Retained placenta management — MCQs

10 questions

A 38-year-old woman, gravida 2, para 1, at 35 weeks' gestation comes to the emergency department because of an episode of vaginal bleeding that morning. The bleeding has subsided. She has had no prenatal care. Her previous child was delivered with a caesarean section because of a breech presentation. Her temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 14/min, and blood pressure is 125/85 mm Hg. The abdomen is nontender and the size of the uterus is consistent with a 35-week gestation. No contractions are felt. The fetal heart rate is 145/min. Her hemoglobin concentration is 12 g/dL, leukocyte count is 13,000/mm3, and platelet count is 350,000/mm3. Transvaginal ultrasound shows that the placenta covers the internal os. Which of the following is the most appropriate next step in management?

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 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 34-year-old G3P2 presents at 33 weeks gestation with vaginal bleeding that started last night while she was asleep. She denies uterine contractions or abdominal pain. She had a cesarean delivery in her previous pregnancy. She also reports a 10 pack-year smoking history. The vital signs are as follows: blood pressure, 130/80 mm Hg; heart rate, 84/min; respiratory rate, 12/min; and temperature, 36.8℃ (98.2℉). The physical examination is negative for abdominal tenderness or palpable uterine contractions. The perineum is mildly bloody. On speculum examination, no vaginal or cervical lesions are seen. A small amount of blood continues to pass through the cervix. Which of the following findings would you expect on ultrasound examination?

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 34-year-old G5P5 woman gave birth to a healthy infant 30 minutes ago by vacuum-assisted vaginal delivery and is now experiencing vaginal bleeding. The placenta was delivered spontaneously and was intact upon examination. The infant weighed 5.2 kg and had Apgar scores of 8 and 9. No perineal tear or intentional episiotomy occurred. The patient has type 1 diabetes. She had good glycemic control throughout her pregnancy. She took a prenatal vitamin daily. Blood pressure is 135/72 mmHg, pulse is 102/min, and respirations are 18/min. Upon physical examination, the uterine fundus is soft and palpated 4 cm above the umbilicus. There are 3-cm blood clots on the patient’s bed pad. Which of the following is the next best step in management for the patient’s bleeding?

A 31-year-old G1P0 woman with a history of hypertension presents to the emergency department because she believes that she is in labor. She is in her 38th week of pregnancy and her course has thus far been uncomplicated. This morning, she began feeling painful contractions and noted vaginal bleeding after she fell off her bike while riding to work. She is experiencing lower abdominal and pelvic pain between contractions as well. Her temperature is 97.6°F (36.4°C), blood pressure is 177/99 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 98% on room air. Physical exam is notable for a gravid and hypertonic uterus and moderate blood in the vaginal vault. Ultrasound reveals no abnormalities. Which of the following is the most likely diagnosis?

A 36-year-old G4P3 is admitted to the obstetrics floor at 35 weeks gestation with painless vaginal spotting for a week. She had 2 cesarean deliveries. An ultrasound examination at 22 weeks gestation showed a partial placenta previa, but she was told not to worry. Today, her vital signs are within normal limits, and a physical examination is unremarkable, except for some blood traces on the perineum. The fetal heart rate is 153/min. The uterine fundus is at the xiphoid process and uterine contractions are absent. Palpation identifies a longitudinal lie. Transvaginal ultrasound shows an anterior placement of the placenta with a placental edge-to-internal os distance of 1.5 cm and a loss of the retroplacental space. Which of the following statements best describes the principle of management for this patient?

