Obstetrics/Gynecology ER

One Step Further Question: What is Fitz-Hugh-Curtis syndrome?

Answer: Perihepatitis associated with PID. It manifests as right upper quadrant pain and is seen in 10% of patients with PID.

One Step Further Question: What is the clinical condition when the placenta attaches to the myometrium?

Answer: Placenta accreta.

One Step Further Question: In reproductive age women, what is the most common cause of abnormal vaginal bleeding?

Answer: Pregnancy-related complications.

One Step Further Question: What are the most common causes of pelvic pain in the nonpregnant patient?

Answer: Salpingitis, ruptured corpus luteal cyst, adnexal torsion, tubo-ovarian abscess, and appendicitis. However, in up to 20% of patients with pelvic pain, no etiologic agent is determined

One Step Further Question: What is the treatment of tender breast engorgement in a non-breast feeding postpartum woman?

Answer: Supportive bra, cold cabbage leaves, and ice packs.

One Step Further Question: What is a corpus luteum cyst?

Answer: The corpus luteum of the ovary supports the pregnancy by secreting beta-hCG/progesterone during the first 6-7 weeks. It often becomes cystic.

One Step Further Question: Why is complete arterial obstruction rare in ovarian torsion?

Answer: The ovary receives dual blood supply from the uterine and ovarian arteries.

One Step Further Question: What is the most common cause of bleeding in the primigravid woman?

Answer: Threatened abortion.

One Step Further Question: What are 3 consequences of PID?

Answer: Tubo-ovarian abscess, infertility, ectopic pregnancy.

One Step Further Question: What is the preferred diagnostic test for placenta previa?

Answer: Ultrasound.

One Step Further Question: How often do patients with placental abruption present without pain or vaginal bleeding?

Answer: Up to 1/5th of patients with placental abruption will have neither bleeding nor pain.

One Step Further Question: What percentage of pregnant patients develop 1st-trimester vaginal bleeding?

Answer: Up to 20% of all pregnant patients develop vaginal bleeding within the first 20 weeks of gestation. Of these, 50% will miscarry; the other 50% will go on to have a term pregnancy.

One Step Further Question: What is the most common cause of postpartum hemorrhage?

Answer: Uterine atony.

One Step Further Question: What do late decelerations signify on fetal tracing?

Answer: Uteroplacental insufficiency.

One Step Further Question: Which population is at greatest risk for a heterotopic pregnancy?

Answer: Women with fertility-assisted pregnancies.

One Step Further Question: Should breast-feeding continue even in the presence of a breast abscess?

Answer: Yes.

One Step Further Question: True or False: Liver transaminases are usually elevated in cases of Fitz-Hugh-Curtis syndrome?

Answer: False.

One Step Further Question: What is the HELLP syndrome?

Answer: HELLP syndrome is a severe form of preeclampsia characterized by hemolysis, elevated liver enzymes and low platelets. Beyond The Boards Recent ACOG guidelines state that proteinuria is not required to make a diagnosis of preeclampsia if there is evidence of end-organ damage as noted above. Massive proteinuria is also not necessary for a diagnosis of severe preeclampsia.]

One Step Further Question: How do normal vital signs change during pregnancy?

Answer: Heart rate increases by 10-15 beats per minute. Blood pressure typically drops during the 2nd trimester.

One Step Further Question: What are two side effects of hypermagnesemia?

Answer: Hyporeflexia and hypoventilation.

One Step Further Question: What is the treatment for postpartum hemorrhage that cannot be controlled with medications?

Answer: Hysterectomy.

One Step Further Question: How long after successful methotrexate therapy will the beta-hCG reach 0?

Answer: In about 2-3 months.

One Step Further Question: What is an alternative regimen to treat endometritis?

Answer: Intravenous ceftriaxone and Intravenous metronidazole.

One Step Further Question: What impact does PID have on future pregnancies?

Answer: It increases the risk of ectopic pregnancy and infertility.

One Step Further Question: What is Wood's corkscrew maneuver?

Answer: It is an alternate approach to shoulder dystocia management. The fetus is rotated 180 degrees in order to release the impacted shoulder

One Step Further Question: Why is ovarian torsion more common on the right side?

Answer: It is believed that the sigmoid colon stabilizes the left ovary so that it is less likely to torse.

One Step Further Question: What bacteria cause bacterial vaginosis?

Answer: It is due to polymicrobial overgrowth of several bacteria that replace the normal vagnial flora. These abnormal bacteria include Prevotella, Mobiluncus, Bacterioides, Gardnerella vaginalis, and Mycoplasma hominis.

One Step Further Question: What is the most frequently occurring pelvic tumor in women?

Answer: Leiomyoma (uterine fibroid).

One Step Further Question: What is the first clinical manifestation of magnesium toxicity?

Answer: Loss of deep tendon reflexes.

One Step Further Question: What treatment is required for recurrent Bartholin's abscesses?

Answer: Marsupialization or excision in the operating room.

One Step Further Question: What is another initial test done in any patient with increased vaginal discharge?

Answer: Microscopic examination of the secretions.

One Step Further Question: Does the insertion of an IUD increase the risk of developing pelvic inflammatory disease?

Answer: No.

One Step Further Question: What is the classic clinical presentation of placental abruption?

Answer: Painful third-trimester vaginal bleeding.

One Step Further Question: What is the perinatal mortality for umbilical cord compression?

Answer: Overall, the perinatal mortality rate is about 15%. However, if a cesarean section can be performed within 10 minutes, the rate decreases to 5%.

One Step Further Question: What is the recommended treatment for pregnant patients with bacterial vaginosis?

Answer: Oral clindamycin 300 mg by mouth every 12 hours x 7 days, or metronidazole 500 mg orally twice a day for 7 days, or metronidazole 250 mg orally three times a day for 7 days.

One Step Further Question: What is the treatment of uterine rupture?

Answer: Emergency C-section.

One Step Further Question: When is HELLP syndrome most commonly diagnosed?

Answer: 28-36 weeks gestation.

One Step Further Question: Approximately what percentage of pregnant females with untreated asymptomatic bacteriuria will go on to develop pyelonephritis?

Answer: 30%.

One Step Further Question: At what age should patients be referred to a gynecologist to rule out Bartholin gland cancer?

Answer: 40.

One Step Further Question: At what crown-rump length is a heartbeat expected on ultrasound?

Answer: 5 mm.

One Step Further Question: What is the success rate of methotrexate in the management of early ectopic pregnancy?

Answer: 85-93%.

One Step Further Question: When prescribing metronidazole, patients should be counseled to avoid consumption of what substance?

Answer: Alcohol should be avoided due to the disulfiram-like reaction that occurs when taken with metronidazole.

One Step Further Question: Does the presence of an intrauterine pregnancy rule out PID?

Answer: Although rare, it can take place concurrently with fertilization or throughout the 1st trimester.

One Step Further Question: Why is amoxicillin/clavulanic acid avoided in the treatment of Preterm PROM?

Answer: Amoxicillin/clavulinic acid has been associated with an increased risk of necrotizing enterocolitis.

One Step Further Question: What is the underlying pathophysiology behind anovulatory bleeding?

Answer: Anovulatory bleeding is caused by the failure of the corpus luteal cyst to form leading to absence of progesterone and unopposed estrogen stimulation on the endometrium.

One Step Further Question: What are the most common complications of shoulder dystocia?

Answer: Asphyxia, brachial plexus injuries and clavicular or humeral fracture.

One Step Further Question: What is the definition of preterm or premature labor?

Answer: Before 37 weeks.

One Step Further Question: What is the most common malpresentation in fetal delivery?

Answer: Breech presentation occurs in approximately 4% of all deliveries.

One Step Further Question: Which embryologic period is associated with increased teratogenicity during organogenesis?

Answer: Days 21-56 of gestation (3-8 weeks).

One Step Further Question: Mixing alcohol and metronidazole leads to what reaction?

Answer: Disulfram-like reaction: flushing, tachycardia, hypotension.

28-year-old woman at 37 weeks gestation presents with abdominal pain and vaginal bleeding. Her vital signs are normal and she has uterine tenderness on palpation of her abdomen. What is the most important diagnosis to rule out given this presentation? Abruptio placenta Placenta previa Subchorionic hemorrhage Vasa previa

Correct Answer ( A ) Explanation: Abruptio placenta is premature separation of the placenta from the uterine wall occurring in 1% of pregnancies. Abruption occurs both spontaneously (associated with hypertension, cocaine use, previous abruption, multiparity, increased maternal age, smoking) or as a result of trauma. Patients experience abrupt onset of bleeding often with abdominal pain. The uterus is tender with contractions. The clinician should defer the pelvic examination in the third trimester until placenta previa has been ruled out by ultrasound. Abruption may be diagnosed on ultrasound but the sensitivity is poor due to similar echogenicity of blood to the placenta, therefore it is usually a clinical diagnosis. Depending on the size of abruption, patients may lose a significant amount of blood. Laboratory analysis may show markers of disseminated intravascular coagulation. Immediate consultation with an Obstetrician should be obtained. Placenta previa (B) is the implantation of the placenta over the cervical os. Patients present with painless vaginal bleeding. Risk factors include multiparity, previous cesarean section, advanced maternal age and smoking. Ultrasound is 95% sensitive and must be performed prior to vaginal examination as bleeding may increase with digital or speculum exam. Subchorionic hemorrhage (C) occurs during the first trimester and is the accumulation of blood between the chorionic membranes and uterine wall. Patients may have vaginal bleeding. The presence of a subchorionic hemorrhage increases the chance of spontaneous abortion. Vasa previa (D) occurs when fetal vessels within the membrane but unsupported by the umbilical cord pass across the internal os ahead of the presenting fetal part. Patients may experience painless vaginal bleeding. These patients require emergent C-section.

A 38-year old woman presents with right upper quadrant pain that is worse with deep breathing. She reports having multiple sexual partners. She was recently treated for "an STD," however didn't complete the entire course of antibiotics because "she felt fine." What is the most likely organism causing this condition? Chlamydia trachomatis Escherichia coli Treponema pallidum Trichamonas vaginalis

Correct Answer ( A ) Explanation: The patient is likely suffering from Fitz-Hugh-Curtis syndrome or perihepatitis that resulted from a partially treated Chlamydia trachomatis infection. Fitz-Hugh- Curtis syndrome causes right upper quadrant pain, which is commonly pleuritic in nature. In most cases, the patient will have either a preceding episode of pelvic inflammatory disease (PID) or have concomitant PID symptoms. Fitz-Hugh-Curtis syndrome can also be seen with a concomitant or preceding gonorrhea infection, although Chlamydia trachomatis is now thought to be more common. Fitz-Hugh-Curtis is not commonly associated with Escherichia coli (B), Trichamonas vaginalis (D) or Treponema pallidum (C) infection.

