PATHO OB MIDTERM

RATIONALE
FROM 1ST SEMESTER 2018-2019

MIDTERMS
ORATIO SAMPLEXIS
OLFU MD 2020
 JCR: GIT, HEPATOBILIARY, and PANCREATIC DISORDERS (7/10)
1) Most common cause of ADHESION BOOK: CHAPTER 54 PAGE 1051
intestinal obstruction in Intestinal Obstruction
pregnancy? Ø In one study, adhesive disease leading to small-
bowel obstruction was the second most common
A. Volvulus cause of an acute abdomen in pregnancy following
B. Carcinoma appendicitis-15 versus 30 percent, respectively.
C. Intussusception Ø Approximately half of cases are due to adhesions
D. adhesion from previous pelvic surgery that includes cesarean
delivery.
Another 25 percent of bowel obstruction cases are
caused by volvulus-sigmoid, cecal, or small bowel.
These have been reported in late pregnancy or early
puerperium.
2) Part of pregnancy that THIRD TRIMESTER BOOK PAGE 1052
mostly likely diagnosed It is indisputable that appendiceal perforation is more
with ruptured appendix? common during later pregnancy. In the studies by
Andersson (200 1) and Ueberrueck (2004), the
A. First trimester incidence of perforation was approximately 8, 1 2, and
B. Second trimester 20 percent in successive trimesters.
C. Third trimester
A. D. Postpartum

3) Crohn's Disease:
A. 3-5% risk of cancer
B. Proctocolectomy is
curative
C. Antineutrophil
cytoplasmic
Antibodies
D. Deep layers of small
and large bowel

4) At risk for developing A. NEWBORN BOOK PAGE 1064

chronic hepatitis b Ø The hepatitis B virus is transmitted by exposure to
infection? blood or body fluids from infected individuals. In
endemic countries, vertical transmission, that is,
A. Newborn from mother to fetus or newborn, accounts for at
B. 8 year old least 35 to 50 percent of chronic HBV infections.
C. 32 year old healthy Ø The highest HBV DNA levels were found in women
woman who transmitted the virus to their fetuses.
D. All of them are at risk

5) 26 year old female at 28

weeks age of gestation is
experiencing generalized
pruritis for 2 weeks. She is

ORATIO SAMPLEXIS OLFU MD 2020 1

icteric & normotensive.
She has 148 bpm heart
rate. What is the
diagnosis?
6) Which of the following
statements regarding
breastfeeding in women
infected with HBV and
HCV?
A. Both are contraindicated
B. Neither are
contraindicated
C. Contraindicated in Hbv
only
D. Contraindicated in hcv
only
7) Primary adverse effect
of hepatitis C?
A. Stillbirth
B. Preterm labor and
delivery
C. LBW
D. Vertical transmission
1) Which is NOT a
component of HELLP
Syndrome?
A. Increased LDH
B. Proteinuria 2+ on
Urine dipstick
C. Increased SGPT
D. Platelet less than
<100,000/µg
B. NEITHER ARE HEP B – PAGE 1065
CONTAINDICATED Ø The American Academy of Pediatrics and the
American College of Obstetricians and
Gynecologists (20 1 7) does not consider maternal
HBV infection a contraindication to breastfeeding.
HEP C – PAGE 1065
Ø HCV genotype, invasive prenatal procedures,
breastfeeding, and delivery mode are not associated
with mother-to-child transmission.
That said, invasive procedures such as internal
electronic fetal heart rate monitoring are avoided.
HCV infection is not a contraindication to
breastfeeding.
D. VERTICAL HEP C - PAGE 1065
TRANSMISSION The primary adverse perinatal outcome is vertical
transmission of HCV infection to the fetus-infant. This
is higher in mothers with viremia.
CCB: CHRONIC HYPERTENSION (9/10)
Proteinuria 2+ on HELLP Syndrome:
Urine dipstick Hemolysis
Elevated Liver enzymes
Low Platelet count

2) 36 weeks. Blurring of MgSO4, (check out the ratio for the next question ☺)
vision and headache. BP: Antihypertensive
180/100 mmHg. Cervix drugs, immediately do
long, firm, uneffaced. CS
What is the management?
A. MgSO4,
Antihypertensive
drugs,
immediately do CS
B. MgSO4,
Antihypertensive
drugs,
Betamethasone,
induce labor
C. (n/a)
D. Observe, wait for 37
weeks for lung
maturity

ORATIO SAMPLEXIS OLFU MD 2020 2

3) 24 y/o, 30 weeks AOG,
BP: 180/110, came in for
her prenatal checkup.
She complains of labor
pains every hour, (+) bag
of waters, albumin 3+,
CBC and platelets, and
SGPT within normal
levels.
Admit patient, give For chronically hypertensive women who have complications such as
fetal-growth restriction or superimposed preeclampsia, the decision to
MgSO4,
deliver is made by clinical judgment. The route of delivery is dictated
antihypertensive by obstetrical factors. Certainly, most women with superimposed
medication plus severe preeclampsia are better delivered even when the fetus is
betamethasone and markedly preterm. Increased risk for placental abruption, cerebral
hemorrhage, and peripartum heart failure attend delivery delays
induction of labor
(Cunningham, 1986, 2005; Martin, 2005 ).
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 50, p. 984

(from transcription, the blue one)

A. Admit patient, Example: Pregnancy at 30 weeks ~ Preterm, but you already have
give MgSO4, IUGR. Ide-deliver niyo na ba agad?
antihypertensive • Ano yung things you have to remember?
1. Admit the patient
medication plus 2. Control the BP
betamethasone 3. You give (importante for the baby kasi
and induction of premature) steroids – Dexamethasone, 6 mg
labor every 12 hrs for 4 doses or Betamethasone 12
mg q24 hrs for 2 doses
B. Discharge patient • After completion of your steroids you deliver the baby. * Route of
and follow-up after 2 delivery, CS or vaginally? Answer: “it depends”, huwag mag-CS
weeks agad, tignan niyo kung naglalabor yan baka 5 cm → induce labor
C. Give MgSO4 plus pero kung close, uneffaced → CS
• Pero kung controlled naman, i-push niyo hanggang mag-37
hypertensive weeks.
medication, then do
CS
D. Give MgSO4 plus
antihypertensive
agent then deliver

