147. A 29-year-old G1 at 9 weeks’ gestation presents to your office for a new OB visit. She reports a history of well-controlled hypothyroidism. She takes 88 mcg of levothyroxine daily. How do you expect her thyroid laboratory values to change during pregnancy?

148. A 19-year-old P0 presents for her first OB visit at 10 weeks’ gestation. You order routine OB laboratory tests, and it returns showing a positive nucleic acid probe for Neisseria gonorrhoeae. One year ago, she was treated with ampicillin for a simple urinary tract infection and developed a severe allergic reaction. Which of the following is the best option for treatment at this time?

149. A 22-year-old pregnant woman has just been diagnosed with toxoplasmosis. Which of the following risk factors is most likely to have contributed to her diagnosis?

150. A 17-year-old woman at 22 weeks’ gestation presents to the emergency department with a 3-day history of nausea, vomiting, and abdominal pain. The pain started in the middle of the abdomen, and is now located along her mid-to-upper right side. She is noted to have a temperature of 38.4°C (101.1°F). She reports no prior medical problems or surgeries. How does pregnancy alter the diagnosis and treatment of the disease?

151. A 24-year-old P1001 presents at 8 weeks’ gestation and reports a history of pulmonary embolism 3 years ago during her first pregnancy. She was treated with intravenous heparin followed by several months of oral warfarin (coumadin) and has had no further evidence of thromboembolic disease. How should her current pregnancy be managed?

152. A 29-year-old G3P2 black woman in the 33 week of gestation is admitted to the emergency room because of acute abdominal pain that has been increasing during the past 24 hours. The pain is severe and is radiating from the epigastrium to the back. The patient has vomited a few times and has not eaten or had a bowel movement since the pain started. On examination, you observe an acutely ill patient lying on the bed with her knees drawn up. Her blood pressure is 100/70 mm Hg, her pulse is 110 beats per minute, and her temperature is 38.8°C (101.8°F). On palpation, the abdomen is somewhat distended and tender, mainly in the epigastric area, and the uterine fundus reaches 31 cm above the symphysis. Hypotonic bowel sounds are noted. Fetal monitoring reveals a normal pattern of fetal heart rate (FHR) without uterine contractions. On ultrasonography, the fetus is in vertex presentation and appropriate in size for gestational age; fetal breathing and trunk movements are noted, and the volume of amniotic fluid is normal. The placenta is located on the anterior uterine wall and no previa is seen. Laboratory values show mild leukocytosis (12,000 cells per mL); a hematocrit of 43%; mildly elevated serum glutamicoxaloacetic transaminase (SGOT), serum glutamic-pyruvic transaminase (SGPT), and bilirubin; and serum amylase of 180 U/dL. Urinalysis is normal. Which of the following is the most likely diagnosis?

153. An 18-year-old G1 is diagnosed with asymptomatic bacteriuria (ASB) at her first prenatal visit at 15 weeks’ gestation, based on a urine culture performed as part of her routine new OB laboratory findings. What is the next step in management?

154. A 20-year-old G1 at 18 weeks of gestation is hospitalized for intravenous antibiotics for the treatment of acute pyelonephritis. She develops shortness of breath and is found to have tachypnea and decreased oxygen saturation. Chest x-ray reveals pulmonary infiltrates consistent with pulmonary edema. What is the most likely cause of this complication?

155. A 30-year-old G1 at 6 weeks’ gestation by last menstrual period presents for prenatal care. Her past medical history is significant for type 1 diabetes, which was diagnosed at the age of 14.

What should you tell her about her insulin requirements during pregnancy?

156. A 30-year-old G1 at 6 weeks’ gestation by last menstrual period presents for prenatal care. Her past medical history is significant for type 1 diabetes, which was diagnosed at the age of 14.

Which of the following is the most common birth defect associated with diabetes?

157. A 30-year-old G1 at 6 weeks’ gestation by last menstrual period presents for prenatal care. Her past medical history is significant for type 1 diabetes, which was diagnosed at the age of 14.

Which of the following diabetic complications is most likely to be permanently worsened by pregnancy?

158. A 33-year-old woman at 10 weeks’ gestation presents for her first prenatal visit. Routine laboratory findings are drawn, and her hepatitis B surface antigen is positive. Liver function tests are normal and her hepatitis B core and surface antibody tests are negative. Which of the following is the best way to prevent neonatal infection?

