Despite the fact that this question includes many true-false options, the knowledge examined is particularly essential in the treatment of women who have genital herpes.
It answers many of the questions that such women have regarding the disease, how it spreads, how it may be controlled, and how it affects an unborn or recently born child.
All of these issues must be addressed in a counselling question.
Currently, the most prevalent type of genital herpes is type 1, while in the past, type 2 was more common, as confirmed by serology testing.
Type 2 illness is nearly always contracted through sexual contact, but it can go undetected for years.
Acyclovir can be taken during pregnancy, and there are particular reasons for its usage.
Neonatal herpes is most usually diagnosed when the newborn has no cutaneous lesions, and past genital herpes in the mother is protective against neonatal infection, although not always.
Where the genital infection is the initial sign of the disease rather than a relapse of earlier disease, neonatal herpes is far more frequent.
Many patients and doctors are unaware that, while the original infection might be deadly, it is usually asymptomatic.
This explains how the illness spreads between sexual partners when neither has had any previous symptoms of the disease.

This woman who is 26 weeks pregnant, has come in contact with a child having chickenpox 48 hours ago. As her IgG antibodies were negative during prenatal testing, she has no immunity against Varicella which makes her susceptible to get chickenpox.

Prophylactic treatment is required if a susceptible pregnant woman is exposed to chickenpox, which includes administration of varicella zoster immune globulin (VZIG), within 72 hours of exposure to infection.

As the patient has already checked for and was found to be negative, checking IgG level again is not relevant. Also, it was already revealed that she is not vaccinated against varicella before pregnancy.

If the patient had any symptoms typical of chickenpox, measuring IgM would have been helpful, but patient is completely asymptomatic in this case so measuring IgM is not indicated.

Vaccine for chickenpox is contraindicated during pregnancy as it is a live vaccine.

Second-trimester ultrasound markers have low sensitivity and specificity for detecting Down syndrome, especially in a low-risk population.

The highest detection rate is acquired with ultrasound markers combined with gross anomalies. Although the detection rate with this combination of markers is high in a high-risk population (50 to 75 percent), false-positive rates are also high (22 percent for a 100 percent Down syndrome detection rate).

Cord entanglement, a condition unique to MoMo pregnancies, occurs in 42 to 80% of the cases and it has been traditionally related to high perinatal mortality. Umbilical cord entanglement is present in all monoamniotic twins when it is systematically evaluated by ultrasound and colour Doppler. Perinatal mortality in monoamniotic twins is mainly a consequence of conjoined twins, twin reversed arterial perfusion (TRAP), discordant anomaly and spontaneous miscarriage before 20 weeks’ gestation. Expectantly managed monoamniotic twins after 20 weeks have a very good prognosis despite the finding of cord entanglement. The practice of elective very preterm delivery or other interventions to prevent cord accidents in monoamniotic twins should be re-evaluated.

An ultrasonography is performed for confirmation, as well as for the evaluation of maternal pelvis, fetal size and viability in cases were breech presentation is suspected on manual examination. As there is a chance for spontaneous correction of breech presentation into cephalic during 36 to 37 weeks, this should be considered in every future visit. The chances for spontaneous version reduces to 25% if breech position persists beyond this period of time.

It an external cephalic version should be offered to all women with breech presentation, provided there are no contraindications or indication for cesarean delivery due to other reasons.

The best antibiotic of choice for empirical treatment of a urinary tract infection (UTI) during pregnancy is cephalexin. Nitrofurantoin and amoxicillin-clavulanate are second and third in-line respectively.
Patients allergic to penicillin, which is manifested as a rash can also be safely treated with cephalexin. But cephalosporins are not recommended if the presentation of allergic reaction to penicillin was anaphylactic, instead they should be treated with nitrofurantoin.

NOTE– Asymptomatic bacteriuria, such as >10 to power of 5 colony count in urine culture of an asymptomatic woman in pregnancy, should best be treated with a one week course of antibiotics, followed by confirming the resolution of infection via a urine culture repeated 48 hours after the completion of treatment.

