Labor and Delivery Complications

what is the earliest that gestational trophoblastic disease can be diagnosed ?

8 weeks

______________ is a group of neoplasms that result from abnormal proliferation of placental trophoblastic tissue. These neoplasms may develop into subsequent malignancies (e.g., invasive mole, choriocarcinoma, placental site trophoblastic tumor, epithelioid trophoblastic tumor).

gestational trophoblastic disease

what is the most common form of gestational trophoblastic disease and what is the cause ?

hydatidiform moles - abnormalities in fertilization

A 20-year-old woman presents at 12 weeks gestation with vaginal bleeding, severe nausea and vomiting, and uterine size larger than expected for dates. β-hCG levels are markedly elevated. Ultrasound shows a "snowstorm" pattern with no fetal tissue. Histology reveals diffusely hydropic chorionic villi surrounded by trophoblastic hyperplasia. Genetic analysis demonstrates a 46,XX karyotype with paternal-only chromosomes. What is the most likely diagnosis?

Complete hydatidiform mole

A 24-year-old woman presents at 14 weeks gestation with irregular vaginal bleeding and less severe uterine enlargement. β-hCG is mildly elevated. Ultrasound reveals a thickened, cystic placenta with an abnormal fetus present. Histology shows focally hydropic villi with mild trophoblastic hyperplasia. Genetic analysis demonstrates a triploid karyotype, such as 69,XXY. What is the most likely diagnosis?

Partial (incomplete) hydatidiform mole

A 28-year-old woman presents 3 months after suction curettage for a complete hydatidiform mole. She reports irregular vaginal bleeding. Serum β-hCG levels remain elevated. Pelvic ultrasound reveals a heterogeneous intrauterine mass invading into the myometrium with areas of hemorrhage, but no fetal tissue. What is the most likely diagnosis?

Invasive mole

what is definitive treatment of a molar pregnancy ?

dilation and curettage (evacuation of uterine contents)

A 29-year-old woman at 32 weeks gestation presents with sudden-onset painless vaginal bleeding. Her uterus is soft and nontender, and fetal heart rate is reassuring. Ultrasound shows the placenta covering the cervical os. What is the most likely diagnosis?

Placenta previa

A 34-year-old woman at 36 weeks gestation presents with sudden painful vaginal bleeding and severe abdominal pain. On exam, her uterus is firm and tender, and fetal monitoring shows late decelerations. What is the most likely diagnosis?

Placental abruption

___________ is the most common cause of persistent first-trimester vaginal bleeding and is defined as loss of a fetus before 20 weeks of gestation.

Spontaneous abortion

what is the most common cause of spontaneous abortion

fetal chromosomal abnormalities

A 27-year-old woman at 9 weeks gestation presents with vaginal bleeding and cramping. On exam, her cervix is open and ultrasound shows no fetal cardiac activity with retained products of conception in the uterus. What is the most likely diagnosis?

Spontaneous abortion

A 29-year-old woman at 10 weeks gestation presents with heavy vaginal bleeding and cramping. On pelvic exam, her cervix is dilated but no tissue has passed. What is the most likely diagnosis?

Inevitable abortion

A 25-year-old woman at 12 weeks gestation presents with vaginal bleeding and abdominal pain. On exam, the cervix is dilated and tissue is seen at the os. Ultrasound shows retained products of conception in the uterus. What is the most likely diagnosis?

Incomplete abortion

A 33-year-old woman at 9 weeks gestation reports sudden heavy bleeding followed by passage of tissue. Her pain has resolved. On exam, the cervix is closed and the uterus is firm and contracted. Ultrasound shows an empty uterus. What is the most likely diagnosis?

Complete abortion

A 27-year-old woman at 11 weeks gestation presents for routine prenatal visit. She reports no bleeding or pain. Ultrasound shows no fetal cardiac activity, and the cervix is closed with retained pregnancy tissue. What is the most likely diagnosis?

Missed abortion

A 30-year-old woman presents with fever, chills, lower abdominal pain, and foul-smelling vaginal discharge after a miscarriage at 13 weeks. On exam, the cervix is open with purulent discharge, and the uterus is tender. What is the most likely diagnosis?

