Definition and classification — MCQs

A 27-year-old woman, gravida 2, para 1, at 26 weeks' gestation comes to the emergency department because of vaginal bleeding and epistaxis for the past 2 days. She missed her last prenatal visit 2 weeks ago. Physical examination shows blood in the posterior pharynx and a uterus consistent in size with 23 weeks' gestation. Her hemoglobin concentration is 7.2 g/dL. Ultrasonography shows an intrauterine pregnancy with a small retroplacental hematoma and absent fetal cardiac activity. Further evaluation is most likely to show which of the following findings?

A 29-year-old G2P2 female gives birth to a healthy baby boy at 39 weeks of gestation via vaginal delivery. Immediately after the delivery of the placenta, she experiences profuse vaginal hemorrhage. Her prior birthing history is notable for an emergency cesarean section during her first pregnancy. She did not receive any prenatal care during either pregnancy. Her past medical history is notable for obesity and diabetes mellitus, which is well controlled on metformin. Her temperature is 99.0°F (37.2°C), blood pressure is 95/50 mmHg, pulse is 125/min, and respirations are 22/min. On physical examination, the patient is in moderate distress. Her extremities are pale, cool, and clammy. Capillary refill is delayed. Which of the following is the most likely cause of this patient’s bleeding?

A 30-year-old woman, gravida 2, para 1, at 42 weeks' gestation is admitted to the hospital in active labor. Pregnancy has been complicated by gestational diabetes, for which she has been receiving insulin injections. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 90/min, respirations are 18/min, and blood pressure is 135/80 mm Hg. The fetal heart rate tracing shows a baseline heart rate of 145/min and moderate variation with frequent accelerations and occasional early decelerations. She undergoes an elective repeat lower segment transverse cesarean section with complete removal of the placenta. Shortly after the operation, she starts having heavy uterine bleeding with passage of clots. Examination shows a soft uterus on palpation. Her bleeding continues despite fundal massage and the use of packing, oxytocin, misoprostol, and carboprost. Her pulse rate is now 120/min, respirations are 20/min, and blood pressure is 90/70 mm Hg. Her hemoglobin is 8 g/dL, hematocrit is 24%, platelet count is 120,000 mm3, prothrombin time is 11 seconds, and partial thromboplastin time is 30 seconds. Mass transfusion protocol is activated and a B-Lynch uterine compression suture is placed to control her bleeding. Which of the following is the mostly likely cause of her postpartum complication?

A 32-year-old woman, gravida 2, para 1, at 38 weeks' gestation comes to the emergency department because of vaginal bleeding for the past hour. The patient reports that she felt contractions prior to the onset of the bleeding, but the contractions stopped after the bleeding started. She also has severe abdominal pain. Her first child was delivered by lower segment transverse cesarean section because of a nonreassuring fetal heart rate. Her pulse is 110/min, respirations are 17/min, and blood pressure is 90/60 mm Hg. Examination shows diffuse abdominal tenderness with no rebound or guarding; no contractions are felt. The fetal heart rate shows recurrent variable decelerations. Which of the following is the most likely diagnosis?

A 37-year-old woman, gravida 4, para 3, at 35 weeks' gestation is admitted to the hospital in active labor. Her three children were delivered by Cesarean section. One hour after vaginal delivery, the placenta is not delivered. Manual separation of the placenta leads to profuse vaginal bleeding. Her pulse is 122/min and blood pressure is 90/67 mm Hg. A firm, nontender uterine fundus is palpated at the level of the umbilicus. Hemoglobin is 8.3 g/dL and platelet count is 220,000/mm3. Activated partial thromboplastin time and prothrombin time are within normal limits. Which of the following is the most likely underlying mechanism of this patient's postpartum bleeding?

A 34-year-old G3P2 is admitted to the hospital after being physically assaulted by her husband. She developed severe vaginal bleeding and abdominal pain. She is at 30 weeks gestation. Her previous pregnancies were uncomplicated, as has been the course of the current pregnancy. The vital signs are as follows: blood pressure, 80/50 mmHg; heart rate, 117/min and irregular; respiratory rate, 20/min; and temperature, 36.2℃ (97.1). The fetal heart rate is 103/min. On physical examination, the patient is pale and lethargic. Abdominal palpation reveals severe uterine tenderness and tetanic contractions. The perineum is grossly bloody. There are no vaginal or cervical lesions. There is active heavy bleeding with blood clots passing through the cervix. An ultrasound shows a retroplacental hematoma with a volume of approximately 400 ml. Laboratory workup shows the following findings: Red blood cells count: 3.0 millions/mL Hb%: 7.2 g/dL Platelet count: 61,000/mm3 Prothrombin time: 310 seconds (control 20 seconds) Partial prothrombin time: 420 seconds Serum fibrinogen: 16 mg/dL Elevated levels of which of the following laboratory markers is characteristic for this patient’s complication?

A 30-year-old woman, gravida 2, para 1, abortus 1, comes to the physician because of failure to conceive for 12 months. She is sexually active with her husband 2–3 times per week. Her first child was born at term after vaginal delivery 2 years ago. At that time, the postpartum course was complicated by hemorrhage from retained placental products, and the patient underwent dilation and curettage. Menses occur at regular 28-day intervals and previously lasted for 5 days with normal flow, but now last for 2 days with significantly reduced flow. She stopped taking oral contraceptives 1 year after the birth of her son. Her vital signs are within normal limits. Speculum examination shows a normal vagina and cervix. The uterus is normal in size, and no adnexal masses are palpated. Which of the following is the most appropriate next step in management?

A 31-year-old G6P6 woman with a history of fibroids gives birth to twins via vaginal delivery. Her pregnancy was uneventful, and she reported having good prenatal care. Both placentas are delivered immediately after the birth. The patient continues to bleed significantly over the next 20 minutes. Her temperature is 97.0°F (36.1°C), blood pressure is 124/84 mmHg, pulse is 95/min, respirations are 16/min, and oxygen saturation is 98% on room air. Continued vaginal bleeding is noted. Which of the following is the most appropriate initial step in management?

Two days after being admitted to the hospital because of severe peripartum vaginal bleeding during a home birth, a 40-year-old woman, gravida 3, para 3, has a 30-second generalized convulsive seizure followed by unconsciousness. Prior to the event she complained of acute onset of sweating and uncontrollable shivering. She was hemodynamically unstable and required several liters of intravenous fluids and 5 units of packed red blood cells in the intensive care unit. The patient's two prior pregnancies, at ages 33 and 35, were uncomplicated. She is otherwise healthy. Prior to admission, her only medication was a daily prenatal vitamin. Temperature is 37.5°C (99.5°F), pulse is 120/min, respirations are 18/min, blood pressure is 101/61 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 96%. Examination shows very little milk expression from the breasts bilaterally. Finger-stick glucose level is 36 mg/dL. Which of the following is the most likely underlying cause of this patient's condition?

A 36-year-old primigravid woman at 34 weeks' gestation comes to the physician because of a 1-week history of upper abdominal discomfort, nausea, and malaise. She had a mild upper respiratory tract infection a week ago. She has a 10-year history of polycystic ovarian syndrome and a 3-year history of hypertension. Her medications include metformin, labetalol, folic acid, and a multivitamin. Her pulse is 92/min, respirations are 18/min, and blood pressure is 147/84 mm Hg. Examination shows a nontender uterus consistent in size with a 34-week gestation. There is mild tenderness of the right upper quadrant of the abdomen. The fetal heart rate is reactive with no decelerations. Which of the following is the most appropriate next step in management?