281

CHAPTER 42

Preterm Labor

42–1. he term small-for-gestational age is generally used to 42–5. A ter achieving a birthweight o at least 1000 grams,
designate newborns whose birthweight is less than neonatal survival rates reach 95 percent at
what percentile? approximately what gestational age with regard to
a. 3% newborn sex?
b. 5% a. 28 weeks or both males and emales
c. 10% b. 30 weeks or both males and emales
d. 15% c. 28 weeks or emales and 30 weeks or males
d. 30 weeks or emales and 28 weeks or males
42–2. he neonatal mortality rate is expected to be
lowest or newborns born at which o the ollowing 42–6. Cesarean delivery or neonates born at the threshold
gestational ages? o viability has been demonstrated to protect against
a. 36 weeks 6 days which o the ollowing adverse newborn outcomes?
b. 37 weeks 4 days a. Seizures
c. 39 weeks 6 days b. Intraventricular hemorrhage
d. 41 weeks 2 days c. Respiratory distress syndrome
d. None o the above
42–3. Late-preterm births, de ined as those between 34 and
36 weeks’ gestation, compose what percentage o all 42–7. Compared with neonates born at term, the risks
preterm births? to those born between 34 and 36 weeks’ gestation
a. 35% include which o the ollowing?
b. 50% a. Increased serious morbidity and mortality rates
c. 70% b. Equivalent serious morbidity and mortality rates
d. 85% c. Increased serious morbidity but decreased
mortality rates
42–4. Which o the ollowing etiologies is largely d. Increased serious morbidity but equivalent
responsible or the increase in preterm birth rates in mortality rates
the United States during the past 20 years?
a. riplet pregnancies 42–8. Maternal stress may potentiate preterm labor by
which o the ollowing mechanisms involving
b. Spontaneous preterm labor corticotropin-releasing hormone (CRH)?
c. Preterm rupture o etal membranes a. Increased production o maternal-derived CRH
d. Indicated (iatrogenic) preterm birth b. Decreased production o maternal-derived CRH
c. Increased production o placental-derived CRH
d. Decreased production o placental-derived CRH
 282 O bstetrica l Complica tions

42–9. A 26-year-old G2P1 presents at 29 weeks’ gestation 42–11. A 24-year-old G2P1 at 6 weeks’ gestation presents
complaining o leaking clear luid rom her vagina. or prenatal care and complains o bleeding, pain ul
A speculum examination reveals scant pooling o gums. Her obstetric history is signi icant or two
S
luid in the posterior vagina, and the microscopic prior preterm births. An oral examination reveals the
E
C
analysis o the luid reveals the ollowing pattern. indings noted in the image below. You counsel her
T
You diagnose premature rupture o the etal that periodontal disease treatment in pregnancy has
I
O
membranes (PROM). O the known risk actors or been proven to have which o the ollowing avorable
N
this condition, which is most commonly identi ied outcomes?
1
1
in such patients?

Reproduced with permission rom Gonsalves WC, Usatine RP: Gingivitis and Periodontal
Reproduced with permission rom Birnbaumer DM: Microscopic f ndings. In Knoop KJ, Disease. In Usatine RP, Smith MA, Chumley H, et al (eds): T e Color Atlas o Family
Stack LB, Storrow AB, et al (eds): T e Atlas o Emergency Medicine, 3rd ed. New York, Medicine. New York, McGraw-Hill, 2009, Figure 38-1.
McGraw-Hill, 2010, Figure 25.24.

a. Improved periodontal health

a. Smoking b. Decreased rates o preterm birth
b. Low socioeconomic status c. Decreased rates o low birthweight
c. Prior pregnancy complicated by PROM d. All o the above
d. None o the above
42–12. Intervals shorter than how many months between
42–10. All EXCEPT which o the ollowing li estyle actors pregnancies have been associated with an increased
has been identi ied as an antecedent or preterm risk or preterm birth?
labor? a. 18
a. Frequent coitus b. 24
b. Illicit drug use c. 36
c. Young maternal age d. 48
d. Inadequate maternal weight gain
42–13. A 33-year-old G2P2 is contemplating pregnancy but
is hesitant since her two prior deliveries occurred at
28 and 29 weeks’ gestation, respectively. You in orm
her that her risk or a recurrent preterm birth less
than 34 weeks’ gestation approximates what value?
a. 15%
b. 25%
c. 40%
d. 70%
 Preterm La bor 283

42–14. A 22-year-old G2P1 at 14 weeks’ gestation 42–17. Which o the ollowing is true regarding sonographic
complains o a malodorous vaginal discharge. A evaluation o the cervix as a part o the assessment
saline preparation o the discharge is prepared, or preterm birth risk?

C
and indings are illustrated in this image. You

H
recommend antimicrobial treatment or this

A
P
condition or what principal reason?

T
E
R
4
2
a. ransabdominal approach is pre erred to avoid
cervical manipulation.
b. In research populations, women with
a. Resolution o symptoms progressively shorter cervices had increased
b. Prevention o preterm birth preterm labor rates.
c. Avoidance o spontaneous abortion c. Women with prior preterm birth and with
d. reatment o intraamnionic in ection cervical lengths equal to 35 mm will bene it rom
cerclage placement.
42–15. Characteristics o Braxton Hicks contractions can d. All o the above
include all EXCEPT which o the ollowing?
a. Pain ul 42–18. Potential indications to per orm the procedure
demonstrated in this image include which o the
b. Nonrhythmical
ollowing?
c. Irregular pattern
d. Associated with cervical change

42–16. Per ormance o routine cervical examinations at each

prenatal care visit has been demonstrated to e ect
what outcome?
a. Decreased preterm birth rate
b. Increased interventions or preterm labor
c. Increased rate o premature rupture o etal
membranes
d. None o the above

Reproduced with permission rom Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Abortion. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014, Figure 18-5C.

a. Recurrent midtrimester losses

b. Short cervix identi ied sonographically
c. hreatened preterm labor with cervical dilatation
d. All o the above
 284 O bstetrica l Complica tions