A 22-year-old woman comes to the physician because of a 1-month history of a light greenish, milky discharge from both breasts. There is no mastalgia. She has hypothyroidism and migraine headaches. Her mother has breast cancer and is currently undergoing chemotherapy. Menses occur at regular 28-day intervals with moderate flow; her last menstrual period was 1 week ago. Current medications include levothyroxine and propranolol. She appears anxious. Her temperature is 37.1°C (98.78F), pulse is 82/min, and blood pressure is 116/72 mm Hg. The lungs are clear to auscultation. Breast examination is unremarkable. Pelvic examination shows a normal vagina and cervix. Serum studies show: Thyroid-stimulating hormone 3.5 μU/mL Progesterone 0.7 ng/mL (Follicular phase: N < 3) Prolactin 18 ng/mL Follicle-stimulating hormone 20 mIU/mL A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

Q10

A 28-year-old woman visits her physician with complaints of inability to become pregnant despite frequent unprotected sexual intercourse with her husband for over a year. She breastfed her only child until about 13 months ago, when the couple decided to have a second child. Over the past year, the patient has had only 4 episodes of menstrual bleeding. She reports occasional milk discharge from both breasts. Her only medication currently is daily pantoprazole, which she takes for dyspepsia. Her BMI is 29 kg/m2. Physical examination and vitals are normal. Pelvic examination indicates no abnormalities. The patient’s breast examination reveals full breasts and a few drops of milk can be expressed from both nipples. Estradiol, serum follicle-stimulating hormone (FSH), testosterone, and thyroid-stimulating hormone (TSH) levels are within the normal range. Which of the following best explains these findings?

Retained placenta management US Medical PG Practice Questions and MCQs

Question 1: A 38-year-old woman, gravida 2, para 1, at 35 weeks' gestation comes to the emergency department because of an episode of vaginal bleeding that morning. The bleeding has subsided. She has had no prenatal care. Her previous child was delivered with a caesarean section because of a breech presentation. Her temperature is 37.1°C (98.8°F), pulse is 88/min, respirations are 14/min, and blood pressure is 125/85 mm Hg. The abdomen is nontender and the size of the uterus is consistent with a 35-week gestation. No contractions are felt. The fetal heart rate is 145/min. Her hemoglobin concentration is 12 g/dL, leukocyte count is 13,000/mm3, and platelet count is 350,000/mm3. Transvaginal ultrasound shows that the placenta covers the internal os. Which of the following is the most appropriate next step in management?

A. Schedule elective cesarean delivery (Correct Answer)
B. Observation only
C. Perform bimanual pelvic examination
D. Perform emergency cesarean delivery
E. Administer oxytocin to induce labor

Explanation: ***Schedule elective cesarean delivery*** - The ultrasound finding of the **placenta covering the internal os** confirms **placenta previa**. Given the patient is at **35 weeks' gestation** and has experienced **vaginal bleeding**, an elective cesarean delivery is the safest management to avoid further bleeding episodes and ensure maternal and fetal well-being. - An elective cesarean delivery is typically scheduled between **36 and 37 weeks' gestation** for placenta previa to minimize the risk of spontaneous labor and potentially catastrophic hemorrhage. *Observation only* - This is inappropriate given the diagnosis of **placenta previa** and the history of **vaginal bleeding**. Observation alone carries a significant risk of recurrent, potentially severe hemorrhage. - While the bleeding has subsided, the underlying condition remains and warrants active management to prevent future complications. *Perform bimanual pelvic examination* - A **bimanual pelvic examination** is **contraindicated** in cases of suspected or confirmed **placenta previa**. - Performing such an examination can **disrupt the placenta** and precipitate a massive, life-threatening hemorrhage. *Perform emergency cesarean delivery* - An emergency cesarean delivery is indicated if the patient presents with **severe, active bleeding** or signs of **fetal distress**. - In this case, the bleeding has subsided, the patient is hemodynamically stable, and the fetal heart rate is normal, so an immediate emergency delivery is not warranted. *Administer oxytocin to induce labor* - **Induction of labor with oxytocin** is **contraindicated** in **placenta previa**. - Stimulating contractions would lead to **cervical dilation**, causing further placental separation and severe hemorrhage, putting both mother and fetus at extreme risk.

