A 36-year-old woman, gravida 1 para 0, at 34 weeks gestation comes to the emergency department due to 4 hours of decreased fetal movement.  She has had no vaginal bleeding, contractions, or leakage of fluid.  The patient reports no headaches, changes in vision, or right upper quadrant pain.  Her last prenatal visit was at 16 weeks gestation; she moved from out of state at 18 weeks gestation for a new job.  A maternal serum alpha-fetoprotein level performed at that visit was normal.  The patient has a history of chronic back pain for which she takes a daily nonsteroidal anti-inflammatory drug.  She has had no surgeries.  The patient does not use tobacco, alcohol, or illicit drugs.  Blood pressure is 160/90 mm Hg and pulse is 68/min.  BMI is 30 kg/m².  Fetal heart rate shows a baseline of 140/min, moderate variability, accelerations, and no decelerations.  The tocometer shows no contractions.  Fundal height is 38 cm.  Bedside ultrasound reveals an estimated fetal weight consistent with 36 weeks gestation and an amniotic fluid index of 30 cm.  Laboratory results are as follows:

Which of the following is the most likely cause of this patient’s ultrasound findings?

A 29-year-old woman, gravida 2 para 0 aborta 1, at 34 weeks gestation comes to the office for a routine prenatal visit.  The patient reports no abdominal pain, leakage of fluid, or vaginal bleeding.  Fetal movement is normal.  Since her last visit 2 weeks ago, she has developed severe pruritus on her abdomen, which has not responded to over-the-counter moisturizers.  The patient has had no recent contact with anyone who has had a fever, rash, or pruritus.  She was diagnosed with gestational diabetes mellitus that is well controlled with an insulin regimen.  Earlier in the pregnancy, she had an episode of vulvar candidiasis that was treated with topical antifungal cream.  The patient has no chronic medical conditions or previous surgeries.  She takes prenatal vitamins daily and has no medication allergies.  The patient does not use tobacco, alcohol, or recreational drugs.  Temperature is 36.7 C (98 F) and blood pressure is 100/70 mm Hg.  BMI is 31 kg/m².  Fetal heart rate is 145/min and fundal height is 35 cm.  Physical examination shows prominent abdominal striae and some linear excoriations on the abdominal wall unrelated to the striae.  The remainder of the skin examination is normal.  Laboratory results are as follows:

Item 1 of 3

Which of the following is the most likely diagnosis in this patient?

Item 2 of 3

The patient is prescribed treatment for her symptoms.  She returns a week later for follow-up and reports good fetal movement and no contractions, vaginal bleeding, or leakage of fluid.  Her pruritus has worsened, and blisters have appeared near her umbilicus and are spread out over her abdomen.  Temperature is 36.7 C (98 F) and blood pressure is 100/70 mm Hg.  Fetal heart rate is 145/min and fundal height is unchanged at 35 cm.  Physical examination reveals the following:

Which of the following is the most likely diagnosis?

Item 3 of 3

Which of the following is the best next step in treatment of this patient?

A 39-year-old woman, gravida 3 para 2, at 7 weeks gestation comes to the emergency department for vaginal bleeding that began 3 hours ago and has soaked through a pad.  Since her arrival, the bleeding has subsided.  She reports no abdominal pain or cramping.  Her first prenatal visit is in 1 week.  The patient has a history of HIV, contracted 3 years ago through unprotected sexual intercourse, but she has declined treatment as she has felt “healthy.”  She has no previous surgeries.  The patient’s 2 prior pregnancies ended in uncomplicated term vaginal deliveries; the last delivery was 4 years ago.  Her last Pap test, 4 years ago, was normal.  She has smoked half a pack of cigarettes a day for 13 years but does not drink alcohol or use illicit drugs.  Blood pressure is 130/80 mm Hg and pulse is 82/min.  BMI is 24 kg/m².  Abdominal examination shows no tenderness or masses.  The external genitalia have no lesions.  Speculum examination reveals minimal bright red blood in the vaginal vault.  The cervix is closed and there is a 3-cm, firm, white, irregular mass on the anterior cervix that bleeds when touched with a cotton applicator.  Laboratory results are as follows:

A bedside transvaginal ultrasound reveals an intrauterine gestation with normal fetal cardiac activity.  Which of the following is the best next step in management of this patient?

