Obstetric Medicine Module 1

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?

Pregnancy affects both the kidney and the remainder of the urinary tract. In pregnancy, all of the following would increase except?

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?

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?

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

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?

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

During pregnancy, many cardiovascular conditions are associated with an increased risk of maternal mortality.

Which one of the following cardiovascular conditions is associated with the highest rate of maternal mortality?
Moderate to severe:

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:

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 examination is otherwise that of a normal pregnancy.

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

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?

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

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

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?

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 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? 

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?

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:

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

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?

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

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?

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

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

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

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

The most appropriate initial management is:

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.

His 12-week pregnant partner should receive which one of the following as prophylaxis?

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: 

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?

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?

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?

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?