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| <quiz display=simple>
| | #REDIRECT [[Kaji review questions (main)]] |
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| {After MINOR abdominal trauma ina viable (> 24 weeks) pregnancy, fetal outcome is best predicted by which of the following?
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| |type="()"}
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| -Maternal vital signs
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| -Abdominal tenderness
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| -Serum D-dimer level
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| -Ultrasound
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| +Cardiotocographic monitoring
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| || Rosen, p. 319. Only cardiotocographic monitoring for a minimum of 4 hours is useful to predict fetal outcome for women with less severe trauma.
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| {The most sensitive indicator of placental abruption is:
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| |type="()"}
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| -vaginal bleeding
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| +fetal distress
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| ||Rosen, p. 319. Classical clinical findings of abruption may include vaginal bleeding, abdominal cramps, uterine tenderness, maternal hypovolemia or a change in the fetal heart rate. The most sensitive indicator of placental abruption is fetal distress. There is a close linkage of abruption to uterine activity. Ultrasound is less than 50% accurate in detecting abruption. If the abruption bleeds externally or the placenta is positioned posteriorly, not enough blood collects to be seen sonographically. Note that 50-70% of fetal losses result from placental abruption.
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| -uterine tenderness
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| -abdominal cramps
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| -ultrasound findings consistent with abruption
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| {A 30 year old G2P1 32 weeks EGA was in a minor motor vehicle crash and sustains a laceration and has no abdominal tenderness to palpation although she did “bump” her lower abdomen. She has a normal exam other than having a gravid, nontender uterus, as well as a small 3cm laceration on her forearm with no neurovascular deficits. She is Rh negative. In managing this patient, which of the following statements is FALSE?
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| |type="()"}
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| -The patient should have 4 hours of cardiotocographic monitoring.
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| -The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 3 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes.
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| -Tetanus toxoid should be administered to the patient if she has not been vaccinated in the last 10 years.
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| +A 50 microgram dose of Rh immune globulin (RhIG) should be administered.
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| ||Rosen, 316-327. All Rh-negative mothers who have a history of abdominal trauma should receive a prophylactic dose of RhIG. In the first trimester, the 50 microgram dose is used because the total fetal blood volume is only 4.2 ml by 12 weeks. During the second and third trimesters, 300 micrograms of RhIG is given, which protects against 30 ml of fetal-maternal hemorrhage. Minor trauma does not exempt the fetus from significant injury as 1-3% of all minor trauma result in fetal loss from placental abruption, and four hours of cardiotocographic monitoring is recommended. The duration of cardiotocographic monitoring should be extended to 24 hours if, during the first 4 hours, she develops > 3 contractions per hour, persistent uterine tenderness, a worrisome fetal monitor strip, vaginal bleeding, or rupture of the membranes. Tetanus toxoid and immune globulin have no detrimental effect on the fetus. Proper immunization of pregnant women decreases the incidence of neonatal tetanus, since the tetanus antibody crosses the placenta.
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| -The most common obstetric problem that is likely to occur in this patient is uterine contractions.
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| {Above what serum hCG level is the absence of intrauterine pregnancy by transvaginal ultrasound (and no fluid in the pouch of Douglass or an ectopic mass) presumptive evidence of ectopic pregnancy?
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| |type="()"}
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| -300
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| -400
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| -500
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| +2000
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| ||LLSA reading list 2007. Clinical policy: Critical issues in the initial evaluation and management of patients presenting to the emergency department in early pregnancy. Ann Emerg Med. 2003;41:123-133. In a prospective study of 354 pregnant women with ectopic pregnancy clinically suspected by presence of abdominal pain, vaginal bleeding, risk factors, or nondiagnostic transvaginal ultrasound, Mol found that a cut off level for serum hCG as presumptive evidence of ectopic pregnancy, was dependent on presence of the sonographic abnormalities of fluid in the pouch of Douglas or an ectopic mass. In patients with these sonographic abnormalities, a serum hCG level greater than 1,500 mIU/mL indicated ectopic pregnancy with virtual certainty. For patients without these sonographic abnormalities, a serum hCG level greater than 2,000 mIU/mL increased the likelihood of ectopic pregnancy and excluded viable intrauterine pregnancy.
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| ||In smaller, prospective, observational studies, Goldstein et al identified all viable intrauterine pregnancies in patients with serum hCG levels above 1,025 mIU/mL, and Nyberg et al identified all viable intrauterine pregnancies above hCG levels of 1,000 mIU/mL. In a study of 52 pregnant women, Bernaschek et al identified all viable intrauterine pregnancies with hCG levels above 750 mIU/mL.
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| -600
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| {What is the frequency of treatment failure in methotrexate therapy for ectopic pregnancy and its implication for ED management?
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| |type="()"}
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| -1-20%
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| -90-100%
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| -20-30%
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| +6-36%
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| ||LLSA reading list 2007. A review of the literature shows that selected patients with close follow-up have been safely treated with methotrexate, with success rates ranging from 64% to 94%. In 1993, Stovall and Ling followed up 120 women diagnosed with ectopic pregnancy and treated with methotrexate by using a combination of hCG titers, serum progesterone levels, transvaginal ultrasonography, and curettage. Successful outcomes correlated with patients meeting the following criteria: An unruptured ectopic mass less than 3.5 cm in size, hemodynamic stability, and absence of active bleeding or signs of hemoperitoneum. In 1996, Stitka et al reviewed the cases of 50 women with ectopic pregnancy treated with methotrexate administered intramuscularly. The success rate was 65% with the first injection. The success rate increased to 78% with a second injection. In 1998, Lipscomb et al. reviewed the cases of 315 women with ectopic pregnancy treated with methotrexate. Overall success rate of resolution without surgery was 90.1%, with 82.5% requiring only 1 injection. In 1999, Lipscomb et al reviewed cases of 350 women with ectopic pregnancy treated with methotrexate. Overall success rate without surgery was 91%. More than 1 dose was given to 20% of the patients. The most important factor associated with single dose methotrexate failure was an elevated hCG level greater than 10,000 mIU/mL. Stitka et al and Lipscomb et al both showed increased success when no fetal cardiac activity was detected. Stitka et al also noted that gastrointestinal side effects of methotrexate therapy are similar to symptoms of ruptured ectopic pregnancy.
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| -80-90%
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| {According to the CDC, empiric treatment of PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if which of the following criteria are met?
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| |type="()"}
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| -cervical motion tenderness
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| -uterine tenderness
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| -adnexal tenderness
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| +if any one of the above are present
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| ||www.cdc.gov Empiric treatment of PID should be initiated in sexually active young women and other women at risk for STDs if they are experiencing pelvic or lower abdominal pain, if no cause for the illness other than PID can be identified, and if ONE or more of the following minimum criteria are present on pelvic examination:
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| ||cervical motion tenderness OR uterine tenderness OR adnexal tenderness. The requirement that all three minimum criteria be present before the initiation of empiric treatment could result in insufficient sensitivity for the diagnosis of PID. The presence of signs of lower genital tract inflammation, in addition to one of the three minimum criteria, increases the specificity of diagnosis. In deciding upon the initiation of empiric treatment, clinicians should also consider the risk profile of the patient for STDs.
