CENTRO ESCOLAR UNIVERSITY- SCHOOL OF MEDICINE

PHYSIOLOGIC OBSTETRICS LONG EXAM 4

December 14, 2018

SET B
MULTIPLE CHOICE: Choose the best answer.

1. Puerperium is defined as how many weeks postpartum?

A. 2 -4 weeks
B. 4-6 weeks
C. 6-8 weeks
D. 8-10 weeks
Rationale: puerperium is derived from Latin—puer, child + parus, bringing forth. Currently, it defines the
time following delivery during which pregnancyinduced
maternal anatomical and physiological changes return to the nonpregnant state. Its duration is
understandably inexact, but is considered to be
between 4 and 6 weeks. (William’s 25th Ed.)

2. As the birth canal return to the non-pregnant state after delivery, the hymen is represented by
small tags of tissue which scar to form this structure
A. Myrtiform caruncles
B. Genital tubercles
C. Urachus
D. Urethral caruncles
Rationale: The vagina and its outlet gradually diminish in size but rarely regain their nulliparous
dimensions. Rugae begin to reappear by the third week but are less prominent than before. The hymen is
represented by several small tags of tissue, which scar to form the myrtiform caruncles. The vaginal
epithelium reflects the hypoestrogenic state, and it does not begin to proliferate until 4 to 6 weeks.
(William’s 25th Ed.)

3. Which of the following describes myometrial involution best?

A. A remarkable feat of destruction or deconstruction that begins 2 days after delivery
B. The total number of myocytes and their size decreases markedly
C. The uterus weighs 500g by 2 weeks postpartum
D. After each successive delivery, the uterus returns to original size of pre-pregnancy size after 4
weeks postpartum
Rationale: Myometrial involution is a truly remarkable feat of destruction or deconstruction that
begins as soon as 2 days after delivery. The total number of myocytes does not decrease
appreciably—rather, their size decreases markedly. The quality of studies that describe the
degree of decreasing uterine weight postpartum are poor. Best estimates show that the uterus
weighs approximately 500 g by 1 week postpartum, about 300 g by 2 weeks, and at 4 weeks,
involution is complete and the uterus weighs approximately 100 g. After each successive
delivery, the uterus is usually slightly larger than before the most recent pregnancy. (William’s 25th
Ed.)

4. Complete endometrial regeneration or full restoration of the endometrium happens how many
days postpartum?
A. 12th day
B. 14th day
C. 16th day
D. 18th day
Rationale: Endometrial regeneration is rapid, except at the placental site. Within a week or so, the free
surface becomes covered by epithelium, and fully restored endometrium was identified in all biopsy
specimens obtained from the 16th day onward. (William’s 25th Ed.)

5. Rapid involution of the uterus happens how many weeks postpartum?

A. 6 weeks
B. 4 weeks
C. 2 weeks
D. 1 week
Rationale: Rapid uterine involution: 1st week

6. A patient came in at the ER due to intermittent vaginal bleeding. She claims to deliver 12 days
ago. On internal examination, the cervix is soft, open and admits 1 finger, the uterus is boggy
and enlarged to 4 months size. What is highly considered in this case?
A. Early postpartum hemorrhage
B. Cervical laceration
C. Uterine sub-involution
D. Endometritis
 Rationale: In some cases, uterine involution is hindered because of infection, retained placental
fragments, or other causes. Such subinvolution is accompanied by varied intervals of prolonged lochia as
well as irregular or excessive uterine bleeding. During bimanual examination, the uterus is larger and
softer than would be expected. With bleeding, pelvic sonography may help exclude retained placenta or,
less-commonly, vascular malformations as the source. (William’s 25th Ed.)

