Chapter 15: Obstetrics and Women's Health

A 24-year-old nulligravida female presents for her annual examination. Her gynecologic history is remarkable for irregular menses, menstruating every 4 to 8 weeks. She would like a more reliable form of contraception (currently using condoms) and would like to have predictable menses, but is very concerned regarding weight gain with various contraceptive methods.

Question 15.1.1 How would you counsel her regarding weight changes and contraception?

A) Studies show there is no significant difference in weight gain of women initiating oral contraceptive pills (OCPs) versus placebo

B) Weight gain of 10 lb is expected during the first year of use with any type of OCPs

C) Weight gain of 10 lb is expected during the first year of use with monophasic pills but not with triphasic formulations

D) Weight loss of 10 lb is expected during the first year of use with Depo-Provera (medroxyprogesterone acetate)

Answer 15.1.1 The correct answer is "A." Studies have shown no significant weight gain with OCP use when compared with placebo. Trials have been conducted evaluating estrogen components of 20 to 50 μg, both monophasic and triphasic. There is no evidence to support the premise that triphasic formulations offer improvement in weight changes. Depo-Provera has variable effects on weight gain. Several studies have shown a weight gain of 3 to 6 kg in the first year of use; however, other studies have shown no difference in weight gain between Depo-Provera and placebo.

Question 15.1.2 After reassuring her regarding the concerns of weight gain, you tell her about the additional potential benefit(s) of OCPs, which include:

A) Improvement in acne

B) Decreased dysmenorrhea

C) Decreased menstrual flow

D) Decreased risk of ovarian cancer

E) All of the above

Answer 15.1.2 The correct answer is "E." Besides these, additional potential benefits of OCP use include regulation and predictability of menses, decreased anemia, decreased hirsutism, and decreased risk of endometrial and colon cancers. (Note: the cancer risk reduction is based on epidemiologic studies, not randomized controlled trials.)

After further discussion, she reports that she has headaches every 1 to 2 months. She has never been evaluated for migraines, but reports that her headaches are bilateral, posterior, throbbing, and relieved with sleep and over-the-counter medication. She denies associated aura, nausea, or focal neurologic changes.

Question 15.1.3 How would you counsel her regarding OCPs and headaches?

A) Headaches are an uncommon reason for discontinuation of OCPs

B) She should not use OCPs because they are contraindicated in anyone with headaches

C) She should use progestin-only pills

D) She can use OCPs, as it is hard to predict whether her headaches will be affected

Answer 15.1.3 The correct answer is "D." Although headache is a frequently cited reason for women to discontinue OCPs, there is no strong correlation between headache frequency and intensity for most women. There is no evidence that the type of progestin or amount of estrogen will alter the headaches, except in women with menstrual migraines. Among women with migraines, headaches improve, worsen, or are unchanged after initiation of OCPs (helpful, right?). There is an increased risk of stroke in women with a history of pseudotumor cerebri or migraines with aura or focal neurologic changes. Therefore, OCPs are CONTRAINDICATED in these specific subgroups of women.

The patient wants to know how long she should use a backup method of contraception after starting the combination estrogen/progesterone OCP.

Question 15.1.4 You tell her the following regarding using a backup method:

A) If she starts taking the pill during the first 5 days of her menstrual period, no backup method is needed

B) If she starts taking the pill greater than 7 days after the onset of her period, she needs a backup method for 7 days

C) She should use a backup method for 2 months after starting the pill regardless of when she started it

D) The OCP provides effective contraception immediately and no backup method is needed

Answer 15.1.4 The correct answer is "A." The old canard of requiring a month of backup contraception after starting OCPs, implants, etc. has fallen by the wayside. For combination estrogen/progesterone OCPs, for example, no secondary method of contraception is needed as long as the OCP is started within 7 days of the onset of the last menses. If the OCP is started greater than 7 days after the onset of the last menses, only 7 days of a secondary contraception method (e.g., condoms, diaphragm) is needed; combination OCPs work within 7 days of the start date. Please see Table 15-1 regarding CDC recommendations for backup contraception.

Eight months later, the patient calls to speak with your nurse regarding nausea and vomiting. Apparently, she decided to stop taking her OCP. Her last menstrual period was 10 weeks earlier, and she had a positive home pregnancy test 5 weeks ago. Over the last week, she has been vomiting once every day, at various times, but is nauseated throughout most of the day. She wants to know if there is anything else that is "safe" that she can do to decrease the nausea.

Question 15.1.5 What is your most appropriate response?

A) "This level of nausea and vomiting is abnormal and needs an immediate workup to rule out other pathology"

B) "This level of nausea and vomiting is very common, and there are several modifications and over-the-counter medications that are safe"

C) "This level of nausea and vomiting is very common; however, there are no medications that can be initiated in the first trimester"

D) "This level of nausea and vomiting is very common. Metoclopramide, promethazine, and ondansetron are our first-line therapies"

E) "Deal with it. You got yourself into this mess"

Answer 15.1.5 The correct answer is "B." Mild-to-moderate nausea and vomiting are very common in the first trimester of pregnancy, often improving by 16 weeks of gestation. Several modifications can improve symptoms, including small, frequent meals, avoiding fatty foods, and avoiding environmental triggers (perfumes, smoking, position changes, or certain movements). Over-the-counter remedies include ginger root or ale, the combination of vitamin B6 (10–25 mg three to four times daily) and doxylamine (10–12.5 mg three to four times daily). Vitamin B6 and doxylamine may be used separately. For those who do not respond, antiemetics including metoclopramide or promethazine should be considered (thus, "D" represents a next step, not a first step). Ondansetron would be third line due to slightly greater potential risk to the fetus. Up to 2% of the time, nausea and vomiting represent hyperemesis gravidarum, which involves weight loss of more than 5% of prepregnancy weight or dehydration and ketonuria.

Question 15.1.6 If the patient had instead presented with 6 to 8 episodes of emesis daily, an 8-lb weight loss since her last menses, and a urine specific gravity of >1.030 and ketonuria, your workup should have included:

A) Quantitative β-human chorionic gonadotropin (β-hCG)

B) Serum electrolytes, BUN, and creatinine

C) Thyroid-stimulating hormone (TSH)

D) Pelvic ultrasound

E) All of the above

Answer 15.1.6 The correct answer is "E." As with any other severely nauseated and vomiting patient, it is reasonable to check for electrolyte imbalances. Severity of nausea and vomiting correlates with higher levels of hCG, as would be seen with a molar or twin pregnancy. Gestational trophoblastic disease, although rare, should be evaluated for with an hCG level. The ultrasound would confirm a twin pregnancy and could provide evidence of a molar pregnancy. TSH can exclude hyperthyroidism.

Fortunately, your patient's symptoms improved with dietary changes, vitamin B6, and doxylamine. She presents for her initial prenatal visit at 12 weeks of gestation.

Question 15.1.7 You offer her the routine prenatal tests at this visit, which include all of the following EXCEPT:

A) Syphilis testing

B) HIV testing

C) 1-hour glucose tolerance test

D) Blood type and antibody screen

E) Fetal nuchal translucency with maternal hCG and plasma-associated pregnancy protein A (PAPP-A)

Answer 15.1.7 The correct answer is "C." Diabetes screening with a 1-hour glucose tolerance test (50-g carbohydrate load with blood glucose obtained at 1 hour) is typically performed between 24 and 28 weeks of gestation. Patients with risk factors for gestational diabetes, which our patient doesn't have, are candidates for earlier screening, even at the first prenatal visit. Risk factors include history of previous pregnancy with gestational diabetes, polycystic ovarian syndrome (PCOS), history of macrosomia, high prepregnancy BMI, first-degree relative with diabetes mellitus type 2 and certain ethnic groups such as East Asian, Hispanic, and Pacific Islander. Syphilis and HIV testing are completed to decrease the risk of perinatal transmission. The blood type and antibody screen are used to identify mothers with blood antibodies that could cause hemolytic disease of the fetus. Mothers who are Rh negative will subsequently receive RhoGAM as well. Two maternal serum markers, hCG and pregnancy-associated plasma protein (PAPP-A … an early screen for Down syndrome), and one fetal marker (nuchal thickness) should be used between 11 and 14 weeks to evaluate for Down syndrome. This method offers a Down syndrome detection rate of approximately 85% with a 5% false-positive rate.

The patient has passed all of her screening tests with flying colors, and she returns at 36 weeks of gestation.

Question 15.1.8 What additional screening test(s) is/are obtained near 36 weeks of gestation?

A) Amniocentesis

B) 3-hour glucose tolerance test

C) Fetal fibronectin (FFN)

D) Group B streptococcus (GBS) culture or PCR

E) All of the above

Answer 15.1.8 The correct answer is "D." The CDC recommends maternal screening for GBS between 35 and 37 weeks of gestation. The only patients who should be excluded from screening are women who had bacteriuria with GBS during the current pregnancy or those who had an infant previously infected with GBS. These mothers are treated empirically with antibiotics in labor and do not need screening. Mothers whose culture or PCR status is unknown should receive antibiotic prophylaxis in labor only if one of the following exists: (1) intrapartum fever (>38°C), (2) preterm labor (<37 weeks of gestation), or (3) prolonged rupture of membranes (>18 hours).

