9. Management
ïĻ Option of terminate pregnancy,further
investigation,delivery at tertiary center
ïĻ Genetic counseling
ïĻ Pediatric surgery consultation
ïĻ Rho(D) Immune Globulin for prevent
isoimmunization
ïĻ Subsequent management : recurrent rate
10. Prenatal Diagnosis of thalassemia
ïĻ Thalassemia
ïĪ Screening test â interpretation
ïĪ Diagnostic test â interpretation
ïĪ Who are couple at risk for severe thalassemia
12. Prenatal Diagnosis of Down syndrome
ïĻ Down syndrome
ïĪ Who have risk of Abnormal fetal
karyotype?
ïĪ Screening test : NT,serum markers.US
ïŪ First
trimester
ïŪ Second trimester
ïĪ Diagnostic test
ïŪ First
trimester : CVS
ïŪ Second trimester : amniocentesis
29. Neural tube defect(NTD)
ïĻ NTDs result from failure of the neural tube to close
normally between the 3rd and 4th weeks after
conception (the 5th and 6th weeks of gestation).
ïĻ Type of NTD :
ïĪ Spine (Spina bifida, meningomyelocele or
myelomeningocele ) , cranium(Anencephaly
,exencephaly, Encephalocele )
ïŪ Open NTDs : often involve spine and cranium
ïŪ Closed NTDs are usually localized and confined to
the spine
30. NTDs & AFP
ïĻ AFP : glycoprotein is synthesized by
ïĪ Fetal yolk sac
ïĪ Fetal GI tract and liver
ïĻ AFP in fetal serum and AF ïą until GA 13 wk. then
ïē and
ïĻ AFPïą in maternal serum after 12 wk., peaks
between GA 28 -32 weeks and then ïē
31. NTDs & AFP
NTDs , ventral wall defects
permit AFP to leak into the AF,
maternal serum
ïąAFP in maternal serum and AF
Women who carry fetuses with NTDs have
:MSAFP at GA 16 â 18 wk. > 2.5 MoM
32. Risk factors of NTDs
ïĻ 95 % of NTDs occur in the absence of risk factor or family
history
ïĻ NTDs : genetic causes and multifactorial disorders
ïĻ Recurrence rate
ïĪ 4 % : couple has previous child with NTD
ïĪ 5 % : either parent was born with NTD
ïĪ 10% : couple has 2 affected children
ïĻ Etiology in some population : mutation MTHFR ïŪ impaired
homocysteine and folate metabolism
33. Risk Factors for Neural-Tube Defects
Family history of neural-tube defects
Exposure to certain environmental agents
Diabetes (hyperglycemia)
Hyperthermia
Drugs and medications
Genetic syndrome with known recurrence risk
Some racial or ethnic groups and/or living in high-risk
geographical regions
Production of anti- folate receptor antibodies
34. Some Risk Factors for NTDs
Genetic cause
âĒFamily historyâmultifactorial inheritance
âĒMTHFR mutationâ677CT
âĒSyndromes with autosomal recessive inheritance : Meckel-Gruber Roberts Joubert
Jarcho-Levin HARDEâhydrocephalusâagyriaâretinal dysplasiaâencephalocele
âĒAneuploidy Trisomy 13 Trisomy 18 Triploidy
Exposure to certain environmental agents
âĒDiabetesâhyperglycemia
âĒHyperthermia Hot tub or sauna Fever (controversial)
âĒMedications Valproic acid Carbamazepine Coumadin Aminopterin Thalidomide
Efavirenz
Geographical regionâethnicity, diet, other factor
âĒUnited Kingdom ,India,China,Egypt,Mexico,Southern Appalachian United States
35. Prenatal diagnosis of NTD
ïĻ Screening test : maternal serum AFP at 2nd
trimester
ïĪ GA 15 â 20 wk.
ïĪ Upper normal limit of maternal serum AFP = 2.0-
2.5 MoM( Abnormal if > 2.0 â 2.5 MoM)
ïĻ Diagnosis test : ultrasound
36. Screening test : MSAFP at 2nd trimester
ïĻ ïą MSAFP ï° risk for NTD and other
disorders
ïĻ ïē MSAFP ï° risk for Down syndrome
37. Factors influence of the maternal serum AFP level
ïĻ Maternal weight : reflect the volume of
distribution
ïĻ GA : maternal serum AFP ï15 % /wk. during
the 2nd trimester
ïĻ Race or ethnicity : African American women
have 10 % ï serum AFP (but low risk NTDs)
ïĻ DM : serum AFP may be ïŊ than non DM
women
ïĻ Twins : ïŪ use higher screening threshold
(âĨ 3.5 MoM)
38. Unexplained ï Abnormal MSAFP often forcast
a poor pregnancy outcome
ïŪLow birth weight
ïŪOligohydramnios
ïŪPlacental abruption
ïŪFetal death
39. Maternal serum
AFP (MoM) adjusted
markers screening
for maternal age ,
(triple screening AFP âĨ2.0MoM
BW,ethinicity,GA,
test at GA 15 -20
twins,DM
weeks
US evaluate to
AFPâĨ2.5 MoM exclude twins , fetal
US
(Abnormal result) death and
recalculate AFP
41. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 18 āļāļĩ G2P1 GA 5 weeks
āļāļĢāļ°āļ§āļąāļāļīāļāļļāļāļĢāļāļāđāļĢāļ āđāļāđāļ spina bifida
āļāļ°āđāļŦāđāļāļēāđāļāļ°āļāļēāļāļ°āđāļĢāđāļāļ·āđāļāļāđāļāļāļāļąāļāļāļēāļĢāđāļāļīāļāļ āļēāļ§āļ°āļāļąāļāļāļĨāđāļēāļ§āļāđāļē
a. Iron
b. Zinc
c. Folic acid
d. B6
e. Thiamine
42. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 31āļāļĩ āļāļĢāļ°āļ§āļąāļāļīāļāļļāļāļĢāļāļāđāļĢāļ āđāļĄāđāļĄāļĩ
āļāļĢāļ°āđāļŦāļĨāļāļĻāļĩāļĢāļĐāļ° āļĄāļēāļāļĢāļ§āļāļāļēāļĢāļāļąāđāļāļāļĢāļĢāļ āđ
āļāļ§āļĢāđāļŦāđāļāļēāļĢāļāļđāđāļĨāļĢāļąāļāļĐāļēāļāļĒāđāļēāļāđāļĢ
a. āđāļŦāđāļāļąāđāļāļāļĢāļĢāļ āđāļāđāļāđāļāđāļāđ
b. āļāļēāļŠāļēāļĄāļĩ āļ āļĢāļĢāļĒāļēāļĄāļēāļāļĢāļ§āļāļāļ§āļēāļĄāļāļīāļāļāļāļāļīāļāļāļāđāļāļĢāđāļĄāđāļāļĄ
c. āđāļŦāđāļāļīāļFolic acidāđāļŠāļĢāļīāļĄ
d. āđāļŦāđāļāļīāļāļāļēāļāļļāđāļŦāļĨāđāļāđāļŠāļĢāļīāļĄ
e. āđāļŦāđāļāļīāļāđāļāļĨāđāļāļĩāļĒāļĄāđāļŠāļĢāļīāļĄ
43. Prevention of neural tube defects
ïĻ Periconceptional folic acid supplementation reduces the
incidence of neural tube defects by 50 - 70 %
ïĻ Women who have risk for NTDs :
ïĪ women with a previously affected child
ïĪ Women who take anticonvulsant drugs
ïĪ family history of NTD
ïĪ insulin-requiring diabetes
44. Prevention of neural tube defects
ïĻ Folic supplementation : started at least
one month prior to conception and continue
throughout the first trimester.