Amoxicillin without clavulanate is recommended only in cases were the susceptibility of the organism is proven.

Macrolides like clarithromycin are usually not recommended for the treatment of UTI.

Aminoglycosides are coming under category D drugs should be avoided during pregnancy, unless there is a severe indication of gram negative sepsis.

Tetracycline, due to their potential teratogenic effects, are contraindicated in pregnancy.

Urologic injury is the most common injury at the time of either obstetric or gynaecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during caesarean section include previous caesarean delivery, adhesions, emergency caesarean delivery, and caesarean section performed during the second stage of labour.

Antiphospholipid syndrome is the most important treatable cause of recurrent miscarriage. The mechanisms by which antiphospholipid antibodies cause pregnancy morbidity include inhibition of trophoblastic function and differentiation, activation of complement pathways at the maternal–fetal interface, resulting in a local inflammatory response and, in later pregnancy, thrombosis of the uteroplacental vasculature. This patient should be offered referral to a specialist clinic as she has had recurrent miscarriages. Low dose aspirin is one of the treatment options to prevent further miscarriage for patients with antiphospholipid syndrome.

In this case, the patient has a missed abortion, which is defined as a dead foetus or embryo without passage of tissue and with a closed cervix. This condition often presents with failure to detect fetal heart tones or a lack of growth in uterine size.

– By 14 weeks estimated gestational age, fetal heart tones should be detected by both handheld Doppler and ultrasonography.
– An inevitable abortion presents with a dilated cervix, but no passage of fetal tissue.
– A blighted ovum involves failure of the embryo to develop, despite the presence of a gestational sac and placental tissue.

Fetal heart rate tracings (FHR) under category I include all of the following:
– baseline rate 110– 160 bpm
– baseline FHR variability moderate
– accelerations present or absent
– late or variable decelerations absent
– early decelerations present or absent

The onset of fetal bleeding is marked by a tachycardia followed by a bradycardia with intermittent accelerations or decelerations. Small amounts of vaginal bleeding associated with FHR abnormalities should raise the suspicion of fetal haemorrhage. This condition demands prompt delivery and immediate reexpansion of the neonatal blood volume.

Nutrition in pregnancy
Weight gain must be:
– In patients <18.5 kg/m2, there should be an increase of 12.7 - 18 kg (28-40 lb)
– In patients 18.5 – 24.9 kg/m2 there should be an increase of 11.4 – 15.9 kg (25-35 lb)
– In patients 25 – 29.9 kg/m2 there should be an increase of 6.8 – 11.4 kg (15-25 lb)
– In patients ≥30 kg/m2 there should be an increase of 5 – 9 kg (11-20 lb)

Supplementation required:
– Intake of daily prenatal vitamin
– Additional specific supplements as indicated
– Avoidance of harmful substances like drugs, alcohol, etc
– Substance abuse counseling
– Avoidance of fish with high mercury levels
– Moderating caffeine intake

Food safety:
– Avoid undercooked meat, fish & eggs
– Clean raw fruits & vegetables before consuming
– Avoid unpasteurized dairy products

Nutrition in pregnancy is addressed at the initial prenatal visit based on pre-pregnancy BMI. Appropriate weight gain for a women with a normal pre-pregnancy BMI of 18.5 – 24.9 kg/m2 should be 11.4 – 15.9 kg (25-35 lb) during pregnancy. This weight gain is equivalent to the increasing caloric intake of 350 kcal/day during the second and 450 kcal/day during the third trimesters.  Patients following any specific diets like veganism can continue their usual diet throughout pregnancy as long as it contains a well-balanced quantity of protein, carbohydrates and fats.

Vitamin and mineral supplementation during pregnancy is a single, daily prenatal vitamin recommended for majority of pregnant women as it helps to fulfill most of the daily vitamin and mineral supplementation requirements. In case of patients with vitamin or mineral deficiencies like iron, calcium, etc, a specific supplementation of the deficit vitamin/mineral only is required rather than multiple prenatal vitamins to avoid consuming harmful amounts of other vitamins like vitamin A.  Vegans, who are at risk for some vitamin and mineral deficiencies like vitamin B12, calcium, iron, etc, secondary to lack of meat consumption, may require supplementation.