Question 2: 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. Chorionic villi invading into the myometrium
B. Placental implantation over internal cervical os
C. Chorionic villi attaching to the decidua basalis
D. Chorionic villi invading into the serosa
E. Chorionic villi attaching to the myometrium (Correct Answer)

Explanation: ***Chorionic villi attaching to the myometrium*** - This describes **placenta accreta**, where the **chorionic villi adhere directly to the myometrium** without invading beyond it. This condition is strongly associated with a history of **prior C-sections**, as the scar tissue increases the risk of abnormal placental implantation. - The profuse hemorrhage immediately following placental delivery, despite the placenta being delivered, suggests a problem with normal placental separation from the uterine wall. **Placenta accreta** can lead to massive postpartum hemorrhage when the placenta attempts to separate, tearing the maternal vessels. *Chorionic villi invading into the myometrium* - This describes **placenta increta**, where the **chorionic villi invade deeper into the myometrium**. While also causing severe hemorrhage, the term "attaching to the myometrium" (accreta) is a more common and slightly less severe form often seen with prior C-sections. - Both accreta and increta present similarly with hemorrhage, but accreta is the initial and most common form of abnormal adherence to the myometrium. *Placental implantation over internal cervical os* - This describes **placenta previa**, which is characterized by **painless vaginal bleeding** typically in the **second or third trimester**, before delivery. - While a prior C-section is a risk factor for placenta previa, the hemorrhage in this case occurred *after* the delivery of the placenta, not before or during labor, ruling out active previa. *Chorionic villi invading into the serosa* - This describes **placenta percreta**, the most severe form where **chorionic villi invade through the myometrium and into the uterine serosa**, potentially involving adjacent organs. - While it causes massive hemorrhage, "attaching to" or even "invading into" the myometrium (accreta/increta) are more probable, given the description, than invasion *through* to the serosa, though all are part of the placenta accreta spectrum. *Chorionic villi invading beyond the serosa* - This is an alternative description for **placenta percreta**, indicating invasion through the uterus and potentially into surrounding structures like the bladder. - While this is a severe cause of postpartum hemorrhage, the provided option "Chorionic villi attaching to the myometrium" (placenta accreta) is the most common form of abnormally adherent placenta in the spectrum and is highly consistent with the patient's history of prior C-section and the clinical presentation of hemorrhage after placental delivery.

Question 3: 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 4: A 34-year-old G3P2 presents at 33 weeks gestation with vaginal bleeding that started last night while she was asleep. She denies uterine contractions or abdominal pain. She had a cesarean delivery in her previous pregnancy. She also reports a 10 pack-year smoking history. The vital signs are as follows: blood pressure, 130/80 mm Hg; heart rate, 84/min; respiratory rate, 12/min; and temperature, 36.8℃ (98.2℉). The physical examination is negative for abdominal tenderness or palpable uterine contractions. The perineum is mildly bloody. On speculum examination, no vaginal or cervical lesions are seen. A small amount of blood continues to pass through the cervix. Which of the following findings would you expect on ultrasound examination?

A. Partial covering of the internal cervical os by the placental edge (Correct Answer)
B. Cysts on the placental surface
C. Retroplacental blood accumulation
D. Placental calcification
E. Loss of the clear retroplacental space

Explanation: ***Partial covering of the internal cervical os by the placental edge*** - This presentation, with painless vaginal bleeding in the third trimester in a patient with a **history of prior C-section** (a major risk factor) and **smoking history**, is highly suggestive of **placenta previa**. - **Placenta previa** is diagnosed when the placenta implants either completely or partially over the **internal cervical os**, which an ultrasound would confirm. *Cysts on the placental surface* - **Placental cysts** are usually benign findings and are not typically associated with active painless vaginal bleeding in the third trimester. - They tend to be **asymptomatic** and are rarely the cause of significant obstetric complications. *Retroplacental blood accumulation* - **Retroplacental blood accumulation** is characteristic of **placental abruption**, which typically presents with painful vaginal bleeding, uterine tenderness, and contractions, none of which are present here. *Placental calcification* - **Placental calcification** is a common, normal finding as pregnancy progresses and the placenta matures; it is not a cause of third-trimester vaginal bleeding. - It indicates **placental aging** and is generally not associated with adverse outcomes unless severe and accompanied by other issues. *Loss of the clear retroplacental space* - **Loss of the clear retroplacental space** is an ultrasound sign indicative of **placenta accreta spectrum**, where the placenta abnormally adheres to the uterine wall. - While a prior C-section is a risk factor for accreta, the primary presenting symptom leading to diagnosis is usually **hemorrhage during placental delivery**, not painless third-trimester bleeding, and it would need further specific imaging features to confirm.

