Immediately following prolonged delivery of the placenta at 40 weeks gestation, a 32-year-old multiparous woman develops vaginal bleeding. Other than mild asthma, the patient’s pregnancy has been uncomplicated. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. Previous pregnancies were uncomplicated. She has no history of a serious illness. She is currently on intravenous infusion of oxytocin. Her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 17/min. Uterine palpation reveals a soft enlarged fundus that extends above the umbilicus. Based on the assessment of the birth canal and placenta, which of the following options is the most appropriate initial step in patient management?

Manual exploration of the uterus

A 35-year-old woman gravida 2, para 1, comes to the physician for her first prenatal visit. Pregnancy and delivery of her first child were uncomplicated. She is not sure about the date of her last menstrual period. Pelvic examination shows a uterus consistent in size with a 10-week gestation. An ultrasound examination confirms the gestational age and shows one fetus with no indication of multiple gestations. During counseling on pregnancy risks and possible screening and diagnostic tests, the patient states she would like to undergo screening for Down syndrome. She would prefer immediate and secure screening with a low risk to herself and the fetus. Which of the following is the most appropriate next step in management at this time?

Nuchal translucency, pregnancy-associated plasma protein-A, human chorionic gonadotropin

Maternal serum α-fetoprotein, human chorionic gonadotropin, unconjugated estriol, and inhibin A

A 33-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of frequent contractions. The contractions are 40 seconds each, occurring every 2 minutes, and increasing in intensity. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her current medications include folic acid and a multivitamin. Her temperature is 36.9°C (98.4°F), heart rate is 88/min, and blood pressure is 126/76 mm Hg. Contractions are felt on the abdomen. There is clear fluid in the vulva and the introitus. The cervix is dilated to 5 cm, 70% effaced, and station of the head is -2. A fetal ultrasound shows polyhydramnios, a median cleft lip, and fused thalami. The corpus callosum, 3rd ventricle, and lateral ventricles are absent. The spine shows no abnormalities and there is a four chamber heart. Which of the following is the most appropriate next step in management?

Perform dilation and evacuation

A 23-year-old primigravid woman comes to the physician at 36 weeks' gestation for her first prenatal visit. She confirmed the pregnancy with a home urine pregnancy kit a few months ago but has not yet followed up with a physician. She takes no medications. Vital signs are within normal limits. Pelvic examination shows a uterus consistent in size with a 36-week gestation. Laboratory studies show: Hemoglobin 10.6 g/dL Serum Glucose 88 mg/dL Hepatitis B surface antigen negative Hepatitis C antibody negative HIV antibody positive HIV load 11,000 copies/mL (N < 1000 copies/mL) Ultrasonography shows an intrauterine fetus consistent in size with a 36-week gestation. Which of the following is the most appropriate next step in management of this patient?

Start cART and schedule cesarean delivery at 38 weeks' gestation

Intrapartum zidovudine and vaginal delivery when labor occurs

Intrapartum zidovudine and cesarean delivery at 38 weeks' gestation

Start cART and prepare for vaginal delivery at 38 weeks' gestation

Conduct cesarean delivery immediately

A 36-year-old G3P2002 presents to her obstetrician’s office for her first prenatal visit at ten weeks and two days gestation. She notes that she has felt nauseous the last several mornings and has been especially tired for a few weeks. Otherwise, she feels well. The patient has had two uncomplicated spontaneous vaginal deliveries at full term with her last child born six years ago. She is concerned about the risk of Down syndrome in this fetus, as her sister gave birth to an affected child at age 43. The patient has a history of generalized anxiety disorder, atopic dermatitis, and she is currently on escitalopram. At this visit, this patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 121/67 mmHg, and respirations are 13/min. The patient appears anxious, but overall comfortable, and cardiopulmonary and abdominal exams are unremarkable. Pelvic exam reveals normal female external genitalia, a closed and slightly soft cervix, a ten-week-sized uterus, and no adnexal masses. Which of the following is the best next step for definitively determining whether this patient’s fetus has Down syndrome?

Genetic testing of patient’s sister

Advanced maternal age for USMLE Step 2 CK: High-Yield OB/GYN Lessons

Definition & Risks - The Age Factor

Advanced Maternal Age (AMA): Defined as a maternal age of ≥35 years at the estimated date of delivery (EDD).
The core issue is ↑ age of oocytes, which predisposes to meiotic nondisjunction.
Maternal Risks:
- ↑ Preeclampsia & gestational hypertension
- ↑ Gestational Diabetes Mellitus (GDM)
- ↑ Placenta previa & abruption
- ↑ Cesarean delivery
Fetal & Neonatal Risks:
- ↑ Aneuploidy (chromosomal abnormalities)
- ↑ Spontaneous abortion
- ↑ Preterm birth & Low Birth Weight (LBW)
- ↑ Stillbirth

⭐ The risk of Down Syndrome (Trisomy 21) increases dramatically with age: approx. 1 in 350 at age 35, rising to 1 in 100 at age 40, and 1 in 30 at age 45.

Antenatal Screening & Care - Proactive Protocols

Genetic Counseling: Essential first step. Discuss risks and outline screening/diagnostic pathways tailored to patient values.
Aneuploidy Screening Options:
- Cell-free DNA (NIPT): Offered at ≥10 weeks. High detection rate for trisomies 21, 18, and 13.
- Invasive Diagnosis: For definitive results or if NIPT is positive.
  - Chorionic Villus Sampling (CVS): 10-13 weeks.
  - Amniocentesis: ≥15 weeks.
Maternal Health Monitoring:
- Low-dose aspirin (81 mg) from 12 weeks to ↓ preeclampsia risk.
- Early screening for Gestational Diabetes (GDM).
- Increased fetal surveillance in 3rd trimester (e.g., BPP, NSTs).

⭐ NIPT is a screening test, not diagnostic. Positive results require confirmation with invasive testing like amniocentesis or CVS.

Intrapartum & Postpartum - Delivery Day Decisions

Timing of Delivery:
- Induction of labor (IOL) is often recommended at 39 0/7 to 39 6/7 weeks.
- This balances risks of prematurity against the ↑ risk of stillbirth after 40 weeks associated with AMA.
Labor Management:
- Continuous intrapartum fetal monitoring is standard due to higher risks of fetal intolerance to labor.
- Lower threshold for operative delivery (Cesarean or vacuum/forceps) due to ↑ risk of labor dystocia.
Postpartum Considerations:
- Increased risk of Postpartum Hemorrhage (PPH), primarily from uterine atony.
- Maintain high index of suspicion for hypertensive disorders and thromboembolic events.

⭐ Exam Favorite: Women of advanced maternal age have a significantly higher rate of Cesarean delivery, often due to failed induction, labor dystocia (inefficient contractions), or non-reassuring fetal status linked to underlying uteroplacental insufficiency.

High-Yield Points - ⚡ Biggest Takeaways

Advanced maternal age (AMA) is defined as age ≥35 at the time of delivery.

The most significant risk is fetal aneuploidy, particularly Down syndrome (Trisomy 21), due to errors in meiotic nondisjunction.

Maternal complications include a higher incidence of gestational diabetes, preeclampsia, and cesarean sections.

Associated with increased risks of placenta previa, preterm labor, low birth weight, and stillbirth.

Management focuses on genetic counseling, offering aneuploidy screening (cfDNA) or diagnostic testing (amniocentesis/CVS).

Continue reading on Oncourse

CONTINUE READING — FREE

or get the app

App Store|Google Play