Pregnant women are counselled on avoidance of harmful substances like alcohol, drugs, etc and substances like fish with high mercury levels.  Although high caffeine intake during pregnancy can be harmful, a moderate intake ie, 1 or 2 cups of coffee a day is thought to be safe.

Safe handling of food is important because some food products are found to result in congenital infection and intrauterine fetal demise. Patients are also counselled to avoid undercooked meat, fish, and eggs; to thoroughly clean raw fruits and vegetables and to avoid consumption of unpasteurized dairy products.

By maintaining a proper maternal nutrition during pregnancy, patients are provide appropriate nutrition to the fetal and thereby reducing the risk of pregnancy related complications like low birth weight, preterm delivery, etc.

Pregnant patients are counseled to avoid exercises like contact sports, downhill skiing, etc which increases the risk of abdominal trauma resulting in increased risk of placental abruption. But those patients with an uncomplicated pregnancy, who are already accustomed with long-duration, high-intensity exercise like running 5 miles/day, as in the given case, can continue with their regimen if tolerated.

Proper nutrition in pregnancy includes appropriate weight gain, supplementation of vitamins and minerals, avoidance of any harmful substances, and safe handling of food. Patients with a normal pre-pregnancy BMI should gain around 11.4-15.9 kg (25-35 lb) during pregnancy by increasing their caloric intake by 350 kcal/day in the second and 450 kcal/day in the third trimesters.

This patient most likely has preeclampsia, which is defined as an elevated blood pressure and proteinuria after 20 weeks gestation. The patient needs further evaluation, including a 24-hour urine for quantitative measurement of protein, blood pressure monitoring, and laboratory evaluation that includes haemoglobin, haematocrit, a platelet count, and serum levels of transaminase, creatinine, albumin, LDH, and uric acid- A peripheral smear and coagulation profiles also may be obtained- Antepartum fetal testing, such as a nonstress test to assess fetal well-being, would also be appropriate.

→ Ultrasonography should be done to assess for fetal intrauterine growth restriction, but only after an initial laboratory and fetal evaluation.
→ It is not necessary to start this patient on antihypertensive therapy at this point. An obstetric consultation should be considered for patients with preeclampsia.
→ Delivery is the definitive treatment for preeclampsia- The timing of delivery is determined by the gestational age of the foetus and the severity of preeclampsia in the mother. Vaginal delivery is preferred over caesarean delivery, if possible, in patients with preeclampsia.

Analysis of presentation shows the patient has developed hyperemesis gravidarum.
She is in early shock, presented as sinus tachycardia and hypotension, with ketonuria and requires immediate fluid resuscitation and anti-emetics. The first line fluid of choice is administration of normal saline 0.9%, and should avoid giving dextrose containing fluids as they can precipitate encephalopathy and worsens hyponatremia.

The most appropriate management of a pregnant patient in this situation is administration of metoclopramide as the first line and Ondansetron as second line antiemetic, which are Australian category A and B1 drugs respectively. The following also should be considered and monitored for:
1. More refractory vomiting.
2. Failure to improve.
3. Recurrent hospital admissions.

Steroids like prednisolone are third line medications which are used in resistant cases of hyperemesis gravidarum after proper consultation.

Group B Streptococcus (GBS) or Streptococcus agalactiae is a Gram-positive bacteria which colonizes the gastrointestinal and genitourinary tract. In the United States of America, GBS is known to be the most common infectious cause of morbidity and mortality in neonates. GBS is known to cause both early onset and late onset infections in neonates, but current interventions are only effective in the prevention of early-onset disease.

The main risk factor for early-onset GBS infection is colonization of the maternal genital tract with Group B Streptococcus during labour. GBS is a normal flora of the gastrointestinal (GI) tract, which is thought to be the main source for maternal colonization.