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| ||More elaborate diagnostic evaluation frequently is needed because incorrect diagnosis and management might cause unnecessary morbidity. These additional criteria may be used to enhance the specificity of the minimum criteria. The following additional criteria can be used to enhance the specificity of the minimum criteria and support a diagnosis of PID:
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| ||oral temperature >101°F (>38.3°C),
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| ||abnormal cervical or vaginal mucopurulent discharge,
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| ||presence of abundant numbers of WBC on saline microscopy of vaginal secretions,
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| ||elevated erythrocyte sedimentation rate,
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| ||elevated C-reactive protein, and laboratory documentation of cervical infection with N. gonorrhoeae or C. trachomatis.
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| ||The majority of women with PID have either mucopurulent cervical discharge or evidence of WBCs on a microscopic evaluation of a saline preparation of vaginal fluid. If the cervical discharge appears normal and no WBCs are observed on the wet prep of vaginal fluid, the diagnosis of PID is unlikely, and alternative causes of pain should be investigated. A wet prep of vaginal fluid offers the ability to detect the presence of concomitant infections (e.g., bacterial vaginosis and trichomoniasis).
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| {Regarding Pelvic Inflammatory Disease (PID), which of the following statements is FALSE?
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| |type="()"}
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| -Up to 10 percent of women with untreated gonorrhea and 20 percent of women with untreated chlamydia infection may go on to develop PID.
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| +Quinolones, such as levofloxacin and ciprofloxacin are first-line agents in treating gonorrhea.
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| ||Due to the rising levels of fluoroquinolone resistance among Neisseria gonorrhoeae isolates, the CDC no longer recommends the use of fluoroquinolones for the treatment of gonorrhea infections, including associated conditions, such as PID. Recommended regimens include: 1) Ceftriaxone (250 mg intramuscularly in a single dose) plus doxycycline (100 mg orally twice a day for 14 days) with or without metronidazole (500 mg orally twice a day for 14 days). 2) Cefoxitin (2 g intramuscularly in a single dose) concurrently with probebenecid (1 g orally in a single dose) plus doxycycline (100 mg orally twice a day for 14 days) with or without metronidazole (500 mg orally twice a day for 14 days). 3) Other parenteral third-generation cephalosporins, such as cefotaxime (1 gram intramuscularly in a single dose) or ceftizoxime (1 gram intramuscularly in a single dose) plus doxycycline (100 mg orally twice a day for 14 days) with or without metronidazole (500 mg orally twice a day for 14 days). The decision to add metronidazole is based upon clinical assessment of the risk of anaerobic organisms in the individual patient. For example, the addition of metronidazole may be considered in patients with: a) Pelvic abscess, b) Proven or suspected infection with Trichomonas vaginalis or bacterial vaginosis, c) History of gynecological instrumentation in the preceding two to three weeks. The removal of fluoroquinolones from the treatment armamentarium has added a degree of complexity to the management of patients with PID. Alternative oral regimens should only be used for patients for whom a parenteral cephalosporin-containing regimen is not feasible. Fluoroquinolones may be considered for PID treatment when the prevalence of fluoroquinolone-resistant N. gonorrhoeae is <5 percent in the locality where the infection was acquired.
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| -The spectrum of antibiotic coverage must include Chlamydia trachomatis, Neisseria gonorrhoeae, streptococci, gram-negative enteric bacilli, and anaerobes.
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| -The optimal duration of therapy is unknown, although most authorities favor 14 days of treatment.
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| -Male sex partners of women with PID should be examined and treated if they had sexual contact with the patient during the previous 60 days prior to the patient's onset of symptoms.
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| {There has been a persistent trend toward outpatient treatment of PID with only 10 to 25 percent of women now being hospitalized. The CDC recommends that the decision to hospitalize for PID should be individualized and at the discretion of the clinician. The CDC’s recommended indications for hospitalization include all of the following EXCEPT:
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| |type="()"}
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| -pregnancy
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| -tubo-ovarian abscess
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| -lack of response to oral medications
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| -severe clinical illness
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| +HIV positivity
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| ||Recommended indications for hospitalization include:
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| ||- Pregnancy
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| ||- Lack of response or tolerance to oral medications
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| ||- Nonadherence to therapy
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| ||- Inability to take oral medications due to nausea and vomiting
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| ||- Severe clinical illness (high fever, nausea, vomiting, severe abdominal pain)
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| ||- Pelvic abscess, including tuboovarian abscess
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| ||- Possible need for surgical intervention or diagnostic exploration for alternative etiology (eg, appendicitis)
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| ||Adolescent females and women >35 years of age have often been targeted for routine initial in-patient treatment. There are no data to suggest improved clinical outcome based upon this criterion for hospitalization. There are also no data suggesting that HIV-infected women have an altered clinical response to standard antibiotic regimens. Therefore, decisions regarding oral versus parenteral antibiotic should not be affected by HIV serostatus (Walker, CK, Wiesenfeld, HC. Antibiotic therapy for acute pelvic inflammatory disease: the 2006 Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines. Clin Infect Dis 2007; 44 Suppl 3:S111.).
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| {Regarding ovarian torsion, which of the following statements is FALSE?
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| |type="()"}
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| -ovarian torsion may occur in all ages.
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| -ovarian torsion may occur in a normal ovary
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| +the gold standard for diagnosis is ultrasound
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| ||Ovarian torsion occurs in all age groups and may occur in a normal ovary. The gold standard for diagnosis is surgery. Three-dimensional (3D) ultrasound or two-dimensional ultrasound with Doppler is useful for preoperative imaging of the adnexa when torsion is suspected. A definitive diagnosis of ovarian torsion is based upon surgical findings.
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| -The clinical diagnosis of ovarian torsion should be considered in women with the lower abdominal or pelvic pain and an ovarian cyst/mass, after exclusion of ectopic pregnancy, pelvic inflammatory disease, appendicitis, and leiomyoma-related symptoms.
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| -Expedient diagnosis of ovarian torsion is important to preserve ovarian function and prevent adverse sequelae (necrosis, infarction, local hemorrhage, peritonitis, systemic infection).
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| {Which of the following types of deliveries predisposes to the highest risk of post-partum endometritis?