42–19. 17-Hydroxyprogesterone caproate has been 42–24. A 25-year-old primigravida at 34 weeks and 5 days’
demonstrated in a randomized, controlled trial to gestation by certain dating criteria is ound to have
decrease the preterm birth rate in women with which preterm rupture o the etal membranes. What is the
S
o the ollowing characteristics? most appropriate management strategy?
E
C
a. Nulliparous a. Expedited delivery
T
I
b. Carrying twins b. Expectant management
O
N
c. Prior preterm birth c. Administer a course o corticosteroids ollowed by
1
delivery
1
d. None o the above
d. Expectant management unless etal lung maturity
42–20. Based on the known natural history o preterm is con irmed
premature ruptured membranes, approximately what
percentage o women will be delivered within 42–25. Corticosteroids administered to women at risk or
48 hours o membrane rupture when this complication preterm birth have been demonstrated to decrease
occurs between 24 and 34 weeks’ gestation? rates o respiratory distress i the birth is delayed or
a. 20% at least what amount o time a ter the initiation o
therapy?
b. 40%
a. 12 hours
c. 70%
b. 24 hours
d. 90%
c. 36 hours
42–21. A 20-year-old primigravida at 18 weeks’ gestation d. 48 hours
presents a ter she noticed a gush o luid rom
her vagina. You con irm the diagnosis o preterm 42–26. When antimicrobials have been administered to
rupture o the etal membranes. Sonographic orestall preterm birth in women with preterm labor,
evaluation con irms anhydramnios. In the unlikely rates o which o the ollowing untoward perinatal
event that she remains undelivered at a viable outcomes have been consistently reduced?
gestational age, perinatal survival would be unlikely a. Neonatal death
because o underdevelopment o what organ system? b. Cerebral palsy
a. Brain c. Chronic lung disease
b. Lungs d. None o the above
c. Heart
d. Kidneys 42–27. Although bed rest is commonly prescribed or
women deemed to be at increased risk or preterm
42–22. What is the only reliable indicator o clinical birth, limited data exist to support a bene it o this
chorioamnionitis in women with preterm rupture o recommendation. Which o the ollowing negative
the etal membranes? outcomes have been reported in pregnant women
placed on bed rest compared with those without this
a. Fever
restriction?
b. Leukocytosis
a. Greater bone loss
c. Fetal tachycardia
b. Impaired etal growth
d. Positive cervical or vaginal cultures
c. Greater maternal weight gain
42–23. Several antibiotic regimens have been used to d. Higher rates o preeclampsia
prolong the latency period in women with preterm
rupture o the etal membranes who are attempting
expectant management. Which antibiotic should be
avoided in this setting because it has been associated
with an increased risk o necrotizing enterocolitis in
the newborn?
a. Ampicillin
b. Amoxicillin
c. Erythromycin
d. Amoxicillin-clavulanate
 Preterm La bor 285

42–28. A 21-year-old primigravida presents at 28 42–30. he combination o ni edipine with what other
weeks’ gestation in active preterm labor, and tocolytic agent can potentially cause dangerous
intravenous terbutaline is administered or neuromuscular blockade?

C
tocolysis. Approximately 2 hours a ter therapy a. Atosiban

H
initiation, she begins to cough, and her peripheral

A
b. erbutaline

P
oxygen saturation is noted to be 80 percent. he

T
ollowing chest radiograph is obtained. In which c. Indomethacin

E
R
o the ollowing clinical settings is the risk or this d. Magnesium sul ate

4
complication increased?

2
42–31. A 28-year-old primigravida at 27 weeks’ gestation
presents with regular pain ul uterine contractions,
and her cervix is 8 cm dilated. he etus has a
vertex presentation. he etal heart rate tracing
is reassuring. Which o the ollowing procedures
will help decrease the risk or intraventricular
hemorrhage in her neonate?
a. Episiotomy
b. Cesarean delivery
c. Forceps-assisted vaginal delivery
d. None o the above

42–32. Although the e icacy is somewhat controversial,

intrapartum administration o magnesium sul ate to
women who deliver preterm has been demonstrated
to reduce rates o which o the ollowing neonatal
outcomes?
a. win pregnancy
a. Cerebral palsy
b. Maternal sepsis
b. Necrotizing enterocolitis
c. Concurrent administration o corticosteroids
c. Neonatal seizure activity
d. All o the above
d. Bronchopulmonary dysplasia
42–29. What reversible complication can be seen when
indomethacin is used or tocolysis longer than 24 to
48 hours?
a. Oligohydramnios
b. Placental abruption
c. Neonatal necrotizing enterocolitis
d. Neonatal intraventricular hemorrhage
 286 O bstetrica l Complica tions

CHAPTER 42 ANSw ER KEy

Q uestion Letter Pa ge
S
number a nswer cited Hea der cited
E
C
T
42–1 c p. 829 Introduction
I
O
42–2 c p. 829 Definition of Preterm
N
1
42–3 c p. 829 Definition of Preterm
1
42–4 d p. 829 Definition of Preterm
42–5 c p. 832 Morbidity in Preterm Infa nts
42–6 d p. 833 Threshold of Via bility
42–7 a p. 835 La te Preterm Birth
42–8 c p. 837 Ma terna l-Feta l Stress
42–9 d p. 839 Preterm Prema ture Rupture of Membra nes
42–10 a p. 841 Lifestyle Fa ctors
42–11 a p. 841 Periodonta l Disea se
42–12 a p. 841 Interva l between Pregna ncies
42–13 c p. 841 Prior Preterm Birth; Ta ble 4 2 -5
42–14 a p. 842 Ba cteria l Va ginosis
42–15 d p. 842 Symptoms
42–16 d p. 843 Cervica l Cha nge
42–17 b p. 843 Length
42–18 d p. 844 Cervica l Cercla ge
42–19 c p. 844 Prior Preterm Birth a nd Progestin Compounds
42–20 d p. 847 N a tura l History
42–21 b p. 848 Risks of Expecta nt Ma na gement
42–22 a p. 848 Clinica l Chorioa mnionitis
42–23 d p. 848 Antimicrobia l Thera py
42–24 a p. 849 Ma na gement Recommenda tions; Ta ble 4 2 -9
42–25 b p. 850 Corticosteroids for Feta l Lung Ma tura tion
42–26 d p. 851 Antimicrobia ls
42–27 a p. 851 Bed Rest
42–28 d p. 852 Ritodrine
42–29 a p. 852 Prosta gla ndin Inhibitors
42–30 d p. 853 Ca lcium Cha nnel Blockers
42–31 d p. 854 Delivery; Prevention of N eona ta l Intra cra nia l Hemorrha ge
42–32 a p. 854 Ma gnesium for Feta l N europrotection
 287

CHAPTER 43

Postterm Pregnanc

43–1. What is the threshold of completed weeks after 43–4. This graphic suggests which of the following
which a pregnancy is considered prolonged? regarding perinatal mortality rates (PMR)?
a. 40 weeks
70
b. 41 weeks 60 60

s
c. 42 weeks

h
50

t
r
i
b
d. 43 weeks 40 33
1943–1952

0
27

0
30

0
1
15 13
43–2. Which of the following is true regarding calculated 20 10 11

r
e
p
gestational age? 10

y
t
i
a. Underestimated if based on last menstrual period 7.2
l
a
t
r
(LMP) alone
o
m
1977–1978
b. Overestimated if based on first-trimester 4.0
l
a
3.1 3.0
t
a
sonographic examination 2.3 2.4
n
i
r
c. Overestimated if based on second-trimester
e
P
sonographic examination and LMP compared
with LMP alone 37 38 39 40 41 42 43 44
d. None of the above We e ks ’ ge s ta tion a t de live ry

Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
43–3. Rare fetal-placental factors associated with postterm Postterm pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
pregnancy include which of the following? Figure 43-2.
a. Wilms tumor
b. Anencephaly a. PMR was lowest in 1943–1952.
c. Adrenal hyperplasia b. PMR was higher in 1977–1978.
d. Autosomal-recessive placental sulfatase c. PMR increases after 41 weeks.
overproduction d. PMR increases after 40 weeks.
 288 O bstetrica l Complica tions

43–5. Major causes of death in postterm pregnancy include 43–7. Which of the following is true concerning the
which of the following? syndrome afflicting this infant?
a. Placenta accreta
S
b. Placental abruption
E
C
T
c. Unexplained stillbirth in diabetic patients
I
O
d. Cephalopelvic disproportion in prolonged labor
N
1
1
43–6. This graphic illustrates which of the following
regarding perinatal mortality rates (PMR)?

