A 34-year-old pregnant woman with unknown medical history is admitted to the hospital at her 36th week of gestation with painful contractions. She received no proper prenatal care during the current pregnancy. On presentation, her vital signs are as follows: blood pressure is 110/60 mm Hg, heart rate is 102/min, respiratory rate is 23/min, and temperature is 37.0℃ (98.6℉). Fetal heart rate is 179/min. Pelvic examination shows a closed non-effaced cervix. During the examination, the patient experiences a strong contraction accompanied by a high-intensity pain after which contractions disappear. The fetal heart rate becomes 85/min and continues to decrease. The fetal head is now floating. Which of the following factors would most likely be present in the patient’s history?
Q2
A 27-year-old woman, gravida 2, para 1, at 37 weeks' gestation is admitted to the hospital in active labor. She has received routine prenatal care, but she has not been tested for group B streptococcal (GBS) colonization. Pregnancy and delivery of her first child were complicated by an infection with GBS that resulted in sepsis in the newborn. Current medications include folic acid and a multivitamin. Vital signs are within normal limits. The abdomen is nontender and contractions are felt every 4 minutes. There is clear amniotic fluid pooling in the vagina. The fetus is in a cephalic presentation. The fetal heart rate is 140/min. Which of the following is the most appropriate next step in management?
Q3
A 25-year-old woman, gravida 2, para 1, at 25 weeks' gestation comes to the emergency department because of a 1-day history of fever and right-sided flank pain. During this period, she also had chills, nausea, vomiting, and burning on urination. Her last prenatal visit was 10 weeks ago. Pregnancy and delivery of her first child were uncomplicated. Her temperature is 39°C (102.2°F), pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows costovertebral angle tenderness on the right. The abdomen is soft and nontender, and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 25-week gestation. Fetal heart rate is 170/min. Laboratory studies show:
Leukocyte count 15,000/mm3
Urine
Nitrite 2+
Protein 1+
Blood 1+
RBC 5/hpf
WBC 500/hpf
Blood and urine samples are obtained for culture and drug sensitivity. Which of the following is the most appropriate next step in management?
Q4
A 31-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the emergency department for sudden leakage of clear vaginal fluid. Her pregnancy has been uncomplicated. Her first child was born at term by vaginal delivery. She has no history of serious illness. She does not drink alcohol or smoke cigarettes. Current medications include vitamin supplements. Her temperature is 37.2°C (98.9°F), pulse is 70/min, respirations are 18/min, and blood pressure is 128/82 mm Hg. Speculum examination demonstrates clear fluid in the cervical canal. The fetal heart rate is reactive at 160/min with no decelerations. Tocometry shows uterine contractions. Nitrazine testing is positive. She is started on indomethacin. Which of the following is the most appropriate next step in management?
Q5
A 29-year-old G2P1 at 35 weeks gestation presents to the obstetric emergency room with vaginal bleeding and severe lower back pain. She reports the acute onset of these symptoms 1 hour ago while she was outside playing with her 4-year-old son. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She received appropriate prenatal care during both pregnancies. She has a history of myomectomy for uterine fibroids. Her past medical history is notable for diabetes mellitus. She takes metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 104/68 mmHg, pulse is 120/min, and respirations are 20/min. On physical examination, the patient is in moderate distress. Large blood clots are removed from the vaginal vault. Contractions are occurring every 2 minutes. Delayed decelerations are noted on fetal heart monitoring. Which of the following is the most likely cause of this patient's symptoms?
Q6
A 35-year-old woman, gravida 4, para 3, at 34 weeks' gestation comes to the physician for a prenatal visit. She feels well. She does not note any contractions or fluid from her vagina. Her third child was delivered spontaneously at 35 weeks' gestation; pregnancy and delivery of her other two children were uncomplicated. Vital signs are normal. The abdomen is nontender and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 34-weeks' gestation. Ultrasonography shows the fetus in a breech presentation. The fetal heart rate is 148/min. Which of the following is the most appropriate next step in management?
