (Hospitalization, IV antibiotics, urine culture monitoring)
- What is the appropriate treatment regimen for pyelonephritis in pregnancy?
A. Nitrofurantoin 100 mg once daily
B. IV Ampicillin + Gentamicin or IV Ceftriaxone
C. Azithromycin single dose
D. No antibiotics, only IV hydration
B. IV Ampicillin + Gentamicin or IV Ceftriaxone
- What is the most common cause of nephrotic syndrome in adults?
A. Focal segmental glomerulosclerosis (FSGS)
B. Minimal change disease
C. Membranous nephropathy
D. IgA nephropathy
A. Focal segmental glomerulosclerosis (FSGS)
- Which of the following is a correct statement regarding nephrotic syndrome?
A. Prognosis is independent of renal insufficiency
B. Heavy proteinuria
C. Decreased risk of thromboembolism
D. AOTA
B. Heavy proteinuria
- Which of the following is NOT a known complication of nephrotic syndrome?
A. Pre-eclampsia
B. Polycythemia
C. Preterm birth
D. Peripheral edema
B. Polycythemia
- Which of the following are characteristic features of nephrotic syndrome?
A. Edema, Proteinuria, Hypoalbuminemia, Hyperlipidemia
B. Hematuria, Hypertension, Oliguria, Azotemia
C. Dysuria, Frequency, Urgency, Nocturia
D. Polyuria, Hypokalemia, Metabolic Acidosis
A. Edema, Proteinuria, Hypoalbuminemia, Hyperlipidemia
- What is the treatment of choice for glomerular disease?
A. Mineralocorticoids
B. Glucocorticoids
C. Hormonal therapy
D. Antibiotics
B. Glucocorticoids
- A woman at 14 weeks AOG comes to the clinic for a prenatal check-up. She discloses that she donated one kidney several years ago. She has no other pertinent medical history. Which of the following is applicable to her pregnancy?
A. She will have significant renal impairment due to pregnancy.
B. If renal function is normal, she can expect to have a normal pregnancy.
C. Pregnancy will lead to rapid decline in renal function.
D. She should be advised against continuing her pregnancy.
B. If renal function is normal, she can expect to have a normal pregnancy.
- A 21-year-old woman comes in for a routine prenatal check-up. Her urine culture shows 30,000 CFU/mL. She denies any medical illness. What is the most probable diagnosis?
A. Acute Cystitis
B. Pyelonephritis
C. Asymptomatic Bacteriuria
D. Physiologic Glycosuria
C. Asymptomatic Bacteriuria
- What is the most probable risk factor for this patient’s condition?
A. The pregnancy itself
B. Poor hygiene
C. Diabetes mellitus
D. Immunosuppression
A. The pregnancy itself
- A urine culture shows more than 30,000 CFU/mL. Should you treat this patient?
A. No, treatment is unnecessary for asymptomatic patients.
B. Yes, because asymptomatic bacteriuria in pregnancy has a high risk of progressing to a symptomatic UTI.
C. Only if symptoms develop.
D. No, unless the patient has a history of recurrent UTIs.
B. Yes, because asymptomatic bacteriuria in pregnancy has a high risk of progressing to a symptomatic UTI.
- What is the drug of choice for treating asymptomatic bacteriuria in pregnancy?
A. Cephalexin
B. Ciprofloxacin
C. Doxycycline
D. Metronidazole
A. Cephalexin
📌 Cephalexin is used for UTIs in pregnancy due to its safety profile and antimicrobial spectrum.
- What is the estimated recurrence rate of asymptomatic bacteriuria in pregnancy?
A. 10%
B. 20%
C. 30%
D. 50%
C. 30%
- When should you request a test for cure after completing antibiotic therapy for asymptomatic bacteriuria?
A. 24 hours after completing antibiotics
B. 1 week after completing antibiotics
C. 2 weeks after completing antibiotics
D. No follow-up testing is required
C. 2 weeks after completing antibiotics
📌 Repeat urinalysis or urine culture should be done 2 weeks after treatment completion. If the patient is hospitalized, urinalysis can be repeated after 48-72 hours.