ïĻ Dose 4 mg daily
45. Prevention of neural tube defects
Primary prevention in low risk women
ïĻ Folic supplementation should be started at
least one month prior to conception and
continue throughout the first trimester.
ïĻ Dose 400ïg(0.4mg) daily
48. RISK FACTORS FOR GENETIC DISORDERS
ïĻ Advanced Maternal Age
ïĻ Previous Pregnancy Affected by Chromosomal
Abnormality
ïĻ History of Early Pregnancy Loss
ïĻ Advanced Paternal Age
ïĻ Ethnicity
Suchila Sritippayawan 2/1/2011
49. Women with Increased Risk of Fetal Aneuploidy
Singleton pregnancy and maternal age older than 35 at delivery
Dizygotic twin pregnancy and maternal age older than 31 at delivery
Previous autosomal trisomy birth
Previous 47,XXX or 47,XXY birth
Patient or partner is carrier of chromosome translocation
Patient or partner is carrier of chromosomal inversion
History of triploidy
Some cases of repetitive early pregnancy losses
Patient or partner has aneuploidy
Major fetal structural defect by sonography
50. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 40 āļāļĩ G1P0 GA 8 weeks
āļĄāļēāļāļēāļāļāļĢāļĢāļ āđ āļāļĢāļąāđāļāđāļĢāļ āļāļąāļāļ§āļĨāļ§āđāļēāļĨāļđāļāļāļ°āđāļāđāļDown
syndrome
āļāļāļāļāļāđāļāļāļēāļŠāļāļĩāđāļāļ°āļāļēāļĢāļāļāļ°āđāļāđāļ Down syndromeāđāļĄāļ·āđāļ
āļāļĨāļāļ
a. 1:50
b. 1:100
c. 1:200
d. 1:300
e. 1:400
51. Singleton GestationâMaternal Age-Related Risk for Down Syndrome
and
Any Aneuploidy at Midtrimester and at Term
Down Syndrome Any Aneuploidy
Maternal Age Midtrimester Term Midtrimester Term
35 1/250 1/384 1/132 1/204
36 1/192 1/303 1/105 1/167
37 1/149 1/227 1/83 1/130
38 1/115 1/175 1/65 1/103
39 1/89 1/137 1/53 1/81
40 1/69 1/106 1/40 1/63
41 1/53 1/81 1/31 1/50
42 1/41 1/64 1/25 1/39
43 1/31 1/50 1/19 1/30
44 1/25 1/38 1/15 1/24
45 1/19 1/30 1/12 1/19
52. āđāļāļāļĒāđ āļāļēāļāļŠāļĄāļĻāļĢāļĩāļāļēāļĒāļļ 48āļāļĩ āļŠāļēāļĄāļĩāļāļēāļĒāļļ 50āļāļĩ āļāļĢāļ°āļ§āļąāļāļīāļĄāļĩāļĨāļđāļāļāļāđāļĢāļ
āđāļāđāļDown syndrome āļāļāļ°āļāļĩāđāļāļēāļĒāļļ2āļāļĩ āļāļĒāļēāļāļĄāļĩāļĨāļđāļāļāļāļāļĩ2 āļāđāļēāļ
āđ
āļāļ°āđāļŦāđāļāļēāđāļāļ°āļāļēāļāļĒāđāļēāļāđāļĢ
a. āļāļēāļāļāļĢāļĢāļ āđāļāļēāļĄāļāļāļāļī
b. āļāļĢāļ§āļāđāļāļĢāđāļĄāđāļāļĄāđāļāđāļāļāļēāļĢāļ
c. āđāļāļ°āļāļēāļāļŠāļĄāđāļāļĩāļĒāļĄāđāļāļĒāđāļāđāļāļŠāļļāļāļīāļāļđāđāļāļ·āđāļ
d. āđāļāļ°āļāļēāļāļēIVFāđāļāļĒāđāļāđāđāļāđāļāļāļāļāļđāđāļāļĢāļīāļāļēāļ
e. āđāļĄāđāļāđāļāļāļāļąāđāļāļāļĢāļĢāļ āđ
53. Prenatal Diagnosisāļāļĩāđāļāļ§āļĢāļĢāļđāđ
ïĻ Down syndrome
ïĪ Screening test : NT,serum markers,US
ïŪ First trimester
ïŪ Second trimester
ïĪ Diagnostic test
ïŪ First trimester : CVS
ïŪ Second trimester : amniocentesis
54. Strategy Analytes DR (%)
First-trimester screen NT, PAPP-A, hCG or free -hCG 79â87
NT (First trimester) NT 64â70
Triple test MSAFP, hCG or free -hCG, uE3 60â69
Quadruple (Quad) test MSAFP, hCG or free -hCG, uE3, inh 67â81
First-trimester screen & Quad testâ
Integrated screen 94â96
results withheld until Quad test completed
First-trimester screen & Quad test
â 1% offered diagnostic test after first
Stepwise sequential
trimester screen â 99% proceed to Quad 90â95
screen
test, results withheld until Quad test
completed
First-trimester screen & Quad test
â 1% offered diagnostic test after first-
Contingent sequential trimester screen â 15% proceed to Quad
88â94
screen test, results withheld until Quad test
completed â 84% have no additional test
after first-trimester screen
55. First-Trimester Screening
ïĻ GA 11 - 14 weeks.
ïĪ hCG or free ïĒ-hCG
ïĪ and PAPP-A(pregnancy-associated plasma
protein A )
ïĪ sonographic evaluation : NT
ïĪ or a combination of both.
In the first trimester, for Down syndrome fetus
âĒ serum hCG levels are >2.0 MoM
âĒ PAPP-A levels are < 0.4 MoM
56. First-Trimester Screening
ïĻ NT measurement ï ïģ 3.5 mm with a normal
karyotype ï° targeted us examination , fetal
echocardiography or both
measured between
GA11(0/7)and 13(6/7) wks.
65. âĒ Who have risk factor?
âĒ Classification of hypertension in pregnancy and
criteria for diagnosis
âĒ Who should be investigation of preeclampsia?
âĒ How to management when preeclampsia occur ?
âĒ When and route of delivery ?
âĒ What are complication of preeclampsia?
66. ïĻ Nulliparity
ïĻ Advanced maternal age
ïĻ Obesity
ïĻ African â American ethnicity
ïĻ Multifetal gestation
ïĻ Pregnancy-associated factors : Hydatidiform mole ,
Hydrops fetalis , Multifetal gestation
ïĻ Specific medical conditions: GDM, type I diabetes, obesity,
chronic hypertension, renal disease, thrombophilias and
APS
67. āđāļāļāļĒāđ Predisposing factor of pre-eclampsia is
A. Anemia
B. Multigravida
C.Dead fetus in utero
D.Multiple pregnancy
E. Chronic renal failure
68. Classifies HT in pregnancy
ïĪ Gestational hypertension
ïĪ Preeclampsia : mild / severe
ïĪ Eclampsia
ïĪ Chronic hypertension
ïĪ Chronic hypertension with superimposed
preeclampsia
ïĪ HELLP syndrome
70. Common pathophysiologic changes seen
in patients with preeclampsia
ïĻ Cardiovascular effects:
Vasoconstriction and ï cardiac output.