Q7
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?
Q8
A 30-year-old woman, gravida 4, para 3, at 39 weeks' gestation comes to the hospital 20 minutes after the onset of vaginal bleeding. She has not received prenatal care. Her third child was delivered by lower segment transverse cesarean section because of a footling breech presentation. Her other two children were delivered vaginally. Her temperature is 37.1°C (98.8°F), pulse is 86/min, respirations are 18/min, and blood pressure is 132/74 mm Hg. The abdomen is nontender, and no contractions are felt. The fetus is in a vertex presentation. The fetal heart rate is 96/min. Per speculum examination reveals ruptured membranes and severe bleeding from the external os. Which of the following is the most likely diagnosis?
Q9
A 24-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the emergency department for vaginal bleeding, cramping lower abdominal pain, and dizziness. She also has had fevers, chills, and foul-smelling vaginal discharge for the past 2 days. She is sexually active with one male partner, and they use condoms inconsistently. Pregnancy and delivery of her first child were uncomplicated. She appears acutely ill. Her temperature is 38.9°C (102°F), pulse is 120/min, respirations are 22/min, and blood pressure is 88/50 mm Hg. Abdominal examination shows moderate tenderness to palpation over the lower quadrants. Pelvic examination shows a tender cervix that is dilated with clots and a solid bloody mass within the cervical canal. Her serum β-human chorionic gonadotropin concentration is 15,000 mIU/mL. Pelvic ultrasound shows an intrauterine gestational sac with absent fetal heart tones. Which of the following is the most appropriate next step in management?
Q10
29-year-old G2P2002 presents with foul-smelling lochia and fever. She is post-partum day three status-post cesarean section due to eclampsia. Her temperature is 101 F, and heart rate is 103. She denies chills. On physical exam, lower abdominal and uterine tenderness is present. Leukocytosis with left shift is seen in labs. Which of the following is the next best step in management?
Chorioamnionitis US Medical PG Practice Questions and MCQs
Question 1: A 34-year-old pregnant woman with unknown medical history is admitted to the hospital at her 36th week of gestation with painful contractions. She received no proper prenatal care during the current pregnancy. On presentation, her vital signs are as follows: blood pressure is 110/60 mm Hg, heart rate is 102/min, respiratory rate is 23/min, and temperature is 37.0℃ (98.6℉). Fetal heart rate is 179/min. Pelvic examination shows a closed non-effaced cervix. During the examination, the patient experiences a strong contraction accompanied by a high-intensity pain after which contractions disappear. The fetal heart rate becomes 85/min and continues to decrease. The fetal head is now floating. Which of the following factors would most likely be present in the patient’s history?
A. Fundal cesarean delivery (Correct Answer)
B. Adenomyosis
C. Intrauterine synechiae
D. Multiple vaginal births
E. Postabortion metroendometritis
Explanation: ***Fundal cesarean delivery***
- The sudden onset of intense pain followed by cessation of contractions, fetal bradycardia, and a floating fetal head in a woman with a prior Cesarean section scar is highly suggestive of **uterine rupture**.
- A previous **classical or fundal Cesarean section** scar carries the highest risk of rupture in subsequent pregnancies due to the incision extending into the contractile upper uterine segment.
*Adenomyosis*
- **Adenomyosis** involves the presence of endometrial tissue within the myometrium, which can cause heavy, painful periods and chronic pelvic pain, but it doesn't directly predispose to uterine rupture during labor.
- While it can complicate pregnancy with an increased risk of preterm birth or miscarriage, it is not associated with the acute presentation described.
*Intrauterine synechiae*
- **Intrauterine synechiae**, or Asherman's syndrome, are adhesions within the uterine cavity, often resulting from endometrial trauma.
- They primarily cause infertility, recurrent pregnancy loss, or abnormal placentation (like placenta accreta), but not uterine rupture.