4) What anti-hypertensive Diuretics (Furosemide) Diuretics

drug/s is/are proven to be Thiazide diuretics are sulfonamides, and these were the first
safe and effective in drug group used to successfully treat chronic
hypertension (Beyer, 1982). These agents and loop-acting
pregnancy?
diuretics such as furosemide are commonly used in
A. Diuretics nonpregnant hypertensive patients. In the short term, they
(Furosemide) provide sodium and water diuresis with volume depletion. But
B. Centrally-acting β- with time, there is sodium escape, and volume depletion is
adrenergic partially corrected. Some aspect of lowered peripheral
antagonists vascular resistance likely contributes to their effectiveness in
reducing long-term morbidity (Umans, 2015).
(Methyldopa) Overall, thiazide diuretics are considered safe in
C. ACE inhibitors pregnancy (Briggs, 2015). But for preeclampsia treatment,
(Captopril) they are considered to be ineffective (Umans, 2015) .
D. All of the Above
Adrenergic-Receptor Blocking Agents
Peripherally acting β-adrenergic-receptor blockers cause a
generalized decline in sympathetic tone and decreased cardiac
output. Examples are propranolol, metoprolol, and atenolol.
Labetalol is a popular and commonly used ɑ/β-adrenergic
blocker that is considered safe.
Some adrenergic-blocking drugs act centrally by reducing
sympathetic outflow to effect a generalized decreased vascular
tone. These include clonidine and ɑ-methyldopa. Drugs in this
class most frequently used in pregnancy to treat hypertension
are methyldopa or an a- or β -receptor blocking agent such as
labetalol.

Angiotensin-Converting Enzyme Inhibitors

ORATIO SAMPLEXIS OLFU MD 2020 3


5) G2P1 30 weeks AOG,
obese, admitted due to
her BP: 180/110. Patient is
asymptomatic. What
treatment should be
given?
A. Clonidine
B. Methyldopa
6) In women with chronic
hypertension and
superimposed
preeclampsia with severe
features, what is the drug
of choice for
neuroprophylaxis?
A. Diazepam
B. Sodium Valproate
C. Carbamazepine
D. Magnesium Sulfate
7) A 21 y/o G1P0 with
chronic hypertension and
superimposed
preeclampsia. What will
be the plan for
management?
A. BPS and NST
B. Double dose of
vitamins
C. Frequent
sonography
D. None of the Above
18) Relative
contraindication in
pregnancy, except:
19 Management of
chronic mild to moderate
hypertension:
These drugs inhibit the conversion of angiotensin-I to the
potent vasoconstrictor angiotensin-II. They can cause
severe fetal malformations when given in the second
and third trimesters. These include oligohydramnios,
hypocalvaria, and renal dysfunction.
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 50, p. 981
Methyldopa Some adrenergic-blocking drugs act centrally by reducing
sympathetic outflow to effect a generalized decreased vascular
tone. These include clonidine and ɑ-methyldopa. Drugs in this
class most frequently used in pregnancy to treat hypertension
are methyldopa or an a- or β -receptor blocking agent such as
labetalol.
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 50, p. 981
Magnesium Sulfate For women with chronic hypertension and superimposed
preeclampsia with severe features, magnesium sulfate
for maternal neuroprophylaxis is recommended (American
College of Obstetricians and Gynecologists, 2013)
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 50, p. 983
Frequent sonography Women with well-controlled chronic hypertension who have
no complicating factors can generally be expected to have a
good pregnancy outcome. Because even those with mild
hypertension have a greater risk of superimposed
preeclampsia and fetal-growth restriction, serial
antepartum assessment of fetal well-being is
recommended by many. That said, according to the
American College of Obstetricians and Gynecologists (2013),
with the exception of sonographic fetal-growth
monitoring, described in Chapter 44 (p. 852), no conclusive
data address either benefit or harm associated with various
antepartum surveillance strategies.
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 50, p. 982-983
Treatment of healthy For most women with mild to moderate hypertension, the
patients with College recommends that treatment be withheld as long as
persistent systolic blood pressure is < 160 mmHg and diastolic blood
>150/100mmHg pressure is < 105 mmHg. Some find it reasonable to begin
antihypertensive treatment in otherwise healthy
pregnant women with persistent systolic pressures >
150 mm Hg or diastolic pressures of 95 to 100 mm Hg or
ORATIO SAMPLEXIS OLFU MD 2020 4
 A. Treatment of greater. (August, 2015; Working Group Report, 2000) . At
persistent BP of Parkland Hospital we initiate treatment with
antihypertensive agents for blood pressures of 150/100
<160/105mmHg
mm Hg or higher. Our preferred regimens include mono
B. Treatment of neuro, therapy with a β-blocking drug such as labetalol or a calcium-
cardio, renal channel blocking agent such as amlodipine. For women in the
C. Treatment of first half of pregnancy, therapy with a thiazide diuretic seems
healthy patients reasonable. This is especially true in black women, in whom
there is a high prevalence of salt-sensitive chronic
with persistent
hypertension.
>150/100mmHg
D. (+) end organ
damage, treat DBP Treatment of neuro, cardio, renal – Severe hypertension
>90mmHg to avoid With end-organ dysfunction, treatment to diastolic pressure
level; 90 mm Hg is reasonable to mitigate further organ
end organ failure
damage.

Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill

Education. Chapter 50, p. 982-983
AVSJ: ABNORMAL LABOR (PASSENGER) (8/10)
21. What is the objective To bring chin under The objective of internal rotation of the face is to bring
of the internal rotation of symphysis pubis the chin under the symphysis pubis, result from the
the face? same factors as in vertex presentations. Only in this
way can the neck traverse the posterior surface of the
a. To flex the head symphysis pubis. (p. 452)
b. To bring chin under
symphysis pubis
c. Short neck can span the
anterior surface of the
sacrum
d. The longer occipito-
mental diameter can
pass through the
symphysis pubis

22. Which differentiates
face from breech during
IE?
a. Breech and ischial
tuberosities in same line
(Anus and ischial
tuberosities in straight
line)
b. Mouth and malar
eminence form a triangle
c. Mouth is bigger than
anus
d. A and B
A and B During cervical examination with a frank breech, the
fetal ischial tuberosities, sacrum and anus are usually
palpable. In some cases, the anus may be mistaken for
the mouth and ischial tuberosities for the malar
eminences. With careful examination, however, the
finger encounters muscular resistance with the anus,
whereas the hard, less yielding jaws are felt through the
mouth. The finger, upon removal from the anus may be
stained with meconium. The mouth and malar
eminences form a triangular shape, whereas the ischial
tuberosities and anus lie in a straight line. (p. 540)

23. Which of the following
is not a predisposing
factor to transverse lie?
a. Oligohydramnios
b. Preterm fetus
c. Tumor previa (Placenta
previa)
OLIGOHYDRAMNIOS A transverse lie is usually recognized easily, often by
inspection alone. The abdomen is unusually wide,
whereas the uterine fundus extends to only slightly
above the umbilicus. The position of the back is readily
identifiable. When the back is anterior, a hard
resistance plane extends across the front of the
abdomen. When it is posterior, irregular

ORATIO SAMPLEXIS OLFU MD 2020 5

d. Contracted pelvis
24. Transverse lie
abdominal palpation,
narrow left, large
nodular right
a. Right acromionodular
anterior
b. Left acromionodular
anterior
c. Right acromionodular
posterior
d. Left acrominonodular
posterior
25. Which of the following
scenario is vaginal
delivery possible in
preterm transverse lie?
a. Fetal shoulder is forced
and accommodated in
large pelvis
b. Fetal assumes
“conduplicato corpore”
attitude
c. One arm prolapses and is
delivered first followed by
the shoulder
d. None of the above
26. 34 weeks PTL, FHT
140/min, 5cm dilation,
+BOW, Station -1,
mentum presentation
a. Emergency CS
b. Wait, VD
c. Manual rotation and
deliver
d. Observe
(Note: Not indicated specific
presentation)
27. Maneuver for
shoulder dystocia, head
(hands) is placed on
posterior shoulder of
fetus and the shoulder is
progressively rotated to
180 degrees
a. McRoberts
b. Corkscrew
c. Rubin’s
nodulations representing fetal small parts are felt
through the abdominal wall. (p. 453)
RIGHT A transverse lie is usually recognized easily, often by
ACROMIONODULAR inspection alone. The abdomen is unusually wide,
POSTERIOR whereas the uterine fundus extends to only slightly
above the umbilicus. The position of the back is readily
identifiable. When the back is anterior, a hard
resistance plane extends across the front of the
abdomen. When it is posterior, irregular
nodulations representing fetal small parts are felt
through the abdominal wall. (p. 453)
FETAL ASSUMES Spontaneous delivery of a fully developed newborn is
“CONDUPLICATO impossible with a persistent transverse lie. If the fetus
CORPORE” is small –usually <800g—and the pelvis is large,
ATTITUDE spontaneous delivery is possible despite
persistence of the abnormal lie. The fetus is
compressed with the head forced against its abdomen.
A portion of the thoracic wall below the shoulder thus
becomes the most dependent part, appearing at the
vulva. The head and the thorax then pass through the
pelvic cavity at the same time. The fetus, which is
doubled upon itself and thus sometimes referred to as
conduplicato corpore, is expelled. (p. 454)
Mentum anterior is deliverable via vaginal delivery
while mentum posterior presentation via cesarean
delivery. (p. 451)
CORKSCREW Woods corkscrew maneuver- hands are placed
behind the posterior shoulder of the fetus and
progressively rotating the posterior shoulder 180
degrees in a corkscrew fashion which could release the
impacted anterior shoulder.
McRoberts maneuver- consists of removing the legs
from the stirrups and sharply flexing them up toward
the abdomen which causes straightening of the sacrum
relative to the lumbar vertebrae, rotation of the
symphysis pubis toward the maternal head, and a
ORATIO SAMPLEXIS OLFU MD 2020 6
d. Zavanelli decrease in the angle of pelvic inclination. Pelvic
rotation cephalad tends to free the impacted anterior
shoulder.
Rubin’s maneuver- Fetal shoulders are rocked from
side to side by applying force to the maternal abdomen.
The pelvic hand reaches the most easily accessible fetal
shoulder, which is then pushed toward the anterior
surface of the chest. This most often abducts both
shoulders which produces smaller bisacromial
diameter.
Zavanelli- involves replacement of the fetal head into
the pelvis followed by cesarean delivery. (pp. 521-523)
28. This maneuver ZAVANELLI (please see above rationale #27)
consists of returning the MANEUVER
head to an OA or OP
position followed by
cesarean delivery.
RCJ: FETAL GROWTH DISORDERS (8/10)
31) Substance abuse such Many areas of growth, metabolism and behavior are affected in the
developing fetus and newly born infant of drug-dependent mothers.
as intake of heroin is
The effects of heroin and methadone differ in these variables. This is
associated with thought to be true partly because of the differing direct effects of these
decreased birthweight by agents and partly because of the differences in nutrition, antenatal
lowering the fetal plasma care and general life-styles among women addicted to these two
agents. In both heroin and methadone addicts there is a noticeable
level of this hormone:
prevalence of abuse of other agents, including tobacco, alcohol and
A. Ghrelin barbiturates, all of which have notable effects on the fetus and newly
B. Chemerin born infant.
C. Leptin Intrauterine growth retardation and prematurity are well-
recognized complications in infants of narcotic-addicted mothers.
D. Omentin 1 These conditions have generally been attributed to poor nutrition of
the mother, but Naeye, Blanc and Leblanc and coinvestigators have
evidence from autopsy specimens that heroin has a primary effect on
antenatal growth. In addition, they found a very high prevalence of
intrauterine infection, which accounted for poor growth as well as
prematurity. In infants of methadone-addicted mothers, intrauterine
growth retardation occurs less frequently. There are reports, however,
of diminished linear growth and head circumference during the first
year of life as well as slightly decreased birth weight. In 1971 Glass,
Rajegowda and Evans reported that respiratory distress syndrome did
not occur in 33 infants prematurely delivered of heroin-addicted
women. However, in 1972 Taeusch and associates studied lung
development in fetal rabbits and confirmed that heroin had a direct
inhibitory effect on fetal growth unrelated to maternal nutrition, with
some indices compatible with acceleration of lung maturation. At the
time of delivery, most infants with antenatal exposure to either heroin
or methadone are vigorous and have good Apgar scores. Respiratory
depression may occur but it can be reversed by treatment with
naloxone (Narcan).
32) Neonatal withdrawal To date, there are only a few studies examining prenatal
of methamphetamine exposure to MDMA in humans, despite concerns about its
symptom: potential harmful effects to the fetus (Ho et al, 2001;
McElhatton et al, 1999; Singer et al, 2012; van Tonningen van
A. Tremors
Driel et al, 1999). Very little is known about the
B. Hypotonia characteristics of pregnant women who use Ecstasy. Using
C. Bradycardia data collected regarding women contacting the Motherrisk
D. Hypothermia Helpline in Toronto (Ho et al, 2001), MDMA users tended to
be younger, single, Caucasian, binge drinkers, and had a
higher prevalence of psychiatric symptoms. Most of these
users discontinued MDMA once pregnancy was known, but
because the recruitment was based on contact initiated by the
mothers, the sample likely overrepresented more ‘motivated’
women. The few available studies demonstrate that pregnant