7. The cardiac output remains elevated 24-48 hours postpartum and returns to non-pregnant values
how many days postpartum?
A. 4 days
B. 6 days
C. 8 days
D. 10 days
Rationale: When the amount of blood attained by normal pregnancy hypervolemia is lost as postpartum
hemorrhage, the woman almost immediately regains her
nonpregnant blood volume. If less has been lost at delivery, blood volume generally nearly returns to its
nonpregnant level by 1 week after delivery. Cardiac output usually remains elevated for 24 to 48 hours
postpartum and declines to nonpregnant values by 10 days. Heart rate changes follow this pattern, and
blood pressure similarly returns to nonpregnant values

8. True of mature breastmilk EXCEPT

A. Contains all vitamins essential for the newborn*
B. Influenced by maternal diet
C. Contains complex and dynamic biological fluid
D. Contains IgA and growth factors
Rationale: After delivery, the breasts begin to secrete colostrum, which is a deep lemon-yellow liquid. It
usually can be expressed from the nipples by the second postpartum day. Compared with mature milk,
colostrum is rich in immunological components and contains more minerals and amino acids It also has
more protein, much of which is globulin, but less sugar and fat. The colostrum content of immunoglobulin
A (IgA) offers the newborn protection against enteric pathogens. Other host resistance factors found in
colostrum and milk include complement, macrophages, lymphocytes, lactoferrin, lactoperoxidase, and
lysozymes. Secretion persists for 5 days to 2 weeks, with gradual conversion from “transitional” to mature
milk by 4 to 6 weeks. Mature milk is a complex and dynamic biological fluid that includes fat, proteins,
carbohydrates, bioactive factors, minerals, vitamins, hormones, and many cellular products. The
concentrations and contents of human milk change even during a single feed and are influenced by
maternal diet and by newborn age, health, and needs. Most vitamins are found in human milk, but in
variable amounts. Vitamin K is virtually absent, and thus, an intramuscular dose is given to the newborn.

9. The following stimulates the growth and development of the milk-secreting apparatus EXCEPT
A. Progesterone
B. Placental lactogen
C. Inulin
D. Cortisol

10. Absolute contraindication for breastfeeding among mothers EXCEPT

A. Illicit drug use
B. Fever of unknown origin
C. HIV infection
D. Active tuberculosis

11. A 28 y/o, G1P1 (1001) is 4 hours postpartum, delivered spontaneously to a term, live baby girl with
good outcome, BW = 3800g who had right mediolateral episiorrhaphy suddenly complains of severe vaginal
and rectal pain. Her vital signs are as follows: BP = 80/50 mmHg, CR 110 bpm, RR 21 cpm, afebrile with pale
palpebral conjunctiva, pale palms and soles, well-contracted uterus, minimal vaginal bleeding noted on
underpad. What is your consideration?
A. Postpartum hemorrhage
B. Cervical laceration
C. Retained placental fragments
D. Vaginal hematoma

12. Women not breastfeeding are expected to have return of menses how many weeks postpartum?
A. 2-4 weeks
B. 4-6 weeks
C. 6-8 weeks
D. 8-10 weeks

13. What sonographic measurement is the most accurate method to establish or confirm gestational age?
A. Mean sac diameter
B. Biparietal diameter
C. Femoral length
D. Crown-rump length

14. What do you call a flattened head shape?

A. Brachycephaly
B. Dolichocephaly
C. Craniosynostosis
D. Anencephaly
1. Which of the different biometric parameters is most affected by fetal growth?
A. Biparietal diameter
B. Femoral length
C. Abdominal circumference
D. Head circumference
Rationale: Of biometric parameters, AC is most affected by fetal growth. Thus, for gestational age
estimation, AC has the greatest variation, which can reach 2 to 3 weeks in the second trimester. To
measure the AC, a circle is placed outside the fetal skin in a transverse image that contains the stomach
and the confluence of the umbilical vein with the portal sinus.
1. What is the significance of measuring of nuchal translucency (NT) during the first trimester?
A. Decreased NT measurement indicates increased risk of cardiac defects
B. Increased NT measurement indicates increased risk of aneuploidy
C. Increased NT measurement indicates increased risk for maternal complications like preeclampsia
D. Decreased NT measurement indicates increased risk for maternal complications
Rationale: Nuchal translucency (NT) evaluation is a component of first-trimester aneuploidy screening. It
represents the maximum thickness of the subcutaneous translucent area between the skin and soft tissue
overlying the fetal spine at the back of the neck. NT is measured in the sagittal plane between 11 and 14
weeks’ gestation using precise criteria. When the NT measurement is increased, the risk for fetal aneuploidy
and various structural anomalies—in particular heart defects—is significantly elevated.

