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  1. In the Name of God Obstetrics Study Guide 4 Mitra Ahmad Soltani 2008

  2. References 1 •  ACOG committee opinion. Ethics in Obstetrics and Gynecology.second edition.2004 • Anderoli Thomas E, et al. Cecil Essentials of Medicine. 5th edition. W.B.Saunders; 2001 • British guideline on the management of asthma in adults, The British Thoracic Society & Scottish Intercollegiate Guidelines Network Thorax 2008 May; 63 (Suppl 4) : 1-121. See: Asthma/AsthmaGuidelines/tabid/83/Default.aspx • • Braunwald Eugene, et al. Harrison's Principles of Internal Medicine. 16th edition. McGrawHill; 2005 • Braunwald et al. IHD clinical practice guidelines. 2002 • Cunningham G, Gant N, Leveno K, et al. Williams Obsterics. 22nd Ed . New York : Mc Graw Hill, 2005. • Gibson P. HTN in Pregnancy. emedicine.DEC 13. 2007 • Hogg K, Dawson D, Mackway K. Outpatient diagnosis of pulmonary embolism: the MIOPED (Manchester Investigation Of Pulmonary Embolism Diagnosis) study .2006 See: • Iranian Council for Graduate Medical Education. Exam questions.1998-2007 • Iranian Council for graduate Medical Education. Board and pre-board Exam questions for OBS and Gyn .2001-2006 • Katzung Bertram G. Pharmacology: Examinatoin & Board Review.7th edition Mcgrawhill. 2005 • Marsha D. Ford. Cecil text book of medicine. Acid-Base disorder. Saunders company.2004 • Massel D, Klein GJ. Guidelines & Policies At The London Health Sciences Centre. 2002. see: • Yanowitz.ECG learning center.2006 • Regional ALS Treatment Protocols and Procedures.EMT-Paramedics,1998 • Safeer ,Richard S., Lacivita ,Cynthia L. Choosing Drug Therapy for Patients with Hyperlipidemia American Family Physician. Vol. 61/No. 11 (June 1, 2000)

  3. References 2 • • ABG interpretation method.(2006) • web page cases.doc. (2006) • • (2006) • Laboratory Findings in Heart Disease. Cardiac Enzymes .(2006)

  4. The process of making decisionfor a pregnant case For Obstetrics cases, a physician faces complexities stemming from the fetus, a woman in a narrower definition of health indices, and the setting. All these are proceeding dynamically interacting with one another. There are priorities that should be considered. This makes “ethics” of outmost importance in Obstetrics.

  5. Ethical approaches 1-Principle-based approach: It seeks to identify the principles and rules pertinent to a case. 2-A virtue-based approach : It is focusing on one course of action would best express the character of a good physician. 3-Ethic of care: It situates a doctor’s duties in the context of a pregnant woman’s values and concerns instead of specifying abstract principles.

  6. Ethical Approaches- cont. 4- Feminist Ethics approach: seeks to change factors that limit a woman’s options. 5-A case-based approach: It considers if there are any relevantly similar cases that constitute precedents for a given case.

  7. A case A 22 wk pregnant woman is a known case of ROM. FHR can be heard. She had a 10 year history of infertility. She says:” I want to put my life in danger for the very rare chance that may be the leakage stop”. So she rejects the option of pregnancy termination. What are possible managements? A- Termination of pregnancy despite the woman’s objection. (Principle-based approach) B-continuation of pregnancy with close observation (Feminist Ethics approach) C-Termination of pregnancy telling the woman that her fetal heart is no longer heard.(This is against virtue-based approach!)

  8. For a better understanding of how to implement our knowledge of internal medicine in a pregnant case, this section of Obstetrics comes with cases.

  9. HTN

  10. A 25 year old 28 week pregnant woman has developed weight gain, head-ache and peripheral edema within the last week. Her BP is 150/105 mmHg. Which drug should not be prescribed for her? a- Methyldopa b- ACE inhibitor c- Hydralazine d- Nifedipine Answer:b

  11. What drug is not used for the treatment of pre-eclampcia? a- Betablocker b- Methyldopa c- ACE inhibitor d- Hydralazine Answer:C

  12. Which statement about treatment of HTN with ACE inhibitors is wrong? a- They are drugs of choice in diabetics. b- They can be used in mild renal failure. c- In unilateral renal artery stenosis, they can be prescribed if the other kidney has a normal function d- They are drugs of choice for pregnancy Answer:D

