Genital tract trauma repair — MCQs

10 questions

A 1-month-old male infant is brought to the physician because of inconsolable crying for the past 3 hours. For the past 3 weeks, he has had multiple episodes of high-pitched unprovoked crying every day that last up to 4 hours and resolve spontaneously. He was born at term and weighed 2966 g (6 lb 9 oz); he now weighs 3800 g (8 lb 6 oz). He is exclusively breast fed. His temperature is 36.9°C (98.4°F) and pulse is 140/min. Examination shows a soft and nontender abdomen. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?

A 36-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the emergency department because of sparse vaginal bleeding for 3 hours. She also noticed the bleeding 3 days ago. She has had no prenatal care. Both of her previous children were delivered by lower segment transverse cesarean section. Her temperature is 37.1°C (98.8°F), pulse is 90/min, respirations are 16/min, and blood pressure is 110/80 mm Hg. The abdomen is nontender, and no contractions are felt. Examination shows that the fetus is in a vertex presentation. The fetal heart rate is 160/min and shows no abnormalities. Which of the following is the most appropriate next step in management?

A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?

A 16-year-old boy presents to the emergency department after a skateboarding accident. He fell on a broken bottle and received a 4 cm wound on the dorsal aspect of his left hand. His vitals are stable and he was evaluated by the surgeon on call who determined that suturing was not required. After several weeks the wound has almost completely healed (see image). Which of the following is the correct description of this patient's wound before healing?

A 56-year-old man is brought to the emergency department after 4 hours of severe abdominal pain with an increase in its intensity over the last hour. His personal history is relevant for peptic ulcer disease and H. pylori infection that is being treated with clarithromycin triple therapy. Upon admission his vital signs are as follows: pulse of 120/min, a respiratory rate of 20/min, body temperature of 39°C (102.2°F), and blood pressure of 90/50 mm Hg. Physical examination reveals significant tenderness over the abdomen. A chest radiograph taken when the patient was standing erect is shown. Which of the following is the next best step in the management of this patient?

A 40-year-old woman comes to the physician because of a 2-week history of anal pain that occurs during defecation and lasts for several hours. She reports that she often strains during defecation and sees bright red blood on toilet paper after wiping. She typically has 3 bowel movements per week. Physical examination shows a longitudinal, perianal tear. This patient's symptoms are most likely caused by tissue injury in which of the following locations?

A 17-year-old girl presents to the gynecologist's office due to lack of menarche. She has been sexually active with 1 male lifetime partner and always uses a condom. Her mother believes that breast development started at 11 years old. On exam, she is a well-appearing, non-hirsute teenager with Tanner V breast and pubic hair development. Her pelvic exam reveals normal external genitalia, a shortened vagina, and the cervix is unable to be visualized. Initial laboratory testing for hormone levels and karyotype is normal, and imaging confirms what you suspect on exam. What is the most likely cause of her lack of menstruation?

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?

Q10

A pregnant woman with a known case of asthma is experiencing postpartum hemorrhage (PPH). Which drug is contraindicated?

Genital tract trauma repair US Medical PG Practice Questions and MCQs

Question 1: A 1-month-old male infant is brought to the physician because of inconsolable crying for the past 3 hours. For the past 3 weeks, he has had multiple episodes of high-pitched unprovoked crying every day that last up to 4 hours and resolve spontaneously. He was born at term and weighed 2966 g (6 lb 9 oz); he now weighs 3800 g (8 lb 6 oz). He is exclusively breast fed. His temperature is 36.9°C (98.4°F) and pulse is 140/min. Examination shows a soft and nontender abdomen. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate next step in management?

A. Administer simethicone
B. Perform lumbar puncture
C. Reassurance (Correct Answer)
D. Administer pantoprazole
E. Recommend the use of Gripe water

Explanation: ***Reassurance*** - The presented symptoms (inconsolable crying lasting hours, resolving spontaneously, in a healthy infant with normal examination) are classic for **infant colic**. Infant colic is a self-limiting condition, and reassurance of the parents is the most appropriate management. - The "rule of threes" for colic includes crying for more than **3 hours a day**, for more than **3 days a week**, for longer than **3 weeks** in an otherwise healthy and well-fed infant. *Administer simethicone* - **Simethicone** is an anti-foaming agent proposed to reduce gas, but studies have not consistently shown it to be effective in treating infant colic. - While generally considered safe, it is not the first-line or most effective intervention for colic. *Perform lumbar puncture* - A **lumbar puncture** is an invasive procedure indicated when there is suspicion of serious CNS infection (e.g., meningitis), which is not supported by the clinical picture here. - The infant is afebrile, well-appearing apart from crying, and has a normal physical examination, making a lumbar puncture unnecessary and potentially harmful. *Administer pantoprazole* - **Pantoprazole** (a proton pump inhibitor) is used to reduce stomach acid in conditions like gastroesophageal reflux disease (GERD). - While GERD can cause crying in infants, the description of crying as "unprovoked" and resolving spontaneously, coupled with normal weight gain and examination, makes GERD less likely and PPI administration unwarranted. *Recommend the use of Gripe water* - **Gripe water** is a combination of herbal remedies (e.g., ginger, fennel, chamomile) and bicarbonate, marketed for colic and gas. - Its efficacy is not scientifically proven, and some formulations may contain alcohol or sugar, making it an unrecommended and potentially unsafe option.