Question 5: 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. Hysteroscopy with potential adhesiolysis (Correct Answer)
B. Measurement of serum FSH and LH concentrations
C. Measurement of antisperm antibody concentration
D. Dilation and curettage
E. Estrogen/progestin withdrawal test

Explanation: ***Hysteroscopy with potential adhesiolysis*** - The patient's history of **postpartum hemorrhage** requiring D&C, followed by significantly **reduced menstrual flow**, strongly suggests **intrauterine adhesions (Asherman's syndrome)**. - **Hysteroscopy** is the definitive diagnostic and therapeutic procedure for Asherman's syndrome, allowing direct visualization and surgical lysis of adhesions. *Measurement of serum FSH and LH concentrations* - This step is typically used to evaluate **ovarian reserve** or **hypothalamic-pituitary-ovarian axis dysfunction** in cases of anovulation or primary ovarian insufficiency. - Given the patient's regular menstrual cycles, ovulatory dysfunction is less likely to be the primary cause of her infertility symptoms. *Measurement of antisperm antibody concentration* - **Antisperm antibodies** are a cause of infertility in a small percentage of couples, affecting sperm function or fertilization. - This test is usually pursued after more common causes of infertility have been ruled out, as there are stronger indicators for Asherman's syndrome in this case. *Dilation and curettage* - A **D&C** was previously performed and is the likely iatrogenic cause of her current symptoms (Asherman's syndrome). - Performing another D&C without addressing the adhesions would likely worsen her condition and lead to further scarring. *Estrogen/progestin withdrawal test* - This test assesses the integrity of the **endometrium** and the presence of sufficient endogenous estrogen if a patient has **amenorrhea**, as bleeding after withdrawal indicates a responsive endometrium. - The patient has regular, albeit reduced, menstrual cycles, making this test less relevant for her specific symptoms.

Question 6: A 34-year-old G5P5 woman gave birth to a healthy infant 30 minutes ago by vacuum-assisted vaginal delivery and is now experiencing vaginal bleeding. The placenta was delivered spontaneously and was intact upon examination. The infant weighed 5.2 kg and had Apgar scores of 8 and 9. No perineal tear or intentional episiotomy occurred. The patient has type 1 diabetes. She had good glycemic control throughout her pregnancy. She took a prenatal vitamin daily. Blood pressure is 135/72 mmHg, pulse is 102/min, and respirations are 18/min. Upon physical examination, the uterine fundus is soft and palpated 4 cm above the umbilicus. There are 3-cm blood clots on the patient’s bed pad. Which of the following is the next best step in management for the patient’s bleeding?

A. Administer misoprostol
B. Manually remove retained placental fragments
C. Perform uterine massage and administer oxytocin (Correct Answer)
D. Perform uterine artery embolization
E. Perform hysterectomy

Explanation: ***Perform uterine massage and administer oxytocin*** - The patient's presentation of a **soft, boggy uterus** palpated 4 cm above the umbilicus after delivery, along with significant vaginal bleeding and clots, is highly indicative of **uterine atony**. - **Uterine massage** and administration of **oxytocin** are the first-line interventions to stimulate uterine contractions and reduce bleeding by compressing placental site blood vessels. *Administer misoprostol* - **Misoprostol** is a prostaglandin analog that can be used for uterine atony when oxytocin is insufficient or contraindicated, but it is not the *first-line* treatment. - Its onset of action may be slower than immediate uterine massage and IV oxytocin, which are preferred for initial management of acute uterine atony. *Manually remove retained placental fragments* - The question states that the **placenta was delivered spontaneously and was intact upon examination**, which makes retained placental fragments less likely as the primary cause of bleeding. - While retained fragments can cause postpartum hemorrhage, the boggy uterus points more strongly to atony, and manual removal is indicated *after* confirming retained placental tissue. *Perform uterine artery embolization* - **Uterine artery embolization** is an interventional radiology procedure typically reserved for cases of postpartum hemorrhage that are refractory to conventional medical and surgical management. - It is an invasive procedure and not the appropriate *next best step* for initial management of suspected uterine atony. *Perform hysterectomy* - **Hysterectomy** is a last-resort, life-saving measure for intractable postpartum hemorrhage when all other medical and surgical options have failed. - It is a highly invasive and irreversible procedure, certainly not the *next best step* in a patient who has just begun to bleed.

