A 31-year-old patient has been on the maternal fetal medicine floor for 2 weeks due to preterm premature rupture of membranes (PPROM) at 28 weeks. The patient is undergoing daily fetal monitoring. Prior to today, the fetus has been reactive with a baseline fetal heart rate (FHR) within normal limits. During fetal monitoring today, it is noted that the FHR has increased and is 180. The patient's vital signs are as follows: T 101.2, HR 103, BP 122/76,02 saturation 98% on room air. The patient also winces in pain when the nurse places the fetal monitor pads on her gravid uterus.

What is the most likely diagnosis?

A 28-year-old G2P1 at 42 weeks is undergoing induction of labor. She was started on oxytocin a few hours ago and is currently receiving 10 mU/min. She has complained of seven very painful contractions over the past 10 minutes. You notice that the fetal strip is showing dramatically decreased baseline variability with a baseline heart rate of 170. The patient's vital signs are as follows: HR 90, BP 126/76, T 98.9. What would be the best course of management for this patient?

(A) (B) (C) (D)

A 26-year-old laboring patient at 40 weeks presents to labor and delivery (L&D) with spontaneous rupture of membranes (ROMs). Prior to today, her pregnancy has been uncomplicated. On fetal monitoring, fetal heart rate (FHR) appears to be 140 with good variability. There are also three deep V-shaped decelerations which last 20 seconds with quick recovery to baseline. What is the most probable cause of the decelerations?

A 32-year-old G2P1 is laboring while you are on service. Past medical history for this patient is significant for prior Cesarean section with her first delivery. She desires a trial oflabor after Cesarean section (TOLAC).

When you last checked the patient, she was 6 em dilated and 1 + station. Her fetal strip has been category 1 throughout the morning. Over the past few minutes, you have observed a few variable and late decelerations on the fetal strip. The maternal vital signs are as follows: HR 105, BP 90/52, T 98.9. When you check on the patient, she appears to be dizzy and confused. She is complaining of severe abdominal pain. Bimanual examination shows that the cervix is 6 em dilated and the fetus is -1 station.

What is the most likely diagnosis?

A 24 year old G1P0 at 39 week's presents to triage and believes she may be in labor. Fetal monitoring shows a baseline of 149bpm with moderate variability and some visually apparent increases in FHR from 140 to 160 that last 30 seconds. One deceleration is present that seems to mirror the patient's uterine contraction. On bimanual exam she is Scm dilated. Patient's contractions appear to be regular and every 3 minutes. Patient is unable to speak through contractions due to pain.

Which of the following would be the best strategy in management for this patient?

A 25-year-old woman G2P0101 presents to the hospital in active labor. She has received no prenatal care. She is 5 em dilated and states she had a gush of fluid more than 24 hours prior to her presentation to the hospital. You obtain an ultrasound that shows she is 41 week's pregnant, and she has a negative urine drug screen. Her labor is progressing normally and the fetal heart rate (FHR) tracing is category 1. She should be treated for:

A 34-year-old primigravida presents in active labor at 36 + 6 weeks. Her pregnancy has been complicated by gestational diabetes as well as having a body mass index of 33. At 35 weeks, she tested positive for group B strep. She is having contractions every 4 minutes and is 5 em dilated. She has no allergies to any medications. Which antibiotic should she receive upon hospital admission?

A G2P1 presents for her routine prenatal care visit at 36 weeks 2 days by sure last menstrual period and consistent with a second-trimester ultrasound. She has chronic hypertension but her BPs have been stable on nifedipine. She has no other complications with her pregnancy. She plans to use the intrauterine device for postpartum birth control.

What test is indicated at this visit?

A G2P1001 comes to your office concerned about the health of her child. Her first child is now 8 years old and displays behavioral problems and poor performance in school. The patient had read that exposure to or ingestion of certain substances during pregnancy can lead to her child's current difficulties.

Which of the following substances is associated with poor school performance and behavioral difficulties?

A 36-year-old, G2Pl, decides to undergo first-trimester genetic screening. At 11 weeks, her blood is drawn and an ultrasound performed. The results are positive for a risk of trisomy 21 above her age-related risk. She is offered chorionic villus sampling (CVS) as a diagnostic test.

Which of the following findings was most likely seen on her firsttrimester screening?