*Multiple vaginal births*
- A history of **multiple vaginal births** generally *reduces* the risk of uterine rupture in subsequent pregnancies as the cervix and lower uterine segment are often more compliant.
- While prolonged labor or instrumental delivery can rarely increase rupture risk, it's not a primary risk factor like a prior classical Cesarean.
*Postabortion metroendometritis*
- **Postabortion metroendometritis** is an infection of the uterus after an abortion.
- While it can lead to complications such as Asherman's syndrome or infertility, it does not typically increase the risk of uterine rupture in a subsequent pregnancy in the manner described.
Question 2: A 27-year-old woman, gravida 2, para 1, at 37 weeks' gestation is admitted to the hospital in active labor. She has received routine prenatal care, but she has not been tested for group B streptococcal (GBS) colonization. Pregnancy and delivery of her first child were complicated by an infection with GBS that resulted in sepsis in the newborn. Current medications include folic acid and a multivitamin. Vital signs are within normal limits. The abdomen is nontender and contractions are felt every 4 minutes. There is clear amniotic fluid pooling in the vagina. The fetus is in a cephalic presentation. The fetal heart rate is 140/min. Which of the following is the most appropriate next step in management?
A. Obtain vaginal-rectal swab for nucleic acid amplification testing
B. Obtain vaginal-rectal swab for GBS culture
C. Administer intrapartum intravenous penicillin (Correct Answer)
D. Reassurance
E. Obtain vaginal-rectal swab for GBS culture and nucleic acid amplification testing
Explanation: ***Administer intrapartum intravenous penicillin***
- This patient has a **previous infant with invasive GBS disease**, which is a strong indication for **intrapartum antibiotic prophylaxis (IAP)** regardless of current GBS colonization status.
- Penicillin is the **first-line agent** for GBS prophylaxis during labor to prevent vertical transmission to the newborn.
*Obtain vaginal-rectal swab for nucleic acid amplification testing*
- While **NAAT** can provide rapid results, the presence of a prior infant with invasive GBS disease is an **absolute indication** for IAP, making testing unnecessary.
- Waiting for NAAT results would **delay necessary antibiotic administration**, increasing the risk of GBS transmission.
*Obtain vaginal-rectal swab for GBS culture*
- A **GBS culture** typically takes 24-48 hours for results, which is too long given the patient is in active labor and requires immediate management.
- As with NAAT, a prior affected infant means that **IAP is indicated regardless of current culture results**.
*Reassurance*
- Reassurance alone is **insufficient** given the patient's history of a previous infant with GBS sepsis, which places her current fetus at high risk.
- **Active intervention** with antibiotics is crucial to prevent recurrence of GBS disease in the newborn.
*Obtain vaginal-rectal swab for GBS culture and nucleic acid amplification testing*
- Performing both tests is **unnecessary and delays treatment** in a patient with a clear indication for intrapartum antibiotics.
- The patient's history of a prior infant with GBS sepsis is classified as a **high-risk factor, necessitating immediate antibiotic prophylaxis** without waiting for test results.
Question 3: A 25-year-old woman, gravida 2, para 1, at 25 weeks' gestation comes to the emergency department because of a 1-day history of fever and right-sided flank pain. During this period, she also had chills, nausea, vomiting, and burning on urination. Her last prenatal visit was 10 weeks ago. Pregnancy and delivery of her first child were uncomplicated. Her temperature is 39°C (102.2°F), pulse is 110/min, respirations are 20/min, and blood pressure is 110/70 mm Hg. Physical examination shows costovertebral angle tenderness on the right. The abdomen is soft and nontender, and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 25-week gestation. Fetal heart rate is 170/min. Laboratory studies show:
Leukocyte count 15,000/mm3
Urine
Nitrite 2+
Protein 1+
Blood 1+
RBC 5/hpf
WBC 500/hpf
Blood and urine samples are obtained for culture and drug sensitivity. Which of the following is the most appropriate next step in management?