ï BP
the earliest clinical finding of preeclampsia
71. āđāļāļāļĒāđ āļāļđāđāļāđāļ§āļĒāļŦāļāļīāļāļāļēāļĒāļļ 33 āļāļĩ GA 33weeks āļĄāļēāļāļēāļāļāļĢāļĢāļ āđ
āļ§āļąāļāļāļ§āļēāļĄāļāļąāļāđāļĨāļŦāļīāļāđāļāđ 140 / 90 mmHg, āļāļąāļ 15 āļāļēāļāļĩāļ§āļąāļāļāđāļēāļāđāļĒāļąāļāđāļāđ
āđāļāđāļēāđāļāļīāļĄ āļāļĢāļ§āļāđāļāļĢāļāļĩāļāđāļāļāļąāļŠāļŠāļēāļ§āļ°āđāļāđ 1 +
āļāļāđāļŦāđāļāļēāļĢāļ§āļīāļāļīāļāļāļąāļĒ
a. Eclampsia
b. Mild preeclampsia
c. Severe preeclampsia
d. Gestational hypertension
72. Am J Obstet Gynecol 2000;183:S1-22.
Suchila Sritippayawan 01/02/54 72
73. Preeclampsia : Management
Gestational age
Term (GA âĨ 37 wks) Term (GA>37 wks)
yes
Delivery&MgSO4 Severe disease present ?
no
Expectant Rx until term
74. Mild preeclampsia GA < 37 wk.
ïĻ Bed rest
ïĻ BP monitoring
ïĻ Urine monitoring
ïĻ Lab evaluation
ïĻ Fetal surveillance : NST
79. Severe preeclampsia :
Management
ïĻ Termination of pregnancy when :
ïĪ Term pregnancy
ïĪ Severe preclampsia with sign of acute renal failure
, thrombocytopenia , pulmonary edema,hepatic
injury,DIC
ïĪ Suspected abruptio placenta
ïĪ Eclampsia
ïĪ HELLP syndrome
ïĪ Non reassuring fetal status
ïĪ Severe IUGR
ïĪ Labor or labor of rupture of membranes
80. Indications for delivery in preeclampsia
āļāđāļēāļāđāļĄāđ āļāđāļēāļāļĨāļđāļ
ïĻ āļāļēāļĒāļļāļāļĢāļĢāļ āđ âĨ 38 āļŠāļąāļāļāļēāļŦāđ
ïĻ āļĄāļĩāļ āļēāļ§āļ° Severe fetal
ïĻ āļāļ§āļāļāļļāļĄāļāļ§āļēāļĄāļāļąāļāđāļĨāļŦāļīāļāđāļĄāđāđāļāđ
growth restriction
ïĻ Severe preeclampsia
ïĻ āļĄāļĩāļ āļēāļ§āļ° Nonreassuring
(āļāļēāļāļēāļĢāđāļĨāļ°āļāļēāļāļēāļĢāđāļŠāļāļ, lab)
results from fetal
ïĻ Eclampsia
testing
ïĻ HELLP syndrome
ïĻ Placental abruption
ïĻ Oligohydramnios
81. Route of delivery
ïĻ Vaginal route delivery is preferred
ïĻ Unfavorable cervix ï° ripening cervix
ïĻ Depen on maternal and fetal condition
ïĻ āļāđāļāļāļ§āļĢāļĢāļ°āļ§āļąāļ : āđāļĄāđāđāļŦāđ ERGOMETRINE
āđāļŦāđoxytocin āđāļāļ
C/S delivery reserved for OB indication
01/02/54 Suchila Sritippayawan 81
82. āļāļēāļĢāļāļđāđāļĨāđāļāļĢāļ°āļĒāļ°Postpartum
ïĻ Most Rapid improved / Some may worsening
ïĻ Continue MgSO4 for 24 hr
ïĻ Monitoring of
ïĪ Blood pressure
Hydralazine or nifedipine PRN BP > 160/110
ïĪ maternal symptoms
ïĪ measurements of fluid intake and urine output.
ïĻ Follow up 2 wk after discharge
If hypertension persist , give thiazide or beta-
blockers or nifedipine
83. Management : eclampsia
ïĻ Prevention of maternal hypoxia and
trauma
ïĻ Blood pressure control
ïĻ Prevention of recurrent seizures
ïĻ Delivery when : stabilized and seizures
have been controlled
84. Management : eclampsia
Mode of delivery depend on
ïĻ Gestational age
ïĻ Bishop score, whether the patient is in
labor
ïĻ Fetal condition and position
85. Management : eclampsia
The definitive treatment of eclampsia is
delivery, irrespective of gestational age
The best way to treat the fetus is to
stabilized the mother
C/S should be reserved for OB condition
86. Management : eclampsia
Stabilizing the mother by administering anticonvulsant drugs
and oxygen Treating severe hypertension (if present)
can help the fetus recover in-utero from the effects of
maternal hypoxia, hypercarbia, and uterine hyperstimulation
if10 â 15 min with no improvement despite maternal
and fetal resuscitative interventions
occult abruption ?
emergent delivery should be considered
87. A. Oral antihypertensive drug
B. Diuretics
C. MgSO4
D. Induction of labor
E. Expectation with materno-fetal
observe
88. āđāļāļāļĒāđ āļāļđāđāļāđāļ§āļĒāļŦāļāļīāļāļāļēāļĒāļļ 31 āļāļĩ GA 32weeks āļĄāļēāļāļēāļāļāļĢāļĢāļ āđāļāļēāļĄāļāļąāļ
āļ§āļąāļāļāļ§āļēāļĄāļāļąāļāđāļĨāļŦāļīāļāđāļāđ 130 / 90 mmHg, āļāļĢāļ§āļāđāļāļĢāļāļĩāļāđāļāļāļąāļŠāļŠāļēāļ§āļ°āđāļāđ 1 +
āđāļĄāđāļĄāļĩāļāļēāļāļēāļĢāļāļ§āļāļĻāļĩāļĢāļĐāļ° āļāļēāļĄāļąāļ§ āļāļļāļāđāļāđāļāđāļāđāļĨāļīāđāļāļāļĩāđ āđāļĄāđāļĄāļĩāļāļāļāļēāļ§ āļāļąāļāļāđāļāļāļāļĨāļāļ
āļāļąāļŠāļŠāļēāļ§āļ°āđāļĄāđāđāļŠāļāļāļąāļ āđāļāļāļĒāđāđāļāļ°āļāļēāđāļŦāđāđāļāļ§āļąāļāļāļ§āļēāļĄāļāļąāļāđāļĨāļŦāļīāļāļāļĩāđ
āļŠāļāļēāļāļĩāļāļāļēāļĄāļąāļĒāđāļāļĨāđāļāđāļēāļ āđāļĨāļ°āļāļąāļāļĄāļēāļāļēāļāļāļĢāļĢāļ āđāļāļĩāļ 1 lāļŠāļąāļāļāļēāļŦāđāļāđāļāļĄāļē
āļ§āļąāļāļāļ§āļēāļĄāļāļąāļāđāļĨāļŦāļīāļāđāļāđ 170 / 110 mmHg, āļāļĢāļ§āļāđāļāļĢāļāļĩāļāđāļāļāļąāļŠāļŠāļēāļ§āļ°āđāļāđ 3+
āļāđāļēāļāļāļ°āđāļŦāđāļāļēāļĢāļāļđāđāļĨāļāļđāđāļāđāļ§āļĒāļĢāļēāļĒāļāļĩāđāļāļĒāđāļēāļāđāļĢ
a. āđāļŦāđ MgSO4
b. āđāļŦāđ Pethidine
c. āđāļŦāđ Oxytocin
d. āđāļŦāđ Diazepam
89. āđāļāļāļĒāđ A 32-week primigravida comes to the antenatal clinic
for her regular appointment. The physical examination
shows 2 kg weight gain in 2 wks, BP 160/110 mmHg,
edema over all extremities, 3+ DTR, and 2+ proteinuria.