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| |type="()"}
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| -elective caesarean delivery
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| +emergency caesarean delivery
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| ||Cesarean delivery is the most important risk factor for development of postpartum endometritis. The rates of endometritis after nonelective cesarean, elective cesarean, and vaginal delivery are about 30, 7, and less than 3 percent, respectively, in the absence of antibiotic prophylaxis. Additional risk factors for postpartum endometritis include:
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| ||Prolonged labor
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| ||Prolonged rupture of membranes
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| ||Multiple cervical examinations
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| ||Internal fetal or uterine monitoring
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| ||Large amount of meconium in amniotic fluid
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| ||Manual removal of the placenta
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| ||Low socioeconomic status
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| ||Maternal diabetes mellitus or severe anemia
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| ||Preterm birth
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| ||Bacterial vaginosis
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| ||Operative vaginal delivery
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| ||Postterm pregnancy
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| ||HIV infection
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| ||Colonization with group B streptococcus
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| -emergency vaginal delivery
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| -induced vaginal delivery
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| -natural vaginal delivery
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| {A 22 year old female present with vaginal bleeding and pelvic pain. She thinks she is 7 weeks pregnant by LMP. She has not had an U/S confirming an IUP. You express your concern for an ectopic pregnancy. What would NOT be accurate to tell her about ectopic pregnancies?
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| |type="()"}
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| -Ectopic pregnancies are the third leading cause of maternal death
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| -IUDs and previous abortions are risk factors for ectopic pregnancies
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| -The risk of having an ectopic pregnancy after a prior ectopic is 22%
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| +Predisposing risk factors for ectopic pregnancy are present in nearly all ectopic pregnancies
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| ||Rosen p. 2742-43. Risk factors for ectopic pregnancy are absent in almost half of patients. Risk factors for ectopic pregnancy include tubal surgery, PID, smoking, advanced age, prior spontaneous abortion, medically induced abortion, history of infertility, and IUD. Adnexal masses are palpated only 10-20% of the time. Ectopic pregnancies occur in approximately 1% of all pregnancies with 98% of those implanting in the fallopian tubes. Prior ectopic pregnancy increases your risk for recurrence. PID increases a person’s risk 7-fold.
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| -Tubal surgeries and advanced age are risk factors for ectopic pregnancies
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| {You are called to the parking lot for a woman who is delivering her baby in the car. You are able to assist her into the ED and safely deliver the baby. Within a few minutes after the placenta is removed, the mother begins to hemorrhage, and you believe that she has a uterine inversion. There is no obstetrician in the house. You should do all of the following EXCEPT:
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| |type="()"}
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| -Attempt manual replacement of the uterus
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| +Administer uterotonic agents, such as pitocin
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| ||Interventions for the management of acute uterine inversion should begin promptly and simultaneously. Uterotonic drugs should be discontinued since uterine relaxation is needed for replacement of uterus. Intravenous access and aggressive fluid resuscitation is critical. An immediate attempt to manually replace the inverted uterus to its normal position should be made. This is best accomplished by placing a hand inside the vagina and pushing the fundus cephalad along the long axis of the vagina. Prompt intervention is important since the lower uterine segment and cervix contract over time, thus making manual replacement progressively more difficult. When immediate uterine replacement is unsuccessful, pharmacologic agents should be given to relax the uterus. Manual replacement should then reattempted. Nitroglycerine is an excellent uterine relaxant: 50 to 500 micrograms are administered intravenously, followed by up to three additional doses of 50 to 250 micrograms, as needed. Its short half-life is advantageous in cases of severe hemorrhage and hemodynamic instability. Terbutaline (0.25 milligrams intravenously or subcutaneously) and Magnesium (4 to 6 grams intravenously over 15 to 20 minutes) are other options for uterine relaxation. Both have relatively mild effects on the myometrium and magnesium sulfate has a slow onset of action, but both drugs are acceptable if other agents are not available or if the practitioner is unfamiliar with their use.
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| -Administer two large bore ivs and begin administering blood
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| -After hemodynamic stabilization is achieved, administer intravenous nitroglycerine
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| -After hemodynamic stabilization is achieved, administer terbutaline
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| {You are in the ER when suddenly a man bursts in and says he thinks his wife about to deliver a baby in the car. You run out to the parking lot to find a woman in the backseat with the fetal head at the perineum. As you begin to attempt to deliver the fetus with slight traction on the head, you realize neither shoulder is able to be delivered. Which of the following are included in your approach to dealing with shoulder dystocia:
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| |type="()"}
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| -Call for backup (obstetrics/neonatology)
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| -Episiotomy
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| -Flex mother’s legs and apply suprapubic pressure
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| -Corkscrew the shoulders
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| +all the above
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| ||Rosen p2815-2816. Management using the HELPER mnemonic successfully delivers almost all cases of shoulder dystocia.
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| ||H call for help
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| ||E episiotomy (or episioproctotomy) to increase the anetroposterior diameter of passage
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| ||L Legs flex (McRoberts maneuver)
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| ||P Pressure- suprapubic pressure and Rubin’s maneuver (applying shoulder pressure to the fetus to decreases the bisacromial diameter)
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| ||E Enter the vagina and attempt Wood’s corkscrew maneuver by pushing the most accessible shoulder toward the chest to corkscrew the shoulders through
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| ||R Remove posterior arm by sweeping it across the chest and bring fetal hand to the chin, grasp and pull out of the birth canal and across the face.
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| {A 30 year old G1P0 EGA 10 weeks pregnant patient presents with vaginal spotting. She has a closed os and an IUP with good cardiac acitivy, confirmed by ultrasound. She asks you how common it is for clinically pregnant women to experience some bleeding, and what percent of women who bleed during early pregnancy miscarry. To respond correctly, you should state that:
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| |type="()"}
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| +About 20 to 25% of clinically pregnant patients experience some bleeding, and approximately 50% of all women who have bleeding during early pregnancy miscarry.
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| ||Rosen, p.2740. About 20 to 25% of clinically pregnant patients experience some bleeding, and approximately 50% of all women who have bleeding during early pregnancy miscarry. The overall embryonic and fetal loss rate after implantation ranges up to one third of detectable pregnancies. The risk of miscarriage rises with increasing maternal and paternal age, tobacco and alcohol use, increased parity and history of vaginal bleeding; whereas the risk is only about 12% in females younger than 20 years old, it rises to about 30% in those older than 40 years of age. About 80% of miscarriages occur during the first trimester. Those with a history of bleeding who do not miscarry have otherwise fairly normal pregnancies, although they have about twice the risk of premature birth and low-weight infants.
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| -Less than 10% of clinically pregnant patients experience some bleeding, and approximately 5% of all women who have bleeding during early pregnancy miscarry.
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| -80% of clinically pregnant patients experience some bleeding, and approximately 75% of all women who have bleeding during early pregnancy miscarry.
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| -90% of clinically pregnant patients experience some bleeding, and approximately 20% of all women who have bleeding during early pregnancy miscarry.
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| -75% of clinically pregnant patients experience some bleeding, and approximately 90% of all women who have bleeding during early pregnancy miscarry.