21-year-old woman with no prenatal care presents for evaluation of lower abdominal pain and fever. She estimates that she is approximately 7.5 months pregnant. On questioning, she acknowledges intermittent pain for two days and a gush of fluid shortly after the pain began. Her temperature is 101.8°F. Physical examination is notable for purulent material in the vaginal vault. Which of the following is the most likely diagnosis? Chorioamnionitis Endometritis Pelvic inflammatory disease Urinary tract infection

Correct Answer ( A ) Explanation: Beginning at 16 weeks, the membranes of the chorioamniotic sac adhere to the cervical os and are at risk for infection. Chorioamnionitis is an intra-amniotic infection of the chorion and amniotic layers of the amniotic sac. The placenta and fetal membranes may also be involved. It is caused by an ascending infection of normal vaginal flora. Risk factors include: premature rupture of membranes, preterm labor, prolonged rupture of membranes, multiple vaginal examinations and genital tract infections. Clinical findings include fever, uterine tenderness and maternal and fetal tachycardia. Women may also have purulent vaginal discharge on examination. This is a clinical diagnosis and patients require intravenous antibiotics, most commonly ampicillin and gentamicin. Endometritis (B) in an infection of the uterine endometrium that affects between 2 and 8% of pregnancies. The infection develops on the second or third post-partum day and is characterized by fever, abdominal pain and foul-smelling lochia. Pelvic inflammatory disease (C) does not occur during this stage of pregnancy due to the mucous plug that seals the cervix. It may occur during the first trimester although it is quite rare. A urinary tract infection (D) does not cause systemic signs of infection as described in the patient unless it has moved to the upper urinary tract causing pyelonephritis.

A 27-year-old woman 32 weeks pregnant presents with bright-red vaginal bleeding for 1 day. The patient denies any pain and is not tender on abdominal exam. Her vital signs are BP 115/70, HR 90, and RR 16. What is the most appropriate next step in management? Obtain intravenous access Order an ultrasound Perform a digital vaginal exam Perform a speculum exam

Correct Answer ( A ) Explanation: Placenta previa is characterized by painless, fresh vaginal bleeding in late pregnancy. Placenta previa occurs in 1% of pregnancies and is defined as a placenta that extends near, partially over, or completely over the cervical os. These patients are at an increased risk for life-threatening hemorrhage. As a result, the first step in management of placental previa is to obtain intravenous access in anticipation of fluid resuscitation and possible transfusion. Obstetrical consultation is also advised. Digital vaginal exam (C) and speculum exam (D) should be avoided in 3rd-trimester bleeding; these procedures can precipitate significant hemorrhage. Ultrasound (B) can be performed to determine fetal and placental positioning. However, this exam should not precede the initiation of IV access and preparation for fluid resuscitation.

A woman presents with fever and foul-smelling vaginal discharge 3 days after delivery of a full-term fetus. She is febrile, with uterine tenderness on pelvic exam. Which of the following is the strongest risk factor for postpartum endometritis? Cesarean section Internal fetal monitoring Multiple gestation Premature rupture of membranes

Correct Answer ( A ) Explanation: Postpartum endometritis is the most common puerperal infection, usually developing on the 2nd or 3rd day postpartum. Typically, the lochia has a foul odor, and the patient develops a leukocytosis. The infection begins in the endometrium and can extend to the myometrium or parametrium. It is a serious infection that can lead to complications such as peritonitis, septic thrombophlebitis, and necrotizing fasciitis. The pathogens involved are typically the flora of the bowel, perineum, vagina, and cervix. The strongest risk factor for endometritis is a cesarean section. Manternal fetal monitoring (B), multiple gestation (C), and premature rupture of membranes (D) also increase the risk for endometritis but are less common than cesarean delivery. Other risk factors include young maternal age, maternal HIV infection, and lower socioeconomic class.

A 28-year-old woman G1P0 at 38 weeks gestation presents with severe abdominal pain and vaginal bleeding. On examination, the uterus is tetanically contracted and tender to palpation. Fetal monitoring shows decreased heart rate variability and late decelerations. Which of the following is the most likely diagnosis? Abruptio placentae Amniotic fluid embolism Placenta previa Uterine rupture

Correct Answer ( A ) Explanation: The patient has abruptio placentae. Abruptio placenta refers to premature separation of the placenta from the uterine wall, and occurs in approximately 1% of pregnancies. The cause of placental abruption is unknown, but identified risk factors include hypertension, trauma, smoking, cocaine use, and previous abruptions. The classic triad of abruptio placenta is vaginal bleeding, painful uterine contractions, and fetal distress. As the placenta separates from the uterine wall vaginal bleeding ensues, though bleeding may be concealed if the blood pools behind the placenta. Uterine irritability is present and the uterus may be tetanically contracted. In severe abruptions, maternal hypotension and tachycardia develop due to blood loss, and activation of the maternal coagulation cascade can result in disseminated intravascular coagulation (DIC). Fetal distress is caused by loss of placental blood flow, and fetal death occurs in approximately 15% of cases. In this case, decreased heart rate variability and late decelerations on fetal tracing signify fetal distress, and are a clue to the diagnosis of placental abruption. Ultrasound may confirm the presence of a retroplacental clot, but is insensitive due to similar echogenicities of fresh blood and placental tissue. Patients with placental abruption should be managed aggressively with crystalloid fluid resuscitation, blood transfusion if hemodynamically unstable, correction of associated coagulopathy, and obstetric consultation for emergent cesarean section. Amniotic fluid embolism (B) is a rare, life-threatening condition caused by amniotic fluid entering the maternal circulation. It presents with hypotension, respiratory distress, altered mental status, and can progress to cardiovascular collapse. Placenta previa (C) presents with painless vaginal bleeding. Mild uterine irritability may be present, but a tetanically contracted, tender uterus suggests placental abruption. Uterine rupture (D) is another third trimester emergency condition which can present with abdominal pain and vaginal bleeding. However, it usually presents nonspecifically with gradually worsening abdominal pain and progresses to fetal distress. There is loss of station of the fetus on cervical exam, and fetal parts, such as foot or hand, may be palpated directly through the abdominal wall.

A 24-year old woman presents with URI symptoms. She is 34 weeks pregnant. As part of her work-up, you order a urinalysis, which shows 2+ bacteria with no WBCs or squamous epithelial cells. Two days later, the lab calls you and informs you that the urine culture is positive. You call the patient back and she denies symptoms of urinary tract infection. With regards to the urine culture results, what treatment is indicated? Cephalexin 500 mg QID for 7 days Ciprofloxacin 500 mg QID for 7 days No treatment is necessary Trimethoprim-sulfamethoxazole 1 DS tablet BID for 3 days

Correct Answer ( A ) Explanation: The patient has asymptomatic bacteriuria of pregnancy confirmed by a positive urine culture and should be treated with an oral antibiotic that is known to be safe in pregnancy, such as cephalexin 500 mg QID for 7 days. Asymptomatic bacteriuria is common in the general population and in most scenarios does not require therapy. However due to the high risk of complication seen during pregnancy, it should be treated with antibiotics. It is seen in 2-10% of pregnant women and is commonly due to E. coli. Pregnant women have an increased risk of developing urinary tract infections due to the pressure that the enlarged uterus exerts on the ureters and bladder, incomplete emptying during voiding and impaired ureteral peristalsis from progesterone-induced relaxation of the ureteral smooth muscle. Complications of untreated asymptomatic bacteriuria include development of a lower urinary tract infection, pyelonephritis, renal abscess, renal failure, bacteremia, sepsis, intrauterine growth retardation, premature labor and neonatal death. Treatment options generally include cephalosporins, such as cephalexin, amoxicillin (or amoxicillin-clavulanate) and nitrofurantoin. All of which are recognized as Category B by the Food and Drug Administration; meaning that animal studies have failed to show a risk to the fetus. Treatment duration should be for 7-10 days.

26-year-old woman is brought to the ED after a first-time seizure. She is postictal and unable to give you any information. Vital signs are T 37.5°C (rectal), BP 220/110 mm Hg, HR 114 bpm, RR 26 per minute. Her exam is normal except for a gravid abdomen and bilateral pitting ankle edema. Her blood glucose is 105 g/dL. What is the most important test to perform next? Bedside ultrasound CT scan of the head Electrocardiogram Lactate level

Correct Answer ( A ) Explanation: This patient has eclampsia, a condition that includes pregnancy-induced hypertension and seizures in a woman who is at least 20 weeks pregnant. A bedside transabdominal ultrasound can quickly confirm a second or third trimester pregnancy. Eclampsia is initially treated with magnesium sulfate (4 to 6 grams IV followed by a drip) rather than anti-epileptic drugs. The definitive treatment of eclampsia is delivery. Eclampsia can occur up to four weeks postpartum. A CT of the head (B) will not lead to the correct diagnosis, although it should be obtained at some point in the workup of a first-time adult seizure. Pregnancy is a prothrombotic state. Seizures may be associated with an underlying stroke. To evaluate for potential toxigenic causes, an electrocardiogram (C) should be considered in any patient who presents with new onset seizure. However, in this particular patient, an electrocardiogram will have limited diagnostic yield. Due to anaerobic metabolism during a seizure, the lactate level (D) will invariably be elevated in the immediate postictal period and provide minimal diagnostic information. The lactate should clear after 30-60 minutes.

A 24-year-old woman presents to the ED complaining of vaginal discharge and discomfort for 3 weeks. She has tried 2 different intravaginal medications with only temporary improvement. The pelvic exam reveals vulvar erythema and excoriations with a white discharge. The os is closed and there is no adnexal tenderness or masses. Urine dipstick is positive for moderate leukocytes. You perform a wet mount as shown above. Which of the following is the most appropriate treatment for this patient? Fluconazole Intravaginal clindamycin cream Intravaginal metronidazole gel Oral metronidazole

Correct Answer ( A ) Explanation: This patient has vulvovaginal candidiasis, usually caused by Candida albicans. Vulvovaginal candidiasis is quite common and causes mild to moderate vulvar itching and vaginal discharge. Pelvic exam typically reveals a white "cottage-cheese" discharge. Satellite lesions on the perineum are also sometimes observed. Wet mount with potassium hydroxide reveals pseudohyphae and spores. Multiple over-the-counter and prescription topical (intravaginal) treatment options are available for uncomplicated candidiasis. Overall, these have an 80% treatment success rate when used properly. Topical treatment failure, as in this patient, should be treated with oral fluconazole. If patients have more than 4 episodes within a year, the presence of complicating factors such as immunosuppression and poorly controlled diabetes mellitus should be investigated.

