Uterine Inversion
A 23-year-old G1 P0 woman at 38 weeks’ gestation delivered a 7lb4oz
baby boy vaginally. Upon delivery of the placenta, there was noted to
be an inverted uterus, which was successfully managed including
replacement of the uterus. Which of the following placental implantation
sites would most likely predispose to an inverted uterus?
A. Fundal
B. Anterior
C. Posterior
D. Lateral
E. Lower segment
A 24-year-old woman underwent a normal vaginal delivery of a term
infant female. After the delivery, the placenta does not deliver even after
30 minutes. Which of the following would be the next step for this
patient?
A. Initiate oxytocin.
B. Wait for an additional 30 minutes.
C. Hysterectomy.
D. Attempt a manual extraction of the placenta.
E. Misoprostol estrogen intravaginally
A 32-year-old G1 P0 woman at 40 weeks’ gestation undergoes a normal
vaginal delivery. Delivery of the placenta is complicated by an inverted
uterus, with subsequent hemorrhage leading to 1500 mL of blood loss.
She is managed with a transfusion of erythrocytes. Which of the
following is the best explanation of the mechanism of hemorrhage?
A. Inverted uterus stretches the uterus, causing trauma to blood vessels
leading to bleeding.
B. Inverted uterus leads to inability for an adequate myometrial
contraction effect.
C. Inverted uterus causes a local coagulopathic reaction to the uterus
and endometrium.
D. Inverted uterus causes muscular abrasions and lacerations leading to
bleeding.
A 33-year-old G5 P5 woman, who is being induced for preeclampsia
delivers a 9 lb baby. Upon delivery of the placenta, uterine inversion is
noted. The physician attempts to replace the uterus, but the cervix is
tightly contracted, preventing the fundus of the uterus from being
repositioned. Which of the following is the best therapy for this patient?
A. Vaginal hysterectomy.
B. Dührssen incisions of the cervix.
C. Halothane anesthesia.
D. Discontinue the magnesium sulfate.
E. Infuse oxytocin intravenously.
Shoulder Dystocia
Which of the following is a risk factor for shoulder dystocia?
A. Maternal gestational diabetes
B. Fetal hydrocephalus
C. Fetal prematurity
D. Precipitous (fast) labor
A 30-year-old woman is noted to be in active labor at 40 weeks’
gestation. Delivery of the fetal head occurs, but the fetal shoulders do
not deliver with the normal traction. The fetal head is retracted toward
the maternal introitus. Which of the following is a useful maneuver for
this situation?
A. Internal podalic version
B. Suprapubic pressure
C. Fundal pressure
D. Intentional fracture of the fetal humerus
E. Delivery of the anterior arm
Match the following mechanisms (A-E) to the stated maneuver (11.3-
11.5):
A. Anterior rotation of the symphysis pubis
B. Decreases the fetal bony diameter from shoulder to axilla
C. Fracture of the humerus
D. Displaces the fetal shoulder axis from anterior-posterior to oblique
E. Separates the maternal symphysis pubis
The clinician performs a delivery of the posterior fetal arm. B
The McRoberts maneuver is utilized. A
The nurse is instructed to apply the suprapubic pressure maneuver.D
Fetal Bradycardia
A 32-year-old G1 P0 woman is at 42 weeks’ gestation and being induced
for postterm pregnancy. She has had an uncomplicated pregnatal
course. Her BP is 100/60 mm Hg. The fundal height is 40 cm. Her cervix
is closed, 3 cm long, and firm on consistency. The obstetrician decides
on using a cervical ripening agent with misoprostol in the vagina.
Approximately 2 hours after placing the misoprostol, the patient has an
episode of fetal prolonged deceleration to the 80 bpm for 6 minutes.
Which of the following is the most likely etiology of the prolonged
deceleration?
A. Placental abruption
B. Sepsis
C. Umbilical cord prolapse
D. Uterine hyperstimulation
A 28-year-old G1 P0 at 35 weeks’ gestation is in the obstetrical (OB)
triage area with spontaneous rupture of membranes. The fetal heart rate
baseline is 150 bpm with normal variability. There are accelerations
seen, and numerous late decelerations noted. In an effort to improve
oxygenation to the fetus, which of the following maneuvers would most
likely help in this circumstance?
