Medical and Surgical complications

Question 1

Which for the following is true regarding management of cerebral aneurysms in pregnancy?
A. Early aneurysmal obliteration after subarachnoid bleed is associated with worse maternal and neonatal outcomes
B. Unruptured aneurysms do not require surveillance during pregnancy
C. Surgical management of pregnant patients with SAH with cerebral aneurysms decreases maternal mortality by nearly 50%
D. Coiling and clipping of aneurysms is contraindicated in pregnancy due to prolonged radiation exposure

Answer 1

C.
Patient management after subarchnoid hemorrhage (SAH) in pregnancy from cerebral aneurysm is the same as that of a non-pregnant patient. Early aneurysmal obliteration after SAH during pregnancy improves both maternal and fetal outcomes. Maternal mortality is decreased by 50% - 66% with surgical management (either coiling and clipping)following SAH. Both methods are safe in pregnancy despite use of prolonged radiation exposure with coil embolization. Asymptomatic unruptured aneurysms in pregnancy are montiored with non-invassive imaging (MRI) without definitive clear recommendations for cesarean delivery over vaginal delivery.

1. Kim YW, Neal, D, Hoh BL. Cerebral aneurysms in pregnancy and delivery:pregnancy and delivery do not increase the risk of aneurysm rupture. Neurosurgery 2013;72(2):143-9.
2. Ng J, Kitchen N Neurosurgery and pregnancy. J Neurol Neurosurg Psychiatry . 2008;79(7):745–752.
3. Treadwell SD, Thanvi B, Robinson TG Stroke in pregnancy and the puerperium. Postgrad Med J . 2008;84(991):238–245.
4. Dias MS Neurovascular emergencies in pregnancy. Clin Obstet Gynecol . 1994;37(2):337–354. 5. Tarnaris A, Haliasos N, Watkins LD Endovascular treatment of ruptured intracranial aneurysms during pregnancy: is this the best way forward? Case report and review of the literature. Clin Neurol Neurosurg . 2012;114(6):703–706. “

Question 2

All of the following are true of complications result from uterine fibroids or their treatment EXCEPT:
A. Bilateral uterine artery embolization (UAE) is associated with poor obstetrical outcomes in most studies
B. Acceptable indications for first trimester myomectomy include intractable pain from a degenerating fibroid, a large or rapidly growing fibroid, or any large fibroid (>5 cm) located in the loewe uterine segment
C. Pain is by far the most likely complication of uterine fibroids in pregnancy
D. The risk of fetal malpresentation increases in women with fibroids compared with control subjects
E. Fetal growth does not appear to be affected by the presence of uterine fibroids

Answer 2

A.
Fetal growth does not appear to be affected by the presence of uterine fibroids. Although cumulative data and a population-based study suggested that women with fibroids are at slightly increased risk of delivering a growth-restricted infant, these results were not adjusted for maternal age or gestational age. Rarely, large fibroids can compress and distort the intrauterine cavity leading to fetal deformities. A number of fetal anomalies have been reported in women with large submucosal fibroids, including dolichocephaly (lateral compression of the fetal skull), torticollis (abnormal twisting of the neck), and limb reduction defects. Fibroid pain during pregnancy is usually managed conservatively by bed rest, hydration, and analgesics. Prostaglandin synthase inhibitors (eg, nonsteroidal anti-inflammatory drugs) should be used with caution, especially prolonged use (> 48 hours) in the third trimester where it has been associated with both fetal and neonatal adverse effects, including premature closure of the fetal ductus arteriosus, pulmonary hypertension, necrotizing enterocolitis, intracranial hemorrhage, or oligohydramnios. Rarely, severe pain may necessitate additional pain medication (narcotic analgesia), epidural analgesia, or surgical management (myomectomy). The risk of fetal malpresentation increases in women with fibroids compared with control subjects (13% vs 4.5%, respectively). Large fibroids, multiple fibroids, and fibroids in the lower uterine segment have all been reported as independent risk factors for malpresentation. It is rare for fibroids to be treated surgically in the first half of pregnancy. If necessary, however, several studies have reported that antepartum myomectomy can be safely performed in the first and second trimester of pregnancy. Acceptable indications include intractable pain from a degenerating fibroid especially if it is subserosal or pedunculated, a large or rapidly growing fibroid, or any large fibroid (> 5 cm) located in the lower uterine segment. Obstetric and neonatal outcomes in women undergoing myomectomy in pregnancy are comparable with that in conservatively managed women, although women who had a myomectomy during pregnancy were far more likely to be delivered by cesarean due to concerns about uterine rupture. Bilateral uterine artery embolization (UAE) has long been performed by interventional radiologists to control postpartum hemorrhage. More recently, UAE has been used as an alternative procedure for treating large symptomatic fibroids in women who are not pregnant and, most importantly, do not desire future fertility. A recent prospective study reported that UAE performed immediately after cesarean delivery in women with uterine fibroids may be effective in decreasing postpartum blood loss and minimizing the risk of myomectomy or hysterectomy by inducing shrinkage of the fibroids. Although not recommended, there are several reports of successful and uneventful pregnancies after UAE for uterine fibroids.

Question 3

Which of the following antibiotics is a first-line empiric treatment for bacterial endocarditis?
A. Piperacillin-tazobactam
B. Meropenem
C. Linezolid
D. Vancomycin
E. Daptomycin

Answer 3

D.
Antibiotic therapy for infective endocarditis should ultimately be targeted to the organism identified in blood cultures, but vancomycin is reasonable empiric therapy for endocarditis while awaiting culture results. Obtaining two sets of blood cultures prior to beginning antibiotic therapy is essential to confirm the diagnosis and tailor antibiotic therapy. While all of the antibiotics listed above are bacteriocidal agents, only vancomycin and daptomycin offer empiric coverage against methicillin-resistant Staphylococcus aureus and other common pathogens including streptococcal and enterococcal species. Extended-spectrum beta lactams such as piperacillin-tazobactam and carbapenems such as meropenem offer broad spectrum coverage but do not cover for MRSA. Though Daptomycin is a reasonable alternative and may offer additional coverage against vancomycin-resistant enteroccocus, the majority of enterococcal endocarditis are caused by E. faecalis subspecies that tend to be vancomycin susceptible. Therefore, daptomycin is not a first line agent. Treatment failures of linezolid against MRSA in the literature make it an inappropriate choice for empiric antibiotic therapy

Question 4

What threshold of bile acids is considered severe disease?
A. 10 umol
B. 20 umol
C. 30 umol
D. 40 umol
E. 50 umol

Answer 4

D.
A serum bile acid of > 40 µmol represents severe disease and is seen in 20% of cases with intrahepatic cholestasis of pregnancy. Although the answer of 50 is consistent with severe disease, the question is asking what is the threshhold value, and therefore the correct answer is 40.

Question 5

What is the most common pregnancy-specific liver disease?
A. HELLP syndrome
B. Acute fatty liver of pregnancy
C. Intrahepatic cholestasis of pregnancy
D. Cholecystitis
E. Choledocholithiasis

Answer 5

C.
Intrahepatic cholestasis of pregnancy is the most common pregnancy specific liver disease. It usually presents in the third trimester with pruritus, abnormal liver function and elevated serum bile acids. The incidence is 0.2-2% of all pregnancies depending on the ethnicity and geopgraphy of the location. Acute fatty liver of pregnancy is extremely rare with an incidence of 1/10.000-20,000 deliveries. The presentation includes malaise, anorexia, nausea, vomiting, jaundice, with abnormal liver function, elevated bilirubin, abnormal coagulation and hypoglycemia. HELLP syndrome has an incidence of 0.1-0.2% of all pregnancies, but of those with preeclampsia with severe features the incidence is as high as 10-20%. Cholecystitis and choledocholithiasis are not unique to pregnancy.

1. “Williamson C, Greenes V. Intrahepatic cholestasis of pregnancy. Obstet Gynecol. 2014 Jul; 124(1):120-33.
2. Sibai BM. Imitators of Severe Pre-elampsia. Semin Perinatol. 2009 Jun;33(3):196-205.
3. Sibai BM. The HELLP Syndrome (hemolysis, elevated liver enzymes, and low platelets): much ado about nothing? Am J obstet Gynecol. 1990; 163(2):311.

Question 6

Which period in pregnancy is associated with the greatest risk of stroke?
A. Second trimester
B. Peripartum
C. Postpartum
D. First trimester
E. Third trimester

Answer 6

C.
The incidence of strokes in the pregnant or postpartum patient is 11-34/100,000 deliveries which is greater than the risk in non-pregnant reproductive age women (10.7/100,000). The distribution of strokes across gestation varies, with 10% occuring antepartum, 40% peripartum and 50% postpartum. The increased risk postpartum is significant. In a study by Kittner and collegues in the NEJM, cerebral infarction had a relative risk of 0.7 during pregnancy and 8.7 in the postpartum period. For intracerebral hemorrhage, the adjusted relative risk was 2.5 during pregnancy and 28.3 postpartum.

James AH, Bushnell CD, Jamison MG, Myers ER. Incidence and risk factors for stroke in pregnancy and the puerperium. Obstet Gynecol 2005; 106:509. Scott CA, Bewley S, Rudd A, et al. Incidence, risk factors, management, and outcomes of stroke in pregnancy. Obstet Gynecol 2012; 120:318. Kittner SJ, Stern BJ, Feeser BR, et al. Pregnancy and the risk of stroke. N Engl J Med 1996; 335:768. Bateman BT, Schumacher HC, Bushnell CD, et al. Intracerebral hemorrhage in pregnancy: frequency, risk factors, and outcome. Neurology 2006; 67:424. Lanska DJ, Kryscio RJ. Risk factors for peripartum and postpartum stroke and intracranial venous thrombosis. Stroke 2000; 31:1274. Kamel H, Navi BB, Sriram N, et al. Risk of a thrombotic event after the 6-week postpartum period. N Engl J Med 2014; 370:1307.

Question 7

What is the most common neurologic complication of preeclampsia, eclampsia, and HELLP syndrome?
A, Hemorrhagic stroke
B. Ischemic stroke
C. Posterior reversible encephalopathy syndrome
D. Ruptured arteriovenous malformation
E. Transient focal neurologic deficit

Answer 7

C.
The most common neurologic complication in preeclampsia is posterior reversible encephalopathy syndrome (PRES) due to impairment of the cerebrovascular autoregulation. Neurologic manifestations include headache, blurred vision, scotomata, cortical blindness and generalized tonic clonic seizures. Imaging usually shows vasogenic edema in subcortical white matter in the parietal and occipital lobes. Although preeclampsia can cause ischemic and hemorrhagic stroke these are not as common as PRES.

Question 8

. All of the following are true regarding uterine fibroids in pregnancy EXCEPT:
A. Fibroids increase in growth for 3 to 6 months postpartum in most women
B. Fibroids are more common in women of South Asian, African, and Middle Esatern origin
C. FIbroids are associated with malpresentation, preterm labor, and an increase in cesarean section rates
D. Uterine fibroids represent one of the most challenging causes of postpartum hemorrhage and are associated with an increase in risk fo peripartum hysterectomy
E. Maternal pain is the most common complication relating to fibroids in pregnancy. Pain is more evident with fibroids greater than 5 cm diameter and during the second and third trimesters

Answer 8

A.
The natural history of fibroids postpartum has been extensively researched. Fibroids regress from early pregnancy to 3–6 months postpartum in over 70% of women. While the precise mechanism for fibroid regression remains unclear, mechanical and cellular changes at birth and involution of the uterus are thought to affect fibroids and regression may occur via a hypoxic mechanism. Therefore the statement in the first answer choice regarding fibroids growing in the postpartum period is false, and should be chosen as the correct answer. The remaining answer choices all represent true statements regarding fibroids, therefore they are not appropriate answer choices for this question.