Question 2: A 27-year-old man presents to the emergency department after being stabbed. The patient was robbed at a local pizza parlor and was stabbed over 10 times with a large kitchen knife with an estimated 7 inch blade in the ventral abdomen. His temperature is 97.6°F (36.4°C), blood pressure is 74/54 mmHg, pulse is 180/min, respirations are 19/min, and oxygen saturation is 98% on room air. The patient is intubated and given blood products and vasopressors. Physical exam is notable for multiple stab wounds over the patient's abdomen inferior to the nipple line. Which of the following is the best next step in management?

A. Exploratory laparotomy (Correct Answer)
B. Diagnostic peritoneal lavage
C. CT scan of the abdomen and pelvis
D. Exploratory laparoscopy
E. FAST exam

Explanation: ***Exploratory laparotomy*** - The patient presents with **multiple stab wounds** to the abdomen and signs of **hemorrhagic shock** (BP 74/54 mmHg, HR 180/min), which are clear indications for immediate surgical intervention. - An exploratory laparotomy allows for direct visualization and repair of internal injuries, which is critical in this life-threatening situation. *Diagnostic peritoneal lavage* - While DPL can detect intra-abdominal bleeding, it is an **invasive procedure** and may delay definitive treatment in a hemodynamically unstable patient with obvious penetrating trauma. - It is **less specific** than a laparotomy for identifying the exact location and nature of injuries, and it has largely been replaced by imaging studies or direct surgical exploration in unstable patients. *CT scan of the abdomen and pelvis* - A CT scan requires a **hemodynamically stable** patient and time for scanning and interpretation, which this patient does not have. - Delaying definitive treatment for imaging in a patient with severe shock could lead to worse outcomes. *Exploratory laparoscopy* - Although less invasive, laparoscopy can be time-consuming and may not be feasible or safe in a patient with **profound hemorrhagic shock** and extensive injuries, especially if major vascular or visceral damage is suspected. - Conversion to a **laparotomy** is often necessary in cases of significant injury, making immediate open exploration more efficient. *FAST exam* - A FAST exam can rapidly detect free fluid in the abdomen, suggesting internal bleeding, but it does **not provide specific information** about the source or extent of the injuries. - While useful in the initial assessment, a positive FAST exam in a hemodynamically unstable patient with penetrating trauma directly points to the need for immediate surgical intervention, not further diagnostic delay.

Question 3: A 36-year-old woman, gravida 3, para 2, at 37 weeks' gestation comes to the emergency department because of sparse vaginal bleeding for 3 hours. She also noticed the bleeding 3 days ago. She has had no prenatal care. Both of her previous children were delivered by lower segment transverse cesarean section. Her temperature is 37.1°C (98.8°F), pulse is 90/min, respirations are 16/min, and blood pressure is 110/80 mm Hg. The abdomen is nontender, and no contractions are felt. Examination shows that the fetus is in a vertex presentation. The fetal heart rate is 160/min and shows no abnormalities. Which of the following is the most appropriate next step in management?

A. Perform cesarean delivery
B. Perform transvaginal sonography (Correct Answer)
C. Perform Kleihauer-Betke test
D. Perform pelvic examination
E. Conduct contraction stress test

