MINISTRY OF PUBLIC HEALTH OF UKRAINE NATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSYA CHAIR OF OBSTETRICS AND GYNECOLOGY №1 METHODICAL INSTRUCTIONS for practical lesson « Diagnostic methods of well-being of fetus. Placental insufficiency. Newborn resuscitation. Abnormalities of the placenta, umbilical cord, and membranes» MODULE 4: Obstetrics and gynecology TOPIC 7
67
Embed
METHODICAL INSTRUCTIONS · Web view2014/03/12 · congenital anomalies (choanal atresia, diaphragmatic hernia, etc.). Irrespective of the reasons for fetal hypoxia, they result in
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
MINISTRY OF PUBLIC HEALTH OF UKRAINENATIONAL PIROGOV MEMORIAL MEDICAL UNIVERSITY, VINNYTSYA
CHAIR OF OBSTETRICS AND GYNECOLOGY №1
METHODICAL INSTRUCTIONS
for practical lesson
« Diagnostic methods of well-being of fetus. Placental insufficiency.
Newborn resuscitation. Abnormalities of the placenta, umbilical cord, and
membranes»
MODULE 4: Obstetrics and gynecology
TOPIC 7
Aim: to know obstetrics terminology, the methods of external and internal examination of
pregnant women. To be able to prescribe and assess of modern methods of diagnostics of fetal
well-being in obstetrics for in-term revealing of pathological changes in pregnant woman's
organism and fetal status; prescribe an adequate treatment to the pregnant women in the case of
fetal hypoxia.
Professional motivation: learning the methods of obstetrics examination of pregnant women is
necessary to diagnose and to estimate the given information. An appropriate interpretation of
fetal well-being tests in light of the natural course of any antenatal problem provides a firm base
on which decisions are made.
Basic level: Student must know:
1. Anatomic terminology in English and Latin
2. Methods of physical examination of patient.
3. The structure of fetal head (anatomy of the skull).
4. Conceptus, development.
5. Obstetric ultrasound examination and its assessment.
6. Fetal heart rate auscultation.
7. To prescribe an adequate therapy of fetal well-being impairment
Assessment of fetal well-being
Assessment of fetal well-being includes maternal perception of fetal activity and several tests
using electronic fetal monitors and ultrasonography
Tests of fetal well-being have a wide range of uses, including the assessment f fetal status at a
particular time and the prediction of fetal status for varying time intervals, depending on the test
and the clinical situation.
An active fetus is generally a healthy fetus, so that quantification of fetal activity is a common
test of fetal well-being. If, for example, the mother detects more than four fetal movements while
lying comfortably and focusing on fetal activity for 1 hour, the fetus is considered to be healthy.
Techniques using electronic fetal monitoring and ultrasonography are most costly, but also
provide more specific information. The most common tests used are the nonstress test, the
contraction stress test (called the oxytocin challenge test if oxytocin is used), and the biophysical
profile.
The nonstress test (NST) measures the response of the fetal heart rate to fetal movement.
Interpretation of the nonstress test depends on whether the fetal heart rate accelerates in response
to fetal movement. A normal, or reactive, NST occurs when the fetal heart rate increases by at
least I5bpm over a period of 15 seconds following a fetal movement. Two such accelerations in a
20-minute span is considered reactive, or normal. The absence of these accelerations in response
to fetal movement is a nonreactive NST. A reactive NST is generally reassuring in the absence of
other indicators of fetal stress. Depending on the clinical situation , the test is repeated every 3 to
4 days or weekly. A nonreactive NST must be immediately followed with further assessment of
fetal well-being.
Whereas the nonstress test evaluates the fetal heart rate response to fetal activity, the contraction
stress test (CST) measures the response of the fetal heart rate to the stress of a uterine
contraction. With uterine contraction, uteroplacental blood flow is temporary reduced. A healthy
fetus is able to compensate for this intermittent decreased blood flow, whereas a fetus who is
compromised is unable to do so, demonstrating abnormalities such as fetal heart rate
decelerations. If contractions are occurring spontaneously, the test is known as a contraction
stress test; if oxytocin infusion is required to elicit contractions,the test is called an oxytocin
challenge test (OCT). The normal fetal heart rate response to contractions is for the baseline fetal
heart rate to remain unchanged and for there to be no fetal heart rate decelerations.
The biophysical profile is a series of five assessments of fetal well-being, each of which is given
a score of 0 or 2. The parameters include a reactive nonstress test, the presence of fetal
movement of the body or limbs, the findings of fetal tone (flexed extremities as opposed to a
flaccid posture). And an adequate amount of amniotic fluid volume. Perinatal outcome can be
correlated with the score derived from these five parameters.
A score of 8 to 10 is considered normal, a score of 6 is equivocal requiring further evaluation,
and a score of 4 or less is abnormal, usually requiring immediate intervention
Table 1. Biophysical profile
Biophysical
Variable
Score Explanation
Fetal
breathing
movements
(FBM)
Norma 1 = 2 At least 1 FBM of at least 30 seconds duration in 30 minutes
Abnormal = 0 No FBM of at least 30-seconds duration in 30 minutes
Gross body
movement
Normal = 2 At least 3 discrete body /limb movements in 1 30 minutes
Abnormal = 0 2 or less discrete body /limb movements in 30 minutes
Fetal tone Normal = 2 At least 1 episode of active extension with return to flexion of fetal
Of muscles limbs/trunk or opening/closing of hand
Abnormal == 0 Either slow extension with return to partial flexion or movement of
limb in full extension or no fetal movement
Reactive
fetal heart
rate
Normal = 2 Reactive NST
Abnormal = 0 Nonreactive NST
Qualitative
amniotic
fluid volume
Normal = 2 At least 1 pocket of amniotic fluid at least 1 cm in two
perpendicular planes
Abnormal = 0 No amniotic fluid or no pockets of fluid greater 1 than 1 cm in two
perpendicular planes
PLACENTAL INSUFFIENCY
Placental insufficiency (PI) is a symptom complex conditioned by violations of transport, trophic,
metabolic, and endocrine functions of the placenta due to structural changes.in it.
