OB

Question 1

What tocolytic drugs are contraindicated for in diabetic pregnant patients in preterm labor?

Answer 1

Terbutaline and Ritodrine

Question 2

When is magnesium sulfate contraindicated for preterm labor?

Answer 2

Patients with myasthenia gravis

Question 3

When is indomethacin contraindicated as a tocolytic?

Answer 3

at 33 weeks due to premature ductus arteriousus closure.

Question 4

What is the mechanism of Magnesium sulfate as a tocolytic?

Answer 4

Competes with calcium for entry into cells.

Question 5

What is the mechanism of action of beta-adrenergic agents (such as terbutaline) as tocolytic agents?

Answer 5

increase cAMP thus decreasing free calcium.

Question 6

What is the mechanism of action of indomethacin as a tocolytic agent?

Answer 6

decrease prostaglandin production by blocking conversion of free arachidonic acid to PG

Question 7

What is a clinical sign of magnesium sulfate toxicity? What are normal levels of magnesium sulfate?

Answer 7

areflexia
Respiratory depression
Cardiac depression

should be between 4-7 mEq/L. Areflexia at 7-10 mEq/L, Cardiac arrest/respiratory depression at 15 mEq/L.

Question 8

When do you use betamethasone?

Answer 8

from 24-34 weeks gestation to increase pulmonary maturity and reduce incidence/severity of RDS (respiratory distress syndrome).
- can also be used for decreasing intracerebral hemorrhage and necrotizing enterocolitis.

Question 9

What four screening tests should be done for Jews of ashkenazi descent?

Answer 9

Fanconi anemia, Tay-sachs disease, Cystic Fibrosis and Niemann-Pick disease.

Question 10

Who is at high risk of beta thalassemia?

Answer 10

Mediterranean

Question 11

Valproic acid, for epilepsy, as a higher risk for what type of fetal anatomical defect?

Answer 11

Neural tube defect, hydrocephalus, craniofacial malformations.

Question 12

Women with poorly controlled diabetes immediately prior to conception or early during pregnancy had a higher risk of what type of anomaly?

Answer 12

structural anomaly - majority of lesions involve CNS (neural tube defect) and cardiovascular system. GI and limb defects have been reported.

Question 13

When is chorionic villus sampling done? What is involved, and what is seen?

Answer 13

10-12 weeks gestation. Sample chrorionic frondosum which contains the most mitotically active villi in the placenta. This is done to analyze fetal chromosomal abnormalities, biochemical, or DNA-based studies (cystic fibrosis). does not detect neural tube defects. Omphaloceles and neural tube defects are diagnosed with ultrasound.

Question 14

What is the risk of fetal loss associated with Chorionic villus sampling?

Answer 14

always 1%

Question 15

What is the most common form of inherited mental retardation?

Answer 15

Fragile X syndrome. Down syndrome is genetic but the majority of cases are not inherited.

Question 16

What are the risk factors for pre-eclampsia?

Answer 16

increases with parity, race/ethnicity, previous history of pre-e, chronic hypertension, multifetal pregnancy, molar pregnancy, extremes of ages, diabetes, renal disease, antiphospholipid antibody syndrome, vascular/connective tissue disease, triploidy

Question 17

What complications is a patient with Type I diabetes at risk for?

Answer 17

increase rate of spontaneous abortions, major congenital malformations (cardiovascular, neural tube defects, caudal regression syndrome), fetal growth restriction (although fetal macrosomia can occur), polyhydramnios, preterm birth, hypertensive conditions.

Question 18

what treatment is best for HIV-infected pregnant woman?

Answer 18

treatment with IV zidovudine at time of delivery decreases transmission rate from 25%-2%.

• c-section prior to labor can reduce ratio to 2%.

Question 19

Asthma can worsen in 40% of pregnant patients. How do you manage?

Answer 19

If they have increased their use of beta agonists for more than 2x/week: use inhaled corticosteroids or cromolyn sodium. Then Theophylline. Then sub cut terbutaline and systemic corticosteroids for acute cases.

Question 20

When do you screen for glucose intolerance for pregnant ladies?

Answer 20

between 24-28 weeks.
Step 1: 50g oral glucose challenge
step 2: 100g oral glucose tolerance test

Question 21

What are the complications of maternal obesity?

