Obstetric Medicine Module 1

Which of the following statements best describes the scoring criteria for severe nausea and vomiting in pregnancy (NVP)?

A PUQE score of 13 or more, reflecting severe NVP.

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A PUQE score of less than or equal to 6, indicating mild NVP.

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A PUQE score between 7 to 12, categorizing as moderate NVP.

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The addition of a fourth question about well-being improves the accuracy of the PUQE score for severe NVP.

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A PUQE score is primarily determined by the number of vomiting episodes, with more than 7 episodes indicating severe NVP.

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What is the best treatment approach for nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG)?

A comprehensive management strategy including interventions to reduce symptoms, maintenance of adequate hydration and nutrition, and the trial of antiemetics.

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Administration of high-dose corticosteroids as the first-line treatment.

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Immediate initiation of intravenous thiamine, irrespective of the patient's nutritional status.

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Systematic discontinuation of all prenatal vitamins to alleviate symptoms.

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Exclusive focus on psychosocial support without addressing physical symptoms.

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During normal pregnancy, significant physiological changes occur to accommodate the growing fetus.

Which of the following best describes the change in renal haemodynamics during this period?

Increase in renal plasma flow (RPF) and GFR

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Decrease in glomerular filtration rate (GFR)

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Decrease in renal plasma flow and increase in GFR

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No change in renal plasma flow or glomerular filtration rate

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Increase in GFR with no change in renal plasma flow

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Pregnancy induces various adaptations in maternal physiology, including alterations in renal tubular function.

Which of the following best describes the change in renal tubular function during pregnancy?

Decreased tubular reabsorption of glucose, leading to persistent glucosuria

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Increased tubular reabsorption of glucose, preventing glucosuria

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Decreased tubular reabsorption of amino acids, leading to persistent aminoaciduria

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Increased secretion of hydrogen ions, leading to a metabolic alkalosis

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Decreased secretion of bicarbonate, leading to a metabolic acidosis

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You are reviewing the case of a 28-year-old pregnant patient with a history of mild chronic hypertension. Her blood pressure consistently averages 145/95 mm Hg. She is currently at 18 weeks of gestation with a singleton fetus.

You recall a recent multicenter randomized trial on the management of mild chronic hypertension during pregnancy. Considering the findings of this trial, which management strategy should you consider to optimize pregnancy outcomes for your patient?

Initiate antihypertensive therapy targeting a blood pressure of less than 140/90 mm Hg to reduce the risk of adverse pregnancy outcomes without increasing the risk of small-for-gestational-age birth weight.

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Advise against the use of antihypertensive medications unless her blood pressure exceeds 160/100 mm Hg, to avoid the risk of fetal growth restriction.

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Recommend only lifestyle modifications, as pharmacological treatment has been shown to significantly increase the risk of small-for-gestational-age infants.

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Wait until severe hypertension develops (systolic pressure, ≥160 mm Hg; or diastolic pressure, ≥105 mm Hg) before considering antihypertensive treatment, as active management has not shown benefits in pregnancy outcomes.

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Focus on monitoring fetal growth exclusively, since managing maternal blood pressure has not demonstrated a reduction in adverse pregnancy outcomes.

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A 32-year-old woman with a singleton pregnancy has been identified as high risk for preterm preeclampsia based on her medical history and early pregnancy screening results. She is currently at 12 weeks of gestation.

Which intervention should be considered to optimize her pregnancy outcome?

Recommend starting low-dose aspirin at a dose of 150 mg per day from 11 to 14 weeks of gestation until 36 weeks of gestation to reduce the risk of preterm preeclampsia.

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Advise against the use of low-dose aspirin as it has not shown significant benefits in reducing the incidence of preterm preeclampsia.

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Suggest the initiation of low-dose aspirin at 20 weeks of gestation for the prevention of preterm preeclampsia.

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Recommend the administration of warfarin instead of low-dose aspirin.

