Women's EOR - Pregnancy Complications pt 1

Spontaneous abortion occurs in up to (fraction) _____of all recognizable pregnancies.

1/4

Before the _________ weeks of gestation, an abortion is considered spontaneous.

20 weeks

Placenta previa is defined as the attachment of placenta to the lower uterine segment over the ______________

internal cervical os

Weight loss (is/is not) a feature of hyperemesis gravidarum.

is

Placental abruption is a (benign/life-threatening) life-threatening complication of the third trimester of pregnancy.

life-threatening

You receive a call at 3 AM from your prenatal patient who is worried about bleeding and cramping that began several hours ago. This is the fourth pregnancy for your patient, which was a planned pregnancy. She has had two uncomplicated, spontaneous vaginal deliveries and one elective abortion in the past. Her prenatal course to date has been uncomplicated. Two weeks ago, you obtained a first-trimester ultrasound study for dating purposes that revealed a 6-week intrauterine pregnancy. She denies any fever, nausea, vomiting, dizziness, lightheadedness, shortness of breath, or arm or chest pain. Her cramps are becoming more intense, but she is managing to control the pain with a heating pad. She reports using approximately three sanitary pads in the past 6 hours for bleeding, none of which were soaked through. The patient is home with her husband, who is a well-known patient of yours as well. They are very anxious and want to know what to do next. You advise your patient to: A. Come to your office first thing in the morning for an evaluation B. Take some ibuprofen and see you at her next scheduled prenatal visit C. Rush to the emergency department because of suspected ectopic pregnancy D. Rush to the emergency department for an immediate dilation and curettage (D& C) E. Cll an obstetrician-gynecologist to schedule an outpatient consultation

A (Come to your office first thing in the morning for an evaluation) (This patient is most likely experiencing an early pregnancy loss (also called a spontaneous abortion, nonviable pregnancy, or early pregnancy failure), which is defined as a spontaneous pregnancy loss at less than 20 weeks of gestation based on the last menstrual period. Because the patient appears to be hemodynamically stable on the basis of your phone conversation, it is reasonable to have her evaluated first thing in the morning in your office. Furthermore, you already have preexisting documentation of an intrauterine pregnancy, which makes the possibility of an ectopic pregnancy highly unlikely. The concomitant presence of an ectopic and intrauterine pregnancy (referred to as a heterotopic pregnancy) is possible but is a very rare occurrence, with an incidence of 1: 30,000 pregnancies. Reports estimate that heterotopic pregnancies are on the rise, with an incidence as high as 1: 2600 pregnancies among certain high-risk subgroups, such as women who have undergone assisted reproductive interventions (e.g., in vitro fertilization). Although sending the patient to the emergency department immediately is a possible option, this will likely cause unnecessary waiting and anxiety for the couple. An immediate D& C is not necessary, given the fact that the patient is stable and not bleeding excessively. Most early pregnancy losses can be managed safely and effectively in the family medicine setting; a consultation with an obstetrician-gynecologist is not mandatory and will depend on the clinician's level of clinical comfort. Telling the patient to take ibuprofen and follow up at her next prenatal visit is not appropriate in the setting of undiagnosed first-trimester bleeding)

What are the three grades of abnormal placental attachment?

Accreta Increta Percreta

___________ are the first-line management in patients with hyperemesis gravidarum, along with thiamine supplementation and parenteral fluid support if necessary.

Antiemetics

_______________ is an autoimmune disorder that is diagnosed based off of history of thrombosis/ spontaneous abortion along with laboratory findings of lupus anticoagulant, anticardiolipin, and/or anti-β2 glycoprotein antibodies.

Antiphospholipid syndrome

Painless and profuse vaginal bleeding in the third trimester is most likely: A. Placenta accreta B. Placenta previa C. Vaso previa D. Bloody show E. Cervical ripening

B (Placenta previa)

A 29-year-old at 36 weeks gestation who arrives at the emergency department with a sudden onset of back pain with uterine contractions that are very close together, one after another. She describes PAINFUL, bright red vaginal bleeding. There is pelvic tenderness on examination which reveals a closed cervix and no evidence of rupture of the membranes. A. Placenta accreta B. Placental abruption C. Placenta percreta D. Premature rupture of membranes E. Placenta previa

B (Placental abruption)

A 27-year-old woman comes to the clinic because of abnormal menstrual periods for the past 6 months. Her periods used to be regular with moderately-heavy flow for 5 days, but they have become very light and now only last for 3 days. Her menstrual cramps have also become much more painful. Her medical history includes a dilation and curettage following a miscarriage 8 months ago. She does not currently take any medications. Her temperature is 37.0°C (98.6°F), pulse is 70/min, respirations are 12/min, and blood pressure is 121/74 mm Hg. The patient rates the pain associated with her menstrual cramps a 9 on a 10-point scale. Physical examination shows no abnormalities. Hysterosalpingogram (shown below) shows multiple intrauterine adhesions and an inability to distend the uterine cavity. Which of the following is the most likely diagnosis? A. Anovulatory cycle B. Asherman syndrome C. Chronic endometritis D. Endometriosis E. Leiomyoma