Answer 21

chronic hypertension, gestational diabetes, pre-e, fetal macrosomia, higher rates of c-section and postpartum complications.

Question 22

What are the classical morphologic evidence of iron-deficiency?

Answer 22

erythrocyte hypochromia and microcytosis.

Question 23

An 18-year-old G1P0 woman is seen in the clinic for a routine prenatal visit at 28 weeks gestation. Her prenatal course has been unremarkable. She has not been taking prenatal vitamins. Her pre-pregnancy weight was 120 pounds. Initial hemoglobin at the first visit at eight weeks gestation was 12.3 g/dL. Current weight is 138 pounds. After performing a screening complete blood count (CBC), the results are notable for a white blood count 9,700/mL, hemoglobin 10.6 g/dL, mean corpuscular volume 88.2 fL (80.8 – 96.4) and platelets 215,000/mcL. The patient denies vaginal or rectal bleeding. Which of the following is the best explanation for this patient’s anemia?

Answer 23

There is normally a 36% increase in maternal blood volume; the maximum is reached around 34 weeks. The plasma volume increases 47% and the RBC mass increases only 17%. This relative dilutional effect lowers the hemoglobin, but causes no change in the MCV. Folate deficiency results in a macrocytic anemia. Iron deficiency and thalassemias are associated with microcytic anemia.

Question 24

A 34-year-old G3P1 woman at 26 weeks gestation reports “difficulty catching her breath,” especially after exertion for the last two months. She is a non-smoker. She does not have any history of pulmonary or cardiac disease. She denies fever, sputum, cough or any recent illnesses. On physical examination, her vital signs are: blood pressure 108/64, pulse 88, respiratory rate 15, and she is afebrile. Pulse oximeter is 98% on room air. Lungs are clear to auscultation. Heart is regular rate and rhythm with II/VI systolic murmur heard at the upper left sternal border. She has no lower extremity edema. A complete blood count reveals a hemoglobin of 10.0 g/dL. What is the most likely explanation for this woman’s symptoms?

Answer 24

Physical examination findings are not consistent with pulmonary embolus (e.g tachycardia, tachypnea, hypoxia, chest pain, signs of a DVT) or mitral stenosis (diastolic murmur, signs of heart failure). Physiologic dyspnea of pregnancy is present in up to 75% of women by the third trimester. Peripartum cardiomyopathy is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic function towards the end of pregnancy or in the several months following delivery. Symptoms include fatigue, shortness of breath, palpitations, and edema. The history and physical do not suggest a pathologic process, nor does her hemoglobin level.

Question 25

An 18-year-old G1P0 woman at 12 weeks gestation reports nausea, vomiting, scant vaginal bleeding and a “racing heart.” These symptoms have been present on and off for the past four weeks. The patient has no significant past medical, surgical or family history. Vital signs are: temperature 98.6°F (37°C); heart rate 120; blood pressure 128/78. On physical examination: uterine fundus is 4 cm below the umbilicus; no fetal heart tones obtained by fetal Doppler device; cervix is 1 cm dilated with pinkish/purple “fleshy” tissue protruding through the os. Labs show: hemoglobin 8.2 gm/dL, quantitative Beta-hCG 1.0 Million IU/mL; thyroid-stimulating hormone (TSH) undetectable; free T4 3.2 (normal 0.7 – 2.5). An ultrasound reveals heterogeneous cystic tissue in the uterus (snowstorm pattern). Which of the following is the most appropriate next step in the management of this patient?

Answer 25

This patient’s presentation is classic for a molar pregnancy. Beta-hCG levels in normal pregnancy do not reach one million. A chest x-ray would be the most appropriate step, as the lungs are the most common site of metastatic disease in patients with gestational trophoblastic disease. Though a repeat quantitative Beta-hCG will be required on a weekly basis, an immediate post-operative value will be of little clinical utility. A PET scan is not indicated and the patient already had a CBC done.

Question 26

What are the indications for initiating methotrexate therapy?

Answer 26

• hemodynamically stable
• nonruptured ectopic pregnancy
• size of ectopic mass <3.5cm with fetal heart rate
• normal liver enzymes and renal function
  normal white count
• patient is able to follow up.