Ob

Question 1

What is the metabolic derailment of hyperemesis gravidum? Etiology? What must you rule out? Management?

Answer 1

Hyponatermic Hypokalemic Hypochloremic Metabolic Alkalosis. Due to increase Beta HCG. Must r/o Gestational Trophoblastic Disease. Rx: Fluids, Antiemetics.

Question 2

34 weeks gestation, Fever, malaise, puritic vesicles. When baby is born they have zigzag lesions, extremity hypoplasia, optic atrophy. Dx? Rx? Prevention? How to rx an infant from a mother with chronic Hep B?

Answer 2

1. Varicella infection. Treatment: Give immunoglobulin to infant. Vaccine to mother before pregnancy. 2. Vaccine (proper time to give vaccine + Immunoglobulin.

Question 3

21 yo 32 weeks gestation. Has swelling in her hands and feet, denies HA, epigastric pain, visual changes. Gained 10 lbs over 2 weeks. BP is 195/55. Urine dip shows 2+ protein. Dx? What is the criteria for this dz? Give 4 risk factors. Management for Close to Term? Far from Term? What should be given for seizure prophylaxis?

Answer 3

Mild Preeclampsia (New onset HTN 140/90 > 20 weeks gestation, Proteinuria (>300mg in 24hr period) and Edema. Risk Factors: 1. Chronic HTN 2. Family Hx 3. Renal dz (SLE and DM) 4. >35 yrs of age or Deliver, Induce with Oxytocin. 2. Far from term then Bed Rest and Expectant Management. Mag sulfate for seizure prophylaxis (This is continued 24 hrs postpartum.)

Question 4

32 yo 32 wks gestation. BP 160/105. Preeclampsia work up shows Elevated Bili, LDH, ALT and AST. Platelet count is 85,000. Dx? Management?

Answer 4

HELLP syndrome (Elevated Hemolysis, Liver Enzymes, Low Platelets.) Management: Stabilize (IVF, Labatelol, and/or Hydralazine) then Delivery induce with Oxy!!

Question 5

21 yo at 32 weeks had Tonic-Clinic seizure, Severe HA, lost control of Bowel and Bladder. Gained 10 lbs in 2 weeks. BP is 185/115. Protein is 4+. Dx? Management?

Answer 5

Eclampsia. Management: Stablize (IVF and Labetelol and/or Hydralazine) then Delivery, induce with Oxy!!!

Question 6

1. What does the Biophysical profile consist of? 2. A biophysical profile of 8 and 10 and 0 and 2 which one is reassuring?

Answer 6

1. Test the Baby MAN. (Fetal Tones, Breathing, Movement, AFI, NST) 8, 10 is reassuring and you can repeat as needed. 4,6 scores are concerning and would want to do a Contraction Stress Test. If CST shows > 50% decelerations then the management is Prompt Delivery.

Question 7

31 weeks gestation, Flank pain, Fever, CVA tenderness Dx? Management?

Answer 7

Pyelonephritis do a UA and Culture. Rx: IV fluids and IV Abx. These pts are Septic looking, negative lipstick sign (pale lips).

Question 8

Why are infants at risk for developing thyrotoxicosis form a mom who has graves dz?

Answer 8

The thyroid stimulating immunoglobin crosses the placenta despite the mother having Surgery and being placed on Levothyroixine.

Question 9

How much does the cardiac output increase by in a pregnant patient and why?

Answer 9

It increases by 33%. HR and SV both go up in pregnancy. The SVR goes down lowering the BP.

Question 10

What causes 1. Early decelerations? 2. Variable decelerations? 3. Late decelerations?

Answer 10

1. Head compression (nadir occurs with the contraction they are synchronized). Cord compression if severe it can be troublesome (sudden drop and sudden return no interaction btw acceleration and contractions) . Placental insufficiency (always troublesome) nadir occurs after the contractions. (VEAL CHOP)

Question 11

21 yo 32 weeks gestation has severe occipital HA, visual changes, mid epigastric pain, light flashes. BP 165/115. She has 3+ edema of hands and feet has gained 10 lbs in 2 weeks. Urine dip shows 4+ protein. Dx ? What is the criteria? Management?

Answer 11

Severe Preeclampsia (end organ effects, BP 160/110 2. 500 mg protein in 24 hrs, 4+ Urine dipstick) Management: Stabilize (Labetolol and/or Hydralazine) then Delivery, induce with Oxy.

Question 12

Pt presents Fever, Tender cervix after Delivery? Management?

Answer 12

Chorioamnionitis. Cervix gram stain + culture. Empiric Abx (amp + gent).