2. Oligohydramnios is defined as:

A. Amniotic fluid index of < 5 cm
B. Single vertical pocket of < 4 cm
C. Amniotic fluid index > 24 cm
D. Single vertical pocket < 5 cm
Rationale: Oligohydramnios is an abnormally decreased amount of amnionic fluid. Oligohydramnios
complicates approximately 1 to 2 percent of pregnancies. When no measurable pocket of amnionic fluid is
identified, the term anhydramnios may be used. Unlike hydramnios, which is often mild and often confers a
benign prognosis in the absence of an underlying etiology, oligohydramnios is always a cause for concern, the
sonographic diagnosis of oligohydramnios is usually based on an AFI less than 5 cm or a single deepest
pocket of amnionic fluid below 2 cm

3. Which of the following is an indication for a targeted fetal anatomical ultrasound examination?
A. Primigravida
B. Multifetal gestation
C. Maternal hypertension
D. Multigravida
Rationale:The targeted sonogram is a type of specialized examination. It is performed when the risk for a fetal
anatomical or genetic abnormality is elevated because of history, screening test result, or abnormal finding
during standard examination (Table 10-7). Targeted sonograms include a detailed anatomical survey.
Because it carries the CPT code 76811, this sonogram is colloquially called the “76811 examination.” It is
intended to be indication-driven and should not be repeated later in the absence of an extenuating
circumstance. Physicians who perform or interpret targeted sonograms should have expertise in fetal imaging,
through both training and ongoing experience.

4. Which of the following events is responsible for the fetal heart rate pattern shown below?

A. Cord compression
B. Uteroplacental insufficiency
C. Head compression
D. Severe fetal anemia
Rationale: Late Decelerations correspond to uteroplacental insufficiency, & is characterized by gradual
decrease and return of the FHR associated with a uterine contraction with the time of onset of the deceleration
to its nadir as ≥30 sec. The decrease is typically symmetrical in shape and is measured from the most recently
determined portion of the baseline to the nadir of the deceleration. The deceleration is delayed in timing, with
the nadir of the deceleration occurring after the peak of the contraction, in most cases the onset, nadir, and
recovery of the deceleration occur after the beginning, peak, and ending of the contraction, respectively. In
early decelerations due to head compression the onset, nadir, and recovery of the deceleration are coincident
with the beginning, peak, and ending of the contraction. When variable decelerations, which correspond to
cord compression, occur in conjunction with uterine contraction, their onset, depth, and duration commonly
vary with successive uterine contractions and is characterized by abrupt decrease in the FHR with the onset of
deceleration to the nadir of <30 seconds. The deceleration should be at least 15 bpm below the baseline,
lasting for at least 15 seconds but <2 minutes in duration. (OB 4S-1 Trans, 2018)

5. What antepartum surveillance evaluates the response of the fetal heart rate to induced contractions
and was designed to unmask poor placental function?
A. Contraction stress test
B. Nonstress test
C. Biophysical profile
D. Doppler velocimetry studies
Rationale: CST Evaluates response of the fetal heart rate to induced contractions & was designed to unmask
poor placental function. NST Evaluates fetal heart rate acceleration in response to fetal movement as a sign of
fetal health, it tests fetal condition. BPP combines the use of five fetal biophysical variables movement, tone,
breathing, amniotic fluid volume, acceleration/NST (Mind The Baby, mAN) as a more accurate means of
assessing fetal health than a single element. Test is performed for 30 minutes. Doppler velocimetry measures
of blood flow velocities in the maternal and fetal vessels & provides information about uteroplacental blood
flow and fetal responses to physiologic challenges (OB 4S-1 Trans, 2018)

6. What is being assessed by the nonstress test?

A. Test of uteroplacental function
B. Test of fetal condition
C. Test of maternal oxygenation.
D. Test of fetal hemoglobin levels
Rationale: refer to item # 14 mga ma’am, sir!