Sampat K, Alleemudder DI. Fibroids in pregnancy: management and outcomes. The Obstetrician & Gynaecologist 2018;20:187–195. https://doi.org/10.1111/tog.12…

Question 9

. All of the following are true regarding uterine fibroids in pregnancy EXCEPT:
A. Fibroids increase in growth for 3 to 6 months postpartum in most women
B. Fibroids are more common in women of South Asian, African, and Middle Esatern origin
C. FIbroids are associated with malpresentation, preterm labor, and an increase in cesarean section rates
D. Uterine fibroids represent one of the most challenging causes of postpartum hemorrhage and are associated with an increase in risk fo peripartum hysterectomy
E. Maternal pain is the most common complication relating to fibroids in pregnancy. Pain is more evident with fibroids greater than 5 cm diameter and during the second and third trimesters

Answer 9

A.
The natural history of fibroids postpartum has been extensively researched. Fibroids regress from early pregnancy to 3–6 months postpartum in over 70% of women. While the precise mechanism for fibroid regression remains unclear, mechanical and cellular changes at birth and involution of the uterus are thought to affect fibroids and regression may occur via a hypoxic mechanism. Therefore the statement in the first answer choice regarding fibroids growing in the postpartum period is false, and should be chosen as the correct answer. The remaining answer choices all represent true statements regarding fibroids, therefore they are not appropriate answer choices for this question.

Sampat K, Alleemudder DI. Fibroids in pregnancy: management and outcomes. The Obstetrician & Gynaecologist 2018;20:187–195. https://doi.org/10.1111/tog.12…

Question 10

. Which of the following are not a risk factor for cholestasis of pregnancy?
A. History of cholestasis in a prior pregnancy
B. Primigravida
C. Multiple gestation
D. Family history of cholestasis
E. Third trimester gestation

Answer 10

B.
Cholestasis of pregnancy (ICP) is diagnosed in the setting of itching on the palms and soles without an associated rash and elevated bile acids, typically > 10micromoles/L. The risk of ICP is increased in multiple gestation, and has a recurrence risk of up to 90%. ICP does appear to have a genetic component and mutations in the ABCB4 gene encoding the multidrug resistance protein 3 are best studied, although other genes (V44AA and ATP8B1) have been studied. 80% of cholestasis occurs in the 3rd trimester. Treatment of ICP is with ursodeoxycholic acid, which improves symptoms. Literature is conflicting on if ursodeoxycholic acid improves the biochemical abnormalities of increased bile acids and elevated LFT. ICP is associated with an increased risk of stillbirth, meconium stained amniotic fluid, preterm delivery, preeclampsia, and gestational diabetes. The risk of stillbirth does not appear to be due to placenta insufficiency and is thought to be due to sudden and fatal fetal arrhythmia due to elevated bile acids. Stillbirths have been reported within days or even hours of reassuring antenatal testing. Despite this, many clinicians perform antenatal testing in the 3rd trimester and empiric delivery at 37 weeks. Maternal liver function should be assessed 6-8 weeks post partum. Persistent abnormal liver function testing is an indication for evaluation for viral hepatitis, primary biliary cirrhosis, and other non-gestational causes of liver dysfunction.

Williamson, C and Geenes, V. “Intrahepatic Cholestasis of Pregnancy”. Obstetrics and Gynecology. 124:1, pp 120-33. 2014.

Question 11

A 30 year old G2P0010 at 36 weeks sees you for a history of congenital heart disease. She says she usually gets antibiotics before she goes to the dentist when she gets her teeth cleaned. Which of the following is an indication for endocarditis prophylaxis at the time of labor?
A. Ventricular septal defect
B. Repaired tetralogy of fallot in childhood
C. Aortic root >4cm
D. Prosthetic heart valve
E. Endocarditis prophylaxis is never indicated during labor

Answer 11

D.
The correct answer is prosthetic heart valve. Infective endocarditis prophylaxis is no longer recommended at the time of delivery In the absence of infection unless the patient is in the subset of patients who are at the highest risk. This includes women with prosthetic heart valves, history of infective endocarditis, unrepaired cyanotic congenital heart disease, completely repaired congenital heart disease with prosthetic maternal during the first 6 months after repair and repared congenital heart disease with residual defects at/adjacent to the site of a patch/device. A ventricular septal defect not causing cyanotic disease, repaired tetralogy and aortic root >4centimeters do not meet current criteria for endocarditis prophylaxis.

Question 12

A 42 year old G4P2103 at 28 weeks presents to the hospital with a fever and chills. She has a history of a ventricular septal defect. She was evaluated with blood cultures, chest xray and laboratory studies. She was started on IV antibiotics and was not improving and underwent transthoracic echocardiography, which revealed a vegetation on tricuspid valve. Which of teh following is not a risk factor for infective endocarditis?
A. Prior history of infective endocarditis
B. Presence of a prosthetic valve
C. History of congenital heart disease
D. Intravenous drug use
E. Age >40

Answer 12

E.
The correct answer is age > 40. There are a number of factors that predispose to the development of infective endocarditis (IE). Age >60 years — The majority of IE cases in the United States occur in patients over the age of 60. This is due to the decline in the incidence of rheumatic heart disease and the increasing proportion of older adult individuals in the general population. Injection drug use — Injection drug use exposes a patient to bloodstream seeding with skin flora, oral flora, and/or organisms contaminating the drug or materials used for injection. Additionally, illicit drugs may cause valvular endothelial damage, which predisposes a patient to subsequent infection. Poor dentition or dental infection — Poor dentition or dental infection are presumed to be risk factors for IE due to the seeding of oral flora. Structural heart disease — 75% of patients with IE have a preexisting structural cardiac abnormality at the time that endocarditis develops. Valvular disease — This includes rheumatic heart disease, mitral valve prolapse, mitral regurgitation, aortic valve disease, and other valvular abnormalities. Prosthetic heart valve — Prosthetic valve endocarditis (PVE) can arise early or late after surgery. Early infection can arise due to microorganisms that can reach the valve prosthesis by direct contamination intraoperatively or via hematogenous spread during the initial days and weeks after surgery. As for late endocarditis related to prosthetic valves, the sewing ring, sutures, and adjacent tissues become endothelialized over the months following valve replacement, sites for adherence of microorganisms and access to host tissues adjacent to the prosthesis are altered. The leaflets of porcine bioprosthetic valves experience age-related alterations in their surface characteristics. These aging leaflets become sites for platelet-fibrin thrombus deposition and subsequent infection. History of infective endocarditis — This is one of the most important predisposing causes for subsequent IE. Presence of intravascular device — Bacteremia associated with the presence of an intravenous catheter or an invasive intravascular procedure can ne risk factors for “healthcare-associated” endocarditis. Chronic hemodialysis — Predisposing factors include intravascular access, calcific valvular disease, and immune impairment.

Question 13

A G1P0 at 28 weeks gestation presents with a sudden, severe headache, with occasional nausea and vomiting. Her blood pressure is normal and she has no history of migraines. You suspect a cerebral aneurysm and order a CT, but it is negative. What is the next step?
A. Lumbar puncture
B. MRI angiography
C. Traditional angiography
D. Emergency cesarean section
E. CT angiography

Answer 13

A.
Noncontrast head computed tomography (CT), with or without lumbar puncture(LP) is the main diagnostic modality for a subarachnoid hemorrhage(SAH), of which the main cause is a saccular aneurysm. A negative head CT and lumbar puncture effectively eliminate the diagnosis as long as both tests are performed within a few days of the event. Misdiagnosis of SAH is common and often related to failure to appreciate the spectrum of symptoms, failure to obtain a head CT scan or failure to understand the limitations of CT and then subsequent failure to perform an LP and correctly interpret the results. The sensitivity of head CT for detecting SAH is highest in the first 6 to 12 hours after SAH (nearly 100 percent) and then declines to about 58 percent at day five. Because the consequences of missing SAH are morbid, most guidelines mandate a follow-up LP when the CT scan is negative. Additionally, the sensitivity of CT may be reduced when symptoms are atypical, such as isolated neck pain, or with minor bleeds. Limited data suggest that brain MRI may be as sensitive as head CT for the acute detection of SAH. LP is mandatory if there is a strong suspicion of SAH despite a normal head CT. The classic findings of SAH are an elevated opening pressure and an elevated red blood cell count that does not diminish from CSF tube one to tube four. CT angiography (CTA) and magnetic resonance angiography (MRA) are useful for screening and presurgical planning. Both CTA and MRA can identify aneurysms as small as 3 to 5 mm with a high degree of sensitivity, but conventional angiography has better resolution. The sensitivity of CTA for the detection of ruptured aneurysms, using conventional angiography or digital subtraction angiography as the gold standard, is 83 to 98. Angiography enables the lesion to be established with certainty and provides important additional information concerning its anatomy.

Question 14

A G3P0111 presents for preconception counseling. In her last pregnancy she suffered from a a subarachnoid hemorrhage caused by a cerebral aneurysm. She recovered well, but still has minor residual motor deficits on her right side. How would you counsel her about stroke recurrence risk?
A. <1%
B. 1-2%
C. 5%
D. 10%
E. 20%

Answer 14

Different b/w ischemia and hemorrhagic strokes

C.
Estimates of stroke incidence during pregnancy vary widely, from 4.3 to 210 strokes per 100,000 deliveries. The risk of stroke is greatest in the few days around the time of delivery. Risk factors include age, anemia, hormonal influences, hypertension, diabetes, smoking, migraines, increased platelet aggregation, reduced tissue plasminogen activity, changes in blood coagulation factors (factors V, VII, VIII, IX, X, and XII and fibrinogen) during late pregnancy, preeclampsia and puerperal septicemia. Other causes of stroke in include thrombophilia, meningovascular syphilis, sickle cell disease, antiphospholipid antibodies; polycythemia, prosthetic cardiac valvular disease and cardiomyopathy. The recurrence rate during a subsequent pregnancy and postpartum period is low (≤1 percent) for most women, particularly if the causative vascular lesions have been repaired. However, data are limited, and the risk in future pregnancies varies depending upon the cause of the initial stroke. For ischemic stroke, the risk of recurrence is low. The risk of recurrence during pregnancy in one study was 1.8 percent (not significantly different from outside pregnancy), but the relative risk of recurrence was higher during the postpartum period (risk ratio 9.7, 95 % CI 1.2-78.9). The outcome of the 187 subsequent pregnancies was not significantly different to that expected from the general population. Therefore, it seems reasonable to counsel women that previous ischemic stroke is not a contraindication to a subsequent pregnancy. There is limited data regarding recurrence after pregnancy-related stroke associated with hypercoagulable states. The largest study evaluated 12 women with a previous cerebrovascular event. In 15 subsequent pregnancies, there were four thromboembolic events and none of the patients had persistent neurologic deficits. Untreated vascular malformations are prone to rebleeding regardless of pregnancy. In one study, the annual rate of recurrent hemorrhage in women with a brain arteriovenous malformation was 31% in the first year following an initial hemorrhage and 6% in subsequent years. Hence, vascular malformations should be definitively treated before reattempting pregnancy, if possible.

