A pathologist is reviewing a placenta. She knows that the patient has had a prior Cesarean section and had to have an emergency hysterectomy with this pregnancy, hence, the placenta and uterus for her review. She reviews the slides and finds that the placenta invades through the myometrium to the uterine serosa.

What is the diagnosis?

A 26-year-old G3P2002 with two previous Cesarean sections presents for her second-trimester ultrasound (U/S). The baby is growing appropriately and there are no markers for chromosomal anomalies. She is diagnosed with a placenta previa. She is also at risk for which of the following?

A 36-year-old G2Pl presents in labor with a history of a prior Cesarean section and of placenta previa and accreta during this pregnancy diagnosed with magnetic resonance imaging (MRI). Her repeat Cesarean section is planned and you review the risks with her. She is at high risk for which of the following?

A 22-year-old Gl at 20 week's gestation undergoes a routine screening ultrasound (U/S). During the procedure, several small areas of hypoechogenicity are seen within normal myometrial tissue. The fetus is developing normally and no other abnormalities are noted. The patient is very concerned about the changes in her myometrium.

As her physician, what do you inform the patient?

A 23-year-old, G2Pl, presents to the emergency room with vaginal bleeding and cramping ultrasound (U/S) shows a 9-week intrauterine pregnancy without fetal cardiac activity. While getting the U /S, her bleeding and cramping increase and she spontaneously passes the products of conception.

What is the most likely etiology of her early pregnancy loss?

A 27-year-old, GlPO, is now at 18 week's gestation. Her first trimester was complicated by a false-positive result on first-trimester screening for trisomy 21. She had chorionic villus sampling (CVS) that revealed a fetal karyotype of 46, XY.

What additional screening test does she need at this time?

A 37-year-old, G1P1, has an amniocentesis at 20 week's gestation for advanced maternal age. Amniotic a-fetoprotein (AFP) is 2.5 multiple of the median. A targeted study of fetal anatomy is performed by ultrasound (U/S) and an neural tube defects (NTD) is diagnosed.

Which of the following recommendations is the most appropriate recommendation for any future pregnancies this patient may have?

A 55-year-old man and his 30-year-old wife present for preconception genetic counseling. A thorough family history shows no significant genetic disorders on either side. The couple is informed that advanced paternal age predisposes the fetus to an increased risk of the following:

After undergoing the quadruple screening test at 16 weeks, a 24-yearold, G2P1, is notified that the fetus is at elevated risk for trisomy 18. She desires definitive diagnosis and plans to have an amniocentesis. During the preprocedure consent process, the risks of amniocentesis are discussed with her in detail.

What is the most likely outcome if amniotic fluid leakage occurs following midtrimester amniocentesis?

A 25-year-old, G2P0010, and her husband present for a routine secondtrimester ultrasound (U IS) at 20 week's gestation. She had previously declined both first- and second-trimester genetic screening. On U/S, a structural defect is discovered and an amniocentesis is offered to the patient.

Which of the following defects is most likely to be associated with aneuploidy?

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

A 40-year-old, G4P3, presents with an unintended pregnancy at 10 week's gestation. She is concerned about her risk of Down syndrome and wishes to pursue the most effective genetic screening modality.

What screening test will have the highest detection rate for Down syndrome?

A 27-year-old, G1PO, is at 12 week's gestation. Her husband is affected with achondroplasia. They desire a first-trimester genetic diagnosis and are scheduled for chorionic villus sampling (CVS). Which of the following ultrasound (U /S) findings will decrease the risk of pregnancy loss following the procedure?

A 37-year-old, GSP4, presents at 22 weeks and 3 days for her first obstetrical (OB) visit and is immediately referred for ultrasound (U/S) screening. During the targeted U /S, multiple anomalies are noted, including rocker bottom feet, an atrial septal defect, and polyhydramnios. The patient desires termination of pregnancy if a significant genetic abnormality is confirmed by diagnostic testing.

What fetal diagnostic procedure will provide fetal DNA analysis most rapidly?

A 39-year-old G3P2 at 9-week 1-day gestational age (GA) by last menstrual period (LMP) undergoes first-trimester genetic screening. She is found to have an increased risk of Down syndrome and would like to undergo genetic testing to assess for genetic abnormalities. It is recommended that she should wait until at least 10-week GA before undergoing chorionic villus sampling (CVS).

What are the risks if CVS is performed prior to 10 weeks?

