A 26-year-old G1P0 woman at 39 weeks’ gestation is admitted to the hospital in labor.

A 26-year-old G1P0 woman at 39 weeks’ gestation is admitted to the hospital in labor. She is noted to have uterine contractions every 7 to 10 minutes. Her antepartum history is significant for a nonimmune rubella status.
On examination, her blood pressure (BP) is 110/70 mm Hg and heart rate (HR) is 80 beats per minute
(bpm). The estimated fetal weight is 7 lbs.
On pelvic examination, she has been noted to have a change in cervical examinations from 4-cm dilation to 7 cm over the last 2 hours. The pelvis is assessed to be adequate on digital examination.

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

Next step in Management: Continue to observe the labor.

Learning Objectives In this Case

1. Know the normal labor parameters in the latent and active phase for nulliparous and multiparous patients.
2. Be familiar with the management of common labor abnormalities and know that normal labor does not require intervention.
3. Know that rubella vaccination, as a live-attenuated preparation, should not beadministered during pregnancy.

Case Discussion:

Diabetes In Pregnancy - Study Questions & Answers

A 30 year old woman with diabetes mellitus presents to her physician  at 19 weeks’ gestation. She is obese and did not realize that she was pregnant until recently. She also has not been “watching her sugar” lately, but is now motivated to improve her regimen. 

A dilated ophthalmologic examination shows no retinopathy. An ECG is normal.
Urinalysis is negative for proteinuria. 

Laboratory studies show:

• HbA1c : 10.8%

• Glucose : 22 mg/dl

• TSH : 1.0 microU/ml

• Free thyroxine: 1.7 ng/dL

• Creatinine: 1.1 mg/dL.

Question: Which of the following condition has the same risk of developing in diabetics as the general population.

a. Asymptomatic bacteriuria

b. Preeclampsia

c. Congenital adrenal hyperplasia

d. PPH after delivery

e. Shoulder dystocia

Answer: c. Congenital adrenal hyperplasia

Question:  A 30-yrs-old G3P2 patient visits an antenatal clinic at 20 weeks. She reveals during history that her first baby was 4.6 kg delivered by cesarean section, second baby was 4,8 kg delivered by c/section. Gynaecologists suspects gestational diabetes and orders a Glucose tolerance test. The blood sugar levels after 50 gms of oral glucose are 206 mg/dl and the patient is thus confirmed as a case of gestational diabetes. 

Rates of successful pregnancy following three spontaneous losses (repeated miscarriages) are

Rates of successful pregnancy following three spontaneous losses (repeated miscarriages) are
a. Very poor
b. Slightly worse than those in the baseline population
c. No different from those in the baseline population
d. Just under 50%
e. Good unless cervical incompetence is diagnosed

Answer:

Physiological changes in pregnancy: uterus and cervix - Extended matching question

Physiological changes in pregnancy: uterus and cervix - Extended matching question

A Oestradiol
B Prostaglandins
C Progesterone
D Cortisol
E Collagenase
F Prolactin
G Human chorionic gonadotrophin (HCG)
H Adrenocorticotrophic hormone (ACTH)
I Oxytocin

For each description below, choose the SINGLE most appropriate answer from the above list of options. Each option may be used once, more than once, or not at all.

1 Levels approximately 15 times higher in third trimester than in non-pregnant state.
2 Induces the process of cervical remodelling.
3 Regulates local uterine blood flow through endothelial effects.
4 Utilized in triple test.
5 Released from posterior pituitary gland.

Answers:

Case Discussion - A Woman Presenting for Preconceptional Counseling ...

Mrs B, 24 years old had a previous baby with Down syndrome who is now one year old.She is desirous of further childbearing but is apprehensive about similar problem in the next baby and has come for preconceptional counseling. The karyotype of the affected child showed Trisomy 21 (47,XY).