A 28-year-old, G 1PO, was referred to a genetic counselor to discuss chorionic villus sampling (CVS) in the first trimester. Her first-trimester screening results indicated an increased risk of trisomy 21: ultrasound revealed a significantly increased size of the nuchal translucency and maternal serum screening for two biochemical markers were abnormal.

Which of the findings most likely reflect the patient's serum test results?

A 38-year-old, G1PO, presents for her first obstetric (OB) visit at 16 weeks. She is concerned about her fetus' risk of chromosomal abnormalities, especially since she is of advanced maternal age (AMA). After counseling, she decides to pursue noninvasive genetic screening.

Which of the following describes the advantages of the quadruple screen over the triple screen?

A 33-year-old, G4P3, had normal first-trimester genetic screening at 12 weeks. Her pregnancy has been uncomplicated and she presents for a routine obstetric (OB) visit at 18 weeks.

Which second-trimester screening test is the most appropriate to further screen her pregnancy for aneuploidy?

A 38-year-old GO and her 39-year-old husband have been trying to conceive for the last 8 months without success. Neither the patient nor the husband has any medical problems. In addition, there are no known genetic diseases in either family. The patient's periods occur at regular intervals and an at-home kit indicates ovulatory cycles. The patient has had regular Pap smears since age 21 with no abnormalities. The patient was diagnosed with bacterial vaginosis 6 months ago, and was treated with metronidazole 500 mg orally two times a day for 7 days with a normal test of cure. Today the patient appears in good health with HR 70, BP 110/72, RR 18, T 98.6, H 63, W 125. Neither the patient nor her husband smoke, drink, or use illicit drugs.

What is the next best step in management of this couple's infertility?

A 32-year-old GO and her husband come to see you for preconception counseling. Both the patient and her husband are of Ashkenazi Jewish descent and are concerned about the risk of having a child with a genetic disorder. The husband informs you that he had one sister who died at 4 years of age after suffering progressive developmental delay and seizures. In addition, the patient's sister had genetic screening performed, which showed that she is a carrier for a genetic disorder, but neither she, nor her two daughters are affected.

What is the next best step in counseling this couple?

A 17-year-old woman, G2POO 10, presents for a second prenatal appointment. Estimated gestational age is currently 10 weeks. A urine culture performed at her first prenatal visit was positive for Escherichia coli. To her knowledge, she has never had a urinary tract infection (UTI) and she denies any urinary symptoms whatsoever.

The appropriate management for this asymptomatic pregnant patient in the first trimester of pregnancy is:

A 22-year-old G2P1 at 13 weeks presents for routine prenatal care. In review of her routine prenatal labs, a positive urine culture Staphylococcus saprophyticus is noted. A urinalysis today reveals negative nitrites. Upon review of systems, she denies any urinary frequency, urgency, or other symptoms.

What is your rationale for antibiotic treatment?

A 30-year-old G2Pl with an uncomplicated prenatal course now at 41 weeks presents in active labor. The fetal heart tracing is category 1. Not long after an examination, reveals she is 5/90/0. She has spontaneous rupture of membranes (ROMs). Light meconium-stained amniotic fluid is noted.

What is the next step?

A 29-year-old G3P2 at 40 weeks presents in active labor. She has had an uncomplicated pregnancy. As you are examining her cervix, it changes rapidly from 4 to 8 em. Shortly thereafter, membranes rupture and meconium-stained amniotic fluid is discovered. Reexamination of the cervix reveals that she is currently 9 em and feeling the urge to push. Fetal heart tones (FHTs) are in the 120s with occasional variable decelerations into the 90s that first occurred after rupture of membranes (ROM). The tracing also has accelerations and no evidence of late decelerations.

What is the next step?

A 28 year old G2Pl with chronic hypertension at 38 week's is sent to L&D from clinic due to a nonreactive nonstress test. An induction was begun using Pitocin because her cervix was 2/50 (%) and -1. Two hours into the induction, you are called to review the tracing above. The patient is currently 4 em dilated. This tracing is particularly worrisome because it is associated with:

(A) (B) (C) (D) (E)

A 36-year-old G5P0222 at 31 6/7 weeks presents to her scheduled obstetric (OB) appointment complaining of decreased fetal movement. The patient denies any somatic complaints and states that she has no other health problems. Today her BP is measured as 125/77 with a heart rate of 66. Fetal heart tones (FHTs) are measured in the 130s.

What is the next step in the management of this patient?