Objectives: Did you learn to…

• Describe contraception options?

• Provide appropriate routine prenatal care?

• Recognize nausea and vomiting of pregnancy and describe its appropriate management?

You are taking obstetric calls for your group over Labor Day (Get it? Bad joke?) weekend. Labor and delivery calls you about a 27-year-old G1P0 at 38 weeks of gestation who awoke this morning complaining of wetness. However, when she went to the bathroom she discovered significant vaginal bleeding that had soaked her bed. She denies any cramping or abdominal pain. She is on her way to the hospital—and so are you.

Question 15.2.1 You tell the nurses to call you with her vital signs and to initiate all of the following interventions immediately upon the patient's arrival EXCEPT:

A) Obtain IV access

B) Draw blood for type and screen

C) Perform a digital vaginal examination

D) Initiate fetal monitoring

E) Draw blood for complete blood count

Answer 15.2.1 The correct answer is "C." A small-to-moderate amount of bleeding is not unexpected during labor; however, the profuse bleeding described by the patient is an obstetric emergency. The first priorities are to obtain IV access and ensure that the mother is hemodynamically stable. Baseline laboratory evaluation will give some indication of the amount of blood loss and establish that blood is available for transfusion if necessary. Monitoring of the fetal heart rate (FHR) will evaluate fetal status. Also, an ultrasound should be done to evaluate for placenta previa. A digital vaginal examination should NOT be performed until the diagnosis of placenta previa has been excluded. A consultation with someone skilled in cesarean section should be obtained if the initial evaluation suggests that immediate fetal delivery is necessary.

When the patient arrives at the hospital, she alters her recollection of events (never happens in our practice) to say that the fluid soaking the bed sheets was blood-tinged and pink in color and first occurred 2 hours ago. She continues to have vaginal leakage but denies any bright red bleeding or contractions. Ultrasound reveals a fundal placenta (not a placenta previa) without any evidence of abruption. Fetal heart tones are in the 140s and reactive. Sterile speculum examination reveals fluid, which is nitrazine and ferning positive (both evidence of ruptured membranes). Her GBS culture performed 3 weeks ago is negative. She is still not feeling contractions, and there are no contractions on the monitor.

Question 15.2.2 What is the most appropriate next step in the management of this patient?

A) Begin an induction of labor

B) Send her home after 4 hours of reassuring fetal monitoring

C) Treat her with IV penicillin for GBS prophylaxis

D) Repeat her GBS test to confirm GBS status

Answer 15.2.2 The correct answer is "A." A patient should not be sent home after rupture of membranes. She is at risk for intrauterine infection, and induction is indicated to reduce the risk of infection at term. Induction of labor, even with an unfavorable cervix, is not associated with an increase in cesarean or operative vaginal delivery, but it is associated with fewer maternal infections and fewer neonatal intensive care unit admissions. "C" and "D" are incorrect. Her GBS status was negative 3 weeks ago. Although GBS colonization can be transient, since the test was collected after 35 weeks it should be reliable. Even if her membranes were ruptured for more than 18 hours, she would not require treatment with antibiotics unless she developed a fever (remember she is GBS negative … review the criteria in answer 15.1.8). If a fever develops, think chorioamnionitis when choosing antibiotic therapy.

Sterile vaginal examination reveals a cervix that is 3 cm dilated, 2 cm long (effacement), soft, anterior, and vertex at a –1 station. The patient agrees to an induction of labor.

Question 15.2.3 The best induction method for this patient is to:

A) Insert intracervical laminaria

B) Begin IV oxytocin at 2 milliunits per minute

C) Insert intravaginal dinoprostone

D) Have her partner sit on her abdomen

E) Have her run a few laps around L&D (or walk around the hospital)

Answer 15.2.3 The correct answer is "B." The use of intravaginal and intracervical methods for cervical ripening could be cautiously considered in patients with premature rupture of membranes with an unfavorable cervix; but "C" is not the best choice—she is already 3cm dilated with a Bishop score of 6! Drugs for cervical ripening may include prostaglandins which act in the cervix to facilitate smooth muscle relaxation resulting in softening and dilatation of the cervix. They also may induce myometrial contraction. Currently the only prostaglandin labeled by the Food and Drug Administration (FDA) for such purpose are the prostaglandin E2 agents such as dinoprostone (Prepidil, Cervidil). Prostaglandin E1 agents such as misoprostol (Cytotec) inserted intravaginally are also commonly used for cervical ripening but do not carry a label by the FDA for this indication. Intracervical use of laminaria (an expanding pledget placed in the cervix) ("A") is generally reserved for pregnancy termination. "D" would not be comfortable and may cause undue harm to mom and the fetus, and is kind of weird. "E" is not the best choice. While walking may stimulate contractions, she already has ruptured membranes and a more aggressive approach is warranted.

Oxytocin should be carefully titrated via IV route for labor induction or augmentation. The general starting doses are 0.5 to 2 milliunits per minute, increased by 1 to 2 milliunits every 20 to 40 minutes, to a maximum dose rarely exceeding 30 to 40 milliunits per minute.

The patient is currently in labor (success!), and now her cervical examination is 6 cm dilation, 1 cm effaced, and –1 station. The amniotic fluid is still clear, having ruptured approximately 22 hours ago. She has had an epidural placed for analgesia. The FHR baseline has increased to 165 beats per minute with minimal variability. Contractions occur every 3 minutes. Maternal temperature is now 38.6°C, and her pulse is 110 bpm. The patient denies any complaints.

Question 15.2.4 Given the history of prolonged rupture of membranes and fever, which of the following is the most likely diagnosis?

A) Normal labor

B) Epidural fever

C) Nosocomial infection

D) Chorioamnionitis

Answer 15.2.4 The correct answer is "D." Chorioamnionitis is the most likely diagnosis and the diagnosis of most concern given the prolonged rupture of membranes (we gave you this answer above if you were reading …). Treatment should be initiated immediately. "A" is incorrect as fever is not a normal part of labor. "B" is possible, but not as likely and a dangerous assumption. There is an association between the use of epidural analgesia and a rise in maternal temperature. Etiologies proposed for this temperature increase include lack of pain-induced hyperventilation and decreased perspiration due to sympathetic blockade. "C" is extremely unlikely given her brief time in the hospital.

Question 15.2.5 What is the next step in the care of this patient?

A) Increase the oxytocin to hasten delivery

B) Remove the epidural

C) Initiate broad-spectrum antibiotics

D) Call your backup for cesarean section (or do it yourself)

E) Give acetaminophen 1,000 mg orally

Answer 15.2.5 The correct answer is "C." Initiation of antibiotics is associated with a decrease in both maternal and neonatal morbidity. Multiple organisms are isolated in more than 66% of cases; therefore, antibiotics should be broad. Approved regimens include ampicillin and gentamicin, ticarcillin/clavulanate, or piperacillin. There is no need to increase the oxytocin ("A"); she has already made good labor progress. There is also no need to proceed with a cesarean delivery ("D") unless there is another indication, such as nonreassuring FHR pattern. Although epidural anesthesia is associated with increased maternal temperature, it should only be removed if it is felt to be contributing to maternal pathology (e.g., meningitis, epidural abscess, or epidural bleed). Acetaminophen is fine, but it should not be used in lieu of antibiotics.

The patient's labor is progressing. Her cervix is 9 cm dilated, completely effaced, and station is +3. Her temperature is 39.0°C. The FHR pattern is shown in Figure 15-1.

FIGURE 15-1.

Question 15.2.6 What is the FHR interpretation?

A) Baseline 165 beats per minute, reactive

B) Baseline 165 beats per minute, with periods of bradycardia

C) Baseline 165 beats per minute, with late decelerations

D) Baseline 165 beats per minute, with variable decelerations

Answer 15.2.6 The correct answer is "C." The FHR pictured is described as Category II (see Table 15-2) with a baseline of about 165 beats per minute. There is moderate variability present. Following each contraction, there are late decelerations to the 110s. "A" is incorrect since "reactive" refers to a nonstress test, not fetal monitoring during labor (see Helpful Tip for more). "B" is incorrect as fetal bradycardia is defined as an FHR of less than 110 beats per minute for at least 10 minutes. "D" is incorrect. Variable decelerations vary with respect to timing, duration, and depth.

Question 15.2.7 What is the likely etiology of the fetal heart rate (FHR) tracing in Figure 15-1?