The principal route of neonatal early onset GBS infection is vertical transmission from colonized mothers during passage through the vagina during labour and delivery.

Intravenous penicillin G is the treatment of choice for intrapartum antibiotic prophylaxis against Group B Streptococcus.

Incidental thrombocytopenia of pregnancy is the most common cause of thrombocytopenia in an otherwise uncomplicated pregnancy. The platelet count finding in this case is of little concern unless it falls below 50×109/L.

Immune thrombocytopenia is a less common cause of thrombocytopenia in pregnancy. The anti-platelet antibodies cam cross the placenta and pose a problem both to the mother and the foetus. Profound thrombocytopenia in the baby is a common finding of this condition.

Thrombocytopenia can occur in patients with severe pre-eclampsia. However, it is usually seen concurrent with other signs of severe disease.

Maternal antibodies that target the baby’s platelets can rarely cause thrombocytopenia in the mother. Instead, it can lead to severe coagulation and bleeding complications in the baby as a result of profound thrombocytopenia.

Systemic lupus erythematosus is unlikely to explain the thrombocytopenia in this patient.

This patient is presenting with a low-lying placenta at 18 weeks of gestation. This is a common finding on ultrasound at 18-20 weeks. If there is not bleeding, there is an 80-90% chance that by late pregnancy, the placenta will have moved and is no longer occupying the lower uterine segment. For this reason, the repeat ultrasound examination is usually performed at 32-34 weeks of gestation. Further discussions about management can then be made after obtaining those results.

Leaving the repeat ultrasound until term would be inappropriate as intervention would be needed prior. If the placenta praevia is still present, it is typically advisable to deliver prior to term.

Cardiotocographic (CT) fetal heart rate monitoring is not required in the absence of bleeding or other symptoms.

Delivery by Caesarean section would not be necessary if the placenta was no longer praevia by the time the repeat ultrasound is done.

Repeat ultrasound examination at 22 weeks of gestation would also unnecessary and inappropriate as it is too close in time for the change to occur.

The presentation is antepartum haemorrhage. Ultrasound should be performed to find the reason for bleeding and assess the fetal well being.

Rubella infection during pregnancy may lead to miscarriage, intrauterine fetal demise, premature labour, intrauterine growth retardation, and congenital rubella syndrome. The risk of developing complications is highest if the infection is contracted within the first 12 weeks of gestation.

In those cases in which a pregnant woman has been exposed to a suspected rubella case, a specimen of blood should be tested as soon as possible for the measurement of rubella-specific IgG antibodies. If it is positive, then the woman was likely to be immune and could be reassured. If it is negative, a determination rubella-specific IgG and rubella-specific IgM antibodies should be obtained in 3 weeks to exclude an asymptomatic primary rubella infection.

CDC urges all women of reproductive age to take 400 micrograms (mcg) of folic acid each day, in addition to consuming food with folate from a varied diet, to help prevent some major birth defects of the baby’s brain (anencephaly) and spine (spina bifida).

Women who are at high risk of having babies with neural tube defects and who would benefit from higher doses of folic acid include those with certain folate-enzyme genotypes, previous pregnancies with neural tube defects, diabetes, malabsorption disorders, or obesity, or those who take antifolate medications or smoke. Such women should take 5 mg/d of folic acid for the 2 months before conception and during the first trimester.

Twin pregnancy is associated with a number of obstetric complications, some of them with serious perinatal consequences, especially for the second twin. The rate of perinatal mortality can be up to six times higher in twin compared to singleton pregnancies, largely due to higher rates of preterm delivery and fetal growth restriction seen in twin pregnancies. Preterm birth and birth weight are also significant determinants of morbidity and mortality into infancy and childhood. More than 50% of twins and almost all triplets are born before 37 weeks of gestation and about 15–20% of admissions to neonatal units are associated with preterm twins and triplets.

Nuchal translucency scans and maternal screening tests simply aid in determining a risk percentage for the presence of Trisomy 21, but an accurate diagnosis cannot be reached.