A 29-year-old G2P0010 woman comes to see you at 6 weeks for her first prenatal visit. The patient had one previous pregnancy that ended in spontaneous abortion. The fetus had multiple congenital anomalies consistent with trisomy 18. The patient is now concerned that she could lose the current pregnancy and would like early prenatal testing. The patient read about chorionic villus sampling (CVS) and would like the procedure performed as soon as possible.

What is the mechanism of limb reduction in CVS before 9 weeks?

A recent immigrant from Nepal with no prenatal care delivers a female infant at 36-week gestational age (GA). Immediately upon delivery of the infant, the following features are apparent: protruding tongue, short arms and legs, large fontanelles, and poor muscle tone.

What is the most likely explanation for these findings?

A 20-year-old G2P1001 with a history of depression, alcohol dependence, and cocaine abuse delivers a 2,046 g baby girl at 36-week gestational age (GA). She took fluoxetine throughout her pregnancy and admits to continued alcohol and cocaine use until 24 week's gestation. She also reveals that she has traded sex for cocaine in the past. On examination, the infant is found to have decreased muscle tone, slanted palpebral fissures, a highly arched palate, and a flattened nasal bridge.

Which of the following likely explains these findings?

A previously healthy, obese 26-year-old G 1PO has a positive glucose challenge test at 28 weeks gestational age (GA). Follow-up testing confirms the diagnosis of gestational diabetes mellitus (GDM). The patient asks what this diagnosis will mean for her baby.

Which of the following can be a significant consequence of poorly controlled GDM to the fetus?

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

A routine prenatal examination for a 27-year-old G4P3003 at 27-week gestational age (GA) reveals a fundal height of only 22 em. The patient is clinically underweight (body mass index [BMI] 18.1) and has a history of pregnancy-induced hypertension in two prior pregnancies; however, she has been normotensive during this pregnancy to date. Nonstress testing (NST) shows a fetal heart rate (HR) of 153 beats/min with moderate variability and no spontaneous decelerations.

What is the best next step in management?

A 37-year-old G3P1011 at 12-week gestational age (GA) presents to the high-risk maternity clinic for counseling after routine blood testing showed elevated levels of amniotic a-fetoprotein (AFP), estriol, and �-hCG. Ultrasound (U/S) shows increased nuchal translucency and echogenic intracardiac focus. Based on this history and these findings, the fetus is at greatest risk for which of the following?

Your patient is a 34-year-old G 1 coming to see you for her first prenatal visit. Based on her last menstrual period (LMP), the patient is at 21 week's gestation. The patient is very excited about her pregnancy and wants to make sure she does everything to ensure a healthy baby. The patient's past medical history includes recurrent sinus infections and hypothyroidism. The patient's surgical history includes an appendectomy performed 3 years ago. The patient currently takes a prenatal vitamin and levothyroxine. The patient's blood pressure (BP) is 110/70 mmHg, HR 80 beats/min, respiratory rate (RR) 15 breaths/min, T 98, height 5'2", and weight 129. Physical examination is normal with a fundal height of 20 em and fetal heart tones (FHTs) of 150 to 160. Her thyroid-stimulating hormone (TSH) is slightly elevated. In addition to standard prenatal care, this patient should also:

A 25-year-old G 1 epileptic comes to see you for her first prenatal visit at 10 weeks. At the appointment, the patient informs you that she stopped taking her epileptic medication 2 months ago because she heard it could damage the fetus. The patient was first prescribed valproic acid 10 years ago and has not had a seizure in 5 years. The patient denies any complications since stopping the medication on her own. You inform your patient that there is an increased risk of fetal anomalies associated with epilepsy, even without medication.

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

A 32-year-old, G2P1, presents for a prenatal visit at 42 weeks 3 days by last menstrual period (LMP) and 8-week ultrasound (U /S). Her previous child was delivered via low-transverse Cesarean section due to fetal distress during a prolonged second stage of labor. The patient has no complaints today, and her pregnancy has been uneventful to this point. The patient's vital signs are within normal limits, but the fetal nonstress testing (NST) is nonreactive. The patient's obstetrical (OB) informs her that they need to deliver the baby, and the patient says that she wishes to try vaginal birth.

What is this patient's greatest risk if she undergoes induction?

A 33-year-old G1PO at 13-week 1-day gestational age (GA) has elected to undergo amniocentesis secondary to results from her first-trimester genetic screen that indicated an increased risk of trisomy 18. She would like to have the test as soon as possible.

What is the earliest recommended time frame that amniocentesis can be performed safely?