B (Asherman syndrome) (Asherman syndrome is a condition of the uterus caused by a loss of the stratum basalis and the replacement of normal endometrium with scar tissue. It is often the result of an aggressive dilation and curettage performed following a birth or miscarriage to remove retained placenta or products of conception)

A 33-year-old primigravid woman at 36 weeks of gestation presents to the emergency department for vaginal bleeding, back pain, and uterine contractions starting two hours prior. She reports that her pregnancy had otherwise been uncomplicated, with her chronic hypertension managed effectively on labetalol. She denies taking any other medications or drinking alcohol during the pregnancy, but she admits that she has smoked one pack of cigarettes per day since the age of 18 and was unable to quit. Ultrasound examination identifies a retroplacental hematoma. Which of the following placental findings is most likely to be present? A. Attachment of anchoring villi to the uterine myometrium B. Bleeding of vessels at the interface of the decidua basalis and the placental villi C. Invasion of the placenta through the myometrium to the bladder D. Penetration of chorionic villi into the uterine myometrium E. Presence of placental tissue over the internal cervical os

B (Bleeding of vessels at the interface of the decidua basalis and the placental villi) (Placental abruption, or premature separation of the placenta from the uterus due to bleeding at the decidual-placental interface, presents with acute painful vaginal bleeding in the third trimester; key risk factors include hypertension, smoking, cocaine use, and trauma)

A 30-year-old Caucasian woman, G3P1 at 12 weeks gestation, comes to the emergency department because of nausea and vomiting that occurs throughout the day and has been worsening over the past 4 weeks. She has been able to maintain oral fluid intake and is still eating regularly, just in smaller amounts. Vital signs show pulse is 90/min and blood pressure is 120/70 mmHg. Physical examination is normal. A urine dipstick shows mild ketonuria and laboratory studies are normal. An ultrasound confirms a 12 week single intrauterine pregnancy. Which of the following is the most appropriate initial treatment option for this patient? A. Methylprednisolone B. Doxylamine/pyridoxine C. Reassurance D. Ondansetron hydrochloride E. Intravenous fluids

B (Doxylamine/pyridoxine) (First-line treatment for nausea and vomiting of pregnancy is pyridoxine with doxylamine and simple conservative measures ensuring appropriate hydration and dietary intake) (Nausea and vomiting in pregnancy are extremely common. Hyperemesis gravidarum is the most severe form of pregnancy associated nausea and vomiting. It is characterized by nausea and vomiting that persist after the first trimester and is associated with ketosis and weight loss of >5% of pre-pregnancy weight. It may cause volume depletion, electrolytes and acid-base imbalances, nutritional deficiencies, and even death. Evaluation should include urinalysis for ketones and specific gravity and obstetric ultrasonography to evaluate for multiple gestations or trophoblastic disease) (Treatment options for nausea and vomiting in pregnancy are based on fetal safety profiles and efficacy. Conservative management is the first step in treatment. This includes proper hydration and simple alterations to dietary intake) (Treatment should begin with vitamin B6 (pyridoxine) and doxylamine (a H1-receptor blocker). This regimen is safe, effective, and should be considered the first-line pharmacologic therapy in patients that are hemodynamically)

A 27-year-old woman comes to the emergency department because of severe vomiting for the past six days. She is 8 weeks pregnant and has had increasing morning sickness for the last 2 weeks. She states she has vomited over 25 times in the past 2 days and reports fatigue, dizziness, and epigastric pain. Physical examination shows she is afebrile, pulse is 107/min, and blood pressure is 100/74 mmHg with a postural drop. She has lost 6 lb (2.7kg) since her initial prenatal visit one week ago. Mucous membranes are dry. Urinalysis is positive for ketones. Lab studies show a hypochloremic, hypokalemic metabolic alkalosis. Which of the following is the most appropriate course of management? A. IV normal saline with dextrose and potassium, and hospital admission B. IV normal saline with thiamine and potassium, and hospital admission C. Oral metoclopramide, and discharge D. IV diphenhydramine, and hospital admission E. Oral ondansetron, and discharge

B (IV normal saline with thiamine and potassium, and hospital admission) (Hyperemesis gravidarum often requires hospital admission for supportive treatment focused on fluid resuscitation,correction of electrolyte and acid-base disturbance, and symptom management)

