High-risk pregnancies — MCQs

A 23-year-old woman comes to the emergency department complaining of abdominal pain and bloody vaginal discharge with clots. Her last menstrual period was 7 weeks ago. She does not smoke cigarettes or drink alcohol. She was admitted to the hospital for a deep vein thrombosis about 1 year ago and was treated with heparin followed by warfarin. Therapy ended after 6 months and she has been monitored by her primary care provider since. She has been sexually active with a new partner for 3 months and uses condoms inconsistently. Her father has type II diabetes and takes insulin. Her mother died of a stroke when she was 50. Her sister had 2 spontaneous first trimester abortions. Temperature is 38°C (100.4°F), blood pressure is 110/70 mm Hg, pulse is 98/min, respirations are 16/min, and BMI is 22 kg/m2 (48.5 pounds). On examination, her lower abdomen is tender to palpation. Vaginal examination reveals an open cervical os with blood pooling in the vaginal vault. Laboratory investigation: Complete blood count Hemoglobin 9.5 g/dl Leucocytes 4,500/mm3 Platelets 90,000/mm3 Serum haptoglobin 25 mg/dl (30-200 mg/dl) Bleeding time 5 minutes APTT 60 seconds Plasma fibrinogen 250 mg/dl (150-400 mg/dl) VDRL positive HbsAg negative After a mixing study, her APTT fails to correct. Urine pregnancy test is positive. What is the most likely diagnosis?

A 21-year-old woman comes to the physician because of hair loss on her frontal scalp over the past year. Menses have occurred at irregular 40- to 60-day intervals since menarche at the age of 17 years. She has no history of serious illness and takes no medications. She is 162 cm (5 ft 3 in) tall and weighs 73 kg (158.7 lb); BMI is 28 kg/m2. Her pulse is 75/min and blood pressure 130/76 mm Hg. Physical examination shows scattered pustules on her face and patches of velvety hyperpigmentation on her axilla and groin. Her morning serum cortisol concentration is 18 μg/dL. This patient's condition is most likely associated with increased stimulation of which of the following types of cells?

A 31-year-old G3P2 woman presents to labor and delivery triage because she has had bleeding over the last day. She is currently 5 months into her pregnancy and has had no concerns prior to this visit. She previously had a delivery through cesarean section and has otherwise had uncomplicated pregnancies. She denies fever, pain, and discomfort. On presentation, her temperature is 99.1°F (37.3°C), blood pressure is 110/70 mmHg, pulse is 81/min, and respirations are 15/min. Physical exam reveals an alert woman with slow, painless, vaginal bleeding. Which of the following risk factors are associated with the most likely cause of this patient's symptoms?

A 21-year-old G2P1 woman presents to the clinic and is curious about contraception immediately after her baby is born. She is anxious about taking care of one child and does not believe that she can handle the responsibility of caring for another. She has no other questions or complaints today. Her past medical history consists of generalized anxiety disorder, antithrombin deficiency, and chronic deep vein thrombosis. She has been hospitalized for acute on chronic deep vein thrombosis. Her only medication is buspirone. Her blood pressure is 119/78 mm Hg and the heart rate is 78/min. BMI of the patient is 32 kg/m2. On physical examination, her fundal height is 21 cm from pubic symphysis. No ovarian masses are palpated during the bimanual examination. Ultrasound exhibits a monoamniotic, monochorionic fetus. Which of the following forms of contraception would be the most detrimental given her risk factors?

A 16-year-old female presents to your clinic concerned that she has not had her menstrual cycle in 5 months. She has not been sexually active and her urine pregnancy test is negative. She states that she has been extremely stressed as she is in the middle of her gymnastics season and trying to get recruited for a college scholarship. Physical exam is remarkable for a BMI of 16, dorsal hand calluses, and fine hair over her cheeks. What other finding is likely in this patient?