159. A 38-year-old G1P0 presents to the obstetrician’s office at 37 weeks’ gestation complaining of a rash on her abdomen that is becoming increasingly pruritic. The rash started on her abdomen, and is starting to spread downward to her thighs. She reports no previous history of any skin disorders or problems, and she reports no malaise or fever. On physical examination, she is afebrile and her physician notes that her abdomen, and most notably her stretch marks, is covered with red papules and plaques. No excoriations or bullae are present. The patient’s face, arms, and legs are unaffected by the rash. Which of the following is this patient’s most likely diagnosis?

160. A 25-year-old G2P0 at 30 weeks’ gestation presents with the complaint of intense itching that is worse on the palms and soles of her feet, and is worse at night. Her physical examination does not show any evidence of rash, but she has obvious excoriations from scratching on her abdomen.

Which of the following tests would be most likely to confirm your suspected diagnosis?

161. A 25-year-old G2P0 at 30 weeks’ gestation presents with the complaint of intense itching that is worse on the palms and soles of her feet, and is worse at night. Her physical examination does not show any evidence of rash, but she has obvious excoriations from scratching on her abdomen.

What is the best next step in treatment for this pregnancy complication?

162. A 23-year-old G3P2002 presents for a routine visit at 34 weeks’ gestation. She reports a history of genital herpes for 5 years. She says that she has had only two outbreaks during the pregnancy, but is very concerned about the possibility of transmitting this infection to her baby. How should you counsel this patient regarding her management during this pregnancy?

163. A 37-year-old G3P2 presents to your office for her first OB visit at 10 weeks’ gestation. She has a history of Graves disease and has been maintained on propylthiouracil (PTU) as treatment for her hyperthyroidism. She is currently euthyroid but asks you if her condition poses any problems for the pregnancy. Which of the following statements should be included in your counseling session with the patient?

164. A 40-year-old P2002 at 37 weeks presents for her routine OB visit. Her pregnancy has been complicated by obesity and gestational diabetes mellitus (GDM) that has been well controlled with diet. Her blood sugar log shows that her fasting and postprandial values have all been within the normal range. Her fetus has an estimated fetal weight of 6½ lb by Leopold maneuvers.

Which of the following is the best next step in her management?

165. A 40-year-old P2002 at 37 weeks presents for her routine OB visit. Her pregnancy has been complicated by obesity and gestational diabetes mellitus (GDM) that has been well controlled with diet. Her blood sugar log shows that her fasting and postprandial values have all been within the normal range. Her fetus has an estimated fetal weight of 6½ lb by Leopold maneuvers.

This patient asks you if GDM has any long-term implications for her. Which of the following statements should be included in your counseling?

166. A 36-year-old G1P0 at 35 weeks’ gestation presents to labor and delivery reporting a several-day history of generalized malaise, anorexia, nausea, and emesis. She reports no headache, vision changes, contractions, vaginal bleeding, or leaking fluid. She reports good fetal movement, and the FHR is in the 150s with good variability and no decelerations. On physical examination, you notice that she is mildly jaundiced and appears to be a little confused. Her vital signs indicate a temperature of 37.7°C (99.9°F), pulse of 70 beats per minute, and blood pressure of 100/62 mm Hg. Laboratory data are as follows—WBC = 25,000, Hct = 42.0%, platelets = 51,000, SGOT/PT = 287/350, glucose = 43 mg/dL, creatinine = 2.0 mg/dL, fibrinogen = 135 g/l, PT/PTT = 16/50 s, serum ammonia level = 90 mmol/L (nl = 11-35). Urinalysis is positive for 3+ protein and large ketones.

Which of the following is the most likely diagnosis?

167. A 36-year-old G1P0 at 35 weeks’ gestation presents to labor and delivery reporting a several-day history of generalized malaise, anorexia, nausea, and emesis. She reports no headache, vision changes, contractions, vaginal bleeding, or leaking fluid. She reports good fetal movement, and the FHR is in the 150s with good variability and no decelerations. On physical examination, you notice that she is mildly jaundiced and appears to be a little confused. Her vital signs indicate a temperature of 37.7°C (99.9°F), pulse of 70 beats per minute, and blood pressure of 100/62 mm Hg. Laboratory data are as follows—WBC = 25,000, Hct = 42.0%, platelets = 51,000, SGOT/PT = 287/350, glucose = 43 mg/dL, creatinine = 2.0 mg/dL, fibrinogen = 135 g/l, PT/PTT = 16/50 s, serum ammonia level = 90 mmol/L (nl = 11-35). Urinalysis is positive for 3+ protein and large ketones.

Which of the following is the recommended treatment for this patient?