Septic abortion

What obstetrics history is required for the diagnosis of cervical insufficiency ?

At least two consecutive second-trimester pregnancy losses or extremely early preterm births (prior to 28 weeks)

cervical length ≤ 25 mm on transvaginal ultrasound examination is considered

cervical insufficiency

A 28-year-old woman in her second trimester presents with painless cervical dilation at 18 weeks gestation. She reports a history of two prior second-trimester pregnancy losses without contractions or bleeding. On transvaginal ultrasound, the cervical length is 20 mm. What is the most likely diagnosis? What is the apprioate management ?

Cervical insufficiency - cervical cerclage

A 27-year-old woman at 16 weeks gestation has no prior history of second-trimester pregnancy loss or preterm birth but is suspected of having cervical insufficiency. What is the appropriate next step in management?

Frequent surveillance with transvaginal ultrasound to monitor cervical length

_____________ is defined as glucose intolerance in a patient who had not been diagnosed with diabetes prior to pregnancy.

gestational diabetes

what is the recommended screening for gestational diabetes and test is used?

24-28 weeks - 50 g oral glucose challenge test

If the patient’s blood glucose level is ≥ 140 mg/dL 1 hour after glucose intake for a 50 g oral glucose challenge test for gestational diabetes screening what does this indicate ?

+ results, a 3-hour oral glucose tolerance test should be performed.

The ____________ is the gold standard for diagnosis of gestational diabetes and is performed after the patient has fasted overnight. T

3-hour 100 g oral glucose tolerance test

A 29-year-old woman at 26 weeks gestation undergoes a 3-hour 100 g oral glucose tolerance test after an abnormal 1-hour screening test. She fasted overnight before the test. Her results show: fasting glucose 102 mg/dL, 1-hour 184 mg/dL, 2-hour 160 mg/dL, and 3-hour 138 mg/dL. Based on these values, what is the diagnosis?

Gestational diabetes mellitus

What is the fasting blood glucose threshold for a positive 3-hour 100 g OGTT?

> 95 mg/dL

What is the 1-hour blood glucose threshold for a positive 3-hour 100 g OGTT?

> 180 mg/dL

What is the 2-hour blood glucose threshold for a positive 3-hour 100 g OGTT?

> 155 mg/dL

What is the 3-hour blood glucose threshold for a positive 3-hour 100 g OGTT?

> 140 mg/dL

How many abnormal values are required on a 3-hour 100 g OGTT to diagnose gestational diabetes?

At least 2 abnormal values

A CBC, blood type with Rh factor, and antibody screen were ordered. Between what gestational weeks would this have been done?

10-12 weeks or at the first prenatal visit

A patient had a UA/UCX, rubella, syphilis, gonorrhea, chlamydia, hepatitis B, HCV, and HIV screening ordered. At what gestational age are these tests typically done?

10-12 weeks or first prenatal visit

A patient is screened with cervical cytology, PPD, thyroid screen, hemoglobin electrophoresis, or varicella antibody (when indicated). At what gestational age are these performed?

10-12 weeks or first prenatal visit

First-trimester aneuploidy screening or cell-free DNA testing is performed. At what gestational age is this done?

11-13 weeks

An ultrasound for nuchal translucency and early anatomy is performed. At what gestational age?

11-13 weeks

Quadruple marker serum screening is performed. Between what gestational weeks is this test done?

15-22 weeks

Maternal serum alpha-fetoprotein (MSAFP) screening is done. At what gestational age is it performed?

16-18 weeks

A fetal anatomy ultrasound with cervical length screening is ordered. At what gestational age is this done?

18-20 weeks

Amniocentesis for chromosomal abnormalities is offered when indicated. During which trimester and weeks is this typically done?

Second trimester, around 15-22 weeks

A repeat CBC, glucose challenge test, and repeat syphilis and HIV screen (when indicated) are performed. At what gestational age?

28 weeks

Anti-D immune globulin is administered to Rh-negative mothers (if indicated). At what gestational age?

28 weeks

Gonorrhea and chlamydia screening, determining a newborn care clinician, and offering childbirth classes are recommended. At what gestational age?

33-36 weeks

Screening for group B Streptococcus is performed. At what gestational age?