A young woman presents with a complaint of stained underwear. She reports that for the last three days she has noticed a malodorous, greenish discharge emanating from her groin. You take a thorough history and perform a pelvic examination. Which of the following is the next best step in evaluating this complaint? Bacterial culture Microscopic examination of discharge Pelvic ultrasonography Serum complete blood count and chemistries

Correct Answer ( B ) Explanation: Infective vaginitis is very likely given the above clinical description. In the initial evaluation of these symptoms, it is important to determine the causative agent. A KOH whiff test can be performed to detect the amine-like fishy odor of bacterial vaginosis or trichomonas vaginitis. However, direct microscopic examination of the discharge suspended in saline (termed wet preparation, or wet prep) will reliably establish the diagnosis, and subsequently direct proper therapy.

A woman presents with right breast pain, fever, and malaise for 3 days. She has been breastfeeding her newborn child for the last 3 weeks. On exam, there is an area of focal erythema and tenderness. No mass or fluctuance is noted. What is the most likely pathogen responsible for causing her condition? Escherichia coli Staphylococcus aureus Streptococcus agalactiae Streptococcus pyogenes

Correct Answer ( B ) Explanation: Mastitis is a localized and painful inflammation of the mammary gland that can be associated with fever and malaise. Lactational mastitis primarily occurs within the 1st few months of breastfeeding when the skin of the breast is prone to damage due to frequent feedings. It may also occur much later when the infant develops teeth and can cause local trauma to the area during feeding. The most common pathogen is Staphylococcus aureus, which accounts for 40% of the cases. It is important to distinguish mastitis (cellulitis) from an abscess (requires surgical drainage) and inflammatory breast cancer (rare, but deadly). In addition to antibiotics such as dicloxacillin or cephalexin that cover for Staphylococcus aureus, the patient should be encouraged to apply cool compresses and continue breastfeeding. If the patient does not respond to antibiotics within 72 hours, the patient should be evaluated again for the possibility of breast abscess. Escherichia coli (A) and Streptococcus species, such as Streptococcus agalactiae (C) and Streptococcus pyogenes (D) have been noted as causes of mastitis as well, but less frequently than Staphylococcus aureus.

24-year-old woman presents to the ED with complaints of vaginal discharge and pelvic discomfort for 3 days. The pelvic exam reveals a thin, white discharge; a friable cervix diffusely tender; and mild adnexal tenderness. Which of the following additional findings should prompt you to admit the patient to the hospital? Allergy to doxycycline Positive urine beta-hCG Recent intrauterine device removal Temperature of 38.3°C

Correct Answer ( B ) Explanation: Pelvic inflammatory disease (PID) is an ascending infection of the upper portions of the genital tract, most commonly caused by Chlamydia trachomatis and Neisseria gonorrhoeae. Woman with PID can have markedly divergent clinical symptoms ranging from mild discomfort to frank peritonitis. Because of this variability, the CDC recommends empiric treatment for PID in all sexually active women who have uterine or adnexal tenderness and cervical motion tenderness. The CDC has also developed several criteria for admission of patients with PID. The patient in the clinical scenario has clinical PID and a positive urine pregnancy test. According to the CDC recommendations (pregnancy), she should be admitted to the hospital for further management.

A 32-year-old gravida 2 para 1 at 33 weeks gestation presents to the emergency room for sharp abdominal pain. She has not had any prenatal care during this pregnancy. Her symptoms include vaginal bleeding, uterine pain between contractions, and fetal distress. Her first pregnancy was uncomplicated, with a vaginal delivery at term. Which one of the following is the most likely diagnosis? Placenta previa Placental abruption Uterine rupture Vasa previa

Correct Answer ( B ) Explanation: Placental abruption is the separation of the placenta from the uterine wall before delivery and is considered an obstetric emergency. Placental abruption typically manifests as painful vaginal bleeding and evidence of fetal distress in the third trimester. The fundus often is tender to palpation, and pain occurs between contractions. Bleeding may be completely or partially concealed or may be bright, dark, or intermixed with amniotic fluid. Common risk factors include abdominal trauma, maternal hypertension, smoking, cocaine use, multiple gestation and previous abruption. The method and timing of delivery depends on the gestational age and the maternal and fetal status. If the mom or the fetus is unstable then immediate cesarean section is the optimal delivery method, regardless of the gestational age. If the mother and the fetus are stable then vaginal delivery is warranted, however the timing depends on the gestational age.

A 27-year-old woman presents with vaginal bleeding. Her last menstrual period was eight weeks ago. On physical examination, there is a small amount of blood in the vaginal vault with an open internal cervical os. Bedside ultrasound reveals an intrauterine pregnancy with a fetal pole but no heartbeat. Which of the following is the most likely diagnosis? Incomplete miscarriage Inevitable miscarriage Missed abortion Threatened miscarriage

Correct Answer ( B ) Explanation: Spontaneous miscarriage before 20 weeks of gestation is the most common serious complication of pregnancy. Most miscarriages (80%) occur in the first trimester of pregnancy and almost all occur before 20 weeks gestation. Up to 25% of pregnant women experience bleeding during pregnancy so the evaluation of threatened miscarriage or abortion is common. The ultimate risk of fetal demise in threatened abortion decreases substantially once a fetal heart beat is visible on ultrasound. The results of the physical examination and ultrasound classify the type of miscarriage. In the case presented, the presence of an open internal os defines the miscarriage as inevitable. Additionally, patients will typically have vaginal bleeding and products of conception can often be felt or visualized through the internal cervical os. An incomplete miscarriage (A) is one in which the products of conception are visible either in the os or vaginal canal. Once all products are expelled and the uterus contracts with a closed cervical os, the miscarriage is complete. A missed abortion (C) is a term that encompasses several clinical scenarios when the pregnancy does not progress but the uterus has not expelled the products of conceptions and the cervical os remains closed. These scenarios include: failure of the uterus to grow over time; an anembryonic gestation where no fetus develop; and fetal death when the age/size of the fetus would have a heart beat but none is detected on ultrasound. A threatened miscarriage (D) is the presence of vaginal bleeding in pregnancy with a closed cervical os. Between 35% and 50% of women will ultimately lose the pregnancy when they have experienced a threatened miscarriage.

A 32-year-old woman presents with an increase in vaginal secretions. You decide to perform a potassium hydroxide wet preparation of a sample. This test evaluates which of the following secretion qualities? Color Odor pH Viscosity

Correct Answer ( B ) Explanation: The main finding in vaginitis is increased vaginal discharge, a symptom which is 80-90% associated with a biologic organism and 10-20% associated with fluctuating chemicals or hormones. A common office test is the KOH "whiff" wet preparation test, in which a secretion sample is mixed with saline and 10-20% potassium hydroxide. The presence of a "fishy" amine odor represents a positive test, while the absence of this abnormal amine-like odor represents a negative result. Normal vaginal secretions, which are mainly comprised of cervical mucus, have a pH of 3.8 - 4.2, are clear or white and have a negative KOH test. Secretions become more basic (pH >4.5), thin, adherent, and gray in bacterial vaginosis and frothy-green in trichomoniasis. White, thick, "cottage-cheese like" secretions are associated with candida vaginitis. The KOH test is mostly positive in bacterial vaginosis and trichomoniasis, but negative in candidiasis.

A 22-year-old woman presents complaining of vaginal bleeding and cramping for the last 4 hours. She is known to be 14-weeks pregnant. Her cervical os is dilated to 4 cm and she is actively bleeding. Pelvic ultrasound shows the gestational sac in the lower uterine segment near the cervix. Which of the following is the most likely diagnosis? Complete abortion Inevitable abortion Missed abortion Septic abortion

Correct Answer ( B ) Explanation: The patient is experiencing an inevitable abortion, which is characterized by an open cervical os and a gestational sac at the opening of the uterus on ultrasound. The case should be discussed with the patient's obstetrician as the patient may ultimately require dilatation and curettage if all the products of conception (POC) do not pass spontaneously or the bleeding is not controlled. A complete abortion (A) occurs when the patient has passed all POC have passed. On examination, the cervix is closed and the uterus is firm and nontender. A missed abortion (C) occurs when a pregnant patient fails to pass the products of conception greater than two months after fetal demise. The pregnancy test will be negative, however ultrasound will show retained POC. A septic abortion (D) occurs when the patient develops foul-smelling discharge, vaginal bleeding, uterine tenderness and peritoneal signs following a spontaneous or induced abortion.

A 18-year-old woman at full term presents in labor. On examination, the baby's head is out but you are unable to deliver either shoulder. What should the first step in management be? Foley catheter placement and instillation of 500-750 ml of normal saline Leg flexion of mother and apply suprapubic pressure Place in left lateral decubitus position Push fetal head back into the vagina and transfer for cesarean section

Correct Answer ( B ) Explanation: This delivery is complicated by shoulder dystocia or failure to deliver either shoulder and should first be managed by the McRoberts' maneuver of leg flexion to a knee-chest position and application of pressure to the suprapubic region. Shoulder dystocia is the second most common malpresentation after breech presentation and has devastating complications. Traumatic brachial plexus injuries, clavicular fractures and hypoxic brain injury are seen in the fetus. Maternal complications include perineal, sphincter and vaginal tears. Shoulder dystocia is diagnosed when the head has presented but the shoulders cannot be delivered. The fetal head may retract toward the perineum ("turtle sign"). Traction on the head may worsen shoulder dystocia by abducting the shoulders and increasing the bisacromial diameter. A number of maneuvers can help in delivering the shoulder and thus relieving the dystocia. The McRoberts' maneuver involves positioning the maternal legs in flexion with knee-chest position. This may result in disengaging of the anterior shoulder allowing for rapid vaginal delivery. Application of pressure suprapubically can help the process. Additionally, an episiotomy can be performed, which may allow access to the posterior shoulder and improve fetal maneuvering. A Foley catheter (A) should be placed to drain the bladder not instill fluid as draining the bladder may create more room for maneuvering. Placement in the left lateral decubitus position (C) is used to relieve pressure from the IVC and increase blood return to the right heart in patients with hypovolemic shock. Pushing the fetal head back into the vagina (D) and proceeding to cesarean delivery is not a recommended option.

