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OBGYN APGO UWise QUESTIONS AND
ANSWERS
An 18-year-old G1P0 woman is seen in the clinic for a routine prenatal visit at 28 weeks gestation. Her prenatal course has been unremarkable. She has not been taking prenatal vitamins. Her pre-pregnancy weight was 120 pounds. Initial hemoglobin at the first visit at eight weeks gestation was 12.3 g/dL. Current weight is 138 pounds. After performing a screening complete blood count (CBC), the results are notable for a white blood count 9,700/mL, hemoglobin 10.6 g/dL, mean corpuscular volume 88.2 fL (80.8 - 96.4) and platelets 215,000/mcL. The patient denies vaginal or rectal bleeding. Which of the following is the best explanation for this patient's anemia? A. Folate deficiency B. Relative hemodilution of pregnancy C. Iron deficiency D. Beta thalassemia trait
E. Alpha thalassemia trait - CORRECT ANSWER_ -B. Relative hemodilution of pregnancy
There is normally a 36% increase in maternal blood volume; the maximum is reached around 34 weeks. The plasma volume increases 47% and the RBC mass increases only 17%. This relative dilutional effect lowers the hemoglobin, but causes no change in the MCV. Folate deficiency results in a macrocytic anemia. Iron deficiency and thalassemias are associated with microcytic anemia. A 34-year-old G3P1 woman at 26 weeks gestation reports "difficulty catching her breath," especially after exertion for the last two months. She is a non-smoker. She does not have any history of pulmonary or cardiac disease. She denies fever, sputum, cough or any recent illnesses. On physical examination, her vital signs are: blood pressure 108/64, pulse 88, respiratory rate 15, and she is afebrile. Pulse oximeter is 98% on room air. Lungs are clear to auscultation. Heart is regular rate and rhythm with II/VI systolic murmur heard at the upper left sternal border. She has no lower extremity edema. A complete blood count reveals a hemoglobin of 10.0 g/dL. What is the most likely explanation for this woman's symptoms? A. Pulmonary embolism
B. Mitral valve stenosis C. Physiologic dyspnea of pregnancy D. Peripartum cardiomyopathy
E. Anemia - CORRECT ANSWER_ -C. Physiologic dyspnea of pregnancy
Physical examination findings are not consistent with pulmonary embolus (e.g tachycardia, tachypnea, hypoxia, chest pain, signs of a DVT) or mitral stenosis (diastolic murmur, signs of heart failure). Physiologic dyspnea of pregnancy is present in up to 75% of women by the third trimester. Peripartum cardiomyopathy is an idiopathic cardiomyopathy that presents with heart failure secondary to left ventricular systolic function towards the end of pregnancy or in the several months following delivery. Symptoms include fatigue, shortness of breath, palpitations, and edema. The history and physical do not suggest a pathologic process, nor does her hemoglobin level. A 24-year-old G4P2 woman at 34 weeks gestation complains of a cough and whitish sputum for the last three days. She reports that everyone in the family has been sick. She reports a high fever last night up to 102°F (38.9°C). She denies chest pain. She smokes a half-pack of cigarettes per day. She has a history of asthma with no previous intubations. She uses an albuterol inhaler, although she has not used it this week. Vital signs are: temperature 98.6°F (37°C); respiratory rate 16; pulse 94; blood pressure 114/78; peak expiratory flow rate 430 L/min (baseline documented in the outpatient chart = 425 L/min). On physical examination, pharyngeal mucosa is erythematous and injected. Lungs are clear to auscultation. White blood cell count 8,700; arterial blood gases on room air (normal ranges in parentheses): pH 7. (7.36 - 7.44); PO2 103 mm Hg (>100), PCO2 26 mm Hg (28 - 32), HCO3 19 mm Hg (22 - 26). Chest x-ray is
nor - CORRECT ANSWER_ -B. Compensated respiratory alkalosis
The increased minute ventilation during pregnancy causes a compensated respiratory alkalosis. Hypoventilation results in increased PCO2 and the PO2 would be decreased if she was hypoxic. A metabolic acidosis would have a decreased pH and a low HCO3. The patient's symptoms are most consistent with a viral upper respiratory infection. A 28-year-old G1P0 internal medicine resident at 34 weeks gestation wants to discuss the values on her pulmonary function tests performed two days ago because she was feeling slightly short of breath. She is a non-smoker, and has no personal or family history of cardiac or respiratory disease. Vital signs are: respiratory rate 16; pulse 90, blood pressure 112/70; oxygen saturation is 99% on room air. On physical