7. What component of the biophysical profile is the first to develop and last to deteriorate?
A. Amniotic fluid
B. Nonstress test
C. Fetal breathing
D. Fetal tone and movement
Rationale:
In terms of Development: Tone (8wks), Movement (9wks) Breathing (21 weeks) NST/FHR (2nd to early 3rd
trimester)
Deterioration: NST Breathing Tone, Movement

8. A 35-year-old primigravid on her 40th week of gestation with oligohydramnios came in for contraction
stress test prior to labor induction. Which of the following scenario indicates a positive contraction stress test?
A. No late or significant variable deceleration throughout the tracing
B. Intermittent late decelerations or significant variable decelerations
C. Fetal heart rate decelerations that occur in the presence of contractions more frequent than every 2
minutes or lasting longer than 90 seconds
D. Late decelerations following 50% or more of the contractions

9. Biophysical profile for a parturient on her 39th week of gestation showed the following findings:
Fetal breathing Absent rhythmic breathing in 30 minutes
Fetal movement 1 discrete limb movement in 30 minutes
Fetal tone 1 extension and return to flexion of a fetal extremity
Amniotic fluid volume Largest vertical pocket 5.0 cm
Nonstress test Minimal variability without any acceleration nor deceleration

How will you interpret the result?

A. Normal, non-asphyxiated fetus
B. Chronic fetal asphyxia suspected
C. Possible fetal asphyxia
D. Probable fetal asphyxia

10. An 18-year-old primigravid with preeclampsia came in at 37 weeks age of gestation. Biophysical
profile showed a score of 6/10 with oligohydramnios. How will you manage the patient?
A. Deliver
B. Repeat test; if repeat score is < 6, deliver
C. Repeat test; if repeat score is > 6, observe and repeat test per protocol
D. No fetal indication for intervention

11. A 28 y/o, G1P0, with diagnosis of pregnancy uterine 38 weeks age of gestation, cephalic in labor
came in for watery vaginal discharge. She has stable vital signs and is afebrile. On IE, cervix 8 cms dilated;
fully effaced; (-) BOW; cephalic, station +1. Baseline intrapartum monitoring showed the following result:

What is your interpretation of the tracing?

A. Category I
B. Category II
C. Category III

12. A 43 y/o G5P4 (4004) was referred for elevated blood pressure. Diagnosis is pregnancy uterine 36
2/7 weeks, cephalic, not in labor; Preeclampsia with severe features; IUGR. BP 160/110; IE: 1 cm, beginning
effacement, (+) BOW, cephalic, floating. Baseline intrapartum monitoring showed the following results.

How will you manage the patient?

A. Observe and augment labor
B. Resuscitate with hydration, oxygen supplementation and left lateral decubitus position
C. Augment labor and for assisted vaginal delivery under epidural anesthesia
D. Deliver by cesarean section

13. A 23 y/o, G1P0 came in for labor pains. Diagnosis is: Pregnancy uterine 40 2/7 weeks, cephalic, in
labor. She has stable vital signs and is afebrile. On IE, cervix is 6 cm dilated, fully effaced, ruptured BOW, with
egress of thinly stained amniotic fluid, cephalic, station -2. IPM shows the following result?

What is the interpretation of the tracing?