Question 15

Which medication is commonly used for mild to moderate active Crohn’s disease?
A. Budesonide
B. Azathioprine
C. Infliximab
D. Methotrexate
E. Parenteral corticosteroids

Answer 15

ACTIVE disease
A.
Inflammatory bowel disease is comprised of two primary disorders: Crohn’s disease and ulcerative colitis. Crohn’s disease is characterized by transmural inflammation and skip lesions. The transmural nature of Crohn’s disease can lead to fibrosis and strictures as well as intestinal obstruction which is not often seen in ulcerative colitis. Assessing disease activity is helpful in determining need for treatment and treatment response. There are two grading systems used to describe disease activity. These are the Crohn’s Disease Activity Index (CDAI) and the Harvey-Bradshaw Index. Although these are helpful, more and more clinical practice is utilizing patient reported outcomes to assess disease activity. The categories are as follows: Clinical remission – asymptomatic and without symptomatic inflammatory sequelae. Patients requiring glucocorticoids to remain asymptomatic are not considered in remission but rather are considered “steroid-dependent”. Mild Crohn’s disease – typically ambulatory and tolerating diet. They have <10% weight loss and no systemic disease symptoms (abdominal pain, fever, tachycardia or signs of obstruction). Moderate to Severe Crohn’s disease – patients who fail treatment for mild or have significant symptoms including weight loss, anemia or intermittent nausea and vomiting. Severe-fulminant disease – patients with persistent symptoms on oral steroids or biologic agents. These can also be patients that present with severe symptoms (high fever, abdominal pain, vomiting, obstruction or abscess).

Treatment of mild to moderate disease has shown that budesonide or other conventional steroid therapies to be most effective. Other medications available for treatment of mild to moderate disease includes mesalamine, sulfasalazine, and metronidazole. Patients with moderate to severe disease are treated with high dose prednisone (40-60mg daily). Additionally, if abscess or infection are present appropriate antibiotics or drainage is necessary. Azathioprine and 6-mercaptopurine as well as parenteral methotrexate can be used to help achieve steroid dependent remission. Anti-TNF monoclonal antibodies can also be used in this group of patients if other treatment options have failed. For patients with severe-fulminant disease should be hospitalized and treated. These patients should receive parenteral corticosteroids. Other possible treatments include cyclosporine or tacrolimus.

Question 16

17. A 28 year old G3P1011 at 32 weeks of gestation presents to triage for decreased fetal movement. Her initial BP is 142/93. A CBC, CMP, and UPC are sent. Her blood pressure returns to baseline (120/70s) after a reassuring NST. Her labs return within normal limits with the exception of serum calcium of 18 mg/dL. What is the most likely diagnosis?
    A. Normal physiologic changes of pregnancy
    B. Preeclampsia
    C. Primary hyperparathyroidism
    D. Sarcoidosis
    E. Malignancy

Answer 16

C.
During pregnancy, total serum calcium fall slightly, while ionized calcium levels remain unchanged. The most common cause of hypercalcemia is primary hyperparathyroidism (likely due to a parathyroid adenoma). Less common causes of hypercalcemia include familial hypocalciuric hypercalcemia and parathyroid hormone–related protein induced hypercalcemia in pregnancy as well as malignancy, thyrotoxicosis, adrenal insufficiency, vitamin overdose, drugs (such as lithium), and granulomatous disease (such as sarcoidosis or tuberculosis).
The definition of preeclampsia includes blood pressures >140/90 at least 4 hours apart. In this case, the patient had a single elevated BP most likely explained by anxiety.

Gabbe (editor). Obstetrics: Normal and problem pregnancies, 7th edition. Chapter 42, 910-37.

Question 17

Which of the following is NOT an indication for urgent surgery for the management of native valve infective endocarditis?
A. Heart failure
B. Staphylococci or non-HACEK gram-negative bacteria
C. Locally uncontrolled infection
D. Infection due to fungal or multidrug resistant organism
E. Embolic episode

Answer 17

B.
The general principles of the surgical management of infective endocarditis should follow those in the nonpregnant adult. Surgical treatment is reserved for those with severe complications of infective endocarditis, and is required in approximately half of patients. Typically, surgery is performed on an elective basis and postponed for 1 to 2 weeks to allow for antibiotic control. However, emergent or urgent surgery performed within 24 hours to a few days may be required during early active stages of the disease. Delivery of a fetus after 28 weeks should be considered prior to cardiac surgery with cardiopulmonary bypass, due to high fetal morbidity and late neonatal neurologic impairment in children.
Heart failure (answer A) is an emergent indication for surgery and is most often secondary to acute regurgitation or obstruction leading to pulmonary edema or cardiogenic shock. Echocardiographic evidence of severe aortic or mitral regurgitation or obstruction associated with poor hemodynamic tolerance is also an indication for urgent surgery.
Uncontrolled infection is another indication for early urgent surgery. Abscesses, false aneurysms, fistulas, or enlarging vegetations are all examples of locally uncontrolled infection (answer C) that warrant urgent surgery. Infection caused by fungi or multi-drug reistant organisms (answer D) is another indication for urgent surgery. Surgery for bacteria including Staphylococci or non-HACEK gram-negative bacteria (answer B) may be warranted on an urgent basis for patients with prosthetic valve endocarditis but not native valve endocarditis. Persistent positive blood cultures despite appropriate antibiotics and adequate control of septic foci may also warrant urgent as opposed to elective surgery.
Embolic evens occur in 20-50% of patients with infective endocarditis with the brain and spleen the most likely sites for left sided lesions and the lungs as the most likely site for right sided lesions. Aortic or mitral endocarditis with persistent vegetations > 10 mm (answer E) warrant surgery after embolic episodes due to the high risk of recurrence and associated morbidity from events such as strokes.

Question 18

All of the following are true about cerebral aneurysms in pregnancy EXCEPT:
A. Aneurysms are more likely to bleed in the later half of gestation and postpartum
B. Aneurysms that cause hemorrhage are most likely to be supratentorial
C. Aneurysms usually occur at sites of vessel branching; mostly in relation to the anterior and posterior communicating arteries
D. Aneurysms can cause intracranial hemorrhage from rupture
E. Intracranial saccular aneurysms are caused from a developmental arterial defect

Answer 18

B.
Patients who present with an intracerebral hemorrhage usually present with a sudden onset, severe headache. Most have focal neurologic deficits on exam corresponding to the location of the hemorrhage. Although, ruptured aneurysms are a common cause of subarchnoid hemorrhage in pregnancy, other less common causes should be considered including AVMs, vasculitides, DIC, eclampsia and metastatic choriocarcinoma. Bleeding cal occur anytime in pregnancy, but most commonly occurs in the last half of pregnancy and postpartum. Intracranial saccular aneurysms occur due to a developmental arterial defect and commonly occur at branching sites of vessels. When evaluating patients with concern for intracranial hemorrhage, a CT head is the appropriate initial test. If a CT is normal a CT angiography can be performed if still concern for aneurysm or AVM.

Question 19

20. When is rebleeding into subarachnoid hemorrhage most likely?
    A. First 6 hours
    B. 7-24 hours
    C. 2-3 days after initial hemorrhage
    D. 1-10 years after initial hemorrhage
    E. First decade

Answer 19

A.
Rebleeding occurs in 8 to 23 percent of patients with aneurysmal subarachnoid hemorrhage (SAH). Most studies have found that the risk of rebleeding is highest in the first 24 hours after SAH, particularly within six hours of the initial hemorrhage.
One study showed a rate of rebleeding of 15% in the first 6 hours and19% in first 24 hours. Of the rebleeding episodes in the first 24 hours, 82% were in the first 6 hours.
Cumulative 8 to 10 year incidences of late rebleeding (more than one year after initial SAH) vary from 0.1 to 3.2 percent. The risk of SAH recurrence has been estimated to be 15 to 22 times higher than the expected rate of a first SAH in a healthy age, sex matched cohorts.

Question 20

Who should not be routinely screened for cerebral aneurysm?
A. First-degree relatives of patients with cerebral aneurysm, when two or more family members have been affected
B. First degree relatives, when one family member has been affected
C. Patients with autosomal dominant polycystic kidney disease
D. Symptomatic patients
E. Patients with glucocorticoid remediable hyperaldosteronism

Answer 20

B.
The estimated 10-year prospective risk of hemorrhage for relatives free of hemorrhage at the time of the index case increases according to the relationship to the index case: one second degree relative, 0.3 percent, one first degree relative, 0.8 percent, two first degree relatives, 7.1 percent.
In adult patients without risk factors, it is estimated that approximately 2% of the population has asymptomatic cerebral aneurysms. Aneurysmal hemorrhage occurs at an estimated rate of 6 - 16 per 100,000; therefore, most aneurysms do not rupture.
Small aneurysms (less than 6 mm) are most commonly identified with screening, and these are at low risk for rupture. Additionally, aneurysm surgery is associated with significant morbidity and mortality. Consequently, the AHA does not suggest widespread screening for cerebral aneurysms. Nevertheless, screening may be considered in some populations at relatively high risk of cerebral aneurysm formation.
The role for radiologic screening of asymptomatic patients with ADPKD is controversial, but most patients are screened especially when 2 or more affected relatives have been affected.
Patients with symptoms such as a sudden, severe headache classically described as the “worst headache of my life” should be screened for aneurysm.
Patients with glucocorticoid-remediable aldosteronism (GRA) are at increased risk of hemorrhagic stroke, in part due to a relatively high frequency of cerebral aneurysm rupture. It has been suggested that all patients with genetically proven GRA should undergo screening for cerebral aneurysm at puberty and every five years thereafter.

Question 21

A 39 year old G2P1001 is admitted at 23 weeks gestation with severe nausea, vomiting, and fatigues. A complete metabolic panel is notable for a calcium level of 12.5 mg/dL (elevated). On additional workup, she was found to have an elevated parathyroid hormone (PTH) level of 156 mg/dL concerning for hyperparathyroidism. What is the best initial treatment for acute maternal hypercalcemia in this setting?
A. Oral phosphates
B. Calcitonin
C. Furosemide
D. Cinacalcet
E. Bisphosphonates

Answer 21

B.
When pregnant women with PHP have severely elevated calcium levels and/or significant symptoms, including hyperemesis gravidarum, pancreatitis, mental status changes, arrhythmias or other potentially life-threatening complications, then immediate hospitalization is necessary for the assessment of fetal and maternal wellbeing. Generally, these patients are volume-depleted from hypercalcemia-induced nephrogenic diabetes insipidus and often require aggressive intravenous fluid replacement. For reducing the serum calcium level to normal reference range during pregnancy, there are several medical management options; for example, eucalcemic diet, oral phosphates, MgSO4, furosemide, calcitonin, cinacalcet, bisphosphonates(BSP).
Oral phosphates, labeled a pregnancy category C medication, are generally well tolerated. The common side effects are hypokalemia and, it may also cause intra- and extravascular calcium phosphate deposits which may lead to severe organ failure. MgSO4 may be used to increase urinary calcium excretion [21Cruikshank DP, Pitkin RM, Donnelly E, Reynolds WA. Urinary magnesium, calcium, and phosphate excretion during magnesium sulfate infusion.
Furosemide, a category C drug, can help promote calciuresis by blocking renal tubular reabsorption of calcium. During the treatment of furosemide, the serum electrolyte levels should be monitored closely and replaced as required.
Calcitonin, a category B, can be helpful in decreasing the serum calcium level via direct inhibition of osteoclastic function. Calcitonin is ideal for acutely lowering the serum calcium. Continuous use yields a persistent mild inhibition of bone resorption and tachyphylaxis. Calcitonin, not crossing the placenta, has been used safely in pregnancy.
Cinacalcet is a calcimimetic that activates the calcium-sensing receptor (CaSR) present on parathyroid cells, C-cells of the thyroid, and renal distal tubular cells. Activation of the CaSR reduces PTH secretion and increases calcitonin release. Activation of the renal tubular cell CaSR reduces renal calcium reabsorption independently of changes in PTH. Due to cinacalcet’s delayed onset of action, monotherapy is not useful for the rapid correction of severe PHP in pregnancy unless combined with calcitonin. Animal studies have shown that cinacalcet crosses the placenta; however, embryonal or fetal toxicity or harmful effects with respect to pregnancy or parturition have not been observed. Based on these data, cinacalcet has been classified as a category C drug.
Bisphosphonates, a category C medication, cross the placenta and have been shown in some animal models to interfere with normal endochondral bone development. Scrupulous risk/benefit analysis must be addressed, before giving any BSP to a pregnant women. They should only be used in emergencies as a short-term intervention to stabilize severe hypercalcemia prior to surgery.