Lactated Ringers solution since admission. She is receiving magnesium sulfate and nifedipine. Vital signs are: 100.2°F (37.9°C); respiratory rate 24; heart rate 110; blood pressure 132/85; pulse oximetry is 97% on a non-rebreather mask. She appears in distress. Lungs reveal bibasilar crackles. Uterine contractions are regular every three minutes. The fetal heart rate is 140 beats/minute. Labs show white blood cell count 17,500/mL with 94% segmented neutrophils. Potassium and sodium are normal. Which of the following has most likely contributed to this patient's respiratory symptoms? A. Increased plasma osmolality B. Use of tocolytics C. Chorioamnionitis D. Preterm labor
E. Increased systemic vascular resistance - CORRECT ANSWER_ -B. Use of tocolytics
his patient has pulmonary edema. Plasma osmolality is decreased during pregnancy which increases the susceptibility to pulmonary edema. Common causes of acute pulmonary edema in pregnancy include tocolytic use, cardiac disease, fluid overload and preeclampsia. Use of multiple tocolytics increases the susceptibility of pulmonary edema, especially with the use of isotonic fluids. Systemic vascular resistance is decreased during pregnancy. Women with chorioamnionitis are also more likely to develop pulmonary edema, but this is not usually the main cause unless the patient is in septic shock and this patient does not have chorioamnionitis. A 25-year-old G1P0 woman is seen for an initial obstetrical appointment at eight weeks gestation. She has had a small ventricular septal defect (VSD) since birth. She has no surgical history and no limitations on her activity. Vital signs are: respiratory rate 12; heart rate 88; blood pressure 112/68. On physical examination: her skin appears normal; lungs are clear to auscultation; heart is a regular rate and rhythm. There is a grade IV/VI coarse pansystolic murmur at the left sternal border, with a thrill. Chest x-ray and ECG are normal. Which of the following is the correct statement regarding cardiovascular adaptation in this patient? A. Approximately 2% of women will normally have a diastolic murmur B. Maternal pulmonary vascular resistance is normally less than systemic vascular resistance C. The maternal cardiac output will increase up to 33% during pregnancy
D. Maternal systemic vascular resistance increa - CORRECT ANSWER_ -C. The maternal cardiac
output will increase up to 33% during pregnancy
The cardiac output increases up to 33% due to increases in both the heart rate and stroke volume. The SVR falls during pregnancy. Up to 95% of women will have a systolic murmur due to the increased volume. Diastolic murmurs are always abnormal. The systemic vascular resistance (SVR) is normally greater than the pulmonary vascular resistance. If the pulmonary vascular resistance exceeds the SVR, right to left shunt will develop in the setting of a VSD, and cyanosis will develop. A 17-year-old G1P0 woman at 32 weeks gestation complains of right flank pain that is "colicky" in nature and has been present for two weeks. She denies fever, dysuria and hematuria. Physical examination is notable for moderate right costovertebral angle tenderness. White blood cell count 8,800/mL, urine analysis negative. A renal ultrasound reveals no signs of urinary calculi, but there is moderate (15 mm) right hydronephrosis. Which of the following is the most likely cause of these findings? A. Smooth muscle relaxation due to declining levels of progesterone B. Smooth muscle relaxation due to increasing levels of estrogen C. Compression by the uterus and right ovarian vein D. Elevation of the bladder in the second trimester
E. Iliac artery compression of the ureter - CORRECT ANSWER_ -C. Compression by the uterus
and right ovarian vein Some degree of dilation in the ureters and renal pelvis occurs in the majority of pregnant women. The dilation is unequal (R > L) due to cushioning provided by the sigmoid colon to the left ureter and from greater compression of the right ureter due to dextrorotation of the uterus. The right ovarian vein complex, which is remarkably dilated during pregnancy, lies obliquely over the right ureter and may contribute significantly to right ureteral dilatation. High levels of progesterone likely have some effect but estrogen has no effect on the smooth muscle of the ureter. A 34-year-old G4P2 woman at 18 weeks gestation presents with fatigue and occasional headache. She has a sister with Grave's disease. On physical exam, vital signs are normal. BMI is 27. Thyroid is difficult to palpate due to her body habitus. The remainder of her exam is unremarkable. Thyroid function studies show: Results Reference Range
reveals heterogeneous cystic tissue in the uterus (snowstorm pattern). Which of the following is the most appropriate next step in the management of this patient? A. Repeat quantitative Beta-hCG
B. Repeat t - CORRECT ANSWER_ -D. Chest x-ray
Classic presentation for molar pregnancy
