ACOG Questions Review With Complete
Solutions
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
E. Macrosomia The patient with type 1 diabetes is at risk for many pregnancy
complications. In women with insulin-dependent diabetes, the rates of spontaneous abortion and
major congenital malformations are both increased. The risk appears related to the degree of
metabolic control in the first trimester. Overt diabetic patients are also at an increased risk for
fetal growth restriction, although fetal macrosomia may also occur. The former becomes a
greater concern as in this patient, with longer-term diabetes and vascular complications, such as
retinopathy. Diabetics also have increased risk for polyhydramnios, congenital malformations
(cardiovascular, neural tube defects, and caudal regression syndrome), preterm birth and
hypertensive complications. Her diabetes does place her at an increased for twins.
, A 24-year-old G2P1 woman has a fetus that is affected by Rh disease. At 30 weeks gestation, the
delta OD450 (optical density deviation at 450 nm) results plot on the Liley curve in Zone 3,
indicating severe hemolytic disease. Which of the following is the most appropriate next step in
the management of this patient?
A. Immediate Cesarean delivery
B. Induction of labor
C. Intrauterine intravascular fetal transfusion
D. Umbilical blood sampling
E. Maternal plasmapheresis Correct answer is C. Values in Zone 3 of the Liley curve
indicate the presence of severe hemolytic disease, with hydrops and fetal death likely within 7-10
days, thus demanding immediate delivery or fetal transfusion. At 30 weeks gestation, the fetus
would benefit from more time in utero. An attempt should be made to correct the underlying
anemia. Intravascular transfusion into the umbilical vein is the preferred method. Intraperitoneal
transfusion is used when intravascular transfusion is technically impossible. If fetal hydrops is
present, the reversal of the fetal anemia occurs much more slowly via intraperitoneal transfusion.
Percutaneous umbilical blood sampling should not be used as a first-line method to evaluate fetal
status. Maternal plasmapheresis is used in severe disease when intrauterine transfusions are not
possible.
Solutions
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
E. Macrosomia The patient with type 1 diabetes is at risk for many pregnancy
complications. In women with insulin-dependent diabetes, the rates of spontaneous abortion and
major congenital malformations are both increased. The risk appears related to the degree of
metabolic control in the first trimester. Overt diabetic patients are also at an increased risk for
fetal growth restriction, although fetal macrosomia may also occur. The former becomes a
greater concern as in this patient, with longer-term diabetes and vascular complications, such as
retinopathy. Diabetics also have increased risk for polyhydramnios, congenital malformations
(cardiovascular, neural tube defects, and caudal regression syndrome), preterm birth and
hypertensive complications. Her diabetes does place her at an increased for twins.
, A 24-year-old G2P1 woman has a fetus that is affected by Rh disease. At 30 weeks gestation, the
delta OD450 (optical density deviation at 450 nm) results plot on the Liley curve in Zone 3,
indicating severe hemolytic disease. Which of the following is the most appropriate next step in
the management of this patient?
A. Immediate Cesarean delivery
B. Induction of labor
C. Intrauterine intravascular fetal transfusion
D. Umbilical blood sampling
E. Maternal plasmapheresis Correct answer is C. Values in Zone 3 of the Liley curve
indicate the presence of severe hemolytic disease, with hydrops and fetal death likely within 7-10
days, thus demanding immediate delivery or fetal transfusion. At 30 weeks gestation, the fetus
would benefit from more time in utero. An attempt should be made to correct the underlying
anemia. Intravascular transfusion into the umbilical vein is the preferred method. Intraperitoneal
transfusion is used when intravascular transfusion is technically impossible. If fetal hydrops is
present, the reversal of the fetal anemia occurs much more slowly via intraperitoneal transfusion.
Percutaneous umbilical blood sampling should not be used as a first-line method to evaluate fetal
status. Maternal plasmapheresis is used in severe disease when intrauterine transfusions are not
possible.