Chorionic villous biopsy (CVB), amniocentesis, and cordocentesis, are all prenatal diagnostic tests that can provide a definitive diagnosis regarding the presence of foetal abnormalities.

Amniocentesis performed at 16 weeks of gestation is associated with the lowest risk for miscarriage and hence is the safest test and should be recommended to the mother (correct answer).

The miscarriage risk from a CVB is at least double the risk following amniocentesis.

Nowadays, cordocentesis is rarely used for sampling of foetal material to detect chromosomal abnormalities as the test poses an even higher risk of miscarriage compared to the other procedures discussed above.

If a mother has been abusing drugs during antenatal period, there are some contraindications to discharge her baby home. These conditions includes:
– excessive weight loss, which is greater than ten percent of birth weigh
– suspected baby neglect or abuse
– suspected domestic violence
– a court order preventing baby from being discharged home or if there is requirement for further assessment of withdrawal symptoms.

A 2-3 percentages weight loss during the early neonatal period is considered to be a normal finding and is therefore not considered as a contraindication to discharge the baby home.

Small teeth with faulty enamel is more associated with fetal alcohol syndrome (FAS).

In FAS, the most common orofacial changes are small eyelid fissures , flat facies, maxillary hypoplasia, short nose, long and hypoplastic nasal filter, and thin upper lip. The unique facial appearance of FAS patients is the result of changes in 4 areas: short palpebral fissures, flat nasal bridge with an upturned nasal tip, hypoplastic philtrum with a thin upper vermillion border, and a flat midface. Other facial anomalies include micrognathia, occasional cleft lip and/or palate and small teeth with defective enamel.

Maternal hypothyroidism which is usually treated with thyroxine is not a contraindication for suppression of labour.
Suppression of labour known as tocolysis is contraindicated in situations like suspected foetal compromise, which is diagnosed by cardiotocograph warranting delivery, in cases of placental abruption, in chorioamnionitis, in severe pre-eclampsia, cases were gestational age is more than 34 weeks, in cases of foetal death in utero and in cases where palliative care is planned due to foetal malformations.

Woman in the given case is taking a full bottle of Whisky every day. As per standards, a small glass of Whisky (1.5 Oz) is equivalent of a standard drink and a bottle definitely exceeds 12 standard drinks. This makes her fetus at significant risk for fetal alcohol syndrome (FAS) which is associated with many congenital malformations. Low-set ears, midfacial hypoplasia, elongated philtrum, upturned nose and microcephaly along with skeletal and cardiac malformations are the congenital malformations commonly associated with fetal alcohol syndrome.

Health risks of benzodiazepines during pregnancy has not been clearly established, but there are inconsistent reports of teratogenic effects associated with fetal exposure to benzodiazepines. Neonatal abstinence syndrome of delayed onset can be associated with regular use of benzodiazepine in pregnancy.

Use of Amphetamine in controlled doses during pregnancy is unlikely to pose a substantial teratogenic risk, but a range of obstetric complications such as reduced birth weight and many these outcomes which are not specific to amphetamines but influenced by use of other drug and lifestyle factors in addition to amphetamine are found commonly among women who use it during pregnancy. Exposure to amphetamines in utero may influence prenatal brain development, but the nature of this influence and its potential clinical significance are not well established.

3,4- methylenedioxymetham phetamine(MOMA), which is an amphetamine derivative and commonly known as ecstasy, have existing evidences suggesting that its use during first trimester poses a potential teratogenic risk. So it is strongly recommended to avoided the use of ecstasy during 2-8 weeks post conception or between weeks four to ten after last menstrual period as these are the considered periods of organogenesis.

Role of cocaine in congenital malformations is controversial as cases reported of malformations caused by cocaine are extremely rare. However, it may lead to fetal intracranial haemorrhage leading to a devastating outcome.

Opiate addictions carry a significant risk for several perinatal complications, but it has no proven association with congenital malformation.