A 31-year-old G3P2 woman presents to labor and delivery triage because she has had bleeding over the last day. She is currently 5 months into her pregnancy and has had no concerns prior to this visit. She previously had a delivery through cesarean section and has otherwise had uncomplicated pregnancies. She denies fever, pain, and discomfort. On presentation, her temperature is 99.1°F (37.3°C), blood pressure is 110/70 mmHg, pulse is 81/min, and respirations are 15/min. Physical exam reveals an alert woman with slow, painless, vaginal bleeding. Which of the following risk factors are associated with the most likely cause of this patient's symptoms? A. Early menarche B. Multiparity C. Presence of uterine fibroids D. Pelvic inflammatory disease E. Smoking

B (Multiparity) (This woman with painless bleeding in the second trimester without prior complications most likely has placenta previa. Multiparity is a risk factor for placenta previa)

A 30-year-old woman, grava 2, para 1, at 36 weeks gestation, comes to the emergency department because of severe abdominal pain for the past hour. She describes sudden onset "sharp" and "cramping" pain which began shortly after she was involved in a motor vehicle accident. She has also noticed a small amount of vaginal bleeding. Vital signs shows no abnormalities. Physical examination shows bright-red blood in the vaginal vault and a firm, tender uterus. Tocometer shows low amplitude regular contractions, approximately every two minutes. Which of the following is the most likely diagnosis? A. Placenta accreta B. Placental abruption C. Placenta percreta D. Premature rupture of membranes E. Placenta previa

B (Placental abruption) (Placental abruption is an abnormal separation of the placenta from the uterus. It is characterised by painful abdominal bleeding and low amplitude, high frequency contractions. Risk factors for placental abruption include trauma and cocaine use)

A 35-year-old woman, grava 1, para 0, at 35 weeks' gestation comes to the emergency department because of painful vaginal bleeding for the past 2 hours. She says the pain began suddenly and is located in her lower abdomen and lower back. She is also experiencing contractions every 10 minutes, which have not increased in frequency or intensity. Her past medical history is significant for hypertension that has been well managed throughout her pregnancy with labetalol. She has smoked 10 cigarettes a day for the past 12 years, and has continued to smoke throughout her pregnancy. She does not drink alcohol, and has not used illicit drugs. Physical examination shows blood in the vaginal vault and a closed cervix. Which of the following is the most likely diagnosis? A. Placenta accreta B. Placental abruption C. Ectopic pregnancy D. Placenta previa E. Preterm labor

B (Placental abruption) (Placental abruption is an abnormal separation of the placenta from the uterus. It is characterised by painful abdominal bleeding and low amplitude, high frequency contractions. Risk factors for placental abruption include, hypertension, smoking, trauma and cocaine use)

A 25-year-old female, G2 P1001, presents to your office at 11-weeks gestation with vaginal bleeding, mild lower abdominal cramping, and bilateral lower pelvic discomfort. On examination, blood is noted at the dilated cervical os. No tissue is protruding from the cervical os. The uterus by palpation is 8-9 weeks gestation. No other abnormalities are found. Which of the following is the most likely diagnosis? A. Threatened abortion B. Inevitable abortion C. Incomplete abortion

B. Inevitable abortion (Inevitable abortion is the gross rupture of membranes in the presence of cervical dilation)

Treatment of Abruptio placentae is DELIVERY OF THE FETUS AND PLACENTA is definitive treatment, along with what studies?

Blood type Cross-match Coag studies

In evaluating a 35-year old pregnant woman (EGA is 37 weeks), who presented with painless vaginal bleeding, which of the following is contraindicated? A. Ultrasonography B. Speculum examination C. Digital examination D. None of the above

C (Digital examination)

An 18-year-old woman pregnant with her first child is in the second stage of labor. She complains of abdominal pain between uterine contractions. What is the most likely diagnosis? A. Posterior presentation B. Breech presentation C. Abruptio placenta D. Vasa previa E. Uterine atony

C (Abruptio placenta) (The patient in labor who develops abdominal pain between uterine contractions or a tender uterus must be presumed to have abruptio placentae. Ultrasound examination has a high false-negative rate in diagnosing abruption and as a result this complication is diagnosed clinically. In one prospective study, 78% of patients with abruptio placentae presented with vaginal bleeding, 66% with uterine or back pain, 60% with fetal distress, and only 17% with uterine contractions or hypertonus. (The management of abruptio placentae is primarily supportive and entails both aggressive hydration and monitoring of maternal and fetal well-being. Coagulation studies should be performed, and fibrinogen and D-dimers or fibrin-degradation products should be measured to screen for disseminated intravascular coagulation (DIC). Packed red blood cells should be typed and held. If the fetus appears viable but compromised, urgent cesarean delivery should be considered)