A. Supine position
B. Epidural anesthesia
C. Morphine sulfate
D. Stop the oxytocin
A 33-year-old G2 P1 woman at 39 weeks’ gestation in active labor is
noted to have a 10-minute episode of bradycardia on the external fetal
heart rate tracing in the range of 100 bpm, which has not resolved. Her
cervix is closed. Which of the following is the best initial step in
management of this patient?
A. Fetal scalp pH assessment
B. Emergency cesarean delivery
C. Intravenous atropine
D. Intravenous terbutaline
E. Assess maternal pulse
Postpartum Hemorrhage
RISK FACTORS FOR UTERINE ATONY
Magnesium sulfate
Oxytocin use during labor
Rapid labor and/or delivery
Overdistension of the uterus (macrosomia,multifetal
pregnancy,hydramnios)
Intra-amniotic infection (chorioamnionitis)
Prolonged labor
High parity
A 24-year-old G1 P0 woman at 39 weeks’ gestation had induction of
labor due to gestational hypertension. She was placed on magnesium
sulfate for seizure prophylaxis. She was placed on oxytocin for 15 hours
and reached a cervical dilation of 6 cm. After being at 6 cm dilation for 3
hours despite adequate uterine contractions as judged by 240
Montevideo units, she underwent a cesarean delivery. The baby was
delivered without difficulty through a low-transverse incision. Upon
delivery of the placenta, profuse bleeding was noted from the uterus,
reaching 1500 mL. Which of the following is the most likely cause of
hemorrhage in this patient?
A. Uterine atony
B. Uterine laceration
C. Coagulopathy
D. Uterine inversion
E. Retained placenta
A 26-year-old G2 P1001 woman underwent a normal vaginal delivery. A
viable 7 lb 4 oz male infant was delivered. The placenta delivered
spontaneously. The obstetrician noted significant blood loss from the
vagina, totaling approximately 700 mL. The uterine fundus appeared to
be well contracted. Which of the following is the most common etiology
for the bleeding in this patient?
A. Retained placenta
B. Genital tract laceration
C. Uterine atony
D. Coagulopathy
E. Endometrial ulceration
A 32-year-old woman has severe postpartum hemorrhage that does not
respond to medical therapy. The obstetrician states that surgical
management is the best therapy. The patient desires future child
bearing. Which of the following is most appropriate to achieve the
therapeutic goals?
A. Utero-ovarian ligament ligation
B. Hypogastric artery ligation
C. Supracervical hysterectomy
D. Ligation of the external iliac artery
E. Cervical cerclage
A 34-year-old woman is noted to have significant uterine bleeding after
a vaginal delivery complicated by placenta abruption. She is noted to be
bleeding from multiple venipuncture sites. Which of the following is the
best therapy?
A. Immediate hysterectomy
B. Packing of the uterus
C. Hypogastric artery ligation
D. Ligation of utero-ovarian ligaments
E. Correction of coagulopathy
Abnormal Serum Screening in Pregnancy
A 23-year-old G1 P0 woman at 20 weeks’ gestation undergoes an
ultrasound examination for size greater than dates. The ultrasound
reveals hydramnios with an amniotic fluid index of 30 cm. The fetal
abdomen reveals a cystic mass in the right abdominal region, and a
cystic mass in the left abdominal area. Which of the following is the most
likely associated condition?
A. Gestational diabetes
B. Congenital ovarian tumors
C. Down syndrome
D. Rh isoimmunization
A 28-year-old woman G1 P0 at 16 weeks’ gestation is noted to have an
elevated msAPF at 2.9 multiples of the median (MOM). She underwent a
targeted ultrasound examination which did not reveal a neural tube
defect. Her physician also undertakes a diligent search for an etiology
for the elevated msAFP without identifying an etiology. Which of the
following conditions is this patient at increased risk?
A. Increased incidence of stillbirth
B. Gestational diabetes
C. Placenta previa
D. Molar pregnancy
E. Down syndrome
A 28-year-old woman delivers a baby with a cleft palate and cleft lip.
The baby is otherwise healthy. The patient asks about whether there is
genetic reason for this anomaly. Which of the following is the best
explanation of the genetics of this condition?