A) Head compression

B) Placental insufficiency

C) Cord compression

D) Any of the above is equally likely to cause the tracing

Answer 15.2.7 The correct answer is "B." Late decelerations are believed to be secondary to transient fetal hypoxia in response to decreased placental perfusion. Prompt evaluation and intervention is warranted. Early decelerations are generally reassuring and attributed to fetal head compression. Variable decelerations are the most common decelerations seen in labor and indicate cord compression. Variable decelerations can sometimes be relieved by maternal repositioning or amnioinfusion (infusing saline or Ringers Lactate to "reexpand" the uterus and relieve the pressure on the cord).

Question 15.2.8 What is the LEAST appropriate course of action now?

A) Administer maternal oxygen

B) Stop oxytocin

C) Forceps or vacuum-assisted vaginal delivery

D) Consider cesarean delivery

E) Reposition mother (roll to one side or knee–chest)

Answer 15.2.8 The correct answer is "C." Increasing maternal oxygenation may improve fetal oxygenation. Oxytocin can decrease placental blood flow via uterine stimulation, and hence should be decreased or stopped if non-reassuring FHR changes are present. If there is evidence of maternal hypotension, maternal hydration may be indicated. Another option is position changes (left lateral) to improve placental perfusion. Maternal position can affect uterine blood flow and placental perfusion. The gravid uterus may compress the vena cava while supine. Because the patient is 9 cm dilated, forceps or vacuum-assisted vaginal delivery (also known as "operative vaginal delivery") is NOT indicated; dilation needs to be complete (10 cm) in order to use forceps or vacuum

The FHR changes resolve with your appropriate interventions. The patient progresses to complete dilation and delivers vaginally 1 hour later. Maternal antibiotics are discontinued following delivery, and the maternal temperature 2 hours after delivery is 37.0°C. On postpartum day 1, your patient complains of sore breasts from breastfeeding but no particular swelling of the breast (beyond what is expected postpartum), and her abdomen is sore "all over." She is having a moderate amount of lochia, and her temperature is 38.4°C.

Question 15.2.9 The most likely cause of the fever at this time is:

A) Endometritis

B) Mastitis

C) Deep vein thrombosis

D) Septic pelvic thrombophlebitis

Answer 15.2.9 The correct answer is "A." Whenever fever occurs in the immediate postpartum period, endometritis should be suspected. The presence of intra-amniotic infection (chorioamnionitis) increases the risk of postpartum endometritis to 13% (or 1 in 8 women, if you prefer fractions). Antibiotics are not routinely continued for chorioamnionitis after a vaginal delivery because the "source" of the infection (the placenta) has been removed. Mastitis ("B") is characterized by a swollen, firm, tender breast with systemic symptoms including fevers, chills, and flu-like symptoms. However, it was stipulated that the breasts were normal for our postpartum patient, and having bilateral mastitis is unlikely. Staphylococcus aureus is the typical pathogen in mastitis. Pregnancy and the postpartum period increase a woman's risk of thrombogenesis. However, DVT ("C") is not a likely source of the fever. Septic pelvic thrombophlebitis ("D") is a diagnosis of exclusion and is usually entertained when fever spikes continue despite treatment for endometritis.

You start appropriate antibiotics and the patient does well. The family, in gratitude, names the child after you (adding the suffix "-tops" to the child's name, like "Triceratops") and makes you the godparent necessitating gifts for the next 18 years on the child's birthday.

Objectives: Did you learn to…

• Triage and manage third-trimester bleeding?

• Recognize and treat a patient with premature rupture of membranes?

• Evaluate and manage intrapartum fever?

• Interpret FHR patterns and begin initial management of abnormal patterns?

• Appreciate the risk factors, evaluation, and management of postpartum infection?

You are seeing a 31-year-old G2P1 at 41 weeks of gestation by definite last menstrual period and 16-week ultrasound. She continues to note fetal movement and her examination is normal: BP 120/68 mm Hg, urine dipstick negative for protein and glucose, fundal height 42 cm, fetus is vertex, FHR 156 bpm. Her cervix is soft, anterior, 2 to 3 cm dilated, 50% effaced, and +1 station. She was induced with her first pregnancy, and this time she wants to have a "natural labor." You decide to calculate a Bishop score.

Question 15.3.1 The Bishop score helps to determine:

A) The health of the fetus

B) The need for cervical ripening agents for induction and helps to predict labor induction success

C) The maturity of the fetal lungs

D) The results of a Catholic intramural baseball game

Answer 15.3.1 The correct answer is "B." The Bishop score, which takes into account cervical dilation, effacement, consistency, and position, as well as fetal station, is a useful tool to determine if cervical ripening agents are needed for induction and to predict induction success. Calculators are readily available online.

The Bishop score is favorable at 9–10.

Question 15.3.2 Which of the following are the most appropriate recommendations at this point?

A) She should be induced at once; there is a high chance of fetal mortality after 41 weeks of gestation.

B) Since her antepartum course has been uncomplicated to date, it is safe for her to await spontaneous labor until 43 weeks of gestation.

C) She should undergo a nonstress test and ultrasound for amniotic fluid index.

D) She should plan for a cesarean section.

Answer 15.3.2 The correct answer is "C." By definition, a term gestation is one completed in 38 to 42 weeks. There is no significant increase in fetal mortality in an uncomplicated pregnancy at term. Virtually all reports suggest an increase in perinatal morbidity and mortality when pregnancy goes beyond 42 weeks of gestation. Antenatal surveillance of post-term pregnancies should be initiated at 41 weeks of gestation.

Question 15.3.3 At 41 weeks she is really (really, really) tired of being pregnant and wants "a natural way" to induce contractions. Which of the following nonpharmacologic methods of inducing or augmenting labor is LEAST likely to be effective?

A) Stripping the amniotic membranes

B) Prolonged walking

C) Amniotomy

D) Nipple stimulation

Answer 15.3.3 The correct answer is "B." Stripping membranes appears to be effective in initiating spontaneous labor within 72 hours. Amniotomy may be used for labor induction, especially if the Bishop score is favorable. However, a Cochrane review from 2013 did not find strong evidence supporting the use of amniotomy alone or in combination with oxytocin for induction. Nipple stimulation causes release of oxytocin and may be utilized for labor induction, but its marginal benefit is only seen in patients with a favorable Bishop score. Walking does not result in labor induction or augmentation, but it's not harmful either.

Question 15.3.4 If induction becomes necessary, which of the following pharmacologic interventions would be the best approach to your patient who has a cervix that is soft, anterior, 2 to 3 cm dilated, 50% effaced, and+1 station?

A) IV oxytocin

B) Intracervical PGE2 (dinoprostone)

C) Intravaginal PGE2 (dinoprostone)

D) Intravaginal PGE1 (misoprostol)

E) None of the above. All pharmacologic interventions are contraindicated

Answer 15.3.4 The correct answer is "A." This patient does not need further cervical ripening but is a candidate for induction of labor. If cervical ripening were needed, there are several available agents. Option "D," PGE1 (misoprostol, brand name Cytotec) can be administered intravaginally or orally (but note that the Food and Drug Administration [FDA] has not approved it for use in pregnancy). "B" and "C", PGE2 (dinoprostone, brand name Cervidil) is administered intravaginally. PGE2 gel (dinoprostone, brand name Prepidil) can be administered either intravaginally or intracervically. Because the cervix is favorable in this case, proceeding with oxytocin is the best option.

Your patient's husband is called up for active duty in Iraq (or Afghanistan … or Libya or … sadly, we are on the 4th edition of this book and have not needed to change this scenario) and is due to report in the next few days. She is now 41 2/7 weeks of gestation and desires induction so he can be with her for the delivery. You admit her to labor and delivery the following morning. The initial FHR monitoring before induction (also known as a nonstress test) is shown in Figure 15-2.

FIGURE 15-2.

Question 15.3.5 What is the correct interpretation?

A) Baseline 150 beats per minute; not reactive

B) Baseline 150 beats per minute; reactive

C) Baseline 180 beats per minute; decelerations to 150s; not reactive

D) Baseline 180 beats per minute; moderate variability; reactive

Answer 15.3.5 The correct answer is "B." The baseline is about 150 beats per minute. There are two accelerations greater than 15 beats and lasting longer than 15 seconds, which meets the criteria for a reactive nonstress test. There is one contraction and evidence of uterine irritability noted as well.

You perform amniotomy with return of particulate meconium-stained fluid. Her cervix is now 5 cm dilated, 80% effaced, with vertex at +1 station. You elect to continue monitoring progress.

Question 15.3.6 Which of the following choices of labor analgesia is MOST appropriate at this point?