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Recommend high dose vitamin C during her pregnancy

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Based on the current understanding of placental biomarkers, which of the following statements is most accurate regarding the utility of biomarkers in predicting the development of superimposed pre-eclampsia in patients with CKD?

A high sFLT1/PlGF ratio is predictive of an increased risk of clinically significant superimposed pre-eclampsia and imminent delivery.

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High levels of placental growth factor (PlGF) indicate an increased risk of clinically significant superimposed pre-eclampsia.

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A decreased ratio of soluble fms-like tyrosine kinase-1 (sFLT1) to PlGF is predictive of imminent delivery in patients with CKD.

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Increased levels of vascular endothelial growth factor (VEGF) are associated with a lower risk of developing superimposed pre-eclampsia in CKD patients.

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Endoglin levels are directly proportional to the risk of superimposed pre-eclampsia, making them the most reliable single biomarker for predicting the condition.

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A 24-year-old pregnant woman reports at her first antenatal visit that her sister gave birth to a child with congenital heart block (CHB).

Which one of the following tests would be most useful in assessing the risk of congenital heart block in this pregnancy?

Antibodies to extractable nuclear antigens (ENA).

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Fluorescent antinuclear antibody (ANA) test

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Antibodies to DNA

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Anticardiolipin antibodies

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Lupus anticoagulant

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Pregnancy is known to have an affect on both kidneys and the remainder of the urinary tract.

With this in mind, all of the following values would typically increase in pregnancy, except?

plasma osmolality

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renal blood flow

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glomerular filtration rate

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glycosuria

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proteinuria

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A 30 year old primigravida who is currently in her 24 weeks gestation presents to your clinic following a referral from the midwife who recorded three blood pressure readings above 140/90. The patient is otherwise asymptomatic.

Which of the following feature would prompt an urgent admission?

Presence of oligohydromnios

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Spot urine protein/creatinine ratio of 25mg/mmol

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A history of chronic hypertension

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A platelet count of 150,000/μL

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+2 proteinuria on urine dipstick

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A 21 year old women who is currently at 25 weeks gestation has been diagnosed with pre-eclampsia. She has a background of depression but has otherwise been previously fit and well. Her blood pressure has been difficult to control so she is on dual anti-hypertensive therapy with oral methyldopa and nifedipine. Two months later, she presented with symptoms of severe depression including a suicide attempt. She was then referred to the psychiatrist for further assessment.

Which of the following would have been the likely cause for this?

oral methyldopa precipitated her depression.

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she has developed maternal psychosis

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she has systemic lupus erythematosus induced psychosis

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malingering behaviour.

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oral nifedipine precipitated her depression.

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Which one of the following is not characteristically elevated in the third trimester of normal pregnancy?

Serum free thyroxine (free T4).

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Serum prolactin.

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Serum alkaline phosphatase (ALP).

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Serum iron binding capacity

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A 28-year-old woman, who emigrated from Cambodia 10 years ago, presents to the emergency department in Auckland with a three-week history of increasing shortness of breath, orthopnoea, nocturnal dyspnoea and ankle oedema. She is 25 weeks pregnant and has no significant past medical history. The presence of pulmonary oedema is confirmed clinically and radiologically. She responds well to intravenous frusemide but remains tachypnoeic with a heart rate of 120/minute in sinus rhythm. Her blood pressure is 125/85 mmHg. Echocardiography demonstrates mitral stenosis with an estimated valve area of 1.3 cm2 and a left atrial diameter of 50 mm.

What is the most appropriate next step in management?

Beta-blocker therapy

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Balloon valvotomy

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Surgical valvotomy.

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Calcium blocker therapy

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Angiotensin converting enzyme (ACE) inhibitor therapy.

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Increasing risk of pre-eclampsia is most strongly related to:

condom use for contraception

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engaging in oral sex.

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increasing time interval between pregnancies

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increasing number of pregnancies.

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a long duration of cohabitation

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Which of the following cardiovascular condition is associated with the highest rate of maternal mortality?

pulmonary hypertension.