Pe rina ta l morta lity ra te

Pe rina ta l ris k index
10
s
h
8
t
r
i
b
0
6
0
0
1
r
4
e
p
s
h
t
2
a
e
D
0
37 38 39 40 41 42 43
We e k of birth

Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Postterm pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
Figure 43-3.

Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
a. Highest PMR occurs at 43 weeks. Postterm pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
Figure 43-4.
b. Highest PMR occurs at 38 weeks.
c. Perinatal risk index, which accounts for risk of all a. Features include simian crease and low-set ears.
ongoing pregnancies, is highest at 36 weeks
b. Its incidence in pregnancies between 41 and
d. None of the above 43 weeks is 20%.
c. Neurological deficits are found in 23% of affected
newborns.
d. Associated oligohydramnios substantially increases
its likelihood at 42 weeks.

43–8. In postterm gestations, which of the following

suggests compromise of fetal oxygenation?
a. Decreased hematocrit
b. Proapoptotic gene upregulation
c. Elevated erythropoietin level
d. None of the above
 Postterm Pregna ncy 289

43–9. This figure demonstrates which of the following? 43–12. This graphic illustrates which of the following?

180 180 1,400

C
150 150 1,300

H
1,200

A
120 120

P
1,100

)
90 90

T
L
m
Uppe r ra nge

E
60 60 1,000

(
R
e
30 30 900

m
4
Me a n

3
u
800

l
o
100 100

v
700

d
80 80

i
u
60 60
600

l
f
c
40 40
500

i
n
20 20

o
i
400

n
0 0

m
300

A
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Postterm pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014, 200 Lowe r ra nge
Figure 43-6. 100
0
a. Late deceleration 38 39 40 41 42 43
b. Variable deceleration We e ks ’ ge s ta tion
c. Prolonged deceleration Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Postterm pregnancy. In Williams Obstetrics, 23rd ed. New York, McGraw-Hill, 2010,
d. None of the above
Figure 37-8.

43–10. In postterm pregnancies, which of the following is

a. Amnionic fluid volume decreases from term until
true of most cases of fetal distress?
43 weeks.
a. Associated with cord occlusion
b. The largest amount of amnionic fluid is present
b. Associated with prolonged labor before term.
c. Not correlated with viscous meconium c. The smallest amount of fluid in the upper range
d. Caused by uteroplacental insufficiency is seen at 41 weeks.
d. The greatest amount of fluid in the lower range is
43–11. Which of the following increases the risk of approximately 700 mL at 38 weeks.
meconium aspiration syndrome?
a. Fetal acidemia
b. Oligohydramnios
c. Postterm pregnancy
d. A and B
 290 O bstetrica l Complica tions

43–13. This graphic illustrates which of the following? 43–16. Concerning an unfavorable cervix, research supports
which of the following statements?
40
a. A cervical length ≤ 3 cm was predictive of
S
successful induction.
E
C
30 b. Of women at 42 weeks, 92% have an unfavorable
T
I
cervix, when defined as a Bishop score < 7.
O
N
s
c. The risk of cesarean delivery is increased twofold
m
20
1
a
in those with a closed cervix at 42 weeks
r
1
G
undergoing labor induction.
10
d. All of the above

0 43–17. Concerning membrane stripping, research supports

20 22 24 26 28 30 32 34 36 38 40 42 which of the following statements?
We e ks ’ ge s ta tion a. Decreases need for induction
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
b. Increases maternal infection rates
Postterm pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014, c. Complications include bleeding and pain
Figure 43-5.
d. All of the above
a. Fetuses lose weight after 40 weeks.
43–18. This graphic illustrates which of the following?
b. Fetal growth continues until at least 42 weeks.
c. The peak of fetal growth occurs in the late
midtrimester. 100%
)
t
100
n
d. Maternal and fetal morbidity associated with
e
c
r
macrosomia would be mitigated with timely
e
p
80
(
induction.
s
e
m
o
43–14. In the presence of macrosomia, which of the 60
c
t
46%
u
following is true?
o
l
40
a
a. Early induction decreases maternal and fetal
m
27%
r
o
morbidity rates. 19%
n
20
b
A
b. Cesarean delivery should be performed for
estimated fetal weight > 4000 g.
c. Cesarean delivery is recommended for estimated 6.7 cm < 5 cm < 2 cm < 1 cm
fetal weights > 4500 g if there is prolonged (5th pe rce ntile )
second-stage labor.
Amnionic fluid inde x La rge s t ve rtica l pocke t
d. None of the above
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
43–15. What percentage of postterm stillbirths are Postterm pregnancy. In Williams Obstetrics, 23rd ed. New York, McGraw-Hill, 2010,
Figure 37-9.
growth-restricted?
a. 10%
a. An AFI < 1 cm had 100% abnormal outcomes.
b. 25%
b. Abnormal fetal outcomes occur when the AFI is
c. 33% at the 5th centile.
d. 50% c. When the AFI is < 2 cm, abnormal outcomes
were increased relative to those at 5th centile.
d. If the largest vertical pocket (LVP) was < 5 cm,
the chance of an abnormal outcome was 27%.
 Postterm Pregna ncy 291

43–19. Concerning the station of the vertex in nulliparous 43–22. Concerning this algorithm that summarizes the
pregnancies at the beginning of induction for American College of Obstetricians and Gynecologists
postterm pregnancy, research supports which of the (ACOG) recommendations, which of the following

C
following statements? is true?

H
a. The cesarean delivery rate is directly related to

A
P
station.

T
Comple te d 41 We e ks

E
b. The cesarean delivery rate is 6% if the vertex is at No othe r complica tions

R
–1 station.