A. Inpatient treatment with intravenous ceftriaxone (Correct Answer)
B. Perform a renal ultrasound
C. Outpatient treatment with oral ciprofloxacin
D. Inpatient treatment with intravenous ampicillin and gentamicin
E. Admit the patient and request an emergent obstetrical consult
Explanation: ***Inpatient treatment with intravenous ceftriaxone***
- The patient presents with classic signs of **pyelonephritis** (fever, flank pain, nausea, vomiting, CVA tenderness) in pregnancy, which warrants **inpatient admission** and **IV antibiotics** to prevent complications such as sepsis, preterm labor, and fetal compromise.
- **Ceftriaxone** is a broad-spectrum cephalosporin that is safe and effective in pregnancy for treating urinary tract infections, including pyelonephritis.
*Perform a renal ultrasound*
- While a **renal ultrasound** may be considered in cases of persistent fever after 48-72 hours of antibiotic therapy or if there's suspicion of obstruction or abscess, it is **not the immediate next step**.
- The priority is to initiate antibiotics promptly to treat the acute infection and prevent further complications.
*Outpatient treatment with oral ciprofloxacin*
- **Outpatient treatment** is inappropriate for **pyelonephritis in pregnancy** due to the high risk of complications for both the mother and the fetus.
- **Ciprofloxacin** (a fluoroquinolone) is generally **contraindicated in pregnancy** because of potential adverse effects on fetal cartilage development.
*Inpatient treatment with intravenous ampicillin and gentamicin*
- Although **ampicillin and gentamicin** are effective for many UTIs and safe in pregnancy, they are often reserved for cases where local resistance patterns favor this combination or as a second-line option.
- **Ceftriaxone** is a preferred first-line empiric choice for pyelonephritis in pregnancy due to its broad coverage and once-daily dosing.
*Admit the patient and request an emergent obstetrical consult*
- While admitting the patient is correct, **immediately requesting an emergent obstetrical consult** is premature as the primary issue is an acute infection requiring medical management.
- Obstetrics consultation is important in managing high-risk pregnancies or complications like preterm labor, but antibiotics for pyelonephritis should be initiated first, and then an obstetrician can be consulted for comanagement.
Question 4: A 31-year-old woman, gravida 2, para 1, at 32 weeks' gestation comes to the emergency department for sudden leakage of clear vaginal fluid. Her pregnancy has been uncomplicated. Her first child was born at term by vaginal delivery. She has no history of serious illness. She does not drink alcohol or smoke cigarettes. Current medications include vitamin supplements. Her temperature is 37.2°C (98.9°F), pulse is 70/min, respirations are 18/min, and blood pressure is 128/82 mm Hg. Speculum examination demonstrates clear fluid in the cervical canal. The fetal heart rate is reactive at 160/min with no decelerations. Tocometry shows uterine contractions. Nitrazine testing is positive. She is started on indomethacin. Which of the following is the most appropriate next step in management?
A. Administer betamethasone and ampicillin (Correct Answer)
B. Administer betamethasone, ampicillin, and proceed with cesarean section
C. Administer betamethasone, ampicillin, and proceed with induction of labor
D. Administer ampicillin and perform amnioinfusion
E. Administer ampicillin and test amniotic fluid for fetal lung maturity
Explanation: ***Administer betamethasone and ampicillin***
- This patient presents with **preterm premature rupture of membranes (PPROM)** at 32 weeks' gestation, indicated by clear vaginal fluid and positive nitrazine test. Given the preterm status, **antenatal corticosteroids (betamethasone)** are crucial for fetal lung maturity, and **antibiotics (ampicillin)** are necessary to prevent intrauterine infection.
- She is not in active labor and the fetus is stable, so conservative management with these medications is appropriate, allowing for continued gestation while mitigating risks associated with prematurity and infection.
*Administer betamethasone, ampicillin, and proceed with cesarean section*
- While betamethasone and ampicillin are appropriate, **proceeding directly with a cesarean section** is not indicated as the patient is not in active labor and there are no signs of fetal distress or immediate need for delivery.
