A 28-year-old woman, gravida 2, para 1, at 31 weeks gestation is admitted to the hospital because of regular contractions and pelvic pressure for 3 hours. Her pregnancy has been uncomplicated so far. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. She has no history of fluid leakage or bleeding. Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation. She smoked 1 pack of cigarettes daily for 10 years before pregnancy and has smoked 4 cigarettes daily during pregnancy. At the hospital, her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 16/min. Cervical examination shows 2 cm dilation with intact membranes. Fetal examination shows no abnormalities. A cardiotocography shows a contraction amplitude of 220 montevideo units (MVU) in 10 minutes. Which of the following is the most appropriate pharmacotherapy at this time?
Q72
A 23-year-old gravida 1-para-1 (G1P1) presents to the emergency department with severe lower abdominal pain that started several hours ago. She has had fevers, malaise, and nausea for the last 2 days. Her last menstrual period was 3 weeks ago. Her past medical history is insignificant. She has had 3 sexual partners in the past 1 month and uses oral contraception. The vital signs include temperature 38.8°C (101.8°F), and blood pressure 120/75 mm Hg. On physical examination, there is abdominal tenderness in the lower quadrants. Uterine and adnexal tenderness is also elicited. A urine test is negative for pregnancy. On speculum examination, the cervix is inflamed with motion tenderness and a yellow-white purulent discharge. Which of the following is the most likely diagnosis?
Q73
A 42-year-old G3P3003 presents to her gynecologist for an annual visit. She complains of urinary incontinence when jogging since the birth of her last child three years ago. Her periods are regular every 30 days. The patient also has cramping that is worse before and during her period but always present at baseline. She describes a feeling of heaviness in her pelvis that is exacerbated by standing for several hours at her job as a cashier. The patient has had two spontaneous vaginal deliveries, one caesarean section, and currently uses condoms for contraception. She is obese and smokes a pack of cigarettes a day. Her mother died of breast cancer at age 69, and her aunt is undergoing treatment for endometrial cancer. The patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 142/81 mmHg, and respirations are 13/min. Pelvic exam is notable for a uterine fundus palpated just above the pubic symphysis and a boggy, smooth texture to the uterus. There is no tenderness or mass in the adnexa, and no uterosacral nodularity is noted. Which of the following is a classic pathological feature of this patient’s most likely diagnosis?
Q74
A 19-year-old woman with no known past medical history presents to the emergency department with increasing lower pelvic pain and vaginal discharge over the last several days. She endorses some experimentation with marijuana and cocaine, drinks liquor almost daily, and smokes 2 packs of cigarettes per day. The patient's blood pressure is 84/66 mm Hg, pulse is 121/min, respiratory rate is 16/min, and temperature is 39.5°C (103.1°F). Physical examination reveals profuse yellow-green vaginal discharge and severe cervical motion tenderness. What is the most appropriate definitive treatment for this patient’s presumed diagnosis?
Q75
A 26-year-old woman presents to her gynecologist with complaints of pain with her menses and during intercourse. She also complains of chest pain that occurs whenever she has her menstrual period. The patient has a past medical history of bipolar disorder and borderline personality disorder. Her current medications include lithium and haloperidol. Review of systems is notable only for pain when she has a bowel movement relieved by defecation. Her temperature is 98.2°F (36.8°C), blood pressure is 114/74 mmHg, pulse is 70/min, respirations are 14/min, and oxygen saturation is 98% on room air. Pelvic exam is notable for a tender adnexal mass. The patient's uterus is soft, boggy, and tender. Which of the following is the most appropriate method of confirming the diagnosis in this patient?
Q76
A 37-year-old woman, gravida 3, para 3, comes to the physician for very painful menses that have caused her to miss at least 3 days of work during each menstrual cycle for the past 6 months. Menses occur with heavy bleeding at regular 28-day intervals. She also has constant dull pain in the pelvic region between cycles. She is otherwise healthy. She weighs 53 kg (117 lb) and is 160 cm tall; BMI is 20.7 kg/m2. Pelvic examination shows no abnormalities. Pelvic ultrasonography shows a uniformly enlarged uterus and asymmetric thickening of the myometrial wall with a poorly defined endomyometrial border. Which of the following is the most likely cause of these findings?