Question 22

A 24 year old G2P1102 is postoperative day 1 from repeat cesarean delivery. Surgery was complicated by previa and an estimated blood loss of 2.3 L. She has a tamponade balloon in place. The nurse reports the patient had decreased urine output overnight and the urine appears darkly concentrated. The patients hgb returns 6.2 g/dL; Hct 21% and the only other finding of note is a creatinine 1.5 mg/dL. To further delineate the underlying renal injury you order:
A. Urinalysis, urine sodium, and urine creatinine
B. Computed tomography of the chest
C. Urology consultation
D. Blood cultures
E. Retroperitoneal ultrasound

Answer 22

A.
This patient’s most likely diagnosis is hypovolemia resulting in a prerenal acute kidney injury or acute tubular necrosis related to blood loss from surgery. Urinalysis and performance of FeNa (fractional excretion of sodium) will help determine the underlying cause. Her change in urine production is not likely related to any thoracic pathology and there is not any evidence of sepsis in the case description to indicate a blood culture is warranted. Retroperitoneal ultrasound would help evaluate the renal system but an obstructive process from either surgery or tamponade balloon are unlikely/rare. Given the case presentation there are additional tests that could be ordered and evaluated by the MFM provider before Urology consultation would be warranted and Nephrology would be the more appropriate consult if needed.

Question 23

Which of the following extraintestinal manifestations is not associated with inflammatory bowel disease?
A. Uveitis
B. Primary sclerosing cholangitis
C. Hypercoagulability
D. Cardiac dysfunction
E. All are associated with inflammatory bowel disease

Answer 23

E.
Inflammatory bowel disease is comprised of two primary disorders: Crohn’s disease and ulcerative colitis. Crohn’s disease is characterized by transmural inflammation and skip lesions. The transmural nature of Crohn’s disease can lead to fibrosis and strictures as well as intestinal obstruction which is not often seen in ulcerative colitis. Ulcerative colitis is characterized by relapsing and remitting episodes of inflammation limited to the mucosal layer of the colon.
In addition to complications related to colitis, both ulcerative colitis and Crohn’s disease have extraintestinal manifestations. These complications are seen in approximately 10% of patients at the time of presentation and 25% of patients will experience extraintestinal complications in their lifetime.
The following is a list of common extraintestinal complications seen.
Arthritis – primarily involving large joints, most common extraintestinal complication. May also see ankylosing spondylitis
Ocular – most frequent complications include uveitis and episcleritis
Skin Disorders – erythema nodosum and pyoderma gangrenosum are the most frequently seen
Liver disorders - Primary sclerosing cholangitis, fatty liver and autoimmune liver disease. Patient with primary sclerosing cholangitis are typically asymptomatic
Coagulation disorders - Increased risk of both arterial and venous thromboembolism. Risk is greatest when patients are having a flare
Pulmonary – Patients can have abnormal pulmonary function tests as well as increased risk of interstitial lung disease, pulmonary fibrosis, bronchitis and vasculitis
Cardiac – Although not common increased risk of pericarditis, myocarditis and endocarditis (more common in ulcerative colitis than Crohns)

Question 24

A 43 year old G4P3104 was delivered emergently for placenta accreta and abruption which required hysterectomy. A total hysterectomy was performed with total EBL of 1850ml. Patient was transfused 1 unit of pRBC in the OR and was hemodynamically stable in the PACU and for the first 18 hours post op. While rounding on the patient she complains of right flank pain that is similar in severity to her incisional pain. Her hgb is appropriate and stable compared to her immediate postop hgb. Her UOP has been appropriate and her Creatinine was 1.0 just prior to your evaluation. A retroperitoneal ultrasound identifies a 4.2cm right renal hydronephrosis with hydroureter and no jet noted. The left side is normal with normal ureteral jet noted. Next steps in her management:
A. Return to the operating room to remove the source of the obstruction
B. Retrograde pyelogram
C. Placement of percutaneous nephrostomy tube
D. Urology consultation for stent placement
E. Fluid bolus and treatment with alpha blocker

Answer 24

C.
This clinical vignette is an example of a patient at high risk for ureteral or urinary tract injury. The risk of ureteral injury is 5 times higher than non-obstetric hysterectomy and in the setting of accreta, almost 3 times higher than hysterectomy for atony. There is no increased risk of ureteral injury in a total versus subtotal hysterectomy although the risk of bladder injury is greater (OR 1.49).
If available, placement of percutaneous nephrostomy tube is the preferred first step to prevent further renal injury and allow time for urologic consultation and evaluation. Retrograde pyelogram is not very helpful in this situation since there is already evidence of obstruction. Returning to the operating room is not recommended until urology is involved in the event there is need for additional intervention to repair or reimplant the obstructed ureter. Fluid bolus and alpha blocker would not be appropriate in this setting as nephrolithiasis is at the bottom of the differential diagnosis based on the clinical situation with evidence of complete obstruction.

Question 25

Which is NOT part of the modified duke criteria for diagnosis of infective endocarditis (IE)?
A. Vegetation or intracardiac abscess
B. Resolution of clinical manifestations occurs after <4 days if antibiotic therapy
C. Positive blood cultures
D. Fever >38
E. Vascular phenomena such as: arterial emboli septic pulmonary infarcts, mycotic aneurysm, conjunctival hemorrhages

Answer 25

B.
The diagnosis of infective endocarditis is based on clinical symptoms, blood cultures and echocardiography. There are accepted criteria for diagnosis called the modified Duke criteria. Resolution of clinical manifestations in ≤ 4 days if antibiotic therapy is considered an exclusion criterion for the diagnosis of IE as resolution of clinical findings usually takes several weeks.
Definite IE is established in the presence of any of the following:
Pathologic criteria
Pathologic lesions: vegetation or intracardiac abscess demonstrating active endocarditis on histology OR Microorganism: demonstrated by culture or histology of a vegetation or intracardiac abscess
Clinical criteria
2 major clinical criteria OR
1 major and 3 minor clinical criteria OR
5 minor clinical criteria
Major criteria
1)Positive blood cultures for IE (one of the following):
a) Typical microorganisms consistent with IE from two separate blood cultures: Staphylococcus aureus, Viridans streptococci, Streptococcus gallolyticus (formerly S. bovis), including nutritional variant strains (Granulicatella spp and Abiotrophia defectiva), HACEK group: Haemophilus spp, Aggregatibacter (formerly Actinobacillus actinomycete comitants), Cardiobacterium hominis, Eikenella spp, and Kingella kingae, Community-acquired enterococci, in the absence of a primary focus; OR
b) Persistently positive blood culture: For organisms that are typical causes of IE: at least two positive blood cultures from blood samples drawn >12 hours apart; for organisms that are more commonly skin contaminants: three or a majority of ≥4 separate blood cultures (with first and last drawn at least one hour apart)
c) Single positive blood culture for Coxiella burnetii or phase I IgG antibody titer >1:800
2) Evidence of endocardial involvement (one of the following):
a) Echocardiogram positive for IE: vegetation (oscillating intracardiac mass on a valve or on supporting structures, in the path of regurgitant jets, or on implanted material, in the absence of an alternative anatomic explanation) OR Abscess OR New partial dehiscence of prosthetic valve
b) New valvular regurgitation: Increase in or change in preexisting murmur not sufficient
Minor criteria
1) Predisposition: Intravenous drug use or presence of a predisposing heart condition (prosthetic heart valve or a valve lesion associated with significant regurgitation or turbulence of blood flow)
2) Fever: Temperature ≥38.0°C (100.4°F)
3) Vascular phenomena: Major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial hemorrhage, conjunctival hemorrhages, or Janeway lesions
4) Immunologic phenomena: Glomerulonephritis, Osler nodes, Roth spots, or rheumatoid factor
5) Microbiologic evidence: Positive blood cultures that do not meet major criteria OR serologic evidence of active infection with organism consistent with IE

Question 26

Your patient is a 33 year-old G2P1001 at 28 weeks’ gestation with a medical history significant for myasthenia gravis. She did not experience any complications in her previous pregnancy and underwent a normal spontaneous vaginal delivery. She takes pyridostigmine which controls her symptoms. She presents with complaints of regular and painful contractions and is diagnosed with preterm contractions/labor. She is admitted and is administered tocolysis and a course of corticosteroids. Soon after she complaints of increased weakness and is having some difficulty breathing. Her symptoms progress and she requires intubation and ventilatory support. The most likely explanation for the patient’s clinical deterioration is:
A. Corticosteroids are interfering with the pyridostigmine
B. The pain of contractions
C. A supratherapeutic dose of pyridostigmine
D. Magnesium sulfate used for tocolysis and fetal neuroprotection

Answer 26

D.
Myasthenia gravis is an autoimmune disease of skeletal muscle that is due to IgG antibodies directed against the acetylcholine receptor at the postsynaptic neuromuscular junction. This will lead to inhibition of impulse transmission through the muscle that leads to contraction. The disease is twice as common in women, with a prevalence approaching 1 in 5000 in the overall population. Clinically, it manifests as fluctuating weakness of extraocular and proximal limb muscles, with involvement of respiratory muscles in more severe cases. Symptoms tend to worsen with repetitive activity and thus are worse at the end of the day. Approximately 15% of patients develop bulbar symptoms, including dysphagia, dysarthria, and facial and neck muscle weakness. Stressors such as infection and surgery may trigger disease progression.
A myasthenic crisis is defined as weakness of respiratory muscles that is severe enough to require intubation and ventilatory assistance. Women are often advised to delay pregnancy 1-2 years after presentation as this is the time when there is the greatest risk of severe exacerbation. Thymectomy can result in complete remission in disease in 40% to 50% of patients and has become the standard of care.
The effects of pregnancy on myasthenia gravis are variable. Exacerbations may occur in pregnancy regardless of the level of control prior to conception, particularly in the first trimester and postpartum. However, there are no long-term adverse effects on the disease.
Medical management aims to improve muscle function by increasing acetylcholine levels at the neuromuscular junction and by suppressing antibody production. Pyridostigmine, an acetylcholine esterase (AChE) inhibitor is a mainstay of treatment. A supratherapeutic dose would result in cholinergic side effects that include abdominal cramping, diarrhea, nausea and/or vomiting and excessive salivation. Thus, choice (C) is incorrect at these symptoms are not noted in this patient. As corticosteroids may serve to treat myasthenia gravis, choice (A) is incorrect. Pain is unlikely to precipitate a myasthenic crisis, thus choice (B) is incorrect. It is important for the clinician to recognize certain medications that may exacerbate symptoms and possibly result in a myasthenic crisis. Magnesium sulfate should be avoided in the patient with myasthenia gravis. Thus, choice (D) is the correct answer as it would explain the patient’s decompensation. A list of medications to avoid in the patient with myasthenia gravis is listed below.
Medications to Avoid in Women With Myasthenia Gravis
Curare, succinylcholine, and related medications
Narcotic analgesics
Magnesium salts (magnesium sulfate, milk of magnesia, magnesium-containing antacids)
Selected antibiotics
· Aminoglycosides (gentamycin, tobramycin, neomycin, streptomycin, kanamycin)
· Fluoroquinolones (ciprofloxacin, forfloxacin)
· Macrolides (erythromycin, azithromycin)
Quinine, quinidine, or procainamide
Beta-blockers
Calcium channel blockers
Botulinum toxin
D-penicillamine
Lithium

