A 37-year-old pregnant woman with type 2 diabetes mellitus and chronic hypertension is 35 weeks' pregnant. Which of the following is the best test to screen for fetal well-being?
Answer(s): E
Of the choices listed, a biophysical profile is the best assessment of fetal well-being. This assesses multiple fetal variables: breathing movement, body or limb movements, tone and posture, fetal heart rate pattern, and amniotic fluid volume. A NST, oxytocin challenge test, and fetal movement counts assess only one determinant of fetal well-being. An amniocentesis has no value in assessing fetal well- being, but may be appropriate to determine fetal lung maturity if induction of labor before 40 gestational weeks is indicated because of her chronic illnesses. Fetal Doppler studies to assess systolic:diastolic (SD) ratio may be a better test of fetal well-being and a significant decrease or reversal of the ratio is an indication for delivery.
A 31-year-old primigravida develops gestational diabetes mellitus and is managed appropriately during pregnancy. She asks you about the consequences of gestational diabetes to her and her fetus. Which one of the following statements is correct?
Answer(s): B
Unlike women with overt or pregestational diabetes mellitus, the risk of fetal anomalies is not increased in women with gestational diabetes. Stillbirth rates are increased in women with gestational diabetes if their fasting plasma glucose concentrations are elevated, but not with elevated postprandial glucose concentrations only. The risk of a growth-restricted infant is increased in women with long-standing diabetes and vascular disease, but not in women with gestational diabetes. There is a slight increase in the frequency of fetal macrosomia (birth weight over 4000 g), though shoulder dystocia and brachial plexus injury are infrequent.
A22-year-old G3P1102 is admitted to the Labor and Delivery ward at 28 weeks' gestation complaining of watery vaginal discharge. You confirm the diagnosis of preterm premature rupture of amniotic membranes (PPROM). Fetal monitoring demonstrates reassuring fetal heart tones and no contractions are noted. The patient is understandably concerned and asks you why this happened and what this means for her pregnancy. Which of the following should you tell her?
Answer(s): D
Preterm premature rupture of membranes is a relatively common condition, affecting 318.5% of all pregnancies. It is estimated that 30% of all preterm deliveries result from PPROM. There are multiple etiologies for PPROM, including ascending vaginal infection. Carriers of GBS, bacterial vaginosis, and gonorrhea are all at increased risk for PPROM. Maternal age is not a risk factor, nor is parity, maternal weight, maternal weight gain, or trauma. According to most experts, patients with this condition should be managed in the hospital due to the high risk for amniotic infection, preterm labor, and umbilical cord compression or prolapse. Pulmonary hypoplasia and fetal compression malformations are seen when rupture of membranes occurs in the previable period (less than 24 weeks). The duration of latency (time from rupture of membranes to delivery) varies inversely with gestational age. In other words, at term, labor generally begins within hours. However, even at 28 weeks, up to 90% of patients will go into labor within 1 week.
A22-year-old G3P1102 is admitted to the Labor and Delivery ward at 28 weeks' gestation complaining of watery vaginal discharge. You confirm the diagnosis of preterm premature rupture of amniotic membranes (PPROM). Fetal monitoring demonstrates reassuring fetal heart tones and no contractions are noted. The patient is understandably concerned and asks you why this happened and what this means for her pregnancy. Which of the following should you tell her? Which of the following is the most appropriate therapy for this woman?
Answer(s): A
Multiple randomized-controlled trials have now demonstrated the benefit of administering antibiotics to women with PPROM at less than 32 weeks' gestation. Most importantly, these drugs prolong the latent period until labor begins, but reductions have also been noted inmaternal infection, fetal infection, fetal respiratory distress syndrome, and fetal intraventricular hemorrhage. Commonly used antibiotics are ampicillin and erythromycin, but efficacy has been noted with many different regimens. Cesarean delivery at this point is not indicated, but might need to be performed in case of nonreassuring fetal status or malpresentation (e.g., breech). Induction of labor generally takes place between 32 and 34 weeks if the patient's status remains stable, or sooner in the event of amniotic infection or other concerns.Amniocentesis may be performed to look for evidence of amniotic infection, but the likelihood of fetal lung maturity at this point is remote. Patients with previously placed cervical cerclages may be candidates for expectant management with the cerclage in place, but it would be inappropriate to place a cerclage after PPROM.
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