Q77
A 35-year-old G3P2 woman currently 39 weeks pregnant presents to the emergency department with painful vaginal bleeding shortly after a motor vehicle accident in which she was a passenger. She had her seat belt on and reports that the airbag deployed immediately upon her car's impact against a tree. She admits that she actively smokes cigarettes. Her prenatal workup is unremarkable. Her previous pregnancies were remarkable for one episode of chorioamnionitis that resolved with antibiotics. Her temperature is 98.6°F (37°C), blood pressure is 90/60 mmHg, pulse is 130/min, and respirations are 20/min. The fetal pulse is 110/min. Her uterus is tender and firm. The remainder of her physical exam is unremarkable. What is the most likely diagnosis?
Q78
A woman presents to the emergency department due to abdominal pain that began 1 hour ago. She is in the 35th week of her pregnancy when the pain came on during dinner. She also noted a clear rush of fluid that came from her vagina. The patient has a past medical history of depression which is treated with cognitive behavioral therapy. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy young woman who complains of painful abdominal contractions that occur every few minutes. Laboratory studies are ordered as seen below.
Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 197,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
Lecithin/Sphingomyelin: 1.5
AST: 12 U/L
ALT: 10 U/L
Which of the following is the best next step in management?
Q79
A 36-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of a gush of clear fluid from her vagina that occurred 1 hour prior. She reports painful pelvic cramping at regular 5-minute intervals. She has missed most of her prenatal care visit because of financial problems from her recent divorce. Her first child was delivered vaginally at 27 weeks' gestation due to spontaneous preterm labor. She has smoked one pack of cigarettes daily for 15 years but has reduced her intake to 2–3 cigarettes per day since finding out she was pregnant. She continues to use cocaine once a week. Vital signs are within normal limits. Sterile speculum examination shows fluid pooling in the vagina, and nitrazine paper testing confirms the presence of amniotic fluid. Which of the following puts her at highest risk of preterm delivery?
Q80
A 37-year-old woman, gravida 3, para 2, at 35 weeks' gestation is brought to the emergency department for the evaluation of lower abdominal and back pain and vaginal bleeding that started one hour ago. She has had no prenatal care. Her first two pregnancies were uncomplicated and her children were delivered vaginally. The patient smoked one pack of cigarettes daily for 20 years; she reduced to half a pack every 2 days during her pregnancies. Her pulse is 80/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. The uterus is tender, and regular hypertonic contractions are felt every 2 minutes. There is dark blood on the vulva, the introitus, and on the medial aspect of both thighs bilaterally. The fetus is in a cephalic presentation. The fetal heart rate is 158/min and reactive with no decelerations. Which of the following is the most appropriate next step in management?
Labor Complications US Medical PG Practice Questions and MCQs
Question 71: A 28-year-old woman, gravida 2, para 1, at 31 weeks gestation is admitted to the hospital because of regular contractions and pelvic pressure for 3 hours. Her pregnancy has been uncomplicated so far. She has attended many prenatal appointments and followed the physician's advice about screening for diseases, laboratory testing, diet, and exercise. She has no history of fluid leakage or bleeding. Her previous pregnancy was complicated by a preterm delivery at 34 weeks gestation. She smoked 1 pack of cigarettes daily for 10 years before pregnancy and has smoked 4 cigarettes daily during pregnancy. At the hospital, her temperature is 37.2°C (99.0°F), blood pressure is 108/60 mm Hg, pulse is 88/min, and respirations are 16/min. Cervical examination shows 2 cm dilation with intact membranes. Fetal examination shows no abnormalities. A cardiotocography shows a contraction amplitude of 220 montevideo units (MVU) in 10 minutes. Which of the following is the most appropriate pharmacotherapy at this time?
A. Magnesium sulfate + Betamethasone (Correct Answer)
B. Betamethasone + Progesterone
C. Progesterone + Terbutaline
D. Oxytocin + Magnesium sulfate
E. Terbutaline + Oxytocin
Explanation: ***Magnesium sulfate + Betamethasone***
- This patient is experiencing **preterm labor** at 31 weeks gestation, as evidenced by regular contractions, cervical dilation, and a previous preterm delivery. **Magnesium sulfate** is an appropriate **tocolytic** to inhibit uterine contractions and prevent preterm birth.
- **Betamethasone** is indicated for **fetal lung maturity** between 24 and 34 weeks of gestation when preterm delivery is threatened, significantly reducing the risk of respiratory distress syndrome.
