OB

Question 1

What medication improves success rate of ECV?

Answer 1

Terbutaline (given 15-30min prior)
-success rate of ECV from 60-75%. W/terb, doubles
-3-4% of infants are breech at term, offer at >37wks
-complications: abruption, fetomaternal hemorrhage, ROM, stillbirth (overall 0.24%)
-contra-I: previa, prior classical
-increased chance of success w/ multiparty, post placenta, unengaged fetus, higher AFI, relaxed uterus

Question 2

Most common cause of Listeria in pregnancy

Answer 2

Consumption of unpasteurized soft cheeses (ie queso fresco/Mexican-style cheese - Nachos)
-Hispanic women 24x more likely to develop Listeria in pregnancy
-Listeria in pregnancy-> PTD, neonatal sepsis, meningitis, IUFD
-if symptomatic +fever, IV amp+gent or TMP-SMX

Question 3

Recommended consumption of fish/shellfish in pregnancy

Answer 3

12oz (340g) 1x/week
-avoid mercury containing fish: Tilefish from the Gulf, shark, swordfish, marlin, orange rouge, bigeye tuna, king mackerel
*mercury->hydrocephaly, cleft palate, PTD

Question 4

Headache worse with sitting up/positional changes after a vaginal delivery is most likely 2/2 what?

Answer 4

dural puncture during epidural placement (1-3%)
-tx: analgesia, hydration, caffeine, supine positioning. If unrelieved, blood patch (1/3 of women)
-MC complications of epidural placement are hypotension, fever in nulliparous women (increased IL-6), transient fetal HR changes, pruritus
-serious complications occur less than 0.001% of cases (epidural hematoma, complete spinal block, abscess, meningitis, neurotoxicity)

Question 5

What is the next best test after newly diagnosed oligohydramnios at 28wks with a negative rule out rupture workup?

Answer 5

NST. To assess for fetal well-being and var decels
-Expectant management is reasonable in GA <36.0wks

Question 6

Marked vaginal bleeding and no palpable fundus on abdominal exam is noted during attempted delivery of the placenta, what should you do next?

Answer 6

-leave the placenta in situ and then relaxation (nitroglycerin, halogenated anesthetics, terbutaline, Mg sulfate) to replace the uterus (vaginally or abdominal - Huntington or Haultain procedures)
-1st degree: corpus extends into the uterine cavity; 2nd is protrusion through the cervical ring; 3rd is extension to the perineum; 4th fundus visible outside the Introits
-RF: fundal placenta, atony, XS traction on the cord, PAS

Question 7

Given dicloxacillin for mastitis 4 days ago now with persistent fever and 4cm fluctuant area noted on exam, next best step?

Answer 7

-I&D (abscess occurs in 5-10%)
-continue pumping/nursing
-MC: staph aureus, MRSA (TMP-SMX), strep, staph epidermis

Question 8

26yoF G3P1011 at 18wks with previous SVD at 24wks (advanced dilatation, PPROM), getting weekly progesterone shots with TVUS showing CL 1.5cm, funneling, and 1/50% on SVE. Neg ROM. Denies ctx, abnl vaginal dc, bleeding, or fever. What is her diagnosis.

Answer 8

Cervical insufficiency
-history indicated cerclage: >1 2nd TM spont losses 2/2 painless dilatation OR prior cerclage due to painless dilation in 2nd TM
-PE indicated: painless dilation in 2nd TM
-u/s indicated: prior SVD <34wks + CL<2.5cm before 24wks

Question 9

Amsel criteria for BV

Answer 9

3 of the 4
>= 20% clue cells
gray discharge
+whiff
>4.5 pH

Question 10

30yoF presents in labor with 4 prior CS and limited PNC, densely adherent placenta noted upon attempted removal. QBL 1500ml, bp 100/60, HR 120. NBS?