  13. What is the accepted screening test for diagnosis of PIH? A-Rollover test B-nitric oxide measurement C-vascular endothelial growth factor D-angiotensin test Ans:A

  14. For a case of severe preeclampsia (BP=180/95) Mg SO4 and C/S is ordered. An hour after C/S BP falls to 110/75. What is the reason of BP fall? A-Delivery removes the effect of vasospasm B-anesthetic drugs C-hemorrhage D-MgSO4 effect Ans: C

  15. Which is true about edema of preeclmpsia? A- it has an unknown etiology B-it is because of increased aldosterone level C- it worsens the prognosis of preeclampsia D- it is because of increased DOC Ans:A

  16. A woman 48 yrs old/ G3/ BP=150/115/ has a high cholesterol level . Her sister and brother had heart attacks in the age of 40. Which is wrong about the management of this case? A-Beta blocker B- diet C-methyl dopa D-regular checking of lab results Ans: A

  17. In a woman with chronic HTN Which factor has the least effect in development of superimposed PIH? A- PIH history B- low dose aspirin C- severity of HTN D-the need for combined drug therapy Ans:B

  18. What is the most common complication of eclampsia? A- abruption B-aspiration pneumonia C-pulmonary edema D- direct maternal mortality Ans:A

  19. Which is true about blindness after eclampsia? A-It has a bad prognosis B-It lasts about 1 month C-it is transient and lasts from 4 hours to 8 days D-in some people it causes permanent blindness Ans:C

  20. Which is wrong about eclampsia? A- eclampsia can cause coma without seizure B- All patients with eclamsia have had signs of preeclampsia C-After seizures respiratory rate is reduced and cyanosis happens D- In all cases of eclampsia severe proteinuria is present Ans:C

  21. Which therapy can prevent preeclampsia? A-Low dose aspirin B-calcium C-fish oil D-Antioxidants Ans:D

  22. A 40 years old woman / G3/P2 /GA=35 wks/ BP=210/110 is in seizure. What is the best way to control her seizure? A-Phenytoin loading dose of 1000 mg/h IV B- Diazepam and creatinin measurement C- amobarbital sodium 250 mg IV D- MgSO4 4-6 gr as loading dose Ans:D

  23. What is the cause of platelet change in preeclampsia? A- increased production B- decreased consumption C- increased platelet aggregation D- decreased platelet- adhering IG Ans:A

  24. A woman 25 years old / G1 suffers HELLP syndrome. What is true about her next pregnancy? A- there is no increased risk in her next pregnancy B-the is increased risk of abruption and preeclampsia C-there is no increased risk of preterm labor or C/S D-there is no increased risk of IUGR Ans:B

  25. Which test has a more PPV for detecting PIH? A-urinary excretion of Kallikrein B- roll over test C- angiotensin II D- hypocalciuria Ans:A

  26. A pregnant woman GA=29 wks / severe headache/ blurred vision/ BP= 200/120 has gone through routine tests and MgSO4 infusion. What other steps should be taken? A-IV hydralazine 20 mg + IV verapamil 10 mg B-IV hydralazine 5 mg C- IV labetalol 80 mg D- sublingual nifedipine 10 mg +thiazide 10 mg Ans:B

  27. A case of eclampsia with seizure is given MgSO4. She is agitated. What drug is appropriate for her agitated state? A-2 gr MgSO4 IV B- 250 mg amobarbital IV C- 10 mg diazepam IM D-no treatment is needed Ans:B “A” would be appropriate if a second seizure occurs

  28. A woman with high blood pressure, proteinuria, Cr>1.5 mg/dl, has an episode of seizure after 4 hours from her delivery. What treatment do you suggest? A-14 gr of MgSO4as the loading dose and then 2.5 gr q4h up to 24 h after delivery B-7 gr of MgSO4 as the loading dose and then 2.5 grq4h up to 24 h after the last seizure C-14 gr of MgSO4 as the loading dose and then 2.5 gr q4h up to 24h after the last seizure D-7 gr of MgSO4 as the loading dose and then 2.5 gr q4h up to 24h after delivery Ans:C

  29. Which is not among pathophysiological changes of preeclampsia? A-reduction in PGE2 B-reduction in prostacyclin C-increased thromboxane A2 D-increased resistance to angiotensin Ans: D