*Betamethasone + Progesterone*
- While **betamethasone** is correctly indicated for fetal lung maturity, **progesterone** is not used for acute management of preterm labor.
- Progesterone is typically used as a prophylactic measure to prevent recurrent preterm birth in women with a history of it, often started earlier in pregnancy.
*Progesterone + Terbutaline*
- **Progesterone** is not indicated for acute management of preterm labor.
- **Terbutaline** is a beta-mimetic **tocolytic** that can be used, but in acute situations, magnesium sulfate is often preferred for its neuroprotective effects in addition to tocolysis.
*Oxytocin + Magnesium sulfate*
- **Oxytocin** is a uterotonic agent used to **induce or augment labor**, which is contraindicated in preterm labor where the goal is to stop contractions.
- While magnesium sulfate is appropriate, combining it with oxytocin would contradict the management strategy for preterm labor.
*Terbutaline + Oxytocin*
- **Terbutaline** is a **tocolytic** used to suppress preterm labor, but combining it with **oxytocin**, a uterotonic that stimulates contractions, would be contradictory and harmful.
- The goal in preterm labor is to inhibit contractions, not to stimulate them.
Question 72: A 23-year-old gravida 1-para-1 (G1P1) presents to the emergency department with severe lower abdominal pain that started several hours ago. She has had fevers, malaise, and nausea for the last 2 days. Her last menstrual period was 3 weeks ago. Her past medical history is insignificant. She has had 3 sexual partners in the past 1 month and uses oral contraception. The vital signs include temperature 38.8°C (101.8°F), and blood pressure 120/75 mm Hg. On physical examination, there is abdominal tenderness in the lower quadrants. Uterine and adnexal tenderness is also elicited. A urine test is negative for pregnancy. On speculum examination, the cervix is inflamed with motion tenderness and a yellow-white purulent discharge. Which of the following is the most likely diagnosis?
A. Pelvic inflammatory disease (Correct Answer)
B. Cervicitis
C. Vaginitis
D. Ruptured ectopic pregnancy
E. Urinary tract infection
Explanation: ***Pelvic inflammatory disease***
- The patient's history of **multiple sexual partners**, **low abdominal pain**, **fever**, **cervical motion tenderness**, **uterine/adnexal tenderness**, and **purulent cervical discharge** are all classic findings of PID.
- PID is an infection of the upper female reproductive tract, often caused by **STIs** like gonorrhea or chlamydia, which ascend from the cervix.
*Cervicitis*
- While **cervicitis** (inflamed cervix with purulent discharge) is present, it is a component of PID and does not explain the **upper tract involvement** (uterine and adnexal tenderness, lower abdominal pain, fever).
- Cervicitis represents a localized infection of the cervix, but the presence of **systemic symptoms** and **adnexal pain** indicates a more widespread infection.
*Vaginitis*
- **Vaginitis** typically presents with vaginal itching, irritation, and discharge, often without significant **abdominal pain** or **fever**, and usually lacks **cervical motion** or **adnexal tenderness**.
- The patient's symptoms are more severe and indicative of an **ascending infection** beyond the vagina.
*Ruptured ectopic pregnancy*
- A ruptured ectopic pregnancy would present with **severe abdominal pain**, but a **negative pregnancy test** rules out this diagnosis.
- Patients typically experience **hemodynamic instability** (e.g., hypotension) and possibly **vaginal bleeding**, which are not described here.
*Urinary tract infection*
- A **urinary tract infection** would primarily cause dysuria, frequency, urgency, and suprapubic pain, often without **cervical discharge** or profound **uterine/adnexal tenderness**.
- The patient's presentation, particularly the **cervical findings** and **adnexal tenderness**, points away from a simple UTI.
Question 73: A 42-year-old G3P3003 presents to her gynecologist for an annual visit. She complains of urinary incontinence when jogging since the birth of her last child three years ago. Her periods are regular every 30 days. The patient also has cramping that is worse before and during her period but always present at baseline. She describes a feeling of heaviness in her pelvis that is exacerbated by standing for several hours at her job as a cashier. The patient has had two spontaneous vaginal deliveries, one caesarean section, and currently uses condoms for contraception. She is obese and smokes a pack of cigarettes a day. Her mother died of breast cancer at age 69, and her aunt is undergoing treatment for endometrial cancer. The patient’s temperature is 98.6°F (37.0°C), pulse is 70/min, blood pressure is 142/81 mmHg, and respirations are 13/min. Pelvic exam is notable for a uterine fundus palpated just above the pubic symphysis and a boggy, smooth texture to the uterus. There is no tenderness or mass in the adnexa, and no uterosacral nodularity is noted. Which of the following is a classic pathological feature of this patient’s most likely diagnosis?