(20–50%) are not recommended. If hypoglycaemia persists investigations, including insulin
measurements, are required.
Infections
Newborn infants are particularly prone to perinatal infection; risk factors include low-
birthweight infants, prolonged ruptured membranes, maternal fever or chorioamnionitis.
Iatrogenic infection is problematic for those undergoing intensive care; the presence of
indwelling cannulae, central venous lines and invasive mechanical ventilation increase the risk.
Organisms responsible for later neonatal infection frequently come from the skin or gut.
Breastfeeding helps promote normal gut flora and reduces the risk of acquired neonatal
infections. Adherence to good hand-washing practices by all staff, parents and visitors can
significantly reduce the risk of acquired infection.
SEPTICAEMIA
The signs of systemic sepsis are non-specific. Infants may present with apnoea,
bradycardia or cyanotic episodes; is a common association. They may be lethargic and hypotonic
and they are hyper or hypothermic. Sepsis frequently presents as a metabolic acidosis or shock
and occasionally causes petechial skin rash or severe jaundice. Organisms which commonly
cause infection in the newborn period are group B streptococci, and gram-negatives such as
Escherichia coli orKlebsiella. The prolonged user multiple changes of antibiotics in the antenatal
period may increase the risk of infection with resistant organisms. Rapid treatment with
antibiotics, immediate resuscitation and, frequently, mechanical ventilation is required.
Investigations include chest X-ray, blood cultures, urine culture, and examination and culture of
the placenta. A lumbar puncture is performed once the baby is stable and will tolerate the
procedure. The mortality of infants who develop septicaemia in the neonatal period is high with
a significant number of survivors developing subsequent impairment.
GROUP B STREPTOCOCCUS INFECTION
Mortality due to maternal colonization by Group B streptococcus (GBS) is reduced by
antibiotic therapy to the Mother during labour and early treatment of infants with evidence of
infection. About 2% of infants of colonized mothers develop infections, and 70% of these
manIFEST risk factors at birth such as preterm labour, prolonged rupture of the membranes or
meconium stained liquor. Urgent antibiotic therapy is indicated for these infants. Well infants
shown by surface cultures to be colonized, do not require treatment. Recurrent GBS infection
can occurbut more commonly GBS infection can occurlater in infancy when meningitis is the
presenting problem.
MENINGITIS
Signs of meningitis in newborn infants are non-specific with a bulging fontanelle;
opisthotonos and seizures occurlate in the disease. Meningitis usually presents as septicaemia
and can be complicated by cerebral oedema, cerebral infarction, brain abscess or deafness.
Common causal organisms are GBS and E. coli. Listeria monocytogenes is a rare cause of
perinatal infection in the United Kingdom.
URINARY TRACT INFECTION
Urinary tract infectionsmaypresent as jaundice, vomiting, poorfeeding orsepticaemia. The
main cause is believed to be spread of blood-borne organisms to the kidney during septicaemia.
Further investigation is essential as 35–50% are associated with urinary tract abnormalities such
as vesico-ureteric reflux or ureterocele. Breastfeeding offers a significant degree of protection.
EYE INFECTION
The majority of sticky eyes are not infected but are due to a blocked nasolacrimal duct. In
the absence of conjunctival redness orswelling investigation forinfection and treatment with
topical antibiotics is not required. Simple measures such as cleaning with boiled water and
lacrimal duct massage suffice with symptoms usually resolving in 3–6 months. Neonatal
conjunctivitis can be caused by such organisms as Staphylococcus aureus,Chlamydia
trachomatis, Haemophlus influenzae,Str eptococcus pneumoniae and Neisseria gonorrhoeae.
Gonococcal ophthalmia usually presents within 24 h of delivery with profuse purulent
conjunctival discharge and immediate diagnosis and treatment (systemic and topical) is required
to prevent damage to the cornea. Chlamydial ophthalmia which is now among the commonest
causes of neonatal conjunctivitis presents between 5 and 12 days postnatal age; some babies
infected as neonates will develop chlamydial pneumonia laterin infancy. Corneal scarring is rare;
14 days systemic and topical treatment is required. The identification of either N. gonorrhoeae or
chlamydia in the baby requires referral of motherand hersexual partnerforinvestigation and
treatment.
SKIN INFECTION
Simple hygienic methods such as bathing, hand washing and routine umbilical cord care
can prevent many skin infections. The infant’s skin is vulnerable to infection by Staphylococci,
which usually leads to small pustules or lesions but can also cause scalded skin syndrome with
severe exfoliation. Staphylococcal infections should therefore be treated with antibiotics after
appropriate cultures have been taken. Streptococci can also cause skin infection and both may
cause systemic illness. Infection of the umbilical cord is commonly limited to periumbilical
redness with a small amount of discharge. The presence of oedema indicating cellulitis can
occasionally lead to complications such as spreading cellulites of the abdominal wall, fasciitis
and septicaemia and requires treatment with systemic antibiotics. Candidiasis usually presents
after the first week of life with napkin dermatitis with or without oral thrush. Topical and oral
treatment is required to prevent the candidiasis returning as the gut is colonized with candidia.
Maternal nipple candidial infection can occur in breastfeeding mothers.