Question 13

1. Passage of tissue through cervix, cervix is closed and US shows empty uterus? 2. Passage of some fetal tissue and some remains, cervix open? 3. Any hemorrhage before 20 weeks with live fetus and no passage of tissue, cervix closed? 4. No passage of tissue and cercix is open? 5. No passage of tissue and cervix is closed and no fetal cardiac motion. 6 How to manage these abortions?

Answer 13

1. Complete AB 2. Incomplete AB 3. Threatened AB 4. Inevitable AB 5. Missed AB 6. Treat all abortions IVF, Rhogam, D&C (if abortus still there.)

Question 14

Positive Beta HCG, Adnexal mass and Empty uterus. Dx? Test? Management if 1. Not ruptured and < 3 cm? 2. Ruptured and Stable? 3. Ruptured and Unstable pt?

Answer 14

Ectopic pregnancy (Caused by previous ectopics, IUD and PID). Beta HCG (1000-1500) and absent of fetus on US. Check Beta HCG in 48 to check for LACK of DOUBLING. 1. Methotrexate or Surgery (Salpingostomy- Mainstay of Treatment) 2. Surgery (Salpingectomy) 3. IV fluids, Blood products then Salpingectomy.

Question 15

How to manage Variable Decelerations (Cord Compression)?

Answer 15

1. Give 02, Change in Maternal position, Amnioeffusion 2. C/s if conservative measures dont work.

Question 16

20 yo G1P0 at 35 weeks gestation experiences regular uterine contractions. Has Fever and High Leukocyte count. Maternal and fetal Tachy. Foul Smelling Vaginal Fluid. There is passage of clear fluid per vagina. The cervix is closed and fluid is pooling from it. Dx? Cause? Best initial test? Most accurate test? Management: > 34 weeks? 32-34 weeks?

Answer 16

Preterm Premature Rupture of Membranes PPROM ( rupture of amniotic membranes BEFORE the onset of labor (Contractions +Dilation) BEFORE 37 wks gestation.) 2/2 Chorioamnionitis. Test: Nitrazine and Fernig test positive. US to Confirm. Management: 1. DELIVER (Oxytocin and PGE2) 2. Steroids induce lung maturity gram stain + culture give amp + gent and bed rest 3. Expectant management with bed rest, gram stain, culture amp + gent.

Question 17

What gestational age should Betamethasone should be given with tocolytics.

Answer 17

24-34 weeks gestation if labor has to be induced.

Question 18

32 yo at 38 weeks has regular/ painful uterine contractions. Previous pregnancy she had a c/s. Cervix is 60% effaced and 6cm dilated. There are variable decelerations. She suddenly develops intense lower abd pain and has vaginal bleeding the fetus went from station 0 to -2 . Dx? Cause? Management? And why? Difference from placental abruption.

Answer 18

Uterine Rupture from a uterine scar from her prior c/s. Management: Emergency C/S because the Mother can Bleed Out leading to Maternal and Fetal death. (Remember With placental abruption the fetal station will not change!!!!!)

Question 19

Previous Gyn surgery such as LEEP or cone biopsy, prior obstetrical trauma, multiple gestational, mullerian anomalies, hx of preterm labor or 2nd trimester pregnancy loss. These are risk factors for what? What confirms this? Rx?

Answer 19

Cervical insufficiency. Transvaingal US can examine funneling and shortening of the cervical length (

Question 20

29 yo G3P2 at 35 weeks gestation complains of PAINLESS BRIGHT RED Vaginal bleeding. 4 yrs ago had Low Transverse Vaginal C/S for 2nd pregnancy. Dx? Cause? Management: Unstable? Preterm and Stable? Full Term (At least 37 weeks) and Stable?

Answer 20

Placenta Previa. (Insertion of the placenta in a way that obstructs the internal cervical os partially, completely or marginally.) Multiparity, Multiple Gestations and Previous C/S can cause this. 1. Unstable? - Emergent C/S. 2. Preterm and stable? - (Expectant management) observe in hospital then send home. 3. Full term (at least 37 weeks) and stable? Elective- c/s

Question 21

PLAINLESS VAGINAL BLEEDING uterine bleeding with rapid DETERIORATION of the FETAL HEART TRACINGS. Dx? Management?

Answer 21

Vasa Previa. When fetal vessels transverse the internal cervical os. Bleedings is from the fetal vessels so you will see the fetus deteriorate only (Bradycardia). Management: Emergent C/S.

Question 21

Pregnant lady in labor with Clear Vesicles and Adenpathy. Dx? Management?

Answer 21

HSV eruption. Need c/s.

Question 23

25 yo 28 weeks gestation presents with strong, regular, uterine contractions that started 4 hrs ago. She Has not had any prenatal care. Cervix is 4cm and 80% effaced. AFI is 4cm***** there is Renal Agenesis seen on US. Dx? Management?