Explanation: ***Perform transvaginal sonography*** - The history of **previous cesarean sections** and **painless vaginal bleeding** raises suspicion for **placenta previa**. - **Transvaginal sonography** is the gold standard for diagnosing placenta previa, as it accurately visualizes the relationship between the placenta and the cervical os without increasing bleeding risk. *Perform cesarean delivery* - While a cesarean delivery may eventually be necessary if **placenta previa** is confirmed, it is premature to proceed without a definitive diagnosis. - An immediate cesarean delivery is indicated only in cases of **heavy, uncontrolled bleeding** or fetal distress, neither of which is present here. *Perform Kleihauer-Betke test* - The **Kleihauer-Betke test** measures the amount of fetal hemoglobin transferred into the maternal bloodstream for quantifying **fetomaternal hemorrhage**, which is typically performed after a potential placental abruption or trauma. - This test is not primarily used for diagnosing the **cause of vaginal bleeding** in this context and would not identify placenta previa. *Perform pelvic examination* - A **digital pelvic examination** is **contraindicated** in cases of suspected placenta previa due to the risk of exacerbating bleeding and potentially causing **massive hemorrhage**. - Even a speculum examination should generally be deferred until a sonogram has ruled out placenta previa to avoid disturbing the placenta. *Conduct contraction stress test* - A **contraction stress test** assesses **fetal well-being** in response to uterine contractions and is used to evaluate uteroplacental insufficiency. - It does not help in diagnosing the cause of **vaginal bleeding** and is not the appropriate first step in a patient with suspected placenta previa.

Question 4: A 45-year-old man undergoes elective vasectomy for permanent contraception. The procedure is performed under local anesthesia. There are no intra-operative complications and he is discharged home with ibuprofen for post-operative pain. This patient is at increased risk for which of the following complications?

A. Prostatitis
B. Seminoma
C. Testicular torsion
D. Sperm granuloma (Correct Answer)
E. Inguinal hernia

Explanation: **Sperm granuloma** - A **sperm granuloma** can occur after vasectomy due to the extravasation of sperm from the severed vas deferens, leading to a foreign body granulomatous reaction. - This complication presents as a **palpable, tender nodule** at the vasectomy site and is a relatively common long-term issue. *Prostatitis* - **Prostatitis** is an inflammation of the prostate gland, and there is no direct mechanistic link or increased risk following a vasectomy. - It is typically caused by bacterial infection or non-infectious inflammatory processes, unrelated to the **vas deferens** ligation. *Seminoma* - **Seminoma** is a type of testicular germ cell tumor, and extensive research has shown no increased risk of developing testicular cancer after vasectomy. - The procedure does not alter the cellular processes or environment within the testicles that predispose to germ cell tumor formation. *Testicular torsion* - **Testicular torsion** is a urological emergency involving the twisting of the spermatic cord, which cuts off blood supply to the testis. - This condition is not associated with vasectomy; it typically occurs due to an anatomical abnormality (e.g., **bell-clapper deformity**) or trauma. *Inguinal hernia* - An **inguinal hernia** is a protrusion of abdominal contents through a weakness in the abdominal wall, specifically in the inguinal canal. - Vasectomy is a superficial procedure that does not involve manipulating or weakening the abdominal wall in a way that would increase the risk of an inguinal hernia.

Question 5: A 16-year-old boy presents to the emergency department after a skateboarding accident. He fell on a broken bottle and received a 4 cm wound on the dorsal aspect of his left hand. His vitals are stable and he was evaluated by the surgeon on call who determined that suturing was not required. After several weeks the wound has almost completely healed (see image). Which of the following is the correct description of this patient's wound before healing?

A. Incised wound (Correct Answer)
B. Abrasion
C. Laceration
D. Avulsion
E. Puncture

Explanation: ***Incised wound*** - An **incised wound** is caused by a sharp object, such as a broken bottle, resulting in a clean, straight cut with well-defined edges and minimal tissue damage. - The characteristics of the injury (sharp object mechanism, 4 cm linear wound) and the clinical decision that suturing was not required suggest a relatively clean incised wound with edges that could approximate well. - Incised wounds typically heal with **fine linear scars** as shown in the image, especially when the edges are well-approximated. *Abrasion* - An abrasion is a **superficial wound** caused by friction or scraping, leading to removal of the epidermis and sometimes the superficial dermis. - This mechanism does not match the described injury from a broken bottle, and abrasions produce broad, shallow wounds rather than deep linear cuts. - Abrasions heal with minimal scarring and would not produce the linear scar pattern shown. *Laceration* - A laceration is a wound with **irregular, torn edges** typically caused by blunt force trauma or crushing injury. - While broken glass can sometimes cause lacerations, the description of a clean "4 cm wound" from falling on a broken bottle more strongly suggests a sharp cutting mechanism rather than tearing. - Lacerations have jagged edges with more tissue damage and typically require debridement or careful closure. *Avulsion* - An **avulsion** involves forcible tearing away of tissue, often resulting in significant tissue loss with irregular, gaping wounds. - This injury pattern is much more severe than described and would typically require complex surgical management, including possible skin grafting. - The mechanism (falling on broken glass) and the relatively straightforward healing do not support an avulsion injury. *Puncture* - A puncture wound is caused by a **pointed object** penetrating the skin, creating a small entry hole with depth greater than width. - The description of a "4 cm wound" indicates a linear length, not a deep narrow penetration typical of puncture wounds. - Puncture wounds carry high infection risk and would not produce the linear scar pattern shown in the image.