TUBERCULOSIS
Tuberculosis is a re-emergent disease and many hospitals now offerBacille Calmette-
Guйrin (BCG) immunization to newborn infants. Infants born to mothers infected with active
tuberculosis should be vaccinated with isoniazidresistantBCGvaccine and kept with the mother
while both receive treatment with appropriate drugs. Breastfeeding should be encouraged. Expert
advice on drug therapy is advisable as patterns of antibiotic susceptibility change overtime.
TETANUS
Neonatal tetanus due to infection of the umbilical stump by Clostridium tetanii is the result
of poor hygiene and is a distressing and severe condition with extremely high mortality.
Opisthotonus and muscle spasms of the jaw and limbs are presenting features and can appear
very rapidly after birth. Prevention centres on maternal vaccination during pregnancy and
education to improve hygiene and change of local cultural practices.
Gastrointestinal disorders
OESOPHAGEAL ATRESIA OR TRACHEO-OESOPHAGEAL FISTULA
These conditions should be suspected when there is polyhydramnios or excessive mucous
from the mouth at birth. The baby may show rapid onset of respiratory stress and cyanosis
particularly after the first feed. X-ray confirms the diagnosis, the naso- oror ogastric tube does
not pass into the stomach. A large bore nasogastric tube should be placed in the oesophageal
pouch, constant suction and regular aspiration help prevent aspiration pneumonia. Associated
congenital anomalies occurin 50% or more of infants. Surgery involves division of the fistula
and oesophageal repair; if primary anastomosis is not possible lengthened procedures are
required before later oesophageal repair. Common long-term complications are gastro-
oesophageal reflux and anastomotic stricture formation both of which may require further
surgical treatment and long-term medication. Survival is usually determined by the severity of
associated congenital anomalies and not the defect itself.
DIAPHRAGMATIC HERNIA
Herniation of the abdominal contents into the hemithorax leads to severe respiratory
difficulties with persistent pulmonary hypertension. Most cases present with respiratory distress
and cyanosis at birth. Essential early management is the passage of a large bore nasogastric tube
into the stomach to prevent gaseous distension, ventilation and rapid transfer to intensive care.
All these infants require tertiary level intensive care, with access to sophisticated mechanical
ventilation and modern vasodilator therapy such as nitric oxide. Surgery is delayed until the
infant’s respiratory status has been stabilized. Survival depends on the degree of underlying
pulmonary hypoplasia and the presence of associated congenital anomalies such as cardiac
defects. Long-term complications include persistent gastro-oesophageal reflux and respiratory
problem; neurodevelopmental problems can develop if neonatal hypoxia was severe.
ABDOMINAL WALL DEFECTS
Exopmhalos, in which part or all of the intestine and abdominal organs are in a peritoneal
sack outside the abdomen, should be differentiated from gastroschisis where a congenital defect
of the abdominal wall allows herniation of the abdominal contents without a peritoneal sac. The
former is frequently associated with other congenital defects, while the latter is not. Urgent
surgery is required if the amniotic sac has broken and for gastroschisis; immediate management
is to wrap the abdominal contents in a plastic wrapper taking care not to twist the bowel and
disrupt its vascular supply. This should help prevent hypovalaemia due to fluid loss from the
exposed bowel. A large bore nasogastric tube is passed and the baby’s circulatory status
constantly assessed. Hypovalaemia orexcessive nasogastric output should be treated with 20
ml/kg 0.9% sodium chloride bolus intravenous infusions. The risk of hypothermia is high unless
good thermal management is present from birth. Primary repair is not always possible if the
abdominal cavity is not large enough to accommodate all the contents; a silo made of sterile
prosthetic material is attached to the abdominal wall and the contents gradually reduced over 7–
10 days. Outcomes are worse for those requiring silo treatment as infected complications are
high. The long-term outcome for most with exopmhalos is determined by the presence of
associated congenital anomalies. In gastroschisis 90%ormor e now survive. However,
theirpostnatal course is often protracted and parenteral nutrition may be required for several
weeks with its risks and complications. In addition bowel atresias and necrotizing enterocolitis
may develop.
INTESTINAL OBSTRUCTION
Highintestinal obstructions usually present with vomiting whichmaybe bile stained, and
this ominous signdemands urgent investigation. Plain X-ray film of the abdomen can confirm the
presence of obstruction by showing a lack of air in the lower gut or a sign such as the ‘double
bubble’ of duodenal atresia. Hypertropic pyloric stenosis does not usually present until 2–6
weeks of age. Lower intestinal obstruction usually presents as failure to pass meconium within
24 h followed by abdominal distension with orwithout vomiting. Causes include Hirshprung’s
disease, meconium ileus due to cystic fibrosis low bowel atresia or hypoplasia and imperforate
anus. Ameconium plug can sometimes mimic obstruction especially in preterm infants.
NEONATAL NECROTIZING ENTEROCOLITIS
This poorly understood inflammatory condition is primarily a condition of
preterminfantsandthose with congenital heart disease. It presents as an acute abdomen in the
days or weeks after birth and varies in severity from mild to fatal. Diagnosis is clinical, aided by
characteristic X-ray changes such as airin the bowel wall orbiliar y tree. Treatment is
conservative with cessation of enteral feeding and with antibiotics orsur gery.
Common queries from parents
Many minor alterations to physiology cause alarm to parents. Some common questions and
responses to them are outlined in Table 11.6 and in the absence of disease, reassurance is all that
is required. It is wise to read your unit’s breastfeeding policy so as not to contradict the advice
given by midwives and lactation consultants.