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| {Regarding pelvic inflammatory disease (PID), which of the following is NOT a criteria for which hospitalization should be considered (according to the CDC)?
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| |type="()"}
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| -Pregnancy
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| -Tuboovarian abscess
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| +vaginal bleeding
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| ||Harwood-Nuss, p. 475-477. Criteria for which hospitalization should be considered include: 1) pregnancy, 2) surgical emergency can’t be excluded, 3) failure of oral antimicrobial therapy, 4) unable to follow or tolerate an outpatient regimen, 5) severe illness, nausea and vomiting, or high fever, and 6) tuboovarian abscess.
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| -A surgical emergency can not be excluded (e.g., appendicitis).
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| -The patient is unable to tolerate an outpatient oral regimen.
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| {Gynecologic question: Most breast abscesses occur 1 to 3 months post-partum, but post-menopausal women may also develop mastitis and abscesses. Which of the following are common to both types?
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| |type="()"}
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| -The abscesses are often found in the subareolar region in association with duct ectasia
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| -causative bacteria are most commonly E coli and group D strep.
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| -the abscess is caused by normal skin pathogens that invade cracks in the nipple.
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| +Staph is a causative species
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| ||Harwood-Nuss p. 486. Staph species are found in both postpartum and postmenopausal breast abscesses. Postpartum abscesses are caused by normal skin pathogens that invade through cracks in the nipple, and breast milk is an ideal culture medium. Unrecognzied infection coalesces into abscesses, usually located away from the areola. Staph are the most common causative agents. Preventive measures include nipple hygiene, hand washing, cleansing of the infant’s skin and early recognition. Postmenopausal abscesses are distinct from puerperial forms in cause and presentation. Causative bacteria include E coli, group D strep, staph, and anaerobes. These abscesses are most often found in the subareolar region in association with ductal ectasia, a chronic inflammation of major ducts below the nipple and areola. Recurrence rates after simple incision and drainage exceed 39%.
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| -infection is most often located away from the areola.
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| {You are practicing in a rural ED without immediate obstetric back-up. A patient presents with a crowning fetus and shoulder dystocia. All of the following maneuvers may be helpful EXCEPT:
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| |type="()"}
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| +hyperextend the mother’s thighs
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| ||Harwood-Nuss p. 520. Hyperflexion of the maternal thighs onto the abdomen may be attempted, but hyperextension has not been demonstrated to be helpful. The all-fours maneuver resulted in an 83% success rate in one series. Disagreement exists about which maneuver, or series of maneuvers is likely to be the most successful.
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| -drain the maternal bladder to create space anteriorly
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| -perform an episiotomy to allow posterior shoulder delivery
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| -have an assistant apply suprapubic pressure on the maternal abdomen in an attempt to dislodge the impacted fetal shoulder while you place gentle downward traction on the fetal head.
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| -place the laboring mother on her hands and feet (the all-fours maneuver).
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| | |
| {Gynecologic question: Metrorrhagia is bleeding at irregular intervals other than the usual time of menstruation, and metorrhagia usually represents an anovulatory disorder. All of the following are causes of anovulatory bleeding except:
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| |type="()"}
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| -Polycystic ovarian syndrome
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| -poorly controlled diabetes
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| +Von Willebrand’s disease (VWD)
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| ||Harwood Nuss p. 478. VWD represents a disorder of hemostasis. Other etiologies of anovulatory bleeding include hypothyroidism, Cushing’s, Addison’s and Congenital Adrenal Hyperplasia.
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| -primary ovarian dysfunction
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| -hyperprolactinemia
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| | |
| {Ectopic pregnancy results form implantation of a fertilized ovum at a site other than the endometrium of the uterus. The most frequent site of implantation is:
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| |type="()"}
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| +the lateral two-thirds of the fallopian tube
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| ||Harwood-Nuss p. 500. The most frequent site of implantation is the lateral 2/3 of the fallopian tube (80%). 15% of ectopic pregnancies implant in the medial 1/3 of the fallopian tube; interstitial or cornual implantation occurs in approximately 3%; and interstitial and cornual implantations carry the greatest risk of mortality because of their hemorrhagic tendencies. Extratubal pregnancies occur in 5%: within the abdomen in 2%, and in the ovary in 3%.
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| -the medial one-third of the fallopian tube
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| -interstitial or corneal
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| -within the ovary
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| -in the abdomen
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| {There are multiple risk factors for ectopic pregnany, such as one or more episodes of salpingitis, the use of an IUD associated with a pregnancy (14% of women who become pregnant with an IUD have an ectopic), prior tubal sterilization associated with a pregnancy (16% of women who become pregnant after being sterilized have an ectopic), and a history of a prior ectopic pregnancy. Approximately what proportion of women diagnosed with an ectopic pregnancy DO NOT have risk factors?
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| |type="()"}
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| -5%
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| -10%
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| -20%
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| +40%
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| ||Harwood-Nuss p. 500. Up to 42% of women with ectopic pregnancy have no historic risk factors. Ectopic pregnancy after tubal sterilization is thought to represent partial recanalization with access of the sperm to the ovum but impaired passage of the fertilized ovum to the uterine cavity. Like IUD wearers, patients who have had prior tubal sterilization are frequently subjected to a dely in diagnosis of ectopic gestation.
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| -60%
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| {A 30 year old G4P4 patient who is post-partum day #3 presents with subjective fevers, abdominal pain, and foul smelling lochia. You suspect post-partum endometritis. All of the following are risk factors for endometritis, EXCEPT:
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| |type="()"}
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| -operative delivery
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| -prolonged rupture of membranes
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| -prolonged stage 2 of labor
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| -frequent or excessive pelvic examinations
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| +urinary tract infection in the third trimester
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| ||Rosen, p.2821. All of the above, except urinary tract infections are associated with post-partum endometritis. Causative organisms for these infections include gram-negative coliforms, bacterioides, and streptococci. Infection occurs when these bacteria proliferate and invade the uterus or other tissues along the birth canal. Classic features of this disorder develop on the second or third day postpartum. Typically, the lochia has a foul odor, and fever and abdominal pain indicate a greater severity of illness. A search for retained products of conception is indicated, especially if bleeding is ongoing. Most patients require admission and treatment with clindamycin and an aminoglycoside, or second or third generation cephalosporin.
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| | |
| {OB question: About 0.4 to 1.3% of pregnant women have asthma. Which of the following statements is FALSE about asthma during pregnancy?
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| |type="()"}
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| +Asthma improves during pregnancy in over 90% of patients.
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| ||Harwood-Nuss p. 225. One third of pregnant patients with asthma improve during pregnancy, one third remain unchanged, and one third become worse. The other statements are true.
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| -asthma therapy during pregnancy is directed at providing adequate oxygenation for both mother and fetus.