- BhCG 1mil (never this high in normal preg) CXR needed because gest. trophoblastic disease mets to lungs Afterwards, repeat BhCG weekly A 42-year-old G5P4 woman at eight weeks gestation presents for her first prenatal appointment. She has glycosuria noted on urine dipstick in the office. She has a history of four prior vaginal deliveries at full-term with birth weights ranging from 9 to 10.5 pounds. Family history is positive for type 2 diabetes in her mother and two siblings. Weight is 265 pounds and height is 5 feet 4 inches (BMI is 45.5 kg/m2). Which of the following recommendations concerning weight gain during this pregnancy is most appropriate? A. Maintain current weight B. Gain 11 - 20 pounds C. Gain 15 - 25 pounds D. Gain 25 - 35 pounds
E. Gain 28 - 40 pounds - CORRECT ANSWER_ -B. Gain 11 - 20 pounds
Recommended wt gain by BMI < 18.5 kg/m2 gains 28 - 40lb 18.5 - 24.9 kg/m2 gain 25 - 35 lb
25 - 29.9 kg/m2 gain 15 - 25 lb
30 kg/m2 gain 11 - 20 lb A 19-year-old G1P0 woman at 41-weeks gestation with two prior prenatal visits at 35-weeks and 40- weeks, presents in active labor. Review of available maternal labs shows: blood type O+; RPR non- reactive; HBsAg negative; and HIV negative. She delivers a small female infant who cries spontaneously. On examination, you find the infant has a slightly flattened nasal bridge. Her ears are small and slightly rotated. What is the most appropriate next step in the management of this patient? A. Tell the mother the infant will be fine B. Tell the mother that her newborn has Down syndrome C. Question the patient why an amniocentesis was not performed D. Further examine the infant for wide-spaced nipples and lymphedema
E. Further examine the infant for sandal gap toes and hypotonia - CORRECT ANSWER_ -E.
Further examine the infant for sandal gap toes and hypotonia A flattened nasal bridge, small size and small rotated, cup-shaped ears may be associated with Down syndrome and should prompt a survey looking specifically for other features seen with Down syndrome that include sandal gap toes, hypotonia, a protruding tongue, short broad hands, Simian creases, epicanthic folds, and oblique palpebral fissures. The initial physical findings may be a variant of normal, therefore, you should not share any concerns with the mother until you perform a detailed physical examination. Wide-spaced nipples and lymphedema are associated with Turner syndrome. It is not standard of care to offer amniocentesis to a 19-year-old, unless she has specific risk factors. A 37-year-old G3P1 woman presents with elevated blood pressure and 2+ proteinuria. She is 37 weeks gestation and the estimated fetal weight is 2500 grams. The patient is diagnosed with preeclampsia and is treated with MgS04. Magnesium level is 7.2 mEq/L. Maternal labs show: blood type B+; RPR non- reactive; HBsAg negative; HIV negative; and GBS negative. She is currently pushing during the second stage of labor and the delivery of the infant is imminent. What is the most likely complication to be encountered in this infant? A. Meconium aspiration syndrome B. Respiratory distress
C. Lethargic, pink with high temperature D. Lethargic, pale with low temperature
E. Lethargic, pale with high temperature - CORRECT ANSWER_ -E. Lethargic, pale with high
temperature This patient clearly has chorioamnionitis. The fetal tachycardia may be in response to the maternal fever. Fetal tachycardia coupled with minimal variability is a warning sign that the infant can be septic. A septic infant will typically appear pale, lethargic and have a high temperature. A 24-year-old G1P0 woman has just delivered 37 week male twins. On your initial assessment, you notice twin A is large and plethoric, and twin B is small and pale. A complete blood count (CBC) is obtained on both twins. What is the most likely finding in this case? A. Twin A is at high risk for polycythemia B. Twin A is at high risk for thrombocytopenia C. Twin B is at high risk for thrombocytopenia D. Twin B is at high risk for tachycardia
E. Twin B is at high risk for hyperbilirubinemia - CORRECT ANSWER_ -A. Twin A is at high risk
for polycythemia This case is suggestive of twin-twin transfusion syndrome (TTTS). Polycythemia is a common complication for the plethoric twin. TTTS is a complication of monochorionic pregnancies. It is characterized by an imbalance in the blood flow through communicating vessels across a shared placenta leading to under perfusion of the donor twin, which becomes anemic and over perfusion of the recipient, which becomes polycythemic. The donor twin often develops IUGR and oligohydramnios, and the recipient experiences volume overload and polyhydramnios that may lead to heart failure and hydrops. A 23-year-old G1P0 at 39 weeks gestation presents in spontaneous labor. Pregnancy was complicated by gestational diabetes. She delivers a 4200 gram infant with ruddy color and jitteriness. The infant is at immediate risk for which of the following conditions?