Advanced life support
If mask ventilation fails to produce an adequate heart rate check again forevidence of
upperair way obstruction and aspirate the nasal passages and nasopharynx. Meconium present in
the trachea should have been aspirated under direct vision using a laryngoscope before
ventilation, but this may need repeating. If clearing of the airway and reventilation fails to
produce a normal heart rate, endotracheal intubation is required. This technique is not difficult
but requires practice and carries a considerable danger in inexperienced hands: the endotracheal
tube will enter the oesophagus easily and significantly inhibi ventilation. If an infant does not
rapidly improve after attempted endotracheal intubation, there is presumptive evidence of the
tube being in the oesophagus. It should be removed and intubation repeated. If there is doubt it
may be safer to concentrate on bag and mask ventilation while awaiting skilled assistance. Once
the endotracheal tube is placed, auscultate the chest overboth lungs to ascertain that breath
sounds are equal. Inequality implies that the tube has been inserted too far and entered one lung,
but could also suggest majorpr oblems such as pneumothorax orcongenital diaphragmatic hernia.
Endotracheal intubation secures access for mechanical ventilation. Initial ventilation should
include an inspiratory time of approximately 1 s todistend collapsed alveoli, and peak pressures
sufficient to visibly move the chest. Once the alveoli are expanded less pressure is required. Thus
the first breaths may require peak pressures of 30 cm of waterormor e in term babies, whereas
afterthis it is usually possible to ventilate the lungs with pressures of approximately half this, and
a respiratory time of 0.5 s at a rate of 40 breaths/min. If there is evidence or presumption of
surfactant deficiency, exogenous surfactant shouldbe administered early. Effective ventilation is
enough to resuscitate most infants and only rarely is cardiac massage or the administration of
blood because of bleeding required. On very rare occasions, endotracheal adrenaline may need to
be administered for persistent bradycardia and if this fails intravenous adrenaline may be given.
It is no longer good practice to administer sodium bicarbonate intravenously to infants unless
blood gases are measured or circulatory failure is very prolonged. Most low-risk infants who
require resuscitation can be extubated within a few minutes and can usually be nursed by their
mothers as long as (1) there is no specific problem such as meconium aspiration, prematurity or a
history of infection and (2) adequate observation can be maintained. Infants who cannot be
extubated successfully in this time or who continue to have respiratory problems require
admission to a neonatal unit.
Tests and Assignments for Self — assessment.
Multiple Choice.
Choose the correct answer / statement:
1-1. Which of the following approximates the incidence of major structural or functional abnor-malities found in neonates?a. <1 %b. 2 to 3%c. 5 to 8%d. 10 to 12%
1-2. Which of the following is NOT currently used for fetal therapy?a. cordocentesisb. fetal tissue biopsyc. stem cell transplantationd. vesicoamnionic shunting
1-3. In women with no obstetrical or family history of aneuploidy, which of the following is the most powerful maternal predictor of aneuploidy?a. ageb. racec. parity
d. socioeconomic status
1-4. Approximately what percentage of all conceptuses are aneuploid?a. 5b. 10c. 25d. 50
1-5. What percentage of stillbirths and neonatal deaths are attributable to chromosomal abnor-malities?a. 1 to 3b. 5 to 7c. 10 to 12d. 15 to 20
1-6. Your patient has just spontaneously aborted a 7-week gestation. You counsel her that aneu-ploidy accounts for approximately what percentage of first-trimester abortion?a. 30b. 50c. 70d. 90
1-7. The fetal death rate following amniocentesis approximates which of the following?a. 1:100b. 1:200c. 1:400d. 1:500
1-8. Women with which of the following characteristics should be offered amniocentesis for fetal karyotyping?a. previous child was 4~.XYYb. twin gestation regardless of maternal agec. will be 35 years or older at time of deliveryd. prior history of 3 first-trimester spontaneous abortions
1-9. At term what is the risk of delivering an aneuploid fetus in a 35-year-old woman?a. 1:50b. 1:100c. 1:200d. 1:400
1-10. What is the recurrence risk of trisomy, either the same involved chromosome or different, in a young mother who had a previous pregnancy complicated by an autosomal trisomy?a. 1%b. 3%c. 5%d. 10%
1-11. What is the approximate recurrence risk of structural abnormalities that are multifactorial in etiology?a. 0.5%b. 1%
c. 2 to 3%d. 10 to 15%
1-12. Your 25-year-old newly pregnant patient informs you that her cousin was born with anencephaly, which has a multifactorial etiology. How do you counsel her regarding her fetus' risk for this abnormality?a. is greater than that of the general populationb. warrants pregnancy terminationc. warrants amniocentesis at 14 to 16 weeksd. warrants MSAFP level measurement at 16 weeks
1-1. Isolated fetal structural dejects are most commonly found in which of the following organs?a. liverb. heartc. bladderd. neural tube
1-14. Your patient's first child had an atrioventricular defect. You counsel her that the risk of recurrence of the same defect in future pregnancies is which of the following?a. 20%b. 40%c. 60%d. 80%
1-15. Additionally, you counsel the patient in Question 14 that fetal ultrasonography and echocardiography should be performed in future pregnancies at what gestational age?a. 6 to 8 weeksb. 10 to 12 weeksc. 20 to 22 weeksd. 26 to 28 weeks
1-16. Your newly pregnant patient informs you that her sister was born with spina bifida. You counsel her which of the following regarding her fetus risk for this abnormality?a. risk is 10 to 15%b. risk equals that of the general populationc. warrants maternal serum alpha-fetoprotein (MSAFP) level measurementd. warrants MSAFP level measurement plus fetal ultrasonographic examination