A. Autosomal dominant
B. Autosomal recessive
C. X-linked dominant
D. X-linked recessive
E. Multifactori
A 22-year-old woman G2 P1 at 25 weeks’ gestation with a sure last
menstrual period asks for serum screening. The patient’s sister has one
child with Down syndrome and, otherwise, there is no family history of
anomalies or genetic disorders. Which of the following is the most
appropriate response?
A. Amniocentesis is the appropriate test.
B. Serum screening should be performed.
C. Explain to the patient that it is too late for serum screening, but that
her risk for Down syndrome is not much higher than her agerelated risk.
D. The patient being only 22 years of age does not need serum
screening. E. The patient has a 25% chance of her baby having Down
syndrome.
A 22-year-old woman is seen for her first prenatal visit at 16 weeks’
gestation with a family history of congenital deafness and neonatal renal
disease. The patient’s hearing is normal. Which of the following is the
best next step?
A. Amniocentesis for karyotype
B. Amniocentesis for rubella PCR
C. Genetic counseling
D. Glucose challenge testing
Twin Gestation with Vasa Previa
A 28-year-old G1 P0 woman is diagnosed as having a twin gestation at
15 weeks’ gestation. Careful examination of the membranes reveals that
there is a very thin membrane between the two fetuses. Which of the
following statements is most accurate?
A. It is likely that one fetus is a male and the other a female.
B. It is likely that this is a dizygotic gestation.
C. It is likely that this is a monozygotic gestation.
D. It is likely that there are two separate placentas.
A 25-year-old G2 P1001 woman at 27 weeks’ gestation has been
followed for twin gestation. She is undergoing her third ultrasound
examination today. Her ultrasound findings are as follows:
Twin A Twin B
Estimated weight 500 g 1100 g
Amniotic fluid 2 cm 26 cm
Which of the following is the best next step for this patient?
A. Chorionic villus sampling
B. Repeat ultrasound in 3 weeks
C. Laser ablation of vessels
D. Revision of dates for twin B
A 32-year-old G1 P0 woman undergoes an IVF pregnancy cycle and
becomes pregnant with triplets. She has been followed in a high-risk
obstetrics clinic with an uncomplicated pregnancy course. She arrives to
the hospital labor and delivery unit at 30 weeks’ gestation with a blood
pressure of 150/100 mm Hg, and 2+ proteinuria. Additionally she
complains of dyspnea. Her oxygen saturation is 82% on room air. She is
contracting every 4 minutes. The patient is diagnosed with
preeclampsia. Which of the following statements is most accurate?
A. The patient should be treated with IV heparin.
B. The patient should be treated with IV furosemide.
C. The patient should be treated with corticosteroids and a tocolytic
agent.
D. The patient likely has a concealed abruption.
Herpes Simplex Virus in Pregnancy
A 32-year-old woman G1 P0 at 24 weeks’ gestation is seen by her
obstetrician for painful vesicles on the vulva. PCR is performed and
returns as HSV-2. The obstetrician counsels the patient about the
possibility of needing cesarean when she goes into labor. Which of the
following is an indication for cesarean section due to maternal herpes
simplex virus?
A. Vesicular lesions noted on the cervix
B. History of lesions noted on the vagina 1 month previously, now not
visible
C. Lesions noted on the posterior thigh
D. Tingling of the chest wall with lesions consistent with herpes zoster
A 29-year-old G2 P1 woman is seen in the office for her pregnancy at 16
weeks’ gestation. She complains of some burning of the vulvar area. Two
blisters are noted on the labia majora. PCR is performed on the lesions,
which returns as HSV-1. Which of the following statements is most
accurate in the counseling of this patient?
A. Because this result is HSV-1, the finding is likely a false-positive result
and the patient does not likely have a herpes infection.
B. Because of the finding of HSV-1, the neonate is not at risk for herpes
encephalitis.
C. The patient should be treated the same whether the infection is HSV-1
or HSV-2.
D. The patient likely has an HIV infection since HSV-1 was isolated in the
vulvar area.
A 35-year-old healthy G2 P1 woman at 20 weeks’ gestation presents with
primary episode of herpes simplex virus, confirmed by PCR. Oral
acyclovir is given for a 10-day course. Which of the following is the
rationale for the acyclovir therapy?