Approach to the Case: 

Points to be asked in History
• Age of the mother at delivery
• Period of gestation at which the pregnancy was registered
• First trimester scan for nuchal translucency
• Whether first or second trimester screening was done
• Second trimester anomaly scan
• Pregnancy outcome: Miscarriage, stillborn or live born

She mentions that her first pregnancy was a spontaneous conception. She sought antenatal care at 20 weeks of pregnancy. She had a term delivery at a hospital of a small for gestational age baby. The baby had mongoloid facies and a ventricular septal defect was diagnosed. The baby had delayed milestones and on investigations the baby was diagnosed with Trisomy 21.

What recurrence risk would you attribute to this lady?
Down’s syndrome cases result from nondisjunction, translocation or mosaic. With a pregnancy complicated by trisomy 21 from nondisjunction, the woman has 1% risk of having a pregnancy with trisomy in subsequent pregnancy. This risk pertains unless her age related risk exceeds it. Because of this risk, she would be offered invasive prenatal diagnosis. Parental karyotype is not indicated in this
couple.

What is the incidence of Down syndrome in general population?
Down’s syndrome occurs in 1 in 800 to 1 in 1000 newborns

Case Discussion - Cardiac Failure Developing On 3rd day Postpartum

A 27 year old female para 2 (h/o of both LSCSs), on the 3rd postoperative day of caesarean develops sudden cardiac failure.
– She has weakness, shortness of breath, palpitation, nocturnal dyspnea and cough.
– O/E- Tachycardia, arrhythmia, peripheral edema, pulmonary rales are present. S3 is present but no murmur is heard.
– She had been a booked patient with regular antenatal checkups and with no prior heart problem and uneventful prior obstetric history.

What is the probable diagnosis?

Case Discussion:
The diagnosis of peripartum cardiomyopathy should be kept in mind in all such cases.

The criteria for diagnosis are:
1. Cardiac failure within last month of pregnancy or within 5 month postpartum.
2. No determinable cause for failure (may be immunological or nutritional).
3. No previous heart disease.
4. Left ventricular dysfunction (Echocardiography) as evidenced by ejection fraction < 45%
5. Left ventricular end-diastolic dimension > 2.7 cm/m2.

Regarding chromosomal aberrations in spontaneous miscarriages...

A 24-year-old woman has had three first-trimester spontaneous miscarriages.
Which of the following statements concerning chromosomal aberrations in miscarriages is true?
a. 45,X is more prevalent in chromosomally abnormal term babies than in abortus products
b. Approximately 20% of first-trimester spontaneous abortions have chromosomal abnormalities
c. Trisomy 21 is the most common trisomy in abortuses
d. Despite the relatively high frequency of Down syndrome at term, most Down fetuses abort spontaneously
e. Stillbirths have twice the incidence of chromosomal abnormalities as live births

Answer:

Regarding Gravidity and Parity...

Regarding Gravidity and Parity...

A G1 P0
B G4 P2
C G0 P0
D G3 P3
E G2 P1
F G1 P2
G G6 P0
H G5 P2
I G1 P1
J G3 P1
K G4 P3
L G2 P0

For each description below, choose the SINGLE most appropriate answer from the above list of options. Each option may be used once, more than once, or not at all.

1 A woman currently pregnant who has had a previous term delivery.
2 A woman not currently pregnant who has had one previous termination, one early miscarriage and one stillbirth at 36/40.
3 A woman who attends for pre-conception counselling, never having been pregnant.
4 A woman currently pregnant with twins who has had one previous early miscarriage.
5 A woman not currently pregnant who previously had a twin delivery at 28/40.

Answers:

Neural tube Defects - A Case Study

Mrs X 30 years old G3 P 2+0  (no living child) with history of both pregnancies affected by neural tube defects (NTD) presented at 8 weeks and 3 days period of gestation. In the first pregnancy patient had conceived spontaneously after one year of marriage and did not seek any antenatal care. Patient delivered at a hospital and anencephaly was detected at birth. However, no comment was made on presence or absence of other anomalies. In the second pregnancy she booked at fifteen weeks pregnancy and had level 2 ultrasound at 19 weeks of gestation. She was diagnosed as occipitomeningomyelocele and opted to terminate the pregnancy. On neonatal review the diagnosis of occipitomeningomyelocele was confirmed and no other gross congenital anomalies were detected.
The parents did not consent for postmortem autopsy or chromosomal study.