- Cesarean section carries maternal risks and is reserved for specific indications such as non-reassuring fetal status, malpresentation, or contraindications to vaginal delivery.
*Administer betamethasone, ampicillin, and proceed with induction of labor*
- Administering betamethasone and ampicillin is correct, but **inducing labor immediately** is not the most appropriate step at 32 weeks with PPROM in a stable patient without chorioamnionitis.
- The goal at this gestational age is typically to prolong the pregnancy to allow for further fetal development, unless there are complications that necessitate delivery, such as chorioamnionitis or non-reassuring fetal testing.
*Administer ampicillin and perform amnioinfusion*
- Ampicillin is appropriate for infection prophylaxis in PPROM, but **amnioinfusion** is generally reserved for cases of **oligohydramnios** with umbilical cord compression, particularly during labor.
- While oligohydramnios can result from PPROM, amnioinfusion is not a standard or primary intervention in the initial management of PPROM before labor onset.
*Administer ampicillin and test amniotic fluid for fetal lung maturity*
- Ampicillin is appropriate, but **testing amniotic fluid for fetal lung maturity** is less critical in this scenario, as corticosteroids will be administered regardless.
- Given the 32-week gestation, fetal lungs are unlikely to be fully mature, and waiting for test results would delay essential interventions (i.e., corticosteroids) that improve fetal outcomes.
Question 5: A 29-year-old G2P1 at 35 weeks gestation presents to the obstetric emergency room with vaginal bleeding and severe lower back pain. She reports the acute onset of these symptoms 1 hour ago while she was outside playing with her 4-year-old son. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She received appropriate prenatal care during both pregnancies. She has a history of myomectomy for uterine fibroids. Her past medical history is notable for diabetes mellitus. She takes metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 104/68 mmHg, pulse is 120/min, and respirations are 20/min. On physical examination, the patient is in moderate distress. Large blood clots are removed from the vaginal vault. Contractions are occurring every 2 minutes. Delayed decelerations are noted on fetal heart monitoring. Which of the following is the most likely cause of this patient's symptoms?
A. Premature separation of a normally implanted placenta (Correct Answer)
B. Amniotic sac rupture prior to the start of uterine contractions
C. Placental implantation over internal cervical os
D. Chorionic villi attaching to the myometrium
E. Chorionic villi attaching to the decidua basalis
Explanation: ***Premature separation of a normally implanted placenta***
- The acute onset of **vaginal bleeding**, **severe lower back pain**, frequent uterine contractions, and **fetal decelerations** in a patient with risk factors like a prior cesarean section and diabetes mellitus are highly suggestive of **abruptio placentae**.
- **Uterine tenderness** and a **firm, rigid uterus** (though not explicitly stated, implied by contractions and pain) are also characteristic findings.
*Amniotic sac rupture prior to the start of uterine contractions*
- This condition presents with a gush of fluid from the vagina, often without significant bleeding or severe pain unless associated with other complications.
- While it can lead to preterm labor, it doesn't directly cause the severe back pain, heavy bleeding with clots, and fetal distress seen here.
*Placental implantation over internal cervical os*
- This describes **placenta previa**, which typically presents with **painless vaginal bleeding**, often bright red, without severe abdominal or back pain.
- The presence of severe abdominal pain and uterine contractions makes placenta previa less likely.
*Chorionic villi attaching to the myometrium*
- This describes **placenta accreta**, a condition where the placenta abnormally adheres to the myometrium. It is typically diagnosed postnatally with **difficulty in placental separation** and severe hemorrhage.
- While a prior C-section is a risk factor, the acute presentation of pain and bleeding in the antepartum period is not the classic presentation of accreta alone.
*Chorionic villi attaching to the decidua basalis*
- This describes the **normal implantation** of the placenta into the decidua basalis of the uterus.
- This is the physiological process of pregnancy and would not cause the symptoms of vaginal bleeding, severe pain, and fetal distress described.