A) Epidural analgesia

B) Local perineal anesthetic infiltration

C) Bilateral pudendal nerve block

D) All of the above are equally appropriate

Answer 15.3.6 The correct answer is "A." Epidural analgesia offers the most effective form of pain relief and generally may be utilized once the patient is determined to be in active labor. Various local anesthetic agents are available for local infiltration of the perineum and vagina to provide analgesia for episiotomy or laceration repair following delivery but not for labor. Bilateral pudendal nerve blocks are useful during the second stage of labor, as a supplement to epidural analgesia for anesthesia of the sacral nerves, or as an option for operative vaginal delivery anesthesia (e.g., forceps, vacuum). Opioid agonists and agonist–antagonists are also available and commonly employed. However, some reports suggest that the analgesic effect of opioids in labor is limited when using the lower doses that are generally regarded as safer for the fetus.

The nurse notices some changes on the fetal heart monitor. The current FHR is shown in Figure 15-3.

FIGURE 15-3.

Question 15.3.7 What is the correct interpretation of this FHR tracing?

A) Baseline 160 beats per minute; reactive

B) Baseline 160 beats per minutes; variable deceleration to the 90s

C) Baseline 160 beats per minute; late decelerations to the 90s

D) Baseline 160 beats per minute; early decelerations to the 90s

Answer 15.3.7 The correct answer is "B." A variable deceleration to the 90s occurs with the first contraction on this strip. Variable decelerations vary with respect to timing, duration, and depth—thus, the name "variable." They are not uniform. Variable decelerations represent changes in the FHR in response to cord compression. Please refer to the Table 15-2 with definitions and FHR tracing categories.

Question 15.3.8 Given the findings in Figure 15-3, which of the following should be performed next?

A) Check the patient's cervix

B) Place a fetal scalp electrode

C) Begin IV oxytocin infusion

D) Place an intrauterine pressure catheter and begin an amnioinfusion

Answer 15.3.8 The correct answer is "A." Variable decelerations are common in labor, and brief variable decelerations are benign. When variable decelerations become recurrent, progressively deeper, and longer lasting with delayed return to baseline, they are non-reassuring and may reflect fetal hypoxia. A pelvic examination should be performed to determine if the umbilical cord is prolapsed or if there has been rapid descent of the fetal head or rapid progression of labor. Oxytocin, "C," should not be considered in this patient since she is having adequate contractions. Replacement of the amniotic fluid ("D,'' amnioinfusion) with normal saline infused through a transcervical catheter has been reported to decrease both the frequency and severity of repetitive variable decelerations and can decrease rate of cesarean section. However, it would first be helpful to assess the cervical status. Of note, amnioinfusion is no longer recommended as a prophylactic intervention for moderate or severe meconium.

Labor progresses without incident. Your patient is now completely dilated and effaced, with fetal head at +3 station. She is comfortable with her epidural and able to push with good effort. The FHR tracing is reassuring. Contractions are every 3 minutes.

Question 15.3.9 Appropriate management at this point is:

A) Continue pushing

B) Vacuum-assisted delivery

C) Forceps-assisted delivery

D) Midline episiotomy

E) Augment with oxytocin

Answer 15.3.9 The correct answer is "A." At this point, labor is progressing and maternal–fetal status is reassuring. You should continue expectant management. No intervention is indicated.

She pushes for 3 hours. She is now exhausted. The fetal head now separates the labia with contractions, and then recedes slightly. You consider offering assistance with delivery.

Question 15.3.10 In counseling your patient and her husband about the maternal risks of operative vaginal delivery, which of the following should you discuss?

A) Vaginal trauma

B) Shoulder dystocia

C) Fetal injury

D) Perineal and rectal trauma

E) All of the above

Answer 15.3.10 The correct answer is "E." Maternal risks of operative vaginal delivery include injury to the lower genital tract and rectal sphincter involvement in the case of a third- or fourth-degree laceration. In addition, fetal complications need to be discussed as well. Shoulder dystocia is more common with operative delivery than with a spontaneous vaginal delivery (see below for more information).

Question 15.3.11 Each of the following is a fetal risk of operative vaginal delivery EXCEPT:

A) Cephalohematoma

B) Skull fracture

C) Brachial plexus injury

D) Respiratory distress syndrome

E) Facial nerve palsy

Answer 15.3.11 The correct answer is "D." Respiratory distress syndrome is not increased by assisted delivery. Neonatal cephalohematoma, retinal hemorrhage, and jaundice (secondary to breakdown and reabsorption of the cephalohematoma) are more common with vacuum-assisted delivery than with forceps-assisted delivery. Skull fracture and facial nerve injury is more common with forceps-assisted delivery than with vacuum-assisted delivery. Shoulder dystocia with resultant brachial plexus injury is more common with vacuum-assisted delivery, prolonged time required for delivery, and increasing birth weight. Note that injury can occur before operative delivery as a result of abnormal labor forces (we don't think anyone has told the malpractice attorneys …).

Delivery of an 8-lb baby is accomplished without operative vaginal assistance. The mere presence of the vacuum on the table was enough to entice the uterus to perform one last massive contraction—assisted by the infant clawing its way out when it saw the vacuum coming. Following spontaneous delivery of the intact placenta 15 minutes later, you note a large gush of blood.

Question 15.3.12 Which of the following is the most likely source of the bleeding?

A) Uterine atony

B) Vaginal laceration

C) Cervical laceration

D) Retained placenta

Answer 15.3.12 The correct answer is "A." Postpartum hemorrhage is most commonly associated with uterine atony. Risk factors include prolonged labor, over-distended uterus (such as from 2 or 8 gestations [remember Octomom?]), very rapid labor, high parity, chorioamnionitis, retained placental tissue, poorly perfused myometrium, halogenated hydrocarbon anesthesia, and previous uterine atony. Maternal trauma to the genital tract ("B" and "C") may result in postpartum hemorrhage and should be routinely investigated, particularly following operative delivery. A retained placenta cotyledon is another common source for postpartum hemorrhage. The placenta should be inspected, and if there is any question of retained products of conception, the uterus should be manually explored.

Question 15.3.13 Which of the following should be undertaken next?

A) Obtain IV access and initiate hydration

B) Begin bimanual uterine compression

C) Inspect vagina and cervix for lacerations

D) Obtain blood for type and screen for possible blood transfusion

E) All of the above

Answer 15.3.13 The correct answer is "E." Postpartum hemorrhage is an obstetrical emergency and must be addressed immediately. The gravid uterus receives 500 mL of blood per minute, which can lead to massive hemorrhage if not addressed quickly. Additional personnel should be notified to help with obtaining IV access and blood draws, while you quickly try to identify the source of bleeding.

After thorough exploration of the vagina and uterus, you suspect uterine atony is the cause of bleeding. While continuing uterine massage, you think about your options.

Question 15.3.14 Which of the following is/are options in treating this patient's bleeding?

A) Dilute oxytocin IV

B) Methylergonovine (Methergine) IM

C) Carboprost tromethamine (Hemabate) IM

D) Misoprostol PR

E) All of the above

Answer 15.3.14 The correct answer is "E." All of the drugs listed cause smooth muscle contraction of the uterus. Oxytocin can be given as a dilute IV solution or IM. It should never be administered as an undiluted IV bolus, due to the risk of hypotension and cardiac arrhythmia. Methergine (methylergonovine) is an ergot alkaloid and may be administered orally or intramuscularly (not intravenously). Caution should be used in women with hypertension, as Methergine can cause hypertension. Hemabate (carboprost tromethamine) is an F-2 prostaglandin analog that is administered IM or directly into the uterine myometrium. Caution should be used in women with asthma, as Hemabate can cause bronchoconstriction. Misoprostol is a prostaglandin E1 analog, that works well and can safely be administered to women with asthma or hypertension. Rectal or oral administration can be used, but rectal administration is preferred in a patient with potential hemodynamic instability. This can be a lifesaver especially in third world countries where other options may not exist.

She requires IV crystalloid and 4 units of packed red cells for symptomatic anemia following delivery. Both mother and infant do well and the patient and baby are discharged on postpartum day 2. You schedule a follow-up appointment in 2 days. You are concerned about Sheehan syndrome given the severe postpartum hemorrhage.

Question 15.3.15 All of the following are characteristic of Sheehan syndrome EXCEPT:

A) Failure in lactation

B) Amenorrhea

C) Desire to be a punk rocker

D) Decreased LH/follicle-stimulating hormone (FSH)

E) Adrenal cortical insufficiency

Answer 15.3.15 The correct answer is "C." Severe intrapartum or postpartum hemorrhage may result in pituitary necrosis due to hypovolemia and hypoperfusion. This leads to a global hypopituitarism known as Sheehan syndrome. Sheehan syndrome is characterized clinically by endocrine deficiency syndromes as a result of loss of anterior pituitary function. Initial symptoms may be vague (lethargy, anorexia, weight loss, difficulty with lactation), and the syndrome can go unrecognized. Later manifestations include failure of lactation, amenorrhea, breast atrophy, loss of pubic and axillary hair, adrenal cortical insufficiency, and hypothyroidism. Desire to be a punk rocker is "Sheena syndrome." If you don't get it, you missed the Ramones.

Objectives: Did you learn to…

• Recognize the risks of prolonged pregnancy and identify appropriate timing of intervention?