- What is the most likely pathogen causing asymptomatic bacteriuria in pregnancy?
A. Klebsiella pneumoniae
B. Proteus mirabilis
C. Staphylococcus saprophyticus
D. Enterococcus faecalis
E. Escherichia coli
E. Escherichia coli
📌 E. coli is the most common cause of asymptomatic bacteriuria and urinary tract infections in pregnancy.
- A 28-year-old multigravid at 27 weeks AOG presents to the ER with hematuria, fever, and costovertebral angle tenderness. What is the most probable diagnosis?
A. Acute Pyelonephritis
B. Asymptomatic Bacteriuria
C. Acute Cystitis
D. Nephrolithiasis
A. Acute Pyelonephritis
📌 Pyelonephritis is unilateral and right-sided in more than half of cases. It presents with fever, chills, flank pain, nausea, vomiting, and CVA tenderness.
- What is the appropriate treatment for acute pyelonephritis in pregnancy?
A. IV antibiotics
B. IV hydration
C. Hospital admission
D. All of the above
D. All of the above
📌 Management depends on symptoms and AOG. If term and in severe pain, prioritize maternal and fetal well-being. If first trimester, treat as a non-pregnant patient.
- A 28-year-old multigravid at 27 weeks AOG presents to the ER with hematuria, fever, and CVA tenderness. What is the first step in management?
A. Discharge and monitor at home
B. Start oral antibiotics
C. Admit the patient
D. Schedule an outpatient follow-up in 2 weeks
C. Admit the patient
📌 Pyelonephritis in pregnancy requires hospitalization due to the risk of complications like sepsis and ARDS.
- What is the cornerstone of treatment for acute pyelonephritis?
A. Hydration
B. Pain management
C. Antibiotics
D. Surgery
A. Hydration
📌 IV hydration helps maintain renal perfusion and urine flow, which is crucial for treating pyelonephritis.
- In pregnant women treated for pyelonephritis, 99% become afebrile within how many days?
A. 1 day
B. 2 days
C. 3 days
D. 5 days
C. 3 days
📌 Most women respond to treatment within 72 hours. If fever persists beyond 48-72 hours, check for obstruction or renal abscess.
- What is the recommended treatment for pregnant women with recurrent pyelonephritis?
A. Nitrofurantoin
B. Ciprofloxacin
C. Doxycycline
D. Metronidazole
A. Nitrofurantoin
📌 Nitrofurantoin (100 mg at bedtime) is used for prophylaxis in pregnant women with recurrent UTIs.
- Which of the following is the hallmark of nephrotic syndrome?
A. Heavy proteinuria
B. Hypertension
C. Red-cell casts
D. Hematuria
A. Heavy proteinuria
📌 Nephrotic syndrome is characterized by massive proteinuria (>3.5 g/day), hypoalbuminemia, hyperlipidemia, and edema.
- Which of the following is a complication associated with nephritic syndrome?
A. Hypertension
B. Impaired renal function
C. Proteinuria
D. All of the above
D. All of the above
📌 Nephritic syndrome presents with hypertension, hematuria, red-cell casts, pyuria, proteinuria, and varying degrees of renal insufficiency.
- Which of the following is NOT a known complication of nephrotic syndrome?
A. Peripheral edema
B. Preterm birth
C. Preeclampsia
D. Polycythemia
D. Polycythemia
📌 Polycythemia (increased RBC count) is not associated with nephrotic syndrome. Common complications include thrombosis, infection, and preeclampsia.
- What is the appropriate management for nephrolithiasis in pregnancy?
A. Antibiotics, hydration, and analgesia
B. Surgery
C. Lithotripsy
D. Observation only
A. Antibiotics, hydration, and analgesia
📌 Most stones pass spontaneously with hydration and pain management. Antibiotics are needed if infection is present. Lithotripsy is contraindicated in pregnancy.
- In which of the following cardiac conditions is pregnancy contraindicated?