Thyroid disease is the second most common endocrine disorder after diabetes in pregnancy. Thyroid disease poses a substantial challenge on the physiology of pregnant women and has significant maternal and fetal implications. Research shows during pregnancy, the size of the thyroid gland increases by 10% in countries with adequate iodine stores and by approximately 20% to 40% in countries with iodine deficiency. During pregnancy, thyroid hormone production increases by around 50% along with a similar increase in total daily iodine requirements.

The different changes occurring in thyroid physiology are as follow:
– An increase in serum thyroxine-binding globulin (TBG) leading to an increase in the total T4 and total T3 concentrations
– Stimulation of the thyrotropin (TSH) receptor by human chorionic gonadotropin (hCG) which increases thyroid hormone production and subsequently reduces serum TSH concentration.

Therefore, compared to the non-pregnant state, women tend to have lower serum TSH concentrations during pregnancy.
The need to adjust levothyroxine dose manifests itself as early as at 4-8 weeks of gestation, therefore justifying the adjustment of levothyroxine replacement to ensure that maternal euthyroidism is maintained during early gestation. Most of well-controlled hypothyroid pregnant women need increased dosage of thyroid hormone after pregnancy.

Patient’s symptoms and signs are suggestive of round ligament strain, which is a normal finding during pregnancy, especially in the 2nd trimester, and it does not require any medical intervention.

Round ligament is a rope-like fibromuscular band which extends from the anterolateral aspect of uterus anteriorly between the layers of the broad ligament, and passing through the deep inguinal ring into the inguinal canal.
A sharp, sudden spasm in the right iliac fossa which lasts for a few seconds which is usually triggered by sneezing, coughing, laughing and rolling over in bed are the common presentations of a round ligament pain.

Ectopic pregnancy and rupture of ectopic pregnancy are two unlikely diagnosis in this patient as she is in the second trimester of her pregnancy, whereas both the mentioned conditions occur during the first trimester.

Although appendicitis presents with pain in right iliac fossa, the pain is not causes by coughing or sneezing. Also, there will be other symptoms like tenderness and rebound tenderness in right iliac fossa in case of appendicitis.

Levonorgestrel, also known as the morning-after pill, is a first-line oral emergency contraceptive pill with approval from the World Health Organization to prevent pregnancy. It is FDA-approved to be used within 72 hours of unprotected sexual intercourse or when a presumed contraceptive failure has occurred.

A prescription is not needed, and it is available over the counter at local pharmacies. The FDA has also approved levonorgestrel availability for all age groups due to its lack of life-threatening contraindications and side-effect profile.

There are several contraindications for the emergency contraceptive form, including allergy, hypersensitivity, severe liver disease, pregnancy, and drug-drug interactions with liver enzyme-inducing drugs. The medication is not for use in women confirmed to be pregnant; however, there is no proof nor reports of adverse effects on the mother or foetus following inadvertent exposure during pregnancy.

This woman at her 37 weeks of gestation, has developed multiple herpetic lesions over her genitals. In every case were the mother develops herpes simplex infection after 28 weeks of pregnancy, chances for intrapartum and vertical transmission of the infection to the neonate is considered to be very high.

Risk factors of intrapartum herpes simplex infection of the child includes premature labour, premature rupture of membrane, primary herpes simplex infection and multiple lesion in the genital area.

The most appropriate methods for managing this case includes:
– checking for herpes simplex infection using PCR testing of a cervical swab.
– starting prophylactic antiviral therapy for the mother from 38 weeks of gestation until delivery.
– preferring a cesarean section delivery if there are active lesions present in the cervix and/or vulva.

Cesarean delivery is advised in this case along with maternal antiviral therapy before delivery to minimise the risk of vertical transmission.

Immediate treatment for infants with suspected meconium aspiration syndrome is to clear/suction the airway. Intubation and tracheal toileting have remained a matter of debate till the most recent times. All neonates at risk of MAS who show respiratory distress should be admitted to a neonatal intensive care unit and monitored closely. The treatment is mainly supportive and aims to correct hypoxemia and acidosis with the maintenance of optimal temperature and blood pressure.