Answer 23

Allow for spontaneous vaginal delivery. This is incompatible with life.
This fetus has congenital anomaly associated with pulmonary hypoplasia.

Question 24

Explain the physiology of thyroid function in pregnancy. TBG, TSH, T4 levels.

Answer 24

In pregnancy the increase in Estrogen leads to increase in TBG. There is also cross reactivity with HCG binding to TSH receptors. TBG binds to T4 causing total T4 and T3 to rise where as free T3 and T4 remain normal.

Question 25

After having an abortion 3 days ago pt presents with fever, chills and abdominal pain. On physical exam pt has uterine tenderness, mild righty and guarding. There is purulent vaginal discharge on pelvic exam. Dx? Management?

Answer 25

Septic abortion due to Retained Products of Conception (possible missed, incomplete or elective AB.) 1. Draw Blood and Urine Cultures, Give IV Abx, D & C.

Question 26

After abnormal levels of MSAFP, Estriol, HCG -triple screen. Or inhibin A - quadruple screen. Correct gestational age confirmed on US and ruled out for multiple gestations and non viable pregnancy. Next step in management?

Answer 26

Amniocentesis at 15 weeks for genetic testing of the child (Chromosomes, trisomy 21 or 18) Edward everything down. Down syndrome: Inhibin A and Beta HCG up.

Question 27

What is the difference btw symmetric and asymmetric fetal growth restriction. What is the abdominal circumference used for?

Answer 27

Symmetric occurs when there is an insult < 28 weeks. The head and the abdomen are abnormal. Asymmetric is when a insult occurs >28 weeks and the head is normal and the Abdomen is Reduced in Size. Fetal growth restriction is when the fundal height is less than 3cm than the actual gestational age. This is confirmed by US. The abdominal circumference tells us fetal weight.

Question 28

African American multiparous women presents with Hirsutism and Virilization. Pt has bilateral solid masses around the pelvis. Dx? Management? How to rule out ddx?

Answer 28

Luteoma of pregnancy. This is benign do reassurance follow up with US. If no mass present due abdominal CT. If BILATERAL and Cystic then Lutein Cyst is the diagnosis. If unilateral then we think malignancy - do laparatomy or laparoscopy for biopsy.

Question 29

Chilean lady in 3rd trimester of pregnancy develops puritis, jaundice and excoriations on skin. Pt has elevated T and D Bili, AST, ALT, GGTP, Alk Phos. Dx? Management?

Answer 29

Intrahepatic cholestasis of pregnancy. Urodeoxycholic Acid + Delivery to protect fetal lungs.

Question 29

Pregnant pt suffering from kidney stones that is refractory to medical treatment. Next step?

Answer 29

Place a J-Stent

Question 30

When is CVS sampling done? Complication?

Answer 30

at 10 weeks only for those at risk pregnancies and LIMB DEFECT.

Question 31

What is the test of choice for suspected appendicitis in a pregnant patient? Rx?

Answer 31

Graded compression US. (Remember Kim Kardashian episode) Then Laproscopy.

Question 32

1. What is considered polyhydramnios? 2. What is considered Oligohydramnios? 3. When is c/s indicated in a macrosomic baby?

Answer 32

1. AFI > 20 on US 2. AFI < 5 3. >5000 g for anyone and >4500 g for DM.

Question 33

Name 6 complications of preterm babies.

Answer 33

1. RDS 2. Interventricular Hemorrhage 3. Necrotizing Enterocolitis 4. PDA 5. Retinopathy of Prematurity. 6. Bronhopulmonary dysplasia.

Question 34

What is a non reactive stress test?

Answer 34

< 2 accelerations in 20 min. A normal would be 2 accelerations 15 bpm above baseline lasting for 15 seconds in 10 minutes.

Question 35

Pregnant Pt presents with Back pain, Abdominal pain and Hectic/Spiking Fevers 105.8. Dx? Test? Rx?

Answer 35

Septic pelvic thrombophlebitis. (Pelvic infection leading to infection of the vein and intimal damage causing thrombogenesis and septic embolization.) 1.CBC, Blood Cultures, CT scan to check for pelvic abscess, IV Broad spectrum Abx and Anticoaguatlion.

Question 37

20-37 weeks, >3 Uterine contraction in 30min. >2 cm dilated. Dx? Management? Prevention?