A. Uncomplicated Patent Ductus Arteriosus (PDA)
B. Hypertrophic Cardiomyopathy
C. Severe Left Heart Obstruction
D. Repaired Tetralogy of Fallot
C. Severe Left Heart Obstruction (ANSWER)
Pregnancy is contraindicated in conditions that severely impair cardiac output, particularly those that prevent adequate blood flow to systemic circulation. Severe left heart obstruction (such as severe aortic stenosis, mitral stenosis, or coarctation of the aorta) limits cardiac output adaptation to pregnancy, leading to heart failure and maternal-fetal complications.
Uncomplicated PDA usually does not cause hemodynamic compromise.
Hypertrophic Cardiomyopathy can be tolerated in pregnancy unless it is associated with severe obstruction.
Repaired Tetralogy of Fallot generally has good pregnancy outcomes if there is no residual right ventricular dysfunction.
- A 24-year-old G2P1, 24 weeks AOG with a repaired PDA developed an upper respiratory tract infection (URTI). Shortly after, she developed progressive dyspnea while walking up stairs and nocturnal cough. What is her NYHA classification?
A. Class I
B. Class II
C. Class III
D. Class IV
C. Class III (ANSWER)
- In which of the following conditions is cesarean section NOT recommended in gravidocardiacs?
A. Acute Congestive Heart Failure (CHF)
B. Dilated Aortic Root >4 cm
C. Recent Myocardial Infarction (MI)
D. Heparin Administration at the Time of Delivery
D. Heparin Administration at the Time of Delivery (ANSWER)
💡 Rationale:
A cesarean section is NOT recommended when the risks outweigh the benefits, such as recent heparin administration, which significantly increases bleeding risk, hematoma formation, and surgical complications.
Acute CHF, a dilated aortic root >4 cm, and recent MI are indications for CS because vaginal delivery may increase hemodynamic stress, worsening maternal condition.
Heparin use near delivery (within 2 hours of C-section) raises the risk of wound hematoma, making surgery more hazardous.
- A 30-year-old, 32 weeks AOG develops chest pain and temporary loss of consciousness. At the ER, she had persistent arrhythmia. Her aortic valve area is <1.5 cm. What is the expected fetal side effect?
A. Fetal Hydrocephalus
B. Fetal Ascites
C. Fetal Bradycardia
D. All of the Above (AOTA)
D. All of the Above (AOTA) (ANSWER)
Severe aortic stenosis (Aortic Valve Area <1.5 cm) in pregnancy leads to decreased cardiac output and placental hypoperfusion, causing fetal distress and hypoxia, which can manifest as:
Fetal bradycardia (most common) due to poor oxygen delivery.
Fetal ascites as a compensatory response to hydrops fetalis.
Fetal hydrocephalus due to placental dysfunction leading to CNS abnormalities.
- A 30-year-old, 32 weeks AOG develops chest pain and temporary loss of consciousness. At the ER, she had persistent arrhythmia. 2D Echo showed aortic valve area to be critically narrowed. Which of the following will be included in the management?
A. Spontaneous Vaginal Delivery
B. Assisted Vaginal Delivery
C. Vaginal Delivery with Spinal Anesthesia
D. Cesarean Section with Continuous Epidural Anesthesia
D. Cesarean Section with Continuous Epidural Anesthesia (ANSWER)
In pregnant women with severe aortic stenosis (<1.5 cm valve area) and persistent arrhythmia, vaginal delivery poses high cardiovascular risk due to hemodynamic instability.
Cesarean section is preferred to allow controlled hemodynamic management with continuous epidural anesthesia to prevent sudden BP changes that could worsen cardiac output.
Spinal anesthesia is avoided because it can cause sudden hypotension, worsening placental perfusion.
Vaginal delivery is too risky in cases with severe cardiac compromise.
- A 33-year-old, 32 weeks AOG develops chest pain and temporary loss of consciousness. Which of the following conditions will NOT precipitate sudden death in this patient?
