A 29-year-old woman, gravida 1, para 0, at 36 weeks' gestation is brought to the emergency department after an episode of dizziness and vomiting followed by loss of consciousness lasting 1 minute. She reports that her symptoms started after lying down on her back to rest, as she felt tired during yoga class. Her pregnancy has been uncomplicated. On arrival, she is diaphoretic and pale. Her pulse is 115/min and blood pressure is 90/58 mm Hg. On examination, the patient is lying in the supine position with a fundal height of 36 cm. There is a prolonged fetal heart rate deceleration to 80/min. Which of the following is the most appropriate action to reverse this patient's symptoms in the future?
Q62
A 39-year-old woman, gravida 3, para 2, at 32 weeks' gestation comes to the emergency department 1 hour after the sudden onset of severe abdominal pain and nausea. She has had one episode of nonbloody vomiting. Pregnancy has been uncomplicated, except for a blood pressure measurement of 150/90 mm Hg on her last prenatal visit. Her first child was delivered vaginally; her second child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. She appears anxious and pale. Her temperature is 36.1°C (96°F), pulse is 115/min, and blood pressure is 92/65 mm Hg. Extremities are cool and clammy. Pelvic examination shows a rigid, tender uterus. The cervix is 30% effaced and 1 cm dilated; the vertex is at -1 station. The fetal heart rate is 100/min. Which of the following is the most likely diagnosis?
Q63
A 24-year-old primigravida presents at 36 weeks gestation with vaginal bleeding, mild abdominal pain, and uterine contractions that appeared after bumping into a handrail. The vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 79/min, respiratory rate 12/min, and temperature 36.5℃ (97.7℉). The fetal heart rate was 145/min. Uterine fundus is at the level of the xiphoid process. Slight uterine tenderness and contractions are noted on palpation. The perineum is bloody. The gynecologic examination shows no vaginal or cervical lesions. The cervix is long and closed. Streaks of bright red blood are passing through the cervix. A transabdominal ultrasound shows the placenta to be attached to the lateral uterine wall with a marginal retroplacental hematoma (an approximate volume of 150 ml). The maternal hematocrit is 36%. What is the next best step in the management of this patient?
Q64
Three hours after the onset of labor, a 39-year-old woman, gravida 2, para 1, at 40 weeks' gestation has sudden worsening of abdominal pain and vaginal bleeding. 18 months ago her first child was delivered by a lower segment transverse cesarean section because of cephalopelvic disproportion. Her temperature is 37.5°C (99.5°F), pulse is 120/min, respirations are 20/min, and blood pressure is 90/50 mm Hg. Examination shows abdominal tenderness and the absence of uterine contractions. The cervix is 100% effaced and 10 cm dilated; the vertex is at -3 station. An hour before, the vertex was at 0 station. Cardiotocography shows fetal bradycardia, late decelerations, and decreased amplitude of uterine contractions. Which of the following is the most specific feature of this patient's condition?
Q65
A 16-year-old girl presents to the emergency department complaining of acute bilateral lower quadrant abdominal pain. She states she is nauseous and reports a 24-hour history of multiple episodes of vomiting. She admits to having unprotected sex with multiple partners. Her temperature is 102.0°F (38.9°C). Physical examination reveals bilateral lower quadrant tenderness. Bimanual pelvic exam reveals cervical exudate and cervical motion tenderness. Her β-HCG is within normal limits. Transvaginal ultrasound reveals a tubular complex lesion located in the right lower quadrant. Which of the following is the most appropriate initial step in the treatment of this patient?
Q66
A previously healthy 20-year-old woman comes to her physician because of pain during sexual intercourse. She recently became sexually active with her boyfriend. She has had no other sexual partners. She is frustrated because she has consistently been experiencing a severe, sharp vaginal pain on penetration. She has tried lubricants without significant relief. She has not been able to use tampons in the past due to similar pain with tampon insertion. External vulvar examination shows no abnormalities. She is unable to undergo a bimanual or speculum exam due to intracoital pain with attempted digit or speculum insertion. Testing for Chlamydia trachomatis and Neisseria gonorrhoeae is negative. Which of the following is the best next step in management?
