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+--- Thread: 15 16 17 - showman (/showthread.php?tid=375204)
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15 16 17 - showman - ArchivalUser - 01-06-2009
15. A 36-year-old woman, gravida 4, para 3, at 38 weeks™
gestation comes to the clinic for a prenatal visit. She
states that she is feeling well, but has noted decreased
fetal movement. She has had some contractions. She
has had no bleeding from the vagina or loss of fluid.
Her blood pressure is 100/60 mm Hg and pulse is
80/min. Her fundal height is 31 cm. The fetal heart rate
is in the 140s. Cervical examination shows her to be 3
cm dilated, 75% effaced, and at 0 station. Her pregnancy
was dated by an 8-week ultrasound and has been significant
for the fact that she has missed several recent
prenatal visits. Her obstetric history is significant for
three term vaginal deliveries of appropriately grown
fetuses. Given the decreased fetal movement, a nonstress
test (NST) is performed that shows a fetal heart
rate in the 140s with some small accelerations and good
variability, but it is not reactive. An ultrasound shows
the fetus to have an estimated fetal weight of 2000 g
(approximately fiftieth percentile for 32 weeks, but less
than tenth percentile for 38 weeks). The umbilical
artery Doppler evaluation shows absent end diastolic
flow. The most appropriate next step in management is
(A) initiate aspirin therapy
(B) initiate heparin therapy
© perform immediate cesarean delivery
(D) re-date the pregnancy to 32 weeks
(E) start an induction of labor
16. A 31-year-old woman, gravida 3, para 0, comes to the
clinic because of vaginal spotting and abdominal pain.
She states that the spotting has been going on for 1 week
and that the abdominal pain started last night. She has a
history of an ectopic pregnancy in the right fallopian
tube that was treated with methotrexate 2 years ago.Her
past obstetric history is also significant for a spontaneous
abortion at 7 weeks™ gestation.Her temperature is
37.1 C (98.8 F), blood pressure is 116/82 mm Hg, pulse
is 84/min, and respirations are 12/min. Her abdomen is
diffusely tender, worse in the lower quadrants, and there
is rebound tenderness. Speculum examination demonstrates
scant blood in the vagina with uterine and adnexal
tenderness found on bimanual examination.
Laboratory evaluation demonstrates an hCG of 8,100
mIU/mL and a hematocrit of 38%. Transvaginal ultrasound
demonstrates moderate free fluid in the pelvis
with a right adnexal mass measuring 4 × 3 cm. No
intrauterine pregnancy is seen. The most appropriate
management is
(A) laparoscopy
(B) laparotomy
© methotrexate
(D) misoprostol
(E) re-evaluation in 1 week
17. A 39-year-old woman, gravida 2, para 1, at 38 weeks™
gestation comes to the labor and delivery unit because
of contractions. She states that she began contracting
this morning and now her contractions are every
3 minutes. She has had no loss of fluid or bleeding from
her vagina. Her prenatal course was complicated by a
herpes outbreak in the second trimester for which she
received acyclovir. Her past obstetric history is significant
for a normal vaginal delivery at term of an 8-lb
male infant. Her past medical history is significant for
herpes. Her past surgical history is significant for a left
salpingectomy for an ectopic pregnancy. She takes a
prenatal vitamin daily and is allergic to sulfa-containing
medications.Her physical examination is significant for
a cervical examination demonstrating her to be 4 cm
dilated, 80% effaced, and at −1 station. Over the next 3
hours she progresses to 8-cm dilation, but her contractions
begin to space out. She is started on oxytocin.
Forty-five minutes after the initiation of oxytocin, her
contractions increase to every 1 to 2 minutes (approximately
7 in 10 minutes). The fetal heart rate, which had
been in the 120s and reactive throughout her labor, now
shows variable decelerations to the 80s. The most
appropriate management is
(A) initiate amnioinfusion
(B) perform cesarean delivery
© perform fetal scalp pH sampling
(D) perform forceps-assisted vaginal delivery
(E) stop the oxytocin infusion
0 - ArchivalUser - 01-06-2009
E
B
E
0 - ArchivalUser - 01-06-2009
E
B
E
0 - ArchivalUser - 01-06-2009
_ Q1: EEE
_ Q2: BBB
_ Q3: BB or EE. go with EEE ( stop oxytocin first)
0 - ArchivalUser - 01-06-2009
15. The correct answer is E. The most common definition
of intrauterine growth restriction (IUGR) is that a fetus
is growth-restricted if its weight is less than the tenth
percentile for its gestational age. There are many causes
of IUGR, including placental insufficiency, fetal chromosomal
anomalies, and fetal infections. Placental
insufficiency can be primary (in which other causes
have been ruled out) or secondary to maternal causes,
such as drug or alcohol abuse, hypertensive disease,
renal disease, autoimmune disease, or poor nutrition.