• Describe the indications and risks associated with induction of labor?

• Interpret intrapartum FHR patterns and choose appropriate management options?

• Evaluate analgesia options, contraindications, and risks during labor and delivery?

• Recognize the indications for and management of operative vaginal and abdominal delivery?

• Evaluate and manage postpartum hemorrhage?

While on call for your small community hospital, a nurse on the labor and delivery ward calls you about a patient with preterm contractions. You come in to see the patient and find a 33-year-old G1P0 at 26 weeks of gestation by in vitro fertilization. She is usually followed at an academic hospital 400 miles away. She looks worried and says, "I'm going to have twins. But not now!" She recalls her prenatal lab results were unremarkable. She recalls her ultrasound showed "two heart beats."

All of the following risks are increased with a multifetal gestation EXCEPT:

A) Preterm labor

B) D-isoimmunization (Rh isoimmunization)

C) Preterm rupture of membranes

D) Intrauterine growth restriction

E) Twin–twin transfusion syndrome

The correct answer is "B." The most significant complication of multiple gestations is preterm labor resulting in preterm delivery. Preterm rupture of membranes and intrauterine growth restriction also occur more frequently in multiple gestations than singleton pregnancies. The risk of all these complications is directly proportional to the number of fetuses. Twin–twin transfusion syndrome rarely occurs and is associated with mono-chorionic gestations. Multifetal gestations do not increase the risk of D-isoimmunization.

After a busy day in clinic, you get the traditional 5 PM call from labor and delivery. The nurse tells you that your partner's patient is presenting with concerns for preterm labor. She is a 24-year-old G1 at 26 weeks by LMP and first-trimester ultrasound. She is having contractions but no vaginal discharge. The contractions started about an hour ago and are 5 to 6 minutes apart. The nurse asks if you want to check fetal fibronectin (FFN).

Question 15.4.1 A NEGATIVE fetal fibronectin is associated with:

A) Fetal lung immaturity

B) Ruptured fetal membranes

C) A decreased risk of preterm birth

D) An increased risk of preterm birth

Answer 15.4.1 The correct answer is "C." FFN is a basement membrane protein produced by the fetal membranes. A negative test is useful in assessing the risk of preterm delivery during the following 2-week period. With a properly performed test in a symptomatic patient, up to 99.5% of patients with a negative FFN will not deliver in the subsequent 7 days. A positive test is not useful as the test has low positive predictive value. In performing FFN testing, the following criteria must be met: intact amniotic membranes, minimal cervical dilation (<3 cm), and sampling between 24 0/7 and 34 6/7 weeks. Recent sexual intercourse and the presence of vaginal discharge or bleeding may cause a false positive test. Collect the swab in the posterior vaginal fornix before cervical checks and transvaginal ultrasound as these can also cause the test to be falsely positive. FFN does not assess fetal lung maturity ("A"). Ruptured membranes ("B") would cause a positive FFN.

You are wondering if this patient is a good candidate for corticosteroid therapy.

Question 15.4.2 Regarding the risks and benefits of corticosteroid therapy for fetal lung maturation, which of the following is FALSE?

A) Corticosteroid therapy is recommended for all pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within 7 days

B) Corticosteroid therapy has been associated with an increased risk of neonatal infection

C) Antenatal corticosteroid therapy reduces the incidence of respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis

D) Corticosteroids accelerate the production of pulmonary surfactant in the fetal lungs

Answer 15.4.2 The correct answer is "B." There is no evidence that antenatal corticosteroid therapy increases the risk of neonatal infection. However, maternal infection is a relative contraindication to corticosteroid therapy. Corticosteroids are recommended for all pregnant women between 24 and 34 weeks of gestation who are at risk of preterm delivery within 7 days. Corticosteroids may be given after 34 weeks if there is documented fetal lung immaturity and delivery will likely occur before lung maturation.

Question 15.4.3 Which of the following FDA-approved tocolytics is regarded as first-line therapy to abort preterm labor?

A) Nifedipine

B) Magnesium sulfate

C) Prostaglandin inhibitors

D) Ritodrine

E) None of the above

Answer 15.4.3 The correct answer is "E." The only FDA-approved agent for use as a tocolytic was ritodrine, a β-adrenergic receptor agonist, which was pulled from the market in the United States in 1993. There are no currently available FDA-approved tocolytics. Thus, other agents have been investigated. Terbutaline, magnesium sulfate, prostaglandin inhibitors, and calcium channel blockers have all been studied and may be utilized in select cases for tocolysis—but realize that these drugs are not approved by the FDA for this indication and that they carry substantial risks. Indomethacin has also been used successfully for tocolysis. Again, it is not approved for this indication.

You examine the patient after collecting a FFN. Her cervix is 1 cm dilated at the external os and closed at the internal os, long, and posterior. Ultrasound shows that the infant is vertex. The monitor shows FHR baselines of 140 and 145 bpm. Contractions are irregular, occurring every 4 to 9 minutes. Urine dipstick shows a specific gravity of 1.030.

Question 15.4.4 The LEAST appropriate intervention in this 26 week gestation is:

A) Continuation of monitoring

B) Oral hydration

C) Obstetrical consult for cerclage placement

D) Test for group B streptococci, gonorrhea, and chlamydia

E) Administration of corticosteroids

Answer 15.4.4 The correct answer is "C." Cerclage (stitch to hold the cervix closed) is indicated for incompetent cervix, not preterm labor. A cerclage is typically placed in the first part of the second trimester after fetal viability has been established. It would not be used at 26 weeks. The patient should be evaluated carefully and the frequency of uterine contractions should be assessed during the initial management. Because dehydration may result in uterine irritability, rehydration may stabilize the uterus. There is no proven benefit of hydration in the patient who is euvolemic. Get cultures to prevent perinatal transmission even though treatment of positive cultures has not been established to aid in the prevention of preterm birth. Corticosteroids are discussed earlier.

Objectives: Did you learn to…

• Recognize preterm labor and manage it appropriately?

• Understand the indications, contraindications, risks, and benefits of tocolytics and corticosteroids?

A 33-year-old G1 at 35 2/7 weeks presents to labor and delivery. Her pregnancy has been complicated by preterm labor. Her GBS status is unknown. On admission, she is uncomfortable with regular contractions every 3 to 4 minutes. The FHR baseline is 135 with moderate variability. Her cervix is 6 cm dilated, completely effaced, with a bulging amniotic sac and fetus in vertex presentation.

Question 15.5.1 Which of the following is your best course of management?

A) Administer corticosteroids

B) Administer tocolytics

C) Initiate GBS prophylaxis

D) Discharge her to home until she is in active labor

E) A, B, and C

Answer 15.5.1 The correct answer is "C." GBS prophylaxis is indicated for preterm delivery if GBS status is unknown. Appropriate antibiotics include penicillin or ampicillin or an alternative intravenous agent if the patient has a penicillin allergy. This patient is outside the window (24–34 weeks) for corticosteroid administration. Given the gestational age (>34 weeks), advanced cervical dilation, and high likelihood of imminent delivery, tocolysis should be avoided.

Objective: Did you learn to…

• Describe indications for GBS prophylaxis?

Risk factors for preterm birth include each of the following EXCEPT:

A) Multiple gestation pregnancy

B) Maternal bacteriuria

C) Maternal history of preterm contractions with term birth

D) Maternal smoking

E) Maternal hypertension

The correct answer is "C." While preterm contractions are concerning, a maternal history of preterm contractions with term birth does not increase the risk of preterm delivery in a subsequent pregnancy. Multiple gestations, history of preterm birth, smoking, cocaine use, asymptomatic bacteriuria, and hypertension are all risk factors for preterm birth.

A 37-year-old G3 P0111 (full term, preterm, abortions/miscarriage for any reason, living children) presents for routine obstetric care at 10 weeks of gestation. Her second pregnancy was complicated by preeclampsia with severe features at 35 weeks requiring induction of labor and magnesium sulfate therapy. Her past medical history is uncomplicated. Her blood pressure is 132/86 mm Hg, urine protein is negative, and physical examination is unremarkable. Uterine size is consistent with dates and fetal heart tones are auscultated. The patient wonders if she will need to deliver early and need magnesium again.

Question 15.6.1 You counsel her that her risk of recurrent preeclampsia with severe features is in the range of:

A) <5%

B) 20% to 30%

C) 50% to 60%

D) >90%

Answer 15.6.1 The correct answer is "B." The risk of recurrence of preeclampsia is affected by both gestational age at diagnosis and the severity of preeclampsia. Preeclampsia at an early gestational age or preeclampsia with severe features increases the risk of recurrence. The overall recurrence risks are estimated at less than 10% for mild preeclampsia and greater than 20% for preeclampsia with severe features. Risk factors for preeclampsia include young maternal age, advanced maternal age, diabetes, and chronic hypertension, among many others.

The patient would like to do anything reasonable to prevent preeclampsia again.