Question 27

Your patient is a 37 year-old G2P1001 at six weeks’ gestation who presents for her initial prenatal visit. Her previous delivery was 11 years ago which was an uncomplicated normal spontaneous vaginal delivery. Approximately three years ago, she was diagnosed with multiple sclerosis when she presented with blurry vision, weakness, fatigue and bowel incontinence. Her symptoms have intermittently worsened since her diagnosis, but she has been doing better over the past year when she was prescribed glatiramer acetate. She is concerned about the effect of pregnancy on her disease and vice versa. Which of the following is true?
A. There is a 30% risk of transmission of multiple sclerosis to her fetus
B. Glatiramer acetate is contraindicated during pregnancy
C. She is at risk of a relapse in the postpartum period
D. The risk of hypertesnive disorders and gestational diabetes is increased

Answer 27

C.
Multiple sclerosis (MS) is a chronic inflammatory disease of the central nervous system that primarily affects the white matter in the brain and spinal cord. It is a progressive degenerative condition involving autoimmune destruction of the myelin sheath that leads to altered electrical impulse conduction to various muscle groups.
Multiple sclerosis is the most common chronic neurologic disability in young adults of reproductive age, affecting women twice as much as men. The etiology of MS is not completely understood, but may be due to a combination of immunologic, environmental and genetic factors. More than 100 genetic susceptibility loci have been identified. Physical symptoms at initial presentation may involve vision, speech, muscle strength and sensation. These may be accompanied by depression, memory loss, cognitive impairment, mood swings and fatigue. Exacerbation of symptoms can be precipitated by infection, stress, fatigue, heat, and heavy metal exposure. The offspring of women with MS are at increased risk of developing MS, but the absolute risk is relatively low at 3-5%. Thus, choice (A) is incorrect.
The risk of relapse during pregnancy is reduced due to its immunosuppressive effects. In the postpartum period, the risk of relapse is increased, as approximately one-third of women with MS experience a relapse within the first three months postpartum. Thus, choice (C) is correct. Pregnancy does not appear to affect the type or severity of MS exacerbation. The risk of hypertensive disorders of pregnancy, gestational diabetes, fetal growth restriction and operative vaginal delivery is not increased in women with MS. Thus, choice (D) is incorrect.
Although some women with MS will not require treatment during pregnancy, some with relapsing-remitting MS may be better served with disease-modifying drugs. Although some recommend stopping these medications prior to conception, there is no consensus about this approach. Some of the best evidence regarding the use of medications during pregnancy is derived from a systematic review that looked at interferon beta drugs, glatiramer acetate and natalizumab. Although the quality of evidence was fair, glatiramer acetate exposure was not associated with any adverse perinatal outcomes including congenital anomalies. In this patient, it would be reasonable to continue the glatiramer acetate, thus choice (B) is incorrect. Terflunomide and mitoxantrone are contraindicated during pregnancy.
Toscano M, Thornburg LL. Neurological diseases in pregnancy. Curr Opin Obstet Gynecol 2019;31:97-109.
Bove R, Alwan S, Friedman JM, Hellwig K, Houtchens M, Koren G, et al. Management of multiple sclerosis during pregnancy and the reproductive years: a systematic review. Obstet Gynecol 2014;124:1157-68.
Baird SM, Dalton J. Multiple sclerosis in pregnancy. J Perinat Neonatal Nurs 2013;27:232-41.
Lu E, Wang BW, Guiimond C, Synnes A, Sadovnick D, Tremlett H. Disease modifying drugs for multiple sclerosis in pregnancy: a systematic review. Neurology 2012;79:1130–35.

Question 28

Which patient should surgical resection of the leiomyomata during pregnancy be considered?
A. A 2 cm prolapsed vaginal fibroid at 12 weeks incidentally found during NT scan
B. A 7 cm pedunculated fibroid at 22 weeks in the setting of acute abdominal pain and evidence of torsion.
C. Intramural fibroid which has increased in size from 3 cm to 5 cm during pregnancy in a patient with a history of preterm birth.
D. 10 cm sub serosal fibroid found at 24 weeks causing pain refractory to Tylenol

Answer 28

B.
Leiomyomata (uterine fibroids) are commonly seen during pregnancy and often do not cause complications. It is difficult to assess how pregnancy is impacted by fibroids due to heterogeneity in the population studied (i.e fibroid number, size location, and type [submucosal, intramural, sub serosal, pedunculated or sessile]). Common complications of fibroids include bleeding, pain and rarely urinary retention. There may also be a slightly increased risk of miscarriage, preterm labor/preterm birth, abnormal fetal presentation and abruption (although the data are mixed). Myomectomy is generally avoided in pregnancy due to concerns regarding pregnancy complications. A and C would not be correct as the fibroids are asymptomatic. In addition, prolapsed fibroids can become intrauterine with advancing gestation. In answer D it would be reasonable to consider a trial of NSAIDs rather than the risk of resection given the size and location of the fibroid in question. It would be reasonable to consider surgical resection of the leiomyoma in answer B because 1) there is an acute change in symptoms 2) there is evidence of a large (> 5 cm) pedunculated fibroid where resection may be anticipated to be relatively straightforward.

Vitale SG, Tropea A, Rossetti D, et al. Management of uterine leiomyomas in pregnancy: review of literature. Updates Surg 2013; 65:179.
Dildy GA 3rd, Moise KJ Jr, Smith LG Jr et al. Indomethacin for the treatment of symptomatic leiomyoma uteri during pregnancy. Am J Perinatol 1992; 8: 185.

Question 29

A patient presents for a routine anatomic survey at 19 weeks gestation and she is found to have severe oligohydramnios. What is the best next step in the care of this patient?
A. Counsel for termination-this pregnancy has a poor prognosis
B. Look for other anomalies, obtain a full history, and rule out rupture of membranes
C. Rule out rupture of membranes only
D. Recommend CVS
E. Administer IV fluids

Answer 29

B.
When new diagnosis of 2nd trimester oligohydramnios is noted, it is imperative to know the etiology as this can help determine the plan of care. Careful attention to the anatomy can help identify any additional anatomic abnormalities, such as severe urinary tract abnormalities or renal agenesis. Other causes of oligohydramnios may be elicited from a history or exam(drug induced oligohydramnios, PPROM or hypertension. Fetal weight measurements would determine whether this is a case of severe, early IUGR with oligohydramnios. While ““A”” may be an correct to offer termination depending on the prognosis and parent’s desires, this should not be considered until a full evaluation is performed and an etiology obtained, as to provide the best evidence of prognosis. While ““C”” is appropriate for evaluation, it is not the complete evaluation for oligohydramnios. Additionally, ““D”” may be appropriate, especially in the case of IUGR with oligohydramnios, since amniocentesis is not possible with minimal amniotic fluid. However, full evaluation to determine whether aneuploidy should be suspected should occur first. While both PO and IV hydration have been noted to improve total AFI in some studies, this therapy for early severe oligohydramnios is not warranted, as the cause has yet to be identified.

Question 30

A patient presents for a routine anatomic survey at 19 weeks gestation and she is found to have severe oligohydramnios. What is the best next step in the care of this patient?
A. Counsel for termination-this pregnancy has a poor prognosis
B. Look for other anomalies, obtain a full history, and rule out rupture of membranes
C. Rule out rupture of membranes only
D. Recommend CVS
E. Administer IV fluids

Answer 30

B.
When new diagnosis of 2nd trimester oligohydramnios is noted, it is imperative to know the etiology as this can help determine the plan of care. Careful attention to the anatomy can help identify any additional anatomic abnormalities, such as severe urinary tract abnormalities or renal agenesis. Other causes of oligohydramnios may be elicited from a history or exam(drug induced oligohydramnios, PPROM or hypertension. Fetal weight measurements would determine whether this is a case of severe, early IUGR with oligohydramnios. While ““A”” may be an correct to offer termination depending on the prognosis and parent’s desires, this should not be considered until a full evaluation is performed and an etiology obtained, as to provide the best evidence of prognosis. While ““C”” is appropriate for evaluation, it is not the complete evaluation for oligohydramnios. Additionally, ““D”” may be appropriate, especially in the case of IUGR with oligohydramnios, since amniocentesis is not possible with minimal amniotic fluid. However, full evaluation to determine whether aneuploidy should be suspected should occur first. While both PO and IV hydration have been noted to improve total AFI in some studies, this therapy for early severe oligohydramnios is not warranted, as the cause has yet to be identified.

Question 31

All of the following can be complications associated with second trimester oligohydramnios except:
A. Pulmonary hypoplasia
B. Contractures
C. Increased incidence of nuchal cord
D. Preterm delivery
E. Placental abruption

Answer 31

C.
Second trimester oligohydramnios carries a higher risk of poor perinatal outcome versus third trimester oligohydramnios. While the lungs are forming, anhydramnios specifically carries a risk for pulmonary hypoplasia which can cause difficulty in resuscitation post delivery and often neonatal death if severe.
Additionally, there is some evidence that the lack of fluid can cause fetal contractures and depending on the cause, especially in PPROM, an increased risk of abruption and preterm delivery.
There is no evidence to support an increase in incidence of nuchal cord in second trimester oligohydramnios.

Question 32

All of the following can be complications associated with second trimester oligohydramnios except:
A. Pulmonary hypoplasia
B. Contractures
C. Increased incidence of nuchal cord
D. Preterm delivery
E. Placental abruption

Answer 32

C.
Second trimester oligohydramnios carries a higher risk of poor perinatal outcome versus third trimester oligohydramnios. While the lungs are forming, anhydramnios specifically carries a risk for pulmonary hypoplasia which can cause difficulty in resuscitation post delivery and often neonatal death if severe.
Additionally, there is some evidence that the lack of fluid can cause fetal contractures and depending on the cause, especially in PPROM, an increased risk of abruption and preterm delivery.
There is no evidence to support an increase in incidence of nuchal cord in second trimester oligohydramnios.

Question 33

All of the following are adverse pregnancy outcomes associated with intrahepatic cholestasis of pregnancy EXCEPT?
A. Preterm birth
B. Neonatal sepsis
C. Nicu admission
D. Stillbirth
E. Respiratory distress syndrome

Answer 33

B?
Intrahepatic cholestasis of pregnancy (ICP) has been associated with numerous adverse perinatal outcomes. In a study looking at 713 women in the UK with severe ICP (> 40micromoles/L bile acids) they found increased risk of preterm birth OR 2.05, 95% CI 1.43-2.94, NICU admission OR 2.34 (1.74-2.94) and stillbirth OR 3.05 (1.29-7.21). Another study also found an association with respiratory distress syndrome independent of the risk of preterm birth. Complications from ICP are believed to be associated with higher levels of bile acids. A Swedish found for every 1-2 micromoles/L increase in bile acids there was a 1-2% increase in adverse outcomes for bile acids greater than 40 micromoles/L.