Although there are many causes of IUGR, it is well
established that morbidity and mortality are increased
significantly among infants when their birth weights
are low (especially less than the third percentile) for
their gestational age. Fetuses with IUGR are also at
increased risk for stillbirth compared with appropriately
grown fetuses. Given these risks, when a fetus is identified
as having IUGR and is at term, delivery is the
most appropriate management.Vaginal delivery should
be attempted in a patient such as this, with her history
of three vaginal deliveries and her favorable cervix. If a
patient has IUGR and is remote from term, regular fetal
testing is recommended with NST or biophysical profile
(BPP). Doppler evaluation of the umbilical artery also
is used to evaluate the fetus with IUGR, looking for
either absent or reverse end-diastolic flow.
To initiate aspirin therapy (choice A) or heparin therapy
(choice B) would not be appropriate. Several interventions
have been tried to improve pregnancy outcomes in
patients with IUGR. Some of these interventions include
aspirin and heparin, as well as bed rest, zinc supplementation,
calcium supplementation, and maternal oxygen
therapy. None of these interventions has been shown to
treat IUGR effectively.
To perform immediate cesarean delivery (choice C)
would not be correct. This fetus should be delivered,
given the IUGR, gestational age, and nonreassuring testing.
With this patient™s history of three vaginal deliveries
and her present cervical examination, however, induction
of labor should be attempted.
To re-date the pregnancy to 32 weeks (choice D) would
be absolutely incorrect. Dating by ultrasound becomes
less accurate as a pregnancy progresses. This patient was
dated originally by an 8-week ultrasound, and this dating
should not be changed.
0 - ArchivalUser - 01-07-2009
17. The correct answer is E. In modern obstetric practice in
many countries, most patients have electronic fetal
monitoring during labor and delivery. A nonreassuring
fetal heart rate is one of the most common indications
for cesarean delivery. It is, therefore, vital to be able to
interpret and respond appropriately to various fetal
heart rate patterns. The patient in this scenario has uterine
hyperstimulation. Uterine hyperstimulation is
defined as a persistent pattern of more than five contractions
in 10 minutes that may or may not result in a
nonreassuring fetal heart rate pattern.Hyperstimulation
can also be defined as contractions lasting 2 minutes or
more, or contractions or normal duration occurring
within 1 minute of each other. During uterine hyperstimulation,
fetal oxygenation often is impaired, which
can result in nonreassuring fetal heart rate patterns,
such as bradycardia or decelerations (as this patient
had). The first step when addressing a nonreassuring
fetal heart rate pattern caused by uterine hyperstimulation
is to stop the oxytocin infusion.
To initiate amnioinfusion (choice A) would not be correct
at this time. Amnioinfusion is used during labor
and delivery for persistent variable deceleration or
meconium, but this patient™s main problem seems to be
uterine hyperstimulation. The oxytocin therefore
should be turned off as the first step.
To perform cesarean delivery (choice B) at this point in
the management of this patient would not be correct.
The uterine hyperstimulation is likely causing this nonreassuring
fetal tracing; therefore, this problem should
be addressed by stopping the oxytocin that is stimulating
the uterus to contract. If the fetus continues to have
a nonreassuring fetal heart rate tracing despite this or
other measures, cesarean delivery can be undertaken.
To perform fetal scalp pH sampling (choice C) would
not be correct. Fetal scalp sampling can be used during
labor and delivery to further evaluate a fetus with a
nonreassuring fetal heart rate tracing. This fetus, however,
needs relief from the uterine hyperstimulation as
the primary measure.
To perform forceps-assisted vaginal delivery (choice D)
would not be correct. The patient is not fully dilated.
She is only 8 cm dilated and, therefore, forceps should
not be used.