ORATIO SAMPLEXIS OLFU MD 2020 7

 MDMA users exhibit a clustering of reproductive risk factors
that contribute to neurobehavioral and teratological
outcomes. A retrospective report of 136 babies exposed to
Ecstasy in utero noted premature births, a significantly
increased risk of congenital defects, cardiovascular
anomalies, and musculoskeletal anomalies (McElhatton
et al, 1999). Another study in the Netherlands reported
congenital cardiac malformation and spontaneous abortions
(van Tonningen-van Driel et al, 1999). A recent
neurobehavioral outcome study suggests that prenatal
MDMA exposure predicts poorer infant mental and motor
development at 4 and 12 months of age in a dose-dependent
manner (Singer et al, 2012).

Ross, E. J., Graham, D. L., Money, K. M., & Stanwood, G. D.

(2014). Developmental Consequences of Fetal Exposure to Drugs:
What We Know and What We Still Must Learn.
Neuropsychopharmacology, 40(1), 6187. doi:10.1038/npp.2014.147

33) 24 y/o, 30 weeks AOG,

asymptomatic.
Ultrasound: live fetus,
placenta lying on the
lower segment 1.5 cm
from the internal os.

A. Complete abruption
B. Partial abruption
C. Complete placenta
previa
D. Low lying placenta

(comment: same question as

that from Obstetrical
Hemorrhage)

34) The risk of Fetal

Growth Restriction in
subsequent pregnancy
nearly approaches what
percentage?

A. 15%
B. 25%
C. 50%
D. 70%

35) Later in adult life, one

who had a history of
Fetal Growth Restriction
has higher incidence of:

ORATIO SAMPLEXIS OLFU MD 2020 8

 A. IUGR sibling
B. Severe malnutrition
C. Obesity
D. hypercholesterolemia

36) Most common Tobacco smoking

maternal preventable
factor in pregnancy that
causes IUGR:
A. Maternal HPN
B. Uncontrolled plasma
glucose level
C. Tobacco consumption
A. D. Maternal
infection

37) Other than

chromosomal aberrations
such as Down and
Edward’s syndromes to
name a few, this/these
rare genetic disorder/s
predisposes to fetal
growth restriction during
fetal life:

A. unipaternal trisomy
B. (n/a)
C. Translocation
D. A and B

38) Which ante- and

intrapartum condition
complicates 50% of
pregnancies with fetal
growth restriction?
A. Asphyxia
B. Preterm
C. Necrotizing
Enterocolitis
D. Respiratory Distress
Syndrome

AJB: PLACENTAL ABNORMALITIES (6/10)

41. The chorion periphery
is thickened, opaque,
gray-white circular ridge
composed of double fold
of chorion and amnion.
A. circummarginate placenta
B. circumvallate placenta
C. placenta abruptio
D. annular placentation
CIRCUMVALLATE Circumvallate Placenta:
PLACENTA assoc. with antepartum bleeding & pt birth, transient,
benign. UTZ shows double fold desc. as thick, linear
band of echoes. Cross section appears as shelf.
Circummarginate:
Fibrin and old hemorrhage lie between the placenta and
the overlying amniochorion

ORATIO SAMPLEXIS OLFU MD 2020 9

 Annular:
A variant of placenta membranacea. Placenta is
annular, partial or complete ring of placental tissue
42. Maternal indication PRETERM DELIVERY Should be thick meconium stain
for pathologic Hyperthyroidism is not a maternal indication
examination DM is not a maternal indication
A. Thin meconium stain Preterm delivery is a maternal indication (see Figure 1)
amniotic fluid
B. Hyperthyroidism
C. DM
D. Preterm delivery
43. Placenta where nearly PLACENTA Clue for answer: ALL MEMBRANES =
all membranes are MEMBRANACEA MEMBRANACEA
covered with functioning
villi Fenestrate: (butas sa gitna)
A. Placenta fenestrate Central portion of a placental disc is missing, with
B. Placenta defect involves only villous tissue and chorionic plate is
membranacea intact
C. Bipartite placenta
D. Succenturiate placenta Bipartite/Bilobate (two pieces):
Placenta form as separate, nearly equal sized discs,
Cord inserts between the two placental lobes – either
into a connecting chorionic bridge or into intervening
membranes

Succenturiate/Small Lobes (loner):

Develop at a distance from the main placenta, and have
vessels that course through the membranes. Read on
vasa previa.
44. Hallmark of AMNION NODOSUM Amnion nodosum is a condition characterized by
oligohydramnios numerous small, light-tan nodules on the amnion
characterized by small, overlying the chorionic plate. These may be scraped of
light tan nodules the fetal surface and contain deposits of fetal squames
overlying the placenta and fibrin that reflect prolonged and severe
A. Amniotic Cyst oligohydramnios. Common in Renal Agenesis,
B. Amnion nodosum Prolonged PPROM, Placenta of Donor Fetus.
C. Amniotic Band
D. Amniotic Sheets Amniotic Sheets are normal amniochorion draped
over preexisting uterine synechia. Risk of preterm
delivery and placental abruption.