4
3
c. The cesarean delivery rate is 43% if the vertex is
at –3 station. S ome choos e to initia te
fe ta l s urve illa nce
d. All of the above

43–20. Concerning induction versus fetal testing in Comple te d 42 We e ks

prolonged pregnancies, research supports which of
the following statements?
a. Testing is associated with decreased cesarean No complica tions Complica tions evide nce for:
delivery rates. (1) Fe ta l compromis e
(2) Oligohydra mnios
b. Most studies are performed during the 43rd week
of gestation. Fe ta l s urve illa nce a La bor induction b
Amnionic fluid (P re fe ra ble with
c. No differences in perinatal death and cesarean volume a s s e s s me nta La bor induction b
favora ble ce rvix)
delivery rates are found between the two
approaches.
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
d. None of the above Postterm pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
Figure 43-10.
43–21. In Alexander’s study (2001) comparing induction
versus awaiting spontaneous labor at 42 weeks’ a. Induction should be performed at 41 completed
gestation, investigators found which of the weeks.
following? b. If no complications exist, labor may be induced at
a. Decreased cesarean delivery rate in the induction 42 completed weeks.
group c. Fetal surveillance should be initiated for a
b. Increased cesarean delivery rate for fetal distress in pregnancy with oligohydramnios at 42 completed
the spontaneous labor group weeks.
c. Increased cesarean delivery rate in the induction d. All of the above
group related to the use of meperidine analgesia
during labor 43–23. Which of the following is true regarding
d. Increased cesarean delivery rate in the induction amnioinfusion?
group related to nulliparity, epidural anesthesia, a. Requires amniotomy
and an unfavorable cervix
b. Reduces late decelerations
c. Reduces the rate of meconium aspiration
syndrome
d. Does not affect the cesarean delivery rate in
postterm fetuses
 292 O bstetrica l Complica tions
43–24. Concerning the nulliparous woman with a postterm
gestation in early labor, which of the following is true?
a. If there are repetitive variable decelerations,
S
amnioinfusion is appropriate.
E
C
b. If cephalopelvic disproportion is suspected,
T
I
immediate cesarean delivery should be performed.
O
N
c. If there is thin meconium, strong consideration
1
should be given to effect prompt cesarean
1
delivery.
d. All of the above
43–25. The American Academy of Pediatrics supports which
of the following practices?
a. Routine suctioning of newborns with meconium
b. Intubation of the depressed newborn with
meconium
c. Meconium suctioning after the head is born to
minimize meconium aspiration syndrome
d. None of the above
43–26. In the postterm fetus, which of the following is true
regarding amniotomy?
a. May identify thick meconium
b. May exacerbate cord compression
c. Is essential to effect continuous fetal monitoring
d. A and B
43–27. Your patient is a 32-year-old G3P2 at 406/7 weeks’
gestation. Her first prenatal visit occurred after
30 weeks’ gestation. Examination today reveals a 1-cm
dilated cervix, cephalic presentation, no ballotment of
the head, and good fetal movement. What is the best
next step in the management of this patient?
a. Nonstress test
b. Labor induction
c. Oxytocin challenge test
d. Sonographic assessment of the amnionic fluid
index (AFI)
43–28. One week later, the patient in Question 43–27
returns to your office. Now her examination reveals
a 1- to 2-cm dilated cervix, cephalic presentation,
and an easily ballottable head. However, she notes
decreased fetal movement. Your management plan
should include which of the following?
a. Nonstress test
b. Labor induction
c. Oxytocin challenge test
d. A or B
43–29. With reassuring status by antepartum surveillance
verified, what might your next step be for the patient
in Question 43-28?
a. Elective cesarean delivery
b. Weekly antepartum surveillance
c. Amniocentesis to verify pulmonary maturity
followed by induction
d. B or C
43–30. Your patient is a 16-year-old G1P0 at 41 weeks’
gestation with complaints of decreased fetal
movement. Her care started during her first
trimester. She has a stated last menstrual period that
agrees with 16-week sonographic measurements.
Examination reveals a 1- to 2-cm dilated cervix,
cephalic presentation, estimated fetal weight of 9 lb,
and a ballottable head. What is a reasonable next
step?
a. Nonstress test
b. Labor induction
c. Umbilical artery Doppler evaluation
d. A or B
43–31. After a reassuring nonstress test (NST) result, the
patient in Question 43-30 returns to your office
1 week later. Examination now reveals a 2-cm dilated
cervix, cephalic presentation, and estimated fetal
weight of 9½ lb. Fetal movement is good, and the
vertex is ballotable. What is a reasonable next step?
a. NST
b. Labor induction
c. Amnionic fluid surveillance
d. All of the above
43–32. Your patient is a 22-year-old G1P0 at 42 weeks’
gestation by excellent dating criteria. She arrives for
induction and cervical examination reveals 1 to 2 cm
dilatation, cephalic presentation, and a head that
is not ballottable. The estimated fetal weight is 8½
lb. Her fetal heart rate pattern is category II. You
perform an amniotomy, place a direct fetal scalp
electrode monitor, and encounter viscous meconium.
What is an appropriate next step?
a. Cesarean delivery
b. Low-dose oxytocin protocol
c. Place intrauterine pressure catheter
d. All may be considered.
Reference:
Alexander JM, McIntire DD, Leveno KJ: Prolonged pregnancy:
induction of labor and cesarean births. Obstet Gynecol 97:911, 2001
 Postterm Pregna ncy 293

CHAPTER 43 ANSw ER KEy

Q uestion Letter Pa ge

C
number a nswer cited Hea der cited

H
A
P
43–1 c p. 862 Introduction

T
E
43–2 d p. 862 Estima ted G esta tiona l Age Using Menstrua l Da tes

R
4
43–3 b p. 863 Incidence

3
43–4 c p. 863 Perina ta l Morta lity
43–5 c p. 863 Perina ta l Morta lity
43–6 d p. 863 Perina ta l Morta lity
43–7 d p. 864 Postma turity Syndrome
43–8 c p. 864 Pla centa l Dysfunction
43–9 c p. 865 Feta l Distress a nd O ligohydra mnios
43–10 a p. 865 Feta l Distress a nd O ligohydra mnios
43–11 d p. 865 Feta l Distress a nd O ligohydra mnios
43–12 a p. 865 Feta l Distress a nd O ligohydra mnios
43–13 b p. 867 Ma crosomia
43–14 c p. 867 Ma crosomia
43–15 c p. 866 Feta l-G rowth Restriction
43–16 d p. 867 Unfa vora ble Cervix
43–17 c p. 868 Cervica l Ripening
43–18 b p. 866 O ligohydra mnios
43–19 d p. 868 Sta tion of Vertex
43–20 c p. 868 Induction versus Feta l Testing
43–21 d p. 868 Induction versus Feta l Testing
43–22 b p. 864 Pla centa l Dysfunction
43–23 a p. 869 Intra pa rtum Ma na gement
43–24 a p. 869 Intra pa rtum Ma na gement
43–25 b p. 869 Intra pa rtum Ma na gement
43–26 d p. 869 Intra pa rtum Ma na gement
43–27 d p. 866 O ligohydra mnios
43–28 a p. 869 Ma na gement Recommenda tions
43–29 d p. 869 Ma na gement Recommenda tions
43–30 d p. 869 Ma na gement Recommenda tions
43–31 d p. 869 Ma na gement Recommenda tions
43–32 d p. 869 Intra pa rtum Ma na gement
294