Question 34

Your patient is a 33 year-old G2P1001 at seven weeks’ gestation. Her previous pregnancy was uncomplicated, undergoing a normal spontaneous vaginal delivery at term. After delivery, her infant was noted to have diffuse petechiae, and laboratory studies revealed thrombocytopenia. This prompted a work-up which yielded a diagnosis of neonatal alloimmune thrombocytopenia (NAIT). Ultrasound confirmed an intracranial hemorrhage (ICH). She has a new partner and wonders if this will have an impact on her current pregnancy.
A. Her pregnancy would be classified as standard risk
B. It is necessary to perform paternal platelet antigen typing, and depending upon the result, fetal platelet antigen typing may be necessary
C. The risk of recurrent intracranial hemorrhage is 30%
D. In the intrapartum period, assessment of the fetal platelet count by scalp blood sampling is indicated

Answer 34

B.
Neonatal alloimmune thrombocytopenia (NAIT) is a condition similar to red blood cell alloimmunization, with two distinctions. It involves platelets instead of red blood cells, and it may affect the first pregnancy. Thrombocytopenia is caused by maternal alloantibodies against human platelet antigens (HPAs) resulting from maternal alloimmunization after exposure to paternally derived antigens on fetal platelets. With maternal-fetal hemorrhage, maternal exposure to these fetal platelet antigens will lead to anti-HPA antibody formation. The most commonly involved antibody is HPA-1a which is responsible for approximately 80% of cases of NAIT.
These IgG antibodies can result in destruction of fetal platelets, with ICH the most serious complication. Different treatment strategies have been investigated to reduce the risk of recurrence of ICH in a subsequent pregnancy. These include intravenous immunoglobulins, corticosteroids and cordocentesis with fetal platelet transfusion.
In this clinical scenario, in light of a new partner, it is important to perform paternal platelet antigen typing to determine if HPA incompatibility exists. Thus, choice (B) is correct. If paternal homozygosity is established, then by definition the couple is HPA incompatible and the fetus will be at risk in every pregnancy. If the paternal HPA genotype reveals heterozygosity, fetal genotyping is indicated, as there is a 50% chance the fetus will inherit the antigen from the father. If the fetus is found not to express the HPA (HPA negative), it is compatible with the mother and would not be at risk.
Choice (D) is incorrect, as avoidance of fetal scalp electrodes, fetal blood sampling and operative vaginal delivery is recommended. The estimated recurrence rate of ICH, without antenatal treatment, is as high as 79%, not 30% as noted in choice (C). Over 80% of ICH’s are estimated to occur before birth, two-thirds before 34 weeks’ gestation and 54% before 28 weeks’ gestation.
Pregnancies are typically classified as standard and high-risk. Standard risk implies thrombocytopenia without a diagnosis of fetal or neonatal ICH. High-risk pregnancies are those with an ICH diagnosed in the previous pregnancy. This patient would be classified as high-risk since her previous child was diagnosed with an ICH. Thus, choice (A) is incorrect. Of note, the earlier the ICH occurred in the previous sibling, the greater the risk for ICH in the currently affected fetus.

Question 35

Your patient is a 33 year-old G2P1001 at seven weeks’ gestation. Her previous pregnancy was uncomplicated, undergoing a normal spontaneous vaginal delivery at term. After delivery, her infant was noted to have diffuse petechiae, and laboratory studies revealed thrombocytopenia. This prompted a work-up which yielded a diagnosis of neonatal alloimmune thrombocytopenia (NAIT). Ultrasound confirmed an intracranial hemorrhage (ICH). She has a new partner and wonders if this will have an impact on her current pregnancy.
A. Her pregnancy would be classified as standard risk
B. It is necessary to perform paternal platelet antigen typing, and depending upon the result, fetal platelet antigen typing may be necessary
C. The risk of recurrent intracranial hemorrhage is 30%
D. In the intrapartum period, assessment of the fetal platelet count by scalp blood sampling is indicated

Answer 35

B.
Neonatal alloimmune thrombocytopenia (NAIT) is a condition similar to red blood cell alloimmunization, with two distinctions. It involves platelets instead of red blood cells, and it may affect the first pregnancy. Thrombocytopenia is caused by maternal alloantibodies against human platelet antigens (HPAs) resulting from maternal alloimmunization after exposure to paternally derived antigens on fetal platelets. With maternal-fetal hemorrhage, maternal exposure to these fetal platelet antigens will lead to anti-HPA antibody formation. The most commonly involved antibody is HPA-1a which is responsible for approximately 80% of cases of NAIT.
These IgG antibodies can result in destruction of fetal platelets, with ICH the most serious complication. Different treatment strategies have been investigated to reduce the risk of recurrence of ICH in a subsequent pregnancy. These include intravenous immunoglobulins, corticosteroids and cordocentesis with fetal platelet transfusion.
In this clinical scenario, in light of a new partner, it is important to perform paternal platelet antigen typing to determine if HPA incompatibility exists. Thus, choice (B) is correct. If paternal homozygosity is established, then by definition the couple is HPA incompatible and the fetus will be at risk in every pregnancy. If the paternal HPA genotype reveals heterozygosity, fetal genotyping is indicated, as there is a 50% chance the fetus will inherit the antigen from the father. If the fetus is found not to express the HPA (HPA negative), it is compatible with the mother and would not be at risk.
Choice (D) is incorrect, as avoidance of fetal scalp electrodes, fetal blood sampling and operative vaginal delivery is recommended. The estimated recurrence rate of ICH, without antenatal treatment, is as high as 79%, not 30% as noted in choice (C). Over 80% of ICH’s are estimated to occur before birth, two-thirds before 34 weeks’ gestation and 54% before 28 weeks’ gestation.
Pregnancies are typically classified as standard and high-risk. Standard risk implies thrombocytopenia without a diagnosis of fetal or neonatal ICH. High-risk pregnancies are those with an ICH diagnosed in the previous pregnancy. This patient would be classified as high-risk since her previous child was diagnosed with an ICH. Thus, choice (A) is incorrect. Of note, the earlier the ICH occurred in the previous sibling, the greater the risk for ICH in the currently affected fetus.

Question 36

All of the following are true about management of fibroids in pregnancy EXCEPT?
A. Pain is the most common complication of fibroids in pregnancy, and is seen most often in women with fibroids > 5 cm during the second and third trimesters of pregnancy.
B. In early pregnancy, spontaneous miscarriage rates are increased in pregnant women with fibroids compared with those without fibroids.
C. Nearly 50% of women with fibroids develop complications during pregnancy.
D. Leiomyomas are reported in about 3-12% of pregnant women.
E. Uterine artery embolization is contraindicated in pregnancy and in women desiring future fertility.

Answer 36

C.
Most fibroids in pregnancy are asymptomatic. However, severe pain can occur if a fibroid undergoes so-called degeneration, torsion (especially pedunculated subserosal fibroids), or impaction/entrapment. Pain is the most common complication of fibroids in pregnancy, and is seen most often in women with large fibroids (> 5 cm) during the second and third trimesters of pregnancy.
Myomas are observed in about 3-12% of pregnant women. Spontaneous miscarriage rates are increased in pregnant women with fibroids when compared to controls in multiple studies. Early miscarriage appears to be more common in women with fibroids located in the uterine corpus than in the lower uterine segment and in women with intramural or submucosal fibroids.
Women with a previous myomectomy should be delivered by cesarean prior to the onset of labor, particularly if the uterine cavity was entered. Uterine artery embolization (UAE) is an alternative to operative intervention for the treatment of symptomatic fibroids, but is an absolute contraindication during pregnancy. In women who desire future fertility, UAE may be considered.

Question 37

Uterine inversion:
- incidence
- etiologies
- Risk factors

Answer 37

Uterine inversion refers to the collapse of the fundus into the uterine cavity, and it is classified by degree and timing. It is a rare event that complicates approximately 1 in 3,000 vaginal births. The two most commonly proposed etiologies for uterine inversion include excessive umbilical cord traction with a fundal placenta and fundal pressure in the setting of a relaxed uterus. Fundal implantation occurs in only 10% of all pregnancies but has been found in a majority of reported cases of acute uterine inversion in which the site of placental implantation was recorded. Other proposed risk factors include uterine overdistention, fetal macrosomia, rapid labor and delivery, protracted labor, congenital uterine malformations, uterine fibroids, invasive placentation, retained placenta, short umbilical cord, use of uterine-relaxing agents, nulliparity, manual placental extraction, and Ehlers-Danlos syndrome. A large population-based study of greater than 8 million deliveries over a nine-year period confirmed some of the classic risk factors associated with uterine inversion including abnormal placentation and prolonged labor. Interestingly, other well accepted risk factors for uterine inversion such as fetal macrosomia and multifetal gestation did not demonstrate a significant association with uterine inversion.

Question 38

Uterine inversion management and clinical symptoms

Answer 38

Complete uterine inversion often presents with brisk vaginal bleeding, inability to palpate the fundus abdominally, and maternal hemodynamic instability. It may occur before or after placental detachment. A globular mass in the vagina or at the perineum is a common clinical presentation of uterine inversion. A key point in minimizing morbidity is early recognition and treatment. Delays in recognition result in increasing tissue edema which worsens constriction of the cervix around the inverted fundus, making reinversion difficult.
Once the diagnosis is made, anesthesiology should be immediately notified. The first step is immediate replacement of the uterus. Uterotonic agents should not be administered until successful uterine replacement. If the placenta is attached, most recommend leaving the placenta in place. If uterine replacement is successful, the clinician’s hand should remain in place and uterotonic agents should then be administered. Establishing large-bore intravenous access, availability of blood products and close monitoring for hypovolemic shock are essential. Tocolytic agents may be used if initial attempts at manual replacement are unsuccessful. If these strategies are unsuccessful, operative attempts are employed.

Question 39

Which of the following is least likely to affect a timed urine protein collection?
A. White class F diabetes
B. Maternal position
C. Hydration status
D. Strenuous exercise
E. Infection

Answer 39

B.
Although deemed the “gold standard” test of proteinuria in the evaluation of preeclampsia, the 24-hour urine collection is subject to a number of factors that can impact results. Urine protein quantity can vary independently of the presence or severity of preeclampsia. Women excrete less protein when bedridden than when upright and active, and heavy exercise can increase proteinuria substantially. Retention and timing errors can be reduced by having the patient hydrated and positioned in lateral recumbency for an hour before the first and last void to create a more dilute and recently produced urine. Causes of functional proteinuria include fever and stress (which can increase circulating catecholamines). Increases in blood pressure resulting in increased glomerular pressure also may increase proteinuria. Increasing GFR transiently as noted with steroid administration can increase protein excretion. Fetal gender has not been clearly associated with proteinuria, although fetal male sex has been inconsistently associated with slightly higher preeclampsia rates in select populations.

Question 40

What is the most common severe complication of renal biopsy in pregnancy?
A. Major bleeding
B. Unintentional renal artery puncture and vasospasm
C. Severe postoperative pain
D. Hematuria
E. Fetal demise

Answer 40

A.
The largest study to date examining the risk of complications of renal biopsy in pregnancy was published in BJOG in 2013 by GB Piccoli, et al. They estimated a 7% risk of relevant complications in pregnancy as compared to 1% after delivery (postpartum). In 66% of cases, the biopsy led to therapeutic changes. Four cases of major bleeding occurred representing 2% of the complications and was the most common, severe complication. All four required blood transfusion and all occurred between 23-26 weeks, suggesting this may be a vulnerable period during gestation. Five further relevant hematomas occurred that did not require transfusion with a median gestational age of 25 weeks. There were no severe complications in the first trimester. The authors concluded that kidney biopsy in pregnancy is a morbid procedure associated with a high risk of severe complications that should be limited to women in whom a diagnosis is required for urgent therapy.

Question 41

. In which of the following situations is renal biopsy MOST indicated during pregnancy?
A. Proteinuria in the setting of poorly controlled diabetes
B. New onset renal disease in the setting of systemic lupus erythematosus (SLE)
C. Rapidly progressive glomerulonephritis with nephrotic range proteinuria in the setting of chronic hypertension
D. History of chronic kidney disease in the setting of family history of polycystic kidney disease
E. Proteinuria and concern for preeclampsia

Answer 41

C.
The decision to perform a renal biopsy during pregnancy is complex and involves the degree of renal disease, gestational age, and the differential diagnosis. A complete history and physical examination can usually provide insight into the underlying diagnosis and aid in treatment. However, when the diagnosis remains unclear, a biopsy may aid in management of the patient with sudden rapid deterioration of renal function. In this case with rapidly progressing glomerulonephritis and an unclear diagnosis, a renal biopsy would likely be beneficial. This patient is at high risk for preeclampsia due to a history of chronic hypertension. At times, the diagnosis of preeclampsia is very challenging, particularly due to imitators of preeclampsia. If preeclampsia is diagnosed, the treatment course may be drastically altered (i.e. consideration of delivery). While renal biopsy is not necessary to make the diagnosis of preeclampsia (and is associated with significant risks), it may be useful in the patient with rapidly progressive glomerulonephritis of uncertain etiology. Glomerular endotheliosis is the pathognomonic histologic finding in the setting of preeclampsia.