A 42-year-old woman, gravida 3, para 3 comes to the physician because of a 14-month history of prolonged and heavy menstrual bleeding. Menses occur at regular 28-day intervals and last 7 days with heavy flow. She also feels fatigued. She is sexually active with her husband and does not use contraception. Vital signs are within normal limits. Pelvic examination shows a firm, irregularly-shaped uterus consistent in size with a 16-week gestation. Her hemoglobin concentration is 9 g/dL, hematocrit is 30%, and mean corpuscular volume is 92 μm3. Pelvic ultrasound shows multiple intramural masses in an irregularly enlarged uterus. The ovaries appear normal bilaterally. The patient has completed childbearing and would like definitive treatment for her symptoms. Operative treatment is scheduled. Which of the following is the most appropriate next step in management?

A 14-year-old girl comes to the physician for exertional leg pain. The pain began last week when she started jogging to lose weight. She is at the 5th percentile for height and 80th percentile for weight. Physical examination shows a broad neck with bilateral excess skin folds that extend to the shoulders, as well as a low-set hairline and ears. There is an increased carrying angle when she fully extends her arms at her sides. Pulses are palpable in all extremities; lower leg pulses are delayed. Which of the following additional findings is most likely in this patient?

A 29-year-old woman, gravida 1, para 0, at 33 weeks' gestation comes to her doctor for a routine visit. Her pregnancy has been uncomplicated. She has systemic lupus erythematosus and has had no flares during her pregnancy. She does not smoke cigarettes, drink alcohol, or use illicit drugs. Current medications include iron, vitamin supplements, and hydroxychloroquine. Her temperature is 37.2°C (98.9°F), pulse is 70/min, respirations are 17/min, and blood pressure is 134/70 mm Hg. She appears well. Physical examination shows no abnormalities. Ultrasound demonstrates fetal rhythmic breathing for > 30 seconds, amniotic fluid with deepest vertical pocket of 1 cm, one distinct fetal body movement over 30 minutes, and no episodes of extremity extension over 30 minutes. Nonstress test is reactive and reassuring. Which of the following is the next best step in management?

A 24-year-old primigravida presents to her physician for regular prenatal care at 31 weeks gestation. She has no complaints and the antepartum course has been uncomplicated. Her pre-gestational history is significant for obesity (BMI = 30.5 kg/m2). She has gained a total of 10 kg (22.4 lb) during pregnancy, and 2 kg (4.48 lb) since her last visit 4 weeks ago. Her vital signs are as follows: blood pressure, 145/90 mm Hg; heart rate, 87/min; respiratory rate, 14/min; and temperature, 36.7℃ (98℉). The fetal heart rate is 153/min. The physical examination shows no edema and is only significant for a 2/6 systolic murmur best heard at the apex of the heart. A 24-hour urine is negative for protein. Which of the following options describe the best management strategy in this case?

A 39-year-old woman seeks evaluation from her gynecologist due to recent changes in her menstrual cycle. Her last menstrual period was greater than 12 months ago. She has 2 children and had regular menstrual periods in the past. She also complains of difficulty in falling and staying asleep, occasional hot flashes, vaginal dryness, and decreased libido. The physical examination is unremarkable, and the height and weight are 1.68 m (5 ft 6 in) and 70 kg (154 lb), respectively. She has the following hormonal panel from 2 months ago when she first sought help for her symptoms. Hormonal panel results Human Chorionic Gonadotropin 4 IU/L (0.8 - 7.3 IU/L) Thyroid Stimulating Hormone 2.5 mIU/L (0.4 - 4.2 mIU/L) Prolactin 5 ng/mL (2-29 ng/mL) Follicle Stimulating Hormone 45 mIU/mL (Follicular phase: 3.1-7.9 mIU/mL; Ovulation peak: 2.3-18.5 mIU/mL; Luteal phase: 1.4-5.5 mIU/mL) Estradiol 5 pg/mL (Mid-follicular phase: 27-123 pg/mL; Periovulatory: 96-436 pg/mL; Mid-luteal phase: 49-294 pg/mL) Which of the following is the most likely diagnosis in this patient?