Uterine compression sutures — MCQs

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 36-year-old African American G1P0010 presents to her gynecologist for an annual visit. She has a medical history of hypertension, for which she takes hydrochlorothiazide. The patient’s mother had breast cancer at age 68, and her sister has endometriosis. At this visit, the patient’s temperature is 98.6°F (37.0°C), blood pressure is 138/74 mmHg, pulse is 80/min, and respirations are 13/min. Her BMI is 32.4 kg/m^2. Pelvic exam reveals a nontender, 16-week sized uterus with an irregular contour. A transvaginal ultrasound is performed and demonstrates a submucosal leiomyoma. This patient is at most increased risk of which of the following complications?

A 24-year-old woman is brought to the emergency department after being assaulted. The paramedics report that the patient was found conscious and reported being kicked many times in the torso. She is alert and able to respond to questions. She denies any head trauma. She has a past medical history of endometriosis and a tubo-ovarian abscess that was removed surgically two years ago. Her only home medication is oral contraceptive pills. Her temperature is 98.5°F (36.9°C), blood pressure is 82/51 mmHg, pulse is 136/min, respirations are 24/min, and SpO2 is 94%. She has superficial lacerations to the face and severe bruising over her chest and abdomen. Her lungs are clear to auscultation bilaterally and her abdomen is soft, distended, and diffusely tender to palpation. Her skin is cool and clammy. Her FAST exam reveals fluid in the perisplenic space. Which of the following is the next best step in management?

A 36-year-old G4P1021 woman comes to the emergency room complaining of intense abdominal pain and vaginal bleeding. She is 9 weeks into her pregnancy and is very concerned as she experienced similar symptoms during her past pregnancy losses. Her pain is described as “stabbing, 10/10 pain that comes and goes.” When asked about her vaginal bleeding, she reports that “there were some clots initially, similar to my second day of menstruation.” She endorses joint pains that is worse in the morning, “allergic” rashes at her arms, and fatigue. She denies weight loss, chills, fever, nausea/vomiting, diarrhea, or constipation. Physical examination reveals an enlarged and irregularly shaped uterus with a partially open external os and a flesh-colored bulge. Her laboratory findings are shown below: Serum: Hemoglobin: 11.8 g/dL Hematocrit: 35% Leukocyte count:7,600 /mm^3 with normal differential Platelet count: 200,000/mm^3 Bleeding time: 4 minutes (Normal: 2-7 minutes) Prothrombin time: 13 seconds (Normal: 11-15 seconds) Partial thromboplastin time (activated): 30 seconds (Normal: 25-40 seconds) What is the most likely cause of this patient’s symptoms?

Five minutes after initiating a change of position and oxygen inhalation, the oxytocin infusion is discontinued. A repeat CTG that is done 10 minutes later shows recurrent variable decelerations and a total of 3 uterine contractions in 10 minutes. Which of the following is the most appropriate next step in management?

Thirty minutes after normal vaginal delivery of twins, a 35-year-old woman, gravida 5, para 4, has heavy vaginal bleeding with clots. Physical examination shows a soft, enlarged, and boggy uterus. Despite bimanual uterine massage, administration of uterotonic drugs, and placement of an intrauterine balloon for tamponade, the bleeding continues. A hysterectomy is performed. Vessels running through which of the following structures must be ligated during the surgery to achieve hemostasis?

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 22-year-old woman is brought to the emergency department because of a 1-day history of double vision and rapidly worsening pain and swelling of her right eye. She had an upper respiratory tract infection a week ago after which she has had nasal congestion, recurrent headaches, and a purulent nasal discharge. She took antibiotics for her respiratory tract infection but did not complete the course. She has asthma treated with theophylline and inhaled β-adrenergic agonists and corticosteroids. She appears to be in severe distress. Her temperature is 38.5°C (101.3°F), pulse is 100/min, and blood pressure is 130/80 mm Hg. Ophthalmic examination of the right eye shows proptosis and diffuse edema, erythema, and tenderness of the eyelids. Right eye movements are restricted and painful in all directions. The pupils are equal and reactive to light. There is tenderness to palpation over the right cheek and purulent nasal discharge in the right nasal cavity. The left eye shows no abnormalities. Laboratory studies show a leukocyte count of 12,000/mm3. Which of the following provides the strongest indication for administering intravenous antibiotics to this patient?

A 24-year-old woman, gravida 2, para 1, at 10 weeks' gestation comes to the emergency department for vaginal bleeding, cramping lower abdominal pain, and dizziness. She also has had fevers, chills, and foul-smelling vaginal discharge for the past 2 days. She is sexually active with one male partner, and they use condoms inconsistently. Pregnancy and delivery of her first child were uncomplicated. She appears acutely ill. Her temperature is 38.9°C (102°F), pulse is 120/min, respirations are 22/min, and blood pressure is 88/50 mm Hg. Abdominal examination shows moderate tenderness to palpation over the lower quadrants. Pelvic examination shows a tender cervix that is dilated with clots and a solid bloody mass within the cervical canal. Her serum β-human chorionic gonadotropin concentration is 15,000 mIU/mL. Pelvic ultrasound shows an intrauterine gestational sac with absent fetal heart tones. Which of the following is the most appropriate next step in management?

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?