Q67
A 28-year-old woman at 30 weeks gestation is rushed to the emergency room with the sudden onset of vaginal bleeding accompanied by intense abdominopelvic pain and uterine contractions. The intensity and frequency of pain have increased in the past 2 hours. This is her 1st pregnancy and she was diagnosed with gestational diabetes several weeks ago. Her vital signs include a blood pressure of 124/68 mm Hg, a pulse of 77/min, a respiratory rate of 22/min, and a temperature of 37.0°C (98.6°F). The abdominal examination is positive for a firm and tender uterus. An immediate cardiotocographic evaluation reveals a fetal heart rate of 150/min with prolonged and repetitive decelerations and high-frequency and low-amplitude uterine contractions. Your attending physician warns you about delaying the vaginal physical examination until a quick sonographic evaluation is completed. Which of the following is the most likely diagnosis in this patient?
Q68
A 52-year-old woman presents with involuntary passage of urine and occasional watery vaginal discharge. She associates the onset of these symptoms with her discharge from the hospital for an abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial carcinoma and a left ovary cyst 2 months ago. The incontinence occurs during both day and night and is not related to physical exertion. She denies urgency, incomplete voiding, painful urination, or any other genitourinary symptoms. She is currently on hormone replacement therapy. Her vital signs are as follows: blood pressure, 120/80 mm Hg; heart rate, 77/min; respiratory rate, 13/min; and temperature, 36.6℃ (97.9℉). On physical examination, there is no costovertebral or suprapubic tenderness. The surgical scar is normal in appearance. The gynecologic examination revealed a small opening in the upper portion of the anterior wall of the vagina. No discharge was noted. How would you confirm the diagnosis?
Q69
A 42-year-old woman comes to the physician because of right flank pain that started 3 days following a procedure. Her vital signs are within normal limits. Physical examination shows right costovertebral angle tenderness. An intravenous pyelogram shows a dilated renal pelvis and ureter on the right with a lack of contrast proximal to the ureterovesical junction. This patient most likely recently underwent which of the following procedures?
Q70
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?
Labor Complications US Medical PG Practice Questions and MCQs
Question 61: A 29-year-old woman, gravida 1, para 0, at 36 weeks' gestation is brought to the emergency department after an episode of dizziness and vomiting followed by loss of consciousness lasting 1 minute. She reports that her symptoms started after lying down on her back to rest, as she felt tired during yoga class. Her pregnancy has been uncomplicated. On arrival, she is diaphoretic and pale. Her pulse is 115/min and blood pressure is 90/58 mm Hg. On examination, the patient is lying in the supine position with a fundal height of 36 cm. There is a prolonged fetal heart rate deceleration to 80/min. Which of the following is the most appropriate action to reverse this patient's symptoms in the future?
A. Performing the Muller maneuver
B. Gentle compression with an abdominal binder
C. Lying in the supine position and elevating legs
D. Lying in the left lateral decubitus position (Correct Answer)
E. Performing the Valsava maneuver
Explanation: ***Lying in the left lateral decubitus position***
- This position relieves **aortocaval compression** by moving the uterus off the **inferior vena cava (IVC)** and aorta.
- Alleviating IVC compression increases **venous return** to the heart, improving **cardiac output** and blood pressure, thereby resolving the patient's symptoms and improving **fetal oxygenation**.
*Performing the Muller maneuver*
- The **Muller maneuver** involves forced inspiration against a closed glottis, creating **negative intrathoracic pressure**.
- This maneuver is used to evaluate **upper airway compromise** and would not address the underlying issue of aortocaval compression.
*Gentle compression with an abdominal binder*
- An **abdominal binder** would apply external pressure to the abdomen, which could worsen rather than alleviate **aortocaval compression**.
- This would further reduce **venous return** and potentially exacerbate the patient's **hypotension** and fetal distress.
*Lying in the supine position and elevating legs*
- Lying in the **supine position** is the cause of the patient's symptoms due to **aortocaval syndrome**.
- While **elevating the legs** can temporarily increase venous return from the legs, it would not relieve the compression of the IVC by the gravid uterus.