Question 6: A 56-year-old man is brought to the emergency department after 4 hours of severe abdominal pain with an increase in its intensity over the last hour. His personal history is relevant for peptic ulcer disease and H. pylori infection that is being treated with clarithromycin triple therapy. Upon admission his vital signs are as follows: pulse of 120/min, a respiratory rate of 20/min, body temperature of 39°C (102.2°F), and blood pressure of 90/50 mm Hg. Physical examination reveals significant tenderness over the abdomen. A chest radiograph taken when the patient was standing erect is shown. Which of the following is the next best step in the management of this patient?

A. Abdominal ultrasound
B. Emergency abdominal surgery (Correct Answer)
C. Abdominal computed tomography
D. Nasogastric tube placement followed by gastric lavage
E. Emergency endoscopy

Explanation: ***Emergency abdominal surgery*** - The chest radiograph shows **free air under the diaphragm** (pneumoperitoneum), confirming a visceral perforation. The patient's severe abdominal pain, fever, tachycardia, and hypotension indicate **septic shock** secondary to peritonitis, necessitating immediate surgical intervention. - Delaying surgery for further diagnostic tests (like CT or ultrasound) or less invasive procedures would be detrimental given the patient's **hemodynamic instability** and clear evidence of perforation. *Abdominal ultrasound* - While an ultrasound could detect fluid collections or sometimes free air, it is **less sensitive** than an upright chest radiograph for detecting pneumoperitoneum and cannot provide the same level of detail as CT for localizing a perforation. - In a hemodynamically unstable patient with clear signs of peritonitis and pneumoperitoneum, performing an ultrasound would **delay definitive treatment**. *Abdominal computed tomography* - An abdominal CT scan is excellent for detecting subtle perforations, localizing them, and assessing associated complications. However, in this patient, the **upright chest radiograph already clearly shows pneumoperitoneum**, and the patient is **hemodynamically unstable**. - Transporting an unstable patient to CT and waiting for the scan results would **waste critical time** and increase morbidity and mortality in the setting of ongoing septic shock. *Nasogastric tube placement followed by gastric lavage* - **Nasogastric tube placement** is appropriate for gastric decompression in cases of suspected obstruction or ileus, but it does not address a perforation. **Gastric lavage** is indicated for specific intoxications or gastrointestinal bleeding, neither of which is the primary concern here. - This procedure would **not treat the underlying perforation** or the resulting peritonitis and septic shock. *Emergency endoscopy* - While an endoscopy can diagnose and sometimes treat upper gastrointestinal perforations (especially iatrogenic ones), it is typically **contraindicated in cases of suspected free perforation** due to the risk of exacerbating the pneumoperitoneum and further contamination. - In an unstable patient with clear pneumoperitoneum and peritonitis, **surgery is the definitive treatment**, not endoscopy.

Question 7: A 40-year-old woman comes to the physician because of a 2-week history of anal pain that occurs during defecation and lasts for several hours. She reports that she often strains during defecation and sees bright red blood on toilet paper after wiping. She typically has 3 bowel movements per week. Physical examination shows a longitudinal, perianal tear. This patient's symptoms are most likely caused by tissue injury in which of the following locations?

A. Anterior midline of the anal canal, proximal to the pectinate line
B. Posterior midline of the anal canal, distal to the pectinate line (Correct Answer)
C. Posterior midline of the anal canal, proximal to the pectinate line
D. Lateral aspect of the anal canal, distal to the pectinate line
E. Anterior midline of the anal canal, distal to the pectinate line

Explanation: ***Posterior midline of the anal canal, distal to the pectinate line*** - The described symptoms of severe **anal pain during and after defecation**, bright red blood on toilet paper, and straining with defecation are classic for an **anal fissure**. - Anal fissures most commonly occur in the **posterior midline** of the anal canal, **distal to the pectinate (dentate) line**, due to reduced blood supply and increased mechanical stress in this area. *Anterior midline of the anal canal, proximal to the pectinate line* - Fissures can occur in the anterior midline but are less common than posterior midline fissures. - Lesions proximal to the pectinate line are typically less painful as this area is innervated by the autonomic nervous system, unlike the highly sensitive somatic innervation distal to the pectinate line. *Posterior midline of the anal canal, proximal to the pectinate line* - While the posterior midline is a common location for fissures, involvement **proximal to the pectinate line** would likely present with less severe pain compared to the highly sensitive area distal to it. - Lesions proximal to the pectinate line are more commonly internal hemorrhoids or proctitis, which present differently. *Lateral aspect of the anal canal, distal to the pectinate line* - Fissures in the lateral position are **atypical** and may suggest underlying conditions such as **Crohn's disease**, tuberculosis, or sexually transmitted infections, which are not indicated in this patient's presentation. - The **midline** positions (anterior or posterior) are far more common for idiopathic anal fissures. *Anterior midline of the anal canal, distal to the pectinate line* - Though the anterior midline, distal to the pectinate line, is a possible location for fissures (especially in women), the **posterior midline** is the **most common** site due to anatomical factors. - Given the classic presentation, the most frequent location is the most likely answer.