A. Respiratory Infection
B. Regional Anesthesia
C. Vena Caval Occlusion
D. Severe Blood Loss
A. Respiratory Infection (ANSWER)
Rationale:
Respiratory infections can cause mild hypoxia but do not typically precipitate sudden cardiovascular collapse unless complicated by sepsis or respiratory failure.
Regional anesthesia (especially spinal anesthesia) can cause sudden hypotension, leading to cardiovascular collapse in high-risk gravidocardiac patients.
Vena caval occlusion (Supine Hypotensive Syndrome) impairs venous return, reducing cardiac output and potentially leading to syncope or cardiac arrest.
Severe blood loss (e.g., postpartum hemorrhage) can precipitate hypovolemic shock and cardiac decompensation in gravidocardiacs.
- Which of the following is NOT a predictor of maternal death in gravidocardiacs?
A. Baseline NYHA Class 3 or greater
B. Left ventricular outflow obstruction
C. Prior heart failure
D. Ejection fraction of less than 60%
D. Ejection fraction of less than 60% (ANSWER)
- Which of the following electrocardiograph findings are indicative of cardiac disease in pregnancy?
A. 15-degree left axis deviation
B. ST-segment elevation
C. Inverted T waves
D. Reduced mean PR interval
B. ST-segment elevation
- A 25-year-old G1P0 with a prior mechanical valve replacement at age 18 for mitral stenosis. Which of the following is TRUE regarding her pregnancy?
A. Pregnancy increases risk for valve replacement
B. Valve replacement can be required within a couple of years
C. Warfarin is the drug of choice for anticoagulation
D. There is decreased risk for embryopathy
C. Warfarin is the drug of choice for anticoagulation (ANSWER)
- A 32-year-old G1P0 with prior mechanical prosthetic aortic valves had a premature rupture of membranes (PROM) at 33 weeks while on low-dose unfractionated heparin. What is the drug of choice in the event of excessive bleeding?
A. Calcium
B. Magnesium
C. Tranexamic Acid
D. Protamine Sulfate
D. Protamine Sulfate
Rationale:
Protamine sulfate is the reversal agent for unfractionated heparin (UFH).
Tranexamic acid is an antifibrinolytic agent and is useful in postpartum hemorrhage but does not reverse heparin.
Calcium and magnesium have no role in reversing anticoagulation.
- A 32-year-old G1P0 with prior mechanical prosthetic aortic valves had a premature rupture of membranes (PROM) at 33 weeks while on low-dose unfractionated heparin. How soon after vaginal delivery must anticoagulation be restarted?
A. After 6 hours
B. Immediately after delivery
C. After 24 hours
D. After 48 hours
A. After 6 hours (ANSWER)
Rationale:
Anticoagulation should be restarted 6 hours postpartum to minimize the risk of thrombosis, especially in patients with mechanical heart valves who are at high risk for stroke and valve thrombosis.
Immediately restarting anticoagulation (Option B) increases the risk of postpartum hemorrhage.
Delaying anticoagulation for 24-48 hours (Options C & D) increases the risk of thromboembolism.
- A 23-year-old primigravid with Rheumatic Heart Disease (RHD) during childhood. What is NOT included in the management of RHD?
A. Calcium Channel Blockers
B. Aggressive Diuresis
C. Balloon Valvuloplasty
D. Open Heart Valvotomy
D. Open Heart Valvotomy
Rationale:
Management of Rheumatic Heart Disease (RHD) in pregnancy is aimed at optimizing cardiac function while avoiding interventions that may pose risks to both mother and fetus.
Calcium Channel Blockers (e.g., Verapamil, Diltiazem) can be used in cases where rate control is needed, particularly in atrial fibrillation with rapid ventricular response.
Diuretics are used cautiously to relieve pulmonary congestion in patients with mitral stenosis, but aggressive diuresis can cause hypovolemia and reduced placental perfusion.
Balloon Valvuloplasty (Percutaneous Balloon Mitral Valvotomy) is the preferred procedure for severe mitral stenosis during pregnancy as it is minimally invasive and preserves valve function.