The most appropriate initial management is
A. Diazepam
B. Furosemide
C.Hydralazine
D.Calcium gluconate
E. Magnesium sulfate
90. A. Observed
B. C/S emergency
C. MgSO4 then observe
D. MgSO4then try ND
E. MgSO4then C/S
91. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 18āļāļĩ G1P0 āļāļēāļĒāļļāļāļĢāļĢāļ āđ 30
āļŠāļąāļāļāļēāļŦāđ āļĄāļēāļŦāđāļāļāļāļĨāļāļāļāđāļ§āļĒāļāļēāļāļēāļĢāļāļ§āļāļĻāļĩāļĢāļĐāļ°
āļ§āļąāļBPāđāļāđ 160/110 mm Hg
āđāļāļēāļ°āđāļĨāļ·āļāļāļāļĢāļ§āļ āļāļāļ§āđāļēāļĄāļĩelevated liver function test
āđāļĨāļ°Platelet count 60,000/mm3
āļāļēāļĢāļāļđāđāļĨāļāļĩāđāđāļŦāļĄāļēāļ°āļŠāļĄāļŠāļēāļŦāļĢāļąāļāļāļđāđāļāļ§āļĒāļĢāļēāļĒāļāļĩāđāļāļ·āļ
āđ
a. āđāļŦāđoral antihypertensive therapy
b. platelet transfusion
c. MgSO4 therapy and induction of labor
d. IV Immunoglobulin therapy
92. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 30āļāļĩ G1P0 āļāļēāļĒāļļāļāļĢāļĢāļ āđ 29
āļŠāļąāļāļāļēāļŦāđ āļĄāļēāļāļēāļāļāļĢāļĢāļ āđāļāļēāļĄāļāļąāļ āļ§āļąāļBPāđāļāđ 140/90 mm Hg
āđāļāļēāļ°āđāļĨāļ·āļāļāļāļĢāļ§āļ liver function test āđāļĨāļ°Platelet count
āļāļāļāļī Urine protein 2+
āļāļēāļĢāļāļđāđāļĨāļāļĩāđāđāļŦāļĄāļēāļ°āļŠāļĄāļŠāļēāļŦāļĢāļąāļāļāļđāđāļāļ§āļĒāļĢāļēāļĒāļāļĩāđāļāļ·āļ
āđ
a. Induction of labor
b. Cesarean section
c. Antihypertensive therapy
d. Expectant management
93. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 25āļāļĩ G1P0 āļāļēāļĒāļļāļāļĢāļĢāļ āđ 38
āļŠāļąāļāļāļēāļŦāđ āļĄāļĩāļāļēāļāļēāļĢāļāļ§āļāļĻāļĩāļĢāļĐāļ° āļĢāļđāđāļŠāļķāļāļ§āđāļēāļĨāļđāļāļāļīāļāļāđāļāļĒāļĨāļ
āđ
āļ§āļąāļBPāđāļāđ 180/110 mm Hg uterine size ~ date ,
DTR +3,Urine protein 2+
āļāļ§āļĢāđāļŦāđāļĒāļēāđāļ
a. Diazepam
b. MgSO4
c. Antihypertensive drug
d. ------
e. -------
94. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 26āļāļĩ G2P1āļāļēāļĒāļļāļāļĢāļĢāļ āđ 32āļŠāļąāļāļāļēāļŦāđ āļĄāļēāļāļēāļ
āļāļĢāļĢāļ āđāļāļēāļĄāļāļąāļāđāļāļāļĒāđāđāļŦāđāļāļāļāđāļĢāļāļāļĒāļēāļāļēāļĨāđāļāļĢāļēāļ°āļ§āļąāļ BPāļāļāļ§āđāļēBPāđāļāđ
170/110 mm Hg āđāļĄāđāļĄāļĩāļāļēāļāļēāļĢāļāļīāļāļāļāļāļīāđāļāđ āļŦāļĨāļąāļāļāļąāļ āļ§āļąāļ BPāļāđāļē =
150/98 mmHg proteinuria = 1 + āđāļāļāļĒāđāļŠāļlabāđāļĨāļ°āđāļŦāđāļāļāļāļāļąāļ
āđ
āđāļāđāļĢāļāļāļĒāļēāļāļēāļĨ āļāđāļāđāļāđāļāđāļāļāļąāđāļāļāļāļāļāđāļāđāļāļāļāļāļāļēāļĢāļāļđāđāļĨāļāļđāđāļāđāļ§āļĒāļĢāļēāļĒāļāļĩ
a. Induced labor : vaginal delivery
b. Cesarean section
c. Phenytoin
d. Labetalol
e. Dexamethasone
95. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 32 āļāļĩ G3P2 GA 35 wk.
underlying CHT āļāđāļ§āļANC BPāđāļĄāđāđāļāļīāļ 140/90 mmHg,no
proteinuria āļĄāļēANC āļāļĢāļąāđāļāļĨāđāļēāļŠāļļāļ BP > 140/83 mmHg urine
protein 24āļāļĄ.=0.35 g
āļāļēāļĢāļāļđāđāļĨāļāļąāļāļāļāļāļāđāļāđāļāļāļ·āļ
āđ
(A) Administer oral furosemide
(B) Prepare for emergent delivery
(C) Restart the patientâs prepregnancy
antihypertensive
regimen
(D) Restricted activity and close monitoring as
an outpatient following initial inpatient
evaluation
(E) Start hydralazine
98. ïĻ Finding : who has risk of DM in pregnancy
ïĻ Screening GDM : 50 gm GCT
ïĻ Confirm diagnosis : who has positive 50gm
GCT(100gm OGTT)
ïĻ Classified type of DM : GDM A1,A2 ,PGDM
ïĻ Management :
ïĪ antepartum ,intrapartum ,postpartum
ïĪ Maternal and fetus
98 2/1/2011
99. āļŠāļīāđāļāļāļĩāđāļāļ§āļĢāļĢāļđāđ
ïĻ Classification of DM : overt DM (PGDM),GDM
ïĻ Screening GDM : who,when ,how
ïĻ Complication of DM : Maternal , fetus
ïĻ Interpretation of BS
ïĻ Management : control DM , monitor
complication,time of delivery and route of delivery
100. āđāļāļāļĒāđ āļāļđāđāļāđāļ§āļĒāļŦāļāļīāļāļāļēāļĒāļļ 39 āļāļĩ āļāđāļēāļŦāļāļąāļ 65 āļāļ.āļŠāļđāļ 152 āļāļĄ.
āļāđāļēāđāļāđāļāđāļāļēāļŦāļ§āļēāļ āļĨāļđāļāļāļāđāļĢāļāļāđāļēāļŦāļāļąāļāđāļĢāļāļāļĨāļāļ 4200 āļ.