A 29-year-old morbidly obese woman, G2P1 at 26 weeks gestational age (GA) presents to clinic for a routine obstetrical (OB) visit. Her previous pregnancy resulted in a term delivery and a third-degree laceration. Her current pregnancy has been complicated by placenta previa and gestational diabetes. Her past medical history is significant for a loop electrosurgical excision procedure (LEEP) 2 years ago secondary to cervical intraepithelial neoplasia II. She denies any abdominal pain or cramping at her visit today.

Which of the following are risk factors which make this patient at risk for cervical incompetence during this pregnancy?

A 34-year-old G 1PO at 18 week's gestation is incidentally found to have a cervical length 0.9 em on a routine ultrasound (U/S). She denies any cervical trauma or prior cervical surgeries. She denies leakage of fluid, cramping, or abdominal pain. Membranes are not bulging on sterile speculum examination.

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

A 29-year-old G3P1011 patient has successfully delivered her second infant at term by a vaginal birth after Cesarean. After 45 minutes, the placenta has still not delivered. Currently the patient is stable with no excessive bleeding. Vital signs: BP 110/76 mmHg, P 105 beats/min. Given this patient's history,

what is the most likely cause of retained placenta?

A 28-year-old G2P1011 patient is currently postoperative day 2 after undergoing a Cesarean section for breech presentation at term. She is successfully breastfeeding exclusively. She was followed up in a highrisk clinic because of a long-standing diagnosis of bipolar disorder with no significant exacerbations during the pregnancy. The remainder of her prenatal course was unremarkable. With her last pregnancy, she experienced an episode of postpartum depression which she was told was exacerbated by not resuming lithium therapy. She requests a refill on her lithium prescription.

Which of the following is true regarding lithium and breastfeeding?

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

A 27-year-old G1PO at 15 week's gestation has a history of chronic hypertension. She presents for her first prenatal visit. Vital signs: T 98°F, P 66 beats/min, R 16 breaths/min, BP 146/98 mmHg. She stopped taking her BP medication 6 weeks ago when she found out that she was pregnant. Of the following medications, which is the best choice for treating chronic hypertension in pregnancy?

A 26-year-old G 1 with no prenatal care presents to labor and delivery (L&D) because of bright red, painless vaginal bleeding that occurred with intercourse after her husband returned from a 6-month tour in Afghanistan. Ultrasound (U/S) in triage places her at 23 week's gestation which is within 1 week with her last menstrual period (LMP). It also reveals a complete placenta previa. There are no contractions and fetal heart tone (FHT) is reactive with average FHT of 140. The bleeding has subsided. Hemoglobin is 12.6 and platelets are 215K. Management of this patient includes which of the following?

A 26-year-old G 1PO at 37 weeks presents with regular painful contractions for the past 6 hours of increasing intensity. Upon examination, there is a bulging bag with cervical dilation of 7 em. No fetal part is detected. A bedside ultrasound (U/S) reveals a footling breech presentation. Fetal heart tracing reveals baseline of 130s with accelerations and no decelerations noted categorized as category 1. The patient is taken for an immediate Cesarean section.

What would be the greatest risk for a vaginal delivery?

A 30-year-old G3P2 with a history of postpartum depression in each of her previous pregnancies presents at 6 weeks for prenatal care. She forgot her prescription bottle and there is no documentation in the medical record regarding the specific medication she has been taking recently. She requests a refill of her prescription which she says is an "SSRI" (selective serotonin reuptake inhibitor). She agrees to call the office with the name of the medication.

Which of the following medications would you advise discontinuing/ substituting immediately?

A 17 -year-old G 1PO at 32 week's gestation arrives to the emergency room (ER) via ambulance after experiencing an eclamptic seizure at the mall. Upon arrival, her BP is 170/110 mmHg, P 110 beats/min, R 12 breaths/ min. She is drowsy but responsive and her airway is protected. Fetal heart tones (FHTs) are in the 130s with minimal variability. No contractions are present. Deep tendon reflexes are +4 with three beats of clonus.

What is your next step?

A 30-year-old G 1PO with chronic hypertension presents at 33 week's gestation for an nonstress testing (NST) and routine prenatal visit. Her pregnancy has been characterized by well-controlled hypertension in the 110 to 120/70 to 80 range. She had an abnormal quad screen with a subsequent amniocentesis confirming a normal male fetus at 21 weeks. Upon arrival, her BP was 142/98. A repeat BP performed 15 minutes later during the NST was 152/102. The NST is reactive. She relates experiencing "heartburn" over the past 36 hours. Upon examination, she has mild right upper quadrant tenderness without rebound. DTRs are 3 + with clonus. You have the medical assistant accompany her over to labor and delivery (L&D) via wheelchair.

What is your immediate concern?