Question 42

You are consulted on a 37 yo G1P0 with an acute left leg DVT at 25 weeks gestation. On reviewing her history, both her father and brother have had unprovoked VTE as well. After starting therapeutic anticoagulation, you begin ordering a thrombophilia evaluation. This evaluation includes all of the following:
A. Protein C
B. Prothrombin Gene Mutation
C. Antiphospholipid Antibodies
D. Factor V Leiden
E. None of the above

Answer 42

A.
Factor V Leiden is identified in 41% of VTE cases. Protein C, Protein S, and antithrombin III levels are affected by both pregnancy as well as acute DVT and do not accurately reflect the patient’s baseline levels. Based on her new DVT and strong family history, Protein C, Protein S, and antithrombin III should be tested if other test results are negative once the patient has completed anticoagulation. MTHFR is no longer included in the thrombophilia workup.

Question 43

Factor XI changes in pregnancy

A. It is part of the intrinsic pathway, not the extrinsic pathway.
B. Levels are stable to decreased during pregnancy
C. It primarily functions to inhibit plasminogen activator inhibitor 1.
D. It is activated by tissue factor and serves as the primary activator of the extrinsic pathway.
E. A and B

Answer 43

E.
Factor XI is the second step after activation of Factor XII to XIIa in the intrinsic pathway. It does not interact with tissue factor or plasminogen activator inhibitor 1. While many other factors are increased in pregnancy, Factor XI levels remain stable to decreased.

Question 44

Which of the following statements is NOT correct?
A. Bilirubin is formed from the breakdown of heme.
B. Bilirubin toxicity (i.e Kernicterus) results for high levels of water insoluble unconjugated bilirubin.
C. In cholestasis of pregnancy, the excretion of conjugated bilirubin is impaired.
D. Inhibition or deficiency of the hepatic enzyme UGT1A1 occurs in breastmilk jaundice, Gilbert syndrome, and Crigler-Najjar syndromes.
E. Urobilinogens cannot be excreted in feces.

Answer 44

E.
Water-insoluble unconjugated bilirubin is associated with the toxic effects of bilirubin. Physiologic mechanisms that protect against bilirubin toxicity include bilirubin binding to plasma albumin and bilirubin uptake, conjugation, and clearance by the liver.

Question 45

What is the effect of epidural anesthesia on labor?
A. None
B. Prolonged the first stage
C. Prolongs the second stage by 13 minutes (not clinically significant)
D. Prolongs the second stage by 73 minutes (clinically significant)
E. Increased risk of cesarean delivery

Answer 45

C.
A meta-analysis of RCTs comparing epidural with no epidural analgesia found that epidural analgesia prolongs the second stage of labor by a mean difference of 13.66 minutes without negative effects to the fetus or neonate. This difference is not clinically significant, and patients can be reassured that an epidural does not increase their risk of cesarean delivery or reduce their likelihood of successful vaginal delivery. While the rate of cesarean delivery is not increased, there is an increased risk of operative vaginal delivery when using an epidural compared with no epidural.

Question 46

Which of the following is the BEST statement regarding the use of renal biopsy during pregnancy?
A. Complication rates are low (<5%) and rarely serious.
B. High-resolution MRI has been shown to be superior to biopsy in determining the etiology of acute renal injury.
C. It can help differentiate renal injury from preeclampsia and other etiologies.
D. It is useful in late preterm pregnancies to determine if delivery is prudent.
E. It has a high rate of complication in pregnancy (>25%) and should be used with extreme caution.

Answer 46

C.
The hemodynamic, inflammatory, and immunologic shifts in pregnancy may unmask underlying kidney disease. Acute as opposed to a chronic kidney injury can be difficult to diagnose during pregnancy. This difficulty may be particularly true for glomerular disease. Kidney biopsy should be considered in women at less than 32 weeks of gestation when delivery is not a viable alternative and treatment may prolong a desired pregnancy. A systematic review of 39 studies provided data for 243 biopsies performed during pregnancy (Piccoli G, et al. Kidney biopsy in pregnancy: evidence for counselling? A systematic narrative review. BJOG 2013;120:412-427). The main indication for biopsy was to differentiate between glomerulonephritis and preeclampsia, and the results led to changes in therapy in 66% of cases. Reports of potential complications of kidney biopsies during pregnancy vary from mild to severe, depending on the pregnancy stage, and appear to be significantly higher later in pregnancy, with a peak at 25 weeks of gestation (ie, major bleeding requiring transfusion, embolization, severe obstetric complications, early preterm delivery, and in one case, presumably related fetal death). Careful consideration of the clinical scenario and counseling of the patient is necessary before proceeding with a kidney biopsy. If a woman presents with decreased kidney function in the late preterm period (34 weeks), the provider should consider whether it might be prudent to wait to biopsy after delivery. Biopsy may still be indicated in certain scenarios, but fetal outcomes are generally good after 34 weeks (Answer D is incorrect); careful discussion of risks and benefits with the patient, obstetrician, and neonatologist is needed before proceeding. Relevant complications were observed in 7% of women during pregnancy and 1% after delivery; therefore, Answers A and E are incorrect. Kidney biopsy performed for the diagnosis of glomerulonephritis or preeclampsia led to therapeutic changes in 66% of cases.

Question 47

A 19 yo G1P0 at 26 weeks of gestation presents to Labor and Delivery complaining of pruritis surrounding the umbilicus and a new rash. You notice erythematous plaques, annular or urticarial in appperance, and several vesicles surrounding the umbilicus and on her extremities. You are concerned the patient may have pemphigoid gestationis. What is the best way to diagnose phemphigoid gestationis?
A. Skin biopsy with positive direct immunofluorescence
B. Skin biopsy with negative direct immunofluorescence
C. No biopsy is needed; purely clinical diagnosis
D. Culture of fluid in vesicles
E. Potassium hydroxide preparation

Answer 47

A.
In addition to clinical presentation, diagnosis is usually confirmed by skin biopsy using histology and direct immunofluorescence (DIF). If the DIF is nondiagnostic, indirect immunofluorescence (IIF), ELISA, and immunoblotting can be performed. In PUPPS, the diagnosis may be made by clinical examination. In rare cases in which the diagnosis is unclear, skin biopsy and negative serum collagen XVII antibodies can help differentiate PG from PUPPS. The pruritis and rash usually respond to oral antihistamines and skin emollients. Culture of the fluid may be beneficial in the setting of herpesvirus or bacterial skin infection. The potassium hydroxide solution test may be beneficial in evaluating fungal infections.

Question 48

A 19 yo G1P0 at 26 weeks of gestation presents to Labor and Delivery complaining of pruritis surrounding the umbilicus and a new rash. You notice erythematous plaques, annular or urticarial in appperance, and several vesicles surrounding the umbilicus and on her extremities. You are concerned the patient may have pemphigoid gestationis. What is the best way to diagnose phemphigoid gestationis?
A. Skin biopsy with positive direct immunofluorescence
B. Skin biopsy with negative direct immunofluorescence
C. No biopsy is needed; purely clinical diagnosis
D. Culture of fluid in vesicles
E. Potassium hydroxide preparation

Answer 48

A.
In addition to clinical presentation, diagnosis is usually confirmed by skin biopsy using histology and direct immunofluorescence (DIF). If the DIF is nondiagnostic, indirect immunofluorescence (IIF), ELISA, and immunoblotting can be performed. In PUPPS, the diagnosis may be made by clinical examination. In rare cases in which the diagnosis is unclear, skin biopsy and negative serum collagen XVII antibodies can help differentiate PG from PUPPS. The pruritis and rash usually respond to oral antihistamines and skin emollients. Culture of the fluid may be beneficial in the setting of herpesvirus or bacterial skin infection. The potassium hydroxide solution test may be beneficial in evaluating fungal infections.

Question 49

A 45 yo G1P0 at 24 weeks of gestation presents to your office complaining of a new-onset pruritic rash that began near the umbilicus, along abdominal striae, with 2-3 cm urticarial plaques. You are concerned that this may be pruritic urticarial papules and plaques of pregnancy. Which of the following is a risk factor for this condition?

A. Multifetal gestation
B. Fetal growth restriction
C. Multiparous women
D. History of rheumatologic disorders
E. Prior eczema

Answer 49

A.
PUPPs is one of the most common skin disorders related to pregnancy. It usually appears in the third trimester of pregnancy; however, it also can occur after delivery. It is more common in primiparous women. The most common risk factor relates to abdominal distension, which can occur in multifetal gestation, polyhydramnios, or fetal macrosomia. In twin pregnancies, the occurrence has been estimated to be from 2.9 to 16% and even higher in triplets.

Question 50

. A 32 yo G1P0 presents with bilateral low extremity +3 pitting edema. Her 24-hr protein is 4 grams (nephrotic range proteinuria). You suspect preeclampsia but her blood pressure readings have been normal throughout her pregnancy, Which of the following is the most appropriate intervention?

A. ACE inhibitor
B. Insulin
C. Deep vein thrombosis prophylaxis
D. Antihypertensive agent

Answer 50

Women with more than 3 g (3000 mg) protein in a 24-hour urine collection are considered to have nephrotic-range proteinuria, and glomerular disease should be suspected. The most common etiology, especially in the third trimester, is preeclampsia. Differential should also include focal segmental glomerulosclerosis (FSGS), membranous and membranoproliferative glomerulopathy, minimal change glomerulopathy, and lupus or diabetic nephropathy, among others. FSGS accounts for up to 35% to 50% of unexplained nephrotic syndrome, and it is identified in one-third of pregnancy-related renal biopsies. In this case, the patient’s blood pressure is normal; hence, choice D is not correct. Choice A is contraindicated in pregnancy. In nephrotic syndrome, the risk for venous thromboembolism is increased due to a hypercoagulable state precipitated by urinary losses of antithrombin III (AT-III), reduced levels of proteins C and S, hyperfibrinogenemia, and enhanced platelet aggregation. Therefore, prophylactic anticoagulation should be considered for pregnant women affected by nephrotic syndrome.

Question 51

Your patient presents at 9 weeks of gestation with RLQ pain and fever and you are concerned about the possibility of appendicitis. You are considering ordering magnetic resonance imaging (MRI). Which of the following is true regarding the use of MRI as a diagnostic tool in this setting?

A. MRI should be avoided due to fetal harm.
B. An MRI may be able to visualize the appendix if an ultrasound exam is unable to.
C. MRI is inferior to other imaging modalities for appendicitis.
D. MRI should be avoided due to its high radiation dose.
E. Gadolinium has been shown to have no ill effects on the fetus and can greatly enhance the diagnostic capabilities of MRI.

Answer 51

B.
The principal advantage of MRI over ultrasonography and computed tomography is the ability to image deep soft tissue structures in a manner that is not operator dependent and does not use ionizing radiation. There are no precautions or contraindications specific to the pregnant woman. Magnetic resonance imaging is similar to ultrasonography in the diagnosis of appendicitis, but when MRI is readily available, it is preferred because of its lower rates of nonvisualization. Although there are theoretical concerns for the fetus, including teratogenesis, tissue heating, and acoustic damage, there exists no evidence of actual harm. With regard to teratogenesis, there are no published human studies documenting harm, and the preponderance of animal studies do not demonstrate risk. Tissue heating is proportional to the tissue’s proximity to the scanner and, therefore, is negligible near the uterus. Finally, available studies in humans have documented no acoustic injuries to fetuses during prenatal MRI. In considering available data and the risk of teratogenicity, the American College of Radiology concludes that no special consideration is recommended for the first (versus any other) trimester in pregnancy. Unlike CT, MRI adequately images most soft tissue structures without the use of contrast. Gadolinium use should be limited to situations in which the benefits clearly outweigh the possible risks.