Amnionic Cyst occurs due to the fusion of amniotic

sheets.

Amniotic bands are formed from disruption of

amnion; entraps fetus impairing growth and
development. Risk of fetal intrauterine amputation.
45. Umbilical cord vessel UMBILICAL VEIN Thrombosis occurs 70% in Venous circulation,
thrombosis although has a lower perinatal morbidity and mortality
A. Umbilical artery rates
B. Umbilical vein
C. U. Art. & Vein Arterial Thrombosis occurs 10%, and is associated
with is associated with IUGR and IUFD.

Combined Artery & Vein – 20%

ORATIO SAMPLEXIS OLFU MD 2020 10

46 Small tan nodules AMNION NODOSUM Refer to #58
overlying placenta
common in
oligohydramnios
A. Amniotic Cyst
B. Amnion nodosum
C. Amniotic Band
D. Amniotic Sheets
CCT: CESAREAN DELIVERY and PERIPARTUM HYSTERECTOMY (10/10)
51) ACOG recommended There are limited studies on cesarean delivery on maternal
elective delivery request and neonatal outcomes; therefore, the literature on
A. 37 weeks cesarean delivery without labor is evaluated in this section.
The risk of respiratory morbidity, including transient
B. 38 weeks
tachypnea of the newborn, respiratory distress syndrome, and
C. 39 weeks persistent pulmonary hypertension, is higher for elective
D. 40 weeks cesarean delivery compared with vaginal delivery when
delivery is earlier than 39–40 weeks of gestation (8, 9). The
literature on elective cesarean delivery without labor also
shows an increased rate of complications related to
prematurity (including respiratory symptoms, other neonatal
adaptation problems such as hypothermia and hypoglycemia,
and neonatal intensive care unit admissions) for infants
delivered by cesarean delivery before 39 weeks of gestation (2).
Because of these potential complications, in the absence of
other indications for early delivery, cesarean delivery on
maternal request should not be performed before a
gestational age of 39 weeks.

Cesarean delivery on maternal request. ACOG Committee Opinion

No. 761. American College of Obstetricians and Gynecologists. Obstet
Gynecol 2019;133:e73–7.
52) G5P4 (4004) after
delivering vaginally, the
uterus remained boggy.
What management?

A. Misoprostol
B. Peripartum
Hysterectomy
C. (n/a)
D. (n/a)

ORATIO SAMPLEXIS OLFU MD 2020 11

53) Indication for
cesarean section delivery

54) 37 weeks AOG, was

rushed to the hospital
with vaginal bleeding.
EFW: 5000g, with rupture
of membranes. What is
the best management?

A. Vaginal delivery
B. Forceps delivery
C. Cesarean section
delivery
D. Vacuum delivery

55) uterine incision CLASSICAL Indications:

delivery in a back-down • If the lower uterus cannot be exposed or entered
transverse lie fetus: safely because of bladder adherent densely from
previous surgery, myoma, invasive CA of the cervix

ORATIO SAMPLEXIS OLFU MD 2020 12

 A. Kerr • Transverse lie with back-down
B. Kronig • Placenta previa with anterior implantation
C. Classical • Massive maternal obesity where the upper uterus is
D. T incision easily accessible

56) 43 y/o G5P4 (4002) REPEAT LOW Cesarean hysterectomies are most commonly
with 2 prior CSD with TRANSVERSE CS with performed to arrest or prevent hemorrhage from
placenta accreta HYSTERECTOMY intractable uterine atony or abnormal placentation.

A. Spontaneous vaginal
delivery with
hysterectomy
B. Repeat low
transverse CS with
hysterectomy
C. Repeat low
transverse CS
D. Classic CS

57) Most common SKIN LACERATION Neonatal Morbidity

neonatal morbidity in CS Skin laceration was most common, but others included
cephalohematomas, clavicular fracture, brachial
A. Cephalohematoma plexopathy, skull fracture, and facial nerve palsy.
B. Brachial plexus
injury
C. Skull fracture
D. Skin laceration

58) What is given to ANTACID Oral antacids are first-line therapy. If severe
minimize lung injury for symptoms persist, sucralfate (Carafate) is given along
gastric aspiration prior with a proton-pump inhibitor, or an H2-receptor
to CS antagonist. Both classes are generally safe in
A. Prophylactic pregnancy.
antibiotic
B. Antacid
C. Increase IV fluid
D. Sedative

59) HELLP syndrome, PROTEINURIA 2+ HELLP Syndrome:

except: Hemolysis
Elevated Liver enzymes
A. LDH Low Platelet count
B. Proteinuria 2+
C. Elevated liver
enzymes
D. Low platelet count

60) To prevent atelectasis DEEP BREATHING After transfer to her room, the woman is assessed at
after CS, which of the least hourly for 4 hours, and thereafter at intervals of 4
following should be hours. Deep breathing and coughing are encouraged to
advised? prevent atelectasis.