A 22-year-old G 1 patient at 18 weeks presented 8 weeks ago with vaginal bleeding and a threatened abortion. Subsequently she had no further bleeding and the fundal height is appropriate for gestational age (GA) and fetal heart tones (FHTs) are present at 140 beats/min. Given her history in this pregnancy, which of the following factors is she at risk for developing?

A 39-year-old G 1P1 is 7 days post-Cesarean section after a failed induction at term. She was diagnosed with endometritis on post -op day 2 and has remained febrile with elevated white blood cells (WBCs). Her antibiotic regimen initially was IV gentamicin and clindamycin. When she remained febrile on day 4, ampicillin was added to the regimen. She spiked a fever to 102.6 this morning. A complete blood count (CBC) revealed a WBC count of 15.3, hemoglobin of 11.4, and platelets at 252K.

What is the next step?

A 26-year-old G3P2 at 38 weeks presents with spontaneous rupture of membrane (ROM) and regular contractions for the last 3 hours. On physical examination, two 1-cm "kissing lesions" are noted at 1 and 11 o'clock on the labia minora. She and her partner both have a history of "fever blisters:' She denies a history of genital herpes.

Which question is most likely to help you with your management decision?

A 24-year-old G lPO at 40 4/7 weeks presents with a 3-day history of malaise, fatigue, and fever and a generalized extremely pruritic eruption of macules, blisters, and crusted lesions. She is contracting regularly and her cervical examination is 7/75/0.

Which of the following statements is true?

A 23-year-old G2Pl who recently moved to the United States from Haiti presents at 32 week's gestation with limited prenatal care. Her previous birth was a normal spontaneous vaginal delivery at home in the Haitian countryside attended by a lay midwife. Routine prenatal labs reveal maternal anemia with a hemoglobin of 7.6, sickle cell trait, and A-negative blood type with a positive antibody screen with a titer of 1/100. Upon (U/S) examination, fetal skin edema (7 mm), fetal ascites, polyhydramnios, and a thickened placenta are noted (see Figure 6-4).

The fetus is suffering from intrauterine growth retardation (IUGR) measuring at 26 weeks.

What is the cause of this condition?

A 22-year-old G1 with last menstrual period (LMP) 18 weeks ago presents with a small amount of bright red bleeding overnight. On examination, her cervix is 2 em dilated but she has not perceived any contractions. Fetal heart tones (FHTs) are 140s by Doppler.

What is the most likely diagnosis?

A 26-year-old primigravida at term presented to labor and delivery (L&D) with painless vaginal bleeding in the absence of contractions. After a new intern panics at the amount of blood and performs a cervix check, she experienced profuse vaginal bleeding but fetal heart tones (FHTs) remain normal. The cervix is 2 to 3 em dilated with an edge of placenta palpable. Her vital signs are currently stable with BP of 96/62 and pulse of 92 beats/min. You estimate she has lost 500 cc of blood since the cervical examination.

Which of the following is the most appropriate treatment?

A 34-year-old woman, G lPO, presents for her second prenatal visit at 9 week's gestation. A review of prenatal laboratory results reveals she is rubella nonimmune. The risk to the fetus should she contract rubella includes which constellation of findings:

A 22-year-old G2Pl at 30 weeks presents to the emergency room (ER) with a history of fever, nausea, and recent onset of right flank pain. A urinalysis obtained by catheter is free of bacteria and negative for nitrites and leukocyte esterase. Appendicitis is considered.

Which of the following is true with respect to appendicitis in pregnancy?

A 26-year-old G2Pl at 29 week's gestation with a history of severe allergies currently on maintenance allergy shots presents to the emergency room (ER) with wheezing, shortness ofbreath, and chest tightness. Her PO 2 is 89% on room air. Her medications include an inhaled cortico steroid and albuterol.

Which of the following is true regarding her obstetrical (OB) management?

A 36-year-old woman, G4P3 at 34 week's gestation, presents with a 36-hour history or anorexia and vomiting that started soon after a dinner consisting of fried chicken, French fries and a milkshake. She describes stabbing pain that is localized to the right epigastric area. Vital signs: T 38.6, P 110, R 18, BP 110/68. Her BMI is 38. Fetal evaluation includes a reactive nonstress testing (NST) and biophysical profile (BPP) of 10/10. Cervix is closed, thick, and high. An obstetrical (OB) ultrasound (U/S) reveals no evidence of intrauterine growth retardation (IUGR). A CBC reveals the following: WBC 16.6, hemoglobin 11.0, hematocrit (HCT) 32.8, and platelets 172,000.