Answer 10

hysterectomy
-RF: previa, prior CS, prior uterine surgery
-w/increasing CS + previa: 3, 11, 40, 61, 67%
-w/increased CS - previa: 0.03, 0.2, 0.1, 0.8%)
-u/s findings: lacunae, loss of retroplacental hypoechogenic zones, myometrial thinning

Question 11

Next step during a shoulder dystocia after McRoberts, suprapubic, attempted posterior arm with episiotomy

Answer 11

anterior shoulder rotation, then Gaskin. Rescue: zavanelli, clavicle frx
-incidence 0.6-1.4%
-brachial plexus injury risk of 40%, but 90% resolve w/o permanent injury

Question 12

When is delivery indicated for PAS?

Answer 12

late preterm 34.0-35.6wks

Question 13

What fetal condition is associated with low PAPP-A levels?

Answer 13

FGR
low PAPP-A has a high PPV for SGA (<5%tile)

Question 14

Management of acute pain crisis in setting of sickle cell disease

Answer 14

-prompt treatment of precipitating factors: hypoxia, dehydration, infxn
-adequate pain control**
-transfuse if necessary (hct <21%)

*Hydroxyurea is contraI in pregnancy - congenital malformation, stillbirth

Question 15

Thickened nuchal fold can be associated MC with what?
If normal karyotype on CVS, what abnormality is MC seen on u/s?

Answer 15

> 3.0mm
-associated with aneuploidy (MC trisomy 21 and Turners)
-if normal karyotype. MC assoc with cardiac defect (4.5%) [ie septal defects]
*management includes diagnostic testing (ie CVS) and genetics referral, detailed anatomy 18-20wks, fetal ECHO 22wks

Question 16

MC cause of PPH is ___.
Other causes of PPH to rule out are:

Answer 16

-PPH occurs in 4-6% w/in 24H (80% 2/2 *atony)
-RF: rapid/augmented labor, h/o PPH, chorizo, over distended uterus
-other causes: laceration, hematoma, retained POC

Question 17

Best evaluation for DM in the postpartum period in a patient with h/o gDM.

Answer 17

75g glucose tolerance test (2H)
-7-fold risk of developing T2DM.
-RF: AMA, race, BMI>25, FHx
-DM complicates 6-8% of pregnancies (90% are gDM)
-Rec q3yr screening if pg complicated by gDM

Question 18

21yoF G1P0 at 8wks with muscle weakness in arms and legs, difficulty speaking, ptosis, and double vision. Edrophonium test and Ach-R Ab are positive. What medications can exacerbate symptoms?

Answer 18

magnesium sulfate, succinylcholine, quinidine, CCBs, beta blockers, aminoglycosides, fluoroquinolones, macrolides
-Tx: anti cholinesterase inhibitors (pyridostigmine), steroids, and immunosuppressants
-exacerbations can lead to resp failure
-affects 10-20% of neonates

Question 19

Lower levels of what complication of prematurity is reduced with transfer to a higher level of care NICU is achieved BEFORE delivery?

Answer 19

mortality, IVH, RDS, PDA, infxn
-higher complication rates with transfer after delivery

Question 20

What vaccines are recommended in HIV+ pregnant patients with adequate CD4 counts?

Answer 20

Tdap, Flu, Pneumonia, hep B (if unvaccinated previously)
-toxoid and inactivated viruses are safe
-contra-I: MMR, varicella, zoster, live influenza
-HPV not recommended

Question 21

28yoF G1P0 at 28wks with recent diagnosis of gDM. What is the next best step?

Answer 21

dietary/lifestyle modifications (2000 cal/day, increase protein/fiber, decrease carbs [limi to 33-40%])
-3 meals and 2 snacks

Question 22

Preferred medications to treat epilepsy in pregnancy (3). How should it be managed in pregnancy?