A. Early ambulation
B. Deep breathing

ORATIO SAMPLEXIS OLFU MD 2020 13

 C. Prophylactic
antibiotics
D. Stop smoking before
the procedure

FAV: OBSTERTICAL HEMORRHAGE (5/10)

61) 35 y/o G8P7, 28 weeks
AOG, consulted for
profuse bleeding which
she notes upon waking.
BP: 90/50 mmHg, PR: 100
bpm. On PE…
A. Total Abruptio
B. Partial
C. Complete Previa
D. Low Lying

62) 30 y/o G605 37 weeks
AOG. Frequent uterine PLACENTA PREVIA
contractions, profuse
vaginal bleeding,
placental edge 5cm from
internal os
A. Placental Abruption
B. Partial placental
abruption
C. Complete placenta
previa
D. Low lying placenta
previa
LOW LYING Clearly, the classification of some cases obf previa will
depend on cervical dilation at the time of assessment
(Dashe, 2013; Reddy, 2014) . For example, a low-lying
placenta at 2-cm dilation may become a partial placenta
previa at 4-cm dilation because the cervix has opened to
expose the placental edge. Conversely, a placenta previa
that appears to be total before cervical dilation may
become partial at 4-cm dilation because the cervical
opening now extends beyond the edge of the placenta.
Digital palpation in an attempt to ascertain these
changing relations between the placental edge and
internal os as the cervix dilates usually causes severe
hemorrhage!

63) 35 y/o G8P7, 28 weeks ULTRASOUND

AOG. Profuse vaginal
bleeding upon waking up.
What is the next step?
BP: 90/60 mmHg
PR: 110 bpm
FHT: 148
A. IE
B. Ultrasound
C. Blood transfusion
D. Cesarean section

64) 38 y/o, 37 weeks AOG. AMNIOTOMY Vaginal delivery is preferred choice of delivery for dead fetus
Frequent uterine except when mother is bleeding profusely. Amniotomy is done
contraction, moderate for better spiral artery compression to diminish implantation
site bleeding.
vaginal bleeding. No FHT.
BP: 160/110mmHg. What
is the next step?
A. Amniotomy
B. Do cesarean
C. Ultrasound
D. Blood transfusion

ORATIO SAMPLEXIS OLFU MD 2020 14

65) a 42 y/o G2P1 was
noted to have a large
amount of subchorionic OLIGOHYDRAMNIOS
hemorrhage by
ultrasound at 10 weeks
AOG. The pregnancy
progressed. At 22 weeks
AOG, she had vaginal
bleeding. A repeat
ultrasound showed
oligohydramnios. What is
the clinical diagnosis?
A. Placenta previa with
severe hemorrhage
B. Chronic abruptio-
oligohydramnios
sequence
C. Abruptio placenta
with concealed
hemorrhage
D. Placenta accrete
with ruptured
membrane
21. During this period of
pregnancy, the peak of
maternal hypoglycemia
is:
A. 10-14 weeks
B. 20-24 weeks
C. 28-32 weeks
D. 34-38 weeks
22. Effects of maternal
growth… (Question was not
properly recalled ☹)
A. Maternal Hyperglycemia
B. Fetal Hypoglycemia
C. (N/A)
D. AOTA/NOTA
23. The incidence of
stillbirth is highest in
pregnancy complicated
by:
A. Pre-gestational
diabetes
B. Gestational Diabetes
C. Overt Diabetes +
Hypertension
D. GDM + Hypertension
CHRONIC Some cases of chronic placental separation begin early in
ABRUPTIO- pregnancy. Dugof and coworkers (2004) observed an
association between some abnormally elevated maternal
serum aneuploidy markers and subsequent abruption. Other
SEQUENCE
have correlated first- and second-trimester bleeding
with third-trimester placental abruption (Ananth, 2006;
Weiss, 2004). In some cases of a chronic abruption,
subsequent oligohydramnios develops chronic
abruption-oligohydramnios sequence-CAOS (Elliott,
1998). Even later in pregnancy, hemorrhage with
retroplacental hematoma formation is occasionally arrested
completely without delivery. These women may have
abnormally elevated serum levels of alpha-fetoprotein or
placenta-specific RNAs as markers of the event (Miura, 2016;
Ngai, 2012) .
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 41, p. 768
NER: DIABETES MELLITUS
A. 10-14 weeks Diabetes tends to be unstable in the first half of pregnancy,
and the incidence of hypoglycemia peaks during the 1st
trimester.
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 57, p. 1106
There is keen interest in the events that precede diabetes, and
this includes the intrauterine environment. Here, early
imprinting is believed to have effects later in life. For example,
in utero exposure of maternal hyperglycemia leads to fetal
insulinemia, causing in increase in fetal fat cells. This leads to
obesity and insulin resistance in childhood. These factors, in
turn, lead to impaired glucose tolerance and diabetes in
adulthood.
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 57, p. 1097
A. Pre-gestational Stillbirth without an identifiable cause is a phenomenon
diabetes relatively limited to pregnancies complicated by overt
diabetes.
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 57, p. 1101
ORATIO SAMPLEXIS OLFU MD 2020 15
24. 25 y/o G1P0 35 weeks Glucose absorption by A likely, albeit unproven explanation is that fetal
with GDM. US revealed the fetal glomerular hyperglycemia causes polyuria.
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
polyhydramnios. What is system
Education. Chapter 57, p. 1102
the reason for the
polyhydramnios? The amniotic fluid glucose concentration is higher in diabetic
A. Maternal endothelial women than in those without diabetes, and the AFI may
leak correlate with the amniotic fluid glucose concentration. Such
B. Glucose findings support the hypothesis that maternal hyperglycemia
causes fetal hyperglycemia with resulting fetal osmotic
absorption by the
diuresis into the fluid compartment.
fetal glomerular Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
system Education. Chapter 11, p. 228
C. Osmotic gradient by
Poorly managed gestational diabetes is associated with fetal
high glucose in macrosomia and polyhydramnios but the pathogenesis has not
amnion fluid been elucidated yet [22]. One possible explanation is fetal
D. AOTA hyperglycemia resulting in increased osmotic diuresis
which subsequently leads to polyuria. This theory is
supported by evidence of a strong association with high
glycosylated hemoglobin values (HBA1c) in cases with
polyhydramnios [22, 23].
Hamza, A., Herr, D., Solomayer, E., & Meyberg-Solomayer, G.
(2013). Polyhydramnios: Causes, Diagnosis and Therapy.
Geburtshilfe Und Frauenheilkunde, 73(12), 1241–1246.doi:10.1055/s-
0033-1360163

