West Coast University Obstetrics
(Gynecology) APGO uWise Revision
Questions and Answers with Rationales
A 28-year-old G1P1 presents to your office. She delivered four days ago
and tearfully reports that yesterday and the day before she had trouble
sleeping, felt anxious and was irritable. She feels somewhat better today,
but is still concerned. What is the most likely diagnosis?
A. Hypothyroidism
B. Blues
C. Depression
D. Normal postpartum state
E. Anxiety
Correct Answer -B. Blues
The patient is describing symptoms of postpartum blues that affects 50%
women within three to six days postpartum. Symptoms include insomnia,
easy crying, depression, poor concentration, irritability or labile affect and
anxiety. Symptoms often last a few hours per day and are mild and
transient. "Blues" are probably related to biochemical changes of
puerperium. Postpartum depression symptoms, such as mood changes,
insomnia, phobias and irritability are more pronounced than with the
"blues."
A 36-year-old G1 began prenatal care at eight weeks gestation. At that
time, the gestational age was confirmed by a transvaginal ultrasound. She
is now at 36 weeks gestation. Her previous medical history reveals
hypertension for eight years and class F diabetes for five years (baseline
proteinuria = 1 g). She smokes one half-pack of cigarettes per day. On
examination at 32 weeks gestation, her fundal height was 29 cm. At 33
,weeks, biometry was consistent with 31-3/7, EFW 1827g, 25th percentile.
Today, ultrasound reveals limited fetal growth over the past three weeks.
Biometry is consistent with 31-5/7, EFW 1900 g, <10th percentile. What is
the most likely etiology of the intrauterine growth restriction in this case?
A. Genetic factors
B. Congenital anomaly
C. Tobacco use
D. Uteroplacental insufficiency
E. Perinatal infection
Correct Answer -D. Uteroplacental insufficiency
There is substantial evidence from experimental animal studies that
suggests that alterations in uteroplacental perfusion affect the growth and
status of the fetus, as well as the placenta. This patient has significant
medical diseases that are affecting her vasculature and, ultimately,
limiting the substrate availability to the fetus with resultant uteroplacental
insufficiency. The vascular disease is evidenced by retinopathy and
proteinuria. The other choices above may all result in fetal growth
restriction; however, they are not the most likely etiology in this clinical
scenario.
36-year-old female G1 presents for her prenatal care visit at 35 weeks
gestation. She has good dating criteria that were confirmed by a first
trimester ultrasound. Her previous medical history is positive for
hypertension and type 2 diabetes. You have been following fetal growth
with serial ultrasounds. At this visit, ultrasound reveals limited fetal
growth over the past three weeks. Biometry is consistent with 32-5/7, EFW
2175 g, <10th percentile. What is the most appropriate next test indicated
in the management of this patient?
A. Amniotic fluid volume, umbilical artery Doppler systolic: diastolic ratio,
non-stress test
,B. Daily fetal kick counts with follow up ultrasound to reassess fetal
growth in one week
C. Amniocentesis for fetal lung maturity
D. Twice daily fetal kick counts with delivery at 37 weeks gestation
E. None, delivery is indicated
Correct Answer -A. Amniotic fluid volume, umbilical artery Doppler
systolic: diastolic ratio, non-stress test
When a pregnancy is complicated by fetal growth restriction, various fetal
physiologic parameters require assessment. In growth-restricted
pregnancies, oligohydramnios is frequently found. This finding is
presumably due to reduced fetal blood volume, renal blood flow and
urinary output. Chronic hypoxia is responsible for diverting blood flow
from the kidney to organs that are more critical during fetal life. The
significance of the amniotic fluid volume with respect to fetal outcome has
been well documented. Ninety percent of patients with oligohydramnios
delivered growth restricted infants. These infants experienced a high rate
of fetal compromise. The systolic/diastolic (S/D) ratio of the umbilical
artery is determined by Doppler ultrasound. An increase in the S/D ratio
reflects increased vascular resistance. It is a common finding in IUGR
fetuses. A normal S/D ratio indicates fetal well-being. As vascular
resistance increases, the S/D ratio increases. With severe resistance, there
is absence and ultimately reversal of end-diastolic flow. These findings
are associated with an increased rate of perinatal morbidity and mortality,
and a higher likelihood of a long-term poor neurologic outcome. Options
for antenatal testing include the non-stress test, contraction stress test, and
the biophysical profile. Any of these may be used in a growth-restricted
fetus as a means of detecting possible or probable fetal asphyxia. While
fetal kick counts may be of value, additional fetal testing such as twice
weekly NST with AFI and weekly umbilical artery Doppler studies is
indicated in monitoring fetuses with IUGR.
, A 36-year-old G1 with type 1 diabetes is diagnosed with intrauterine
growth restriction at 33 weeks gestation. What is the most appropriate next
step in management?
A. Amniocentesis
B. Immediate delivery
C. Weekly ultrasounds to assess fetal growth
D. Antenatal testing of fetal well-being
E. Observation
Correct Answer -D. Antenatal testing of fetal well-being
Once intrauterine growth restriction is detected, the fetus needs to be
evaluated periodically for evidence of well-being until delivery is deemed
necessary. This will result in once or twice weekly testing, depending on
the modality of assessment that is being used. Testing includes: non-stress
test (NST), where the fetal heart beat is recorded over a period of at least
30 minutes while looking for accelerations with fetal movement, and the
biophysical profile, which includes an ultrasound evaluation of fetal
movement, fetal tone, amniotic fluid and breathing. NSTs should be
performed twice weekly with at least a weekly AFI. The BPP may be
performed weekly. Ultrasound for fetal growth is not useful if more
frequent than every two weeks. An amniocentesis for fetal lung maturity
can be considered at more advanced gestational age.
A 28-year-old G1 at approximately 40 weeks gestation presents to triage
with mild contractions. You measure her fundal height at 34 cm. You are
concerned about intrauterine growth restriction and you want to confirm
her dates. In reviewing her records, she reports first feeling fetal
movements at 18 weeks gestation. The crown-rump length measurements
determined at eight weeks and femur length at 20 weeks are consistent
with 40 weeks gestation. Today's assessment reveals biometrics consistent
with 34 weeks, amniotic fluid index of 1, and placental calcifications.