CHAPTER 44

Fetal-Gro th Disorders

44–1. What can be said regarding birthweight in the 44–4. Amino acids undergo which type of transport from
United States? maternal to fetal circulation?
a. All low-birthweight neonates are born preterm. a. Active transport
b. Of low-birthweight neonates, 3% are born at b. Passive diffusion
term. c. Facilitated diffusion
c. The percentage of low-birthweight neonates has d. None of the above
been decreasing since the mid-1980s.
d. None of the above 44–5. This graph depicts the relationship between
birthweight percentile and perinatal mortality and
44–2. Given the graphic below, what can be said regarding morbidity rates. Below which threshold value of
the velocity of fetal growth at different gestational birthweight percentile do perinatal mortality rates
ages? increase most rapidly?

80 100 Morbidity 175

90 Morta lity
)
t
60
n
150
e
P
80
c
e
)
r
g
e
r
(
i
p
n
y
(
40

a
70
a
y
t
d
100

a
t
i
r
l
d
e
m
i
p
60
b
o
r
h
20
o
r
t
t
w
m
a
o
l
50 75

i
l
r
t
G
a
y
t
r
a
a
0
n
40

t
i
e
r
e
(
50
p
p
e
30
e
r
v
i
1
t
0
20 25 30 35 40 45
a
l
20

0
u
0
25
m
Ge s ta tiona l a ge a t la s t ultra s ound (we e ks )
)
u
C
10
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Fetal growth disorders. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
Figure 44-1.
> 10 10 9 8 7 6 5 4 3 2 1 <1
Birthwe ight pe rce ntile
a. At 24 weeks’ gestation, growth averages 5 g/day.
b. At 34 weeks’ gestation, growth averages Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Fetal growth disorders. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
25–30 g/day. Figure 44-3.
c. There is considerable variation in the velocity of
fetal growth. a. 3
d. All of the above b. 5
c. 7
44–3. Elevated C-peptide levels are associated with which
of the following? d. 10
a. Hyperinsulinemia
b. Hypercholesterolemia
c. Fetal-growth restriction
d. All of the above

44–6. Symmetrical growth restriction is characterized by a
reduction in which of the following?
a. Head size
b. Body size
c. Both body and head size
d. Both body and femur length
44–7. Which of the following correctly represents current
thinking on asymmetrical versus symmetrical growth
restriction?
a. Neonatal morbidity rates are higher with
asymmetrical growth restriction.
b. Uteroplacental insufficiency leads to asymmetrical
growth restriction in most cases of preeclampsia.
c. Assigning specific morbidity to specific fetal-
growth restriction patterns is a straightforward
process.
d. None of the above
44–8. Growing evidence suggests that fetal-growth
restriction affects organ development, especially
which of the following?
a. Brain
b. Heart
c. Kidney
d. Thyroid
44–9. Compared with appropriately grown fetuses of
equivalent gestational age, growth-restricted fetuses
have which of the following perinatal advantages?
a. Lower stillbirth rate
b. Lower perinatal mortality rate
c. Lower rate of respiratory distress syndrome
d. None of the above
44–10. Which of the following is true regarding women
with pregravid weights less than 100 lb compared
with normal-weight women?
a. They have a twofold risk of having growth-
restricted fetuses.
b. They have a slightly increased risk of having a
fetus with aneuploidy.
c. The risk of fetal-growth restriction may be
modulated by appropriate maternal gestational
weight gain.
d. All of the above
Feta l-Growth Disorders 295
44–11. Which of the following is true regarding maternal
nutrition during pregnancy?
a. Providing micronutrient supplementation to
C
undernourished women consistently lowers rates
H
of small-for-gestational-age newborns.
A
P
b. For all maternal weight categories, excessive
T
E
maternal weight gain during pregnancy is
R
associated with large-for-gestational-age newborns.
4
4
c. For all maternal weight categories, maternal
weight gain in the second and third trimesters
that is less than recommended is associated with
fetal-growth restriction.
d. All of the above
44–12. Women screened during pregnancy for psychosocial
risk factors compared with pregnant women who
do not undergo such screening have which of the
following?
a. Lower preterm birth rates
b. More appropriate interventions
c. Lower rates of low-birthweight newborns
d. All of the above
44–13. Which of the following vascular diseases in women
during pregnancy leads to the highest perinatal
morbidity rates?
a. Class F diabetics
b. Chronic hypertension
c. Ischemic heart disease
d. Valvular heart disease
44–14. Which of the following is true concerning diabetes
in pregnancy?
a. Compared with type 1 diabetics, type 2 diabetics
have a higher risk of delivering a large-for-
gestational-age (LGA) newborn.
b. Type 1 diabetics have a proportionately higher
risk of delivering a small-for-gestational-age
(SGA) than an LGA newborn.
c. Type 1 diabetics without vascular involvement
have a proportionately higher risk of delivering an
LGA newborn than an SGA one.
d. None of the above
44–15. Which of the following are true concerning chronic
hypoxia?
a. Women with cyanotic heart disease have a higher
rate of growth-restricted fetuses.
b. Neonates born at lower altitudes have a lower risk
of being small for gestational age.
c. Neonates born at higher altitudes have a lower
risk of being large for gestational age.
d. All of the above
 296 O bstetrica l Complica tions

44–16. Regarding maternal anemia, which of the following 44–20. Which of the following drugs are associated with
is true? fetal-growth restriction?
a. It confers a high associated risk of fetal-growth a. Metoclopramide
S
restriction. b. Diphenhydramine
E
C
b. Fetal-growth restriction rates are higher in women c. Cyclophosphamide
T
I
with sickle-cell trait.
O
d. Low-dose aspirin
N
c. Fetal-growth restriction is related to restricted
1
maternal blood volume expansion. 44–21. This growth-restricted newborn was born at
1
d. All of the above 36 weeks’ gestation. All EXCEPT which of the
following are infectious causes of fetal-growth
44–17. Which of the following is the primary autoantibody restriction?
that predicts obstetrical antiphospholipid antibody
syndrome?
a. Lupus anticoagulant
b. Anticardiolipin antibodies
c. Anti-beta-glycoprotein-I antibodies
d. Anti-double-stranded DNA antibodies

44–18. Fetal-growth restriction is associated with all

EXCEPT which of the following?
a. Prior infertility
b. Placental chorangioma
c. Inherited thrombophilia
d. Velamentous cord insertion

44–19. The graph below suggests which of the following

regarding fetal-growth restriction and multifetal
pregnancy?