A 31-year-old woman, G1P0 at 12 weeks gestation, comes to the emergency department because of persistent vomiting for the past 5 days. She has been unable to keep down solids or liquids for the last 36 hours. Vital signs show her temperature is 37°C (98.6°F), pulse is 95/min, respirations are 12/min, and blood pressure is 112/78mmHg. Her pre-pregnancy weight was 61kg (135lb) and her current weight is 58kg (128lb). Physical examination shows dry mucous membranes, crackled lips, and poor sign turgor. In a case of suspected hyperemesis gravidarum which of the following investigations is required to establish the underlying cause? A. Urinalysis B. Serum amylase and lipase C. B-hCG and Ultrasound D. Complete Metabolic Panel E. Liver function tests

C (B-hCG and Ultrasound) (Molar pregnancy, characterized by an elevated bHCG and abnormal ultrasound, is important to exclude in a patient presenting with hyperemesis gravidarum)

A 25-year-old woman, gravida 1, para 0, at 12 weeks' gestation comes to the emergency department because of severe pelvic pain as well as the passage of bloody clots and tissues. She saw her primary care physician roughly four weeks ago and there were no abnormalities noted at the time. She has eaten a balanced diet and been compliant with taking prenatal vitamins. She denies recent fevers, trauma, or changes in physical activity. Pelvic examination shows a closed cervical os and the presence of blood within the vaginal vault, but the source of the bleeding is not visualized. Ultrasound shows a thickened endometrium but an empty uterus. Which of the following is the most likely cause of this event? A. Listeria monocytogenes infection B. Cocaine use during pregnancy C. Fetal karyotypic abnormality D. Maternal age

C (Fetal karyotypic abnormality) (The most common cause of a miscarriage, or spontaneous abortion, (pregnancy loss prior to 20 weeks' gestation) is a fetal karyotypic abnormality (most often trisomy 16). (This woman most likely suffered a spontaneous abortion, which is a natural loss of a pregnancy before twenty weeks gestational age. Women may be characterized by abdominal pain and heavy vaginal bleeding with the presence of clots. She may or may not notice the passage of the products of conceptus as it may be confused with the clots. When the cervical os is closed on pelvic examination, this often means that a complete abortion has occurred. If imaging determines that the uterine cavity is empty, usually no further treatment is needed as uterine contractions are efficient at removing the products of conception. The most common cause of this is a fetal karyotypic abnormality, such as one of the trisomies (most often trisomy 16). Other predisposing factors include advanced maternal age or infections such as Streptococcus agalactiae and Listeria monocytogenes)

A 30-year-old woman, gravida 2, para 1, at 11 weeks gestation comes to her obstetrician/gynecologist for a routine prenatal visit. She indicates that this pregnancy has been "easier" than her first pregnancy, during which she experienced significant morning sickness and breast tenderness. Review of systems is positive for a light brown stain on her underwear approximately 1 week ago, but negative for fever, nausea, vomiting, abdominal pain, or cramping. Medical history shows that her previous pregnancy was uncomplicated. Pelvic examination shows a closed cervix with no blood in the vault; no abdominal, cervical or adnexal tenderness. Transabdominal sonogram shows a collapsed, intrauterine gestational sac. Which of the following is the most likely diagnosis? A. Complete abortion B. Incomplete abortion C. Missed abortion D. Threatened abortion E. Ectopic pregnancy

C (Missed abortion) (Missed abortion is defined as a spontaneous abortion in a patient with or without symptoms and a closed cervical os) (The evaluation of a patient with suspected spontaneous abortion should consider the following key aspects: 1) clinical presentation (extent of vaginal bleeding, presence of cramps, etc.); 2) ultrasound findings; 3) degree of cervical dilation. These factors help distinguish between the various types of spontaneous abortions: threatened, missed, inevitable, incomplete, complete, and septic. The patient in question experienced minimal vaginal bleeding, has a closed cervix, and a collapsed intrauterine gestational sac on ultrasound. These findings are consistent with a missed abortion, which is characterized by the retention of the products of conception. In other words, the pregnancy is not viable but has not been successfully expelled either, meaning that the cervix remains closed and the patient may experience minimal symptoms.)

A 26-year-old woman, gravida 2, para 1, at 11 weeks' gestation comes to the emergency department due to heavy vaginal bleeding since this morning. A few hours after bleeding onset, she began to experience mild abdominal cramps, which subsided on her way to the hospital. The patient and her husband indicate that their first prenatal visit 5 weeks ago was reassuring, and that the physician showed her a sonogram of the intrauterine gestational sac. Pelvic examination shows a closed cervix with blood visualized in the vaginal vault. The patient is very concerned about her pregnancy but is otherwise feeling well. Her temperature is 37.0°C (98.6°F), pulse is 80/min, respirations are 16/min, and blood pressure is 110/70 mm Hg. Which of the following is the most appropriate next step in the management of this patient? A. Computed tomography of the abdomen and pelvis B. Non-stress test C. Pelvic ultrasonography D. Reassurance E. Serial beta-HCG testing

C (Pelvic ultrasonography) (Spontaneous abortion, or miscarriage, is defined as pregnancy loss before 20 weeks of gestational age. There are various types of spontaneous abortions, which can be distinguished by the patient's clinical presentation, pelvic examination, and sonographic findings)