1-17. Which of the following has NOT been associated with an increased risk of fetal neural-tube defects?a. concurrent trisomy 1b. poorly controlled diabetesc. first-trimester acetaminophen used. high maternal fever early in gestation
1-18. Exposure to which of the following drugs is associated with an increased risk of fetal neural-tube defects?a. carbamazepineb. isotretinoinc. valproic acidd. all of the above
1-19. The most common hemoglobinopathy in the US. is found among persons belonging to which crhnic or geographic background?a. Mediterraneanb. Middle Easternc. Southeast Asiand. African American
1-20. Individuals of Jewish ancestry are at increased risk for which of the following diseases?a. Canavanb. Gaucherc. Tay-Sachsd. all of the above
1-21. Which of the following fetal structures is NOT involved in the synthesis of alpha-fetoprotein (AFP)?a. liverb. yolk sacc. bone marrowd. gastrointestinal tract
1-22. AFP can be found in which of the following body fluids?a. fetal urineb. fetal serumc. maternal serumd. all of the above
1-23. At which gestational age is the highest level of amnionic fluid AFP observed?a. 7 weeksb. 11 weeksc. 1 weeksd. 17 weeks
1-24. At which gestational age is the highest level of MSAFP observed?a. 10 weeksb. 14 weeksc. 18 weeksd. 22 weeks
1-25. Levels of MSAFP are influenced by which of the following maternal factors?a. raceb. diabetic statusc. maternal weightd. all of the above
1-26. In screening your patient's fetus for neural-tube defects at 16 weeks gestation, you obtain an MSAFP result which is 3.0 MoM.Your patient has no history indicating an increased risk for this defect. Which of the following is the next best step in her management?a. repeat MSAFP level measurementb. amniocentesis for fetal karyotypingc. amniocentesis for amnionic fluid AFP level measurementd. ultrasonography and amniocentesis for amnionic AFP level measurement
1-27. Which of the following accounts for the largest portion of elevated MSAFP levels in the absence of fetal anomaly?a. fetal deathb. maternal obesityc. multiple gestationd. incorrect gestational dating
1-28. Which ,of the following is NOT a condition associated with an elevated MSAFP level?a. omphalocoeleb. cloacal extrophyc. oligohydramniosd. complete molar pregnancy
1-29. In screening your patient's fetus for neural-tube defects at 16 weeks gestation, you obtain an MSAFP result that is 4.0 MoM.Your patient has no history indicating an increased risk for this defect. Which of the following is the next best step in her management?a. ultrasonographic examinationb. repeat MSAFP measurementc. amniocentesis for fetal karyotypingd. amniocentesis for amnionic fluid AFP level measurement
1-30. Which of the following fetal cranial ultrasonographic findings is NOT associated with neural-tube defects?a. lemon signb. banana signc. cabbage signd. ventriculomegaly
1-31. Open spine defects are associated with specific cranial lesions in what percentage of cases?a. 5b. 33c. 67d. 99
1-32. In screening your patient's fetus for neural-tube defects at 17 weeks gestation, you obtain an MSAFP result of 5.0 MoM. Your patient has no history that points to an increased risk for this defect. Ultrasonography reveals a viable singleton gestation with no structural anomalies, normal amnionic fluid index, and fetal measurements consistent with gestational age. Which of the following is the next best step in her management?a. reassuranceb. repeat MSAFP level measurementc. amniocentesis for fetal karyotypingd. amniocentesis for amnionic fluid AFP level measurement
1-33. In a woman with an elevated MSAFP level and elevated amnionic fluid AFP, what further testing should be performed on the amnionic fluid?a. Δ OD 450b. fetal fibronectin assayc. C-reactive protein assayd. acetylcholinesterase assay
1-34. Unexplained elevated abnormal AFP levels are associated with which of the following
complications?a. fetal deathb. low birthweightc. preterm rupture of membranesd. all of the above
1-35. Which of the following maternal serum analytes is NOT included in the "triple screen" for Down syndrome?a. AFPb. placental lactogenc. unconjugated estriold. chorionic gonadotropin
1-36. What percentage of fetuses with Down syndrome can be detected in women older than 35 years using the triple screen?a. 50 to 55b. 65 to 70c. 75 to 80d. 90 to 95
1-37. Which of the following is a maternal serum marker used in first-trimester Down syndrome screening?a. placental lactogenb. acetylcholinesterasec. pregnancy-associated plasma protein Ad. all of the above
1-38. Ultrasonographic measurement of which of the following is commonly used in first-trimester Down syndrome screening protocols?a. femur lengthb. intraorbital distancec. nuchal translucencyd. placental sonolucencies
1-39. Cystic fibrosis is inherited via which genetic transmission pattern?a. imprintingb. X-Iinkedc. autosomal recessived. autosomal dominant
1-40. Antenatal cystic fibrosis screening should be offered when both members of a couple are from which of the following ethnic groups?a. Southeast Asianb. Ashkenazi Jewishc. African Americand. Hispanic American
1-41. Which of the following is the most common cause of familial mental retardation?a. trisomy 1b. Down syndromec. 47.XXY genotyped. fragile X syndrome
1-42. Which of the following patients need NOT be offered screening for fragile X syndrome?a. males with unexplained mental retardationb. females with unexplained mental retardationc. first-degree relative of patients with known fragile X syndromed. first-degree relatives of patients with unexplained mental retardation
1-43. What is the most rational initial approach when a major fetal malformation is discovered using ultrasonography?a. MSAFP testingb. fetal karyotypingc. parental karyotypingd. serial ultrasonographic examinations
1-44. What is the most rational initial approach when two minor structural abnormalities are discovered using ultrasonography?a. MSAFP testingb. fetal karyotypingc. parental karyotypingd. serial ultrasonographic examinations
1-45. Which of the following changes in the fetal nasal bone have been used as a marker for Down syndrome?a. absenceb. increased sizec. decreased sized. increased opacification