A 36-year-old woman, gravida 3 para 2, at 32 weeks gestation comes to the emergency department due to abdominal pain.  The patient’s symptoms started a day ago as mild right-sided abdominal pain.  Since then, the pain has become increasingly severe and is accompanied by fever, heartburn, and diarrhea.  The patient has had no contractions, vaginal bleeding, or leakage of fluid.  Fetal movement is normal.  The pregnancy has been uncomplicated.  She has no chronic medical conditions and has had no surgeries.  The patient takes a daily prenatal vitamin and does not use tobacco, alcohol, or illicit drugs.  Temperature is 38.9 C (102 F), blood pressure is 140/80 mm Hg, and pulse is 112/min.  Fetal heart rate monitor shows a baseline of 160/min, moderate variability, and no decelerations.  Tocometry shows no contractions.  Cardiopulmonary examination reveals tachycardia but a regular rhythm and no rubs.  The lungs are clear to auscultation.  Abdominal examination reveals tenderness throughout the right lower quadrant and flank but no uterine fundal or costovertebral angle tenderness.  There is no rebound or guarding.  McBurney point is nontender.  Pelvic examination reveals no adnexal masses or tenderness.  Laboratory results are as follows:

Item 1 of 2

Which of the following is the best next step in diagnosing this patient’s condition?

Item 2 of 2

Inadequate treatment would put this patient at increased risk for which of the following complications?

A 22-year-old primigravida comes to the office at 13 weeks gestation for her first prenatal visit.  The patient was unaware that she was pregnant until last week, when she went to the emergency department for persistent vomiting; ultrasonography confirmed an intrauterine pregnancy.  The patient has irregular menstrual cycles due to polycystic ovary syndrome.  Nine months ago, she stopped taking oral contraceptives due to intolerable adverse effects; she did not inform her provider.  The patient also has a history of idiopathic seizures beginning in childhood and receives valproate monotherapy.  She states, “I just read in one of those maternity books that seizure medications can be bad for my baby.  Should I stop now?  I have not had a seizure in a long time.”  Her last seizure occurred a year ago after an attempt to change her medication regimen; she was hospitalized for aspiration pneumonia afterward.  The patient does not use tobacco, alcohol, or recreational drugs.  There is no family history of congenital abnormalities.

Item 1 of 2
Which of the following is the best strategy for management of this patient?

Item 2 of 2
This patient’s pregnancy was uneventful and she delivered a healthy baby.  She has heard about the benefits of breastfeeding and asks if she can breastfeed while taking her medication.  Which of the following is the most appropriate response to this patient?

A 32-year-old woman, gravida 1 para 0, at 19 weeks gestation comes to the emergency department due to vaginal pressure and spotting.  Over the past few days, she has had clear vaginal discharge, for which she has used sanitary napkins.  Today, the patient has had increasing pelvic pressure and has noticed blood spots on the sanitary napkins.  She has had no cramping or pelvic pain; fetal movement has been normal.  The patient’s pregnancy was previously uncomplicated; initial prenatal laboratory testing was normal.  She was scheduled to have an anatomy ultrasound later in the week.  The patient has no chronic medical conditions and has had no previous surgeries.  She takes a prenatal vitamin daily and acetaminophen as needed for headaches.  She was treated for Chlamydia trachomatis cervicitis at age 20.  The patient does not use tobacco, alcohol, or recreational drugs.  Temperature is 36.7 C (98.1 F), blood pressure is 110/70 mm Hg, pulse is 65/min, and respirations are 18/min.  Fetal heart rate is 145/min by Doppler ultrasound.  Speculum examination shows amniotic membranes bulging at the vaginal introitus.  There is no blood or pooling of fluid in the vaginal vault.  Nitrazine paper does not turn blue on application of the vaginal discharge.  The cervix is 3 cm dilated and 100% effaced on digital examination.

Item 1 of 2

Which of the following is the most likely diagnosis in this patient?

Item 2 of 2

The patient is informed of the examination findings.  She asks about the prognosis for this pregnancy.  Which of the following is the most appropriate response to the patient at this time?

A 37-year-old woman, gravida 3 para 2, at 13 weeks gestation comes to the office for fetal aneuploidy screening.  The patient had painless vaginal spotting a few weeks ago that has since resolved.  Her previous 2 pregnancies ended in uncomplicated term vaginal deliveries.  The patient has no chronic medical conditions.  She is the vice principal at a local elementary school, volunteers as a basketball coach, and attends a yoga class 3 times a week.  The patient takes a prenatal vitamin and an iron supplement daily.  Blood pressure is 110/70 mm Hg and pulse is 68/min.  BMI is 26 kg/m².  Fetal heart rate is 150/min.  Ultrasound reveals a 13-week fetus with a normal nuchal translucency measurement and a 1.8-cm, crescent, hypoechoic area between the gestational sac and the uterus, which is consistent with a hematoma.  The patient’s blood type is B, Rh positive.  Fetal aneuploidy screening results are normal.