A. Decrease the likelihood of recurrence and need for cesarean
B. Decrease the likelihood of transplacental transmission to the fetus
C. Decrease the duration of viral shedding and duration of the current
infection
D. Increase the patient’ immunity and IgG levels to HSV
A 34-year-old woman is seen at her internist’s office complaining of
vulvar pain. On examination, three ulcers are noted on the right labia
majora. The lesions have ragged edges, a necrotic base, and there is
adenopathy noted on the right inguinal region. Which of the following is
the most likely diagnosis?
A. Syphilis
B. Herpes simplex virus
C. Chancroid
D. Squamous cell carcinoma
E. Bartholin gland abscess
Antepartum Vaginal Bleeding
A 28-year-old woman at 32 weeks’ gestation is seen in the obstetrical
(OB) triage area for vaginal bleeding described as significant with clots.
She denies cramping or pain. An ultrasound is performed revealing that
the placenta is covering the internal os of the cervix. Which of the
following is a risk factor for this patient’s condition?
A. Prior salpingitis
B. Hypertension
C. Multiple gestations
D. Polyhydramnios
A 21-year-old patient at 28 weeks’ gestation has vaginal bleeding and is
diagnosed with placenta previa. Which of the following is a typical
feature of this condition?
A. Painful bleeding
B. Commonly associated with coagulopathy
C. First episode of bleeding is usually profuse
D. Associated with postcoital spotting
A 33-year-old woman at 37 weeks’ gestation, confirmed by first-
trimester sonography, presents with moderately severe vaginal
bleeding. She is noted on sonography to have a placenta previa. Which
of the following is the best management for this patient?
A. Induction of labor
B. Tocolysis of labor
C. Cesarean delivery
D. Expectant management
E. Intrauterine transfusion
A 22-year-old G1 P0 woman at 34 weeks’ gestation presents with
moderate vaginal bleeding and no uterine contractions. Her blood
pressure (BP) is 110/60 mm Hg and heart rate (HR) 103 beats per minute
(bpm). The abdomen is nontender. Which of the following sequence of
examinations is most appropriate?
A. Speculum examination, ultrasound examination, digital examination
B. Ultrasound examination, digital examination, speculum examination
C. Digital examination, ultrasound examination, speculum examination
D. Ultrasound examination, speculum examination, digital examination
An 18-year-old adolescent female is noted to have a marginal placenta
previa on an ultrasound examination at 22 weeks’ gestation. She does
not have vaginal bleeding or spotting. Which of the following is the most
appropriate management?
A. Schedule cesarean delivery at 39 weeks.
B. Schedule an amniocentesis at 36 weeks and deliver by cesarean if the
fetal lungs are mature.
C. Schedule an MRI examination at 35 weeks to assess for possible
percreta involving the bladder.
D. Reassess placental position at 34 to 35 weeks’ gestation by
ultrasound.
E. Recommend termination of pregnancy.
Suspected Placental Abruption
An 18-year-old pregnant woman is noted to have vaginal bleeding. She
is bleeding from venipuncture sites, IV sites, and from her gums. Which
of the following is the most likely underlying diagnosis?
A. Placental abruption
B. Placenta previa
C. Gestational diabetes
D. Multifetal gestation
E. Gestational trophoblastic disease
A 32-year-old woman is seen in the obstetrical unit at the hospital. She is
at 29 weeks’ gestation, with a chief complaint of significant vaginal
bleeding. She had a stillbirth with her prior pregnancy due to placental
abruption. The patient asks the physician about the accuracy of
ultrasound in the diagnosis of abruption. Which of the following
statements is most accurate?
A. Fetal ultrasound is more accurate in diagnosing placental abruption
than placenta previa.
B. Fetal ultrasound is quite sensitive in diagnosing placental abruption.
C. Ultrasound is sensitive in diagnosing abruption that occurs in the
lower aspect of the uterus.
D. Fetal ultrasound is not sensitive in diagnosing placental abruption.
Which of the following is the most significant risk factor for abruptio
placentae?
A. Prior cesarean delivery
B. Breech presentation
C. Trauma
D. Marijuana use
E. Placenta accrete
A 35-year-old woman presents with bright red vaginal bleeding at 30
weeks’ gestation. Her urine drug screen is positive. Which of the
following is most likely to be present in her drug screen?
A. Marijuana
B. Alcohol
C. Barbiturates
D. Cocaine
E. Benzodiazepines