A. Category I
B. Category II
C. Category III

14. Which of the following vessel has a low impedance circulation and reflects the status of the placental
circulation?
A. Uterine artery
B. Middle cerebral artery
C. Ductus venosus
D. Umbilical artery

15. What is the phenomenon wherein fetal hypoxemia causes dilatation and redistribution of the middle
cerebral artery blood flow?
A. Doppler effect
B. Brain sparing effect
C. Decompensation
D. Reversed end diastolic flow

16. Which high impedance vessel has a characteristic biphasic flow and is the reflection of the fetal
venous circulation?
A. Portal vein
B. Ductal arch
C. Ductus venosus
D. Umbilical vein

17. What is the significance of measuring and observing blood flow patterns in the uterine artery?
A. Assess pregnancies high risk for developing uteroplacental insufficiency
B. Predicts preterm labor
C. Indicates preeclampsia
D. There is no additional benefit in observing the uterine artery dopplers

18. For a rare environmental exposure associated with rare defect, essential criteria of teratology required
how many reported cases at the minimum?
A. one well-documented case
B. at least two
C. three reports of similar cases
D. four cases with proven biological plausibility

19. Teratogen exposure at this age of gestation may result in major malformation.
A. 2 weeks from fertilization to implantation
B. 2nd to 8th week
C. beyond 8 weeks
D. any age if teratogen is potent

20. Exposure to this teratogen is an exception in the tenet that the agent should produce an adverse
effect in many different species
A. ACE inhibitors
B. valproic acid
C. thalidomide
D. methotrexate

21. Paternal exposure to teratogens could cause gene mutations if it occurred when?
A. 3 months before conception
B. 2 weeks before conception
C. 4 weeks before conception
D. 2 months before conception

22. Which explains the pathophysiology of ACE-Inhibitor Fetopathy?

A. fetal hypotension → renal hypoperfusion → anuria → oligohydramnios → pulmonary hypoplasia
B. fetal hypertension → renal hypoperfusion → ischemia → calvarium maldevelopment
C. fetal hypotension → renal hypoperfusion → anuria → polyhydramnios → limb contracture
D. fetal hypertension → renal hypoperfusion → growth restriction
23. By strict definition, this is a group of agents that interferes with normal maturation and function of an
organ.
A. Teratogens
B. Mutagens
C. Trophogens
D. Hadegens

24. Exposure to teratogens during this period confers an “all or none” response.
A. preimplantation period
B. embryonic period
C. 2nd to 8th week
D. beyond 8 weeks

25. Smooth philtrum, intrauterine growth restriction, and a small head are diagnostic of what fetal
syndrome?
A. Fetal hydantoin syndrome
B. Fetal alcohol syndrome
C. ACE-Inhibitor fetopathy
D. Fetal methotrexate-aminopterin syndrome

26. Studies in pregnant women have not shown an increased risk for fetal abnormalities if administered
during the first trimester of pregnancy, and the possibility of fetal harm appears remote.
A. Category A
B. Category B
C. Category C
D. Category D

27. An example of a US FDA Category A drug

A. Norfloxacin
B. Valproate
C. Levothyroxine
D. Cefuroxime

28. Rubella vaccine falls under what US FDA Category?

A. Category A
B. Category D
C. Category X
D. Category C

29. Gene mutations can result from preconceptional paternal exposure to teratogens for this duration
A. 1 month
B. 2 months
C. 3 months
D. 6 months

30. Which is not a component of the Fetal Hydantoin Syndrome?

A. upturned nose
B. distal digital hypoplasia
C. long upper lip with thin vermilion border
D. ambiguous genitalia

31. Indomethacin may cause fetal ductus arteriosus constriction starting what age of gestation?
A. 8 weeks
B. 14 weeks
C. 22 weeks
D. 30 weeks

32. What can cause a yellowish-brown discoloration of deciduous teeth?

A. Tetracyclines
B. Nitrofurantoin
C. Sulfonamides
D. Fluconazole

33. What nerves transmit labor pain caused by uterine contractions and cervical dilation?
A. visceral afferent sympathetic nerves entering the spinal cord from T10 through L1
B. visceral efferent sympathetic nerves entering the spinal cord from T10 through L1
C. visceral afferent sympathetic nerves entering the spinal cord from S2 through S4
D. visceral afferent sympathetic nerves entering the spinal cord from T10 through S2

34. What nerves transmit painful stimuli caused by perineal stretching?

A. pudendal nerve and sacral nerves S1 through S2
B. pudendal nerve and sacral nerves S2 through S3
C. pudendal nerve and sacral nerves S2 through S4
D. pudendal nerve and sacral nerves S1 through S4
35. Which of the following is TRUE of the maternal physiological responses to labor pains?
A. hyperventilation may induce hypercarbia.
B. A greater metabolic rate augments oxygen supplementation.
C. Increases in cardiac output and vascular resistance may lower maternal blood pressure.
D. Pain, stress, and anxiety trigger release of stress hormones such as cortisol and β-endorphins.
E. The parasympathetic nervous system response to pain leads to a marked elevation in circulating
catecholamines that can adversely affect uterine activity and uteroplacental blood flow.