4000 S ingle tons

3500
3000
Twins
)
g
(
2500
t
h
Triple ts
g
2000
i
e
w
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
1500 Qua druple ts
h
Fetal growth disorders. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
t
r
i
Figure 44-7.
B
1000
500 a. Congenital syphilis
0 b. Maternal tuberculosis
20 25 30 35 40 45
Ge s ta tiona l a ge a t de live ry (we e ks ) c. First-trimester primary cytomegalovirus infection
d. Antepartum maternal seroconversion for
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): toxoplasmosis
Fetal growth disorders. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
Figure 44-5.
44–22. In which chromosomal aneuploidy is fetal-growth
a. Most growth-restricted neonates result from restriction virtually always present?
quadruplet pregnancies. a. 45,X
b. Fetal-growth restriction can be detected at 20 b. Trisomy 13
weeks’ gestation in quadruplets. c. Trisomy 18
c. In multifetal gestations, fetal-growth restriction d. Trisomy 21
typically becomes apparent in the early third
trimester.
d. All of the above
 Feta l-Growth Disorders 297

44–23. Which of the following is true regarding serial 44–28. For the patient in Question 44–27, when will you
fundal height measurements to detect fetal-growth reevaluate fetal growth?
restriction? a. 1 week

C
a. Sensitivity < 25%, specificity < 50% b. 2 weeks

H
A
b. Sensitivity < 35%, specificity > 90% c. 3 weeks

P
T
c. Sensitivity < 70%, specificity < 50% d. 6 weeks

E
R
d. Sensitivity < 85%, specificity > 90%

4
44–29. Your next obstetrical sonographic evaluation of the

44–24. Which of the following sonographic assessments
of fetal-growth restriction is the most predictive of
obstetrical outcome?
a. Biometric growth < 3rd percentile
b. Biometric growth < 5th percentile
c. Biometric growth < 3rd percentile and abnormal
umbilical artery Doppler velocimetry results
d. Biometric growth < 5th percentile and absent
end-diastolic flow noted during umbilical artery
Doppler velocimetry study
44–30. For the patient in Question 44–27, studies indicate
44–25. Which of the following is true regarding
oligohydramnios?
a. It is associated with fetal-growth restriction.
b. It is associated with congenital fetal
malformations.
c. It is associated with a higher cesarean delivery
rate.
d. All of the above
4
patient in Question 44–27 is performed 4 weeks after
the first one and now at an estimated gestational age
of 36 weeks. The fetus now has measurements similar
to a 30-week fetus. Growth restriction seems more
likely. What is appropriate at this time?
a. Delivery
b. Strict bed rest
c. Umbilical artery Doppler velocimetry
d. Sonographic fetal biometry in 1 week
a systolic/diastolic (S/D) ratio of 4, and the patient
has an amnionic fluid index (AFI) of 9 cm. What is
appropriate at this time?
a. Delivery
b. Betamethasone administration
c. Sonographic fetal biometry in 1 week
d. Serial umbilical artery Doppler studies and AFI
assessment

44–26. Which of the following is true concerning the
prevention of fetal-growth restriction?
a. In the United States, malaria prophylaxis assists
prevention.
b. Preconceptional and antepartum smoking
cessation assists prevention.
c. For the gravida with chronic hypertension,
antihypertensive therapy assists prevention.
d. Aspirin therapy assists prevention and is
recommended by the American College of
Obstetricians and Gynecologists.
44–31. For the patient in Question 44–27, during the
next week, umbilical artery Doppler velocimetry
indicates reversed end-diastolic flow (REDF), and
the amnionic fluid index (AFI) is 4 cm. What is
appropriate at this time?
a. Deliver the fetus
b. Plan delivery at 38 weeks after amniocentesis for
pulmonary maturity
c. Continue serial umbilical artery Doppler studies
and AFI assessment
d. All are reasonable

44–27. Ms. Smith is a 37-year-old multigravida who 44–32. According the American College of Obstetricians
presents to your office at 32 weeks’ gestation and Gynecologists, which of the following is the
as calculated by her last menstrual period. Her threshold above which macrosomia is defined?
hematocrit is 29 volume percent, and she has sickle- a. 4000 g
cell trait. During sonographic evaluation, the fetus
b. 4250 g
has biometric values that correlate with a 28-week
fetus. What is the most likely explanation? c. 4500 g
a. Aneuploidy d. 5000 g
b. Chronic hypoxia
c. Poor pregnancy dating
d. First-trimester cytomegalovirus infection
 298 O bstetrica l Complica tions

44–33. For the prediction of macrosomia, how does clinical 44–34. In pregnancies with estimated fetal weights
estimation of fetal weight compare with sonographic > 4000 g after 37 weeks’ gestation, prophylactic
estimation? labor induction has which of the following effects?
S
a. Less accurate a. Increases the cesarean delivery rate
E
C
b. Similar accuracy b. Decreases the shoulder dystocia rate
T
I
O
c. Modestly more accurate c. Decreases the postpartum hemorrhage rates
N
d. Significantly more accurate d. All of the above
1
1
 Feta l-Growth Disorders 299

CHAPTER 44 ANSw ER KEy

Q uestion Letter Pa ge

C
number a nswer cited Hea der cited

H
A
P
44–1 b p. 872 Introduction

T
E
44–2 c p. 872 Feta l G rowth

R
4
44–3 a p. 872 Feta l G rowth

4
44–4 a p. 872 Feta l G rowth
44–5 a p. 874 Feta l G rowth Restriction, Definition
44–6 c p. 875 Symmetrica l versus Asymmetrica l G rowth Restriction
44–7 a p. 875 Symmetrica l versus Asymmetrica l G rowth Restriction
44–8 b p. 876 Feta l Undergrowth
44–9 d p. 877 Accelera ted Lung Ma tura tion
44–10 c p. 877 Constitutiona lly Sma ll Mothers
44–11 b p. 877 G esta tiona l W eight G a in a nd N utrition
44–12 d p. 878 Socia l Depriva tion
44–13 c p. 878 Va scula r Disea se
44–14 c p. 878 Pregesta tiona l Dia betes
44–15 d p. 878 Chronic Hypoxia
44–16 c p. 878 Anemia
44–17 a p. 878 Antiphospholipid Antibody Syndrome
44–18 c p. 879 Inherited Thrombophilia s; Infertility; Pla centa l a nd Cord Abnorma lities
44–19 c p. 879 Multiple G esta tions
44–20 c p. 879 Drugs with Tera togenic a nd Feta l Effects
44–21 d p. 879 Ma terna l a nd Feta l Infections
44–22 c p. 880 Chromosoma l Aneuploidies
44–23 b p. 880 Uterine Funda l Height
44–24 c p. 880 Sonogra phic Mea surements of Feta l Size
44–25 d p. 881 Amnionic Fluid Volume Mea surement
44–26 b p. 882 Prevention
44–27 c p. 880 Recognition of Feta l-G rowth Restriction
44–28 c p. 880 Sonogra phic Mea surements of Feta l Size
44–29 c p. 882 Ma na gement
44–30 d p. 883 Figure 4 4 -9
44–31 a p. 883 Figure 4 4 -9
44–32 c p. 885 Empirica l Birthweight
44–33 b p. 885 Dia gnosis
44–34 a p. 886 Prophyla ctic La bor Induction
300