0 - ArchivalUser - 01-07-2009
17e
0 - ArchivalUser - 01-07-2009
17. The correct answer is E. In modern obstetric practice in
many countries, most patients have electronic fetal
monitoring during labor and delivery. A nonreassuring
fetal heart rate is one of the most common indications
for cesarean delivery. It is, therefore, vital to be able to
interpret and respond appropriately to various fetal
heart rate patterns. The patient in this scenario has uterine
hyperstimulation. Uterine hyperstimulation is
defined as a persistent pattern of more than five contractions
in 10 minutes that may or may not result in a
nonreassuring fetal heart rate pattern.Hyperstimulation
can also be defined as contractions lasting 2 minutes or
more, or contractions or normal duration occurring
within 1 minute of each other. During uterine hyperstimulation,
fetal oxygenation often is impaired, which
can result in nonreassuring fetal heart rate patterns,
such as bradycardia or decelerations (as this patient
had). The first step when addressing a nonreassuring
fetal heart rate pattern caused by uterine hyperstimulation
is to stop the oxytocin infusion.
To initiate amnioinfusion (choice A) would not be correct
at this time. Amnioinfusion is used during labor
and delivery for persistent variable deceleration or
meconium, but this patient™s main problem seems to be
uterine hyperstimulation. The oxytocin therefore
should be turned off as the first step.
To perform cesarean delivery (choice B) at this point in
the management of this patient would not be correct.
The uterine hyperstimulation is likely causing this nonreassuring
fetal tracing; therefore, this problem should
be addressed by stopping the oxytocin that is stimulating
the uterus to contract. If the fetus continues to have
a nonreassuring fetal heart rate tracing despite this or
other measures, cesarean delivery can be undertaken.
To perform fetal scalp pH sampling (choice C) would
not be correct. Fetal scalp sampling can be used during
labor and delivery to further evaluate a fetus with a
nonreassuring fetal heart rate tracing. This fetus, however,
needs relief from the uterine hyperstimulation as
the primary measure.
To perform forceps-assisted vaginal delivery (choice D)
would not be correct. The patient is not fully dilated.
She is only 8 cm dilated and, therefore, forceps should
not be used.
0 - ArchivalUser - 01-07-2009
16a
in a patient who is reliable, with a
small, unruptured ectopic pregnancy, methotrexate
may be the treatment of choice. This would allow the
ectopic pregnancy to be treated without the patient
needing to have surgery. In a patient who is hemodynamically
unstable, laparotomy is usually the best
management. This patient is between these two
extremes with what seems to be a ruptured ectopic
(given her history, physical, laboratory, and ultrasound
findings), but she is not hemodynamically unstable;
therefore, laparoscopy would be the most appropriate
management of this patient.
0 - ArchivalUser - 01-07-2009
17. The correct answer is E. In modern obstetric practice in
many countries, most patients have electronic fetal
monitoring during labor and delivery. A nonreassuring
fetal heart rate is one of the most common indications
for cesarean delivery. It is, therefore, vital to be able to
interpret and respond appropriately to various fetal
heart rate patterns. The patient in this scenario has uterine
hyperstimulation. Uterine hyperstimulation is
defined as a persistent pattern of more than five contractions
in 10 minutes that may or may not result in a
nonreassuring fetal heart rate pattern.Hyperstimulation
can also be defined as contractions lasting 2 minutes or
more, or contractions or normal duration occurring
within 1 minute of each other. During uterine hyperstimulation,
fetal oxygenation often is impaired, which
can result in nonreassuring fetal heart rate patterns,
such as bradycardia or decelerations (as this patient
had). The first step when addressing a nonreassuring
fetal heart rate pattern caused by uterine hyperstimulation
is to stop the oxytocin infusion.
To initiate amnioinfusion (choice A) would not be correct
at this time. Amnioinfusion is used during labor
and delivery for persistent variable deceleration or
meconium, but this patient™s main problem seems to be
uterine hyperstimulation. The oxytocin therefore
should be turned off as the first step.
To perform cesarean delivery (choice B) at this point in
the management of this patient would not be correct.
The uterine hyperstimulation is likely causing this nonreassuring
fetal tracing; therefore, this problem should
be addressed by stopping the oxytocin that is stimulating
the uterus to contract. If the fetus continues to have
a nonreassuring fetal heart rate tracing despite this or
other measures, cesarean delivery can be undertaken.
To perform fetal scalp pH sampling (choice C) would
not be correct. Fetal scalp sampling can be used during
labor and delivery to further evaluate a fetus with a
nonreassuring fetal heart rate tracing. This fetus, however,
needs relief from the uterine hyperstimulation as
the primary measure.
To perform forceps-assisted vaginal delivery (choice D)
would not be correct. The patient is not fully dilated.
She is only 8 cm dilated and, therefore, forceps should
not be used.