36. A primigravid on her 38th week of gestation came in for labor pains. On examination, she has stable
vital signs with good fetal heart tones. On internal examination, cervix is 2 cms dilated, beginning effacement,
with intact bag of waters and fetal head at station -4. She complains of severe pain during contractions, with
VAS 10/10. How will you manage the patient?
A. Reassure the patient that since she is still at the latent phase of labor, no further intervention is
indicated
B. Advise her to rest and do deep breathing exercises
C. Give parenteral analgesic like meperidine 25 mg IV every 2 hours
D. Give subarachnoid anesthetic to relieve severe pain

37. A parturient on the second stage of labor was given opioids. The neonate was noted to be limp and
without spontaneous respiration. How should the newborn be managed?
A. Aggressively stimulate the newborn by rubbing the back and soles of the feet
B. Administer naloxone to reverse respiratory depression
C. Administer nitrous oxide to reverse CNS depression
D. Observe and await improvement of sensorium as the opioid’s effects wear off

38. What is the usual manifestation of CNS toxicity from anesthetic administration during labor?
A. Immediate loss of consciousness
B. Uncontrollable seizures
C. Initial hyperstimulation, followed by nervous depression
D. Hypotension

39. A term pregnant patient received epidural anesthesia suddenly had seizures. What is the best course
of action?
A. Deliver the baby immediately by cesarean section to prevent neonatal asphyxia
B. Administer 20% lipid emulsion solution
C. Give magnesium sulfate
D. Give diazepam to control seizure and secure the airway

40. Where is the location of the pudendal nerve?

A. The pudendal nerve passes beneath the sacrospinous ligament just as the ligament attaches to the
ischial spine.
B. The pudendal nerve passes above the sacrospinous ligament just as the ligament attaches to the
ischial spine.
C. The pudendal nerve passes above the anterior sacroiliac ligament just as the ligament attaches to the
ilium.
D. The pudendal nerve passes below the anterior sacroiliac ligament just as the ligament attaches to the
ilium.

41. For the first stage of labor, at what level should sensory block be achieved?
A. T4
B. T10
C. S1
D. S2

42. During the second stage of labor and for operative vaginal delivery, adequate sensory block should
be at what level?
A. T4
B. T10
C. S1
D. S2

43. What is the desired level of sensory blockade for cesarean delivery?
A. T4
B. T10
C. S1
D. S2

44. What is the most common complication of regional anesthesia?

A. Hypotension
B. Tachycardia
C. Postdural headache
D. Fetal bradycardia
45. What is the gold standard for treatment of postdural headache?
A. Fluid administration
B. Bed rest
C. Analgesics
D. Epidural blood patch

46. How soon can we give regional anesthesia to a woman receiving once-daily, low-dose low-
molecular-weight heparin?
A. At least 6 hours from last injection
B. At least 12 hours from last injection
C. At least 24 hours from last injection
D. At least 48 hours from last injection

47. What is the most common and dreaded complication of general anesthesia?
A. Failed intubation
B. Hypotension
C. Aspiration
D. Fetal distress

For #s 63-65: Matching type: Match the type of lochia with the associated observations
A. Lochia alba
B. Lochia serosa
C. Lochia metra
D. Lochia rubra

48. Admixture of leukocytes and reduced fluid content and assumes a white or yellow-white color

49. There is blood sufficient to color it red few days after delivery

50. The lochia becomes progressively pale in color 3-4 days after delivery

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