A. Focal hyperplasia of the myometrium
B. Presence of endometrial tissue outside of the uterus
C. Nuclear atypia of endometrial cells
D. Presence of endometrial tissue within the myometrium (Correct Answer)
E. No pathognomonic findings expected
Explanation: ***Presence of endometrial tissue within the myometrium***
- The patient's symptoms of **dysmenorrhea**, **pelvic heaviness**, and an **enlarged, boggy uterus** are classic for **adenomyosis**.
- **Adenomyosis** is pathologically characterized by the presence of **endometrial glands and stroma** directly within the **myometrial muscle** of the uterus.
*Focal hyperplasia of the myometrium*
- While the myometrium may be enlarged due to adenomyosis, **focal hyperplasia** specifically refers to an increase in the number of muscle cells in a localized area, which is more characteristic of a **leiomyoma (fibroid)**, which typically presents with a **firm, often irregularly shaped uterus**.
- The patient's uterus is described as **smooth and boggy**, rather than firm and nodular.
*Presence of endometrial tissue outside of the uterus*
- This describes **endometriosis**, which involves endometrial tissue in locations such as the ovaries, peritoneum, or bowel.
- While endometriosis can cause dysmenorrhea and pelvic pain, it typically does not present with a **globular, boggy uterus** as seen in adenomyosis.
*Nuclear atypia of endometrial cells*
- **Nuclear atypia** refers to abnormal changes in the nuclei of endometrial cells, which is a feature of **endometrial hyperplasia with atypia** or **endometrial cancer**.
- This patient's clinical presentation, specifically the boggy uterus and chronic pelvic pain, is not primarily indicative of an immediate malignant process of the endometrium.
*No pathognomonic findings expected*
- This statement is incorrect because adenomyosis has a distinct and recognizable pathological feature: **ectopic endometrial tissue within the myometrium**.
- The clinical findings strongly point towards a specific diagnosis that can be confirmed histologically.
Question 74: A 19-year-old woman with no known past medical history presents to the emergency department with increasing lower pelvic pain and vaginal discharge over the last several days. She endorses some experimentation with marijuana and cocaine, drinks liquor almost daily, and smokes 2 packs of cigarettes per day. The patient's blood pressure is 84/66 mm Hg, pulse is 121/min, respiratory rate is 16/min, and temperature is 39.5°C (103.1°F). Physical examination reveals profuse yellow-green vaginal discharge and severe cervical motion tenderness. What is the most appropriate definitive treatment for this patient’s presumed diagnosis?
A. Cefoxitin × 14 days
B. Single-dose ceftriaxone IM
C. Clindamycin + gentamicin × 14 days (Correct Answer)
D. Exploratory laparotomy
E. Levofloxacin and metronidazole × 14 days
Explanation: ***Clindamycin + gentamicin × 14 days***
- This combination is the recommended inpatient treatment for **severe pelvic inflammatory disease (PID)**, which this patient likely has given her symptoms of **pelvic pain**, **vaginal discharge**, **fever**, **tachycardia**, and **cervical motion tenderness**. The patient's **hypotension** and **fever** suggest systemic involvement and a need for inpatient IV antibiotics.
- **Clindamycin** provides coverage for **anaerobes** (important for treating tubo-ovarian abscesses) and some gram-positives, while **gentamicin** is a broad-spectrum antibiotic covering **gram-negative bacteria**, including *Neisseria gonorrhoeae* and *Chlamydia trachomatis*, which are common causes of PID.
*Cefoxitin × 14 days*
- While **cefoxitin** is a second-generation cephalosporin used in PID treatment, it is typically given in combination with **doxycycline** and for a shorter duration (e.g., 24-48 hours intravenously, transitioning to oral doxycycline) for less severe cases or as part of a regimen that does not include systemic signs like hypotension and fever.