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| -the management of pregnant asthmatics is essentially the same as that for nonpregnant asthmatics.
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| -inhaled beta agonists and corticosteroids appear to be safe in pregnancy.
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| -theophylline is safe in pregnancy.
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| {Which of the following is NOT an absolute or relative contraindication for use of methotrexate for the medical treatment of ectopic pregnancy?
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| |type="()"}
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| -hemodynamic instability
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| +beta hcg of 2000
| |
| ||The optimal candidates for MTX treatment of ectopic pregnancy are hemodynamically stable, willing and able to comply with posttreatment follow-up, have a beta-subunit (hCG) concentration =5000 mIU/mL, and no fetal cardiac activity. Ectopic mass size less than 3 to 4 cm is also commonly used as a patient selection criterion; however, this has not been confirmed as a predictor of successful treatment. Some women are not appropriate candidates for medical therapy and should be managed surgically, including women with the following characteristics: A. Hemodynamically unstable; B. Signs of impending or ongoing ectopic mass rupture (ie, severe or persistent abdominal pain or >300 mL of free peritoneal fluid outside the pelvic cavity);C. Clinically important abnormalities in baseline hematologic, renal or hepatic laboratory values; D.Immunodeficiency, E. active pulmonary disease, F. peptic ulcer disease; G. Hypersensitivity to MTX; H. Coexistent viable intrauterine pregnancy; I. Breastfeeding ; J. Unwilling or unable to be compliant with post-therapeutic monitoring; or K. Do not have timely access to a medical institution. MTX is renally cleared, and in women with renal insufficiency, a single dose of MTX can lead to death or severe complications, including bone marrow suppression, acute respiratory distress syndrome and bowel ischemia. Relative contraindications include: A. High hCG concentration — A high serum hCG concentration is the most important factor associated with treatment failure. Women with a high baseline hCG concentration (greater than 5000 mIU/mL) are more likely to require multiple courses of medical therapy or experience treatment failure; B. Fetal cardiac activity — The presence of fetal cardiac activity is another relative contraindication to medical treatment. In a metaanalysis, sonographic evidence of cardiac activity was significantly associated with treatment failure (OR 9.1, 95% CI 3.8-22.0) C. Large ectopic size — Although large size of the ectopic pregnancy (=3.5 cm) is often used as criterion for exclusion in medical treatment regimens, this restriction is based on small studies with inconsistent protocols and results. Studies have generally restricted use of MTX to women with an ectopic mass less than 3 to 4 cm.
| |
| -ectopic mass of 6cm
| |
| -> 300 ml of free fluid in the pelvis
| |
| -fetal cardiac activity
| |
| | |
| {The leading cause of death in pregnancy is:
| |
| |type="()"}
| |
| -appendicitis
| |
| -trauma
| |
| -placental abruption
| |
| +thromboembolic disease
| |
| ||Rosen, p.2756. Thromboembolic disease accounts for almost 20% of obstetric mortality, making it the leading cause of death in pregnancy. The risk of venous thrombosis increases during pregnancy to five to six times that of nonpregnant women. The risk is increased throughout pregnancy but is highest during the puerperium. Women who smoke, have varicose veins, or have a prior veneous thrombosis, as well as those who deliver prematurely or have postpartum hemorrhage are at higher risk.
| |
| -ectopic pregnancy
| |
| | |
| {You are seeing a G3P2 36 year old female who is 10 weeks by dates. She presents with vaginal bleeding. The pelvic ultrasound demonstrates a subchorionic bleed. True statements about this finding on ultrasound include which of the following:
| |
| |type="[]"}
| |
| | |
| -The finding of such a bleed has no prognostic impact for the pregnancy outcome
| |
| +The outcome of the pregnancy depends upon the size of the hematoma
| |
| ||Subchorionic hemorrhage (subchorionic hematoma) is the most common sonographic abnormality in the presence of a live embryo. Vaginal bleeding affects 25% of all women during the first half of pregnancy and is a common reason for first-trimester ultrasonography. Sonographic visualization of a subchorionic hematoma is important in a symptomatic woman because pregnant women with a demonstrable hematoma have a prognosis worse than women without a hematoma. However, small, asymptomatic subchorionic hematomas do not worsen the patient's prognosis. In women whose sonogram shows a subchorionic hematoma, the outcome of the fetus depends on the size of the hematoma, the mother's age, and the fetus's gestational age. Rates of miscarriage increase with advancing maternal age and increasing size of hematoma. Late first- or second-trimester bleeding also worsens the prognosis.
| |
| +The outcome of the pregnancy depends upon the age of the fetus
| |
| +The outcome of the pregnancy depends upon the age of the mother
| |
| -The outcome of the pregnancy depends upon the age of the father
| |
| | |
| {You are seeing a 29 year old female who is post-partum day #8. She presents with fever, uterine tenderness, foul lochia, and some mild vaginal bleeding. You suspect post-partum endometritis. What is the most important risk factor for this entity?
| |
| |type="()"}
| |
| | |
| -history of Group B strep colonization
| |
| -history of pelvic inflammatory disease
| |
| -history of pre-term labor
| |
| +history of cesarean section
| |
| ||Cesarean delivery is the most important risk factor for development of postpartum endometritis. The rates of endometritis after nonelective cesarean, elective cesarean, and vaginal delivery are about 30, 7, and less than 3 percent, respectively, in the absence of antibiotic prophylaxis. Additional risk factors for postpartum endometritis include: 1) Prolonged labor, 2) Prolonged rupture of membranes, 3) Multiple cervical examinations, 4) Internal fetal or uterine monitoring, 5) Large amount of meconium in amniotic fluid, 6) Manual removal of the placenta, 7) Low socioeconomic status, 8) Maternal diabetes mellitus or severe anemia, 9) Preterm birth, 10) Bacterial vaginosis, 11) Operative vaginal delivery, 12) Postterm pregnancy, 13) HIV infection, and 14) Colonization with group B streptococcus. Nonelective cesarean deliveries are more likely to be associated with risk factors than elective procedures, thus accounting for the high rate of endometritis after nonelective cesarean birth.Bacterial vaginosis is important in the setting of cesarean delivery. In a multivariable analysis, the odds of developing postcesarean endometritis associated with bacterial vaginosis were 5.8 (95% CI 3.0-10.9) after adjusting for duration of labor, duration of membrane rupture, and maternal age. The propensity to upper genital tract infection in women with bacterial vaginosis may be related to higher vaginal concentrations of certain anaerobic and facultative bacteria observed in this disorder. Endometritis may also occur with chorioamnionitis, but the diagnosis is not made until the patient is postpartum.
| |
| -history of bacterial vaginosis
| |
| | |
| {You are seeing a G4P4 34 year old obese female (with hx of asthma) who is 28 weeks by dates, and she complains of shortness of breath and dry cough. Which of the following should be part of your differential diagnosis?