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

A 32-year-old woman, G2P1, was discovered to have a complete placenta previa during a routine anatomy ultrasound (U/S) at 18 weeks. A repeat U/S today at 24 weeks confirms a complete placenta previa. She is concerned about complications associated with placenta previa and wants to know if it is safe to attend her grandfather's funeral approximately 2 hours away by car. In discussing the risks of bleeding due to placenta previa, you advise her the time most commonly associated with the first significant bleed due to placenta previa occurs:

A 26-year-old G2P1 at 38 week's gestation presents to labor and delivery (L&D) with profuse vaginal bleeding. Her BP is 100/56 mmHg, pulse is 120 beats/min, and respirations are 20 breaths/min. fetal heart tones (FHTs) are in the 120s with no evidence of decelerations and moderate variability. An ultrasound (U/S) reveals a probable partial previa. Speculum exam reveals a visually closed cervix and active bleeding.

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

A 17-year-old, G1PO, currently at 22 week's gestation with no prenatal care is admitted to the antenatal floor after presenting to the emergency room (ER) with right flank pain, nausea, and a fever of 1 02.6°F. She has an elevated WBC count of 16.6, a hemoglobin of 10.3, a mucopurulent cervical discharge, and a urinalysis that is positive for nitrites and + 2 glucose. This hospitalization could most likely have been prevented with earlier prenatal care that detected and instituted a management plan for which of the following?

A 32-year-old woman, G2P2, at 32 weeks has just delivered via Cesarean section for severe preeclampsia . She received a 4 g bolus of magnesium sulfate followed by 2 g an hour. Her risk for magnesium toxicity associated with high magnesium plasma levels can best be explained by which of the following?

A 38-year-old G 1PO at 38 weeks who has had an uncomplicated course during this pregnancy presents for a routine 38-week prenatal visit. Her vital signs are P 72 beats/min, R 16 breaths/min, BP 180/110 mmHg.

Which of the following conditions provide support for a suspected diagnosis of severe preeclampsia?

A 42-year-old woman, G2P1, is currently at 35 week's gestation. Her BPs have remained 160/110 on two separate occasions over the past 6 hours. Labetalol successfully normalizes the BP. She complains of a severe headache that improves slightly with acetaminophen. A CBC reveals a WBC count of 6.8, hemoglobin of 13.2, and platelet count of 150,000. Ultrasound (U/S) reveals a mildly growth-restricted fetus in vertex presentation with a biophysical profile (BPP) of 8/10.

Which statement is correct regarding management of this patient?

A 29-year-old G2P1 woman at 41 week's gestation with gestational diabetes presented 12 hours ago in active labor. The estimated fetal weight is 3,900 g. Her previous vaginal delivery was uncomplicated and her infant weighed 3,700 g. She progressed normally through labor and has pushed for 2 hours. She is exhausted and requesting "help" with the vacuum. During an informed consent discussion, shoulder dystocia is discussed. Of the following complications associated with shoulder dystocia, which is the most common?

A 39-year-old woman at 41 week's gestation G3P2 is delivering an infant with estimated fetal weight of 4,200 g. The second stage lasted 45 minutes and she is pushing effectively. When the head crowns, you note a "turtle sign:'

What would be your first maneuver?

A 23-year-old G2P0100 at 25 weeks presents with a complaint of loss of fluid vaginally. The fluid was copious and clear. Assessment by sterile speculum examination reveals vaginal pooling; ferning was noted under the microscope and nitrazine paper turned blue. She is very worried because she lost her first son about 4 weeks after he was born at 26 weeks due largely in part to severe respiratory distress. To reassure her, you discuss using antenatal corticosteroids.

Which of the following is the most correct statement with respect to antenatal corticosteroids?

A 24-year-old primigravida is transferred from an outlying hospital because they do not have a neonatal intensive care unit. She is currently 26 weeks, 3 em dilated, and contracting regularly. The transport will take 90 minutes. She will be accompanied by an EMT with little labor and delivery (L&D) experience.

Which tocolytic agent will be the safest for this person to manage?

A 26-year-old woman, G4P3021, is found to have a low-lying placenta during routine anatomy screen at 18 weeks. Her first child was stillborn at term due to a vasa previa. She is very concerned because the stillbirth was also associated with a low-lying placenta found at the secondtrimester routine ultrasound (U/S).

Which of the following represents the best technique to evaluate this pregnancy for the presence of vasa previa?

