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.
A 38-year-old G4P3013 woman is seeing you for her annual gynecologic examination. She has no specific complaints, but notes that her menses have gradually become heavier over the past 23 years. Your pelvic examination is normal aside from an enlarged uterus, which you estimate at 12 weeks' size. Office ultrasonography confirms that she has multiple uterine fibroids. Which of the following statements is true regarding leiomyomata?
Answer(s): C
Leiomyomata lead to more hysterectomies than any other gynecologic condition and can be found in up to 50% of all women. Most are asymptomatic, but symptoms can include heavy menstrual bleeding, pelvic pain, "pressure symptoms," and even preterm birth. Symptoms depend on where the fibroids are located-- those closest to the endometrial cavity cause more problems with bleeding and dysmenorrhea, while those closest to the serosa can be expected to cause more pressure symptoms such as bladder frequency or constipation. However, the typical bleeding disturbance associated with uterine fibroids is heavy regular bleeding as opposed to bleeding or spotting between periods, which deserves separate evaluation.Leiomyosarcomas are malignant tumors that appear very similar to benign leiomyomata-- however, they are now felt to arise de novo and not from degeneration of a benign fibroid. Leiomyomata do seem to respond to sex steroids but oral contraceptives do not cause more rapid growth or regression.
A 38-year-old G4P3013 woman is seeing you for her annual gynecologic examination. She has no specific complaints, but notes that her menses have gradually become heavier over the past 23 years. Your pelvic examination is normal aside from an enlarged uterus, which you estimate at 12 weeks' size. Office ultrasonography confirms that she has multiple uterine fibroids. Which of the following statements is true regarding leiomyomata?Your patient comes back 6 months later with a calendar demonstrating continued worsening of her menstrual bleeding, now 10 days in duration and requiring one pad hourly during her heaviest days. Which of the following statements are true regarding treatment of leiomyomata?
As mentioned, leiomyomata account for more hysterectomies than any other gynecologic disorder, but alternative treatments continue to be explored. Myomectomy (e.g., removal of uterine fibroids) can be performed via laparotomy, laparoscopy, hysteroscopy, or even vaginally. However, it is generally not considered a "simpler" or safer procedure than hysterectomy, and bleeding can be excessive. Uterine artery embolization is an angiographic procedure currently reserved for women who do not desire future pregnancy, as the effects of embolizing both uterine arteries and then allowing pregnancy is uncertain.GnRH agonists are useful in reducing uterine bleeding and reducing fibroid volume up to 50%, but this effect is short-lived and completely reversible. Therefore, this therapy is useful as an adjunct to surgery in improving hemoglobin or allowing a vaginal approach rather than abdominal. No specific size limit exists for removal of a single myoma.
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