CHAPTER 45

Multifetal Pregnanc

45–1. Compared with singleton pregnancies, multifetal 45–5. When trying to establish chorionicity of the
gestations have a higher risk of all EXCEPT which pregnancy shown in the image here, which of the
of the following complications? following statements is true?
a. Preeclampsia
b. Hysterectomy
c. Maternal death
d. Postterm pregnancy

45–2. Compared with singleton pregnancies, multifetal

gestations have an infant mortality rate that is how
many times greater?
a. Twofold
b. Threefold
c. Fivefold
d. Tenfold

45–3. Which of the following mechanisms may prevent

monozygotic twins from being truly “identical”? Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
Multifetal pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
a. Postzygotic mutation Figure 45-7B.
b. Unequal division of the protoplasmic material
c. Variable expression of the same genetic disease a. There are two placentas.
d. All of the above b. The twins must be monozygotic.
c. The twins share the same amnion.
45–4. A patient delivers a twin gestation in which one d. The twins must have arisen from two separate
infant has blood type A and one has type O. ova.
The patient and her husband are both type O. A
particular phenomenon is proposed as the etiology of 45–6. Which of the following factors increases the risk for
the discordant blood types. How would you explain monozygotic twinning?
this to the mother?
a. Increased parity
a. The proposed phenomenon does not b. Increased maternal age
spontaneously occur in humans.
c. The father is an identical twin.
b. It involves fertilization of one ovum that splits
into two during the same menstrual cycle. d. None of the above
c. It involves fertilization of two ova within the
same menstrual cycle, but not at the same coitus.
d. It involves fertilization of two ova separated in
time by an interval as long as or longer than a
menstrual cycle.
 Multifeta l Pregna ncy 301

45–7. The first-trimester sonographic image here shows 45–10. What can be confirmed about the placenta being
two fetal heads arising from a shared body. How examined in the image here?
many days after fertilization must the division of

C
this zygote have occurred to lead to the abnormality

H
shown?

A
P
T
E
R
4
5
a. Dizygosity
b. Monozygosity
c. One chorion, two amnions
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds): d. Two chorions, two amnions
Multifetal pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
Figure 45-16.
45–11. Which of the following is true regarding the rate of
a. 0–3 days monozygotic twinning?
b. 4–7 days a. It approximates 1 in 250 worldwide.
c. 8–12 days b. It is increased with maternal age and parity.
c. It is lower for Hispanic women than for white
d. More than 13 days
women.
45–8. A patient with twins is referred for prenatal d. It can be modified by FSH (follicle-stimulating
care. At the referring clinic, she had several hormone) treatment.
sonographic examinations that establish these to be
monochorionic twins. Today, you see only one fetus 45–12. Which of the following statements is true regarding
sonographically. Which of the following statements chorionicity in multifetal pregnancy?
is false regarding the risk of a vanishing twin? a. Dichorionic pregnancies are always dizygotic.
a. The risk exceeds 10% in multifetal gestations. b. Monochorionic membranes should have four
b. The risk is higher in monochorionic than in layers.
dichorionic pregnancies. c. Monochorionic pregnancies are always
c. This risk is increased if she used assisted monozygotic.
reproductive technologies to conceive. d. Chorionicity is accurately determined by
d. A vanishing twin does not affect first-trimester measuring the thickness of the dividing
biomarker testing if it occurs after 10 weeks’ membranes during sonographic examination in
gestation. the first trimester.

45–13. Among the following choices, which is the strongest

45–9. What is the approximate risk of triplet or higher-
risk factor for multifetal pregnancy?
order multifetal gestation if ovarian stimulation
and intrauterine insemination is used to achieve a. Advanced maternal age
pregnancy? b. Use of clomiphene citrate
a. 10% c. African American ethnicity
b. 20% d. Maternal history of being a twin herself
c. 30%
d. 40%
 302 O bstetrica l Complica tions

45–14. A patient presents for prenatal care at 12 weeks’ 45–17. A fetus that is part of a dichorionic twin pair is
gestation and wants to know about specific risks to estimated to weigh 2000 g at 33 weeks’ gestation.
her pregnancy. She has spontaneously conceived a What can be said about its growth?
S
monochorionic twin gestation. Which statement is
E
5000
C
false regarding these twins?
T
a. They have a higher risk of pregnancy loss than
I
S ingle tons 75 th
O
fraternal twins. 4000 50 th
N
25 th

)
1
g
b. Those born at term have a higher risk of cognitive

(
1
3000 50 th

t
delay than term singletons.

h
g
i
e
c. They have twice the risk of malformations

w
2000

h
compared with singleton pregnancies. Twins

t
r
i
B
d. They have a lower risk of pregnancy loss 1000
than identical twins conceived with assisted
reproductive technologies. 0
25 30 35 40
45–15. The differential diagnosis of clinically suspected Ge s ta tiona l a ge (we e ks )
twins includes all EXCEPT which of the following?
Reproduced with permission from Cunningham FG, Leveno KJ, Bloom SL, et al (eds):
a. Obesity Multifetal pregnancy. In Williams Obstetrics, 24th ed. New York, McGraw-Hill, 2014,
Figure 45-8.
b. Hydramnios
c. Leiomyomas
a. The fetus already shows growth restriction.
d. Blighted ovum
b. The fetus will be growth restricted at term.
45–16. Regarding maternal adaptations to multifetal c. The fetal growth is adequate for gestational age.
pregnancy, which of the following is lower in d. Growth differences will not be apparent until
twin pregnancy compared with that in a singleton delivery.
pregnancy?
a. Blood volume expansion 45–18. Among complications that may be seen in twin
pregnancies, which of the following may be seen in
b. Blood pressure at term dichorionic pregnancies?
c. Blood loss at delivery a. Acardiac twin
d. Systemic vascular resistance b. Fetus-in-fetu
c. Twin-twin transfusion syndrome
d. Complete mole with coexisting normal twin

45–19. What is the major cause of increased neonatal

morbidity rates in twins?
a. Preterm birth
b. Congenital malformations
c. Abnormal growth patterns
d. Twin-twin transfusion syndrome
 Multifeta l Pregna ncy 303

45–20. When diagnosed at 20 weeks’ gestation, which of 45–23. A pair of monochorionic twins presents at 20 weeks’
the following statements is true regarding the twin gestation with sonographic findings that suggest
vascular complication seen in the image here? twin-twin transfusion syndrome. There is significant

C
growth discordance, no bladder is visualized in the

H
smaller twin, neither twin has ascites or hydrops, and

A
P
umbilical Doppler studies are normal. What would

T
be the assigned Quintero stage?