āļāđāļāđāļāđāļāđāļāļāļ§āļēāļĄāđāļŠāļĩāđāļĒāļāļāđāļāļāļēāļĢāđāļāđāļāđāļĢāļāđāļāļēāļŦāļ§āļēāļāļāļāļāļāļđāđāļāđāļ§āļĒ
āļĢāļēāļĒāļāļĩāđāļĄāļēāļāļāļĩāļŠāļļāļ
a. āļāđāļ§āļ
b. āđāļāļĩāđāļĒ
c. āļāđāļēāđāļāđāļāđāļāļēāļŦāļ§āļēāļ
d. āļĨāļđāļāļāļāđāļĢāļāđāļāđāļmacrosomia
e. āļāļēāļĒāļļāđāļĄāđ> 25āļāļĩ
101. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 30 āļāļĩ G3P2 GA 25wk. āļĄāļĩāļāļĢāļ°āļ§āļąāļāļī
āļāļĢāļĢāļ āđāļāļĩāđāđāļĨāđāļ§āđāļāđāļGDM
āļāļĢāļĢāļ āđāļāļĩāđ āđāļĄāļ·āđāļ GA 10 wk.FBS=110 mg/dL,no glucouria
āļāļđāđāļāđāļ§āļĒāļāļļāļĄāļāļēāļŦāļēāļĢāđāļāļ 2-3 wk.PTA āļĄāļĩāļāļēāļāļēāļĢ
polyuria,fatigue
āļāļ°āļāļđāđāļĨāļāļđāđāļāļ§āļĒāļĢāļēāļĒāļāļĩāđāļāļĒāđāļēāļāđāļĢāļāđāļāđāļ
āđ
(A) Administer a 3-hour glucose tolerance test
(B) Administer a 50-g 1-hour glucose tolerance test
(C) Begin insulin therapy
(D) Check a urinalysis and start insulin if urinalysis
reveals glucose in the urine
(E) Prescribe metformin to be taken daily
102. āļāļĨāļļāđāļĄāļāļ§āļēāļĄāđāļŠāļĩāđāļĒāļāļāđāļē (āļāļāļāļļāļāļāđāļāļāđāļāđāļāļāļĩāđ) āļāļĩāđāđāļāļ°āļāļēāļ§āđāļē
āļāļēāļāđāļĄāđāļāļēāđāļāđāļāļāđāļāļāļāļĢāļ§āļāļāļąāļāļāļĢāļāļ
102
ïĻ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ<25āļāļĩ
ïĻ āļĄāļĩāđāļāļ·āđāļāļāļēāļāļīāļāļĩāđāļĄāļĩāļāļ§āļēāļĄāđāļŠāļĩāđāļĒāļāļāđāļē ( āļĒāļāđāļ§āđāļāđāļāļ·āđāļāļāļēāļāļī Hispanic, African, Native
American, South or East Asian origins)
ïĻ āđāļĄāđāļĄāļĩāļāļĢāļ°āļ§āļąāļāļīāļāļĢāļāļāļāļĢāļąāļ§ āļāļēāļāļīāđāļāļĨāđāļāļīāļāđāļāđāļāđāļāļēāļŦāļ§āļēāļ
ïĻ āļāļ.āļāđāļāļāļāļąāđāļāļāļĢāļĢāļ āđāđāļĨāļ°āļāļ.āļāļĩāđāđāļāļīāđāļĄāļĢāļ°āļŦāļ§āđāļēāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļāļāļī (BMI< 26 kg./m2)
ïĻ āđāļĄāđāļĄāļĩāļāļĢāļ°āļ§āļąāļāļīāļāļēāļāļŠāļđāļāļīāļĻāļēāļŠāļāļĢāđāļāļĩāđāļāļīāļāļāļāļāļīāļāļĩāđāđāļāļĩāđāļĒāļ§āļāđāļāļāļāļąāļ
GDM(macrosomia,stillbirth,malformation)
ïĻ āđāļĄāđāđāļāļĒāļĄāļĩāļāļĢāļ°āļ§āļąāļāļīāļĢāļ°āļāļąāļāļāđāļēāļāļēāļĨāđāļāđāļĨāļ·āļāļāļāļīāļāļāļāļāļī
ADA ,Diabetic
Suchila Sritippayawan care 2004;(Suppl 1):S88 â 90
2/1/2011
2/1/2011
Chula
103. Recommended Screening Strategy Based on Risk
Assessment for Detecting Gestational Diabetes
High Risk
Perform blood glucose testing as soon as feasible. If
gestational diabetes is not diagnosed, blood glucose
testing should be repeated at 24-28 weeks or at any
time a patient has symptoms or signs suggestive of
hyperglycemia
High risk â women with marked obesity, strong family
history of type 2 diabetes, prior gestational diabetes,
or glucosuria
103 2/1/2011
104. ïĻ The best time to screen for DM during
pregnancy :
ïĪ GA 24 â 28 weeks
ïĻ Patient with âĨ 1 risk factors for developing
GDM should be screened at
ïĪ The first prenatal visit and
ïĪ GA 24 â 28 weeks or
ïĪ symptoms or signs suggestive of
104 hyperglycemia 2/1/2011
105. Who have risk factor of GDM
50 gm glucose challenge test
for 80% detection
āļāđāļēāļāļīāļāļāļāļāļī âĨ 140 mg/dL
100 gm OGTT Diagnostic test
105 Suchila Sritippayawan 2/1/2011
2/1/2011
113. āļāļĨāļļāđāļĄāļāļ§āļēāļĄāđāļŠāļĩāđāļĒāļāļāđāļē (āļāļāļāļļāļāļāđāļāļāđāļāđāļāļāļĩāđ) āļāļĩāđāđāļāļ°āļāļēāļ§āđāļē
āļāļēāļāđāļĄāđāļāļēāđāļāđāļāļāđāļāļāļāļĢāļ§āļāļāļąāļāļāļĢāļāļ
113
ïĻ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ<25āļāļĩ
ïĻ āļĄāļĩāđāļāļ·āđāļāļāļēāļāļīāļāļĩāđāļĄāļĩāļāļ§āļēāļĄāđāļŠāļĩāđāļĒāļāļāđāļē ( āļĒāļāđāļ§āđāļāđāļāļ·āđāļāļāļēāļāļī Hispanic, African, Native
American, South or East Asian origins)
ïĻ āđāļĄāđāļĄāļĩāļāļĢāļ°āļ§āļąāļāļīāļāļĢāļāļāļāļĢāļąāļ§ āļāļēāļāļīāđāļāļĨāđāļāļīāļāđāļāđāļāđāļāļēāļŦāļ§āļēāļ
ïĻ āļāļ.āļāđāļāļāļāļąāđāļāļāļĢāļĢāļ āđāđāļĨāļ°āļāļ.āļāļĩāđāđāļāļīāđāļĄāļĢāļ°āļŦāļ§āđāļēāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļāļāļī (BMI< 26 kg./m2)
ïĻ āđāļĄāđāļĄāļĩāļāļĢāļ°āļ§āļąāļāļīāļāļēāļāļŠāļđāļāļīāļĻāļēāļŠāļāļĢāđāļāļĩāđāļāļīāļāļāļāļāļīāļāļĩāđāđāļāļĩāđāļĒāļ§āļāđāļāļāļāļąāļ
GDM(macrosomia,stillbirth,malformation)
ïĻ āđāļĄāđāđāļāļĒāļĄāļĩāļāļĢāļ°āļ§āļąāļāļīāļĢāļ°āļāļąāļāļāđāļēāļāļēāļĨāđāļāđāļĨāļ·āļāļāļāļīāļāļāļāļāļī
ADA ,Diabetic
Suchila Sritippayawan care 2004;(Suppl 1):S88 â 90
2/1/2011
2/1/2011
Chula
114. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 32 āļāļĩ āļĄāļēANC GA 22 wk. āļĄāļĩāļāļĢāļ°āļ§āļąāļāļīāđāļāđāļ
DM āļĄāļē 3 āļāļĩāđāļāđ insulināļĄāļēāļāļĨāļāļ FBS 105 mg/dL,2hr.PP BS
139 mg/dL
āļāļ°investigation āļāļ°āđāļĢāđāļāļīāđāļĄāđāļāļīāļĄ
A. BPP
B. Maternal serum triple screening test
C. Maternal serum AFP
D. Fetal Doppler US
E. Fetal echocardiography ïž
115. a. āļāđāļ§āļ BMI 28.1 āļāļ./āļāļēāļĢāļēāļāđāļĄāļāļĢ
b. āđāļāļĩāđāļĒ
c. āļāđāļēāđāļāđāļāđāļāļēāļŦāļ§āļēāļ
d. āļĨāļđāļāļāļāđāļĢāļāđāļāđāļmacrosomia
e. āļāļēāļĒāļļāđāļĄāđ> 25āļāļĩ
116. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 30 āļāļĩ G2P1 12 weeks āļĄāļēāļāļēāļāļāļĢāļĢāļ āđ
āđāļāļĒāļāļĨāļāļāļāļēāļĢāļāļŦāļāļąāļ 3900 āļāļĢāļąāļĄ āļĄāļĩāļāđāļēāđāļāđāļāđāļāļēāļŦāļ§āļēāļ
āļāļđāđāļāđāļ§āļĒāļŦāļāļąāļ 72 āļāļ. āļŠāļđāļ 155 āļāļĄ.