Question 7: A 31-year-old G1P0 woman with a history of hypertension presents to the emergency department because she believes that she is in labor. She is in her 38th week of pregnancy and her course has thus far been uncomplicated. This morning, she began feeling painful contractions and noted vaginal bleeding after she fell off her bike while riding to work. She is experiencing lower abdominal and pelvic pain between contractions as well. Her temperature is 97.6°F (36.4°C), blood pressure is 177/99 mmHg, pulse is 100/min, respirations are 20/min, and oxygen saturation is 98% on room air. Physical exam is notable for a gravid and hypertonic uterus and moderate blood in the vaginal vault. Ultrasound reveals no abnormalities. Which of the following is the most likely diagnosis?

A. Uterine rupture
B. Abruptio placentae (Correct Answer)
C. Placenta previa
D. Normal labor
E. Vasa previa

Explanation: ***Abruptio placentae*** - Vaginal bleeding after **trauma** (fall off bike), **hypertension**, and a **hypertonic uterus** with **lower abdominal/pelvic pain** between contractions are classic signs of placental abruption. - Abruption occurs when the **placenta prematurely separates** from the uterine wall, leading to bleeding and uterine irritability. *Uterine rupture* - While uterine rupture involves abdominal pain and bleeding, it typically presents with **fetal distress**, **loss of uterine tone**, and a feeling of **'ripping'** or tearing, none of which are described. - A uterine rupture is more common in women with a history of **prior C-section** or uterine surgery, which is not mentioned here. *Placenta previa* - Characterized by **painless vaginal bleeding** in the late second or third trimester, often with a soft, non-tender uterus. - The presence of **painful contractions**, a **hypertonic uterus**, and a clear cause of trauma rules out placenta previa. *Normal labor* - While this patient is in labor, the presence of **significant vaginal bleeding**, **post-traumatic onset**, and **severe lower abdominal pain** between contractions are not typical for uncomplicated normal labor. - Normal labor contractions are usually regular and progress, but the associated symptoms point to a more serious underlying issue. *Vasa previa* - Characterized by **fetal blood vessels** running within the membranes over the cervical os, leading to **painless vaginal bleeding** when these vessels rupture. - This condition is often associated with **fetal distress** and **fetal hemorrhage**, which is not indicated here, and bleeding typically occurs upon rupture of membranes, not from trauma.

Question 8: A 36-year-old G4P3 is admitted to the obstetrics floor at 35 weeks gestation with painless vaginal spotting for a week. She had 2 cesarean deliveries. An ultrasound examination at 22 weeks gestation showed a partial placenta previa, but she was told not to worry. Today, her vital signs are within normal limits, and a physical examination is unremarkable, except for some blood traces on the perineum. The fetal heart rate is 153/min. The uterine fundus is at the xiphoid process and uterine contractions are absent. Palpation identifies a longitudinal lie. Transvaginal ultrasound shows an anterior placement of the placenta with a placental edge-to-internal os distance of 1.5 cm and a loss of the retroplacental space. Which of the following statements best describes the principle of management for this patient?