Open Heart Valvotomy is NOT recommended in pregnancy due to high risks associated with cardiopulmonary bypass, fetal hypoxia, and preterm labor. This is only considered postpartum or in extreme cases where maternal survival is at risk.
- A 23-year-old G1P0 with RHD developed cough, dyspnea, and chest pain. What is the preferred route of delivery?
A. Assisted vaginal delivery with Simpson forceps under epidural anesthesia
B. Spontaneous vaginal delivery without anesthesia
C. Emergency cesarean section
D. General anesthesia with cesarean section
A. Assisted vaginal delivery with Simpson forceps under epidural anesthesia (ANSWER)
Rationale:
Vaginal delivery is preferred over cesarean section in most cardiac patients to avoid excessive blood loss and fluid shifts.
Epidural anesthesia is preferred to minimize sympathetic stimulation and hemodynamic stress.
Assisted vaginal delivery (forceps or vacuum) is preferred to shorten the second stage of labor, reducing cardiac workload.
Cesarean section is reserved for obstetric indications or severe cardiac decompensation.
- In which of the following conditions is endocarditis prophylaxis NOT recommended in pregnancy?
A. Repaired cyanotic heart disease
B. Prosthetic heart valve
C. History of infective endocarditis
D. Congenital heart disease with residual defects
A. Repaired cyanotic heart disease (ANSWER)
Rationale:
Endocarditis prophylaxis is only recommended for high-risk patients, such as those with:
Prosthetic heart valves
Previous history of infective endocarditis
Congenital heart disease with residual defects
Repaired cyanotic heart disease without residual defects does NOT require prophylaxis.
- What complication may occur in a 28-year-old primigravid with cardiac disease in pregnancy?
A. Pulmonary edema
B. Arrhythmias
C. Heart failure
D. All of the Above (AOTA)
D. All of the Above (AOTA) (ANSWER)
Rationale:
Pregnancy places increased stress on the cardiovascular system, leading to complications such as:
Pulmonary edema due to increased blood volume
Arrhythmias due to hormonal and hemodynamic changes
Heart failure due to excessive cardiac workload
- A 28-week G1P0 developed anxiety, palpitations, and atypical chest pain on exertion. What is the most likely diagnosis?
A. Mitral Valve Prolapse (MVP)
B. Pulmonary embolism
C. Acute myocardial infarction
D. Pulmonary hypertension
A. Mitral Valve Prolapse (MVP)
Rationale:
Mitral Valve Prolapse (MVP) is one of the most common cardiac conditions in young pregnant women and can present with:
Palpitations
Atypical chest pain
Anxiety and dyspnea
Pulmonary embolism and MI would present with more severe symptoms and hemodynamic instability.
- A 25-year-old primigravid consulted at the ER with dyspnea and palpitations. Her pulse rate is 184 bpm. What is the most likely diagnosis?
A. Paroxysmal Supraventricular Tachycardia (PSVT)
B. Sinus tachycardia
C. Atrial fibrillation
D. Ventricular tachycardia
A. Paroxysmal Supraventricular Tachycardia (PSVT) (ANSWER)
Rationale:
PSVT is the most common tachyarrhythmia in pregnancy due to increased sympathetic tone and hormonal effects on conduction.
HR >150 bpm suggests PSVT rather than sinus tachycardia.
Atrial fibrillation would show an irregularly irregular rhythm, and ventricular tachycardia is usually associated with hemodynamic compromise.
- Which of the following is NOT included in the management of PSVT in pregnancy?
A. Anticoagulant
B. Vagal maneuvers
C. Adenosine
D. Beta-blockers
A. Anticoagulant
Rationale:
First-line treatment for PSVT in pregnancy is vagal maneuvers (Valsalva, carotid massage).
Adenosine is safe and effective for terminating PSVT in pregnant women.
Beta-blockers (e.g., Metoprolol) are used for prevention if recurrent episodes occur.