  30. Which is wrong about proteinuria of preeclampsia? A-Some women deliver before proteinuria occurs B-1+ proteinuria equals 300 mg protein in a 24 hour sample C-NPV of a trace or negative dipstick test is about 30 % D-PPV of 3+/4+ proteinuria is 70% Ans:D

  31. For a primigravida in 30 weeks gestation a roll-over test is done. An increase of 35 mmHG has occurred in diastolic BP. Which is wrong for this case? A- She has a high probability of developing HTN B-She is abnormally sensitive to angiotensin II C-increased BP is because of hyperactivity of parasympathetic system D-33% of these patients will develop preeclampsia Ans:C

  32. Which is wrong for visual disturbances of preeclampsia? A-it is because of occipital region lesions B-if blindness does not resolve within a week , it will remain permanently C- It is because of retinal artery spasm that can resolve by MgSO4 D-it is because of retinal detachment that is most often unilateral Ans:B

  33. Which is wrong about superimposed preeclampsia? A-it occurs earlier in pregnancy and most often is accompanied by IUGR B- BP changes remain through life C-some women have increased BP after 24 weeks gestation D- above 90% of them have a history of essential HTN Ans:B

  34. A woman GA=38 wks/G2/L1/history of chronic HTN is diagnosed as a case of severe preeclampsia. Her pregnancy is terminated. Her BP and proteinuria and edema are improved but she has developed orthopnea. What is your first diagnosis? A-ATN and overload B- hypoalbuminemia C-peripartum cardiomyopathy D-MS signs aggravated by fluid shift Ans:C

  35. What drug has the complication of tachycardia? A-methyl dopa B-propranolol C-nifedipine D-hydralazine Ans: D

  36. 27-Which does not happen in preeclampsia? A-reduced renal perfusion and GFR B-increased renin-angiotensin level C-constant electrolyte concentration D- increased microangiopathic hemolysis Ans:B

  37. A woman 32 years old/ NP /obese / 38 wks GA/ mild preeclampsia delivers her child . BP does not decrease after several IV doses of hydralazine. Which is not a good management? A-Im hydralazine B-oral labetalol C-thiazides D-IV MgSO4 Ans:D

  38. HTN drugs of importance

  39. Which is true about a 12 wk pregnant woman with Eisenmenger syndrome? A- therapeutic abortion is indicated B-heparin throughout pregnancy should be given C-pregnancy should be terminated when the fetus is viable D- she has to be hospitalized throughout pregnancy Ans:A

  40. A pregnant woman with artificial valve on heparin has undergone C/S. When should the anticouagulant be started after the operation? A- 6 hours B- 8 hours C-24 hours D- immediately after C/S Ans:c -24 hrs after C/S and 6 hrs after vaginal delivery. (Warfarin has no contraindication during lactation)

  41. Which is wrong about idiopathic cardiomyopathy in pregnancy? A- terbutaline is a predisposing factor B-ICM has the symptoms of congestive heart failure C-ICM is more prevalent in pregnancy than non pregnant state D-dyspnea is an important symptom Ans: c Therapy is hydralazine and heparin. ACE inhibitors are contraindicated during pregnancy

  42. Which is more fatal to a pregnant woman? A-bioprosthetic valve replacement B-corrected fallot tetralogy C-pulmonary or tricuspid disease D- mitral stenosis with AF Ans:D

  43. Risks of various types of heart dis. Group 1-min risk: ASD, VSD, PDA, Pul or tri dis FT corrected MS NYHA I, II Group 2-mod : MS class III,IV AS Aortic Coarctation FT uncorrected MI HX Marfan syn. MS with AF Artificial valve Group3-major: Pul. HTN Coarctation +valve involvement Marfan +aortic involvement

  44. A 39 wk pregnant woman in labor has a history of VSD corrected without a patch. She states a history of bradycardia and permanent pacemaker six months prior to her pregnancy. What is true about this case? A- There is no need for endocarditis prophylaxis. B- She is in moderate risk group and needs prophylaxis. C-She is high risk and needs prophylaxis. D- Prophylaxis depends on her heart functional class. Ans:A

  45. A patient with Mitral Stenosis in class II NYHA suffers hypotension and tachycardia during labor. Which is a better management? A- fluid and electrolyte administration B-spinal analgesia to reduce pain C-immediate pregnancy termination D- beta blocker to reduce heart rate Ans:D AF caused by MS is treated by 5-10 mg verapamil IV or cardioversion