A. Cesarean hysterectomy should be considered for the management of this patient
B. She can be managed with an unscheduled vaginal delivery with a switch to cesarean delivery if needed
C. Any decision regarding the mode of delivery in this patient should be taken after an amniocentesis to determine the fetal lung maturity
D. This patient without a significant prepartum bleeding is unlikely to have an intra- or postpartum bleeding
E. With such placental position, she should be managed with a scheduled cesarean in the lower uterine segment at 37 weeks’ pregnancy (Correct Answer)

Explanation: ***With such placental position, she should be managed with a scheduled cesarean in the lower uterine segment at 37 weeks’ pregnancy*** - This patient presents with signs highly suggestive of **placenta accreta spectrum (PAS)**, including a history of multiple **cesarean deliveries**, current **partial placenta previa** (placental edge 1.5 cm from internal os), and a **loss of retroplacental space** on ultrasound, all of which increase the risk of massive hemorrhage. A **scheduled cesarean section at 37 weeks** is the standard management for placenta previa and suspected accreta without significant bleeding, as it allows for proper preparation, a multidisciplinary team, and optimized outcomes. - Delaying delivery until 37 weeks, if the patient remains stable without significant bleeding, helps to ensure **fetal lung maturity** while minimizing maternal risks associated with prolonged pregnancy in the presence of PAS disorders. *Cesarean hysterectomy should be considered for the management of this patient* - While **cesarean hysterectomy** might ultimately be necessary in cases of confirmed placenta accreta spectrum with significant invasion, it is typically a **contingency plan** for managing severe hemorrhage or unmanageable placental adherence during a planned cesarean delivery, not the *initial primary management* decision without more extensive bleeding or definitive diagnosis pre-delivery. - Elective cesarean hysterectomy is associated with **increased morbidity** and is usually reserved for cases where conservative management of the placenta is deemed unsafe or unsuccessful during surgery. *She can be managed with an unscheduled vaginal delivery with a switch to cesarean delivery if needed* - The presence of even a **partial placenta previa** and suspected **placenta accreta spectrum** makes vaginal delivery unsafe due to a high risk of **massive hemorrhage** when the cervix dilates or the placenta detaches. - An unscheduled attempt at vaginal delivery could lead to an **emergency situation**, compromising both maternal and fetal well-being, and is contraindicated with this placental position. *Any decision regarding the mode of delivery in this patient should be taken after an amniocentesis to determine the fetal lung maturity* - While fetal lung maturity is a concern for preterm deliveries, the primary concern in this patient is the **maternal risk of hemorrhage** associated with placenta previa and suspected accreta, which dictates the timing and mode of delivery. - Given the high suspicion for **placenta accreta spectrum**, delaying delivery for amniocentesis adds unnecessary risk without significantly altering the mode of delivery, which will almost certainly be a **cesarean section** regardless of lung maturity results. *This patient without a significant prepartum bleeding is unlikely to have an intra- or postpartum bleeding* - This statement is incorrect. The classic presentation of **placenta accreta spectrum** often involves **painless vaginal bleeding** as described, and the absence of *significant* prepartum bleeding does not negate the high risk of **severe intrapartum or postpartum hemorrhage** due to the abnormally adherent placenta. - The risk of hemorrhage in PAS is primarily associated with the **failure of placental separation** during or after delivery, not necessarily with pre-delivery bleeding patterns.

Question 9: A 22-year-old woman comes to the physician because of a 1-month history of a light greenish, milky discharge from both breasts. There is no mastalgia. She has hypothyroidism and migraine headaches. Her mother has breast cancer and is currently undergoing chemotherapy. Menses occur at regular 28-day intervals with moderate flow; her last menstrual period was 1 week ago. Current medications include levothyroxine and propranolol. She appears anxious. Her temperature is 37.1°C (98.78F), pulse is 82/min, and blood pressure is 116/72 mm Hg. The lungs are clear to auscultation. Breast examination is unremarkable. Pelvic examination shows a normal vagina and cervix. Serum studies show: Thyroid-stimulating hormone 3.5 μU/mL Progesterone 0.7 ng/mL (Follicular phase: N < 3) Prolactin 18 ng/mL Follicle-stimulating hormone 20 mIU/mL A urine pregnancy test is negative. Which of the following is the most appropriate next step in management?