Question 52

Which of the following management strategies has the least evidence for routine practice in obese gravidas?
A. Nutritional consult
B. Exercise
C. Closure of the subcutaneous layer if >2cm (if cesarean delivery)
D. Vertical skin incision for cesarean delivery

Answer 52

D.
Available evidence concerning which skin incision is best for obese pregnant women remains uncertain.
The following are recommended for obese pregnant women:
1. Calculate BMI on all women
2. Offer nutritional counseling to obese women (healthy starches, fiber, ≥5 servings of fruit and vegetables, low fat. Limit fried and sugary foods (fast foods))
3. Recommend an exercise program
4. If cesarean delivery use pneumatic compression devices or SCDs
5. Consider a higher dose of peri-op antibiotics
6. Use suture to close subcutaneous fat (if >or equal to 2cm in depth
7. Obtain anesthesia consult early in labor
8. Encourage patient to see a weight reduction specialist before her next pregnancy

Question 53

What is the recommended caloric intake in normal weight pregnant women with gestational diabetes?
A. 40 kcal/kg
B. 25 kcal/kg
C. 30 kcal/kg
D. 35 kcal/kg

Answer 53

C.
The recommended diet in pregnant women with diabetes should include a plan of 3 meals with 3 snacks per day. The diet should include 30 kcal/kg for normal-weight women, 25 kcal/kg for >120% desirable body weight, and 35 kcal/kg for <90% desirable body weight. In general, 2000-2400 kcalories daily is recommended.

Question 54

What is the recommended carbohydrate diet composition for pregnant women with diabetes?
A. 40-50%
B. 25%
C. 15%
D. 35%

Answer 54

A.
The recommended diet in pregnant women with diabetes should include the following composition: Carbohydrate: 40-50%, complex high fiber; Protein: 20%; Fat: 30-40% (<10% saturated).

Question 55

. A 32-year-old G1P0 at 20 weeks of gestation presents to your office with vesicles and bullae densely clustered at the umbilicus extending to the trunk, buttocks and lower extremities. You diagnose her with pemphigoid gestationis (previously known as herpes gestationis). You counsel her that she is at increased risk for which of the following complications?

A. Fetal growth restriction
B. Preterm birth
C. Graves disease
D. Recurrence in postpartum period
E. All of the above

Answer 55

E.
In cases with early-onset and blistering, PG has an increased association with preterm birth and fetal growth restriction. One potential theory is that placental insufficiency stems from IgG and complement deposition along the basement membrane. There is an increased frequency of Graves’ disease found in association with PG. This may be explained by the presence of HLA-DR3 and DR4. Postpartum flares may occur in up to 50% to 75% of patients with pemphigoid gestationis. The highest timeframe for an exacerbation typically is 24-48 hours after delivery and can last for up to weeks or months. In the postpartum period, the skin lesions may persist for >1 year in women who are not breastfeeding, compared to 1-6 months in breastfeeding women.

Question 56

A 25 y/o G1P0 at 32 weeks is sent to you for evaluation due to polyhydramnios. Her 1-hour glucose challenge test was 85mg/dL at 27 weeks of gestation. She is without any obstetric complaint. An anatomic survey ultrasound at 20 weeks revealed normal anatomy, and polyhydramnios was identified after evaluation for size greater than dates at 32 weeks of gestation. On your evaluation, the fetus is normally grown (67th percentile) with an AFI of 27.4 cm. Anatomically, the fetus appears normal; in particular nose/lips are normal and a stomach bubble is present with normal-appearing bowel. You counsel her that the polyhydramnios is most likely idiopathic and review the risks, including which of the following complications?

A. Abruption
B. Preeclampsia
C. Preterm labor and delivery
D. fetal anomalies
E. Fetal growth restriction
F. PPH

A. All of the above
B. B, D and F
C. A, C, D, and F
D. A, C, and E
E. D, E, F

Answer 56

C.
There are little quality data regarding polyhydramnios, as most are observational in nature. However, abruption, preterm labor and delivery, fetal anomalies, and PPH are the most common complications identified in reviews.

Question 57

Which statement regarding meconium stained fluid and meconium aspiration syndrome is NOT correct?
A. Higher rates of meconium passage and meconium aspiration syndrome are seen in prolonged/post-term pregnancies
B. Reduction in post-term pregnancies leads to reduction in reported meconium aspiration syndrome
C. Meconium aspiration syndrome is a condition where a baby experiences respiratory distress (often tachypnea, cyanosis and/or reduced pulmonary compliance) secondary to the swallowing of meconium in utero or at the time of delivery
D. Amnioinfusion for meconium and nasopharyngeal and oro-pharyngeal suction of meconium at the perineum at the time of delivery has been shown to reduce reported meconium aspiration syndrome cases

Answer 57

D.
Post-term (prolonged) pregnancy is defined as a gestation that exceeds 42 weeks from the first day of the last menstrual period (LMP) and affects approximately 10% of singleton gestations. Given the known increased risk of perinatal morbidity and mortality, induction of labor at 42 weeks is currently standard to care. Meconium and meconium aspiration syndrome are known complications of post-term/prolonged gestations. Meconium passage in utero occurs more frequently with increasing gestational age. Meconium aspiration syndrome is used to describe the condition where a baby experiences respiratory distress (often tachypnea, cyanosis, and reduced pulmonary compliance) in response to the swallowing of meconium at the time of delivery. A Cochrane review of RCTs evaluating a policy of induction of labor showed that at 41 weeks gestation, labor induction reduced the risk of meconium aspiration syndrome (RR: 0.29; 95% CI 0.12 to 0.68; four trials,1325 women). There have been no data to support either amnioinfusion at the time of meconium-stained fluid diagnosis on labor and delivery or nasopharyngeal or oro-pharyngeal suction of meconium at the perineum as methods to statistically decrease rates of meconium aspiration syndrome.

Question 58

Which of the following is NOT associated with post term pregnancy?
A. Higher rates of stillbirth
B. Increased rates of neonatal death
C. Increased rates of necrotizing enterocolitis
D. Increased rates of infant death
E. Intraventricular hemorrhage

Answer 58

C.
Post-term pregnancy is defined as a gestation that exceeds 42 weeks from the first day of the last menstrual period (LMP) and affects approximately 10% of singleton gestations. Given the known increased risk of perinatal morbidity and mortality, induction of labor at 42 weeks is currently standard of care. Earlier reports that suggested no increase in stillbirth in prolonged pregnancy, but this was erroneous and based on studies performed with the denominator of all deliveries, as opposed to those undelivered pregnancies that are at risk of stillbirth (an infant that is born is no longer at risk for stillbirth). When using the appropriate denominator of undelivered pregnancies rather than all pregnancies, it is clear that post-term pregnancies carry an increased risk of stillbirth, neonatal death, and infant death. While necrotizing enterocolitis is the most common cause of gastrointestinal related morbidity and mortality in the neonatal intensive care unit, it is most common in preterm births, not post-term births.

Question 59

A patient is transferred to your care for possible placenta accreta at 24 weeks. She has a history of 3 prior cesareans, a placenta previa, and a posterior myomectomy. You perform an ultrasound, which is suspicious for placenta accreta. You are debating whether or not you should refer her for an MRI. Which statement regarding MRI in comparison to ultrasound for suspected placenta accreta spectrum is correct?

A. MRI is less expensive than ultrasound and more widely available
B. MRI is the perfered modality for diagnosis of placenta accreta spectrum
C. Magnetic resonance imaging may be useful for diagnosis of difficult cases, such as posterior placenta previa, surrounding organ involvement, and to assess depth of invasion in suspected percreta
D. MRI expertise is more available than ultrasound expertise
E. It is clear that MRI improves diagnosis of placenta accreta spectrum beyond that achieved with ultrasonography

Answer 59

C.
MRI is a useful diagnostic tool for the antepartum diagnosis of the placenta accreta spectrum. However, ultrasound remains the imaging modality of choice. The accuracy of MRI for the prediction of placenta accreta spectrum is good, with a systematic review reporting sensitivities of 75-100% and specificities of 65-100%. The overall sensitivity of MRI was 94.4% (95% CI, 86.0-97.9) and the specificity was 84.0% (95% CI, 76.0-89.8), which is similar to ultrasonography. However, these data are prone to selection bias because generally only patients with an indeterminate diagnosis on ultrasound examination or at very high risk of placenta accreta spectrum undergo MRI. It is unclear whether MRI improves diagnosis of placenta accreta spectrum beyond that achieved with ultrasonography; however, MRI may be useful for diagnosis of difficult cases, such as posterior placenta previa, and to assess depth of invasion in suspected percreta. However, proof of clear value is lacking, and there are several negatives of MRI that are worthy of discussion. MRI is more expensive than ultrasonography and is less widely available. The expertise required to interpret MRI studies is currently limited. In addition, a recent study of 78 women with suspected placenta accreta spectrum noted MRI confirmed an incorrect diagnosis or incorrectly changed a diagnosis based on ultrasonography in 38% of cases. Accordingly, MRI is not the preferred recommended modality for the initial evaluation of possible placenta accreta spectrum.

Question 60

Yesterday, you diagnosed ventriculomegaly with a fetal ultrasound and referred the patient for a fetal MRI. Today, you are seeing a patient with a different anomaly, and your resident asks you why you are not ordering a fetal MRI for this patient. Which of the following is NOT an appropriate indication for fetal MRI?

A. Brain and spine abnormalities
B. Preoperative evaluation for fetal intervention procedure
C. Monochorionic-diamniotic twin with demise of one twin
D. Bilateral pyelectasis
E. Congenital diaphragmatic hernia

Answer 60

D.
When evaluating whether or not to use fetal MRI, it is potentially important to think of the impact on the child after delivery. One advantage of fetal MRI is to enhance the diagnostic potential of ultrasound to detect additional abnormalities when certain anomalies are incompletely diagnosed (e.g. fetal lung mass, suspected brain anomaly). For example, MRI can provide an alternative or additional diagnosis in 38-50% of fetuses with an ultrasound diagnosis of a fetal lung mass. This information is often important for counseling, planning for delivery, and management decisions. An additional technical advantage of MRI includes the large field of view, no image degradation from the overlying fetal skeleton, minimal image degradation from maternal obesity or oligohydramnios, and superior soft-tissue contrast resolution. Initially, MRI was mainly applied to the central nervous system. However, the radiographic, genetic, and obstetric literature have reported the expanded utility of MRI for evaluating specific anomalies of the fetal face, eyes, skin, heart, lungs, gastrointestinal, and genitourinary systems. Nevertheless, fetal MRI has several downsides. It is associated with a higher cost than ultrasound and has limited availability. Fetal MRI is not helpful in the first trimester due to inherently low spatial resolution. In addition, with ultrasound, fetal behavior can also be analyzed, which is not the case with MRI. Use of 2D and 3D/4D scans demonstrates real‐time movement over longer periods of time than fetal MRI. For example, neurogenic arthrogryposis can be depicted by using 3D ultrasound to demonstrate typical morphologic features. Ultrasound also excels at imaging fetal skeletal anatomy, discerning limb anomalies, and diagnosing skeletal dysplasias. Both ultrasound and MRI have a role in the diagnosis of fetal malformations. What is not known is the additional information about the differences in diagnostic accuracy between fetal MRI and ultrasound. The added value of fetal MRI is improved family counseling, pregnancy management including termination of pregnancy counseling, surgical/postnatal planning, in some circumstances prognosticating regarding fetal brain findings, and reducing complications in the newborn period.