*Performing the Valsava maneuver*
- The **Valsalva maneuver** involves forced exhalation against a closed glottis, which increases **intrathoracic pressure** and decreases **venous return**.
- This would further reduce **cardiac output** and worsen the symptoms of **hypotension** and **fetal compromise**.
Question 62: A 39-year-old woman, gravida 3, para 2, at 32 weeks' gestation comes to the emergency department 1 hour after the sudden onset of severe abdominal pain and nausea. She has had one episode of nonbloody vomiting. Pregnancy has been uncomplicated, except for a blood pressure measurement of 150/90 mm Hg on her last prenatal visit. Her first child was delivered vaginally; her second child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. She appears anxious and pale. Her temperature is 36.1°C (96°F), pulse is 115/min, and blood pressure is 92/65 mm Hg. Extremities are cool and clammy. Pelvic examination shows a rigid, tender uterus. The cervix is 30% effaced and 1 cm dilated; the vertex is at -1 station. The fetal heart rate is 100/min. Which of the following is the most likely diagnosis?
A. Ruptured vasa previa
B. Placenta accreta
C. Abruptio placentae (Correct Answer)
D. Ruptured uterus
E. Placenta previa
Explanation: ***Abruptio placentae***
- The sudden onset of **severe abdominal pain**, **uterine rigidity and tenderness**, maternal hypovolemic shock (tachycardia, hypotension, cool and clammy extremities), and **fetal bradycardia** are classic signs of **abruptio placentae**.
- **Hypertension** (150/90 mm Hg) is a risk factor, and a prior **cesarean section** may slightly increase the risk as well, although the primary risk factor here is hypertension.
*Ruptured vasa previa*
- **Vasa previa** typically presents with **painless vaginal bleeding** when membranes rupture, accompanied by rapid fetal deterioration due to fetal blood loss, and would not cause severe maternal abdominal pain and shock.
- The bleeding in vasa previa originates from fetal vessels, leading to a profound impact on fetal heart rate *before* significant maternal symptoms.
*Placenta accreta*
- **Placenta accreta** is typically diagnosed prenatally via ultrasound or suspected at delivery due to difficulty with placental separation. It does not usually present with acute, severe abdominal pain and hypovolemic shock during pregnancy.
- Patients with placenta accreta are at high risk for significant hemorrhage *after* delivery of the fetus, but before placental delivery.
*Ruptured uterus*
- While a prior **cesarean section** is a risk factor for uterine rupture, the presentation of **rigid and tender uterus** is more characteristic of abruptio placentae. Uterine rupture often involves a **sudden cessation of contractions**, palpable fetal parts outside the uterus, and often severe, sharp pain, but not typically a rigid uterus.
- The fetal heart rate in uterine rupture often shows a **sudden, profound deceleration** or absence, but the specific finding of a rigid, tender uterus with ongoing severe pain points away from frank rupture.
*Placenta previa*
- **Placenta previa** typically presents with **painless vaginal bleeding** in the second or third trimester.
- It does not usually cause severe abdominal pain, uterine tenderness, or maternal hypovolemic shock unless accompanied by abruptio placentae, which is the more dominant and acute finding here.
Question 63: A 24-year-old primigravida presents at 36 weeks gestation with vaginal bleeding, mild abdominal pain, and uterine contractions that appeared after bumping into a handrail. The vital signs are as follows: blood pressure 130/80 mm Hg, heart rate 79/min, respiratory rate 12/min, and temperature 36.5℃ (97.7℉). The fetal heart rate was 145/min. Uterine fundus is at the level of the xiphoid process. Slight uterine tenderness and contractions are noted on palpation. The perineum is bloody. The gynecologic examination shows no vaginal or cervical lesions. The cervix is long and closed. Streaks of bright red blood are passing through the cervix. A transabdominal ultrasound shows the placenta to be attached to the lateral uterine wall with a marginal retroplacental hematoma (an approximate volume of 150 ml). The maternal hematocrit is 36%. What is the next best step in the management of this patient?