- Using cefoxitin monotherapy for 14 days is not a standard or sufficiently broad-spectrum approach for severe PID requiring inpatient care, especially without anaerobic coverage.
*Single-dose ceftriaxone IM*
- **Single-dose ceftriaxone IM** is appropriate for uncomplicated **gonorrhea** but is insufficient for treating **PID**, especially in a patient with severe symptoms, fever, and signs of systemic inflammatory response (hypotension, tachycardia).
- PID requires a longer course of antibiotics to prevent long-term complications such as infertility and chronic pelvic pain.
*Exploratory laparotomy*
- **Exploratory laparotomy** is a surgical intervention and is typically reserved for cases of **suspected ruptured tubo-ovarian abscess (TOA)**, failure of medical management, or diagnostic uncertainty unresponsive to antibiotics.
- While a **tubo-ovarian abscess** can be a complication of severe PID, initial management is usually medical unless there are clear signs of rupture or sepsis unresponsive to antibiotics.
*Levofloxacin and metronidazole × 14 days*
- This oral regimen (levofloxacin combines well with metronidazole) could be used as an outpatient treatment for **mild to moderate PID** or as a step-down therapy after initial intravenous treatment.
- Given the patient's **hypotension** and **fever**, oral antibiotics alone are not appropriate for initial definitive treatment, which requires inpatient intravenous therapy to achieve adequate systemic levels rapidly.
Question 75: A 26-year-old woman presents to her gynecologist with complaints of pain with her menses and during intercourse. She also complains of chest pain that occurs whenever she has her menstrual period. The patient has a past medical history of bipolar disorder and borderline personality disorder. Her current medications include lithium and haloperidol. Review of systems is notable only for pain when she has a bowel movement relieved by defecation. Her temperature is 98.2°F (36.8°C), blood pressure is 114/74 mmHg, pulse is 70/min, respirations are 14/min, and oxygen saturation is 98% on room air. Pelvic exam is notable for a tender adnexal mass. The patient's uterus is soft, boggy, and tender. Which of the following is the most appropriate method of confirming the diagnosis in this patient?
A. Endometrial biopsy
B. MRI
C. Transvaginal ultrasound
D. Laparoscopy (Correct Answer)
E. Clinical diagnosis
Explanation: ***Laparoscopy***
- **Laparoscopy** with biopsy is considered the **gold standard** for diagnosing endometriosis, allowing direct visualization of endometrial implants and histopathological confirmation.
- The patient's symptoms (dysmenorrhea, dyspareunia, chest pain with menses, and rectal pain with defecation) are highly suggestive of **endometriosis**, and pelvic exam findings (tender adnexal mass, boggy uterus) further support this, making definitive visual and histological confirmation crucial.
*Endometrial biopsy*
- An **endometrial biopsy** samples the uterine lining and is primarily used to diagnose endometrial pathologies, such as hyperplasia or carcinoma, not ectopic endometrial tissue.
- It would not detect or confirm the presence of **endometrial implants** outside the uterus, which is characteristic of endometriosis.
*MRI*
- **MRI** can identify larger endometriomas and deep infiltrating endometriosis but is generally **less sensitive** than laparoscopy for detecting small or superficial endometrial implants.
- While useful for surgical planning, it is not the **definitive diagnostic method** for all forms of endometriosis.
*Transvaginal ultrasound*
- A **transvaginal ultrasound** is a good initial imaging modality, effective for identifying **endometriomas** (cysts) and sometimes adenomyosis, but it cannot definitively diagnose peritoneal endometriosis.
- It offers **limited specificity** for small or diffuse endometrial implants, and the absence of findings does not rule out the disease.
*Clinical diagnosis*
- While the patient's symptoms are highly suggestive, relying solely on a **clinical diagnosis** of endometriosis can be inaccurate, as other conditions can mimic these symptoms.
- A definitive diagnosis is often necessary for **appropriate treatment planning** and ruling out other pathologies, especially given the presence of an adnexal mass.
Question 76: A 37-year-old woman, gravida 3, para 3, comes to the physician for very painful menses that have caused her to miss at least 3 days of work during each menstrual cycle for the past 6 months. Menses occur with heavy bleeding at regular 28-day intervals. She also has constant dull pain in the pelvic region between cycles. She is otherwise healthy. She weighs 53 kg (117 lb) and is 160 cm tall; BMI is 20.7 kg/m2. Pelvic examination shows no abnormalities. Pelvic ultrasonography shows a uniformly enlarged uterus and asymmetric thickening of the myometrial wall with a poorly defined endomyometrial border. Which of the following is the most likely cause of these findings?