A. Hyperglycemia B. Anemia C. Thrombocytopenia D. Polycythemia
E. Hypercalcemia - CORRECT ANSWER_ -D. Polycythemia
Infants born to diabetic mothers are at increased risk for developing hypoglycemia, polycythemia, hyperbilirubinemia, hypocalcemia and respiratory distress. Thrombocytopenia is not a risk. A 25-year-old G6P2 woman in active labor is treated with mepiridine (Demerol). The patient reports the use of marijuana to control nausea during her pregnancy. She quickly progresses from 4 cm to fully dilated in 1 hour and is now pushing. A limp unresponsive infant is delivered. Heart rate is greater than 90 beats/minute. The infant has no respiratory effort. Which of the following is the most appropriate next step in the management of this patient? A. Give positive pressure ventilation and prepare to intubate B. Give positive pressure ventilation and prepare to give naloxone C. Give stimulation only and continue to monitor heart rate D. Suction thoroughly and check heart rate
E. Suction thoroughly and give naloxone - CORRECT ANSWER_ -A. Give positive pressure
ventilation and prepare to intubate You should give positive pressure ventilation and prepare to intubate the infant, if necessary. Any history of substance abuse may be a relative contraindication to the use of naloxone (Narcan) because the mother may have used narcotics during the pregnancy and administration of naloxone to the infant can cause life-threatening withdrawal. Stimulation may not be sufficient for this infant. Suction will not necessarily stimulate a respiratory effort.
ventilation in a newborn infant. It is important to also secure the mask to the infant's face and to observe an initial chest rise. A recommended rate of oxygen flow is 10 L/minu At one minute of life, an infant has a heart rate greater than 120 beats/minute, is crying, has acrocyanosis, gags when suctioned and is vigorously moving all four extremities. What is the APGAR score for this infant? A. 5 B. 6 C. 7 D. 8
E. 9 - CORRECT ANSWER_ -E. 9
Heart rate= 2, Respiratory rate= 2, Reflex = 2, Activity =2, Color =1. Therefore, the one-minute APGAR score is 9. A 28-year-old G2P1 woman presents at 20 weeks gestation for a routine prenatal care visit. This pregnancy has been complicated by scant vaginal bleeding at seven weeks and an abnormal maternal serum alpha fetoprotein (MSAFP), with increased risk for Down syndrome, but had a normal amniocentesis: 46, XX. Her previous obstetric history is significant for a Cesarean delivery at 34 weeks due to placental abruption and fetal distress. Prenatal labs at six weeks showed blood type A negative, antibody screen positive: anti-D 1:64. Which of the following is the most likely cause of the Rh sensitization? A. ABO incompatibility B. Placental abruption C. Amniocentesis D. Abnormal maternal serum alpha fetoprotein (MSAFP)
E. First trimester bleeding - CORRECT ANSWER_ -B. Placental abruption
This patient was sensitized during her first pregnancy that was complicated by abruption and required Cesarean delivery. Transplacental hemorrhage of fetal Rh-positive red blood cells into the circulation of the Rh-negative mother may occur following a number of obstetric procedures and complications, such as amniocentesis, chorionic villus sampling, spontaneous/threatened abortion, ectopic pregnancy, dilation and evacuation, placental abruption, antepartum hemorrhage, preeclampsia, cesarean section, manual removal of the placenta and external version. A 24-year-old Rh-negative G1P1 woman just delivered a healthy term infant who is Rh-positive. You recommend RhoGAM administration but she declines because she does not desire any blood products. What is her approximate risk of isoimmunization if she does not receive the RhoGAM? A. Less than 20% B. 40% C. 60% D. 80%
E. 100% - CORRECT ANSWER_ -A. Less than 20%