25. G101 at 35 weeks, ALL of the ABOVE Gestational age, rather than overt diabetes is likely the most
diagnosed with GDM. significant factor associated with RDS.
Neonate stayed in Leveno, K. J. (2018). Williams Obstetrics, 25th Edition.
McGraw-Hill Education. Chapter 57, p. 1102
nursery due to
Respiratory Distress
The increased incidence of the idiopathic respiratory distress
Syndrome. What is/are syndrome (IRDS) in infants of diabetic mothers may be
the probable cause/s of explained by preterm delivery and asphyxia but the
RDS? metabolic derangement per se may also be responsible for the
A. Indicated Preterm inadequate production of surfactant. Experimental studies of
Delivery the underlying mechanisms in the lungs of fetuses of pregnant
B. Delayed Type II diabetic rats have shown a decreased formation of the two
major surfactant phospholipids disaturated phosphatidyl
pneumocyte choline and phosphatidyl glycerol. In addition, the activities of
maturation key enzymes responsible for the production of these
C. Decreased phospholipids are decreased in the fetal lung tissue.
Surfactant Inadequate utilization of pulmonary glycogen for surfactant
production due to biosynthesis has also been observed. Furthermore,
experimental studies support that other changes than fetal
maternal hyperinsulinaemia are needed to produce a state of disturbed
hyperglycemia surfactant production. In human diabetic pregnancy strict
D. AOTA metabolic control allows the fetal lungs to mature in a near-
normal fashion. The presence of phosphatidyl glycerol in the
amniotic fluid seems to be the best available predictor of lung
maturity in diabetic pregnancy, in which both the
lecithin/sphingomyelin ratio and amniotic fluid cytology may
result in false-positive and false-negative values.

Certain risk factors increase the likelihood of neonatal

respiratory disease. These factors include prematurity,
meconium-stained amniotic fluid (MSAF), caesarian section
delivery, gestational diabetes, maternal chorioamnionitis, or
prenatal ultrasonographic findings, such as oligohydramnios
or structural lung abnormalities.

ORATIO SAMPLEXIS OLFU MD 2020 16


26. Hyperbilirubinemia,
complication of diabetic
mothers, what is/are the
possible cause/s?
A. Newborn Polycythemia
B. Relative fetal hypoxia
C. (n/a)
D. AOTA
27. Inherited risk for D. None of the Above
newborn diabetes
A. Breast feeding
increases risk
B. Genetic with Type 1
diabetes
C. both parents with
Type 2 diabetes,
increased risk of 20%
D. None of the Above
RCG: POSTTERM PREGNANCY
81. Post term case
a. 294 days
b. G1P0, consulted oct
24, 2018 LMP 3 days
before new year’s eve
c. 41 1/7 week
d. A and b
e. AOTA
82. Perinatal adverse
outcomes of prolonged
pregnancy
a. Stillbirth
b. Shoulder Dystocia
c. Lung immaturity
syndrome
d. All
e. A and C
Respiratory disease may result from developmental
abnormalities that occur before or after birth. Early
developmental malformations include tracheoesophageal
fistula, bronchopulmonary sequestration (abnormal mass of
pulmonary tissue not connected to the tracheobronchial tree),
and bronchogenic cysts (abnormal branching of the
tracheobronchial tree). Later in gestation, parenchymal lung
malformations, including congenital cystic adenomatoid
malformation or pulmonary hypoplasia from congenital
diaphragmatic hernia or severe oligohydramnios, may
develop.
Reuter, S., Moser, C., & Baack, M. (2014). Respiratory Distress in the
Newborn. Pediatrics in Review, 35(10), 417–429. doi:10.1542/pir.35-
10-417
Newborn Hyperbilirubinemia and Polycythemia.
Polycythemia The pathogenesis of hyperbilirubinemia in neonates of
diabetic mothers is uncertain. A major contributing factor is
newborn polycythemia, which raises the bilirubin load (Chap.
33, p. 626). Polycythemia is thought to be a fetal response to
relative hypoxia.
According to Hay (2012) , the sources of this fetal hypoxia are
hyperglycemia-mediated elevations in maternal affinity for
oxygen and fetal oxygen consumption. Together with insulin-
like growth factors, this hypoxia leads to elevated fetal
erythropoietin levels and red cell production. Fetal renal vein
thrombosis is reported to result from polycythemia.
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 57, p. 1102
Inheritance of Diabetes.
The risk of developing type 1 diabetes if either parent is
affected is 3 to 5 percent. Type 2 diabetes has a much stronger
genetic component. If both parents have type 2 diabetes, the
risk of developing it approaches 40 percent. Both types of
diabetes develop after a complex interplay between genetic
predisposition and environmental factors. Type 1 diabetes is
prompted by environmental triggers such as infection, diet, or
toxins and heralded by the appearance of islet cell
autoantibodies in genetically vulnerable individuals (Pociot,
2016; Rewers, 2016) . Some but not all studies have shown a
reduction in risk for type 1 or type 2 diabetes associated with
breastfeeding (Owen, 2006; Rewers, 2016).
Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 57, p. 1102-1003
Stillbirth Perinatal Adverse Outcomes of Post term pregnancy
• Stillbirth
• Post maturity syndrome
• NICU admission
• Meconium Aspiration
• Neonatal convulsions
• Hypoxic-ischemic encephalopathy
• Birth injuries
• Childhood obesity
ORATIO SAMPLEXIS OLFU MD 2020 17
83. 38 yr old; 41 4/7 with
chronic hypertension
management:
a. NST 2-3 days
b. Immediate CS
c. AFV weekly
d. Labor induction
84. Antepartum
Management of a 41 week
not in labor includes
a. Pre induction cervical
ripening
b. Membrane sweeping
c. oxytocin induction
d. AOTA
85. One complication of
post term pregnancy,
oligohydramnios is
diagnosed
ultrasonographically by
measuring the:
a. Deepest vertical
pocket
b. Intrauterine pressure
displaced by the fluid
c. 4 quadrant AF pocket
d. Amount of fluid
obtained after amniotomy
86. Significantly
associated with
prolonged pregnancy
a. Diabetes
b. Obesity
c. Multiparity
d. Smoking
87. True or False
There is evidence that
paternal not maternal is
associated in post term
pregnancy
Case for Nos. 1-5
1-5 G1P0, 16weeka AOG Hgb 10mg/dl asymptomatic
1. Most common
diagnosis
A. IDA
B. Anemia
C. Megaloblastic
D. Hemolytic
Labor induction 41-week pregnancies without other complications are
considered normal. No interventions made until 42
completed weeks. If there are complications such as
hypertension, decreased fetal movement or
oligohydramnios, then Labor induction is carried out.
William 24th ed p.869
D. AOTA(?) Antepartum Management
• Induction factors cervical ripening – PGE,
mifepristone
• Membrane Sweeping/Stripping
William 24th ed p.868
Preinduction cervical ripening and labor induction are
a continuum. Thus, ripening will also stimulate labor.
If not, induction or augmentation may be continued
with solutions of oxytocin.
Williams 24th ed p. 529
A. Deepest vertical Diminished amniotic fluid determined by sonographic
pocket methods identifies a post term fetus with increased
risk. AFI or the deepest vertical pocket is measured.
Williams 24th ed. p.866-867
B. Obesity Only pre pregnancy body mass index BMI >25 and
nulliparity were significantly associated with
prolonged pregnancy
Williams 24th ed p.863
False Laursen and associates (2004) found that maternal but
not paternal, genes influence prolonged pregnancy.
SSM: HEMATOLOGIC DISORDERS (7/10)
Iron Deficiency Normal values for concentrations of many cellular
Anemia elements are listed in the [figure] below. The Centers
for Disease Control and Prevention (1998) defined
anemia in iron-supplemented women using a cutoff of
the 5th percentile – 11g/dL in the 1st and 3rd trimesters,
and 10.5 g/dL in the second trimester.
ORATIO SAMPLEXIS OLFU MD 2020 18
2. Initial work-up, except. Erythro The initial evaluation of a pregnant woman with
moderate anemia includes
A. Red Cell Indices • measurements of hemoglobin, hematocrit, and red
B. Hematocrit cell indices;
C. Serum Ferritin • careful examination of a peripheral blood smear;
D. Erythro • a sickle-cell preparation if the woman has African
origin;
• and evaluation of serum iron ferritin levels, or both.