A. Manage as an outpatient with modified rest
B. Induction of vaginal labor
C. Corticosteroid administration and schedule a cesarean section after
D. Admit for maternal and fetal monitoring and observation (Correct Answer)
E. Urgent cesarean delivery
Explanation: ***Admit for maternal and fetal monitoring and observation***
- This patient presents with signs of a **mild placental abruption** (vaginal bleeding, contractions, mild abdominal pain, retroplacental hematoma) after trauma, but her **vital signs are stable**, fetal heart rate is reassuring, and the abruption volume is relatively small.
- Expectant management with **close monitoring** for signs of worsening abruption (increasing pain, vital sign changes, fetal distress) is appropriate for a patient at 36 weeks with a non-catastrophic abruption.
*Manage as an outpatient with modified rest*
- Given the presence of **vaginal bleeding, contractions**, and a **retroplacental hematoma** suggesting placental abruption, outpatient management is not safe.
- There is a risk of the abruption progressing, requiring immediate medical intervention, making **hospital admission for close monitoring** essential.
*Induction of vaginal labor*
- While vaginal delivery might be considered for a stable abruption in some cases, **active induction is not the immediate next step** given the patient's stable status and the need for continuous monitoring.
- The **cervix is long and closed**, indicating that she is not in active labor and immediate induction might not be successful or necessary.
*Corticosteroid administration and schedule a cesarean section after*
- **Corticosteroids** are typically administered for fetal lung maturity when delivery is anticipated before **34 weeks of gestation**; at 36 weeks, this is generally not indicated.
- A scheduled cesarean section is premature as the patient is **stable**, and the immediate goal is to monitor for progression or resolution of the abruption, not immediate delivery.
*Urgent cesarean delivery*
- There are no signs of **maternal or fetal distress** (stable vitals, reassuring fetal heart rate) that would necessitate an urgent cesarean delivery.
- An urgent cesarean is reserved for cases of **severe abruption** with significant bleeding, hemodynamic instability, or fetal compromise.
Question 64: Three hours after the onset of labor, a 39-year-old woman, gravida 2, para 1, at 40 weeks' gestation has sudden worsening of abdominal pain and vaginal bleeding. 18 months ago her first child was delivered by a lower segment transverse cesarean section because of cephalopelvic disproportion. Her temperature is 37.5°C (99.5°F), pulse is 120/min, respirations are 20/min, and blood pressure is 90/50 mm Hg. Examination shows abdominal tenderness and the absence of uterine contractions. The cervix is 100% effaced and 10 cm dilated; the vertex is at -3 station. An hour before, the vertex was at 0 station. Cardiotocography shows fetal bradycardia, late decelerations, and decreased amplitude of uterine contractions. Which of the following is the most specific feature of this patient's condition?
A. Loss of fetal station (Correct Answer)
B. Fetal distress
C. Abdominal tenderness
D. Absent uterine contractions
E. Hemodynamic instability
Explanation: ***Loss of fetal station***
- The sudden **retraction of the presenting part** (vertex moving from 0 to -3 station) after a period of labor progression is a classical and highly specific sign of **uterine rupture**.
- This occurs because the uterus tears, allowing the fetus to partially or wholly slip out of the birth canal into the abdominal cavity.
*Fetal distress*
- While fetal bradycardia and late decelerations indicate **fetal distress**, this is a common finding in many obstetric emergencies, including placental abruption and cord prolapse, and is not specific to uterine rupture.
- Fetal distress reflects the immediate impact on the fetus but doesn't pinpoint the exact maternal pathology.
*Abdominal tenderness*
- **Abdominal tenderness** is a general symptom that can be present in various conditions such as placental abruption, chorioamnionitis, or even normal labor with strong contractions, making it non-specific for uterine rupture.
- The type of tenderness and its severity can vary, but by itself, it does not confirm a uterine rupture.
*Absent uterine contractions*
- The cessation of uterine contractions is a significant finding in uterine rupture, as the uterus can no longer effectively contract to expel the fetus.
- However, contractions can also decrease or become absent in cases of maternal exhaustion, failed induction, or excessive analgesia, thus not being entirely specific to rupture.
*Hemodynamic instability*
- The patient's **hypotension** (90/50 mm Hg) and **tachycardia** (120/min) indicate significant blood loss and **hypovolemic shock**, which commonly occur with uterine rupture.