A. MRI of the head
B. Ultrasound of both breasts
C. Reassurance and recommend avoidance of nipple stimulation (Correct Answer)
D. Mammogram of both breasts
E. Galactography of both breasts

Explanation: ***Reassurance and recommend avoidance of nipple stimulation*** - The patient's **prolactin level (18 ng/mL)** is within the normal range (<25 ng/mL for non-pregnant women), making further diagnostic workup for hyperprolactinemia unnecessary. - Given the normal prolactin, regular menses, negative pregnancy test, and unremarkable breast exam, the galactorrhea is likely **physiologic** and exacerbated by nipple stimulation or anxiety. *MRI of the head* - This would be indicated if the patient had **hyperprolactinemia (prolactin >25 ng/mL)** to rule out a pituitary adenoma. - Since her prolactin level is normal, a pituitary MRI is not warranted at this time. *Ultrasound of both breasts* - Breast imaging (ultrasound or mammogram) is usually indicated for **palpable masses**, **bloody or unilateral nipple discharge**, or signs suspicious for malignancy. - The patient has bilateral, milky discharge with no masses, making imaging less urgent. *Mammogram of both breasts* - A mammogram is typically performed in women over 40 for **screening** or for evaluation of suspicious breast symptoms, especially those suggestive of malignancy. - This patient is 22 years old and presents with bilateral, non-bloody discharge, not a mass, and her risk factors are primarily for physiological galactorrhea. *Galactography of both breasts* - Galactography (ductography) is typically performed for cases of **unilateral, bloody, or serous nipple discharge** to identify intraductal pathologies like papillomas or carcinomas. - Her discharge is bilateral and milky, which is not an indication for galactography.

Question 10: A 28-year-old woman visits her physician with complaints of inability to become pregnant despite frequent unprotected sexual intercourse with her husband for over a year. She breastfed her only child until about 13 months ago, when the couple decided to have a second child. Over the past year, the patient has had only 4 episodes of menstrual bleeding. She reports occasional milk discharge from both breasts. Her only medication currently is daily pantoprazole, which she takes for dyspepsia. Her BMI is 29 kg/m2. Physical examination and vitals are normal. Pelvic examination indicates no abnormalities. The patient’s breast examination reveals full breasts and a few drops of milk can be expressed from both nipples. Estradiol, serum follicle-stimulating hormone (FSH), testosterone, and thyroid-stimulating hormone (TSH) levels are within the normal range. Which of the following best explains these findings?

A. Prolactinoma (Correct Answer)
B. Pantoprazole
C. Primary ovarian insufficiency
D. Normal findings
E. Sheehan’s syndrome

Explanation: ***Prolactinoma*** - The patient's symptoms of **galactorrhea** (milk discharge from breasts) and **oligomenorrhea** (infrequent menstrual bleeding), leading to **infertility**, are classic signs of hyperprolactinemia. - Given that other hormonal levels like FSH, estradiol, and TSH are normal, a **prolactinoma** (a pituitary tumor secreting prolactin) is the most likely cause of elevated prolactin. *Pantoprazole* - While **proton pump inhibitors** like pantoprazole can cause hyperprolactinemia, this is a less common and typically milder side effect compared to the profound symptoms described, especially with sustained galactorrhea and significant menstrual irregularities. - The severity and chronicity of symptoms, including infertility, make **prolactinoma** a more probable diagnosis than drug-induced hyperprolactinemia. *Primary ovarian insufficiency* - **Primary ovarian insufficiency (POI)** is characterized by elevated FSH and low estradiol levels, as the ovaries are no longer responding to FSH stimulation. - The patient's **normal FSH and estradiol levels** effectively rule out primary ovarian insufficiency as the cause of her symptoms. *Normal findings* - The patient's symptoms of **infertility, galactorrhea, and oligomenorrhea** are clearly abnormal and warrant investigation. - A healthy reproductive system would not present with these combined features, especially after a year of unprotected intercourse with a desire for pregnancy. *Sheehan’s syndrome* - **Sheehan's syndrome** typically occurs after severe postpartum hemorrhage, leading to pituitary necrosis and subsequent **panhypopituitarism**, presenting with amenorrhea, lactation failure (not galactorrhea), and often symptoms of adrenal or thyroid insufficiency. - The patient's **galactorrhea**, normal TSH, and the absence of a history of postpartum hemorrhage do not align with Sheehan's syndrome.

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