Serum ferritin levels normally decline during

pregnancy, and levels <10 to 155 mg/L confirm Iron
Deficiency Anemia.
3. Treatment of choice ORAL IRON 10-11 g/dl Oral Iron, 200 mg/day

A. Oral Iron
B. Iron Dextran
C. Erythropoietin
D. Blood Transfusion

4. Anemia caused by MEGALOBLASTIC Megaloblastic Anemia

impaired DNA synthesis ANEMIA These anemias are characterized by blood and bone-
marrow abnormalities from impaired DNA synthesis.
A. Anemia of Chronic (not in the choices from This leads to large cells with arrested nuclear
disease recalls) maturation, whereas the cytoplasm matures more
B. Hemolytic Anemia normally. Worldwide, the prevalence of megaloblastic
C. Hypoplastic Anemia anemia during pregnancy varies considerably. It is rare
in the United States.

Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill

Education. Chapter 57, p. 1077

ORATIO SAMPLEXIS OLFU MD 2020 19

5. Gastric resection 4 MEGALOBLASTIC In our limited experience, vitamin B l2 deficiency in
years ago. Possible risk ANEMIA pregnancy is more likely encountered following gastric
for? resection. Those who have undergone total gastrectomy
require 1000 µg of vitamin B 12 given intramuscularly each
month. Those with a partial gastrectomy usually do not need
A. Iron Deficiency
supplementation, but adequate serum vitamin B 1 2 levels
Anemia should be ensured (Appendix, p. 1258 ) . Other causes of
B. Anemia of Chronic megaloblastic anemia from vitamin B 12 deficiency
Disease include Crohn disease, ileal resection, some drugs, and
C. Megaloblastic bacterial overgrowth in the small bowel (Hesdorfer, 2015 ;
Stabler, 2013).
Anemia
D. Hemolytic Anemia Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
Education. Chapter 57, p. 1078
6. IDA in pregnancy with BLOOD If a moderately anemic woman-defined by a hemoglobin
hemoglobin of <7 mg/dL TRANSFUSION value of approximately 7 g/dL – is hemodynamically stable,
should be given: is able to ambulate without adverse symptoms, and is not
septic, then blood transfusions are not indicated. Instead,
oral iron therapy is given for at least 3 months (Kraft, 2005).
A. Iron dextran
B. Iron sucrose Leveno, K. J. (2018). Williams Obstetrics, 25th Edition. McGraw-Hill
C. Recombinant Education. Chapter 57, p. 1077
erythropoietin
(from the transcription, the blue one)
D. Blood transfusion TREATMENT OF IDA IN PREGNANCY
Target Hgb: 11.0 g/dl

Our target depending on the normal values 11-15 for non-

pregnant women, of course for pregnant women our target is
higher. But because of hemodilution or physiologic aspect of
being a pregnant woman, our target is 11g/dL.
• Get Hemoglobin level:
Ø 10-11 g/dl Oral Iron, 200 mg/day
Ø 9-9.9 g/dl Iron Sucrose, 200mg 1-2x/wk
Ø <9 g/dl Iron Sucrose, 200mg 2x/wk
Ø <8.5 g/dl rHEPO with Iron Sucrose
Ø <7 g/dl Blood Transfusion

7. Iron (Ferrous Sulfate) 30-60 mg Scott and co-workers (1970 established that as little as
daily requirement for 30mg of elemental iron, supplied as Ferrous gluconate,
pregnant women: sulfate, or fumarate, and taken daily throughout the
latter half of pregnancy, provides sufficient iron to
A. 10-20 mg meet pregnancy requirements and protect preexisting
B. 30-60 mg iron stores.
C. 90-120 mg Pregnant women may benefit from 60 to 100mg of
D. 150-180 mg elemental iron per day if:
• she is large,
• has a multifetal gestation,
• begins supplementation late in pregnancy,
• takes iron regularly, or

has a somewhat depressed hemoglobin level.

ORATIO SAMPLEXIS OLFU MD 2020 20