Question 15.6.2 In addition to obtaining baseline laboratory evaluation (CBC, AST, ALT, creatinine, 24-hour urine for protein) to aid in early diagnosis, you recommend the following therapy:

A) Low-sodium diet

B) Diuretic for hypertension and edema

C) Aspirin 81 mg daily

D) Subcutaneous heparin therapy at prophylactic doses

E) None of the above

Answer 15.6.2 The correct answer is "C." ACOG's Task Force on Hypertension in Pregnancy from November 2013 recommends the use of 81 mg aspirin daily in patients who have a history of early-onset preeclampsia with preterm delivery or in patients with a history of preeclampsia in more than one prior pregnancy. USPSTF recommends the use of low-dose aspirin as a preventive medication after 12 weeks of gestation in women who are at high risk for preeclampsia.

Because of her age (37 years), the patient also inquires about her risk for delivering a baby with Down syndrome.

Question 15.6.3 What is her estimated risk of a Down syndrome baby with this pregnancy?

A) 1/9,000

B) 1/1,200

C) 1/150

D) 1/12

Answer 15.6.3 The correct answer is "C." The risk of Down syndrome begins to rise rapidly at age 35, with an estimated risk of 1/250 at age 35, 1/150 at age 37, and 1/70 at age 40.

After hearing her age-related risk for Down syndrome, the patient asks about what tests she should have to screen for Down syndrome.

Question 15.6.4 You counsel her regarding various tests and offer:

A) First-trimester triple screening (PAPP-A, hCG, and nuchal lucency)/integrated screening

B) Chorionic villus sampling (CVS)

C) Amniocentesis

D) Second-trimester quadruple screening (hCG, maternal serum alpha fetal protein [MSAFP], estriol, inhibin A)

E) Cell-free fetal DNA testing from maternal peripheral blood

F) All of the above

Answer 15.6.4 The correct answer is "F." All patients should be offered first-trimester screening, and if declined, they should be offered second-trimester quadruple screening. Because of her advanced age (>35 years at the time of delivery), the patient should be offered CVS and amniocentesis as well. Patients should understand that the first- and second-trimester screening tests are just that—screening methods. However, both CVS and amniocentesis can diagnose Down syndrome, in addition to other chromosomal abnormalities. CVS is typically completed between 10 and 13 weeks of gestation, whereas amniocentesis is performed after 15 weeks. Both are invasive procedures, which carry risks, including pregnancy loss, rupture of membranes, and fetal injury. Cell-free fetal DNA testing is a newer and noninvasive screening test that can be done after 10 weeks of gestation in patients at high risk for aneuploidy. If abnormal, it should be followed up with a diagnostic test, such as an amniocentesis.

The patient has a negative first-trimester screening, which decreases her Down syndrome risk to 1/800. She declines an amniocentesis. You draw her MSAFP only at 17 weeks, because, as you learned above, the first-trimester screening does not evaluate for neural tube defects. The AFP is normal. She subsequently undergoes diabetes screening with a 1-hour post-50-g glucose test, which shows a glucose level of 170 mg/dL.

Question 15.6.5 The next step is:

A) Order a 3-hour glucose tolerance test

B) Set up diabetes teaching and a consult with a nutritionist/dietician

C) Start glyburide

D) Start insulin

E) All of the above

Answer 15.6.5 The correct answer is "A." The 1-hour 50-g glucose load test is a screening test for gestational diabetes. Since hers is abnormal (≥140 mg/dL), the next step is to perform a diagnostic test, which is the fasting 3-hour glucose tolerance test, utilizing a 100-g glucose load.

The patient completes her glucose tolerance test with values of:

• Fasting: 92 mg/dL

• 1 hour: 194 mg/dL

• 2 hours: 169 mg/dL

• 3 hours: 148 mg/dL

Question 15.6.6 The next step in management is:

A) Continue routine prenatal care

B) Set up diabetes teaching and a consult with a nutritionist/dietician

C) Start glyburide

D) Start insulin

Answer 15.6.6 The correct answer is "B." The recommended upper limit of normal serum glucose levels for the 3-hour glucose tolerance test are:

• Fasting: 95 mg/dL

• 1 hour: 180 mg/dL

• 2 hours: 155 mg/dL

• 3 hours: 140 mg/dL

If a patient has two or more glucose levels that are above these, she is diagnosed with gestational diabetes (GDM). Your patient fails on three of four of her results. The recommendation is to initiate dietary modifications including carbohydrate restriction with frequent blood sugar monitoring. If the target glucoses cannot be met with dietary changes alone, medical therapy should be started. Although insulin has been the standard therapy, glyburide or metformin are also equally appropriate for first-line therapy. Insulin is better than metformin, which is better than glyburide (BMJ. 2015; 350:h102).

The patient is seen for her 32-week visit and her fundal height is only 28 cm (which surprises you, given her diagnosis of gestational diabetes … the babies of diabetic mothers tend to be large!). She has been compliant with the dietary changes and her blood sugars are usually 80s fasting and 120s 2-hour postprandial. She has gained 20 lb so far in the pregnancy. You send her for an ultrasound, which reveals an infant measuring only 28 3/7 weeks of gestation, weighing 1,168 g (<10th percentile). Amniotic fluid volume and umbilical artery Dopplers are normal.

Question 15.6.7 Appropriate follow-up includes:

A) Changing the estimated due date

B) Scheduling an induction

C) Repeating the ultrasound for growth in 1 week

D) Repeating the ultrasound for growth in 4 weeks

Answer 15.6.7 The correct answer is "D." Current ultrasound techniques are not sensitive enough to assess growth at weekly intervals ("C"), and therefore waiting 4 weeks would give a better assessment of growth rate. This infant demonstrates intrauterine growth restriction. The patient had a first-trimester ultrasound with her first-trimester screening, which establishes her due date. It is inappropriate to change her due date based on a 32-week ultrasound ("A"). Initiating an induction would be inappropriate without further investigation, given the early gestational age ("B"). You could do an ultrasound at 1 to 2 weeks to assess amniotic fluid and umbilical Doppler but not fetal size. Antenatal surveillance is indicated at this time with bi-weekly nonstress testing.

The patient continues with bi-weekly nonstress tests and her ultrasound at 35 weeks reveals appropriate interval growth, but remains growth-restricted at a weight of 1,846 g (<10th percentile). Today her blood pressure is 146/88 mmHg and urine protein on dipstick is +1. Ugh … she can't seem to catch a break.

Question 15.6.8 At this time, appropriate intervention includes:

A) Administering corticosteroids

B) Obtaining a 24-hour urine for protein

C) Following up with a routine appointment in 1 week

D) Starting labetalol

E) Starting lisinopril

Answer 15.6.8 The correct answer is "B." Given the patient's elevated blood pressure and 1+ protein on dipstick, you need to be concerned about recurrent preeclampsia. Urinary excretion of protein may be transient, and a 24-hour urine protein level is a more accurate reflection of proteinuria and the preferred method to diagnose preeclampsia. Alternatively, a protein/creatinine ratio of at least 0.3 mg/dL can also be used for preeclampsia diagnosis. "A" is incorrect. The patient is at 35 weeks of gestation (although measuring smaller), which is beyond the recommended gestation at which corticosteroids are administered (24–34 weeks). This patient must be followed up in a couple of days so that you don't miss the diagnosis of preeclampsia. Although anti-hypertensives such as labetalol can be utilized in pregnancy, they are not routinely initiated for mild elevations in blood pressure at later gestations. We hope you avoided "E," as ACE inhibitors are contraindicated in pregnancy.

Serial blood pressure measurements in the clinic reveal no blood pressures greater than 146/88. Her nonstress test is reactive. The patient is sent home to collect her 24-hour urine and returns in 2 days. Her blood pressure is now 148/90 mm Hg and she has trace protein on urine dipstick. The 24-hour urine returns at 180 mg (her baseline 24-hour urine protein at the beginning of the pregnancy was 116 mg). She denies any headache, visual changes, nausea, or abdominal pain.

Question 15.6.9 Your diagnosis is:

A) Gestational hypertension

B) Preeclampsia

C) Preeclampsia with severe features

D) Acute renal failure

Answer 15.6.9 The correct answer is "A." She now has two blood pressure readings greater than 140/90 mmHg and more than 6-hours apart, which satisfy the criteria for hypertension. Given that this elevation in blood pressure started after 20 weeks of gestation, it is likely pregnancy related. She does not have protein >300 mg in a 24-hour urine collection, so she does not meet that diagnostic criterion for preeclampsia and does not have symptoms that would qualify her for a diagnosis of preeclampsia with severe features. Note that proteinuria is no longer required to make the diagnosis of preeclampsia. Another abnormality such as elevated LFTs, thrombocytopenia, renal insufficiency, CHF, or CNS symptoms can make the diagnosis of preeclampsia even in the absence of proteinuria. The diagnostic criteria for preeclampsia are outlined in Table 15-4.