A. Endometrial tissue within the uterine wall (Correct Answer)
B. Infection of ovaries, fallopian tubes, and uterus
C. Cystic enlargement of the ovaries
D. Benign smooth muscle tumors of the uterus
E. Endometrial tissue in the fallopian tubes
Explanation: ***Endometrial tissue within the uterine wall***
- The classic presentation of **adenomyosis** includes severe dysmenorrhea, menorrhagia, and a uniformly enlarged uterus with diffuse thickening of the myometrial wall and a poorly defined endomyometrial border on ultrasound.
- The presence of **ectopic endometrial glands and stroma** within the myometrium causes inflammation, hypertrophy, and hyperplasia of the surrounding smooth muscle, leading to the clinical symptoms described.
*Infection of ovaries, fallopian tubes, and uterus*
- This description is consistent with **pelvic inflammatory disease (PID)**, which typically presents with pelvic pain, fever, vaginal discharge, and cervical motion tenderness.
- PID would not cause a uniformly enlarged uterus or asymmetric thickening of the myometrial wall, and the patient has no signs of infection (e.g., fever).
*Cystic enlargement of the ovaries*
- **Ovarian cysts** or **polycystic ovary syndrome (PCOS)** might cause pelvic pain and menstrual irregularities, but they would involve the ovaries and not primarily lead to a uniformly enlarged uterus with myometrial thickening.
- The ultrasound findings of an enlarged uterus and myometrial changes are not characteristic of ovarian pathologies.
*Benign smooth muscle tumors of the uterus*
- **Leiomyomas (fibroids)** are benign smooth muscle tumors that can cause menorrhagia, pelvic pressure, and an enlarged, irregularly shaped uterus.
- While fibroids cause uterine enlargement, they typically present as discrete masses or nodules, not as a **uniform thickening** and asymmetric myometrial wall thickening with a poorly defined endomyometrial border, which is more specific to adenomyosis.
*Endometrial tissue in the fallopian tubes*
- This describes **endometriosis** affecting the fallopian tubes, which can cause chronic pelvic pain, dysmenorrhea, and infertility.
- While endometriosis can cause similar pain symptoms, it typically manifests as **ectopic endometrial implants outside the uterus**, not within the myometrial wall, and would not cause a uniformly enlarged uterus with the specific myometrial ultrasound findings described.
Question 77: A 35-year-old G3P2 woman currently 39 weeks pregnant presents to the emergency department with painful vaginal bleeding shortly after a motor vehicle accident in which she was a passenger. She had her seat belt on and reports that the airbag deployed immediately upon her car's impact against a tree. She admits that she actively smokes cigarettes. Her prenatal workup is unremarkable. Her previous pregnancies were remarkable for one episode of chorioamnionitis that resolved with antibiotics. Her temperature is 98.6°F (37°C), blood pressure is 90/60 mmHg, pulse is 130/min, and respirations are 20/min. The fetal pulse is 110/min. Her uterus is tender and firm. The remainder of her physical exam is unremarkable. What is the most likely diagnosis?
A. Placental abruption (Correct Answer)
B. Eclampsia
C. Vasa previa
D. Preterm labor
E. Preeclampsia
Explanation: ***Placental abruption***
- The patient's presentation with **painful vaginal bleeding** after blunt abdominal trauma (motor vehicle accident), a **tender and firm uterus**, maternal **hypotension** and **tachycardia**, and fetal **bradycardia** is highly characteristic of placental abruption.
- Risk factors like **smoking** and trauma further increase the likelihood of placental abruption.
*Eclampsia*
- Eclampsia is characterized by **new-onset grand mal seizures** in a pregnant woman with preeclampsia, which is not present in this scenario.
- While the patient's low blood pressure and tachycardia are concerning, they do not point to eclampsia.
*Vasa previa*
- Vasa previa involves **fetal blood vessels** running within the fetal membranes over the internal cervical os, risking rupture during labor or membrane rupture, leading to **painless vaginal bleeding** and **fetal distress**.
- The bleeding in this case is described as painful, and the uterine tenderness and firmness are not typical of vasa previa.