A 24-year-old G2P1001 at 38 4/7 presents to labor and delivery (L&D) with complaints of a steady amount of painless vaginal bleeding immediately following rupture of membrane (ROM) approximately 2 hours earlier. Since that time, she has not felt the baby move. Fetal heart tones (FHTs) cannot be detected via Doppler. A bedside ultrasound (U/S) reveals no cardiac activity. A formal U /S confirms a fetal demise. Vital signs: BP 98/72 mmHg, P 78 beats/min, R 20 breaths/min. The physical examination is normal. Sterile speculum examination is fern, pooling, and nitrazine positive. CBC = WBC 10.3, Hgb 12.1, hematocrit (HCT) 35.2, platelets 350K.

What is the most likely finding upon delivery of the placenta?

A G3P2 at term was just checked and found to be 7 cm. At that point, amniotomy was performed, and bright red bleeding was noted. The fetal heart tracing that had been reactive until this point dropped to 60 immediately after artificial rupture of membrane (ROM) and then decreased to 40 beats/min verified by internal scalp electrode.

What is the most important intervention?

A primigravid patient from your clinic presents to the hospital with excessive vomiting. She is 14-week gestational age (GA) dated by last menstrual period (LMP) and has lost 15 lb since becoming pregnant. On physical examination, you note a dry oral mucosa and poor capillary refill. You decide to admit her to the hospital, and she is started on IV fluids and antiemetics. Her blood sugar and other vitals are stable.

Which of the following tests should be included in your evaluation of her condition?

A 24-year-old G2P1 at 24 weeks presents to the hospital with a fever of 102.1, severe right flank pain, and urine dip positive for nitrates.

What is your plan for this patient?

A patient is being discharged to home after inpatient treatment of pyelonephritis. She will continue oral antibiotics for a total of 10 to 14 days to complete her treatment of the infection.

What will you advise after her follow-up visit?

A 33-year-old G3P1102 presents to the prenatal clinic for her 37-week appointment. She denies any medical complaints but states that she wants this pregnancy to be over. Her BP is 122/75 with a pulse of 66 beats/min and a fundal height of 38 em. Her last ultrasound (U /S) showed that the fetus was in the frank breech position with an amniotic fluid index (AFI) of 15 em. Leopold maneuvers today confirm the same position.

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

A 22-year-old G 1PO at 32 weeks presents to the obstetrical (OB) clinic complaining of malodorous vaginal discharge for the past 18 hours. The patient denies fever, abdominal cramping, vaginal bleeding, or dysuria. Vaginal examination shows a copious amount of fluid in the vaginal vault. Laboratory examination reveals a clear to whitish, mildly odorous fluid with 0 to 5 WBCs/high power field, 0 to 5 RBCs, and a few budding yeast. Ferning is noted in the report.

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

A 38-year-old G5P3013 woman presents to clinic at 19 weeks. You are concerned due to fundal height of23 em. In-office ultrasound (U/S) reveals an active fetus with measurements consistent with 19 weeks. The fetal HR is in the 140s and multiple small echodense areas are noted in the uterine wall.

What is the most effective treatment of this patient's condition?

A 35-year-old G2P0101 Hispanic woman at 34 weeks presents for a prenatal visit. The patient is dated by last menstrual period (LMP) as this is her first visit to the clinic. She complains of swollen feet and difficulty sitting. Her BP is 110/65 with a pulse of 85 beats/min. Fetal HR is 135 mmHg, and fundal height is 44 cm.

What would you expect to find on ultrasound (US)?

A 15-year-old G1PO at 41 weeks presents to triage in active labor and is admitted to labor and delivery (L&D). On examination, it is noted that her membranes are intact and her cervix is 5 em dilated, 90% effaced, and at -1 station. Upon review of her chart, it is noted that her last ultrasound (U IS) showed an amniotic fluid index (AFI) of 4 em. Fetal heart tracing is reactive with intermittent accelerations and variable decelerations.

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

A 31-year-old G2P1001 presents to the emergency room (ER) at 8 week's gestation complaining of heavy vaginal bleeding over the past week and is concerned about the well-being ofher baby. As part of her workup, the ER draws a quantitative �-hCG that is reported as 1,850 lUlL. You are consulted to see the patient on the obstetrical (OB) or gynecologic team. After interviewing the patient, the physical examination is performed and reveals a closed cervix, 10 to 15 mL of blood, and no tissue in the vaginal vault.

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

A 20-year-old G3P0111 with no prenatal care presents with bleeding and abdominal pain. She is uncooperative but appears to be in good health. You obtain her obstetrical (OB) history remarkable for previous preterm birth at 34 weeks for preeclampsia and a spontaneous abortion. Her vital signs are as follows: BP 150/105, P 100, R 18, T 99. She appears to be in moderate pain. Fetal heart tones (FHTs) are noted in Figure 6-5.