- However, hemodynamic instability can also be seen in other severe obstetric hemorrhages like placental abruption or postpartum hemorrhage from other causes, making it a sensitive but non-specific indicator.
Question 65: A 16-year-old girl presents to the emergency department complaining of acute bilateral lower quadrant abdominal pain. She states she is nauseous and reports a 24-hour history of multiple episodes of vomiting. She admits to having unprotected sex with multiple partners. Her temperature is 102.0°F (38.9°C). Physical examination reveals bilateral lower quadrant tenderness. Bimanual pelvic exam reveals cervical exudate and cervical motion tenderness. Her β-HCG is within normal limits. Transvaginal ultrasound reveals a tubular complex lesion located in the right lower quadrant. Which of the following is the most appropriate initial step in the treatment of this patient?
A. Ceftriaxone and azithromycin (Correct Answer)
B. Levofloxacin and metronidazole
C. Fluconazole
D. Metronidazole
E. Cefoxitin and doxycycline
Explanation: ***Ceftriaxone and azithromycin***
- The patient presents with classic signs and symptoms of **pelvic inflammatory disease (PID)**, including acute lower abdominal pain, fever, cervical exudate, and cervical motion tenderness.
- **Ceftriaxone** provides coverage against **Neisseria gonorrhoeae**, and **azithromycin** covers **Chlamydia trachomatis**, which are the most common causative organisms for PID.
*Levofloxacin and metronidazole*
- While **levofloxacin** is recommended for some sexually transmitted infections, it is generally considered a second-line or alternative agent for PID treatment in specific cases, and **metronidazole** covers anaerobes, but is usually added for severe cases or those with tubo-ovarian abscesses.
- This combination is not the primary empiric regimen for uncomplicated PID given the high prevalence of gonorrhea and chlamydia.
*Fluconazole*
- **Fluconazole** is an antifungal medication primarily used to treat ** Candida infections**, such as vaginal candidiasis.
- It has no antibacterial activity against the common bacterial pathogens causing PID.
*Metronidazole*
- **Metronidazole** is an antibiotic effective against **anaerobic bacteria** and certain parasites.
- While anaerobes can play a role in PID, especially in abscess formation, it is not sufficient as a monotherapy for initial empiric treatment of PID, which requires broad-spectrum coverage for gonorrhea and chlamydia.
*Cefoxitin and doxycycline*
- **Cefoxitin** is a second-generation cephalosporin that covers sensitive *Neisseria gonorrhoeae*, and **doxycycline** covers *Chlamydia trachomatis*. These are appropriate for inpatient regimens or when cefoxitin is available.
- However, for outpatient PID treatment, **ceftriaxone** is often preferred due to its single-dose administration and well-established efficacy, combined with azithromycin.
Question 66: A previously healthy 20-year-old woman comes to her physician because of pain during sexual intercourse. She recently became sexually active with her boyfriend. She has had no other sexual partners. She is frustrated because she has consistently been experiencing a severe, sharp vaginal pain on penetration. She has tried lubricants without significant relief. She has not been able to use tampons in the past due to similar pain with tampon insertion. External vulvar examination shows no abnormalities. She is unable to undergo a bimanual or speculum exam due to intracoital pain with attempted digit or speculum insertion. Testing for Chlamydia trachomatis and Neisseria gonorrhoeae is negative. Which of the following is the best next step in management?
A. Sex psychotherapy
B. Lorazepam
C. Vaginal estrogen cream
D. Vaginal Botox injections
E. Pelvic floor physical therapy (Correct Answer)
Explanation: ***Pelvic floor physical therapy***
- This patient's symptoms of **severe, sharp vaginal pain on penetration (dyspareunia)**, inability to use tampons, and pain during attempted gynecological exams are classic for **vaginismus**, a type of **genito-pelvic pain/penetration disorder**.
- **Pelvic floor physical therapy** is the **first-line treatment** for vaginismus, as it aims to relax and desensitize the hypertonic and painful pelvic floor muscles.
*Sex psychotherapy*
- While psychological factors often contribute to and are exacerbated by vaginismus, **psychotherapy alone is typically not sufficient** as a primary treatment for the physical muscular spasm and pain.