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hypertrophic cardiomyopathy.

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coarctation.

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aortic regurgitation

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peripartum cardiomyopathy

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A 36-year-old woman presents to her physician with persistent erythematous rash of the left breast, which developed while breastfeeding her first child. She stopped breastfeeding three months ago but the rash did not resolve despite two courses of antibiotics. She is afebrile. On examination there is a non-tender area of erythema on the breast and no masses are detected. Her pregnancy test is negative.

The most appropriate next step in her management is:

biopsy of the erythematous area

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ultrasound of the breast

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mammography.

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intravenous broad spectrum antibiotics

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topical antifungal therapy.

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A 38-year-old primiparous woman presents in the third trimester with facial weakness. She noticed this on waking this morning.

On examination, she cannot wrinkle her brow, has some eversion of the lower eye lid, drooping of the corner of the mouth with drooling and loss of the nasolabial fold.

The abdominal examination is otherwise that of a normal pregnancy.

Which of the following is most appropriate investigation prior to starting treatment?

No further investigation required.

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Facial electromyography

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Facial nerve conduction studies

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Computed tomography (CT) scan of the brain

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Lumbar puncture

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The postpartum state is associated with a substantially increased risk of thrombosis.

How many weeks post delivery does a patient remain at risk of thrombosis?

12 weeks

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6 weeks

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24 weeks

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3 weeks

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18 weeks

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In pregnant patients, which clinical feature is most likely to be associated with chronic hypertension as opposed to pre-eclampsia?

Elevated diastolic blood pressure at week 16 of pregnancy.

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Systolic blood pressure less than 160 mmHg

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Primigravida status.

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Proteinuria.

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Age less than 20 years.

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The pathogenetic mechanisms of pre-eclampsia are best attributed to:

uteroplacental ischaemia

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microvascular disease from longstanding hypertension

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complement activation.

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renal hypoperfusion.

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relative maternal hypovolaemia.

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Which of the following is the most important reason to measure thyroid stimulating antibodies in the third trimester of pregnancy in a woman with Graves disease?

Predict risk of neonatal thyrotoxicosis.

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Allow withdrawal of anti-thyroid medication

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Detect foetal goitre.

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Guide dose adjustment of anti-thyroid medication

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Predict risk of flare of thyrotoxicosis post-partum.

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A 32-year-old seven-month pregnant woman, on bed rest because of pregnancy-induced hypertension, presents with acute dyspnoea and left-sided pleuritic chest pain.

Physical examination showed: temperature 37.2°C, blood pressure is 130/90, pulse 118/minute, respiratory rate 28/minute, with moderate tenderness over the right calf. Positive foetal heart sounds.

ECG shows sinus tachycardia. Arterial blood gases on room air are PaO2 66 mmHg, PaCO2 28 mmHg and pH of 7.51.

A chest X-ray shows minimal shadowing at the left base with obliteration of the left costophrenic angle. A duplex scan of the legs shows a non-occlusive thrombus in the right common femoral vein. A ventilation-perfusion lung scan will not be available for 48 hours.

Which one of the following should be the next step in the management of this patient?

Intravenous heparin followed by subcutaneous heparin.

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Intravenous heparin followed by warfarin

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Thrombolytic therapy followed by heparin and warfarin.

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Observation until ventilation-perfusion lung scan can be performed.

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Placement of an inferior vena cava filter.

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A 23-year-old woman, during her first pregnancy, has a blood pressure of 145/90 mmHg (on repeated measurements) at 32 weeks gestation. Her previous blood pressures have been 125/75 mmHg or less.

Her serum electrolytes, urea and creatinine are normal but her serum uric acid is 0.38 mmol/L [0.09-0.36].

Urinalysis shows proteinuria +++, but no evidence of blood or glucose. Liver function tests and full blood count are normal.

Which one of the following is the most appropriate initial treatment?

Methyldopa.

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Bed rest.