Question 6: A 35-year-old woman, gravida 4, para 3, at 34 weeks' gestation comes to the physician for a prenatal visit. She feels well. She does not note any contractions or fluid from her vagina. Her third child was delivered spontaneously at 35 weeks' gestation; pregnancy and delivery of her other two children were uncomplicated. Vital signs are normal. The abdomen is nontender and no contractions are felt. Pelvic examination shows a uterus consistent in size with a 34-weeks' gestation. Ultrasonography shows the fetus in a breech presentation. The fetal heart rate is 148/min. Which of the following is the most appropriate next step in management?
A. Internal cephalic version
B. Intravenous penicillin
C. Cesarean section
D. Observation (Correct Answer)
E. External cephalic version
Explanation: ***Observation***
- At 34 weeks' gestation, **spontaneous version** from **breech to cephalic presentation** can still occur, especially in multiparous women.
- Waiting until 37 weeks allows time for the fetus to turn naturally before considering interventions.
*Internal cephalic version*
- This procedure involves a physician inserting a hand into the uterus to manually turn the fetus from inside.
- It is typically performed during **labor** to correct a **malpresentation** once the cervix is dilated sufficiently and is not appropriate for an antepartum breech presentation.
*Intravenous penicillin*
- **Penicillin** is administered to prevent **Group B Streptococcus (GBS) transmission** to the neonate, usually during labor for GBS-positive mothers.
- There is no indication for **GBS prophylaxis** in this case, and GBS status is not provided.
*Cesarean section*
- While breech presentation often necessitates a **cesarean section**, it is generally planned for 39 weeks' gestation or when labor begins if other interventions fail.
- It is premature to schedule a **C-section** at 34 weeks, as the fetus might still undergo spontaneous version.
*External cephalic version*
- This procedure involves manually manipulating the fetus through the maternal abdomen to turn it from breech to cephalic.
- It is usually attempted at **37 weeks' gestation** to maximize success rates and minimize risks, as earlier attempts have lower success and higher re-version rates.
Question 7: 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?
A. Initiate misoprostol therapy
B. Allow vaginal delivery (Correct Answer)
C. Perform dilation and evacuation
D. Initiate nifedipine therapy
E. Perform cesarean delivery
Explanation: ***Allow vaginal delivery***
- The presence of severe fetal anomalies, including **holoprosencephaly** (median cleft lip, fused thalami, absent corpus callosum, 3rd and lateral ventricles), indicates that the fetus is **incompatible with life**.
- Given the prognosis, the most appropriate and safest approach for the mother is to **allow vaginal delivery**, as there is no benefit to delaying delivery or attempting a surgical intervention that might pose more risks to the mother.
*Initiate misoprostol therapy*
- **Misoprostol** is a prostaglandin analog used to induce labor or abortion, particularly in cases of uterine atony or to ripen the cervix.
- While it aids in cervical ripening and uterine contractions, the cervix is already 5 cm dilated and 70% effaced, indicating a **rapidly progressing labor** not requiring additional induction.
*Perform dilation and evacuation*
- **Dilation and evacuation (D&E)** is typically performed in the second trimester for fetal demise or termination of pregnancy, usually before 24 weeks' gestation.
- At 26 weeks' gestation with advanced labor and significant cervical dilation, D&E is a **high-risk procedure** for the mother and less appropriate than vaginal delivery.
*Initiate nifedipine therapy*
- **Nifedipine is a tocolytic** used to suppress preterm labor by relaxing the uterine muscles.
- Given the **lethal fetal anomalies** and the advanced stage of labor (5 cm dilated, 70% effaced, intense contractions), stopping labor would only prolong a non-viable pregnancy and increase maternal risk.
*Perform cesarean delivery*
- **Cesarean delivery** would expose the mother to surgical risks (e.g., infection, hemorrhage, future pregnancy complications) without any benefit to the fetus, who has anomalies **incompatible with survival**.