1-46. Which of the following is a risk associated with second-trimester amniocentesis?a. chorioamnionitisb. amnionic fluid leakagec. fetal needle stick injuryd. all of the above
1-47. Higher rates of which of the following is a disadvantage of early amniocentesis compared with second-trimester amniocentesis?a. fetal deathb. foot deformitiesc. membrane ruptured. all of the above
1-48. Increased risk of which of the following is associated with chorionic villous sampling performed after 9 weeks gestation?a. fetal deathb. limb-reduction defectsc. oromandibular defectsd. cavernous hemangiomas
1-49. What is an advantage of transcervical chorionic villous sampling compared with second-trimester amniocentesis?a. lower fetal death rateb. test results received at an earlier gestational age
c. able to perform even if vaginal bleeding is presentd. able to perform on an extremely anteverted or retroverted uterus
1-50. Which of the following procedures has the highest fetal death rate?a. second-trimester amniocentesisb. transcervical chorionic villus samplingc. transabdominal chorionic villus samplingd. all have approximately equivalent rates
1-51. In which of the following situations would cordocentesis be appropriate?a. red cell alloimmunizationb. nonimmune fetal hydropsc. suspected primary fetal CMV infectiond. all of the above
1-52. Fetal tissue biopsy has been used for antenatal diagnosis of which of the following diseases?a. muscular dystrophyb. epidermolysis bullosac. mitochondrial myopathyd. all of the above
1-53. Preimplantation genetic analysis techniques can use genetic material from which of the following?a. blastocystb. first polar bodyc. second polar bodyd. all of the above
1-54. Which of the following has NOT been shown to be an effective method for administering medications for fetal medical therapy?a. injection into fetal buttockb. injection into amnionic fluidc. injection into the umbilical cordd. oral administration to the mother
1-55. Fetal medical therapy is LEAST likely to show beneficial effects in which of the following fetal conditions?a. cardiac arrhythmiasb. maternal-fetal infectionc. posterior urethral valvesd. congenital adrenal hyperplasia
15-56. In assessing the usefulness of fetal surgery to correct or ameliorate major malformations, which of the following should be considered?a. maternal risksb. natural history and prognosis of the malformationc. associated high incidence of genetic abnormalitiesd. all of the above
1-57. Of the following conditions, which cannot be ameliorated by antepartum vesicoamnionic shunting?
1-58. Thoracoamnionic shunting is performed to prevent which of the following?a. pectus carinatumb. congenital scoliosisc. pulmonary hypoplasiad. left ventricular hypertrophy
1-59. Which of the following statements in advocacy of antenatal repair of congenital diaphragmatic hernia is true?a. Less than 30% of neonates survive postnatal hernia repair.b. Antenatal surgery is associated with only a 15% incidence of preterm birth.c. Several antenatal repair procedures are associated with improved neonatal survival.d. None of the above are true.
1-60. Pulmonary sequestration and congenital cystic adenomatoid does NOT result in which of the following?a. fetal hydropsb. pleural effusionc. oligohydramniosd. pulmonary hypoplasia
1-61. Antenatal repair of spina bifida has been shown to be associated with which of the following?a. minimal maternal morbidityb. improved lower extremity mobilityc. reduced need for ventriculoperitoneal shunt placementd. none of the above
2-1. What is the goal of antepartum fetal surveillance?a. prevent fetal deathsb. prevent early deliveriesc. increase fees for obstetriciansd. delay delivery until lung maturity achieved
2-2. What is the negative-predictive value of antenatal fetal testing?a. 10%b. 40%c. 70%d. ~100%
2-3. What is the positive-predictive value of antenatal fetal testing?a. <10%b. 10 to 40%c. 40 to 80%d. 80 to ~100%
2-4. At what gestational age does passive, unstimulated movement begin?a. 3 weeks
b. 7 weeksc. 11 weeksd. 2 weeks
2-5. At which gestational age do fetuses begin to exhibit rest-activity cycles?a. <1.0 weeksb. 10 to 20 weeksc. 20 to 30 weeksd. 30 to 40 weeks
2-6. All of the following have been used to describe fetal behavioral states EXCEPTa. breathingb. heart ratec. eye movementsd. body movements
2-7. Quiescent sleep is described by which of the following behavioral states?a. 1Fb. 2Fc. 3Fd. 4F
2-8. Fetuses spend most of their time in which of the two states?a. 1F and 2Fb. 1F and 4Fc. 2F and 3Fd. 3F and 4F
2-9. What is the mean length of the quiet or inactive state for term fetuses (i.e., "sleep cyclicity")?a. 11 minb. 23 minc. 75 mind. 105 min
2-10. What is the range of normal weekly counts of fetal movement?a. 20 to 600b. 50 to 950c. 100 to 1000d. 200 to 1200
2-11. Using maternal perception to quantify fetal movement, the threshold for fetal well-being at term is which of the following?a. 10 movements in 1 hourb. 30 movements in 2 hoursc. 100 movements in 1 dayd. none of the above
2-12. Which of the following statements regarding fetal movement is true?a. Its highest rates are at term.b. It is affected by amnionic fluid volume.c. Maternal perception of movement generally correlates poorly with instrumental measurement.
d. All of the above are true.
2-13. All of the following are descriptions of respiratory movements in the fetus EXCEPTa. gaspingb. paradoxical breathingc. glossopharyngeal breathingd. irregular bursts of breathing
2-14. In normal fetuses, what is the length of time that fetal breathing movements may be totally absent?a. 20 minb. 60 minc. 120 mind. 200 min
2-2. Which of the following may affect fetal breathing movement rates?a. laborb. fetal hypoxiac. cigarette smokingd. all of the above
2-3. True statements regarding fetal breathing include which of the following?a. They are affected by sound.b. They are unaffected by maternal eating.c. The highest respiratory rates are at term.d. They are used in the assessment of the four fetal behavioral states.