Anticoagulation is NOT required unless there is a risk of thromboembolism (e.g., atrial fibrillation with clot risk).
- Which of the following congenital heart defects in pregnant women carries the highest risk of having a similarly affected offspring?
A. Marfan Syndrome
B. Atrial Septal Defect (ASD)
C. Ventricular Septal Defect (VSD)
D. Patent Ductus Arteriosus (PDA)
A. Marfan Syndrome (ANSWER)
Rationale:
Marfan Syndrome is an autosomal dominant genetic disorder with a 50% chance of inheritance.
ASD, VSD, and PDA have multifactorial inheritance and lower recurrence risk.
Marfan Syndrome poses additional pregnancy risks due to aortic dilation and dissection potential.
- Which of the following statements is true regarding pregnancy and the cardiovascular system?
A. Pregnancy is a high cardiac output state
B. Maternal hypovolemia is maximal at 28 weeks AOG
C. Cesarean section (CS) is the preferred route of delivery for cardiovascular disease
D. Cardiovascular MRI cannot be used in pregnancy
A. Pregnancy is a high cardiac output state
Rationale:
Pregnancy is a high cardiac output (CO) state, with CO increasing by 30-50% due to increased blood volume and heart rate.
Maternal blood volume is maximal at 28–32 weeks, but hypovolemia does not occur unless there is hemorrhage or dehydration.
CS is NOT the preferred route of delivery for all cardiovascular diseases—vaginal delivery is recommended unless obstetric or cardiac indications dictate otherwise.
MRI is safe in pregnancy, whereas CT scans should be avoided due to radiation exposure risks.
- Which of the following parameters is decreased in pregnancy?
A. Cardiac output
B. Heart rate
C. Systemic vascular resistance (SVR)
D. Blood volume
C. Systemic vascular resistance (SVR) (ANSWER)
- What is the best contraceptive advice for a postpartum G1P1 woman with severe mitral stenosis?
A. Bilateral tubal ligation (BTL)
B. Combined oral contraceptives (COCs)
C. Copper intrauterine device (IUD)
D. Progesterone-only pills
A. Bilateral tubal ligation (BTL)
Rationale:
Bilateral tubal ligation (BTL) is the preferred contraceptive method because this patient is at high risk for heart failure and future pregnancies could be life-threatening.
COCs are contraindicated due to thrombotic risk.
IUDs may increase infection risk and provoke cardiovascular complications if septicemia occurs.
Progesterone-only pills may be considered, but they are not as effective in high-risk cardiac patients who must absolutely avoid future pregnancies.
- A 28-year-old G1P0 at 28 weeks AOG presents with exertional dyspnea. Which of the following findings would indicate the presence of cardiovascular disease?
A. Occasional atrial and ventricular premature contractions
B. Mammary souffle
C. Grade 3/6 systolic murmur
D. Mild tricuspid regurgitation
C. Grade 3/6 systolic murmur (ANSWER)
Rationale:
Grade 3/6 systolic murmur suggests pathological valvular disease (e.g., mitral stenosis or aortic stenosis).
Occasional premature contractions and mild tricuspid regurgitation are common in normal pregnancy.
Mammary souffle is a benign, pregnancy-related vascular sound due to increased breast vasculature.
- At what stage of pregnancy is maternal mortality most likely to occur in the presence of cardiac disease?
A. 8 weeks of gestation
B. 28 weeks of gestation
C. Peripartum
D. Postpartum
D. Postpartum (ANSWER)
💡 Rationale:
The postpartum period is the highest-risk phase for maternal mortality in cardiovascular disease.
Rapid fluid shifts, autotransfusion of blood from the uterus, and hemodynamic stress can lead to decompensation.
The peripartum period is also a high-risk time due to labor-induced cardiac stress.
- In which of the following conditions is cesarean section (CS) NOT recommended?
A. Acute congestive heart failure
B. Dilated aortic root >4 cm
C. Recent myocardial infarction
D. Heparin administration at the time of delivery
D. Heparin administration at the time of delivery (ANSWER)
💡 Rationale:
Heparin administration within 2 hours of delivery significantly increases the risk of hemorrhage and wound hematoma; thus, CS is not recommended unless absolutely necessary.