āļāđāļāđāļāđāļāđāļāļāļąāļāļāļąāļĒāđāļŠāļĩāđāļĒāļāļāļĩāđāļāđāļāļāļāļąāļāļāļĢāļāļāđāļāļēāļŦāļ§āļēāļ
a. āļāđāļ§āļ BMI 29.96 āļāļ./āļāļĢ.āđāļĄāļāļĢ
b. āđāļāļĩāđāļĒ
c. āļāđāļēāđāļāđāļāđāļāļēāļŦāļ§āļēāļ
d. āđāļāļĒāļāļĨāļāļāļāļēāļĢāļāļāļąāļ§āđāļ
118. DIABETES INSULI
DURATI VASCULAR
CLASS ONSET AGE N
ON (Y) DISEASE
(Y) NEED
Gestational diabetes
A1 Any Any 0 0
A2 Any Any 0 +
Pregestational diabetes
B >20 <10 0 +
C 10-19 or 10-19 0 +
D <10 or >20 + +
F Any Any + +
R Any Any + +
T Any Any + +
H Any Suchila Sritippayawan
Any 2/1/2011 + +
122. Complication :Pregestational Diabetes Mellitus
(PGDM)
Maternal effect :
ïĻ Ketoacidosis: (insulin resistance ïŪ insulin
deficiency)
ïŪ Common risk factors : new onset diabetes;
infections(influenza and UTI); poor patient
compliance; insulin pump failure; and
treatment with Îē-mimetic tocolytic
medications and antenatal corticosteroids
Suchila Sritippayawan 2/1/2011
123. Complication :Pregestational Diabetes
Mellitus (PGDM)
Maternal effect :
ïĻ Infection (DM type 1)
Common infection : candida vulvovaginitis , UTI ,
URI ,puerperal and pelvic infection
4% antepartum pyelonephritis develop (with DM
type 1)
ïŪ screening for asymptomatic bacteriuria
Suchila Sritippayawan 2/1/2011
124. Management
Goal :
ïĻ to lower the likelihood of Macrosomia
ïĻ To reduce neonatal hypoglycemia
Suchila Sritippayawan 2/1/2011
125. Management :
Pregestational Diabetes Mellitus
ïĻ Prepregnancy counseling
ïĻ Glycemic control during gestation : Diet ,insulin
ïĻ Fetal assessment
ïĻ Timing and mode of delivery
ïĻ Glycemic management during labor
ïĻ Postpartum care and lactation
ïĻ Contraception
Suchila Sritippayawan 2/1/2011
126. Prepregnancy counseling
ïĻ Optimal care and patient education : prevent early
pregnancy loss and congenital malformation
ïĻ Preconceptional glucose control
ïĪ Prepandial glucose : 70 â 100 mg/dl
ïĪ Postpandrial glucose : 1 hr. < 140 mg/dl
2 hr. < 120 mg/dl
ïĪ Glycated Hb : within 3 SD of normal mean
ïĻ Folic acid supplement 400 ïg/day
(periconception â during early pregnancy) to
decrease NTD
Suchila Sritippayawan 2/1/2011
127. Glycemic management during pregnancy
PGDM
ïĻ The management of diabetes in pregnancy
must focus on excellent glucose control
achieved using a careful combination of
diet, exercise, and insulin therapy
Suchila Sritippayawan 2/1/2011
128. Glycemic management during pregnancy
PGDM
ïĻ Caloric requirement :
ïĪ usually require 30â35 kcal/kg/d.
ïĻ Caloric composition includes
ïĪ 40â50% from complex,high-fiber carbohydrates
ïĪ 20% from protein
ïĪ 30â40% from primarily unsaturated fats.
Suchila Sritippayawan 2/1/2011
129. Fetal assessment
ïĻ Early US : fetal viability and to accurate date the
pregnancy
ïĻ Target US GA 18 â 20 weeks
ïĻ Periodic US : to confirm fetal growth
ïĻ Antepartum fetal monitoring :
ïĪ Initiation of testing at GA 32â34 weeks
ïĪ Earlier GA in high risk conditions.
ïĪ Daily fetal movement count
Suchila Sritippayawan 2/1/2011
130. Indication for delivery in diabetes pregnancy
Fetal ï Non reactive , positive CST
ï Reactive positive CST, mature fetus
ï GA 40 â 41 weeks
ï U/S evidence of Fetal growth arrest
ï Decline in fetal growth rate with decreased AF
Maternal ï Severe preeclampsia,
ï Mild preeclampsia mature fetus
ï Markedly falling renal function( Cr clearance <
40 ml/min)
Obstetric ï Preterm labor with failure of tocolysis
ï Mature fetus , inducible cervix
Suchila Sritippayawan 2/1/2011
131. Timing and route of delivery
ïĻ Early delivery may be indicated :
ïĪ in patients with vasculopathy, nephropathy
ïĪ poor glucose control
ïĪ prior stillbirth
ïĻ patients with well-controlled may be allowed to
progress to their expected date of delivery as
long as antenatal testing remains reassuring
Suchila Sritippayawan 2/1/2011
132. Timing and route of delivery
ïĻ To prevent traumatic birth injury :
Cesarean delivery may be considered if the
EFW > 4,500 g in women with diabetes.
ïĻ Notify neonatologist
ïĻ Stop insulin after placental was removal
ïĻ Beware shoulder dystocia
Suchila Sritippayawan 2/1/2011
134. āđāļāļāļĒāđ āļŦāļāļīāļāļāļēāļĒāļļ 34 āļāļĩ āļĄāļĩāļāļēāļāļēāļĢāļāļąāļŠāļŠāļēāļ§āļ°āđāļŠāļāļāļąāļāđāļĨāļ°āđāļāđāļāļāļĩāđāļāļĢāļīāđāļ§āļ
āļāđāļāļāļāļĨāļāļ āļāļĢāļ§āļāļĢāđāļēāļāļāļēāļĒāļāļ vesicular lesion with shallow
ulcer at vulva
āļāļāđāļŦāđāļāļēāļĢāļ§āļīāļāļīāļāļāļąāļĒ
A. Herpatic vulva
B. Molluscum contagiosum
C. Candiadiasis at vulva
D. Syphilis
136. Central dimpling bumps multiple umbilicated flesh-
Diameter 2-5 mm, firm colored or hypopigmented
Painless papules.