She returns to the office for her appointment 5 days later at 36 weeks of gestation after having felt well over the weekend. However, today she developed a headache. Her blood pressure is 166/112 and her urine dipstick reveals 3+ protein.

Question 15.6.10 Your next step is to:

A) Start oral labetalol and see the patient back in 2 days for a blood pressure check

B) Repeat the 24-hour urine for protein

C) Admit to labor and delivery for blood work and monitoring, with plans to move toward delivery

D) Immediate Cesarean section

Answer 15.6.10 The correct answer is "C." The clinical picture is now developing into preeclampsia with severe features (headache, systolic BP >160, diastolic BP >110, and 3+ proteinuria … see Table 15-4). The patient needs to be admitted for further monitoring of blood pressure and symptoms. In addition, blood work should be obtained including a CBC and liver and renal studies. Starting oral labetalol would treat the patient's hypertension, but this step alone is not prudent for a patient who appears to have preeclampsia with severe features. The 24-hour urine protein collection may be helpful in meeting the technical criteria to diagnose preeclampsia and can be done during admission; however, the results would not change the immediate management of the patient. If a faster evaluation is needed, the protein/creatinine ratio could be done in this case. However, as noted above, preeclampsia with severe features can also be diagnosed without the presence of proteinuria in the presence of certain clinical and/or laboratory findings (see Table 15-4).

You admit her to the hospital. Repeat blood pressure is 164/98 mmHg and urine dipstick shows 3+ protein. Her cervix is soft, 2 cm dilated, 50% effaced, with fetus vertex at –2 station.

Question 15.6.11 What is the most appropriate intervention at this point?

A) Begin induction of labor

B) Start magnesium sulfate

C) Prepare for a cesarean delivery in case it is needed

D) All of the above

Answer 15.6.11 The correct answer is "D." All of these options are important to consider at this time. Induction with oxytocin and treatment of preeclampsia with magnesium are appropriate at this point. Obstetrical backup should be involved earlier rather than later unless you possess the skill to do the cesarean section yourself.

You begin magnesium sulfate for the preeclampsia and oxytocin for induction. The induction proceeds without incident, and she delivers a viable male infant.

Question 15.6.12 How long will you continue the magnesium sulfate?

A) Until delivery of the placenta

B) For 12 hours after delivery

C) For 24 hours after delivery

D) Until the urine protein dipstick is negative

E) Until discharge

Answer 15.6.12 The correct answer is "C." Treatment should be continued for 24 hours following delivery.

Objectives: Did you learn to…

• Screen for, diagnose, and manage gestational diabetes?

• Evaluate, diagnose, and manage hypertension in pregnancy?

• Define and manage preeclampsia?

• Identify intrauterine growth restriction?

Now, you have to rush from L&D back to clinic (this never happens, right?) where you meet a 31-year-old woman for preconception counseling. She has a history of hypertension and a heart murmur. She has dyspnea when climbing stairs but performs normal activities of daily living with minimal difficulty. She takes lisinopril 10 mg daily for her blood pressure. On physical examination, heart rate is 82 bpm and blood pressure is 138/90 mm Hg. Height is 5′ 6″ and weight is 160 lb. She appears well.

Question 15.7.1 Regarding the management of her chronic hypertension during pregnancy, which is the most appropriate next step?

A) Discontinue lisinopril and begin methyldopa, labetolol, or nifedipine and recheck blood pressure in 2 weeks

B) Increase lisinopril to 20 mg daily and recheck blood pressure in 2 weeks

C) Make no changes at this time

D) Discontinue lisinopril; recheck blood pressure in 2 weeks

E) Either A or D is correct

Answer 15.7.1 The correct answer is "E." ACE inhibitors are contraindicated in pregnancy; therefore, a woman contemplating pregnancy should discontinue the medication or replace it with a safer alternative. In fact, for a woman capable of conceiving, ACE inhibitor use is discouraged unless no better alternative exists and the patient is using a reliable form of birth control. Women with mild chronic hypertension (systolic blood pressure 140–160 mm Hg) have a low risk for cardiovascular complications during pregnancy and can be managed with nonpharmacologic therapy as long as asymptomatic. In 2 weeks, when she has her return visit, if she is hypertensive (>140–160/>100 mm Hg), select a medication regarded as safe during pregnancy; methyldopa, nifedipine, or labetalol would be preferred. You could also start one of these at the current visit while discontinuing the ACE inhibitor. Note that the ACOG recommendation is to treat chronic hypertension in pregnancy only if the systolic BP is >160/105 mm Hg. If the patient has hypertension secondary to preeclampsia, ACOG would recommend treating only if the blood pressure is greater than >160/110 mm Hg or if there are symptoms. These recommendations are controversial and many would initiate blood pressure control in both groups at a lower BP. Treating hypertension reduces the incidence of "severe" hypertension, but does not change outcomes (N Engl J Med. 2015;372:407–417). See also Obstet Gynecol. 2013;122:1122 if you are interested in this topic.

Question 15.7.2 Which of the following statements about cardiovascular physiology in pregnancy is INCORRECT?

A) Blood volume and cardiac output increase by approximately 50% during pregnancy

B) Heart rate increases by 10 to 20 beats per minute, peaking in the third trimester

C) Systemic arterial pressure increases during the first trimester, reaches a peak in mid-pregnancy, and remains at that level until labor and delivery

D) Left ventricular ejection fraction remains constant or increases slightly throughout pregnancy

E) A temporary rise in venous return immediately following delivery may lead to a substantial rise in left ventricular filling pressure and cardiac decompensation in women with certain types of heart disease

Answer 15.7.2 The correct answer (and what does not happen in pregnancy) is "C." Systemic arterial pressure decreases during the first trimester, reaches a nadir during the second trimester, and returns to prepregnancy levels in the third trimester. The other statements are true. "E" deserves special mention. Immediately following delivery, relief of caval compression may cause a rise in venous return leading to clinical deterioration in some women with heart disease.

Objectives: Did you learn to…

• Manage hypertension during preconception counseling?

• Recognize normal cardiac physiological changes associated with pregnancy?

You are seeing a 28-year-old female who's LMP was approximately 7 days ago. She is complaining of vaginal bleeding and states that she is going through one pad every 20 minutes. Needless to say she is concerned. She is not using anything for contraception. Her vital signs and examination are unremarkable except for blood at the os.

Question 15.8.1 After ruling out pregnancy and assuring that her hemoglobin is stable, what is your next step?

A) Fresh frozen plasma

B) Cyclic medroxyprogesterone 10 mg a day

C) DDAVP to maximize platelet function

D) Observation: nonintervention is the best policy if the hemoglobin is normal

Answer 15.8.1 The correct answer is "B." This patient has abnormal uterine bleeding, which is a broad term that includes different functional and structural causes of uterine bleeding. Dysfunctional uterine bleeding (DUB) secondary to anovulation is a very common cause of abnormal uterine bleeding. One popular regimen for DUB is medroxyprogesterone 10 mg/day for 10 days. This should be followed by a withdrawal bleed. This regimen can be repeated for the first 10 days of the next 3 months. Other options include starting a monophasic OCP (three pills twice a day for 1 day, two pills twice a day for 1 day, one pill twice a day for 1 day, and then finish out the pack). Conjugated estrogens are a third option. Tranexamic acid (an antifibrinolytic) 1.3 g orally TID for 5 days is an additional alternative for patients with contraindications to hormonal therapy.

Question 15.8.2 The most common side effect of medroxyprogesterone at the above dose includes:

A) Bone marrow suppression

B) Thromboembolic disease

C) Depression

D) Sore breasts

Answer 15.8.2 The correct answer is "C." Many women will become depressed when taking this dose of medroxyprogesterone. They should be made aware of this ahead of time. The major side effect of the OCP regimen for abnormal uterine bleeding is nausea and vomiting. Consider giving the OCP regimen with an antiemetic. "B" is of note. Progesterones alone do not increase clot risk. They do inhibit thrombolysis, however.

Question 15.8.3 Causes of this patient's bleeding could include all of the following EXCEPT:

A) Hypothyroidism

B) Von Willebrand disease

C) Prolactinoma

D) Parathyroid disease

E) Uterine cancer

Answer 15.8.3 The correct answer is "D." All of the remaining can cause abnormal bleeding. Obviously, uterine cancer would be unlikely in a 28-year-old. Other causes of bleeding to consider are cervical polyps, endometrial polyps, adenomyosis, fibroids, and endocrine problems such as PCOS and hypo/hyperthyroidism, etc.

Objectives: Did you learn to…

• Evaluate a patient with abnormal uterine bleeding?

• Treat a patient with abnormal uterine bleeding?

A 37-year-old G3 P1112 (full term, preterm, abortions/miscarriage from any cause, living children) presents for an annual gynecologic examination and has questions regarding contraception. She is wondering if she is a candidate for an IUD.