While 75% of all gravidas have evidence of transplacental hemorrhage during pregnancy or immediately after delivery, 60% of these patients have <0.1 cc of fetal blood in the maternal circulation, which is enough to sensitize a patient. The incidence and size of transplacental hemorrhage increases as pregnancy advances. During the second month of gestation, 5-15% of women will have evidence of feto- maternal hemorrhage. By the third trimester, this number increases to 45% of patients. The risk of isoimmunization is 2% antepartum, 7% after full term delivery, and 7% with subsequent pregnancy. A 24-year-old Rh-negative G2P1 woman at 18 weeks gestation is positive for anti-D antibodies. In discussing the risks of Rh sensitization with her, you tell her that her fetus may be at increased risk of significant perinatal disease including fetal anemia. Which of the following non-invasive tests can detect severe fetal anemia? A. Umbilical artery systolic-diastolic ratio B. Biophysical profile C. Amniotic fluid index D. Umbilical artery blood flow
B. 20 cc C. 30 cc D. 40 cc
E. 50 cc - CORRECT ANSWER_ -C. 30 cc
30 cc of fetal blood is neutralized by the 300 micrograms dose of RhoGAM. This is equivalent to 15 cc of fetal red blood cells. At 28-weeks gestation, 300 micrograms of Rh-immune globulin is routinely administered after testing for sensitization with an indirect Coombs' test. Administration is given following amniocentesis at any gestational age. A 28-year-old Rh negative G1P0 woman at eight weeks gestation presents to the clinic for a first prenatal visit. Which of the following is the current recommendation for RhoGAM administration to prevent Rh isoimmunization? A. Routine administration for every Rh-sensitized woman at term B. Administration for Rh-negative patients with no Rh antibodies at 28 weeks C. Administration for every Rh-negative woman who delivers an Rh-negative infant D. Routine administration for all Rh-negative patients during first trimester
E. Routine administration for all Rh-negative patients during each trimester - CORRECT
ANSWER_ -B. Administration for Rh-negative patients with no Rh antibodies at 28 weeks
RhoGAM (Anti-D-immunoglobulin) is administered to Rh-negative women to prevent isoimmunization. Each dose provides 300 micrograms of D-antibody and is given to the D-negative non-sensitized mother to prevent sensitization after any pregnancy-related events that could result in fetal-maternal hemorrhage. Up to 2 percent of women with a spontaneous abortion and 5 percent of those undergoing elective termination become isoimmunized without D-immunoglobulin. The current recommendations for Rh-negative women without evidence of Rh immunization is prophylactically at 28-weeks gestation (after an indirect Coombs' test) and within 72 hours of delivering an Rh-positive baby, following spontaneous or induced abortion, following antepartum hemorrhage and following amniocentesis or chorionic villus sampling. If the father of the fetus is known to be Rh-negative, RhoGAM is not necessary, since the fetus will be Rh-negative and not at risk for hemolytic disease.
A 24-year-old G1P0 woman presents at 32 weeks gestation with vaginal bleeding due to placental abruption. What is the most appropriate method to determine the correct RhoGAM dose to give to the patient? A. Determine delta OD 450 (optical density) B. Measure fetal hemoglobin levels C. Perform a Kleihauer-Betke test D. Measure maternal hemoglobin levels
E. Administer routine dose of RhoGAM at time of incident - CORRECT ANSWER_ -C. Perform a
Kleihauer-Betke test The routine dose of RhoGAM neutralizes 30 cc of fetal blood. The Kleihauer-Betke test is an accurate and sensitive acid elution test. It has great value in determining the incidence and size of fetal transplacental hemorrhage. In this test, using acid elution, the mother's red blood cells become very pale, while fetal cells, which contain a different form of hemoglobin, remain stained. Simple comparative counts allow an estimate of whether a significant fetal maternal transfusion has occurred. A 24-year-old G2P1 woman is diagnosed with Rh hemolytic disease at 24 weeks gestation. Measurement of which of the following in the amniotic fluid is best indicative of the severity of the disease? A. Hemoglobin B. Iron C. Anti-D antibody titer D. Glucose
E. Bilirubin - CORRECT ANSWER_ -E. Bilirubin
In the presence of a severely erythroblastotic fetus, the amniotic fluid is stained yellow. The yellow pigment is bilirubin, which can be quantified most accurately by spectrophotometric measurements of the optical density between 420 and 460nm, the wavelength absorbed by bilirubin. The deviation from linearity of the optical density reading at 450nm is due to the presence of heme pigment, an indicator of severe hemolysis.