Answer 37

Preterm labor due to (Previous preterm, Smoking, Ascending Infection, Multiple Gestations, Genetic Anomalies. 1. Confirm 2. Make sure there are no contraindications to labor 3. Mag IV for neuroprotection 4. Tocolysis with Terbertuline, Nifedipine or Indomethacin for 48 hrs to allow Bethamethosone to work. Prevention: Cervical Cerclage if that is the issue. 17 alpha-OH Progesterone for patients with a previous history of PTB

Question 38

32 yo hx of multigravida 31 weeks gestation is admitted to the birthing due to painful uterine contractions and vaginal bleeding. Pregancy complicated by pre-eclampsia. Mother and fetus are stable. Dx? Management?

Answer 38

Placental Abruption caused by HTN. Stablize and perform vaginal delievery. Do c/s if there are obstetrics indications or mother and fetus unstable.

Question 39

1. What lab blood test should be screened at first visit? 2. What viral test? 3. What bacterial test?

Answer 39

1. UA, Urine culture, Hgb, Hct, Blood type, Rh type, Thyroid function, Diabetes in high risk individuals. 2. Rubella, Varicella, HIV, Hep B. 3. Group B, Spyhillis, G and C. G and C specifically for high risk groups.

Question 40

Contractions occur every 3min and last 50secs with 50 mmgh pressure. Fetus is LOA. Management of a pt with Prominent Ischial Spines and arrest of decent and dilation.

Answer 40

Low transverse C/S. This is cephalopelvic disproportion.

Question 41

At what weeks should the OGTT be done? Management of screening and confirming Diabetes in pregnant pts.

Answer 41

At 28 weeks Screen with 1 Hr 50g-OGTT if > 140 mg/dl then confirm with 3 Hr. For 3 Hr: Normal should be FBS < 95 mg/dl, After 1 Hr < 180 mg/dl 2 Hr < 155 mg/dl 3hr <140 mg/dl. 2 Abnormal values confirms DM.

Question 42

4 hrs after undergoing C/S followed by tubal ligation pt develops dizziness and confusion. C/s was complicated by 800 ccs of blood loss. Pt became hypotensive and tachycardic. Abdomen is distended and tender with no bowel sounds present. Pt is disoriented to person, place and time. Dx?

Answer 42

Post-operative intrabdominal hemorrahge.

Question 43

Management of Posterm Pregnancy (>42 weeks gestation)?

Answer 43

Make sure dates are correct and make sure cervix is favorable. 1. Correct dates and favorable cervix (Bishop socre >5) -> Deliver give to induce Oxytocin. 2. Correct dates and cervix not favorable -> PGE2(ripens cervix) then deliver 3. Dates unsure and cervix not favorable then conservative management.

Question 44

Give the time frame for each stage of labor in Nullgravida and Multigravida pt: 1. First stage a. Latent Phase b. Active Phase 3. Second Stage 4. Third Stage.

Answer 44

1. <14 Hrs a. Variable b. 1cm dilation/hr, 1.2 cm dilation/hr 3. 30min-5hrs, 5min-30 min 4. 0-30min, 0-30min

Question 45

What laboratory values of the fetus tells us that emergent c/s needs to be done?

Answer 45

1. Scalp pH < 7.1 2. Fetal 02 status deteriorating.

Question 46

1. First step in management to assess 3rd trimester bleeding? 2. What is the management of 3rd trimester bleeding?

Answer 46

1. US need to r/o vasa previa before performing any manuevers. 2. IVF, 02, Rhogam if not sensitized. Then order CBC, Coagug studies, Urine tox screen (check for cocaine) and do US.

Question 47

What are the contraindications to Tocolytics?

Answer 47

1. Preeclampsia 2. Severe Hemorrhage 3. Chorioamnionitis 4. IUGR 5. Fetal Demise

Question 48

Management of Uterine Atony?

Answer 48

1. Bimanual compression and massage with Oxy infusion running. 2. Ergonovine (Contraindicated in maternal HTN) or Misoprostol if that doesnt work 3. Hysterectomy when all else fails.

Question 49

Management of Uterine Inversion?

Answer 49

Cause is iatrogenic. Push it back.

Question 50

What is the management when a pt who develops Endometritis does not improve on abx?

Answer 50

1. After doing Gram stain + cultures and givin broad spectrum abxs Then do CT scan to assess for Pelvic abscess or Pelvic Thrombophlebitis. Give Heparin if Thrombophlebitis is present.

Question 51

Management of Acute fatty liver pregnancy? What is the complication of this condition?

Answer 51

1. IVF, Glucose and FFP to correct the coagulopathies. Delivery is the only curative treatment. More serious then Intrahepatic Cholestasis of pregnancy.

Question 52

BP sustained 140/90 throughout pregnancy without proteinuria then subsides after delievery. Dx?

Answer 52

Gestational HTN. R/o preeclampsia by checking urine protein then give labetolol.