137. Candida vulvovaginitis
ïĻ Hx : Vulvar pruritus is the dominant feature of
vulvovaginal candidiasis
ïĻ PE : erythema of the vulva and vaginal
mucosa and vulvar edema
ïĻ Discharge : thick, adherent, and "cottage
cheese-like
139. Vulvaginal infections in pregnancy
ïĻ Bacterial vaginosis :
ïĪ In pregnancy, it is associated with preterm birth
ïĪ treatment does not reduce preterm birth, and routine screening is not
recommended
ïĪ Rx(symptomatic) : Metronidazole 500 mg twice daily orally for 7 days
ïĻ Candidiasis :
ïĪ Asymptomatic colonization : no treatment
ïĪ Characteristic : profuse, irritating discharge associated with a pruritic,
tender, edematous vulva
ïĪ Topical treatment is recommended (Clotrimazole, miconazole, nystatin,
and terconazole)
140. Vulvaginal infections in pregnancy
ïĻ Trichomoniasis :
ïĪ Characteristic : foamy leukorrhea with pruritus and irritation
ïĪ (Some studies) In pregnancy, it is associated with preterm birth
but treatment has not decreased this risk
ïĪ screening and treatment of asymptomatic women is not
recommended during pregnancy
ïĪ Rx : single 2-g dose of Metronidazole
141. āđāļāļāļĒāđ āļāļđāđāļāđāļ§āļĒāļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 19 āļāļĩ GA 40 wk. āļĄāļĩ
genital lesion herpes āđāļāđāļāļāļĢāļąāđāļāđāļĢāļ āļāļ°āļ§āļēāļāđāļāļāļāļđāđāļĨ
āļāļđāđāļāđāļ§āļĒāļĢāļēāļĒāļāļĩāđāļāļĒāđāļēāļāđāļĢ
a. Cesarean section
b. Oxytocin
c. Prostaglandin
d. Amniotomy
e. āļĢāļāļāļāđāļāđāļāļāđāļāļāļāļĨāļāļ
142. Rx Dx BV CV TV
Metronidazole Clotrimazole(100mg) Metronidazole
Non pregnanct (500mg) 1X2 oral 1tab vg 2 g orally in a
x7 days suppo.x7days single dose
The same as non Treat (symptom)
pregnant Treat (symptom)
pregnant
Sexual partner Not treat Not treat Treat
The same as HIV
The same as HIV The same as HIV neg
HIV
neg neg
When persist or
F/U no no
recur within 2 mo.
143. Genital HSV infection and pregnancy
ïĻ Fetal and neonatal effect :
ïĪ Fetal infection : congenital HSV (hydrops fetalis , fetal
demise,survivor (skin lesion,CNS manifestration)
ïĪ Neonatal infection : SEM ,manifestration , CNS
manifestration (meningoencephalitis) , disseminated
disease
ïĻ When the risk of neonatal infection occur
ïĻ Route of delivery
ïĻ Treatment for prevention or decreased risk of
neonatal infection
144. Risk factors for neonatal herpes
ïĻ The risks are greatest :
women with primary genital herpes in the 3rd
trimester particularly within 6 weeks of
delivery),
145. Approach pregnant women with Hx HSV infection
women without symptoms and
signs of genital herpes or
prodromal symptoms
They can be deliver vaginally
146. Recommendation of CDC and ACOG
Cesarean delivery should
be offered
Who have history of Who have ruptured of
genital herpes
membranes > 6 hours,
Who have active lesions or
(although the benefit is not
prodromal symptoms at
the time of delivery clearly proven)
147. Approach pregnant women with Hx HSV infection
Cesarean delivery
not recommended for
women with recurrent genital herpes
and active nongenital HSV lesions
148. Treatment
ïĻ In women with first episode genital HSV :
Acyclovir (400 mg PO three times daily) 7 - 14 days , regardless of
the timing of infection during pregnancy
( to decrease duration of lesion and viral shedding)
ïĻ In women with a history of recurrent genital HSV, or primary
infection during pregnancy:
suppressive Acyclovir (400 mg three times daily) be given at GA 36
weeks through delivery
ïĻ Women who do not have a history of genital herpes but HSV-2
seropositive : not recommend antiviral therapy
149. Recommended doses of antiviral medication for
Herpes in pregnancy
Indication Acyclovir Valacyclovir
Primary or 1st 400 mg po tid 1 g bid for 7-14
episode HSV for days
7-14 days
Symptomatic 400 mg po tid 500 mg po bid
recurrent HSV for 5 days for 5 days
Daily 400 mg po tid 500 mg po bid
suppressive from GA 36 from GA 36
therapy wk.to delivery wk.to delivery
Obstet Gynecol 2005;106:845-56
150. A. āļŠāđāļUAāļŦāļē UTI
B. āđāļāđāļāļļāļāļĒāļēāļāļāļāļēāļĄāļąāļĒāđāļ§āļĨāļēāļĄāļĩāđāļāļĻāļŠāļąāļĄāļāļąāļāļāđ
C. āļāļĢāļ§āļculture GC āļāļēāļcervix,urethra
D. āđāļāļ°āļāļēāđāļŦāđāļŠāļēāļĄāļĩāļĄāļēāļāļĢāļ§āļSTD
E. āļāļĢāļ§āļāđāļĨāļ·āļāļscreen STD (syphilis,HIV)āļāļēāļĄāļāļāļāļī
153. ïĻ Podophyllin : a plant-based resin that blocks cell
division at metaphase and leads
ïĻ Trichloroacetic acid : destroy the wart tissue via
chemical coagulation of tissue proteins
ïĻ 5-FU :a pyrimidine antimetabolite that interferes
with DNA synthesis
ïĻ Imiquimod :a positive immune response
modifier, which acts by local cytokine induction
154. Genital wart during pregnancy
ïĻ Three important issues
ïĪ Worsening of the disease in the pregnant state
ïĪ Choice of safe and effective treatment
ïĪ Potential vertical transmission to the fetus
155. External genital warts during pregnancy
ïĻ During pregnancy ïŪ impaired immune ïŪ
increased proliferation of condylomata.
ïĻ During the post-partum period ïŪ spontaneous
regression.
156. Treatment
ïĻ Aims of treatment : debulking symptomatic
genital warts.
ïĻ Eradical of warts during pregnancy is not
always necessary
157. Treatment
Effective regimen for genital warts :
ïĪ 80-90% TCA solution applied typically once a
week
ïĪ Cryotherapy
ïĪ Laser ablation ?
Podophyllin resin
Podofilox â gel or solution are not
recommended in
5-FU cream pregnancy
Imiquimod cream
158. Route of delivery
Current OB data :
ïĻ Data support the rarity of
perinatal HPV transmission āđāļĄāđāđāļāļ°āļāļēāđāļŦāđ
ïĻ Limitation understanding of â āļāđāļēāļāļąāļāļāļĨāļāļāđāļāļ·āđāļ
āļĨāļāļāļēāļĢāļāļīāļāđāļāļ·āđāļ
the development of
laryngeal papillomatosis
āļāļēāļĢāļāļīāļāđāļāļ·āđāļāļāļāļāļāļēāļĢāļāđāļĄāđāđāļāļĩāđāļĒāļ§āļāđāļāļāļāļąāļ
route of delivery
159. ïą āļāđāļēāđāļŦāđāļ genital condyloma āđāļāđāļāđāļāļāļēāļ
āđāļāļ·āđāļāļāļāļēāļ
ïķāļŠāļąāļĄāļāļąāļŠlesionāđāļāļĢāļ°āļŦāļ§āđāļēāļāļāļĨāļāļāļāļēāļāļāđāļāļ
āļāļĨāļāļ
ïķāļāđāļēāđāļāđāļāđāļāđāļāđāļŦāđ rule out sexual abuse
āļāđāļ§āļĒ
173. āđāļāļāļĒāđ Most common cause of perinatal
death in twin pregnancy
a. Antepartum hemorrhage
b. Birth asphyxia
c. IUGR
d. Prematurity
e. Twin â twin transfusion
176. āđāļāļāļĒāđ the most common presentation at
delivery of near term twins are
vertex - vertex 40%
a. Both cephalic â vertex - breech
breech - vertex
26%
10%
breech - breech 10%
b. Both breech vertex - transverse 8%
others 6%
c. One cephalic , one breech
d. One cephalic , one transverse
e. One breech , one transverse
178. āļŦāļāļīāļāđāļāļĒ G2 āļĄāļēāļāļēāļāļāļĢāļĢāļ āđ GA 18 wk āļāļĢāļ§āļāđāļĨāļ·āļāļ
āđāļĄāđ A- āļāđāļ B+ (āļāļēāļāļŠāļĨāļąāļāļāļąāļ āļāļĢāļ°āļĄāļēāļāļāļĩ) āļāļēāļĄ
āđ
āļāļēāđāļĢāļāđāļ
1. Anti D
2. Cordocentesis
3. direct comb
4. Amniocentesis
5. indirect coomb
179. ïĻ The direct Coombs' test : detection of antibody on the
surface of the RBC
ïĻ The indirect Coombsâtest : detection antibodies
against RBCs that are present unbound in the patient's
serum.