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Chlorothiazide.

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Irbesartan.

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Enalapril

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A 22-year-old woman with primary generalised epilepsy presents for advice regarding a planned pregnancy. At age 16 years, she presented with a seizure following sleep deprivation and alcohol excess.

She was commenced on phenytoin, but after two further seizures in similar circumstances she was changed to sodium valproate and has been seizure-free for three years. She seeks pre-conception advice regarding ongoing anticonvulsant therapy.

To have the best probability of a successful pregnancy, the patient should be advised to minimise provoking factors, take folate and:

stop anticonvulsant therapy

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continue sodium valproate therapy

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change to carbamazepine therapy

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change to topiramate therapy

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change to clonazepam therapy.

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Which one of the following medications is most likely to cause foetal abnormalities if taken in the first trimester of pregnancy?

Warfarin.

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Enalapril.

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Gentamicin.

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Ibuprofen.

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Tetracycline

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A 24-year-old woman is on doxycycline 100 mg/day for moderately severe acne. She wants to become pregnant. In terms of foetal outcome, at what stage of pregnancy (measured from last menstrual period) is the risk to the foetus greatest from exposure to doxycycline?

12-40 weeks

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Pre-conception.

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0-4 weeks

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4-8 weeks

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8-12 weeks.

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Which of the following maternal conditions is associated with the greatest risk of cardiac complications during pregnancy?

Eisenmenger syndrome

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Atrial septal defect

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Ventricular septal defect.

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Patent ductus arteriosus

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Mitral valve prolapse

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A 25-year-old female with a history of allergic rhinitis and mild atopic dermatitis is currently pregnant with her second child. Her two-year-old son has infantile eczema and peanut allergy confirmed on skin prick testing.

The patient requests advice about dietary interventions during this pregnancy to reduce the risk of the second child developing peanut sensitisation.

Which of the following is the most appropriate advice?

No specific dietary intervention

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Avoidance of peanuts and peanut products.

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Avoidance of all nuts

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Omega-3 fatty acid supplementation

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Elimination diet (low allergen, additive and preservative).

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Abuse of which one of the following recreational drugs during pregnancy presents the greatest risk of birth defects to the foetus?

Cocaine.

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Amphetamines.

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Heroin.

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THC (tetrahydrocannibol).

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Tobacco

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The most effective way of preventing mother-to-child transmission of human immunodeficiency virus (HIV) is:

antiretroviral therapy to the mother during pregnancy.

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antiretroviral therapy to the mother during delivery.

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antiretroviral therapy to the newborn baby

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bottle-feeding.

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caesarean section

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Which one of the following best describes hepatitis E virus infection?

Enteric transmission, acute self-limiting course, increased mortality in pregnant women

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Parenteral transmission, chronic course, mortality due to chronic liver disease.

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Mode of transmission unknown, chronic course, mortality due to chronic liver disease

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Parenteral transmission, acute self-limiting course, increased mortality in pregnant women

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Mode of transmission unknown, chronic course, does not cause clinically significant illness.

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A 36-week pregnant woman is exposed to a child with chickenpox, 24 hours prior to her presentation. She has no prior history of chicken pox.

The most appropriate initial management is:

urgent serology for varicella-zoster virus.

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hyperimmune immunoglobulin (ZIG).

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chickenpox vaccine

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aciclovir.

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observation

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A 37-year-old man presents to the emergency department with symptoms of meningitis. Gram stain of the cerebrospinal fluid reveals the presence of gram-negative diplococci.

Which of the following antibiotic should his 12-week pregnant partner receive as prophylaxis?

Ceftriaxone

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Ciprofloxacin.

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Rifampicin.