A 30-year-old woman presents with fever and abdominal pain. She is three days postpartum after cesarean section. Physical examination reveals lower abdominal tenderness to palpation and foul smelling vaginal discharge. What management is indicated? Ceftriaxone IM and azithromycin PO Clindamycin IV plus gentamicin IV Fluconazole Metronidazole

Correct Answer ( B ) Explanation: This patient presents with endometritis and should be treated with broad-spectrum antibiotics and admitted to the hospital. Endometritis affects 1 in 20 vaginal deliveries and 1 in 10 cesarean sections. There are a number of associated risk factors including operative delivery, prolonged rupture of membranes, lack of prenatal care and frequent vaginal examinations. Endometritis is a polymicrobial infection with gram-positive cocci and gram-negative coliforms involved. Patients typically present with abdominal pain, fever and foul-smelling lochia or discharge. It commonly develops the second or third day post partum. Diagnosis is made clinically but ultrasound is recommended to identify any possible retained products of conception. Patients should be treated empirically with broad spectrum antibiotics. Clindamycin IV and gentamicin IV are typically recommended. Although most patients with endometritis are admitted for IV antibiotics (especially those who are ill appearing, have had cesarean section or have underlying illnesses), patients with mild illness may be treated as an outpatient with oral antibiotics and close OB follow up.

An 18-year-old woman at 37 weeks gestation presents with a spontaneous leakage of fluid from the vagina. She has no other signs of active labor. Vital signs are unremarkable and the patient has no complaints except for the leakage of fluid. What management is indicated? Administer corticosteroids Admit to obstetrics for delivery Amoxicillin IV Tocolysis

Correct Answer ( B ) Explanation: This patient presents with likely premature rupture of membranes (PROM) at 37 weeks of gestation and should be delivered to reduce the risk of developing an infectious complication. PROM or amniorrhexis is the rupture of the amniotic and chorionic membranes prior to the onset of labor. It is important to note that premature here does not refer to fetal prematurity. Once the membranes rupture, management will proceed based on fetal maturity, gestational age, presence or absence of infection and fetal well-being or distress. If the fetus is immature (24 - 34 weeks of gestation), corticosteroids should be considered to accelerate pulmonary maturity. Over 34 weeks of gestation, delivery is preferred. All patients should be assessed for signs of intra-amniotic infection, which typically manifests with fever and lower abdominal pain. In PROM with fetal immaturity, ampicillin or amoxicillin is given prophylactically. PROM is confirmed with a sterile speculum exam showing one of the following: (1) A pool of fluid in the posterior fornix, (2) A pH > 6.5 (nitrazine paper turns blue), (3) ferning of fluid as it dries on a slide. Corticosteroids (A) have not been shown to be effective in patients with PROM (as opposed to those with preterm PROM). Amoxicillin (C) should be considered in PROM if there are signs of infection. Tocolysis (D) is controversial and delivery is preferred.

A 32-year-old woman presents with vaginal bleeding for two weeks. She states she has had to change her pad every 2-3 hours with the bleeding. Vital signs are stable and physical exam only reveals blood coming from the cervical os. The patient's hemoglobin is 12 g/dL and her pregnancy test is negative. What treatment is indicated for this patient? Admission for dilation and curettage Combination oral contraceptives Hysterectomy Intravenous estrogen therapy

Correct Answer ( B ) Explanation: This patient presents with non-life threatening abnormal uterine bleeding (previously called dysfunctional uterine bleeding), which can initially be managed with combination oral contraceptives. Bleeding is typically split into anovulatory (90%) and ovulatory (10%). In patients with vaginal bleeding of childbearing age, the most important first step in diagnosis is to rule out pregnancy. After this, it is important to explore other causes including medications, genital tract pathology and systemic disease. Once these are excluded, a diagnosis of abnormal uterine bleeding can be reached. Some treatments include NSAIDs that inhibit PGE1 production and can both relieve cramping and pain and also decrease bleeding. In anovulatory bleeding, combination oral contraceptive pills can aid in regulating the menstrual cycle and counteract the effects of unopposed estrogen. Typically, patients are instructed to take combination oral contraceptive pills twice a day for 5-7 days or until the bleeding stops followed by once daily dosing. Dilation and curettage (A) is typically offered to patients with heavy vaginal bleeding evidenced by hemodynamic instability. A hysterectomy (C) is rarely needed in the treatment of AUB but is indicated for patients with heavy bleeding and hemodynamic instability in which conservative management fails. Intravenous estrogen therapy (D) is effective in stopping heavy bleeding but is not considered first-line therapy.

A 17-year-old G1P0 woman at 25-weeks gestation presents with intermittent blurred vision. On presentation, she is currently asymptomatic. Vital signs are HR 84, BP 165/97, oxygen saturation 97%. Physical examination reveals 2+ pitting edema on both lower extremities and urinalysis has 3+ protein on dip. Which of the following is the next best step in management? Administration of phenytoin Admit for further obstetrics evaluation Arrange follow up with the patient's obstetrician Emergency cesarean section

Correct Answer ( B ) Explanation: This patient presents with severe preeclampsia and should be admitted for further obstetric evaluation. Preeclampsia is defined as gestational hypertension (>140/90 mm Hg) with proteinuria (>300 mg/24 hr) that occurs after 20-weeks gestation. Progression from preeclampsia to eclampsia (hypertension, proteinuria and seizures) is unpredictable and can occur rapidly. In preeclampsia, patients may be asymptomatic. In severe disease, typically defined as a blood pressure >160/110 mm Hg, patients may have associated epigastric or liver tenderness, visual disturbances or severe headaches. These patients should be admitted for further management. Treatment for these patients is the same as in eclampsia. The goal of treatment is prevention of seizures or permanent maternal organ damage. Magnesium should be given for seizure prophylaxis. Phenytoin (A) is not indicated for seizure prophylaxis in preeclampsia. Instead, magnesium is the drug of choice for seizure prophylaxis when necessary. Patients with mild preeclampsia without symptoms or isolated maternal hypertension can be managed as outpatients (C) but not those with severe preeclampsia. Ultimately, delivery is the potentially curative therapy for preeclampsia but at this stage in pregnancy, an emergent cesarean section (D) would not be indicated. Beyond The Boards Recent ACOG guidelines state that proteinuria is not required to make a diagnosis of preeclampsia if there is evidence of end-organ damage as noted above. Massive proteinuria is also not necessary for a diagnosis of severe preeclampsia.]

A 23-year-old, sexually active woman presents with abdominal pain. Vital signs are normal. Pelvic examination reveals cervical motion tenderness and bilateral adnexal tenderness. Which of the following treatments is most likely indicated? Ceftriaxone 250 mg IM once + azithromycin 1000 mg PO once Ceftriaxone 250 mg IM once + doxycycline 100 mg PO BID for 14 days Clindamycin 300 mg PO BID for 7 days Metronidazole 500 mg PO BID for 7 days

Correct Answer ( B ) Explanation: This patient presents with signs and symptoms consistent with pelvic inflammatory disease (PID) and should be treated with ceftriaxone 250 mg IM and 2 weeks of doxycycline. PID is an ascending infection beginning in the cervix and vagina and ascending to the upper genital tract. Neisseria gonorrhoeae and Chlamydia trachomatis are most commonly implicated. It can present with a myriad of symptoms although lower abdominal pain is the most common. Other symptoms include fever, cervical or vaginal discharge and dyspareunia. Pelvic examination reveals cervical motion tenderness (CMT), adnexal tenderness and vaginal or cervical discharge. Inadequately treated PID can lead to tubo-ovarian abscess, chronic dyspareunia and infertility. Due to the variable presentation and serious sequelae, the CDC recommends empiric treatment of all sexually active women who present with pelvic or abdominal pain and have any one of the following: 1) CMT, 2) adnexal tenderness or 3) uterine tenderness. Treatment should cover the most common organisms and typically consists of a third generation cephalosporin (ceftriaxone) and a prolonged course of doxycycline. Patients with systemic manifestations or difficulty tolerating PO should be admitted for management. Ceftriaxone and azithromycin (A) are used in the treatment of cervicitis or urethritis. Clindamycin (C) and metronidazole (D) are used in the treatment of bacterial vaginosis.

A 29-year-old woman who is one week postpartum following a pregnancy complicated by preeclampsia with delivery of a full-term infant is brought in by emergency medical services with an ongoing generalized tonic-clonic seizure. Which of the following medications should be administered first? Labetalol Lorazepam Magnesium sulfate Phenobarbital

Correct Answer ( C ) Explanation: A pregnant or recently postpartum patient with new-onset seizure should be considered to have eclampsia. Eclampsia refers to seizures that develop as a complication of severe preeclampsia. The clinical manifestations of preeclampsia are hypertension after 20 weeks of pregnancy plus proteinuria. Severe preeclampsia is evidenced by marked hypertension (blood pressure ≥ 160 mm Hg systolic or ≥110 mm Hg diastolic) with evidence of end-organ dysfunction, such as visual disturbances, mental status changes, pulmonary edema, epigastric or right upper quadrant pain, elevated liver function tests, thrombocytopenia, proteinuria, oliguria, or impaired fetal growth. Most cases of eclampsia occur in the 3rd trimester, with approximately 80% occurring during delivery or within the first 48 hours after delivery, though seizures may occur as late as several weeks postpartum. Seizures are most commonly tonic-clonic and last 60 to 90 seconds. Magnesium sulfate is the drug of choice for eclamptic seizures. A loading dose of 4-6 g of magnesium sulfate should be administered over 15-20 minutes followed by a maintenance infusion of 1-2 g per hour. Most eclamptic seizures terminate with magnesium. Labetalol (A) may be used to control severe hypertension in a patient with preeclampsia or eclampsia, but does not treat seizures. Lorazepam (B) and phenobarbital (D) are second- and third-line choices, respectively, if eclamptic seizures are refractory to magnesium.

A 19-year-old woman presents with lower abdominal pain for 5 days. You consider pelvic inflammatory disease as a diagnosis. Which of the following is a likely contributor for this condition? Age over 25 years Barrier contraception Multiple sexual partners Pregnancy

Correct Answer ( C ) Explanation: Although there are no definitive risk factors for pelvic inflammatory disease (PID), there are several contributors. Multiple sexual partners increases the chances for developing PID. Other risk factors include earlier age at first intercourse; instrumentation, including induced abortion and intrauterine device insertion; and the period immediately following menses. Most cases of PID occur in women <25 years of age (A). Females 15-24 have increased numbers of sexual partners, have a cervical barrier more easily breached by pathogens, often have less frequent use of barrier contraception (B) and tend to seek health care later. Pregnancy (D) confers protection from PID after the 1st trimester when the uterine cavity is obliterated by the pregnancy. However, PID can occur in the 1st trimester.