Item 1 of 2
Which of the following is the best next step in management of this patient?

Item 2 of 2
Appropriate action was taken.  Given the ultrasound findings, this patient is at increased risk for which of the following complications?

A 40-year-old woman, gravida 3 para 0 aborta 2, at 16 weeks gestation comes to the office for prenatal care.  She reports no abdominal pain, vaginal bleeding, or leakage of fluid.  She has a history of polycystic ovary syndrome and required in vitro fertilization for all of her pregnancies.  This pregnancy was complicated by first-trimester vaginal bleeding, which resolved spontaneously.  A prophylactic cerclage was placed 2 weeks ago because her first 2 pregnancies ended with painless spontaneous abortions at 18 weeks gestation.  The patient also has a history of type 2 diabetes mellitus and chronic hypertension, both managed with oral medications.  She takes a daily prenatal vitamin with iron supplementation.  She does not use tobacco, alcohol, or recreational drugs.  Prior to her in vitro fertilization, the patient did hot yoga 2 days a week and jogged for 30-45 minutes approximately 3 days a week, which she would like to resume.  Blood pressure is 140/90 mm Hg and pulse is 88/min.  BMI is 30 kg/m².  The fetal heart rate is 150/min by Doppler sonography.  Laboratory results are as follows:

Which of the following is the best recommendation for this patient regarding exercise during pregnancy?

A 42-year-old woman, gravida 6 para 6, is evaluated in the postpartum unit on postoperative day 2 after a cesarean delivery.  The patient has had increasing vaginal bleeding, abdominal pain, and fever.  She is breastfeeding exclusively with a good latch.  The patient was initially admitted to the hospital for prelabor rupture of membranes at 40 weeks gestation.  The patient had a negative Group B Streptococcus rectovaginal culture.  A primary cesarean delivery was performed for arrest of descent of a 5-kg (11-lb) infant after 3 hours of pushing.  The pregnancy was complicated by recurrent vaginal candidiasis.  Prior pregnancies were uncomplicated; the patient’s last delivery was 12 years ago.  Temperature is 38.7 C (101.7 F), blood pressure is 110/70 mm Hg, pulse is 114/min, and respirations are 18/min.  On physical examination, the patient appears pale and tired.  The lungs are clear to auscultation bilaterally; the breasts are full but without erythema.  The uterine fundus is tender to palpation.  Speculum examination shows heavy lochia but no active bleeding.  The transverse incision across the lower abdomen is intact and without erythema or drainage.

Item 1 of 2
Which of the following is the most appropriate pharmacotherapy for this patient?

Item 2 of 2
Which of the following is this patient’s most important risk factor for her current postpartum infection?

A 27-year-old woman, gravida 1 para 0, at 28 weeks gestation comes to the office for a routine prenatal visit.  Her initial prenatal laboratory results at 12 weeks gestation were as follows:

The patient reports no vaginal bleeding, leakage of fluid, or contractions.  There is good fetal movement.  She has increasing urinary frequency and nocturia but no dysuria or hematuria.  The patient has a history of tension headaches, which have become more frequent but resolve with acetaminophen.  She has no other chronic medical conditions or previous surgeries.  The patient works in a retirement home and reports leg swelling at the end of her shift.  She is a vegetarian and takes a daily prenatal vitamin.  She does not use tobacco, alcohol, or illicit drugs.  Temperature is 37 C (98.6 F), blood pressure is 128/76 mm Hg, and pulse is 86/min.  BMI is 30 kg/m²; the patient has been gaining 0.5 kg (1.1 lb) a week during the pregnancy.  The fetal heart rate is 152/min.  Examination shows a uterus consistent with a 28-week gestation.  There is trace lower extremity edema bilaterally.  The patient has had no laboratory evaluations since her initial prenatal visit.

Item 1 of 3

Which of the following is the most appropriate laboratory evaluation to perform at this visit?

Item 2 of 3

The patient’s test results from the 28-week prenatal visit are as follows:

Which of the following is the most likely diagnosis?

Item 3 of 3

The patient comes to the hospital at 38 weeks gestation in active labor and with spontaneous rupture of membranes.  Blood pressure is 130/84 mm Hg and heart rate is 96/min.  Fetal heart rate tracing is reassuring.  Uterine contractions are regular and occur every 4 minutes.  Cervical examination reveals 5-cm dilation, 100% effacement, and a vertex presentation at −1 station.  Complete blood count on admission is as follows:

The patient requests neuraxial labor analgesia.

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