168. A 32-year-old G1P0 presents for a routine OB visit at 14 weeks’ gestation. Laboratory findings drawn at her first prenatal visit 4 weeks ago showed a platelet count of 60,000/μL. Follow up laboratory findings revealed a normal PT, PTT, and bleeding time. All her other laboratory findings were normal. During the present visit, her blood pressure is 120/70 mm Hg, she has no proteinuria on urine dip, and she reports no complaints. On taking a more in-depth history you learn that, prior to pregnancy, she had a history of occasional nose and gum bleeds, but no serious bleeding episodes. She has considered herself to be a person who just bruises easily. Which of the following is the most likely diagnosis?

169. A 23-year-old G1P0 presents for a routine OB visit at 28 weeks’ gestation. Laboratory findings drawn at her prenatal visit 2 weeks ago reveal a 1-hour glucose test of 128 mg/dL, hemoglobin of 10.8 g/dl, and a platelet count of 80,000/μL. All her other laboratory findings were normal. During the present visit, her blood pressure is 120/70 mm Hg, and her urine dip is negative, and she has no complaints. She has no known medical problems, but does report a history of epistaxis on occasion, but no other bleeding. What is the next step in treatment for her thrombocytopenia?

170. A 21-year-old G2P1 at 25 weeks’ gestation presents to the emergency room with a chief complaint of shortness of breath. She reports a history of asthma, and states her peak expiratory flow rate (PEFR) with good control is usually around 400 L/min. When speaking, the patient has to stop to catch her breath between words; her PEFR is 210. An arterial blood gas is drawn and oxygen therapy is initiated. She is afebrile, and on physical examination expiratory wheezes are heard in all lung fields. Which of the following is the most appropriate next step in her management?

171. A 28-year-old G1 presents at 25 weeks’ gestation complaining of severe left calf pain and swelling. On physical examination, the area of concern is slightly edematous, and the patient demonstrates a positive Homans sign, but no erythema is apparent. Which of the following diagnostic modalities should you order to confirm your suspected diagnosis?

172. A 20-year-old G1 patient delivers a live-born infant with cutaneous lesions, limb defects, cerebral cortical atrophy, and chorioretinitis. Her pregnancy was complicated by pneumonia at 18 weeks.

For each clinical scenario presented later, select the most likely causative agent.

173. A 34-year-old G2 at 36 weeks delivers a growth-restricted infant with cataracts, anemia, patent ductus arteriosus, and sensorineural deafness. She has a history of chronic hypertension, which was well controlled with methyldopa during pregnancy. She had a viral syndrome with rash in early pregnancy.

For each clinical scenario presented later, select the most likely causative agent.

174. A 25-year-old G3 at 39 weeks delivers a small-for-gestational-age infant with chorioretinitis, intracranial calcifications, jaundice, hepatosplenomegaly, and anemia. The infant displays poor feeding and tone in the nursery. The patient denies eating any raw or undercooked meat and does not have any cats living at home with her. She works as a nurse in the pediatric intensive care unit at the local hospital.

For each clinical scenario presented later, select the most likely causative agent.

175. A 23-year-old G1 with a history of a flulike illness, fever, myalgias, and lymphadenopathy during her early third trimester delivers a growth-restricted infant with seizures, intracranial calcifications, hepatosplenomegaly, jaundice, and anemia.

For each clinical scenario presented later, select the most likely causative agent.

176. A 32-year-old G5 delivers a stillborn fetus at 34 weeks. The placenta is noted to be much larger than normal. The fetus appeared hydropic and had petechiae over much of the skin.

For each clinical scenario presented later, select the most likely causative agent.

177. A 38-year-woman at 39 weeks delivers a 7-lb infant (female) without complications. At 2 weeks of life, the newborn develops fulminant liver failure and dies.

For each clinical scenario presented later, select the most likely causative agent.

178. A 20-year-old woman who works as a kindergarten teacher presents for her routine visit at 32 weeks. Her fundal height measures 40 cm. An ultrasound reveals polyhydramnios, an appropriately grown fetus with ascites and scalp edema. The patient denies any recent illnesses, but some of the children at her school have been sick recently.

For each clinical scenario presented later, select the most likely causative agent.

180. A 22-year-old woman delivers a 7-lb male infant at 40 weeks without any complications. On day 3 of life, the neonate develops respiratory distress, hypotension, tachycardia, listlessness, and oliguria.

For each clinical scenario presented later, select the most likely causative agent.

179. A 25-year-old woman in her first pregnancy delivers a 6-lb male neonate at 38 weeks. The newborn develops fever, vesicular rash, poor feeding, and listlessness at 1 week of age.

For each clinical scenario presented later, select the most likely causative agent.