- A previous cesarean section does not preclude a vaginal delivery in this context, especially when **fetal viability is not a concern**.
Question 8: A 30-year-old woman, gravida 4, para 3, at 39 weeks' gestation comes to the hospital 20 minutes after the onset of vaginal bleeding. She has not received prenatal care. Her third child was delivered by lower segment transverse cesarean section because of a footling breech presentation. Her other two children were delivered vaginally. Her temperature is 37.1°C (98.8°F), pulse is 86/min, respirations are 18/min, and blood pressure is 132/74 mm Hg. The abdomen is nontender, and no contractions are felt. The fetus is in a vertex presentation. The fetal heart rate is 96/min. Per speculum examination reveals ruptured membranes and severe bleeding from the external os. Which of the following is the most likely diagnosis?
A. Placenta accreta
B. Threatened abortion
C. Bloody show
D. Placenta previa
E. Ruptured vasa previa (Correct Answer)
Explanation: ***Ruptured vasa previa***
- The sudden onset of painless **vaginal bleeding** at 39 weeks with **fetal heart rate deceleration** (96/min) immediately after membrane rupture is highly indicative of vasa previa rupture.
- In vasa previa, fetal blood vessels lie within the membranes over the cervical os; rupture leads to rapid fetal blood loss.
*Placenta accreta*
- This condition involves abnormal adherence of the **placenta to the uterine wall** and usually presents with hemorrhage during the **third stage of labor** when the placenta fails to separate.
- While a previous cesarean section is a risk factor, the acute scenario with fetal distress following membrane rupture is less typical for placenta accreta as the primary cause of this specific bleeding episode.
*Threatened abortion*
- A threatened abortion occurs **before 20 weeks' gestation** and is characterized by vaginal bleeding with a closed cervix, and would not occur at 39 weeks' gestation.
- The symptoms presented by the patient, including being at term and having severe hemorrhage with fetal heart rate deceleration, are inconsistent with a threatened abortion.
*Bloody show*
- **Bloody show** is typically a small amount of blood-tinged mucus that occurs as the cervix begins to dilate and efface.
- It is not associated with severe, acute hemorrhage or immediate fetal distress, as seen in this case.
*Placenta previa*
- **Placenta previa** typically presents as painless vaginal bleeding in the late second or third trimester but usually does not cause acute, severe fetal heart rate deceleration unless there is significant maternal hypovolemia or placental abruption secondary to the previa.
- The sudden severe bleeding with a rapid drop in fetal heart rate after membrane rupture strongly points away from uncomplicated placenta previa and rather towards fetal vessel rupture.
Question 9: A 24-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the emergency department for vaginal bleeding, cramping lower abdominal pain, and dizziness. She also has had fevers, chills, and foul-smelling vaginal discharge for the past 2 days. She is sexually active with one male partner, and they use condoms inconsistently. Pregnancy and delivery of her first child were uncomplicated. She appears acutely ill. Her temperature is 38.9°C (102°F), pulse is 120/min, respirations are 22/min, and blood pressure is 88/50 mm Hg. Abdominal examination shows moderate tenderness to palpation over the lower quadrants. Pelvic examination shows a tender cervix that is dilated with clots and a solid bloody mass within the cervical canal. Her serum β-human chorionic gonadotropin concentration is 15,000 mIU/mL. Pelvic ultrasound shows an intrauterine gestational sac with absent fetal heart tones. Which of the following is the most appropriate next step in management?
A. Intravenous clindamycin and gentamicin followed by suction and curettage (Correct Answer)
B. Oral clindamycin followed by suction curettage
C. Intravenous clindamycin and gentamicin followed by oral misoprostol
D. Intravenous clindamycin and gentamicin followed by close observation
E. Oral clindamycin followed by outpatient follow-up in 2 weeks
Explanation: ***Intravenous clindamycin and gentamicin followed by suction and curettage***
- This patient presents with signs of **septic abortion**, including fever, chills, foul-smelling vaginal discharge, hypotension, tachycardia, and a dilated cervix with intrauterine gestational sac and absent fetal heart tones.