2-17. Which of the following fetal activities is monitored during a contraction stress test?a. breathingb. eye movementsc. heart rated. body movements
2-18. In a contraction stress test, all of the following may be a source of contractions EXCEPTa. oxytocinb. fundal massagec. nipple stimulationd. spontaneous onset
2-19. What controls fetal heart rate acceleration?a. autonomic function at brainstem levelb. aortic baroreceptor reflexesc. carotid baroreceptor reflexesd. humeral factors such as atrial natriuretion peptide
2-20. Fetal heart rate accelerations during the nonstress test are affected by which of the following?a. fetal lieb. fetal acidemiac. fetal sexd. all of the above
2-21. What is the American College of Obstetricians and Gynecologists' (ACOG) definition of a reactive nonstress test (NST)?a. 1 acceleration in 20 minb. 2 accelerations in 20 minc. 8 accelerations in 20 mind. 2 accelerations in 20 min
2-22. What is the associated risk of perinatal pathology for a fetus with a nonreactive nonstress test for 90 minutes?a. 10%b. 25%c. 50%d. 90%
2—23. Investigators advocate which nonstress testing schedule?a. dailyb. once weeklyc. twice weeklyd. all of the above
2-24. Fetal death within 7 days of a normal nonstress test occurs most commonly with which indication for testing?a. postterm pregnancyb. gestational diabetesc. gestational hypertensiond. fetal growth restriction
2-25. During acoustic stimulation testing, what fetal response is measured?a. breathingb. heart ratec. eye movementsd. body movements
2-26. Which of the following is NOT a fetal biophysical variable used in the biophysical profile?a. heart rateb. breathingc. eye movementd. body movement
2-27. Which of the following best describes a biophysical score of 6?a. normal scoreb. acidotic scorec. equivocal scored. abnormal score
2-28. The modified biophysical profile is described by which of the following?a. contraction stress test and Doppler umbilical artery velocimetryb. acoustic stimulation nonstress test and amnionic fluid index determinationc. acoustic stimulation nonstress test and Doppler umbilical artery velocimetryd. none of the above
2-29. Which of the following results describes abnormal umbilical artery velocimetry?
a. absent end-diastolic arterial flowb. reversed end-diastolic arterial flowc. systolic/diastolic ratio greater than the 95th percentile for gestational aged. all of the above
2-30. According to the ACOG, Doppler yelocimetry may be beneficial in which of the following clinical situations?a. gestational diabetesb. postterm gestationc. fetal growth restrictiond. antiphospholipid antibody syndrome
2-31. According to the ACOG, which of the following is considered the BEST test to evaluate fetal well-being?a. modified biophysical profileb. contraction stress testc. umbilical artery Doppler velocimetryd. none of the above
2-32. The most important consideration in deciding when to begin antepartum testing is which of the following?a. prognosis for neonatal survivalb. type of maternal diseasec. severity of maternal diseased. none of the above
Chapter 3. Ultrasonography and Doppler
3-1. Abdominal ultrasonography is most commonly performed using transducers that generate which range of sound frequency?a. 1 to 3 mHzb. 3 to 5 mHzc. 5 to 7 mHzd. 7 to 9 mHz
3-2. What is the major biological hazard from fetal ultrasonography?a. noneb. chromosomal breakagec. impaired neonatal hearingd. early spontaneous abortion
3-3. Several studies have shown the utility of fetal ultrasonography for which of the following?a. assist in aneuploidy detectionb. decrease postterm delivery induction ratec. determine gestational age more accurately than the last menstrual periodd. all of the above
3-4. According to the American Institute of Ultrasound in Medicine (AIUM), assessment of fetal anatomy is best performed no earlier than what gestational age?a. 14 weeksb. 18 weeksc. 22 weeks
d. 26 weeks
3-5. According to AIUM, which of the following should be evaluated during a first-trimester ultrasound?a. fetal weightb. fetal presentationc. placental locationd. maternal adnexal evaluation
3-6. With transabdominal ultrasonography, the gestational sac is reliably seen in the uterus by which gestational age?a. 4 weeksb. 5 weeksc. 6 weeksd. 7 weeks
3-7. With transvaginal ultrasonography, fetal cardiac motion is reliably seen by which gestational age?a. 4 weeksb. 5 weeksc. 6 weeksd. 7 weeks
3-8. A standard fetal ultrasonographic examination includes evaluation of which of the following?a. gallbladderb. large colonc. umbilical cord insertiond. hand and foot digit count
3-9. In determining gestational age between 14 and 26 weeks, which of the following is the most accurate parameter to measure?a. femur lengthb. biparietal diameterc. crown-rump lengthd. abdominal circumference
3-10. Which of the following ultrasonographic views is used to measure the biparietal diameter?a. trans thalamicb. transcerebellarc. transventriculard. transhemispheric
3-11. Which of the following fetal measurements shows the greatest variation?a. femur lengthb. biparietal diameterc. crown-rump lengthd. abdominal circumference
3-12. During standard ultrasonographic examination which of the following cranial structures is NOT routinely evaluated?a. cisterna magna
b. pituitary glandc. choroid plexusd. lateral ventricles
3-13. What is the incidence of neural-tube defects in the United States?a. 0.8 per 1000b. 1.6 per 1000c. 8 per 1000d. 3 per 1000
3-14. Encephalocele is usually associated with which of the following?a. hepatomegalyb. hydrocephalusc. normal intelligenced. all of the above
3-2. Ultrasonographic findings of spina bifida and the lemon sign are suggestive of which malformation?a. anencephalyb. Budd-Chiaric. Arnold-Chiari Id. Arnold-Chiari II