ïĻ The indirect Coombsâtest is used to screen pregnant
women for antibodies that may cause hemolytic
diseasee of the newborn
180. Isoimmunization
ïĻ Etiology : maternal Ab production in response
to exposure to RBC Ag
ïĻ Rh isoimmunization : Ab against to Rh group
ïĻ Rh Ag are present on fetal cells by the 38th
day postconception
183. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 20 āļāļĩ G1P0 GA 38 wk. car
accident āļĄāļēāļāļĩāđāļŦāđāļāļāļāļļāļāđāļāļīāļ āļĄāļĩāđāļĨāļ·āļāļāļāļāļāļāļēāļāļāđāļāļāļāļĨāļāļ āļāđāļāļĄāļē
āļāļĨāļāļāļāļļāļāļĢ āđāļŠāļĩāļĒāđāļĨāļ·āļāļ 900ml āļāļāļ°āļāļĩāđāļāļđāđāļāđāļ§āļĒāļĢāļēāļĒāļāļĩāđāļāļĨāļāļāļ āļąāļĒāđāļĨāđāļ§
āļāļĢāļēāļāļāđāļāļĄāļđāļĨāļāļēāļāļāļēāļĢāļāļēāļāļāļĢāļĢāļ āđ āļāļāļ§āđāļēRh negative Anti D
negative
āļāļąāđāļāļāļāļāļāđāļāđāļāđāļāļāļēāļĢāļāļđāđāļĨāļāļđāđāļāđāļ§āļĒāļĢāļēāļĒāļāļĩāđ
a. Perform CBC
b. Transfuse PRC
c. Performed Kleihauer-Betke test
d. Give additional Rh immune globulin
e. Assess neonatal Rh Ag status
184. Kleihauer-Betke test : the number of fetal red cells
in the maternal circulation to measure the amount of
fetal Hb transferred from a fetus to a mother's
bloodstream
âĒ the differential resistance of fetal hemoglobin to
acid
âĒPositive test : the rosette test
âĒMaternal red blood cells
appear as pale "â
185. āđāļāļāļĒāđ āļŦāļāļīāļāļāļąāđāļāļāļĢāļĢāļ āđāļāļēāļĒāļļ 27 āļāļĩ G1P0 GA 27 wk. āļĄāļēāļāļĩāđERāđāļāļ·āđāļāļāļāļēāļ
āļāļļāļāļąāļāļīāđāļŦāļāļļāļāļēāļāļĢāļMC āđāļĄāđāļĄāļĩāļāļēāļāļēāļĢāļāļ§āļāļāđāļāļ āļāđāļāļāđāļāđāļ āđāļĄāđāļĄāļĩāđāļĨāļ·āļāļāļāļāļ
FHSāļāļĒāļđāđāđāļāđāļāļāļāđāļāļāļāļī āļāļĢāļ§āļāļĢāđāļēāļāļāļēāļĒ Abd :not tender
PV cervix:os close no effacement ,no bleeding per vagina
Lab : Rh +(āđāļĄāđāļĢāļđāđāļāļĨāļāļāļāļāđāļ) āđāļĄāđāļĄāļĩHx blood transfusion ,
Kleihauer-Betke test shows a combination
of pale and stained RBCs.
(A) Administer an appropriate dose of IM Rh0(D) immune globulin
(B) Amniocentesis to measure the amniotic fluid bilirubin level
(C) Emergent cesarean section
(D) Induction of vaginal labor with prostaglandins and oxytocin
(E) Treatment with betamethasone
186. Indication for Anti-D immunoglobulin in
unsensitized pregnant women
ïĻ Abortion
ïĻ Ectopic pregnancy
ïĻ Antepartum bleeding(1st ,2nd trimester)
ïĻ Abdominal trauma
ïĻ After amniocentesis,CVS
ïĻ After external cephalic version
187. Management : maternal Rh neg
with unsensitized
ïĻ Treat with Rh immunoglobulin at GA 28 wk.
and after delivery(within /72 hr.) if the Fetal is
Rh positive
ïĻ Dose 300ïg of Rh immunoglobulin can protect
from an exposure of up to 30 ml of fetal blood
188. Management : maternal Rh neg
with sensitized
Assess GA
by US
Check
paternal
blood type
Paternal Rh :
Paternal
homozygous for D or
Rh neg
heterozygous for D
No further Assess
manageme prior OB
nt Hx
Serial
maternal Ab
titer ,US ,MCA
Doppler
velocimetry
190. ïĻ Chorioretinitis : Toxoplasmosis infection,CMV
infection
ïĻ Ebsteinâs anomaly (malformation
of the tricuspid valve and right ventricle) :
Lithium
ïĻ Rash : neonatal lupus āļĄāļĩ erythematous annular
lesions on the scalp and periorbital area. the
rash is typically mild and resolves by 6â8
months of age.
192. āđāļāļāļĒāđ āļŦāļāļīāļāļāļēāļĒāļļ 26 āļāļĩ āļāļēāļĒāļļāļāļĢāļĢāļ āđ 8 āļŠāļąāļāļāļēāļŦāđ āļāļēāļĢāļāļĢāļ§āļ
ultrasoundāđāļāļ·āđāļāļāļĢāļ°āđāļĄāļīāļāļāļēāļĒāļļāļāļĢāļĢāļ āđ āļāđāļāđāļāđāļĄāđāļāļĒāļēāļāļĩāđāļŠāļļāļ
a. Femur length
b. Biparietal diameter
c. Crown rump length
d. Abdominal circumference
e. Head circumference
196. āđāļāļāļĒāđ Transvaginal USG at GA 8 wk āļāļ sac 30 mm.
āđāļĄāđāļĄāļĩ embryonic echo āļāļēāļāļ°āđāļĢ
A.Transquillizer and rest
B.Progestin and rest
C.Laparoscopy
D.Medical or surgical termination of pregnancy
E.Serial B-HCG
197. Abnormal pregnancy during 1st trimester
ïĻ Viable pregnancy : āđāļŦāđāļ yolk sac , fetal echo.fetal
heart
ïĻ Nonviable pregnancy : early embryonic death , blighted
ovum, ectopic pregnancy,molar pregnancy
Diagnosis early embryonic death :
TAS CRL 9 mm āđāļĄāđāđāļŦāđāļ fetal heart
TVS CRL 5 mm āđāļĄāđāđāļŦāđāļ fetal heart