*Preterm labor*
- Preterm labor is defined by **regular uterine contractions** causing cervical changes before 37 weeks of gestation, which is not aligned with the patient being 39 weeks pregnant or her symptoms.
- While trauma can initiate labor, the severity of the bleeding and maternal/fetal distress point away from isolated preterm labor.
*Preeclampsia*
- Preeclampsia is characterized by **new-onset hypertension** (blood pressure ≥140/90 mmHg) and **proteinuria** after 20 weeks of gestation.
- This patient presents with hypotension and no mention of hypertension or proteinuria, making preeclampsia unlikely.
Question 78: A woman presents to the emergency department due to abdominal pain that began 1 hour ago. She is in the 35th week of her pregnancy when the pain came on during dinner. She also noted a clear rush of fluid that came from her vagina. The patient has a past medical history of depression which is treated with cognitive behavioral therapy. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 100/min, respirations are 17/min, and oxygen saturation is 98% on room air. On physical exam, you note a healthy young woman who complains of painful abdominal contractions that occur every few minutes. Laboratory studies are ordered as seen below.
Hemoglobin: 12 g/dL
Hematocrit: 36%
Leukocyte count: 6,500/mm^3 with normal differential
Platelet count: 197,000/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 4.3 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 99 mg/dL
Creatinine: 1.1 mg/dL
Ca2+: 10.2 mg/dL
Lecithin/Sphingomyelin: 1.5
AST: 12 U/L
ALT: 10 U/L
Which of the following is the best next step in management?
A. Oxytocin
B. RhoGAM
C. Expectant management
D. Betamethasone (Correct Answer)
E. Terbutaline
Explanation: ***Betamethasone***
- The patient presents with **preterm premature rupture of membranes (PPROM)** at 35 weeks, indicated by a "rush of fluid" and contractions, making her a candidate for **antenatal corticosteroids** to accelerate fetal lung maturity.
- While lung maturity (L/S ratio 1.5) is borderline, **betamethasone** is still recommended between 34 0/7 and 36 6/7 weeks of gestation in PPROM to reduce the risk of respiratory distress syndrome, intraventricular hemorrhage, and neonatal death.
*Oxytocin*
- **Oxytocin** is used for **induction of labor** or augmentation of contractions, which is not the immediate priority given the gestational age and the need for lung maturity in PPROM.
- Administering oxytocin without corticosteroid coverage first in this preterm scenario could increase the risk of neonatal complications.
*RhoGAM*
- **RhoGAM** (Rh immunoglobulin) is administered to Rh-negative mothers with an Rh-positive baby to prevent Rh sensitization; there is no information in the vignette to suggest the patient is Rh-negative or that it's clinically indicated as the next step.
- This intervention is for preventing **hemolytic disease of the newborn** and is not directly related to managing preterm labor or PPROM.
*Expectant management*
- While conservative management often occurs with PPROM, active contractions and the potential for imminent delivery (even at 35 weeks) necessitates interventions to improve neonatal outcomes rather than just watching and waiting.
- Expectant management alone would delay necessary interventions like corticosteroids, increasing the risk of neonatal morbidity from **prematurity**.
*Terbutaline*
- **Terbutaline** is a **tocolytic agent** used to suppress uterine contractions in preterm labor.
- While contractions are present, the benefit of tocolysis in PPROM at 35 weeks to prolong gestation for corticosteroid efficacy is limited, given the impending delivery and the recommendation for corticosteroids even without prolonging gestation.
Question 79: A 36-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of a gush of clear fluid from her vagina that occurred 1 hour prior. She reports painful pelvic cramping at regular 5-minute intervals. She has missed most of her prenatal care visit because of financial problems from her recent divorce. Her first child was delivered vaginally at 27 weeks' gestation due to spontaneous preterm labor. She has smoked one pack of cigarettes daily for 15 years but has reduced her intake to 2–3 cigarettes per day since finding out she was pregnant. She continues to use cocaine once a week. Vital signs are within normal limits. Sterile speculum examination shows fluid pooling in the vagina, and nitrazine paper testing confirms the presence of amniotic fluid. Which of the following puts her at highest risk of preterm delivery?