| |
| |type="[]"}
| |
| | |
| +asthma exacerbation
| |
| ||Four criteria are needed to meet the definition of peripartum cardiomyopathy: 1) Development of cardiac failure in the last month of pregnancy or within five months of delivery; 2) Absence of an identifiable cause for the cardiac failure; 3) Absence of recognizable heart disease prior to the last month of pregnancy; 4) LV systolic dysfunction (eg, left ventricular ejection fraction [LVEF] below 45 percent or a reduced shortening fraction). Women who develop cardiomyopathy earlier in pregnancy do not meet the definition of PPCM based upon the first and third criteria; however, the disease process is probably the same (so it should be part of the differential diagnosis). The characteristics of early onset disease were evaluated in a review of 123 women with a history of cardiomyopathy diagnosed during pregnancy. One hundred women met the traditional criteria for PPCM, presenting at a mean of 38 weeks, and 23 presented earlier at a mean of 32 weeks. There were no differences between the two groups in terms of age, race, associated conditions, LVEF (29 versus 27 percent), the rate and time of recovery, and maternal outcomes. These observations suggest that patients with an early presentation may be part of the spectrum of PPCM.
| |
| +decreased functional residual capacity due to gravid uterus and obesity
| |
| +pulmonary embolus
| |
| +peripartum cardiomyopathy
| |
| +viral URI
| |
| | |
| {You are seeing a 27 year old female in whom your suspect ovarian torsion. True statements about this entity include all of the following EXCEPT:
| |
| |type="()"}
| |
| | |
| -Classically, patients present with sudden onset, severe, unilateral lower abdominal pain that worsens intermittently over many hours.
| |
| -Fever may occur as a late finding as the ovary becomes necrotic.
| |
| -A unilateral, tender adnexal mass has been reported in between 50 and 90% of patients. However, absence of such a finding does not exclude the diagnosis.
| |
| +Torsion of a normal ovary does not occur.
| |
| ||Multiple factors have been found to be responsible for the development of ovarian torsion. Although torsion may rarely occur in normal adnexa, it more frequently arises from one of many anatomic changes. Torsion of a normal ovary is most common among young children, in whom developmental abnormalities such as excessively long fallopian tubes or absent mesosalpinx may be responsible. In fact, less than half of torsed ovaries in pediatric patients involve cysts, teratomas, or other masses. During early pregnancy, the presence of an enlarged corpus luteum cyst likely predisposes the ovary to torsion. Women undergoing induction of ovulation for infertility carry an even greater risk, as numerous theca lutein cysts significantly expand the ovarian volume. Ovarian tumors, both benign and malignant, are implicated in 50-60% of cases of torsion. Involved masses are nearly all greater than 4-6 cm, although torsion is possible with smaller masses. CT may be useful in ruling out other possible causes of lower abdominal pain in cases of diagnostic uncertainty. Additionally, CT can exclude the presence of a pelvic mass, which greatly adds in the ability to rule out torsion.
| |
| -Computed tomography may demonstrate an enlarged ovary and adnexal masses but is unable to evaluate the presence or absence of blood flow to the involved ovary.
| |
| | |
| {You are seeing a 50 year old female with a complaint of profuse vaginal bleeding. You suspect dysfunctional uterine bleeding (DUB). True statements about DUB include all of the following EXCEPT:
| |
| |type="()"}
| |
| | |
| +Approximately 10% of DUB results from anovulation, and 90% occur with ovulatory cycles.
| |
| ||Approximately 90% of DUB results from anovulation, and 10% occur with ovulatory cycles. During an anovulatory cycle, the corpus luteum fails to form, which causes failure of normal cyclical progesterone secretion. This results in continuous unopposed production of estradiol, stimulating overgrowth of the endometrium. Without progesterone, the endometrium proliferates and eventually outgrows its blood supply, leading to necrosis. The end result is overproduction of uterine blood flow. Most severe cases of DUB occur in adolescent girls during the first 18 months after the onset of menstruation, when their immature hypothalamic-pituitary axis may fail to respond to estrogen and progesterone, resulting in anovulation.
| |
| -In ovulatory DUB, prolonged progesterone secretion causes irregular shedding of the endometrium. This probably is related to a constant low level of estrogen that is around the bleeding threshold. This causes portions of the endometrium to degenerate and results in spotting.
| |
| -Obese females tend to have irregularities in their menstrual cycles due to nonovarian endogenous production of estrogen often related to their degree of adipose tissue. This usually results in prolonged cycles of amenorrhea that alternate with cycles of metrorrhagia or menometrorrhagia.
| |
| -Although, DUB in itself is rarely fatal, distinguishing this presentation from that of endometrial cancer is important. Development of endometrial cancer is related to estrogen stimulation and endometrial hyperplasia. Symptoms include postmenopausal bleeding, which is usually considered cancer until proven otherwise.
| |
| -DUB is most common at the extreme ages of a woman's reproductive years, either at the beginning or near the end, but it may occur at any time during her reproductive life.
| |
| | |
| {You are seeing a G1P0 patient who is 10 3/7 weeks pregnant with vaginal bleeding. She has not previously had an ultrasound confirming an intrauterine pregnancy. Which of the following sites outside the endometrial cavity results in a presentation of an ectopic pregnancy typically AFTER 8 weeks’ gestation?
| |
| |type="[]"}
| |
| | |
| -fallopian tube
| |
| -fibriae
| |
| -ovary
| |
| +cervical
| |
| ||Cornual ectopic pregnancy implants in the myometrium in the proximal portion of the fallopian tube. Although 0.7mm wide and 1-2 cm long, this area is more distensible than the fallopian tube and typically presents after 8 weeks’ gestation. However, rupture may occur as early as 5 weeks’ gestation. Maternal mortality rate for cornual ectopic pregnancy is 2-3 %. Cornual ectopic pregnancy is diagnosed on ultrasound in only 65-71% of case, and laparoscopy remains the most accurate tool. The most common location for ectopic pregnancy is the fallopian tubes (3%). The least common location is the cervical region, but is as high as 9.8% after assisted reproductive treatment, specifically IVF. Although very rare, diagnosis of cervical ectopic pregnancy is also often delayed due to decreased accuracy of ultrasound, leading to rupture, and emergent hysterectomy.
| |
| +cornual (interstitial)
| |
| | |
| | |
| {Which of the following is NOT a known risk factor for ectopic pregnancy?
| |
| |type="[]"}
| |
| | |
| +prior ectopic pregnancy
| |
| ||All of these listed are known risk factors. However, 40-50% of patients with confirmed ectopic pregnancy have no risk factors, so the absence of such factors does not rule out the diagnosis. The incidence is as high as 20% in patients who have had a prior tubal surgery, and ART is a well-established risk factor. According to the CDC, women 35-44 had the highest rates of ectopic pregnancy when compared to patients in the 15-24 year old groups, possibly because these older patients may be exposed to more risk factors with increasing age.