A 37-year-old G3P2 pregnant woman at 33 weeks gestation is brought to the emergency department because of the onset of brisk vaginal bleeding. Her husband says that they were having sexual intercourse when they both noticed the onset of the bleeding. She says that she has not had any pain with the bleeding and that she had not noticed any bleeding in the previous few days or weeks. Physical examination shows that the uterus is non-tender and 32 cm above the symphysis. Pelvic examination with a speculum reveals the presence of a large amount of bright red vaginal blood that now seems to be gushing out. The source of the bleeding cannot be immediately determined. Which of the following is the most likely diagnosis? A. Chorioamnionitis B. Placenta percreta C. Placenta previa D. Placental abruption E. Threatened abortion

C (Placenta previa) (Placenta previa classically presents as painless, bright red vaginal bleeding that occurs during the third trimester of pregnancy. It may be precipitated by sexual intercourse) (The classic clinical presentation of placenta previa is painless, bright red vaginal bleeding. This diagnosis must be considered in all patients beyond 24 weeks' gestation who present with bleeding. Bleeding may be provoked with intercourse. Typically, the abdomen is soft and non-tender. Risk factors include previous C-section, high parity or multiple gestations, older maternal age, multiple gestation and chronic hypertension. When this is suspected, an abdominal ultrasound must be performed in order to determine the location to of the placenta. Then, if necessary, a manual pelvic examination with a speculum may be done as well. If not performed in this order, the speculum may unwittingly dislodge the placenta from the uterine wall, potentially resulting in massive bleeding that can be fatal to the fetus or mother)

A 38-year-old woman, gravida 5, para 4, at 30 weeks gestation comes to the office because she is concerned about some vaginal bleeding she had recently. She states that yesterday she noticed that she had blood in her underwear when she went to the bathroom. She describes the flow as less than a period but enough that she needed to use a sanitary pad. She noted that it stopped spontaneously a few hours later. She denies any pain or contractions. Medical history shows that she has not experienced any similar symptoms with her previous pregnancies. Which of the following is the most likely diagnosis? A. Ectopic pregnancy B. Placenta accreta C. Placenta previa D. Placental abruption E. Preterm labor

C (Placenta previa) (Placenta previa is painless vaginal bleeding associated with the implantation of the placenta on or near the internal cervical os)

Which of the following is a maternal risk factor for spontaneous abortion? A. Uterine intramural myomata B. Progesterone deficiency elevated serum beta HCG C. Tobacco use D. Controlled diabetes

C (Tobacco use)

_____________________ are the most common cause of spontaneous abortion.

Chromosomal abnormalities

Pts w/placenta previa should be on bed rest, possibly hospitalized if the condition is severe. If bleeding is persistent, the baby should be delivered via _____________ as soon as possible, even if premature, to prevent further fetal distress.

C-section

_____________ abuse can cause placental abruption in pregnant women.

Cocaine

Diffuse ____________ is a disease associated with placental abruption in which both kidneys necrose.

Cortical necrosis

_______________ (drug class) are used to help the fetal lung mature in patients with placenta previa

Corticosteroids

A _____________________ is a complication of placental abruption in which blood extravasates between myometrial fibers, appearing like bruises on the serosal surface.

Couvelaire uterus

All of the following would be appropriate management strategies for an incomplete abortion except: A. Expectant management B. Uterine aspiration C. Medical management with vaginal misoprostol D. Exploratory laparoscopy E. Serial β-human chorionic gonadotropin (β-hCG) measurements

D (Exploratory laparoscopy) (Traditionally, clinicians performed immediate D& Cs to treat spontaneous abortions. Recent evidence provides support for the role of expectant management and medical management instead of surgical intervention. Expectant management allows the patient time to complete the process of spontaneous abortion on her own. This process can occur during the course of 2 to 4 weeks, depending on the patient's clinical symptoms and the patient's and clinician's level of comfort with waiting. Clinicians can monitor the progress of an ongoing pregnancy loss with serial β-hCG levels or ultrasound examination. The β-hCG level should double approximately every 48 hours in a viable intrauterine pregnancy. A rise of less than 50% is associated with an abnormal pregnancy. A change of less than 15% is considered to be a plateau, which is most predictive of an ectopic pregnancy. For incomplete spontaneous abortions, the success rate of expectant management is excellent at 82% to 96%. However, the success rate of expectant management declines with anembryonic pregnancy or fetal or embryonic death (25% to 76%).)