The monitor strip can be described as:

The nurse notes that the fundus is tender when the monitors were applied. Fundal height is 35 em. She denies trauma, recent intercourse, and cocaine or other drug use.

What is the most urgent clinical question you must make answer?

A quick ultrasound (U /S) reveals breech presentation with anterior placenta with no retroplacental accumulation of blood. A quick fetal head measurement is consistent with 34 week's gestation. A pelvic is remarkable for 200 mL of clot and active bright red bleeding. The cervix is 1 em, thick and high.

What is your next step?

The patient undergoes emergency Cesarean section and is delivered of a viable male Apgar score of 2/4/8 weighing 2,100 g. Estimated blood loss is 1,500 mL. She is transfused 4 units of blood.

What blood work would you order intraoperatively?

You are shadowing the genetic counselor who is seeing a young couple with abnormal quad screen at 17 weeks dated by last menstrual period (LMP) and ultrasound (U/S). The patient is a 24-year-old Latin American woman G2P0010 now at 19 weeks with a negative history except for a previous spontaneous abortion at 8 weeks and normal prenatal course thus far. The quad screen risk factor for Down syndrome is 1 in 8.

What would you recommend to this couple?

You are following up A.G., a 34-year-old G3P1102 at 35 weeks who had a previous classical Cesarean at 29 weeks with her last pregnancy for breech presentation with preterm premature rupture of membranes (PPROM) and labor at 26 weeks. The maternal fetal medicine specialist recommends delivery before the onset of labor because of her uterine scar. She is a gestational diabetic on insulin and is having twice weekly nonstress testings (NSTs) and weekly biophysical profiles (BPPs) and you are called because of a score of 2 on her BPP and a nonreactive NST.

What is your next step?

A 23-year-old G 1PO presents to the emergency room (ER) complaining of contractions and fluid loss. She has had no prenatal care, but her gestational age (GA) is around 36 to 38 weeks by her last menstrual period (LMP). Her fundal height is 34 em. She labors for several hours and gives birth to a male infant weighing 2,200 g who has small palpebral fissures, a thin lip, and head circumference less than the 1Oth percentile.

What substance is the most likely cause of this infant's appearance?

A 40-year-old G2P0010 at 10 week's gestation presents to your clinic to discuss her options for genetic testing. She previously had an elective termination at 17 weeks after genetic tests revealed trisomy 18. She would like to know if the current pregnancy is also affected by a genetic abnormality.

Which of the following tests will allow for the earliest and most definitive diagnosis of genetic abnormalities?

A 37-year-old G4P2012 at 18 week's gestation presents to your clinic to discuss the results of her recent quadruple screen. The results of the quad screen are as follows: decreased Amniotic a-fetoprotein (AFP), increased hCG, decreased estriol, increased inhibin A. She is concerned about the results and would like further evaluation.

What is the next step in evaluating this patient's risk of aneuploidy?

A 29-year-old G 1PO at 24 week's gestation presents for routine prenatal care. She had a prepregnancy BMI of32 kg/m2 and has gained 18lb since her first visit at 8 week's gestation. Her pregnancy has been uncomplicated so far and a 20-week ultrasound (U/S) revealed normal fetal anatomy.

What is the patient's most likely complication this pregnancy?

A 34-year-old G2Pl001 at 12 week's gestation presents to your clinic following an abnormal first-trimester screen. She desires genetic testing for further evaluation. You explain the risks and benefits and she decides to have an amniocentesis performed during the second trimester.

Had the patient chosen chorionic villus sampling (CVS) before 10 weeks, which of the risks would be of specific concern?

A 24-year-old G 1PO at 18 week's gestation presents for initiation of prenatal care. Her past medical history is significant for asthma for which she occasionally uses an albuterol inhaler. Her last Pap smear revealed atypical cells of undetermined significance. She reports drinking four alcoholic beverages per week prior to pregnancy. She has smoked for 8 years.

How is this pregnancy most likely to be affected by her history?

A 22-year-old G 1PO at 19 weeks presents to discuss the results of her recent quad screen. She was diagnosed with epilepsy as a child and was taking valproic acid until she discovered that she was pregnant at 12 week's gestation. Assuming that the pregnancy has been affected by valproic acid, you expect her quad screen results will mirror the results seen with which of the following disorders?