Other relevant questions to ask in history: 
Present Pregnancy
• Gestational age
• History of exposure to drugs particularly which interfere with folic acid metabolism
• Any history of hyperthermia and hyperglycemia
• Intake of folic acid in periconceptional period
• History of consanguinity.

History of Previous Pregnancies
• Any history of folic acid intake in periconceptional period.
• History of hyperthermia or hyperglycemia in periconceptional period.
• History of antifolate drug intake in periconceptional period.
• Mode of diagnosis of NTDs (prenatal ultrasound, postnatal diagnosis)
• Associated malformations and dysmorphisms to delineate genetic disorders
• Fetal autopsy done or not
• Fetal karyotype done or not
• Family history of neural tube defects.

Examination
In the first half of pregnancy, there may not be anything remarkable in the examination. However, with advanced gestational age, polyhydramnios may cause increased fundal height and presence of
fluid thrill. The presentation of the fetus may be breech or face.

Heart Diseases in Pregnancy

Regarding heart diseases in pregnancy answer the following questions:

1. Which cardiovascular change is not physiological in pregnancy:
a. Split 1st heart sound
b. Mid diastolic murmur
c. Shift of apex beat to 4th ICS and outwards
d. Decreased peripheral vascular Resistance.

Answer: b. Mid diastolic murmur

2. Indication for cesarean section in pregnancy is:
a. Mitral stenosis
b. Aortic aneurysm
c. PDA
d. Transposition of great vessels

Answer: b. Aortic aneurysm

3. Surgery for mitral stenosis during pregnancy is done at:
a. 8 wks
b. 10 wks
c. 14 wks
d. 22 wks

Answer: c. 14 wks

4. Which of the following disease has worst prognosis during pregnancy:
a. Pulmonary stenosis
b. Mitral stenosis
c. VSD
d. ASD

Answer: b. Mitral stenosis

5. All of the following are predictors of cardiac event during pregnancy except:
a. NYHA class>3
b. Obstructive lesion of the heart (mitral valve and aortic valve <1 cm2
c. Previous H/O heart failure
d. Ejection fraction <40%.

Answer: a. NYHA class>3

Discussion:

Regarding the chances of recurrence after first spontaneous miscarriage...

After an initial pregnancy resulted in a spontaneous loss in the first trimester, your patient is concerned about the possibility of this recurring.
An appropriate answer would be that the chance of recurrence
a. Depends on the genetic makeup of the prior abortus
b. Is no different than it was prior to the miscarriage
c. Is increased to approximately 50%
d. Is increased most likely to greater than 50%
e. Depends on the sex of the prior abortus

Answer:

Regarding Hypermagnesemia...

A pregnant woman in her 32nd week of gestation is given magnesium sulfate for pre-eclampsia. The earliest clinical indication of hypermagnesemia is
a. Loss of deep tendon reflexes
b. Flaccid paralysis
c. Respiratory arrest
d. Hypotension
e. Stupor

Answer:

Regarding Pre-existing maternal conditions

From the list given below regarding the pre existing maternal conditions choose an option for each description:
A Diabetes
B Hypertension
C Epilepsy
D Vitiligo
E Factor V Leiden deficiency
F HIV
G Asthma
H Smoking
I Crohn’s disease
J Mitral valve stenosis
K Myasthenia gravis
L Glomerulonephritis

1 Reduces intrauterine growth in a dose-dependent manner.
2 Increases risk of venous thromboembolism (VTE) in the puerperium.
3 Increased frequency of episodes during pregnancy.
4 Risk of fetal macrosomia if condition not well controlled.
5 Maternal muscle fatigue in labour.
6 Requires prophylactic antibiotics for instrumental delivery.