Risk factors for abruptio placentae include all of the following except: A. Smoking B. Hypertension C. Multiparity D. Hyperemesis gravidarum

D (Hyperemesis gravidarum)

Your pregnant pt with bleeding and cramping comest to your office for evaluation.She appears tearful but calm. Her temperature is 98.4 ° F, blood pressure is 120/ 80 mm Hg, pulse is 80 beats/ minute, and respiratory rate is 16 breaths/ minute. She reports that since she spoke to you, she has passed a few dime-sized clots but no obvious tissue. She continues to have lower abdominal cramping. You perform a speculum examination, which reveals some blood in the vaginal vault and a small amount of tissue protruding from an open, dilated cervical os. A bimanual examination reveals a 6-week-size uterus with minimal tenderness but no peritoneal signs. The most likely diagnosis is A. Missed abortion B. Recurrent spontaneous abortion C. Complete abortion D. Incomplete abortion E. Inevitable abortion

D (Incomplete abortion) (The patient is experiencing an incomplete abortion. The terminology to describe nonviable pregnancies was devised before the advent of ultrasonography and can be confusing. Traditionally, nonviable pregnancies are divided into different categories based on physical examination findings: (1) a threatened abortion refers to vaginal bleeding, with or without cramping, in the presence of a closed cervix; (2) an inevitable abortion refers to a dilated cervical os without the passage of tissue; (3) an incomplete abortion refers to a dilated cervical os with the passage of some but not all products of conception; and (4) a complete abortion refers to the complete expulsion of the products of conception. Recurrent spontaneous abortion refers to three or more consecutive pregnancy losses. In clinical trials, an embryonic or fetal demise has been sonographically defined as an embryonic pole or crown-rump length between 5 and 40 mm without cardiac activity. An anembryonic pregnancy (commonly called a blighted ovum) refers to a gestational sac with a mean diameter between 16 and 45 mm without evidence of a fetal pole, inadequate growth of the gestational sac, or an increase in β-hCG levels of less than 15% during a 2-day period in the presence of a yolk sac visualized on ultrasound examination)

A 37-year-old woman, gravida 3, para 2, at 19-weeks' gestation comes to the emergency department due to concern for decreased fetal movements. She denies any vaginal bleeding, abdominal pain, trauma, or any other symptoms. Physical examination shows a fundal height of 18 cm. Doppler examination is unable to find fetal heart tones. A bedside ultrasound confirms a lack of fetal heart beat. Which of the following is the most likely diagnosis? A. Incomplete abortion B. Intrauterine death C. Intrauterine growth restriction D. Missed abortion E. Placental abruption

D (Missed abortion) (A missed abortion, also called missed miscarriage, is defined as the intrauterine death of a fetus before 20 weeks gestation without any bleeding, abdominal pain, or expulsion of the products of conception)

A 37-year-old woman, gravida 4, para 3, at 38 weeks gestation comes to the emergency department because of painless vaginal bleeding earlier that day. Her three prior pregnancies were delivered by Cesarean section. She is in no acute distress, but admits that because she has not been taking her regular anxiolytic medications lately, she has been more anxious than usual. Medical history is negative for similar symptoms during previous pregnancies. Her temperature is 37.1°C (98.8°F), pulse is 84/min, respirations are 12/min, and blood pressure is 115/80 mm Hg. Fetal heart sounds are heard on Doppler ultrasound. Which of the following is the next best step in management? A. Administer betamethasone B. Administer tocolytics C. Computed tomography of the abdomen and D D. Perform transabdominal ultrasound E. Perform vaginal examination

D (Perform transabdominal ultrasound) (Placenta praevia and placental abruption are the two most common causes of 3rd trimester bleeding in pregnancy. Placenta praevia usually presents with painless vaginal bleeding, while placental abruption typically presents with painful vaginal bleeding)

Traditionally abortion/miscarriage is managed by _______ only, monitor progress with B-hCG levels or ultrasound examination.

D&C

A 27-year-old woman comes to the emergency department because of severe vomiting for the past two days. She is 9 weeks pregnant and began experiencing regular morning sickness in the form of mild nausea, with occasional episodes of vomiting, 7 weeks into her pregnancy. Her episodes of vomiting have since become more frequent. In the past 2 days, she says she has vomited over 25 times. Her other complaints include fatigue, dizziness, and epigastric pain associated with vomiting. Physical examination shows she is afebrile, pulse is 107/min, and blood pressure is 120/74 mmHg. Her arterial blood gas shows: pH 7.51 pCO2 46 mmHg pO2 80 Bicarbonate 32 Which of the following acid-base disturbances is present in this patient? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis E. Normal physiologic pH

D. (Metabolic alkalosis) (Hyperemesis gravidarum can result in a metabolic alkalosis. This is indicated by an elevated pH and an elevated serum bicarbonate level. This is caused by the loss of hydrogen, chloride and potassium within gastric secretions.)

___________________ is a possible complication of placental abruption that can present after delivery as bleeding from catheter insertion sites.