| |
| +prior sexually transmitted disease
| |
| +tubal infection or pelvic adhesions
| |
| +assisted reproductive treatment (ART)
| |
| +increased maternal age
| |
| | |
| | |
| {The radiology resident refuses to do the pelvic ultrasound you ordered to rule out an ectopic because the beta on your patient is 100, and he states that women can not rupture an ectopic pregnancy when the beta is that low. Is his statement true or false?
| |
| |type="[]"}
| |
| | |
| +The radiology resident’s statement is false. A single beta hcg level cannot rule in or rule out an ectopic pregnancy. A beta-hcg in a patient who presents to the ED with abdominal pain or vaginal bleeding with a beta-hcg < 1500 are less likely to have a normal IUP. A beta < 1500 in these patients more than doubles the odds of having an ectopic pregnancy. Women can rupture, however, an ectopic pregnancy with beta hcg at any level. The risk of ectopic pregnancy is in fact increased when the likelihood of a normal IUP is low. Therefore, transvaginal ultrasound should be performed in women at risk for ectopic pregnancy regardless of the beta hcg level.
| |
| | |
| {A 32 year old g3p2 patient who is 20 weeks by dates presents after a Tylenol ingestion. True statements about Tylenol in pregnancy include which of the following?
| |
| |type="()"}
| |
| | |
| -acetaminophen does not cross the placenta
| |
| -acetaminophen is a teratogen
| |
| -n-acetylcysteine does not cross the placenta
| |
| -the Rumack-Matthew nomogram should be adjusted in pregnancy
| |
| +the management is the same for pregnant and non-pregnant patients
| |
| ||acetaminophen readily crosses the placenta, which places the fetus at risk for hepatotoxicity. However, NAPQI does not cross the placenta, and thus, the fetus must metabolize the acetaminophen for toxicity to occur. The fetus is able to start metabolizing acetaminophen into toxic and non-toxic metabolites at approximately 18 weeks of gestational age. NAC does cross the placenta and its use is indicated in pregnant women whose serum concentration is above the treatment line of the Rumack-Matthew nomogram. Fetal outcome appears to be worse with delays in commencing NAC.
| |
| | |
| {Your patient with an ectopic pregnancy wants to know if she is a candidate for non-surgical treatment (methotrexate). Which of the following statements about methotrexate for ectopic pregnancy is true?
| |
| |type="[]"}
| |
| | |
| +40% of patients with ectopic pregnancy meet criteria for medical management.
| |
| ||The beta-hcg should be < 5000 IU/L. The overall success rate for methotrexate is 89%. Patients may experience transient abdominal pain within 3-7 days after the start of treatment classified as separation pain. If the pain progresses in severity, is persistent, or is accompanied by other signs and symptoms, treatment failure or rupture of the ectopic should be suspected. The most common side effects from methotrexate are stomatitis, nausea, vomiting, and dizziness. If the patient meets criteria for methotrexate, then baseline liver function tests should be ordered. The single-dose regimen involves methotrexate 50 mg/m2 IM on day 1 and on day 7 if the beta decreases by less than 15% between days 4 and 7.
| |
| +To be eligible, the nonruptured ectopic pregnancy should be < 4 cm
| |
| -To be eligible, the beta-hcg should be < 1000
| |
| +To be eligible, there should be no cardiac activity in the fetus
| |
| +To be eligible, the patient must be hemodynamicallys table, be reliable, and be amenable to the treatment regimen
| |
| | |
| {Regarding venous thromboembolism and pregnancy, which of the following is TRUE?
| |
| |type="[]"}
| |
| | |
| +30% of isolated episodes of pulmonary embolism are associated with silent deep-vein thrombosis, and in patients with symptoms of deep-vein thrombosis, the frequency of silent pulmonary embolism ranges from 40 to 50%.
| |
| ||Marik PE, Plante LA. Thromboembolism and Pregnancy. NEJM 2008: 359:19:2025-2033. Pulmonary embolism and deep-vein thrombosis are the two components of a single disease called venous thromboembolism. Approximately 30% of apparently isolated episodes of pulmonary embolism are associated with silent deep-vein thrombosis, and in patients presenting with symptoms of deep-vein thrombosis, the frequency of silent pulmonary embolism ranges from 40 to 50%. Venous thromboembolism is both more common and more complex to diagnose in patients who are pregnant than in those who are not pregnant. The incidence of venous thromboembolism is estimated at 0.76 to 1.72 per 1000 pregnancies, which is four times as great as the risk in the nonpregnant population. A meta-analysis showed that two thirds of cases of deep-vein thrombosis occurred in the antepartum period and were distributed relatively equally among all three trimesters. In contrast, 43 to 60% of pregnancy-related episodes of pulmonary embolism appear to occur in the puerperium. There is a striking predisposition for deep-vein thrombosis to occur in the left leg (approximately 70 to 90% of cases), possibly because of exacerbation of the compressive effects on the left iliac vein due to its being crossed by the right iliac artery. The incidence of isolated deep-vein thrombosis in the iliac vein is thought to be higher in pregnant women than in nonpregnant women. This complicates the diagnosis of deep-vein thrombosis in symptomatic pregnant women, because compression ultrasonography, the test of choice in nonpregnant subjects with suspected deep-vein thrombosis, does not reliably detect iliac deep-vein thrombosis. Isolated iliac-vein thrombosis may present with abdominal pain, back pain, and swelling of the entire leg; however, patients may also be asymptomatic and have no findings on physical examination. A thrombophilia is defined as a disorder of hemostasis that predisposes a person to a thrombotic event. The prevalence of the inherited thrombophilias depends on the population studied. Data suggest that at least 50% of cases of venous thromboembolism in pregnant women are associated with an inherited or acquired thrombophilia.
| |
| -The majority of cases of pulmonary embolism occur in the first trimester.
| |
| -DVTs occur more commonly in the right leg, rather than the left leg.
| |
| -Ultrasound reliably detects DVT in the iliac vein.
| |
| +50% of cases of venous thromboembolism in pregnant women are associated with an inherited or acquired thrombophilia.
| |
| | |
| {An intrauterine pregnancy can be diagnosed by sonographic findings in the following CORRECT order of appearance:
| |
| |type="()"}
| |
| | |
| -fetal pole, double gestational sac, double ring sign, and fetal heart rate activity
| |
| -double gestational sac, fetal pole, double ring sign, and fetal heart rate activity
| |
| +double ring sign, double gestational sac, intrauterine fetal pole, and intrauterine fetal heart activity
| |
| ||(Rosen’s p. 2272): c. Transvaginal ultrasound can identify an intrauterine gestational yolk sac at 5 weeks gestation, and this correlates with a quantitative hCG of 1800 IU/liter. Fetal heart motion can be detected with the transvaginal ultrasound at 6 weeks’ gestation and correlates with an hCG of 6770 IU/L. Transabdominal ultrasonography at 4-5 weeks gestation can identify the presence of a small white gestational ring, which disappears after the 11th week. At 6 weeks the gestationals ac can be visualized by trans abdominal sonography. An intrauterine pregnancy can be diagnosed by sonographic findings in the following order of appearance: the double ring sign, the double gestational sac, the intrauterine fetal pole, and intrauterine fetal heart activity.