Answer 22

-lamotrigine, levetiracetam, oxcarbazepine. Check levels to ensure it remains therapeutic
-valproate- increased risk of NTD
-rec 1-4mg folic acid daily

Question 23

Prevalence of obesity in the US

Answer 23

32.2%

Question 24

Complications of obesity in pregnancy

Answer 24

increased risk of CS
preE
gDM
LGA->risk of birth injury, obesity/DM later in life

Question 25

What form of bariatric surgery is BOTH restrictive and malabsorptive?

Answer 25

-Restrictive and malabsorptive = Roux-en-Y (bypasses the duodenum)
->vit def: protein, iron, vit B12, vit D, folic acid, and calcium
-Restrictive bariatric surgical options: vertical banded gastroplasty, vertical sleep gastrectomy, adjustable gastric banding
-less assoc with vit deficiencies
-malabsorptive options: biliopancreatic diversion, biliopancreatic diversion with duodenal switch, jejunoileal bypass
-gastric artery embolization - not available in US. Only experimental

Question 26

What vitamin is recommended to be taken with iron to improve absorption after bariatric surgery?

Answer 26

Vitamin C

Question 27

Highest risk of what infection after a needlestick injury during surgery?

Answer 27

Hep C - 1.8%
Hep B (if unvaccinated) - 6-30% *pt in vignette was vaccinated in which case it is basically 0%)
HIV - 0.3%

Question 28

Rh negative mother at 14wks with a previously affected term neonate should have what done?

Answer 28

-fetal rhesus type by noninvasive prenatal testing
-maternal titer is not useful in setting of a previously affected neonate
-MCA dopplers should be measured between 18-34wks to eval for fetal anemia

Question 29

Define recurrent pregnancy loss

Answer 29

3 or more consecutive SABs before 19.6wks
-occurs in 1% of couples
-APS is found in 3-15% of these pts. Rec tx with heparin and LDA (can decrease risk by 50%)

Question 30

Diagnostic criteria for chorioamnionitis

Answer 30

-maternal T >100.4F + at least 2 of 4:
1. maternal OR fetal tachycardia
2. fundal tenderness
3. foul smelling amniotic fluid
4. maternal leukocytosis
-incidence 1-4% at term

Question 31

In setting of ICP, what has the most significant association with risk of IUFD?

Answer 31

-bile acid level (esp if >40 micromol/L)
-risk of recurrence is 40-60%. Incidence is 0.2-6%
-RF: multiple gestation, IVF, Hep C+, AMA
-assoc with PTD, NRFHT, mec, and IUFD
-delivery by 36-37wks

Question 32

What is the incidence of preE in triplet pregnancies? What is the recommendation to decrease risk?

Answer 32

-10%
-ASA (between 12-28wks) or selective reduction

Question 33

Indications for neonatal therapeutic hypothermia to decrease the risk of neonatal encephalopathy.

Answer 33

-Apgars of <5 at 5 and 10min
-fetal arterial pH <7 or base deficit of >12
-MRI c/w hypoxic-ischemic changes
-multisystem organ failure c/w with HIE
Done by maintaining 33-35C (91.4-95F) for 72H within 6H of birth

Question 34

Between what weeks are asthma exacerbations most common?

Answer 34

Between 24-36wks. Least common at term
-SABA -> low dose ICS -> +LABA/LTRA/theophylline -> med dose ICS+ LABA -> high dose ICS + LABA -> high dose ICS+LABA+systemic steroid

Question 35

What is an intrapartum maternal factor strongly associated with neonatal encephalopathy?

Answer 35

maternal fever

Question 36

What is the treatment for syphilis?

Answer 36

-if primary or secondary, then penG x1 IM. If latent, penG IM weekly x3 doses (if dose missed, course restarted). IV PCN if it’s neurosyphilis
-painless chancre -> secondary presents over the following 2-10wks (fever, myalgia, HA, palms/soles rash) -> tertiary with neuro/cardiac sx
-congenital infxn: hydrops, placentomegaly, FGR
-neonatal: hepatosplenomegaly, maculopapular rash, rhinorrhea, SGA