A couple has just learned by a third-trimester ultrasound (U/S) that their baby has a decreased femur length compared with biparietal diameter as well as other findings highly suspicious for dwarfism. Both parents are of normal height and deny any dwarfism in their family. The mother is 34 years old and otherwise healthy. She reports compliance with prenatal vitamins, takes no other medications, and has had no complications throughout the pregnancy. The father is 42 years old and is otherwise healthy.

What is the most likely interpretation of these results?

A 28-year-old woman G3P2 at 25 weeks has just moved to the United States from Eastern Europe. As part of her routine health screening she received a purified protein derivative (PPD) test and now presents to the clinic for her results. She currently denies any fever, shortness of breath, cough, wheezing, or chest pain. She denies any previous vaccinations or regular medical care previously. Her injection site shows 10-mm induration.

What is the next best step in management?

A 34-year-old woman presents to the emergency room (ER) after experiencing intense vaginal bleeding, abdominal pain, and passage of clots and possibly tissue. She is uncertain of when her last menstrual period (LMP) occurred. She has had three previous term pregnancies. She says that she had not suspected pregnancy because of a history of irregular periods. Earlier in the day, she had intense abdominal cramping following episodes of bleeding and passage of clots. The bleeding and cramping increased over the next few hours. She reports continued cramping and bleeding. She is afraid and tearful. She says she has never experienced anything like this. Her vital signs are BP 135/75 mmHg, HR 80 beats/min, RR 18 breaths/min, T 98.9. Pelvic examination reveals an 8-week sized boggy uterus with an open cervical os and brisk active bleeding. There is no adnexal fullness or tenderness. Your transvaginal probe is broken. What is the next best step in management?

An African American married couple has met with a genetic counselor in order to discuss pregnancy. The man reports that he has never been genetically tested but does not have sickle cell disease. He reports that his father had sickle cell disease. His mother did not have the disease. The woman was adopted and does not know her family history but has never been diagnosed with the disease. They want to know the risk of their baby having sickle cell disease. You decide to do further testing to ascertain the carrier status of the woman. Testing reveals she is a carrier.

What would be the risk of their child developing sickle cell disease?

A 29-year-old G1P0010 patient comes to see you for the first time in clinic to establish routine care. She mentions to you that she is not using any contraception methods and that she and her husband are hoping to have children someday soon. She has no known medical conditions or surgical history and takes no medications. The noted vitals are within normal ranges and she has a BMI of24. Her family history is unremarkable and she has no gynecologic complaints at this time. She has questions about attempting pregnancy. You learn that her previous abortion was spontaneous and within the first trimester. The most common genetic anomaly associated with first-trimester pregnancy loss is:

A 23-year-old woman G 1 last menstrual period (LMP) 6 weeks ago comes into the emergency room (ER) with vaginal bleeding and cramping abdominal pain. Pregnancy is confirmed by �-hCG of 4,200 miU/ mL. She is surprised by the news of pregnancy. She denies any use of illicit substances, tobacco, or alcohol. She reports a diagnosis of chlamydia 2 years ago that was treated. Her last Pap smear was 7 months ago. She is sexually active and lives with her boyfriend. She works at a bar in the evenings and attends community college. She reports diffuse lower abdominal pain as a 5/10 with cramping. BP is 125/73 mmHg, HR 75 beats/min, RR 16 breaths/min, T 98.8. Pelvic examination reveals a closed cervical os, mild active bleeding, 6-week sized boggy uterus, and no adnexal masses.

What is the best next step in management?

A 28-year-old G2P1 is seen in your clinic for her initial obstetrical (OB) visit. Vitals today are BP 110/72 mmHg, HR 75 beats/min, RR 15 breaths/min, T 98.0. Her last menstrual period (LMP) was 8 weeks ago. She denies any spotting or discharge. She reports a weight gain of about 5 lb over the past 2 months. She reports taking prenatal vitamins and continuing her exercise regimen. She delivered a 7 lb 2 oz baby vaginally 3 years ago without any complications. She has no family history of any genetic disorders. She reports to you that she adheres to a diet rich in fish and vegetables. Upon further questioning, she tells you that she mostly eats canned albacore tuna.

What are the best recommendations you can give her about how much she should consume weekly?

A 25-year-old primigravida with gestational hypertension presents to your clinic for routine prenatal care. She is now at 37-week gestational age (GA) with dates confirmed by first-trimester ultrasound (U/S). In clinic, she has a BP of 150/85 and you are considering delivering her early due to potential complications from her disease. Her urine protein is negative and she denies any headache, vision changes, or abdominal pain.

Which of the following test results would be most reassuring that the fetus would not have respiratory distress after birth?