Acute CHF, dilated aortic root >4 cm, and recent MI are indications for CS to avoid hemodynamic stress during labor.
- What is the mainstay in the management of preeclampsia with severe features?
A. Hydralazine
B. Magnesium Sulfate (MgSO₄)
C. Furosemide
D. Aspirin
B. Magnesium Sulfate (MgSO₄) (ANSWER)
- Which of the following is considered a severe feature of preeclampsia?
A. Intrauterine Growth Restriction (IUGR)
B. Creatinine of ≥1.1 mg/dL or a 2× increase from baseline
C. Double increase in uric acid levels
D. Oligohydramnios
B. Creatinine of ≥1.1 mg/dL or a 2× increase from baseline (ANSWER)
- A 25-year-old with fever and dyspnea presents with a heart rate of 184 bpm and complications. What is the best initial management for Paroxysmal Supraventricular Tachycardia (PSVT)?
A. Valsalva maneuver
B. Adenosine
C. Beta-blockers
D. Cardioversion
A. Valsalva maneuver (ANSWER)
Rationale:
Valsalva maneuver is the first-line treatment for stable PSVT as it activates the vagus nerve to slow conduction through the AV node.
If vagal maneuvers fail, adenosine is the next step.
Beta-blockers may be used for long-term prevention.
Cardioversion is reserved for unstable patients with hemodynamic compromise.
- A 30-year-old at 32 weeks AOG presents with chest pain, temporary loss of consciousness, and persistent arrhythmia. The patient has severe aortic stenosis (<0.1 cm²). What is the appropriate management?
A. Diuresis
B. Beta-blocking agents
C. Valvuloplasty
D. Maintain balance between cardiac output and circulation
B. Beta-blocking agents (ANSWER)
Rationale:
Beta-blockers (e.g., Metoprolol) are the primary treatment for symptomatic aortic stenosis in pregnancy, as they reduce heart rate and myocardial oxygen demand.
Diuresis is used cautiously because aortic stenosis is a preload-dependent condition (excessive diuresis can lead to hypotension and worsening symptoms).
Valvuloplasty may be considered in severe, symptomatic cases but is NOT first-line due to fetal risks.
Maintaining hemodynamic stability is crucial but not a direct treatment strategy.
- A 30-year-old at 32 weeks AOG presents with severe chest pain. What is the definitive management?
A. Emergency valve replacement
B. Diuretic therapy
C. Magnesium sulfate
D. Expectant management
A. Emergency valve replacement (ANSWER)
Rationale:
Aortic valve replacement (AVR) is the definitive treatment for symptomatic severe aortic stenosis.
Diuretics may be used to manage pulmonary congestion but are NOT curative.
Magnesium sulfate is used in eclampsia but has no role in aortic stenosis.
Expectant management is NOT recommended for symptomatic patients, as untreated severe aortic stenosis leads to high maternal mortality.
- Which of the following ECG findings is indicative of cardiac disease in pregnancy?
A. None
B. 15-degree left axis deviation
C. ST-segment elevation
D. Shortened PR interval
C. ST-segment elevation (ANSWER)
💡 Rationale:
ST-segment elevation is a hallmark of myocardial infarction (MI) or acute coronary syndrome (ACS).
Slight left axis deviation is normal in pregnancy due to diaphragmatic elevation.
Shortened PR interval is a normal physiological change due to increased sympathetic tone.
- A 32-year-old with a mechanical prosthetic valve and premature rupture of membranes (PROM) while on low-dose unfractionated heparin. What is the drug of choice to reverse excessive bleeding in the event of delivery?
A. Calcium
B. Magnesium
C. Tranexamic Acid
D. Protamine sulfate
D. Protamine sulfate (ANSWER)
💡 Rationale:
Protamine sulfate is the antidote for unfractionated heparin-induced bleeding.