A 40-year-old woman with a history of asthma presents to the ED with symptoms of wheezing and shortness of breath similar to previous exacerbations. Her vital signs are BP 115/70, HR 80, RR, 14, and pulse oximetry is 99% on room air. The patient is offered and agrees to a point-of-care beta-hCG test that returns positive. Upon further questioning, patient denies any vaginal or urinary complaints. On exam, you note mild bilateral wheezing with good air movement. Which of the following is the most appropriate next step in management? Delay treating her asthma until her pregnancy status is further clarified Treat her asthma as indicated, and perform a beta-hCG quantitative level Treat her asthma as indicated, if improved, discharge with outpatient obstetrical follow-up Treat her asthma as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound

Correct Answer ( C ) Explanation: As a good public health practice, many EDs offer routine screening for pregnancy using point-of-care testing. In this patient—with isolated respiratory complaints and lack of findings on physical or pelvic exam that indicate anything other than a normal pregnancy—an incidental positive beta-hCG does not warrant any further attention other than a referral for follow-up with an obstetrician. The patient's asthma is the treatment priority. Standard therapy should be administered even in the setting of pregnancy.

Which of the following is true regarding uterine fibroids? Increase in size during menopause More common in White women than African American women Surgical removal is associated with a 25% to 30% rate of recurrence Typically occur as a single fibroid

Correct Answer ( C ) Explanation: Leiomyomas (uterine fibroids) are benign tumors of muscle cell origin that cause pain and abnormal bleeding. Uterine fibroids are associated with severe pain when part of the fibroid undergoes torsion or degeneration (due to rapid growth and loss of blood supply most common in early pregnancy). Diagnosis is made by ultrasound. The treatment depends on size and symptoms. Initial management usually includes NSAIDs, medroxyprogesterone, and gonadotropin-releasing hormone agonists. Surgical removal is associated with a 25% to 30% rate of recurrence and significant bleeding complications. Uterine fibroids decrease in size during menopause (A) and enlarge early in pregnancy. Uterine fibroids are 2x more common in African American women (B) than in White women. Uterine fibroids are usually multiple in nature (D) rather than single.

A 21-year-old woman presents with acute pain in the right pelvis. Which of the following makes the diagnosis of ovarian torsion more likely? Elevated WBC count Previous caesarean section Teratoma of the right ovary Vaginal bleeding

Correct Answer ( C ) Explanation: Ovarian torsion must be on the differential diagnosis of women presenting with acute pelvic pain and is the cause of 3% of gynecologic emergencies. Most commonly torsion occurs in women of reproductive age because of the development of corpus luteal cysts. It is rare for a normal ovary to torse, but not impossible. More than 50% of cases of ovarian torsion are associated with an ovarian tumor or cyst. Benign tumors, particularly teratomas or dermoid cysts, carry a particularly high risk of torsion. Other risk factors include large ovarian cysts, ovarian hyperstimulation syndrome as a result of fertility treatment, and polycystic ovarian syndrome. When the ovary twists on its pedicle, the venous and lymphatic systems initially obstruct causing edema of the ovary. Eventually arterial flow is compromised causing ischemia and eventual necrosis of the ovary. The clinical presentation varies and may be subtle, especially in the case of intermittent torsion. Pelvic ultrasonography with Doppler imaging of the ovary is the initial diagnostic test of choice. Ultrasound findings are variable. Edema of the ovary is the most common finding. Cysts are commonly visualized as well as pelvic fluid which may confuse the diagnosis with a ruptured ovarian cyst. Using Doppler, flow to the ovary may be compromised compared to the contralateral ovary but this is a late finding and also not sensitive enough to exclude the diagnosis. If clinical suspicion persists, patients need diagnostic laparoscopy to directly visualize the ovary in question. An elevated WBC count (A) is non-specific for ovarian torsion. The WBC count is elevated in many conditions including infections, inflammatory conditions and ischemia. Previous caesarean section (B) is not a risk factor for ovarian torsion. However, women who have had a tubal ligation are at increased risk because of scarring that occurs around the fallopian tube and the chance of this scar tissue creating a base on which the pedicle of the ovary can twist. Vaginal bleeding (D) is not a common symptom of ovarian torsion. Vaginal bleeding with pregnancy is associated with ectopic pregnancy or threatened abortion. Additionally, hemorrhagic cysts may lead to vaginal bleeding.

Which of the following is most associated with amenorrhea? Adenomyosis Neoplasia Perimenopause Uterine fibroid

Correct Answer ( C ) Explanation: Perimenopause is the period between the onset of irregular menstrual cycles and the last menstrual period. This period is marked by fluctuations in reproductive hormones and is characterized by the following menstrual irregularities: prolonged and heavy menstruation intermixed with episodes of amenorrhea, decreased fertility, vasomotor symptoms, and insomnia. Some of these symptoms may emerge 4 years before menses ceases, with a perimenopausal mean age of onset of 47.5 years. During the menopausal transition, estrogen levels decline, and levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) increase. Adenomyosis (A) is the condition in which endometrial glands grow deeply into the underlying myometrium. Dysmenorrhea occurs just before or at the time of menstruation. Neoplasia (B) typically leads to bleeding. Endometrial hyperplasia or endometrial cancer must be considered in women >35 years old or in younger women with other risk factors who present with abnormal vaginal bleeding. Uterine fibroids (D) are associated with pain and bleeding.

Which of the following confirms an intrauterine pregnancy? Beta-hCG of 200,000 Fetal heart activity Intrauterine fetal pole and yolk sac Single layer intrauterine gestational sac

Correct Answer ( C ) Explanation: The fetal pole is a mass of fetal cells separate from the yolk sac that first becomes apparent on transvaginal ultrasound just after the 6th week of gestation. It is the fetus in its somite stage. Usually, you can identify rhythmic fetal cardiac movement within the fetal pole, although it may need to grow several millimeters before this is apparent. Identification of an intrauterine fetal pole and yolk sac on ultrasound confirms an intrauterine pregnancy. Other ways that increase the likelihood, but does not confirm an intrauterine pregnancy include identifying the double ring, also known as the double decidual sign, which usually appears by 5.5-6 weeks' gestation. The double ring helps to distinguish a true gestational sac from an intrauterine fluid collection or pseudosac. Identifying intrauterine fetal heart activity within the uterus confirms an intrauterine pregnancy; however presence of fetal heart activity alone does not guarantee an intrauterine pregnancy. Beta-hCG levels (A) increase at a predictable rate in the early stages of pregnancy. Levels of beta-hCG double every 2-3 days during the first 7-8 weeks of normal pregnancies. However, there are conditions other than an intrauterine pregnancy that can lead to significant elevations of beta-hCG, such as gestational trophoblastic disease and molar pregnancy. This disorder is characterized by proliferation of chorionic villi. The associated high level of beta-hCG often leads to hyperemesis. Identifying fetal heart activity (B) does not confirm an intrauterine pregnancy because an ectopic pregnancy can progress to have fetal activity. Only when fetal heart activity is detected within the gestational sac can the pregnancy be confirmed as intrauterine. A true gestational sac is identified on ultrasound by the double ring, also known as the double decidual sign, and strongly suggests an intrauterine pregnancy. A single layer gestational sac (D), or pseudosac, is possible, which looks very similar to a true gestational sac. In this setting, there can still be an ectopic fetus. Therefore, most clinicians confirm an intrauterine pregnancy when a gestational sac with a fetal pole or yolk sac is present.

A 27-year-old woman currently breast-feeding presents to the ED with an inflamed and painful right breast. Her vital signs are BP 125/70 mm Hg, HR 105, RR 16, and T 38.3°C. On exam, you note extensive cellulitis of the right breast that begins at the nipple. You begin antibiotic therapy. The patient wants to know whether to continue breast-feeding. What should you advise her to do? Consult her obstetrician Continue to breast-feed but only from the noninfected breast Continue to breast-feed from both breasts Wean from breast-feeding and begin formula feeding

Correct Answer ( C ) Explanation: The patient has acute puerperal mastitis. In all cases of mastitis, the woman should be advised to nurse as frequently as possible from the affected breast. Nursing dilates the mammary blood vessels, thus improving blood flow to the infected tissue. The flow of milk also helps to clear milk ducts of infective organisms. Studies have demonstrated that contamination of the infant's skin, mouth, or nose with the pathogen preceded infection of mother's milk. Therefore, the patient should be started on an oral antibiotic such as dicloxacillin and instructed to continue breast-feeding from both breasts. The patient can be referred to her obstetrician (A) as an outpatient. There is no increased risk of transmitting the pathogen from mom to infant by breast-feeding from the affected breast. Continued feeding from the infected breast (B) is recommended to enhance blood flow, clear milk ducts, and maintain infant's feeding. Weaning (D) from the onset of mastitis means that the already contaminated infant is deprived of antibodies to the infecting organism that mother develops in the course of her mastitis

A 22-year-old woman presents with lower abdominal pain and abnormal vaginal discharge for 4 days. She is sexually active with multiple partners and does not consistently use barrier contraception. She has bilateral adnexal tenderness and yellow discharge on pelvic exam. Her urine pregnancy test is negative. In addition to a 1-time dose of ceftriaxone, what is the most appropriate outpatient course of antibiotics for the patient? Azithromycin 1 gram PO x 1 Ciprofloxacin 500 mg PO BID x 14 days Doxycycline 100 mg PO BID x 14 days Metronidazole 500 mg PO BID x 14 days

Correct Answer ( C ) Explanation: The patient's presentation is consistent with pelvic inflammatory disease (PID), which represents a spectrum of disorders usually secondary to 1 or more sexually transmitted diseases involving the upper genital tract of women. PID can include any of the following: mucopurulent cervicitis, endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis. Patients typically present with complaints of lower abdominal pain, with or without dyspareunia; abnormal bleeding; or abnormal vaginal discharge. On exam, patients usually have lower abdominal tenderness, cervical motion tenderness, and bilateral adnexal tenderness. Outpatient management is appropriate for mild cases of PID and includes ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg PO BID for 14 days. A single 1-gram dose of azithromycin (A) is part of the regimen to treat cervicitis and urethritis in men. It can also be used for PID but should be administered once weekly for 2 weeks. The CDC no longer recommends fluoroquinolones (B) for the treatment of gonococcal infections and associated conditions such as PID due to high resistance. Metronidazole (D) is not required as part of the PID treatment regimen, but it is added sometimes to also treat trichomoniasis or vaginitis or if there is a concern for anaerobic infection.