35-37 weeks

Determining fetal presentation is performed. At what gestational age?

36+ weeks

If pregnancy reaches 41 weeks, what is typically offered?

Induction of labor

______________ is a genetic syndrome that affects collagen and increases the risk of cervical insufficiency.

Ehlers-Danlos syndrome

A 29-year-old woman at 33 weeks gestation presents for a routine prenatal visit. Her blood pressure is 148/92 mm Hg. Urinalysis shows 2+ protein. She has no headache, visual changes, right upper quadrant pain, or signs of end-organ dysfunction. Fetal growth and nonstress testing are normal. What is the most appropriate next step in management?

Continued monitoring with frequent maternal and fetal assessments, as this is preeclampsia without severe features (<160/110 mm Hg and no end-organ involvement)

A 35-year-old woman at 30 weeks gestation presents with severe headache, visual disturbances, and blood pressure of 172/114 mm Hg. Laboratory studies reveal elevated liver enzymes and thrombocytopenia. What is the most appropriate next step in management?

Immediate delivery, as she has preeclampsia with severe features and is at high risk for maternal complications regardless of gestational age

A 26-year-old woman at 37 weeks gestation is diagnosed with preeclampsia without severe features. She is asymptomatic, and fetal testing is reassuring. What is the recommended next step?

Delivery at 37 weeks gestation, as expectant management is no longer indicated beyond this point

A 30-year-old woman at 34 weeks gestation presents with blood pressure of 168/112 mm Hg. She has no neurologic symptoms or other signs of end-organ dysfunction. What is the most appropriate immediate intervention?

Initiate antihypertensive therapy (e.g., labetalol, hydralazine, or nifedipine) to reduce the risk of maternal stroke, as blood pressure is ≥160/110 mm Hg

Ectopic pregnancy Treatment indications

For stable patients, ___________is the initial therapy of choice, pending the adnexal mass is ≤ 3–4 cm and serum hCG values are < 5,000 mIU/L. Following administration, the patient is monitored with serial hCGs until the values are 0 mIU/L, thus the patient must be able to follow up.

methotrexate

Ectopic Pregnancy Treatment Indications

For unstable patients, patients with an adnexal mass > 3–4 cm, or those with serum hCG values > 5,000 mIU/L, _is the management of choice.

laparoscopic salpingostomy

What is the result if an ectopic pregnancy is left untreated ?

fallopian tube rupture and hemorrhage

What is the first sign of hypermagnesemia in patients being treated with magnesium sulfate to prevent seizures?

Loss of patellar reflex

What is possible severe complication of placental abruption ?

Disseminated intravascular coagulation

A 26-year-old woman presents with 7 weeks of amenorrhea, abdominal pain, and vaginal spotting. She is hemodynamically stable. Transvaginal ultrasound shows a 2.5-cm right adnexal mass without intrauterine pregnancy. Her serum β-hCG is 3,200 mIU/mL. She has normal liver and renal function and is able to return for close follow-up. What is the most appropriate management?

Methotrexate therapy with serial β-hCG monitoring until undetectable

A 30-year-old woman presents with sudden severe lower abdominal pain and dizziness. On exam, she is hypotensive and tachycardic. Transvaginal ultrasound reveals a 5-cm left adnexal mass with free intraperitoneal fluid. Her serum β-hCG is 8,500 mIU/mL. What is the most appropriate management?

Urgent surgical management with laparoscopic salpingostomy (or salpingectomy if rupture is severe)

A 29-year-old woman at 30 weeks gestation presents with sudden-onset vaginal bleeding and abdominal pain. Fetal heart monitoring is reassuring, and both mother and fetus are hemodynamically stable. She is not in active labor. What is the most appropriate management?

Administer intravenous corticosteroids and tocolytics to promote fetal lung maturity and prevent labor; administer intravenous magnesium sulfate for fetal neuroprotection (<32 weeks); continue expectant management with close monitoring

Ectopic pregnancies occur most frequently between _______ weeks after the start of the last menstrual period

6 to 8 weeks

A 33-year-old woman at 35 weeks gestation presents with sudden-onset heavy vaginal bleeding and severe abdominal pain. On exam, her uterus is firm and tender, and she is hypotensive and tachycardic. Fetal heart monitoring shows late decelerations. What is the most appropriate initial management?