- **Immediate broad-spectrum IV antibiotics** (clindamycin and gentamicin) are crucial to treat the infection, followed by **prompt evacuation of retained products of conception** via suction and curettage to remove the source of infection.
*Oral clindamycin followed by suction curettage*
- **Oral antibiotics are inadequate** for a patient presenting with an acute, severe infection and hemodynamic instability consistent with septic abortion.
- The delay in switching to IV antibiotics could worsen her condition, and suction curettage without prior full IV antibiotic course is suboptimal due to the risk of continued seeding of infection.
*Intravenous clindamycin and gentamicin followed by oral misoprostol*
- While IV antibiotics are appropriate, **oral misoprostol is typically used for medical abortion or to induce labor/expel products of conception in a stable patient**.
- Its action is slower and less reliable for immediate evacuation in a septic patient compared to suction and curettage.
*Intravenous clindamycin and gentamicin followed by close observation*
- Administering IV antibiotics is correct, but **close observation alone is insufficient** when there are retained infected products of conception.
- The source of infection must be removed promptly to prevent progression to septic shock and organ damage.
*Oral clindamycin followed by outpatient follow-up in 2 weeks*
- This approach is entirely inappropriate as the patient is **acutely ill and hemodynamically unstable** with an active infection.
- Delaying treatment and using oral antibiotics could be life-threatening.
Question 10: 29-year-old G2P2002 presents with foul-smelling lochia and fever. She is post-partum day three status-post cesarean section due to eclampsia. Her temperature is 101 F, and heart rate is 103. She denies chills. On physical exam, lower abdominal and uterine tenderness is present. Leukocytosis with left shift is seen in labs. Which of the following is the next best step in management?
A. Endometrial culture
B. Intravenous clindamycin and gentamicin treatment (Correct Answer)
C. Prophylactic intravenous cefazolin treatment
D. Intramuscular cefotetan treatment
E. Blood culture
Explanation: **Intravenous clindamycin and gentamicin treatment**
* This patient presents with **fever**, **foul-smelling lochia**, **uterine tenderness**, and **leukocytosis with left shift** on postpartum day three after a cesarean section, which are classic signs of **postpartum endometritis**.
* The recommended first-line treatment for **postpartum endometritis** is **broad-spectrum intravenous antibiotics**, typically a combination of **clindamycin** and **gentamicin**, which covers the polymicrobial nature of the infection, including anaerobes and gram-negative rods.
*Endometrial culture*
* While useful for identifying specific pathogens, **endometrial cultures** are generally **not recommended prior to initiating treatment for postpartum endometritis** as the infection is typically polymicrobial, and treatment should be started empirically.
* **Contamination with normal vaginal flora** is a significant concern, making interpretation of cultures difficult and potentially delaying appropriate treatment.
*Prophylactic intravenous cefazolin treatment*
* **Cefazolin** is a first-generation cephalosporin often used for **surgical prophylaxis** before a cesarean section to prevent infection.
* This patient already has clear signs of an established **postpartum infection (endometritis)**, so prophylactic antibiotics are no longer appropriate; she requires therapeutic treatment.
*Intramuscular cefotetan treatment*
* **Cefotetan** is a second-generation cephalosporin with good coverage against some anaerobes and gram-negative bacteria.
* However, for established **postpartum endometritis**, especially after a cesarean section, **intravenous administration** of broad-spectrum antibiotics is preferred for faster therapeutic levels and better efficacy than intramuscular delivery.
*Blood culture*
* **Blood cultures** are important to rule out **bacteremia** or **sepsis**, especially in patients with high fever or signs of systemic illness.
* While an important diagnostic step, it is **not the *next best step in management*** for a patient with clear signs of endometritis; empirical antibiotic therapy should be initiated promptly while awaiting culture results.
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