3-3. Which of the following is used to describe an elongation and downward displacement of the cerebellum?a. lemon signb. pickle signc. melon signd. banana sign
3-17. What is the average diameter in millimeters of the lateral ventricular atrium at 2 weeks' gestation and older?a. 2 to 4b. 6 to 8c. 10 to 12d. 14 to 3
3-18. A free-floating or dangling choroid plexus is suggestive of which of the following?a. hydrocephalusb. cerebral atrophyc. aqueductal stenosisd. choroid plexus cyst
3-19. Cystic hygroma is the result of which of the following?a. lymphatic obstructionb. meningeal herniationc. arterial aneurysm formationd. cystic degeneration of the sternocleidomastoid muscle
3-20. What percentage of cystic hygromas are associated with aneuploidy?a. 20 to 30b. 40 to 50
c. 60 to 70d. 80 to 90
3-21. What is the most common chromosomal anomaly associated with cystic hygroma in second- or third-trimester fetuses?a. triploidyb. trisomy 18c. trisomy 21d. monosomy X
3-22. The lungs are best visualized beginning at which gestational age?a. 3 to 20 weeksb. 20 to 25 weeksc. 25 to 28 weeksd. 28 to 32 weeks
3-23. In greater than 90% of cases, congenital diaphragmatic hernias are located in which of the thoracic quadrants?a. left anteriorb. left posteriorc. right anteriord. right posterior
3-24. Which of the following is a specific ultrasonographic finding in fetuses with diaphragmatic hernia?a. cardiac displacementb. small abdominal circumferencec. absence of intra-abdominal stomach bubbled. all of the above
3-25. What is the incidence of congenital cardiac malformation in newborns?a. 8 per 100b. 8 per 1000c. 8 per 10,000d. 8 per 100,000
3-26. What percentage of congenital heart defects are due to multifactorial or polygenic transmission?a. 10b. 33c. 67d. 90
3-27. Ultrasonographic examination identifies a hypoplastic left heart in your patient's fetus at 18 weeks' gestation. The next most appropriate management step includes which of the following?a. Doppler aortic arch velocimetryb. amniocentesis for fetal karyotypingc. cordocentesis to assess level of fetal anemia d. amniocentesis for acetylcholinesterase level measurement
3-28. The four-chamber view of the heart is seen transversely at which fetal body level?a. 4th rib
b. T-8 vertebrac.immediately above the diaphragmd. branching of the main stem bronchus
3-29. Which of the following typically should NOT prompt fetal echocardiography?a. fetal arrhythmiab. maternal diabetesc. first-degree relative with heart defectd. elevated maternal serum alpha-fetoprotein level
3-30. Which of the following ultrasonographic findings has been most frequently associated with fetal heart defects?a. oligohydramniosb. mediastinal shiftc. left-axis deviationd. raised left hemidiaphragm
3-31. The ultrasonographic detection rate of fetal heart defects in a low-risk population approximates which of the following?a. 2%b. 35%c. 65%d. 85%
3-32. Nonvisualization of the fetal stomach during an ultrasonographic examination is common in all of the following EXCEPTa. anencephalyb. esophageal atresiac. diaphragmatic herniad. tracheoesophageal fistula
3-33. Which of the following is NOT associated with echogenic bowel seen ultrasonographically?a. trisomy 21b. cystic fibrosisc. thick meconium-stained fluidd. swallowed intra-amnionic blood
3-34. Gastroschisis is associated with which of the following?a. aneuploidyb. other bowel abnormalitiesc. poor postnatal survivald. all of the above
3-35. Which of the following is more likely to be associated with aneuploidy?a. anal atresiab. gastroschisisc. omphalocoeled. esophageal atresia
3-36. The "double-bubble" sign is an ultrasonographic finding of which of the following anomalies?
a. cystic hygromab. duodenal atresiac. aqueductal stenosisd. two-vessel umbilical cord
3-37. What percentage of fetuses with the "double-bubble" sign will have trisomy 21?a. 5b. 2c. 30d. 50
3-38. With which of the following anomalies is hydramnios NOT a typical associated finding?a. anal atresiab. anencephalyc. gastroschisisd. esophageal atresia
3-39. The fetal kidneys can routinely be visualized by what gestational age (weeks)?a. 8b. 12c. 18d. 22
3-40. Which of the following is NOT characteristic of Potter syndrome?a. tight skinb. abnormal fadesc. limb deformitiesd. pulmonary hypoplasia
3-41. Which of the following can NOT be reliably diagnosed antenatally?a. renal agenesisb. obstructive pyelectasisc. multicystic dysplastic kidney diseased. autosomal dominant polycystic kidney disease
3-42. Which of the following is the most common cause of neonatal hydronephrosis?a. posterior urethral valvesb. multicystic dysplastic kidneyc. collecting system duplicationd. ureteropelvic junction obstruction
3-43. Umbilical artery Doppler velocimetry is recommended in the evaluation of which of the following fetal indications?a. macrosomiab. growth restrictionc. suspected cyanotic heart lesiond. suspected pulmonary hypoplasia
3-44. Doppler evaluation has been used to screen inductus arteriosus constriction after exposure which of the following?a. heparinb. valproic acid
c. indomethacind. inhalation anesthetics
3-45. Peak velocities of blood flow through the fet middle cerebral artery have been shown by Doppler velocimetry to be increased in which of the following fetal complications?a. anemiab. cerebral palsyc. fetal alcohol syndromed. congenital HIV infection
References:
1. Danforth's Obstetrics and gynaecology. - Seventh edition.- 1994. - P. 289-304.
2. Obstetrics and gynaecology. Williams & Wilkins Waverly Company. - Thirdl Edition.- 1998.
- P. 118-130.
3. Basic Gynecology and Obstetrics. - Norman F. Gant7 F. Gary Cunningham, -j 1993. - P. 328-
397.
4. Obstetrics and gynecology. - Pamela S.Miles, William F.Rayburn, J.Christopher. Carey. -