Question 15.9.1 All of the following are contraindications to IUD placement EXCEPT:

A) Pregnancy

B) Acute pelvic infection

C) Undiagnosed vaginal bleeding

D) History of chlamydia infection

Answer 15.9.1 The correct answer is "D." Although active cervicitis and acute pelvic inflammatory disease (PID) are contraindications to placement of an IUD, a prior chlamydia infection does not exclude a patient from obtaining an IUD. Undiagnosed vaginal bleeding can be a sign of either endometritis or structural abnormalities of the uterine cavity, which must be addressed prior to considering an IUD. If you chose "A," some goons from the Board are coming to relieve you of your certification.

Your patient has none of these contraindications, and she would like to proceed with the IUD. Her friends have told her that all IUDs cause abortions, and she is unsettled by this idea.

Question 15.9.2 The mechanism of action of IUDs (copper or progesterone) is:

A) Abortifacient

B) Causes a sterile inflammatory reaction to a foreign body

C) Impairs sperm transport from the cervix to the fallopian tube

D) B and C

E) All of the above

Answer 15.9.2 The correct answer is "D." Studies detecting levels of hCG reveal that this hormone is not present in IUD users during the luteal phase. Thus, the IUD is NOT an abortifacient. Studies suggest that the mechanism of action of IUDs includes interference with sperm transport from the cervix to the fallopian tube, inhibition of sperm survival, and endometrial inflammatory changes that inhibit implantation.

After all of that counseling (that you can't bill for), her husband undergoes a vasectomy. During a routine appointment 2 years later, she complains of worsening menorrhagia. She denies intermenstrual spotting. She has not noticed any lightheadedness or dizziness, but does complain of generalized fatigue. On physical examination, you find a normal sized thyroid and an enlarged, irregular uterus measuring 10 to 12 weeks in size. There are no distinct adnexal masses, but this is somewhat difficult to discern due to the irregular uterus.

Question 15.9.3 Your initial workup in this 39-year-old female should include all of the following EXCEPT:

A) CBC

B) TSH

C) CA-125

D) Pelvic ultrasound

E) Pregnancy test

Answer 15.9.3 The correct answer is "C." A CBC will provide information regarding the hematocrit (and therefore the level of anemia) and platelet count—important information for someone with heavy menstrual bleeding. TSH will screen for hypothyroidism, which is a common cause of menorrhagia in a 39-year-old female. A pelvic ultrasound will aid in the evaluation of the mass palpated on examination and characterize the location and size of any uterine fibroids that may contribute to the bleeding; it will also evaluate for any adnexal masses. A pregnancy test is always a good idea to rule out possible pregnancy, ectopic pregnancy, and miscarriage as an underlying etiology. CA-125 is a nonspecific tumor marker that has a high false-positive rate in premenopausal women. Thus, CA-125 is not recommended as a screening test for ovarian cancer. It can be used as an adjunct to pelvic ultrasound when a complex adnexal mass is identified.

The patient returns in 2 weeks following her ultrasound. Her hematocrit was 31% (indices are consistent with iron-deficiency anemia), platelets 195,000, and TSH 2.8 mU/L (normal). The ultrasound reveals a uterus measuring 12 × 8 × 6 cm, with multiple small intramural fibroids measuring less than 2 cm in diameter. There is one subserosal, pedunculated fibroid measuring 3.5 cm at the fundus.

Question 15.9.4 What is the most appropriate initial management?

A) Expectant management and reassurance

B) Nonsteroidal anti-inflammatory drugs (NSAIDs)

C) Gonadotropin releasing hormone (GnRH) agonists

D) Blood transfusion

E) Hysterectomy

Answer 15.9.4 The correct answer is "B." Most fibroids are asymptomatic, although the most common symptom associated with leiomyomata (fibroids) is abnormal bleeding. This patient's fibroids are not impinging on the uterine cavity but may be contributing to the patient's menorrhagia. Initial treatment of menorrhagia may include NSAIDs that inhibit prostaglandin synthesis. NSAIDs have been shown to reduce menstrual blood loss by 30% to 50% in women with menorrhagia. GnRH agonists may be utilized to produce a medical menopause. However, they are expensive, and long-term usage is associated with significant side effects (e.g., osteoporosis). Hysterectomy is the definitive treatment for leiomyomata in symptomatic women who have completed childbearing. However, the mortality associated with hysterectomy is approximately 0.5/1,000, at that age. It is generally reserved for women who have failed medical management or have symptoms or signs related to fibroid size. Of particular note, levonorgestrel-releasing IUD can be used as an alternative. Studies have shown a reduction in uterine volume and bleeding and an increase in hematocrit after placement of IUD. If the fibroids are intracavitary, an IUD should NOT be used.

You start an NSAID. She responds moderately well. You add an OCP, which adequately controls her symptoms. If the patient had not responded to medical therapy, you might have considered referral to a gynecologist for potential surgical therapy.

Question 15.9.5 What other characteristic(s) would have prompted evaluation for surgery?

A) Prolapsing fibroid through the cervix

B) 5-cm submucosal myoma protruding 50% into the uterine cavity

C) Rapidly enlarging uterus

D) 20-week sized uterus and pelvic pressure

E) All of the above

Answer 15.9.5 The correct answer is "E." A fibroid prolapsing through the cervix has a potential for necrosis and infection and may require surgical removal. A submucosal myoma, especially one that distorts the uterine cavity, can contribute to menorrhagia. A rapidly enlarging uterus would be concerning for a uterine malignancy and would require further investigation. Larger uterine fibroids are more likely to contribute to symptoms of pelvic pressure and pain, which may only respond to surgical correction.

The patient returns in 1 year for her annual examination, and her pelvic examination is unchanged. However, she expresses concern that these fibroids could become cancerous.

Question 15.9.6 What is the risk of uterine malignancy (leiomyosarcoma) in a patient with fibroids?

A) <1%

B) 5% to 10%

C) 40% to 50%

D) 90% to 95%

Answer 15.9.6 The correct answer is "A." The estimated incidence of leiomyosarcoma discovered at the time of surgery for fibroids is less than 1%. A leiomyosarcoma is a malignant tumor that does not arise from preexisting benign leiomyoma. Leiomyosarcomas typically arise in the fifth or sixth decade of life and are usually associated with abnormal bleeding or a rapidly enlarging uterus.

Objectives: Did you learn to…

• Recognized contraindications to IUD use?

• Treat menorrhagia?

• Describe management principles for uterine leiomyomas?

A 20-year-old nulligravid female presents for evaluation of irregular menstrual cycles. Her past medical history is uncomplicated. Her gynecologic history is remarkable for menarche at age 12 years, irregular menses occurring every 21 to 40 days, and lasting 5 days, with last menstrual period 6 months ago. Her examination reveals no abnormal hair growth, no acne, normal Tanner stage V breast development, normal external genitalia and cervix, with a slightly enlarged uterus at 10 weeks size, and no adnexal masses.

Question 15.10.1 What is the first test you should order?

A) Pelvic ultrasound

B) Serum prolactin level

C) Urine hCG

D) Serum FSH

E) Serum TSH

Answer 15.10.1 The correct answer is "C." Primary amenorrhea is defined as either (1) the absence of menarche by 15 years with secondary sexual characteristics or (2) the absence of menarche by 13 years of age in the absence of secondary sexual characteristics. Secondary amenorrhea is defined as the absence of periods for 3 cycles in a woman who previously had menses. Pregnancy is the most common cause of secondary amenorrhea and thus must always be ruled out. After pregnancy has been excluded, the diagnostic focus is on differentiating between anatomic cause, ovarian failure, and endocrine abnormalities. The other tests may be done at some point, but a pregnancy test is first.

The urine pregnancy test is positive. Because of her irregular menses, you schedule her in 1 week for a vaginal ultrasound to confirm her gestational age. However, she calls your nurse in 3 days with vaginal spotting and lower pelvic cramping.

Question 15.10.2 The most important diagnosis to confirm or exclude is:

A) Spontaneous abortion

B) Incomplete abortion

C) Inevitable abortion

D) Ectopic pregnancy

E) Twin gestation

Answer 15.10.2 The correct answer is "D." Ectopic pregnancy is the leading cause of pregnancy-related death during the first trimester in the United States. Risk factors for ectopic pregnancy include prior PID, prior ectopic pregnancy, and prior tubal or other pelvic surgery. Spontaneous, incomplete, inevitable, threatened, and missed abortions (or miscarriages) are terms to describe pregnancy loss occurring before 20 weeks of gestation. Each can result in significant maternal morbidity (including hemorrhage and infection) or death. However, these outcomes are less frequent than with an ectopic pregnancy.

Question 15.10.3 Which of the following tests is/are important in the management of this patient?

A) Progesterone level

B) Serum quantitative β-hCG

C) Hematocrit, blood type, and screen

D) Pelvic ultrasound