- It may be a useful adjunct to address anxiety, fear, or relationship issues, but it does not directly treat the **hypertonicity of the pelvic floor muscles**.
*Lorazepam*
- **Lorazepam is an anxiolytic** and could potentially help with anxiety related to sexual activity, but it does not directly address the **localized muscular spasm** causing vaginismus.
- Using systemic sedatives for localized pain is **not a targeted or appropriate primary treatment** for this condition.
*Vaginal estrogen cream*
- **Vaginal estrogen cream** is used to treat **atrophic vaginitis**, which is characterized by vaginal dryness, thinning of vaginal tissue, and pain, typically in **postmenopausal women** or those with estrogen deficiency.
- This young, previously healthy 20-year-old woman is unlikely to have **vaginal atrophy**, and her symptoms of pain with tampon insertion predate sexual activity.
*Vaginal Botox injections*
- **Botox (botulinum toxin)** injections into the pelvic floor muscles can be used in **refractory cases of vaginismus** after failure of conservative treatments like physical therapy.
- It is an **invasive and second-line option**, not the best initial step for a newly diagnosed case.
Question 67: A 28-year-old woman at 30 weeks gestation is rushed to the emergency room with the sudden onset of vaginal bleeding accompanied by intense abdominopelvic pain and uterine contractions. The intensity and frequency of pain have increased in the past 2 hours. This is her 1st pregnancy and she was diagnosed with gestational diabetes several weeks ago. Her vital signs include a blood pressure of 124/68 mm Hg, a pulse of 77/min, a respiratory rate of 22/min, and a temperature of 37.0°C (98.6°F). The abdominal examination is positive for a firm and tender uterus. An immediate cardiotocographic evaluation reveals a fetal heart rate of 150/min with prolonged and repetitive decelerations and high-frequency and low-amplitude uterine contractions. Your attending physician warns you about delaying the vaginal physical examination until a quick sonographic evaluation is completed. Which of the following is the most likely diagnosis in this patient?
A. Miscarriage
B. Vasa previa
C. Placenta abruption (Correct Answer)
D. Placenta previa
E. Uterine rupture
Explanation: **Placenta abruption**
- The sudden onset of **vaginal bleeding** with **intense abdominopelvic pain**, **uterine contractions**, and a **firm, tender uterus** strongly suggests **placental abruption**.
- **Fetal decelerations** and the physician's warning against immediate vaginal examination (due to potential for exacerbating hemorrhage if it were placenta previa) further support this diagnosis.
*Miscarriage*
- This patient is at **30 weeks gestation**, whereas a miscarriage is defined as pregnancy loss before **20 weeks of gestation**.
- While bleeding and pain occur, the gestational age rules against a diagnosis of miscarriage.
*Vasa previa*
- **Vasa previa** is characterized by rupture of fetal vessels, leading to **fetal bleeding** and **sudden, painless vaginal bleeding**.
- The patient's presentation includes **intense abdominopelvic pain** and **uterine contractions**, which are not typical of vasa previa.
*Placenta previa*
- **Placenta previa** typically presents with **painless vaginal bleeding** and usually does not involve intense abdominal pain or a **firm, tender uterus**.
- The patient's symptoms of significant pain and uterine contractions are inconsistent with placenta previa.
*Uterine rupture*
- **Uterine rupture** is a catastrophic event, often preceded by a history of **uterine surgery** or trauma, and presents with sudden, severe pain, **fetal distress**, and a **palpable fetal parts** outside the uterus.
- While there is pain and fetal distress, the presence of a **firm, tender uterus** and the absence of a history of uterine surgery make abruption a more likely diagnosis.
Question 68: A 52-year-old woman presents with involuntary passage of urine and occasional watery vaginal discharge. She associates the onset of these symptoms with her discharge from the hospital for an abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial carcinoma and a left ovary cyst 2 months ago. The incontinence occurs during both day and night and is not related to physical exertion. She denies urgency, incomplete voiding, painful urination, or any other genitourinary symptoms. She is currently on hormone replacement therapy. Her vital signs are as follows: blood pressure, 120/80 mm Hg; heart rate, 77/min; respiratory rate, 13/min; and temperature, 36.6℃ (97.9℉). On physical examination, there is no costovertebral or suprapubic tenderness. The surgical scar is normal in appearance. The gynecologic examination revealed a small opening in the upper portion of the anterior wall of the vagina. No discharge was noted. How would you confirm the diagnosis?