| |
| | |
| {The most common symptom of placenta previa is:
| |
| |type="()"}
| |
| | |
| -painful uterine contractions
| |
| -signs of fetal distress
| |
| -painful vaginal bleeding
| |
| +painless fresh vaginal bleeding
| |
| ||(Rosen’s p.2286-88): Painless, fresh vaginal bleeding is the most common symptom of placenta previa. In about 20% of cases, some degree of uterine irritability is present. Placenta previa is implantation of the placenta over the cervical os, and is the other major cause (other than abruption) of bleeding episodes during the second half of pregnancy. Digital or instrumental probing of the cervix should NEVER be done during the second half of pregnancy because it can precipitate severe hemorrhage in the patients with an asymptomatic or minimally symptomatic placenta previa. In the ED, speculum examination of the vagina and cervix should be performed only in those settings in which obstetric consultation is not readily available. The exam should be limited to an atraumatic partial speculum insertion to identify whether the bleeding is coming from the cervical os (and a presumed placenta previa), hemorrhoids, or a vaginal lesion that might require urgent management.
| |
| -hemodynamic instability of the mom
| |
| | |
| {A 29 yo female presents with vaginal spotting for the last 5 days associated with llq abdominal pain. You suspect possible ectopic pregnancy. True statements about this entity include which of the following?
| |
| |type="[]"}
| |
| | |
| -Incidence of ectopic pregnancy has decreased in incidence over the last several decades.
| |
| -90% of women who have ectopic pregnancies have a risk factor for an ectopic.
| |
| +A single serum hcg value neither identifies the presence of an intrauterine or ectopic pregnancy nor predicts rupture, but it can serve as a surrogate marker for gestational age.
| |
| ||Barnhart KT. Ectopic pregnancy. NEJM 2009; 361:379-387. The incidence of ectopic pregnancy increased by a factor of six between 1970 and 1992, but it has since remained stable. The associated mortality has decreased markedly to 0.5 deaths per 1000, because of early diagnosis and treatment before rupture. Damage to the fallopian tubes from PID, prior tubal surgery, or a previous ectopic pregnancy is strongly associated with an increased risk of ectopic. However, half of all women who receive a diagnosis of an ectopic do NOT have any risk factors. The risk of recurrence of ectopic is 10% among patients with one previous ectopic and at least 25% among women with 2 or more previous ectopics. Statements C-E are true. The ultrasound may be nondiagnostic because the gestational sac may not have developed in an early IUP, and an early ectopic may be too small.
| |
| +Discriminatory hcg value has been reported to be between 1500 to 3000 mIU.
| |
| +In 8 to 31% of women in whom ectopic pregnancy is suspected, the initial ultrasound does not show a pregnancy in either the uterus or in the fallopian tubes.
| |
| | |
| | |
| {A 29 yo female presents with vaginal spotting for the last 5 days associated with llq abdominal pain. You suspect possible ectopic pregnancy. True statements about DIAGNOSING this entity include which of the following?
| |
| |type="[]"}
| |
| | |
| +serial measurement of hcg can help distinguish potentially viable IUPs from an ectopic.
| |
| ||Barnhart KT. Ectopic pregnancy. NEJM 2009; 361:379-387. All of the statements are true. Approximately 99% of viable IUPs are associated with an increase in hcg levels of at least 53% in 2 days (note that this is slower than the 66% that we learned in med school). Although statement B is true, 71% of women with ectopics have serial serum hcg values that increase more slowly than would be expected with a viable IUP or decrease more slowly than would be expected with a miscarriage. Regarding accuracy of ultrasound, in one study, when the hcg value was < 1500, the PPV of ultrasound for an IUP was only 80% and that for an ectopic was only 60%.
| |
| +50% of women with ectopics present with increasing hcg levels and 50% present with decreasing hcg levels.
| |
| +In women who have decreasing hcg levels, serial hcg should be performed until hcg is no longer detectable in the serum (this may take 6 weeks).
| |
| +Sensitivity and specificity of progesterone level is not sufficiently high to rule in or rule out an ectopic pregnancy.
| |
| +The accuracy of ultrasound varies according to the serum hcg level.
| |
| | |
| | |
| {A 29 yo female presents with vaginal spotting for the last 5 days associated with llq abdominal pain. You suspect possible ectopic pregnancy. True statements about TREATING this entity include which of the following?
| |
| |type="()"}
| |
| | |
| -The preferred surgical treatment is laparotomy
| |
| +Medical management may be with single-dose, two-dose, or multidose regimens of methotrexate
| |
| ||Barnhart KT. Ectopic pregnancy. NEJM 2009; 361:379-387. Laparoscopy is cost-effective and is the preferred surgical approach (salpingectomy or salpingostomy). Laparotomy is reserved for patients with extensive intraperitoneal bleeding, intravascular compromise, or poor visualization of the pelvis. Medical management with methotrexate is commonly used and is a safe alternative, and the number of doses needed varies. Data from randomized trials are lacking to inform the optimal management of ectopic pregnancy (medical vs. surgical) with respect to recurrence rates and potential for future fertility. There is also no consensus on a threshold value of hcg above which methotrexate is used.
| |
| -Tubal patency for medical treatment is better than surgical treatment
| |
| -Medical treatment decreases the recurrence rate
| |
| -Surgical treatment improves potential for future fertility
| |
| | |
| {Which of the following are factors associated with failure of medical management with methotrexate for an ectopic pregnancy?
| |
| |type="()"}
| |
| | |
| -Initial hcg > 5000mIU
| |
| -Ultrasound detection of moderate to large amount of free pelvic fluid
| |
| -Presence of fetal cardiac activity
| |
| -Pretreatment increase in serum hcg of more than 50% over a 48 hour period
| |
| +All of the above
| |
| ||Barnhart KT. Ectopic pregnancy. NEJM 2009; 361:379-387. Note that absolute contraindications for methotrexate include breastfeeding, lab evidence of immunodeficiency, preexisting blood dyscrasias, active pulmonary disease, peptic ulcer disease, alcoholism, or chronic liver disease. Additionally, relative contraindications include an ectopic mass > 3.5 cm or embryonic cardiac motion.
| |
| | |
| </quiz>
| |
| | |
| [[Category:OB/GYN]][[Category:Board Review]]
| |
| | |
| ==Sources==
| |