A 15-year-old G1P0 woman at 23 weeks presents with sharp, left lower quadrant abdominal pain for one hour. She previously had an ultrasound confirming the presence of a single intrauterine pregnancy. The pain is severe and associated with nausea. Pelvic examination reveals tenderness of the left adnexa. The patient's urinalysis is unremarkable. What test should be ordered to diagnose the patient? Abdominal X-ray CT scan of the abdomen and pelvis Pelvic ultrasound White blood cell count

Correct Answer ( C ) Explanation: This patient presents with a history concerning for ovarian torsion and should undergo a pelvic ultrasound. Ovarian torsion is an organ threatening disease, involving twisting of the ovary or fallopian tube or both on the vascular pedicle. It is more commonly seen on the right side (due to the effects of the sigmoid colon being on the left) and in women of childbearing age. Patients typically present with sharp, severe unilateral abdominal pain with nausea or vomiting. However, the classic presentation is often not present making diagnosis challenging. Risk factors for torsion include the presence of an ovarian mass or infertility treatment. Clinicians must maintain a high suspicion for this disease in order to make a timely diagnosis and prevent ovarian necrosis. Pelvic ultrasound, while imperfect, represents the best initial imaging modality. The classic ultrasound appearance in torsion is enlargement with a heterogenous stroma and peripherally displaced follicles. The most common findings are an increased ovarian size and an abnormal position in relation to the uterus. The addition of Doppler ultrasound may demonstrate decreased blood flow to the ovary but these findings are inconsistent. Additionally, Doppler ultrasound may be completely normal in intermittent torsion. Ultimately, patients with suspected ovarian torsion may require laparoscopy to confirm or rule out torsion. Abdominal X-ray (A) does not aid in diagnosis of ovarian pathology. CT scan of the abdomen and pelvis (B) has a sensitivity that is similar to ultrasound but exposes the patient to the risks of radiation and IV contrast. A small percentage of patients with torsion will have an elevated white blood cell count (D) over 15,000 but this is not a reliable finding.

A 24-year-old woman at full term presents with rupture of membranes and contractions. Sterile exam reveals a crowning infant with a visible cord protruding. After elevating the fetal head, what management is indicated? Clamp and cut cord and proceed with delivery Continue with standard delivery Emergent cesarean section Intravenous tocolytics

Correct Answer ( C ) Explanation: This patient presents with a prolapsed cord requiring emergent cesarean section as prolapse leads to decreased fetal oxygen supply. Cord prolapse occurs when the umbilical cord precedes delivery of the fetus. Pressure from the presenting part of the fetus (usually the head) compresses the cord leading to disrupted oxygen delivery to the fetus. Umbilical cord prolapse is associated with malpresentations (shoulder, compound or breech). Typically, cord prolapse is apparent on pelvic examination. There are a number of maneuvers and management strategies directed at both decreasing pressure on the umbilical cord and restoring blood flow to the fetus and to reduce the prolapsed cord. Ultimately, cesarean section is the best management approach to patients with umbilical cord prolapse. While preparing for cesarean section, the patient should be instructed not to push as this may worsen compression of the cord. The mother should be placed in a knee-chest position with the bed in Trendelenburg and the presenting part should be elevated off of the umbilical cord. Placement of a Foley catheter with instillation of 500-750 ml of saline will help to lift the fetus off the cord as well. If surgical delivery cannot be performed, funic reduction (manual replacement of the cord into the uterus, should be attempted followed by rapid vaginal delivery). The cord should not be clamped and cut (A) at this time as it is the only supply of oxygenated blood to the fetus. Standard delivery (B) should not be pursued with a prolapsed cord as pushing will result in further compression of the cord and hypoxia. Tocolysis (D) with medications is not recommended as a primary treatment; however tocolysis can be useful to help prevent cord compression while mobilizing the patient to the operating room for an emergent c-section.

32-year-old woman 8 weeks pregnant by dates presents to the ED with a 2-cm laceration to her index finger sustained while she was cutting a tomato. On review of systems, she also notes 2 days of vaginal spotting and lower abdominal cramping. Vital signs are within normal limits. Physical exam is consistent with a simple 2-cm laceration. The pelvic exam reveals a closed os and no adnexal tenderness or masses. Which of the following statements best describes the next step in management? Delay treating her laceration until her pregnancy status is further clarified Treat her laceration as indicated, and perform a beta-hCG quantitative level Treat her laceration as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound Treat her laceration as indicated, then discharge with outpatient obstetrical follow-up

Correct Answer ( C ) Explanation: This patient presents with an isolated finger laceration, but the review of systems revealed signs concerning for a threatened abortion or ectopic pregnancy. In addition to caring for her laceration, the patient requires further workup of her pregnancy. A beta-hCG level should be obtained to correlate with her stated dates and to help identify an intrauterine pregnancy, miscarriage, ectopic pregnancy, or molar pregnancy. A pelvic ultrasound should also be performed to evaluate for ectopic pregnancy, given the severity, prevalence, and difficulty of diagnosis without the ultrasound. A type and screen should also be obtained to determine her Rh status and the potential need for RhoGam administration. Delay of treatment is not necessary (A) in this patient. If her vital signs were unstable, then priority would be given to treating a life-threatening condition. The patient should not be discharged (D) without further investigation into her pregnancy-related complaints. Determining the beta-hCG level (B) alone is insufficient to investigate the state of her pregnancy and the cause of her vaginal bleeding.

A 26-year-old sexually active woman presents to the clinic with several days of vulvovaginal discomfort and pruritus. A pelvic exam shows copious frothy green vaginal discharge, inflamed vaginal walls, and a cervix with punctate hemorrhages. This physical exam is most consistent with which of the following causes of vaginitis? Atrophic vaginitis Bacterial vaginosis Trichomonas vaginalis Vulvovaginal Candidiasis

Correct Answer ( C ) Explanation: Trichomonas vaginalis is a common infectious cause of vulvovaginal discomfort in women that will likely present with the above symptoms. Though Trichomonas vaginalis is often harbored asymptomatically for periods of 5 days to 4 weeks, patients who are diagnosed while symptomatic typically present with vulvovaginal pruritus, dyspareunia, dysuria, or pelvic discomfort. A physical exam will show a classic copious, yellow or green, frothy vaginal discharge. Examining the cervix may show punctate hemorrhages, referred to as a "strawberry cervix." The diagnostic test of choice is a wet mount of the vaginal discharge, which shows mobile trichomonads. The first line treatment for Trichomonas vaginalis is oral metronidazole. All infected sexual partners should also be treated, even if asymptomatic, to prevent the development of symptomatic disease and reduce spread to future partners. Atrophic vaginitis (A) is generally a condition of menopausal women in low-estrogen states that causes thinning of the vaginal mucosa and decreased vaginal lubrication leading to vaginal discomfort and dyspareunia. A pelvic exam shows pale mucosa and a decrease in size of the introitus and cervix. Bacterial vaginosis (B) is a non-sexually-transmitted disease caused by an overgrowth of Gardnerella and other anaerobes. The hallmarks of this disease are a heavy, malodorous grey discharge without presence of vaginitis, increased vaginal pH, and "clue cells" (epithelial cells with borders obscured by the presence of excessive bacteria) visualized on a wet mount. There may also be a notable amine, or "fishy", odor with the addition of potassium hydroxide to a drop of the vaginal discharge. Vulvovaginal Candidiasis (D) is an overgrowth of the yeast Candida which cause vaginal burning and pruritus. The physical exam should show vaginitis, erythema, and a white, curd-like vaginal discharge with no apparent odor. A wet mount with potassium hydroxide added will show spores and hyphae.

You are the emergency physician in a rural hospital with no obstetrical backup when a woman is brought into the ED in active labor. You perform a pelvic exam and note a prolapsed umbilical cord. Which of the following is the most appropriate next step in management? Clamp the cord in 2 places and cut it Instruct the patient to stop pushing and arrange to transfer to a hospital with obstetrical services Manually replace the cord into the uterus and prepare for rapid vaginal delivery Perform a crash bedside cesarean section

Correct Answer ( C ) Explanation: Umbilical cord prolapse occurs when the umbilical cord precedes the fetal presenting part or the presenting part does not fill the birth canal completely. Cord prolapse is associated with 50% of malpresentations (compound, shoulder, and breech). Whenever a prolapsed cord occurs with a viable infant, cesarean section is the delivery method of choice. However, if surgical delivery cannot be achieved in a timely manner, as in this case, the clinician should perform maneuvers to preserve umbilical circulation. The patient should be placed in the knee-chest position with the bed in Trendelenburg as the presenting part is digitally elevated off the umbilical cord and the umbilical cord is manually replaced into the uterus. The cord should not be clamped (A) until delivery is completed or there is evidence of a nuchal cord. The risk of fetal hypoxia depends on the time of cord prolapse. Transfer (B) will likely delay delivery and increase the likelihood of fetal hypoxia. Performing a cesarean section (D) is not in the scope of practice for the emergency physician. In the rare circumstance, a perimortem cesarean section may be necessary. In the case of a prolapsed cord, temporizing measures can be performed.

A 21-year-old woman at 36 weeks gestation presents to the ED with a sudden onset of severe constant abdominal pain and vaginal bleeding. She states that the pain started shortly following smoking crack cocaine. Her BP is 156/68 mmHg, RR is 20, HR is 122, oxygen saturation is 99% on room air, and T is 38.6°C. Which of the following is the most likely diagnosis? Placenta accreta Placenta previa Uterine rupture Vasa previa

Correct Answer ( C ) Explanation: Uterine rupture presents as sudden severe uterine pain and vaginal bleeding. It is most prevalent in women who have had a previous cesarean section or recent cocaine or prostaglandin use. Prior C-section may result in poor uterine healing or scar formation. Cocaine use leads to a sympathomimetic state and may cause chronic vasoconstriction leading to compromised uterine blood flow with development of thin, friable, necrotic uterine tissue that is prone to rupture. In the setting of 3rd-trimester bleeding, it is important to note that any instrumentation or digital exam can provoke severe exsanguination and must be undertaken with extreme caution. If possible, any pelvic examination should occur following abdominal ultrasound in the delivery suite with an obstetrician in attendance. There are several other important causes of vaginal bleeding in the 3rd trimester. Placenta accreta (A) is usually painless and may be associated with brisk, bright-red vaginal bleeding. It is caused by an indistinct placental cleavage plane and most commonly seen during placental delivery. Placenta previa (B) also causes painless bright red vaginal bleeding that occurs as cervical effacement exposes and disrupts a low lying placenta. This is typically mild but can be severe and lead to exsanguination. In vasa previa (D), the fetal umbilical vessels are part of the amniotic membrane and can tear as labor progresses. It should be suspected when rupture of membranes is followed by a painless intrapartum hemorrhage. Because the volume of fetal blood is small, even a small amount of bleeding can result in fetal exsanguination and emergency C-section should be initiated.

