ACOG Review: Questions With In-Depth Solutions
A 34-year-old G4P3 woman at 19 weeks gestation presents to the emergency
department with chest pain, palpitations and sweating, which began 2-3 hours
ago. On further questioning, she states that she has been very anxious lately
and is not sleeping well, which she attributes to the pregnancy. She reports
that she has lost 40 pounds in the last year without trying. She denies
significant medical problems. On exam, the patient appears diaphoretic and
anxious, her eyes are wide open, prominent, with easily visible sclera
surrounding the pupil. Vital signs are: temperature 100.2°F (37.9°C); pulse
132; and blood pressure 162/84. Her height is 5 feet 10 inches and weight is
128 pounds. Her thyroid is palpably enlarged, with an audible bruit.
Electrocardiogram shows sinus tachycardia. Remaining labs are pending.
Which of the following therapies is contraindicated at this time?
A. Radioactive iodine (I-131)
B. Propylthioura Right Ans - A. This patient is in thyroid storm, an acute,
life-threatening, hypermetabolic state. *Radioactive iodine (I-131)
concentrates in the fetal thyroid and may cause congenital hypothyroidism*,
so it should not be intentionally used in pregnancy. Acute treatment of thyroid
storm may include thioamides (i.e. PTU), propranolol, sodium iodide and
dexamethasone. Oxygen, digitalis, antipyretics and fluid replacement may also
be indicated. Maternal mortality with thyroid storm exceeds 25%.
An 18-year-old G1 woman presents for prenatal care at 16 weeks gestation
without complaints. The patient denies any history of sexually transmitted
disease, although admits to a history of multiple sex partners, with irregular
use of condoms. She is allergic to penicillin, which causes anaphylaxis.
Physical exam is unremarkable. Pertinent labs: rapid plasma reagin test (RPR)
positive (titer = 32); fluorescent treponemal antibody absorption test (FTA-
ABS) is positive. Which of the following is the best treatment for this patient?
A. Oral erythromycin
B. Oral doxycycline
C. Desensitization and penicillin
D. Intravenous erythromycin
E. Intravenous cefazolin Right Ans - This patient has syphilis, and the
fluorescent treponemal antibody absorption test (FTA-ABS) confirms the
diagnosis. The transmission rates for primary and secondary disease are
approximately 50-80%. *There are no proven alternatives to penicillin
therapy during pregnancy and penicillin G is the therapy of choice to treat
, syphilis in pregnancy*. Women with a history of penicillin allergy can be skin
tested to confirm the risk of immunoglobulin E (IgE)-mediated anaphylaxis. If
skin tests are reactive, *penicillin desensitization is recommended and is
followed by intramuscular benzathine penicillin G treatment*. Erythromycin
has an 11% failure rate. Doxycycline is contraindicated in pregnancy.
Cefazolin is commonly used to treat urinary tract infections and is not
effective in the treatment of syphillis.
A 34-year-old G1 woman at eight weeks gestation presents for prenatal care.
She is healthy and takes no medications. Family history reveals type 2
diabetes in her parents and brothers. She is 5 feet 2 inches tall and weighs 220
pounds (BMI 40.2 kg/m2). Which of the following is the best recommendation
to screen her for gestational diabetes?
A. Screen at 24-28 weeks with a 50-g oral glucose challenge test
B. Screen at 16-20 weeks with a 50-g oral glucose challenge test
C. Screen at 12 weeks with a 50-g oral glucose challenge test
D. Screen now with a 50-g oral glucose challenge test
E. Begin an oral hypoglycemic agent now Right Ans - D. Screening should
be performed between 24 and 28 weeks in those women not known to have
glucose intolerance earlier in pregnancy. This evaluation can be done in two
steps: a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral
glucose tolerance test (OGTT) if initial results exceed a predetermined plasma
glucose concentration. Patients at low risk are not routinely screened. For
those patients of *average risk screening is performed at 24-28 weeks* while
those at *high risk (severe obesity and strong family history) screening should
be done as soon as feasible*.
A 28-year-old G0 woman presents to your office for preconception counseling.
She has a history of type 1 diabetes, diagnosed at age six, and uses an insulin
pump for glycemic control. She has a history of proliferative retinopathy
treated with laser. Her last ophthalmologic examination was three months
ago. Her last hemoglobin A1C (glycosylated hemoglobin level) six months ago
was 9.2%. Which of the following complications is of most concern for her
planned pregnancy?