E
R
a. Stage I

4
5
b. Stage II
c. Stage III
d. Stage IV

45–24. The recipient cotwin in a monochorionic twin

gestation affected by twin-twin transfusion syndrome
may experience all EXCEPT which of the following
neonatal complications?
a. Thrombosis
Used with permission from Dr. Jodi Dashe. b. Hypovolemia
c. Kernicterus
a. It precludes vaginal delivery.
d. Heart failure
b. It implies the twins are conjoined.
c. It has a 50% associated fetal mortality rate. 45–25. What percentage of Quintero stage I cases remain
d. It can be monitored effectively with daily stable without intervention?
sonography. a. 25%
b. 50%
45–21. Which are the most common vascular anastomoses
seen in monochorionic twin placentas? c. 75%
a. Deep vein-vein d. 90%
b. Deep artery-vein 45–26. Which of the following therapies for severe twin-
c. Superficial artery-vein twin transfusion syndrome has been shown in a
d. Superficial artery-artery randomized trial to improve survival rates of at least
one twin to age 6 months?
45–22. Which of the following statements is true in twin- a. Septostomy
reversed-arterial-perfusion (TRAP) sequence? b. Amnioreduction
a. It is caused by a large arteriovenous placental c. Selective feticide
shunt.
d. Laser ablation of vascular anastomoses
b. The donor is at risk of cardiomegaly and high-
output heart failure. 45–27. What is the calculated fetal growth discordance of a
c. The most effective treatment is injection of KCl twin pair where the estimated fetal weight of twin A
into the recipient twin. is 800 g and that of twin B is 600 g?
d. Placental arterial perfusion pressure in the a. 10%
recipient exceeds that of the donor. b. 15%
c. 25%
d. 33%
 304 O bstetrica l Complica tions

45–28. A second sonographic evaluation of the twin 45–33. Which of the following findings can predict a lower
pair described in Question 45–27 shows 27% risk of preterm birth in twins?
discordance. One fetus is male and one is female. a. Closed cervix on digital examination
S
Which mechanism is not the likely cause of their
b. Negative fetal fibronectin assessment
E
C
discordance?
c. Normal cervical length measured by transvaginal
T
a. Unequal placental sharing
I
O
sonography
N
b. Different growth potential d. All of the above
1
c. Histological placental abnormality
1
d. Suboptimal implantation of one placental site 45–34. Which is the most common presentation of twins in
labor?
45–29. With growing discordance, rates of which of the a. Vertex/vertex
following neonatal complications are increased? b. Vertex/breech
a. Neonatal sepsis c. Breech/vertex
b. Necrotizing enterocolitis
d. Vertex/transverse
c. Intraventricular hemorrhage
d. All of the above 45–35. For twins in labor, risk factors for an unstable fetal
lie include all EXCEPT which of the following?
45–30. Which of the following is the most important a. Small fetuses
predictor of neurological outcome of the survivor
b. Polyhydramnios
after death of a cotwin?
c. Increased maternal parity
a. Chorionicity
d. Vertex/vertex presentation
b. Gestational age at time of demise
c. Malformations present in the deceased twin 45–36. Which of the following scenarios presents the best
d. Length of time between demise and delivery of opportunity for a vaginal trial of labor?
survivor a. Nonvertex/vertex presentation
b. Vertex/nonvertex presentation
45–31. Which of the following methods of antepartum fetal
surveillance has been shown to improve outcomes in c. Nonvertex second twin whose estimated fetal
twin pregnancies? weight is < 1500 g
a. Nonstress test d. Vertex second twin whose estimated fetal weight
is > 20% larger than the presenting vertex twin
b. Biophysical profile
c. Doppler velocimetry of the umbilical artery
d. None of the above

45–32. Which of the following interventions has been

shown to decrease the rate of preterm birth in twins?
a. Cerclage
b. Betamimetics
c. 17-Hydroxyprogesterone caproate
d. None of the above
 Multifeta l Pregna ncy 305

CHAPTER 45 ANSw ER KEy

Q uestion Letter Pa ge

C
number a nswer cited Hea der cited

H
A
P
45–1 d p. 891 Introduction

T
E
45–2 c p. 891 Introduction

R
4
45–3 d p. 892 Dizygotic versus Monozygotic Twinning

5
45–4 c p. 892 Superfeta tion a nd Superfecunda tion
45–5 b p. 896 Sonogra phic Determina tion of Chorionicity-
45–6 d p. 892 Frequency of Twinning
45–7 d p. 893 Figure 4 5 -1
45–8 d p. 892 The “Va nishing” Twin
45–9 a p. 895 Infertility Thera py
45–10 d p. 896 Pla centa l Exa mina tion
45–11 a p. 892 Frequency of Twinning
45–12 d p. 896 Sonogra phic Determina tion of Chorionicity; G enesis of Monozygotic Twins
45–13 b p. 894 Fa ctors Tha t Influence Twinning
45–14 b p. 899 Pregna ncy Complica tions; Long-Term Infa nt Development
45–15 d p. 896 Clinica l Eva lua tion
45–16 d p. 898 Ma terna l Ada pta tions to Multifeta l Pregna ncy
45–17 c p. 899 Low Birthweight; Figure 4 5 -8
45–18 d p. 902 Aberra nt Twinning Mecha nisms
45–19 a p. 900 Preterm Birth
45–20 a p. 901 Monoa mniotic Twins; Figure 4 5 -1 3
45–21 d p. 904 Monochorionic Twins a nd Va scula r Ana stomoses
45–22 b p. 908 Aca rdia c Twin
45–23 b p. 907 Dia gnosis
45–24 b p. 904 Twin-Twin Tra nsfusion Syndrome
45–25 c p. 907 Ma na gement a nd Prognosis
45–26 d p. 907 Ma na gement a nd Prognosis
45–27 c p. 909 Dia gnosis
45–28 a p. 909 Etiopa thogenesis
45–29 d p. 909 Dia gnosis
45–30 a p. 910 Dea th of O ne Fetus
45–31 d p. 912 Tests of Feta l W ell-Being
45–32 d p. 913 Prevention of Preterm Birth
45–33 d p. 913 Prediction of Preterm Birth
45–34 a p. 915 Feta l Presenta tion
45–35 d p. 915 Feta l Presenta tion
45–36 b p. 916 Cepha lic-N oncepha lic Presenta tion