A. Substance abuse during pregnancy
B. Low socioeconomic status
C. Advanced maternal age
D. Smoking during pregnancy
E. History of spontaneous preterm birth (Correct Answer)
Explanation: ***History of spontaneous preterm birth***
- A previous **spontaneous preterm birth** is the strongest independent risk factor for recurrence, increasing the risk of another preterm delivery significantly.
- The patient's first child was delivered vaginally at **27 weeks due to spontaneous preterm labor**, placing her at high risk for a similar outcome in this pregnancy.
*Substance abuse during pregnancy*
- **Cocaine use** is associated with an increased risk of preterm labor and placental abruption, due to its **vasoconstrictive effects**.
- While significant, it is generally considered a less potent risk factor for preterm delivery recurrence compared to a previous history of preterm birth itself.
*Low socioeconomic status*
- **Low socioeconomic status** can indirectly contribute to preterm birth through factors like inadequate prenatal care, poor nutrition, and higher psychological stress.
- However, in the context of this specific patient's history, it is not the most direct or strongest predictor compared to her prior obstetric history.
*Smoking during pregnancy*
- **Smoking** is a known risk factor for various adverse pregnancy outcomes, including preterm birth, **intrauterine growth restriction**, and **placental complications**.
- Although the patient smokes, her prior history of extremely preterm birth is a more dominant risk factor for recurrence than her current smoking habits.
Question 80: A 37-year-old woman, gravida 3, para 2, at 35 weeks' gestation is brought to the emergency department for the evaluation of lower abdominal and back pain and vaginal bleeding that started one hour ago. She has had no prenatal care. Her first two pregnancies were uncomplicated and her children were delivered vaginally. The patient smoked one pack of cigarettes daily for 20 years; she reduced to half a pack every 2 days during her pregnancies. Her pulse is 80/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. The uterus is tender, and regular hypertonic contractions are felt every 2 minutes. There is dark blood on the vulva, the introitus, and on the medial aspect of both thighs bilaterally. The fetus is in a cephalic presentation. The fetal heart rate is 158/min and reactive with no decelerations. Which of the following is the most appropriate next step in management?
A. Administration of terbutaline
B. Transvaginal ultrasonography
C. Vaginal delivery
D. Administration of betamethasone
E. Emergent cesarean delivery (Correct Answer)
Explanation: ***Emergent cesarean delivery***
- The patient's presentation with **vaginal bleeding**, **lower abdominal and back pain**, a **tender, hypertonic uterus**, and regular contractions is highly suggestive of **placental abruption**. Given the maternal and fetal stability at this moment, but the potential for rapid deterioration, **emergent cesarean delivery** is the most appropriate next step to ensure the safety of both mother and fetus.
- A risk factor for placental abruption is a history of **smoking**, which the patient has, and the dark vaginal bleeding further supports the diagnosis. Prompt delivery is crucial to prevent complications such as fetal hypoxia, maternal hemorrhage, and coagulopathy.
*Administration of terbutaline*
- **Terbutaline** is a tocolytic used to relax the uterus and inhibit uterine contractions, typically in cases of preterm labor or uterine hyperstimulation.
- In placental abruption, contractions are often a result of uterine irritation from placental separation and are not the primary problem; inhibiting them could delay necessary delivery and worsen fetal compromise.
*Transvaginal ultrasonography*
- While imaging can sometimes identify placental abruption, especially if an abruption is large, **ultrasound is not reliable for definitively ruling out placental abruption**.
- Clinical signs and symptoms are paramount, and delaying definitive management for an ultrasound could be detrimental given the urgency of the situation.
*Vaginal delivery*
- While vaginal delivery might be considered in some cases of small, non-progressive abruption or if the fetus is already in distress and delivery is imminent, the presence of ongoing dark bleeding and a **hypertonic, tender uterus** with regular contractions in a patient at 35 weeks, points towards a potentially progressive abruption.
- The risk of significant maternal hemorrhage and fetal distress during labor makes emergent cesarean delivery safer for both, especially with a viable fetus that is not yet in obvious distress but is at high risk.
*Administration of betamethasone*
- **Betamethasone** is a corticosteroid administered to promote fetal lung maturity, typically for fetuses expected to be delivered between 24 and 34 weeks' gestation.
- Although the patient is at 35 weeks, the primary concern is the immediate and potentially life-threatening emergency of placental abruption, which requires urgent delivery, not a several-day course of corticosteroids. Lung maturity is usually adequate by 35 weeks.