Question 8: A 17-year-old girl presents to the gynecologist's office due to lack of menarche. She has been sexually active with 1 male lifetime partner and always uses a condom. Her mother believes that breast development started at 11 years old. On exam, she is a well-appearing, non-hirsute teenager with Tanner V breast and pubic hair development. Her pelvic exam reveals normal external genitalia, a shortened vagina, and the cervix is unable to be visualized. Initial laboratory testing for hormone levels and karyotype is normal, and imaging confirms what you suspect on exam. What is the most likely cause of her lack of menstruation?

A. Androgen insensitivity
B. Premature ovarian failure
C. Müllerian agenesis (Correct Answer)
D. 5-alpha reductase deficiency
E. Turner syndrome

Explanation: ***Müllerian agenesis*** - The patient presents with **primary amenorrhea**, normal secondary sexual characteristics (Tanner V breast and pubic hair), normal hormone levels, and a **shortened vagina** with an absent cervix, consistent with the diagnosis. - This condition is characterized by the **failure of Müllerian duct development**, leading to an absent or hypoplastic uterus and vagina, while ovarian function and chromosomal makeup are normal. *Androgen insensitivity* - This would present with **primary amenorrhea**, but the patient would typically have a **46 XY karyotype** and lack pubic and axillary hair due to androgen receptor insensitivity, despite normal breast development. - While breast development occurs, pubic hair development (Tanner V) would not be expected in **complete androgen insensitivity syndrome** since testosterone cannot stimulate hair follicles. *Premature ovarian failure* - This condition involves the **cessation of ovarian function** before the age of 40, leading to elevated FSH and LH levels due to lack of ovarian feedback, and often a lack of secondary sexual characteristics, which is not seen here. - While it causes **primary amenorrhea**, it would not result in a shortened vagina or Müllerian anomalies; the uterus and vagina would typically be present. *5-alpha reductase deficiency* - Individuals with this condition are **genetically male (XY)** and are unable to convert testosterone to dihydrotestosterone (DHT), leading to varying degrees of masculinization at puberty, which is not consistent with a phenotypically female patient with normal external genitalia. - This condition typically results in **ambiguous genitalia at birth** and virilization at puberty (clitoromegaly, partial fusion of labia), not a female phenotype with a shortened vagina. *Turner syndrome* - This is a chromosomal disorder (typically **45, XO**) characterized by **gonadal dysgenesis**, leading to short stature, webbed neck, cardiac defects, and most importantly, **absent or delayed puberty** and primary amenorrhea due to streak gonads. - The patient would have **poor or absent breast development** due to ovarian failure, and elevated gonadotropins, which contradicts the normal breast development and hormone levels in this case.

Question 9: 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.

Question 10: A pregnant woman with a known case of asthma is experiencing postpartum hemorrhage (PPH). Which drug is contraindicated?

A. Methyl ergometrine
B. Carboprost (Correct Answer)
C. Misoprostol
D. Oxytocin

Explanation: ***Carboprost*** - **Carboprost** is a **prostaglandin F2-alpha analog** that causes strong uterine contractions but also leads to **bronchoconstriction** and increased airway resistance. - Due to its potent bronchoconstrictive effects, **carboprost** is **absolutely contraindicated in patients with asthma** as it can precipitate a severe asthmatic attack. *Methyl ergometrine* - **Methyl ergometrine** is an **ergot alkaloid** that causes sustained uterine contractions and is effective for PPH. - It is contraindicated in patients with **hypertension** or **pre-eclampsia** due to its vasoconstrictive properties, but not typically in asthma. *Misoprostol* - **Misoprostol** is a **prostaglandin E1 analog** used for PPH management, causing uterine contractions. - It is generally safe for use in patients with asthma as it does not have significant bronchoconstrictive side effects. *Oxytocin* - **Oxytocin** is a first-line uterotonic agent for PPH, working by causing rhythmic uterine contractions. - It is generally considered safe in patients with asthma and is not known to exacerbate respiratory conditions.

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