Answers:

Hepatitis B and Pregnancy

A baby is born to a mother who is known to have chronic hepatitis B. The mothers latest results are as follows:
HBsAg Positive , HBeAg Positive
What is the most appropriate strategy for reducing the vertical transmission rate?
A. Give the newborn hepatitis B vaccine + hepatitis B immunoglobulin
B. Give the newborn hepatitis B vaccine
C. Give the newborn hepatitis B immunoglobulin
D. Give the mother intravenous zidovudine during labour
E. Give the mother hepatitis B immunoglobulin shortly before birth + the newborn hepatitis B vaccine

Answer:

Maternal Heart Conditions With An Unacceptably High Risk In Pregnancy?

A 32-year-old woman with a history of congenital heart disease is planning to start a family. She has no other significant medical history and is currently symptomatically stable on a small dose of loop diuretic.

Question
Which one of the following conditions is associated with an unacceptably high risk in pregnancy?
A Corrected tetralogy of Fallot
B Perimembranous ventricular septal defect
C Secundum atrial septal defect
D Coarctation of the aorta
E Pulmonary hypertension of any cause

Answer:

Regarding Use Of Folic Acid Before Planning A Pregnancy

A 25-year-old woman presents for preconception counseling. She wants to know more about nutrition, particularly about folic acid. She has read a lot about it in magazines. You can tell her that:

A. Folic acid supplementation is associated with an increased level of alpha-fetoprotein in maternal serum.
B. She needs to take either a prenatal vitamin or a supplement that provides at least 4 mg (4,000 µg) of folic acid.
C. She needs to start folic acid supplementation as soon as her pregnancy test is positive.
D. Most women get enough folic acid through their diet.
E. Folic acid requirements are higher in women with type 1 diabetes mellitus.

Answer And Discussion:

Risk Of Epidural Anesthesia During LAbor

In discussing the risk of placing an epidural during labor, you explain to your patient that
A) The ACOG (The American Congress of Obstetricians and Gynecologists) recommends that epidural anesthesia in nulliparous women is not recommended until cervical dilation has reached 4 to 5 cm regardless of maternal request.
B) Early epidural anesthesia increases the risk of cesarean section.
C) Epidural anesthesia may increase the rate of vacuum extraction.
D) Epidural anesthesia has no effect on the length of the second stage of labor.
E) Epidural anesthesia is of little help with pain management in early labor.

Answer and Discussion
The answer is

Managing A 31 Year Old G2P1 At 41 Weeks Gestation (Case Study)

Case Scenario: You are seeing a 31-year-old G2 P1 at 41 weeks gestation by definite last menstrual period and 16-week ultrasound. She continues to note fetal movement and her examination is normal: BP 120/68, urine dipstick negative for protein and glucose, fundal height 42 cm, vertex, FHR 156. Her cervix is soft, anterior, 2–3 cm dilated, 50% effaced, and +1 station. She was induced with her first pregnancy, and this time she wants to have a “natural labor.”

Q 1. You decide to check a Bishop score. The Bishop score helps to determine:
A) The health of the fetus.
B) The likely success with induction.
C) The maturity of the fetal lungs.
D) The results of a Catholic Intramural Baseball game.

Answer And Discussion
The correct answer is “B.” The likely success with induction
The Bishop score, which takes into account cervical dilation, cervical effacement, station of the infant, and cervical consistency, can be used to predict the likelihood of a successful induction.

Q 2. The Bishop score is favorable.
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 gestation.
B) Since her antepartum course has been uncomplicated to date, it is safe for her to await spontaneous labor until 43 weeks gestation.
C) She should undergo a nonstress test and ultrasound for amniotic fluid index.
D) She should plan for a cesarean section.

Answer And Discussion

Most Common Cause Of Postpartum Bleeding

The most common cause of postpartum bleeding is
A) Retained placenta
B) Vaginal laceration
C) Uterine atony
D) Coagulopathy
E) HELLP syndrome

Answer and Discussion

Over-the-counter Medications That Should Be Avoided In Pregnancy

Which of the following over-the-counter medications is generally avoided during pregnancy?
A) Acetaminophen
B) Chlorpheniramine
C) Pseudoephedrine
D) Dextromethorphan
E) Aspirin

Answer and Discussion