A. Cystometry
B. Voiding cystourethrography (Correct Answer)
C. Urine flow test
D. Transabdominal ultrasound
E. Antegrade pyelography
Explanation: ***Voiding cystourethrography***
- This imaging technique involves filling the bladder with contrast and taking X-rays during voiding, which would clearly demonstrate a **vesicovaginal fistula** by showing contrast leakage into the vagina.
- The patient's history of recent pelvic surgery for gynecological cancer, continuous leakage unrelated to exertion, and the finding of a small opening in the anterior vaginal wall are highly suggestive of a **fistula**.
*Cystometry*
- This test measures bladder pressure and volume during filling and emptying and is useful for evaluating **detrusor activity** and bladder capacity.
- It would not directly visualize a fistula or the leakage of urine into the vagina, making it less effective for confirming this specific diagnosis.
*Urine flow test*
- This measures the **rate and volume of urine flow** during voiding, assessing for outflow obstruction or bladder muscle weakness.
- It would not provide direct evidence of a vesicovaginal fistula and is more useful for complaints like urgency, frequency, or incomplete voiding.
*Transabdominal ultrasound*
- While useful for visualizing the overall urinary tract and reproductive organs, a transabdominal ultrasound may not reliably detect a small **vesicovaginal fistula**, especially without contrast enhancement.
- Its primary role is to assess for **hydronephrosis** or large anatomical abnormalities, not small fistulous tracts.
*Antegrade pyelography*
- This involves injecting contrast directly into the kidney's collecting system, typically used to evaluate the **upper urinary tract** for obstructions or fistulae originating in the ureters or kidneys.
- Given the symptoms and physical exam findings pointing towards a connection between the bladder and vagina, antegrade pyelography would not be the most direct or appropriate test.
Question 69: A 42-year-old woman comes to the physician because of right flank pain that started 3 days following a procedure. Her vital signs are within normal limits. Physical examination shows right costovertebral angle tenderness. An intravenous pyelogram shows a dilated renal pelvis and ureter on the right with a lack of contrast proximal to the ureterovesical junction. This patient most likely recently underwent which of the following procedures?
A. Hysterectomy (Correct Answer)
B. Foley catheter insertion
C. Cesarean delivery
D. Appendectomy
E. Inguinal hernia repair
Explanation: ***Hysterectomy***
- **Ureteral injury** is a known complication of hysterectomy due to the ureter's close proximity to the uterine arteries and adnexa, especially near the **ureterovesical junction**.
- The presented symptoms of flank pain, CVA tenderness, and hydronephrosis (dilated renal pelvis and ureter with lack of contrast flow) occurring post-procedure strongly indicate **ureteral obstruction** or injury during the surgery.
*Foley catheter insertion*
- While catheterization can cause trauma, it would typically lead to **urethral or bladder injury**, not a ureteral obstruction at the ureterovesical junction causing hydronephrosis.
- The symptoms are more consistent with an injury higher up in the urinary tract that is not usually associated with a Foley catheter.
*Cesarean delivery*
- A C-section involves opening the abdomen to deliver a baby, but it generally does not involve dissection near the ureters to the extent that a hysterectomy does, making ureteral injury less common.
- The primary surgical field during a C-section is the uterus, while ureteral injury is more characteristic of procedures involving extensive pelvic dissection, such as hysterectomy.
*Appendectomy*
- An appendectomy is a procedure to remove the appendix and typically involves the right lower quadrant of the abdomen, away from the course of the ureter and ureterovesical junction.
- Injury to the ureter is a very rare complication of appendectomy and would not typically manifest as this type of obstruction.
*Inguinal hernia repair*
- Inguinal hernia repair involves structures in the groin region, anterior to the peritoneal cavity, and is far removed from the ureters and bladder.
- Ureteral injury is not a recognized complication of inguinal hernia repair.
Question 70: 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.