Disseminated intravascular coagulation

A 30-year-old female presents to the fertility clinic with a history of multiple miscarriages. She is frustrated as she and her partner have been trying to conceive for over 2 years. Her medical history is unremarkable and her physical exam is within normal limits. A hysterosalpingogram reveals What process resulted in this abnormality? A. Incomplete degeneration of the hymen B. Incomplete degeneration of the paramesonephric ducts C. Failure of the mesonephric ducts to fuse D. Failure of the processus vaginalus to close E> Failure of the paramesonephric ducts to fuse

E (Failure of the paramesonephric ducts to fuse) (This patient is presenting with a bicornuate uterus. A bicornuate uterus is caused by the failure of the paramesonephric ducts (Mullerian ducts) to fuse completely)

A 26-year-old woman, gravida 1, para 0, at 10 weeks' gestation, comes to the clinic because of severe nausea. Every morning for the last three weeks, she has experienced nausea and vomiting that interrupts her day, leaving her feeling fatigued and uncomfortable. Physical examination shows no abnormalities and shows she is gaining the expected weight for pregnancy. Urinalysis is normal. Laboratory studies are within the normal range. Which of the following is the most appropriate management for her symptoms? A. Advise her that this is a normal part of pregnancy B. Droperidol C. Hospitalization for intravenous fluid hydration D. Ondansetron E. Pyridoxine (B6)

E (Pyridoxine (B6)) (Nausea and vomiting of pregnancy is generally a mild, self-limiting condition that may be controlled with conservative measures. First line measures include pyridoxine(vitamin B6) either alone or in conjunction with doxylamine)

A 26-year-old woman, gravida 1, para 0, at 14 weeks gestation comes to the emergency department complaining of scant vaginal bleeding for the past 3 days. She says that she has only used one pad per day and has not noticed any clots or clumps of tissue. She also describes cramping abdominal pains, similar to the pain she experiences during her menstrual period. She denies any nausea, vomiting, or diarrhea. Pelvic examination shows that the cervical os is closed, and a small amount of blood is pooling in the vagina. Abdominal ultrasound shows a viable fetus in the uterine cavity. Which of the following is the correct name for her condition? A. Complete abortion B. Incomplete abortion C. Inevitable Abortion D. Missed Abortion E. Threatened abortion

E (Threatened abortion) (A threatened abortion describes any bleeding during pregnancy which occurs prior to 20 weeks gestation, with a closed cervical os. Though it puts the pregnancy at increased risk for miscarriage, half of the pregnancies go on to have no further issues)

A 36-year-old woman, gravida 2, para 1, at 30 weeks gestation comes to the emergency department because of vaginal bleeding which started two hours previously. She had been otherwise feeling well and denies fever, abdominal or pelvic pain, vaginal discharge, or onset of pelvic contractions. She has spent more time playing with her 3-year-old child lately, but denies any recent trauma. Her previous pregnancy was delivered at term via cesarean section. Her temperature is 37.3°C (99.1°F), pulse is 110/min, respirations are 14/min, and blood pressure is 100/60 mm Hg. Two large-bore intravenous lines are established for fluid support. Which of the following is the next best step in this patient's management? A. Administration of tocolytics B. Bimanual pelvic examination C. Magnetic resonance imaging D. Reassurance and outpatient follow-up E. Transabdominal ultrasonography

E (Transabdominal ultrasonography) (Placenta previa usually presents with painless bleeding, whereas placental abruption (PA, as in PAin) causes significant pain. Third-trimester bleeding should not be explored via pelvic exam until the position of the placenta has been determined by ultrasound)

All women with early pregnancy bleeding and pain are assumed to have __________________ until this diagnosis has been excluded by laboratory and imaging studies.

Ectopic pregnancy

Complication of pregnancy caused by high serum levels of β-hCG that is characterized by severe nausea and vomiting such that weight loss and dehydration occurs.

Hyperemesis gravidarum

______________is nausea and vomiting in pregnancy characterized by persistent nausea and vomiting associated with ketosis and weight loss that is greater than five percent of prepregnancy weight.

Hyperemesis gravidarum

Dilated cervical os with the passage of some but not all products of conception before 20 weeks of gestation

Incomplete abortion

A 35-year-old G3P2 with cervical dilatation >3 cm, ruptured membranes, bleeding >7 days, and the presence of cramping. What is the most likely diagnosis?

Inevitable abortion

Dilated cervical os without passage of tissue before 20 weeks of gestation

Inevitable abortion

_______________ and hydatidiform moles are the commonest conditions associated with hyperemesis gravidarum.

Multiple gestation

_______________ is the most common benign smooth muscle tumor in females age 20-40 years old. May be asymptomatic, cause abnormal uterine bleeding, or result in miscarriage.

Leiomyoma

________________ infection in pregnant women can cause amnionitis and spontaneous abortion, in addition to other fetal disorders.

Listeria monocytogenes

____________ (type) of placenta previa is when the placenta is within 2 cm of the internal cervical os but does not fully cover it.