Hemodynamic stabilization with intravenous fluids and blood products, followed by immediate cesarean delivery due to fetal distress and maternal instability

A 27-year-old Rh-negative woman is pregnant with an Rh-positive fetus. Serial maternal anti-D antibody titers are being monitored due to concern for hemolytic disease of the fetus and newborn. At 28 weeks gestation, her antibody titer rises to 1:32. What is the most appropriate next step in fetal assessment?

Doppler velocimetry of the fetal middle cerebral artery to evaluate for fetal anemia

A 26-year-old woman at 20 weeks gestation presents with dysuria, urinary frequency, and urgency. She denies fever, flank pain, or costovertebral angle tenderness. Urinalysis shows positive leukocyte esterase and nitrites. What is the most likely diagnosis and appropriate management?

Cystitis - Fosfomycin, amoxicillin-clavulanate, and cefpodoxime

A 27-year-old woman at 26 weeks gestation presents with fever, chills, nausea, and severe right-sided flank pain. She reports dysuria and urinary frequency for several days. On exam, she has costovertebral angle tenderness and a temperature of 39.2 °C (102.6 °F). Urinalysis shows pyuria and positive nitrites. What is the most likely diagnosis and appropriate management?

Acute pyelonephritis in pregnancy; hospitalize for intravenous broad-spectrum antibiotics (e.g., ceftriaxone)

A 30-year-old G2P1 woman with no prenatal care delivers a male infant at 34 weeks gestation via spontaneous vaginal delivery at home. The infant is brought to the emergency department shortly after birth with severe pallor, generalized edema, ascites, and respiratory distress. On exam, there is hepatosplenomegaly, and laboratory studies reveal a hemoglobin level of 5.2 g/dL and marked indirect hyperbilirubinemia. The mother's first pregnancy was uncomplicated, and her first child was healthy. Which of the following is the most likely cause of this infant's presentation?

Rh incompatibility

A 35-year-old G1P0 woman presents with severe nausea, vomiting, and vaginal bleeding at 10 weeks gestation. Her β-hCG level is 280,000 mIU/mL. Transvaginal ultrasound shows no fetal tissue and a diffuse "snowstorm" appearance. She undergoes suction curettage for definitive treatment. Which of the following is the most appropriate next step in management after surgery?

Weekly monitoring of serum β-hCG until levels are undetectable (<5 mIU/mL)

A 28-year-old woman presents 6 weeks after suction curettage for a complete molar pregnancy with persistent vaginal bleeding. Serial β-hCG levels have plateaued and remain elevated despite initial treatment. Pelvic ultrasound shows a heterogeneous intrauterine mass invading into the myometrium but no evidence of extrauterine spread or distant metastasis. What is the most appropriate management?

Single-agent chemotherapy with methotrexate

TRUE OR FALSE Polyhydroamnios is a complication associated with gestational diabetes.

True

A 30-year-old woman at 32 weeks gestation presents with persistent shortness of breath, wheezing, and nocturnal cough despite as-needed albuterol use. Her blood pressure is 148/94 mm Hg on two occasions four hours apart. She is diagnosed with gestational hypertension. Which of the following antihypertensive medications is most appropriate for this patient?

Extended-release Nifedipine (Labetalol and other nonselective beta-blockers should be avoided due to risk of bronchoconstriction in asthma.)

A 27-year-old woman presents 4 months after suction curettage for a complete molar pregnancy with persistent vaginal bleeding. She also reports new-onset cough and shortness of breath. Serum β-hCG is markedly elevated. Chest X-ray reveals multiple bilateral pulmonary nodules. Pelvic ultrasound shows no intrauterine pregnancy. What is the most likely diagnosis?

Choriocarcinoma

A 22-year-old G1P0 woman at 14 weeks gestation presents for her first prenatal visit. Routine prenatal screening with nucleic acid amplification testing is positive for Chlamydia trachomatis. She is treated with a single dose of azithromycin. Which of the following is the most appropriate next step in management?

Test of cure in 4 weeks