Tranexamic acid is an antifibrinolytic used for postpartum hemorrhage but does NOT reverse heparin.
Calcium and magnesium have no role in reversing anticoagulation.
- A 27-year-old at 28 weeks AOG presents with anxiety, palpitations, and atypical chest pain. What is the most likely diagnosis?
A. Mitral Valve Prolapse (MVP)
B. Myocardial infarction
C. Pulmonary embolism
D. Aortic stenosis
A. Mitral Valve Prolapse (MVP) (ANSWER)
Rationale:
Mitral Valve Prolapse (MVP) is common in young women and can present with:
Palpitations
Atypical chest pain
Anxiety and panic-like symptoms
- What complication can occur in a 28-year-old primigravid with uncorrected Ventricular Septal Defect (VSD)?
A. Left ventricular heart failure
B. Bacterial endocarditis
C. Pulmonary hypertension
D. All of the Above (AOTA)
D. All of the Above (AOTA)
Uncorrected VSD can cause:
Left ventricular heart failure due to volume overload.
Bacterial endocarditis from abnormal turbulent blood flow.
Pulmonary hypertension (Eisenmenger syndrome) in long-standing cases.
- A 23-year-old primigravid at 30 weeks AOG presents with BP 200/110 at home and 190/100 in the ER. What is the best initial treatment?
A. Hydralazine 5 mg IV (every 15-20 minutes until max dose of 30-40 mg is reached)
B. Nitroglycerin patch
C. Nifedipine IV bolus
D. Expectant management
A. Hydralazine 5 mg IV (every 15-20 minutes until max dose of 30-40 mg is reached) (ANSWER)
Rationale:
Hydralazine is the first-line agent for severe hypertension in pregnancy.
Nitroglycerin is NOT first-line for hypertensive emergencies in pregnancy.
Nifedipine is preferred as an oral agent, NOT given IV bolus.
- In which of the following cardiac conditions is pregnancy contraindicated?
A. Mitral Valve Prolapse with mild regurgitation
B. Repaired Tetralogy of Fallot
C. Severe Aortic Dilatation
D. Paroxysmal Ventricular Tachycardia
C. Severe Aortic Dilatation
- A 20-year-old G2P1 at 24 weeks AOG with a successfully repaired mitral valve now experiences progressive dyspnea when walking upstairs and nocturnal cough. What is her NYHA classification?
A. Class I
B. Class II
C. Class III
D. Class IV
C. Class III (ANSWER)
- A 24-year-old G2P1 at 32 weeks gestation with a mitral valve prosthesis on low-molecular-weight heparin (LMWH) had premature preterm rupture of membranes (PPROM) and was rushed to the emergency room in imminent delivery. What must be given immediately?
A. Coumadin (Warfarin)
B. Protamine Sulfate
C. Calcium Gluconate
D. Tranexamic Acid
B. Protamine Sulfate (ANSWER)
- A 23-year-old primigravid with RHD went into decompensation at 24 weeks AOG. 2D echo showed Mitral Valve Stenosis (MVA <2 cm²). What is the preferred mode of delivery?
A. Spontaneous vaginal delivery without anesthesia
B. Assisted vaginal delivery with outlet forceps under epidural anesthesia
C. Vaginal delivery with spinal anesthesia
D. Cesarean section under general anesthesia
B. Assisted vaginal delivery with outlet forceps under epidural anesthesia (ANSWER)
- In which of the following conditions in pregnancy is endocarditis prophylaxis NOT recommended?
A. Prosthetic valve
B. Prior endocarditis
C. Repaired cyanotic heart disease without pelvic infection
D. Valvulotomy after heart transplantation
C. Repaired cyanotic heart disease without pelvic infection (ANSWER)
- What complication may occur in a 30-year-old G2P0 with an uncorrected ventricular septal defect (VSD)?
A. Left-sided heart failure
B. Bacterial endocarditis
C. Pulmonary hypertension
D. All of the above (AOTA)
D. All of the above (AOTA) (ANSWER)