A. Fetal growth restriction
B. Fetal cardiac arrhythmia
C. Twins
D. Oligohydramnios
A 34-year-old G4P3 woman at 19 weeks gestation presents to the emergency
department with chest pain, palpitations and sweating, which began 2-3 hours
ago. On further questioning, she states that she has been very anxious lately
and is not sleeping well, which she attributes to the pregnancy. She reports
that she has lost 40 pounds in the last year without trying. She denies
significant medical problems. On exam, the patient appears diaphoretic and
anxious, her eyes are wide open, prominent, with easily visible sclera
surrounding the pupil. Vital signs are: temperature 100.2°F (37.9°C); pulse
132; and blood pressure 162/84. Her height is 5 feet 10 inches and weight is
128 pounds. Her thyroid is palpably enlarged, with an audible bruit.
Electrocardiogram shows sinus tachycardia. Remaining labs are pending.
Which of the following therapies is contraindicated at this time?
A. Radioactive iodine (I-131)
B. Propylthioura Right Ans - A. This patient is in thyroid storm, an acute,
life-threatening, hypermetabolic state. *Radioactive iodine (I-131)
concentrates in the fetal thyroid and may cause congenital hypothyroidism*,
so it should not be intentionally used in pregnancy. Acute treatment of thyroid
storm may include thioamides (i.e. PTU), propranolol, sodium iodide and
dexamethasone. Oxygen, digitalis, antipyretics and fluid replacement may also
be indicated. Maternal mortality with thyroid storm exceeds 25%.
An 18-year-old G1 woman presents for prenatal care at 16 weeks gestation
without complaints. The patient denies any history of sexually transmitted
disease, although admits to a history of multiple sex partners, with irregular
use of condoms. She is allergic to penicillin, which causes anaphylaxis.
Physical exam is unremarkable. Pertinent labs: rapid plasma reagin test (RPR)
positive (titer = 32); fluorescent treponemal antibody absorption test (FTA-
ABS) is positive. Which of the following is the best treatment for this patient?
A. Oral erythromycin
B. Oral doxycycline
C. Desensitization and penicillin
D. Intravenous erythromycin
E. Intravenous cefazolin Right Ans - This patient has syphilis, and the
fluorescent treponemal antibody absorption test (FTA-ABS) confirms the
diagnosis. The transmission rates for primary and secondary disease are
approximately 50-80%. *There are no proven alternatives to penicillin
therapy during pregnancy and penicillin G is the therapy of choice to treat
, syphilis in pregnancy*. Women with a history of penicillin allergy can be skin
tested to confirm the risk of immunoglobulin E (IgE)-mediated anaphylaxis. If
skin tests are reactive, *penicillin desensitization is recommended and is
followed by intramuscular benzathine penicillin G treatment*. Erythromycin
has an 11% failure rate. Doxycycline is contraindicated in pregnancy.
Cefazolin is commonly used to treat urinary tract infections and is not
effective in the treatment of syphillis.
A 34-year-old G1 woman at eight weeks gestation presents for prenatal care.
She is healthy and takes no medications. Family history reveals type 2
diabetes in her parents and brothers. She is 5 feet 2 inches tall and weighs 220
pounds (BMI 40.2 kg/m2). Which of the following is the best recommendation
to screen her for gestational diabetes?
A. Screen at 24-28 weeks with a 50-g oral glucose challenge test
B. Screen at 16-20 weeks with a 50-g oral glucose challenge test
C. Screen at 12 weeks with a 50-g oral glucose challenge test
D. Screen now with a 50-g oral glucose challenge test
E. Begin an oral hypoglycemic agent now Right Ans - D. Screening should
be performed between 24 and 28 weeks in those women not known to have
glucose intolerance earlier in pregnancy. This evaluation can be done in two
steps: a 50-g oral glucose challenge test is followed by a diagnostic 100-g oral
glucose tolerance test (OGTT) if initial results exceed a predetermined plasma
glucose concentration. Patients at low risk are not routinely screened. For
those patients of *average risk screening is performed at 24-28 weeks* while
those at *high risk (severe obesity and strong family history) screening should
be done as soon as feasible*.
A 28-year-old G0 woman presents to your office for preconception counseling.
She has a history of type 1 diabetes, diagnosed at age six, and uses an insulin
pump for glycemic control. She has a history of proliferative retinopathy
treated with laser. Her last ophthalmologic examination was three months
ago. Her last hemoglobin A1C (glycosylated hemoglobin level) six months ago
was 9.2%. Which of the following complications is of most concern for her
planned pregnancy?
A. Fetal growth restriction
B. Fetal cardiac arrhythmia
C. Twins
D. Oligohydramnios