n rare occasion, an Rh-negative woman will subsequently be sensitized, despite prophylaxis. The protection afforded by a standard RhoGAM administration is dose-dependent. One dose will prevent Rh sensitization to an exposure of as much as 30 cc of Rh-positive red blood cells. With greater exposure, there is only partial protection and Rh sensitization may occur as a result of failure to diagnose massive transplacental hemorrhage. Alternatively, an Rh-negative woman may be sensitized in the latter part of pregnancy or soon after delivery before the post-delivery prophylaxis dose is given. Inadvertent maternal transfusion of Rh-positive blood may result in Rh sensitization to the D or another red blood cell antigen. Patients may become sensitized if they do not receive RhoGAM following an episode of antenatal bleeding or after an invasive procedure, such as amniocentesis or chorionic villus sampling. In addition, RhoGAM only confers protection against the D antigen. Therefore, despite administration of RhoGAM to Rh-negative patients, they may still become sensitized to other red blood cell antigens. Pregnancy spacing does not affect the presence of the antibody. A 24-year-old G4P0 presents to your office at seven weeks gestation after two days of bleeding and cramping. She thinks that she miscarried at home and did not bring in the tissue for pathologic evaluation. What is the karyotype most likely to be found on chromosomal analysis? A. Turner Syndrome (45, X) B. Autosomal Trisomy C. Monoploidy D. Triploidy
E. Tetraploidy - CORRECT ANSWER_ -B. Autosomal Trisomy
Autosomal trisomy is the most common abnormal karyotype encountered in spontaneous abortuses, accounting for approximately 40-50% of cases. The most common chromosomal aneuploidy noted in abortuses is Trisomy 16. Triploidy accounts for approximately 15%, and tetraploidy for 5% of cases. Monosomy X (45X, 0) is seen in 15-25% of losses. A 34-year-old G1 is in a motor vehicle accident. While in the emergency department, the doctors order multiple x-rays to evaluate her injuries. At what gestational age would the fetus be most susceptible to developing mental retardation with sufficient doses of radiation? A. 0-7 weeks B. 8-15 weeks
C. 16-25 weeks D. 26-30 weeks
E. 31-35 weeks - CORRECT ANSWER_ -8-15 weeks
A 21-year-old G1 presents to labor and delivery at 39 weeks gestation with a chief complaint of decreased fetal movement over the last two days. An ultrasound shows a fetus with biometry consistent with 34 weeks gestation with no cardiac activity. The head circumference and biparietal diameter are consistent with 37 weeks and the abdominal circumference, femur and humerus lengths are all lagging by approximately five weeks. The amniotic fluid volume is slightly decreased. No other abnormalities are identified. The patient's medical history is notable for a deep venous thrombosis which she had three years ago while she was using oral contraceptives. She had a reassuring quad screen. She denies any history of fever or viral illnesses during the pregnancy. She works as a preschool teacher. The patient had a fetal ultrasound at 20 weeks gestation. At that time all of the fetal anatomy was well-visualized
and no abnormali - CORRECT ANSWER_ -E. Factor V Leiden mutation
This patient is most likely to have the autosomal dominant Factor V Leiden (FVL) mutation based on her history. FVL is the most common inherited thrombophilic disorder affecting approximately 5% of Caucasian women in the United States. It is a point mutation which alters factor V making it resistant to inactivation by protein C. The thrombophilic effect of a FVL mutation has been clearly established. Heterozygosity for FVL is associated with a five to ten-fold increased risk of thrombosis, while homozygosity is associated with an 80-fold increased risk. The FVL mutation is associated with obstetric complications including stillbirth, preeclampsia, placental abruption and IUGR. Fetuses with Trisomy 18 are likely to have congenital anomalies that are detectable on prenatal ultrasound. Over 90% of cases of trisomy 18 may be detected with the quad screen. A congenital parvovirus infection associated with a fetal demise would likely cause hydrops in the fetus which would be identified on ultrasound. Although poorly controlled diabetes mellitus and cord accidents are associated with fetal demise, they are not the most likely etiologies in this patient whose presentation is classic for the FVL mutation. A 39-year-old G4P1 at 36 weeks gestation presents to labor and delivery. Upon initial evaluation, no fetal heart tones were noted on Doptone. Ultrasound confirms a stillbirth. Problems during the pregnancy include diagnosis of an open neural tube defect, estimated fetal weight >90th percentile, polyhydramnios and a nonreactive NST (non-stress test) the week prior to admission. What is the most likely etiology of this stillbirth? A. Uncontrolled hypertension