A 22-year-old woman presents with pain and swelling to the vulva. On examination, you notice an area of swelling with induration and central fluctuance at the 8 o'clock position. Which of the following statements is true regarding this? All patients require antibiotics Gonorrhea and chlamydia are the most common causes Incision should be performed in the operating room Word catheter is placed for four to six weeks

Correct Answer ( D ) Explanation: A Bartholin's abscess occurs with infection of an obstructed Bartholin gland, a pea-sized mucous secreting gland located on each side of the labia minora in the 4 and 8 o'clock positions. When the duct that drains fluid from the gland becomes blocked, a mucous-filled cyst forms and eventually, if not drained, bacterial overgrowth occurs leading to an abscess. It is also possible to have a primary infection of the Bartholin gland itself. Most commonly, the causative organism is normal vaginal flora of which E. coli is most prevalent in cultures. Treatment of the abscess is with incision and drainage. After the loculations are broken up and all contents of the abscess have been expressed, either gauze packing or a Word catheter is placed. Gauze packing is removed after 24 to 48 hours and patients may require marsupialization at a later date. The Word catheter is a plastic catheter with a balloon on the end that is filled with 2 to 4mL of water and expanded within the abscess cavity. It is important that the incision is made only slightly larger than the opening required for catheter placement. The catheter remains in place for four to six weeks and patients are instructed to abstain from vaginal intercourse. This duration is required for epithelialization of the tract and the formation of a small fistula tract that will allow appropriate drainage without obstruction.

A 34-year-old woman presents complaining of dysuria and vaginal itching. Your speculum exam reveals the findings seen in the image. Which of the following statements is correct regarding this diagnosis? A fishy odor is present when vaginal discharge is mixed with potassium hydroxide Metronidazole is the recommended treatment Multiple petechiae are often seen on the vaginal wall The pH of the discharge is less than 4.5 Vaginal discharge is often foul smelling

Correct Answer ( D ) Explanation: Candidal vaginitis is characterized by a thick, curdy white (cottage cheese-like) discharge. Patients typically complain of vaginal itching, dysuria, and dyspareunia. Risk factors include diabetes, HIV, recent antibiotic use, and pregnancy. A microscopic slide prepared with 10% potassium hydroxide (KOH) will reveal characteristic branch chain hyphae (pseudohyphae) and spores. The pH of the discharge is less than 4.5, whereas the pH of the other causes of vaginitis is greater than 4.5. Bacterial vaginosis (A) is characterized by a malodorous discharge with a pH >4.5 and a transient fishy odor when mixed with a drop of potassium hydroxide. Vaginal candidiasis is treated with topical antifungals (clotrimazole) or oral fluconazole. Metronidazole (B) is used for Trichomonal vaginitis and bacterial vaginosis. Trichomonal vaginitis is occasionally associated with petechiae (C) on the vaginal wall or cervix. This is often referred to as a strawberry cervix. Unlike Trichomonal vaginitis and bacterial vaginosis, the discharge of candidal vaginitis generally has no associated odor (E).

Which of the following is a risk factor for ectopic pregnancy? Alcohol use Cocaine use Heroin use Tobacco use

Correct Answer ( D ) Explanation: Ectopic pregnancy is the 3rd-leading cause of maternal death and now accounts for up to 2% of all pregnancies. Multiple risk factors for ectopic pregnancy include prior ectopic pregnancy or tubal surgery, pelvic inflammatory disease (PID), tobacco use, advanced maternal age, prior spontaneous or medically induced abortion, a history of infertility treatment, and a current intrauterine device (IUD). The classic presentation is the sudden onset of severe unilateral pelvic pain and vaginal bleeding in a patient with a known or suspected pregnancy. Unfortunately, these findings are nonspecific. Up to 25% of patients with an ectopic pregnancy will lack some or all of them. Physical exam findings are also quite variable, and a normal exam does not eliminate the possibility of the diagnosis. Alcohol (A) is considered a teratogen, and abuse during pregnancy has been associated with a characteristic syndrome of neurological and structural abnormalities known as fetal alcohol syndrome. Cocaine (B) is a potent vasoactive substance associated with spontaneous abortion and placental abruption, as well as preterm and low-birth-weight babies. The abuse of heroin (C) and other opiates leads to fetal physical dependence and can result in neonatal withdrawal.

A 36-year-old G1P0 woman presents at 32 weeks gestation with right upper quadrant abdominal pain. She has no past medical history and her pregnancy has thus far been uncomplicated. Her vital signs on arrival are T 37.3°C, HR 110, BP 125/75, RR 24. Her physical exam is significant for moderate right upper quadrant tenderness to palpation. Her laboratory studies are remarkable for WBC 14 x 109/L, hemoglobin 9 g/dL, hematocrit 27%, platelets 70 X 109/microL, AST 120 U/L, ALT 100 U/L, total bilirubin 1.5 mg/dL and LDH 1000 U/L. Which of the following is the most likely diagnosis? Cholecystitis Choledocholithiasis Fitz-Hugh Curtis syndrome HELLP syndrome

Correct Answer ( D ) Explanation: HELLP syndrome is a severe form of preeclampsia associated with hemolysis, transaminitis, and thrombocytopenia. While most cases of HELLP are associated with the hallmark hypertension and proteinuria of preeclampsia, hypertension and proteinuria are not necessary for the diagnosis of HELLP syndrome. In fact, hypertension and proteinuria are absent in 15% of cases of HELLP syndrome. Labetalol, hydralazine, and nifedipine are the drugs of choice for acute, severe hypertension associated with HELLP syndrome. Like in preeclampsia and eclampsia, delivery is the only definitive management of HELLP. Cholecystitis (A) is inflammation of the gallbladder most commonly due to gallbladder disease. Fever, leukocytosis and right upper quadrant pain are typically seen. Choledocholithiasis (B) refers to obstruction of the common bile duct with a stone. Presenting symptoms include right upper quadrant pain, nausea, and vomiting. While elevation of liver function tests can be seen with cholecystitis and choledocholthiasis, neither is associated with thrombocytopenia or anemia as shown above. Fitz-Hugh Curtis syndrome (C), also known as perihepatitis, is inflammation of the liver capsule and the associated peritoneal surface due to pelvic inflammatory disease from infection with N. gonorrhoeae or C. trachomatis. It is associated with severe right upper quadrant tenderness but would not cause the anemia and thrombocytopenia seen in the laboratory results above.

A 23-year-old woman presents with concerns of tender breast enlargement. Two weeks ago, she gave birth to a healthy newborn, whom she currently breast feeds. Examination reveals subjective fevers, myalgias, and general erythema, warmth and edema of the right breast. There are no superficial abnormalities, no palpable mass and no purulent nipple discharge is present. The left breast appears normal. Which of the following is the most likely diagnosis? Breast abscess Breast engorgement Inflammatory breast cancer Lactation mastitis

Correct Answer ( D ) Explanation: Mastitis generally refers to breast inflammation, which can be infectious, noninfectious or associated with inflammatory breast cancer. Of the infectious subclass, lactation mastitis is the most common and occurs within a few weeks post-delivery in postpartum women. Typical symptoms include, general body ache fever, malaise and tender breast engorgement (almost always unilateral) with erythema and induration. More serious disease may present with purulent nipple discharge. This condition may progress into or present initially as an abscess (A), a more defined and localized pocket of infection which is usually discretely palpable. Postpartum women who do not breast feed may experience symmetric breast engorgement (B) typically within 3 days post-delivery, but usually do not have the associated inflammatory symptoms as above. Although breast cancer (C) can present at many different ages, the patient's young age makes inflammatory cancer less likely. Furthermore, inflammatory breast cancer is associated with skin thickening and dimpling, as well as axillary lymphadenopathy. A blocked breast duct, inspissation, can mimic mastitis, but usually does not have an associated fever.

A woman has just delivered a term fetus via normal spontaneous vaginal delivery. She continues to have bleeding after delivery of the placenta. She is tachycardic and hypotensive. What is the most common cause of postpartum hemorrhage? Maternal birth trauma Placenta accreta Retained products of conception Uterine atony

Correct Answer ( D ) Explanation: Postpartum hemorrhage is the most common complication of labor and delivery and is defined by greater than 500 mL of postpartum blood loss. It affects up to 10% of all deliveries and accounts for up to 25% of all obstetrical deaths. Due to the physiologic changes of pregnancy, the patient may not show signs of shock until >1,500 mL of volume is lost. Although a diagnosis of exclusion, uterine atony is the most common cause (up to 90%) of serious postpartum hemorrhage. Postpartum hemorrhage from the placental implantation site is normally limited by contraction of the myometrium constricting the spiral arteries. If the uterus does not contract, ongoing hemorrhage will occur. Treatment includes uterine massage and uterotonic medications such as oxytocin. In conjunction with these therapies, fluid resuscitation and preparation for transfusion or surgery should be initiated if uterine atony is not the cause of postpartum hemorrhage Maternal birth trauma (A) is a common cause of postpartum hemorrhage but not the most common. Although genitourinary structures are commonly involved, any part of the birth canal-associated anatomy may be injured. Retained products of conception (C) prevents complete myometrial constriction and lead to both immediate and delayed postpartum hemorrhage. Placenta accreta (B) describes an abnormal attachment of the placenta to the uterus, specifically when the placenta adheres to the myometrium without the intervening decidua basalis.

Which of the following is a contraindication to methotrexate therapy for ectopic pregnancy? Beta-hCG <5,000 mIU/mL Ectopic gestational sac <3.5 cm No fetal cardiac activity Renal insufficiency

Correct Answer ( D ) Explanation: Single-dose methotrexate (MTX) is effective in 85% of patients. Methotrexate is a folic acid antagonist that inhibits DNA synthesis and cell reproduction, targets rapidly growing cells, and has replaced surgery for many patients with ectopic pregnancy at low risk for rupture. Methotrexate is rapidly cleared from the body by the kidneys, with 90% of an intravenous dose excreted unchanged within 24 hours of administration. Methotrexate is renally cleared, and in women with renal insufficiency, a single dose of methotrexate can lead to death or severe complications, including bone-marrow suppression, acute respiratory distress syndrome, and bowel ischemia. Treatment with methotrexate is associated with significant abdominal pain several days after treatment. Patients with lower Beta-hCG tend to have lower treatment failures with MTX. Patients should be counseled on risks and benefits, understand the need for follow-up visits and lab work, and that MTX may fail. Some side effects include stomatitis, conjunctivitis, enteritis, pleuritis. Beta-hCG may increase for 4 days after MTX, repeat Beta-hCG testing is usually between 4-7 days. By day 7, if Beta-hCG has not decreased by 25%, a second dose of MTX is given.