(A) (B) (C) (D) (E)

A 16-year-old G4P0131 at 30 3/7 weeks presents to your clinic complaining of occasional contractions. The patient states that they occur sporadically a few times per hour and last for less than 30 seconds. She states that she has not felt well and has not been eating. Records show that she has gained 15 lb during the course of this pregnancy and has not gained any weight in the past 4 weeks. Her BP is 122/65 with a heart rate of 77. Fetal heart tones (FHTs) are measured in the 120s. Fundal height is 26 cm.

What is the next step in the management of this patient?

A 25-year-old G3P2002 presents for her 32-week prenatal visit and states that she is not feeling the baby move as much as she did in her previous pregnancies. The patient's BP is 114/76 with a pulse of 66. Fetal heart rate (FHR) is in the 120s by Doppler. Fundal height is measured to be 33 cm.

What is the next step in the management of this patient?

A 26-year-old G2P1001 presents to clinic for her 20-week prenatal visit. She excitedly reports that she no longer feels sick all the time and also denies any complaints. Her BP is 118/64 with a pulse of 76. The uterus is midway between the pubis and the umbilicus. Fetal heart tones (FHTs) are in the 150s.

What is the next step in the management of this patient?

A 35-year-old G3P1102 at 35 2/7 weeks presents for her scheduled obstetric (OB) visit. The patient denies any complaints today and states that she feels the baby move "some:' Her pregnancy course was complicated by bleeding early in the pregnancy that subsided by week 10. She has had no complications since then. The patient denies recent vaginal discharge or bleeding. She states that she is experiencing occasional Braxton-Hicks contractions but denies other signs oflabor. Fetal heart tones (FHTs) are in the 130s. Her abdomen is gravid measuring 40 em. A 20-week ultrasound showed a fetus measuring in the 55th percentile.

What is the next step in the management of this patient?

A 22-year-old G2P0101 at 30 4/7 weeks presents for her scheduled obstetric (OB) appointment. A 24-week ultrasound showed the fetus to be in the 11th percentile for growth. The patient missed the previous three appointments but came today and denies any complaints today. The patient's previous pregnancy was complicated by preterm labor with delivery at 34 weeks. The patient denies vaginal discharge, bleeding, or abdominal cramping. Abdominal examination today shows a gravid uterus measuring 25 em. Fetal heart tones (FHTs) are in the 140s.

What is the next step in the management of this patient?

A 37-year-old G6P3205 at 34 4/7 with gestational diabetes moderately controlled with insulin presents for her scheduled obstetric (OB) appointment. During the course of the visit, the patient notes that the fetus is moving, but "sleeps a lot:' Her previous pregnancy was also complicated by gestational diabetes and fetal macrosomia. Her BP is 138/85. Fetal heart tones (FHTs) are in the 130s. Fundal height measures 36 em. Her last ultrasound was at 28 weeks and showed a fetus in the 93rd percentile.

What is the next step in the management of this patient for this visit?

A 28-year-old G2P1001 at 34 weeks presents to the clinic for her regular obstetric (OB) visit. Her pregnancy has been complicated by gestational diabetes initially managed by diet. She missed her last appointment. The patient's blood glucose log indicates postprandial glucose measurements now ranging from 180 to 360. She has an ultrasound scheduled in 2 weeks. In addition to starting the patient on insulin therapy,

what would be the next step in the care of this patient?

The patient is a 36-year-old G 1PO chronic hypertensive at 29 5/7 weeks. She denies somatic complaints today. She has been on methyldopa during this pregnancy with good results. Her BP today is 139/88 and the patient comments that that is "good for her:' Her urine is negative for protein. On her 20-week ultrasound, it was noted that the fetus was in the 25th percentile. She denies vaginal bleeding, discharge, and abdominal cramping.

What is the next step in the management of this patient?

(A) (B) (C)(D)

A 37-year-old G8P6107 has been laboring on labor and delivery (L&D) for 14 hours. She has a history of diabetes mellitus, hypertension, and Marfan syndrome, all diagnosed prior to pregnancy. Her membranes are still intact, and she is contracting regularly. She states that "she feels it coming" and adamantly wants to continue walking as she labors. As her physician, you convince her to go back to her room for a few minutes so that you can perform intermittent monitoring (see Figure 5-8). On examination, the cervix is dilated 6 em, 95% effaced, and at + 1 station. The strip below is recorded.

What is the likely etiology of the recorded tracing?