Marginal

Maternal risk factors for a spontaneous abortion include:

Maternal infections (e.g., herpes simplex) Uterine defects Endocrine abnormalities Drug use Tobacco use Immunologic factors Physical trauma.

Death of the fetus before 20 weeks of gestation, with products of conception remaining intrauterine

Missed abortion

What are the risk factors for a spontaneous abortion?

Parity Maternal age (35 +) Paternal age (45 +) Women who conceive within 3 months of a term birth

Placenta (accreta/increta/percreta) is the most common of the placental-myometrium attachment disorders.

Placenta accreta

Placenta __________ is a pregnancy complication where the placenta attaches to, but does not penetrate, the myometrium.

Placenta accreta

Placenta __________ presents with difficult placenta delivery and postpartum bleeding.

Placenta accreta

When all or part of the placenta attaches abnormally to the myometrium (the muscular layer of the uterine wall), rather than being restricted within the decidua basalis.

Placenta accreta

Chorionic villi invades into the myometrium.

Placenta increta

Chorionic villi invade through the myometrium

Placenta percreta

________________is a disease of new-onset hypertension with proteinuria during pregnancy that can cause placental abruption.

Preeclampsia

Risk factors for placental abruption include:

Preeclampsia Hypertension Trauma Smoking Cocaine abuse

Risk factors for placenta previa include:

Prior cesarean sections Grand multiparous Advanced maternal age

First-line treatment for nausea and vomiting of pregnancy is ________________ with _____________ and simple conservative measures ensuring appropriate hydration and dietary intake

Pyridoxine Doxylamine

Diagnosis of placenta previa requires ___________ to locate the placenta.

Ultrasound

Expulsion of all or part of the products of conception *before 20 weeks of gestation*

Spontaneous abortion

Symptoms of _________________ include passage of fetal tissues, vaginal bleeding, and cramping pain.

Spontaneous abortion

(Drug class) ___________ are the treatment for severe, intractable hyperemesis gravidarum.

Steroids

______________ is one of the TORCHES infections that commonly results in stillbirth/ miscarriage, hydrops fetalis.

Syphilis

(Vitamin) ________________ supplementation to prevent encephalopathy is part of first-line management in patients with hyperemesis gravidarum, along with antiemetics and fluid support.

Thiamine (vitamin B1)

Bloody vaginal discharge before 20 weeks of gestation with or without uterine contractions in the presence of a closed cervix

Threatened abortion

The most common chromosomal trisomy leading to spontaneous abortion is _____________

Trisomy 16

The teratogenic effects of excess __________ on a fetus include spontaneous abortion, cleft palate, cardiac abnormalities.

Vitamin A

___________, is a teratogen and results in bone deformities, fetal hemorrhage, abortion, and ophthalmologic abnormalities.

Warfarin

A cesarean delivery is (indicated/avoided) in placental abruption if the fetus is dead.

avoided

Placenta previa usually presents with painless (bright red / dark red) vaginal bleeding.

bright red

A(n) ___________is indicated in placental abruption if there is maternal and fetal jeopardy.

cesarean delivery

Risk factors for placenta accreta include a history of (delivery method) _________________, inflammation, and placenta previa.

cesarean section

Placental abruption usually presents with painful (bright red / dark red) vaginal bleeding.

dark red

The βHG should _________ every 48 hours in a viable intrauterine pregnancy

double

Acute ____________ is defined as acute infection of the endometrium, typically due to retained products of conception that act as a nidus for infection.

endometritis

Following a medical or spontaneous abortion, women may develop _____________ due to retained products of conception.

endometritis

Multiple gestation and ______________________ are the commonest conditions associated with hyperemesis gravidarum.

hydatidiform mole

Placental abruption can lead to ______________shock and fetal distress if there has been severe blood loss.

hypovolemic

Placenta accreta often requires ____________ as definitive treatment.

hysterectomy

Multiparity (increase/decrease) the risk of placenta previa.

increase

Embryologic abnormality with incomplete fusion of paramesonephric ducts

maternal bicornuate uterus

Placental abruption presents with (painless/painful) bleeding from the vagina in the third trimester of pregnancy.

painful

Placenta previa presents with (painful / painless) bleeding, most commonly after 20 weeks of gestation.

painless

If a child survives after a maternal __________ infection during pregnancy they will present with facial abnormalities (eg, notched teeth, saddle nose, short maxilla), saber shins, CN VIII deafness.

syphilis

Placenta previa presents with painless bleeding most commonly in the _________ trimester.

third

Placental abruption presents in the (second/third) trimester with pervaginal bleeding.

third

High levels of (hormone)_________________ cause hyperemesis gravidarum.

β-human chorionic gonadotropin

Any type of abortion is diagnosed by decreased _____________ and classification is based on ultrasound findings.

βHG