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Meningococcal vaccine

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Erythromycin

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A 39-year-old primigravida at 32 weeks gestation presents with right upper quadrant pain and vomiting. Physical examination reveals poor peripheral perfusion, a pulse rate of 96/minute and blood pressure of 160/100 mmHg. There is tenderness in the right upper quadrant. Urine dipstick 1+ proteinuria

Liver function tests show:

bilirubin 14 μmol/L [2-14]
alkaline phosphatase (ALP) 200 U/L [40-130]
gamma glutamyltranspeptidase (GGT) 15 U/L [1-35]
aspartate transaminase (AST) 630 U/L [8-35]
alanine transaminase (ALT) 550 U/L [8-40]

The most likely cause of her abnormal liver function tests is:

pre-eclampsia.

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cholelithiasis.

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acute fatty liver of pregnancy.

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acute viral hepatitis.

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cholestasis of pregnancy.

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A healthy 24-year-old primigravida is noted to have isolated thrombocytopenia (platelets 100 x109/L) on a full blood examination performed at 32 weeks gestation.

She has no prior history of thrombocytopenia, and is normotensive. Her urinalysis is unremarkable.

Which of the following is the most likely explanation for this abnormality?

Gestational Thrombocytopenia

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Pre-eclampsia

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Anti-phospholipid syndrome

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Thrombotic Thrombocytopenic Purpura

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Immune Thrombocytopenic Purpura

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In a woman with antiphospholipid syndrome and recurrent pregnancy loss, which of the following treatment approaches provides the greatest chance of her achieving a successful pregnancy?

Aspirin and low molecular weight heparin

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Low-dose corticosteroids

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Low-dose corticosteroids and aspirin

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Intravenous immunoglobulin

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Warfarin.

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A 35-year-old woman with amenorrhoea is diagnosed with a microprolactinoma and is treated with bromocriptine 2.5 mg/day. Her prolactin level normalises and her periods become regular. A year later she presents six weeks pregnant.

What would be the most appropriate next step in management?

Stop bromocriptine and observe

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Continue bromocriptine and observe

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Increase bromocriptine dosage

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Change to cabergoline

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Advise termination of pregnancy

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A 30-year-old woman, treated successfully in her teens for osteosarcoma, develops striking dyspnoea during her first pregnancy.

Investigation reveals that she has cardiomyopathy with cardiac failure.

Which of the following is likely to be the cause of this?

Doxorubicin

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Cisplatin.

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Ifosfamide

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Methotrexate.

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Radiotherapy

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A 28-year-old woman, 16 weeks pregnant, is diagnosed with gestational diabetes during her routine antenatal care visit. She has a family history of type 2 diabetes and had a high body mass index at the start of her pregnancy.

After discussing her diagnosis, her obstetrician discusses her treatment options.

Which of the following is the most appropriate next step in managing her gestational diabetes?

Advise immediate dietary and lifestyle modifications, and commence insulin therapy if needed, to potentially reduce the incidence of adverse neonatal outcomes.

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Defer any treatment or interventions for gestational diabetes until the oral glucose-tolerance test is repeated at 24 to 28 weeks' gestation.

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Focus solely on monitoring fetal growth and well-being, as immediate treatment has been shown to significantly increase pregnancy-related hypertension.

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Initiate treatment only if signs of serious adverse events associated with gestational diabetes, such as polyhydramnios or fetal macrosomia, are detected.

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Recommend immediate pharmacological treatment to significantly increase the neonatal lean body mass.

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A 32-year-old woman with a known history of immune thrombocytopenia (ITP), not currently receiving treatment, presents for prenatal care at 12 weeks of gestation.

Her platelet count is reported to be 25×10^3 per cubic millimeter.

She had an inadequate response to prednisone and severe headaches with intravenous immune globulin (IVIG) in the past, and did not respond to rituximab.

Which of the following is the most appropriate next step in management?

Start romiplostim to increase the platelet count safely.

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Await natural improvement of platelet count until after delivery.

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Perform a splenectomy as soon as it is feasible during the pregnancy.

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Administer dexamethasone to rapidly increase the platelet count.

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Retry IVIG despite past side effects, as it is the safest option during pregnancy.

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Obstetric Medicine Module 1

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