A 31-year-old woman at 35-weeks gestation presents with brief painless, bright red vaginal bleeding. In addition to fetal monitoring, which of the following is the most important initial management? Administration of betamethasone to hasten fetal lung maturity Sterile digital cervical exam Sterile speculum examination Transvaginal ultrasound

Correct Answer ( D ) Explanation: The differential diagnosis for third-trimester vaginal bleeding includes placental abruption, placenta previa, cervical or rectal lesions, or bloody show (expulsion of a blood-tinged mucus plug). The clinical scenario of painless, bright red vaginal bleeding is most suggestive of placenta previa. In placenta previa, the placenta abnormally overlies the cervical os. Most cases of placenta previa diagnosed on 20-week ultrasound resolve in the months prior to delivery as the lower uterine segment elongates and the placenta no longer overlies the cervical os. However, in up to 20% of cases the placenta remains positioned over the cervix, which can cause significant and life-threatening hemorrhage at the time of delivery. A patient presenting to the ED with vaginal bleeding should undergo ultrasound to evaluate for placenta previa. Transvaginal ultrasound is safe and more accurate than transabdominal ultrasound for diagnosis of placenta previa​, although transabdominal ultrasound can be utilized as an initial screening study. Patients with suspected placenta previa should not undergo speculum exams or digital cervical exams due to the risk of precipitating significant hemorrhage. The vagina may be visually inspected to confirm and quantify vaginal bleeding but more invasive exams should not performed unless an obstetrician is present. Patients with confirmed placenta previa are managed by elective cesarean section. Administration of betamethasone to hasten fetal lung maturity (A) is indicated for women with preterm labor (contractions resulting in cervical dilatation) prior to 37 weeks gestation. Sterile speculum examination (C) and sterile digital cervical exam (B) are contraindicated until placenta previa is ruled out as this can lead to significant hemorrhage.

A 22-year-old woman presents with lower abdominal pain and vaginal discharge. She is sexually active with men with inconsistent barrier protection. Her temperature is 101°F. On examination, there is yellow cervical discharge, no cervical motion tenderness, but uterine and left adnexal tenderness. An ultrasound does not show any evidence of tubo-ovarian abscess. Which of the following is the most appropriate treatment for this patient's condition? Cefoxitin 2 gm and metronidazole 500 mg PO BID for 14 days Cefoxitin 2 gm IM and clindamycin 600 mg IV Ceftriaxone 250 mg IM and azithromycin 1 gm PO Ceftriaxone 250 mg IM and doxycycline 100 mg BID for 14 days

Correct Answer ( D ) Explanation: This patient has a clinical presentation consistent with pelvic inflammatory disease (PID). PID is an ascending infection that begins in the vagina or cervix. In the sexually active female, the most common responsible organisms are Chlamydia trachomatis and Neisseria gonorrhoeae. Frequently, the infection is polymicrobial. The most common presenting symptom is lower abdominal pain. Patients may also develop fever, vaginal discharge, dyspareunia, or abnormal bleeding. On physical examination, the patient typically has a fever and is tender on pelvic examination either in the lower abdomen over the uterus, on cervical motion, or in the adnexa. The absence of cervical motion tenderness does not rule out PID and the CDC recommends empiric treatment for sexually active women presenting with lower abdominal pain and one of the following if no other cause is identified: cervical motion tenderness, adnexal tenderness, or uterine tenderness. For outpatient management, patients are treated with ceftriaxone 250 mg IM followed by a 2-week course of doxycycline. Metronidazole is sometimes added to the regimen at the judgment of the clinician. Ceftriaxone 250 mg IM and azithromycin 1 gm PO (C) is the recommended treatment choice for cervicitis without suspicion for PID. The CDC changed the guidelines to recommend 250 mg of ceftriaxone for the treatment of all gonococcal infections because of increasing resistance. Cefoxitin 2 gm IM and clindamycin 600 mg IV (B) and cefoxitin 2 gm IM and metronidazole 500 mg PO BID for 14 days (A) are not standard regimens for pelvic inflammatory disease. Cefoxitin and doxycycline are used together intravenously for the inpatient treatment of PID. If the patient cannot tolerate those medications an alternative regimen is clindamycin and gentamicin intravenously.

A 32-year-old woman presents with pain and swelling in the vaginal area. Examination reveals the above finding. What management is indicated? Acyclovir Cephalexin and surgery follow up Incision and drainage of the external surface of the vestibule Incision and drainage of the mucosal surface of the vestibule

Correct Answer ( D ) Explanation: This patient presents with a Bartholin's abscess and should have incision and drainage (I+D) performed with the incision on the mucosal surface. Bartholin's abscesses are infections located in the Bartholin's glands which lie inferiorly to the vaginal opening. Patients develop cysts of the gland that become secondarily infected. These abscesses typically are caused by normally occurring aerobic and anaerobic bacteria in the vagina but may also be caused by sexually transmitted infections. Patients present with swelling and pain near the labium. Examination revels a tender, fluctuant mass along the posterolateral margin of the vaginal vestibule. Treatment focuses on incision and drainage with insertion of a Word catheter. The Word catheter has a small balloon at the end that is inflated after insertion and remains in place for 6 to 8 weeks. Because of this duration, the incision should be made on the mucosal surface so that the Word catheter can be tucked into the vaginal opening for patient comfort. Incision and drainage is usually adequate but patients with overlying cellulitis may require antibiotics. After discharge, patients should perform sitz baths to aid with drainage. Recurrence is common.

26-year-old woman presents with abdominal cramping after a positive home pregnancy test. Her vitals are T 98.7°F, HR 94, BP 110/66, RR 18, oxygen saturation 97%. Her exam is unremarkable. Labs reveal a serum beta HCG of 1000 mIU and she is Rh positive. She states that the pregnancy is wanted. An ultrasound is performed as seen above. Which of the following is appropriate management for this patient? Administer methotrexate Administer Rhogam and discharge home with repeat beta hCG in 48 hours Administer Rhogam and methotrexate Discharge home with repeat beta hCG in 48 hours

Correct Answer ( D ) Explanation: This patient presents with abdominal pain and a positive pregnancy test raising the concern for an ectopic pregnancy. Ectopic pregnancy complicates about 1.5 - 2.0% of pregnancies and is potentially life threatening. There are a number of risk factors for ectopic pregnancy including pelvic inflammatory disease, prior tubal surgery, and previous ectopic pregnancy. This patient has an early pregnancy based on the low beta hCG. The transvaginal ultrasound shows an early gestational sac without a yolk sac or fetal pole within the uterus. This ultrasound does not rule out the diagnosis of an ectopic pregnancy as an ectopic pregnancy can cause a decidual reaction in the uterus, which appears similar to an early gestational sac. The definitive ultrasound finding for an intrauterine pregnancy would be the presence of a yolk sac or fetal pole. It is expected that above the discriminatory hCG zone of 1500-2500 mIU, a definitive IUP should be identified. Patients with a beta hCG below the discriminatory zone without a definitive IUP can be managed conservatively with a repeat hCG level in 48 hours (the level should double every 48 hours) and repeat ultrasound. Rhogam (B & C) is recommended for patients who are Rh negative and have vaginal bleeding. If the mother is exposed to fetal blood, she may develop antibodies that threaten future pregnancies. This patient does not have vaginal bleeding and is Rh positive obviating the need for Rhogam. Methotrexate (A) is a chemotherapeutic agent that can be used for the treatment of early ectopic pregnancy. This approach is not indicated in a wanted pregnancy with a beta hCG below the discriminatory zone as repeat testing may show a viable intrauterine pregnancy.

A 19-year-old G1P0 woman at 26 weeks presents with abdominal pain after being involved in a motor vehicle collision. External pelvic examination reveals vaginal bleeding. Which of the following is true regarding this presentation? A normal ultrasound rules out placental abruption Disseminated intravascular coagulation is uncommon in placental abruption Early pelvic digital examination should be performed Emergent fetal monitoring and obstetric consultation are required

Correct Answer ( D ) Explanation: This patient presents with painful vaginal bleeding in late pregnancy after a trauma concerning for placental abruption and should have emergent fetal monitoring and obstetric consultation. Late pregnancy vaginal bleeding is never normal and raises suspicion for placental abruption, placenta previa and vasa previa; all potentially life threatening disorders to both the mother and fetus. Abruption occurs when there is separation of the placenta from the uterine wall leading to hemorrhage. It is more common in women with hypertension, preeclampsia, smoking, thrombophilia, cocaine use, trauma and prior abruption. Although most patients with abruption will present with dark vaginal bleeding, there are patients who will have hidden hemorrhage in which bleeding is contained between the placenta and the uterus. In patients with late term vaginal bleeding, emergent obstetric consultation should be obtained to further investigate and differentiate the causes. Fetal monitoring should be performed as distress may prompt emergent delivery depending on gestational age. Disseminated intravascular coagulation (DIC) (B) is relatively common and should always be considered. A digital examination (C) should be deferred until placenta previa is ruled out as digital examination may lead to worsening hemorrhage in this disorder. Ultrasound (A) should be obtained early in management to help to identify placenta previa and placental abruption but it is insensitive as the echogenicity of fresh blood is difficult to distinguish from the placenta. Therefore, a normal ultrasound does not rule out abruption.

You are treating a 23-year-old woman for a suspected ectopic pregnancy. Which of the following is an indication for an emergent laparotomy? A positive ßhCG with an empty uterus on ultrasound Heavy vaginal bleeding with use of 1 pad every 2 hours Hemoglobin level of 10 mg/dL with no history of anemia Persistent tachycardia despite adequate resuscitation

Correct Answer ( D ) Explanation: When evaluating a patient with suspected ectopic pregnancy, stable versus unstable hemodynamic status is the first critical decision. Hemodynamically stable patients should be evaluated with a quantitative ßhCG, ultrasound, and other indicated testing. Unstable patients should be resuscitated by aggressive volume repletion with normal saline and blood products, as indicated. Persistent tachycardia, despite adequate volume resuscitation in a patient known or suspected to have an ectopic pregnancy, should undergo an emergent laparotomy. A positive ßhCG with an empty uterus (A) on ultrasound should increase suspicion for an ectopic pregnancy. Most ectopic pregnancies develop within the fallopian tubes and can be visualized on ultrasound as a mass in the adnexa. A missed abortion or early pregnancy is also in the differential. If the vital signs are stable, the patient can be discharged with obstetric follow-up and repeat ßhCG in 48 hours. Ongoing vaginal bleeding may indicate continued hemodynamic instability, but pads (B) are a notoriously inaccurate measure of the extent of bleeding. A ruptured ectopic pregnancy can cause significant hemorrhage; however, hemoglobin levels (C) may not accurately measure the extent of bleeding. The value can lag behind the clinical course and does not correlate with hemodynamic instability.