Rosh Review Obs-gyn (2019)

Obstetrics/Gynecology ER
Study online at quizlet.com/_677kec
1. A 15-year-old G1P0 woman at 23 weeks presents with sharp, left lower quadrant abdominal pain for one hour. She previously had
an ultrasound confirming the presence of a single intrauterine pregnancy. The pain is severe and associated with nausea. Pelvic
examination reveals tenderness of the left adnexa. The patient's urinalysis is unremarkable. What test should be ordered to
diagnose the patient?
Abdominal X-ray
CT scan of the abdomen and pelvis
Pelvic ultrasound
White blood cell count:
Correct Answer ( C )
Explanation:
This patient presents with a history concerning for ovarian torsion and should undergo a pelvic ultrasound. Ovarian torsion is an organ
threatening disease, involving twisting of the ovary or fallopian tube or both on the vascular pedicle. It is more commonly seen on the
right side (due to the effects of the sigmoid colon being on the left) and in women of childbearing age. Patients typically present with
sharp, severe unilateral abdominal pain with nausea or vomiting. However, the classic presentation is often not present making
diagnosis challenging. Risk factors for torsion include the presence of an ovarian mass or infertility treatment. Clinicians must maintain
a high suspicion for this disease in order to make a timely diagnosis and prevent ovarian necrosis. Pelvic ultrasound, while imperfect,
represents the best initial imaging modality. The classic ultrasound appearance in torsion is enlargement with a heterogenous stroma
and peripherally displaced follicles. The most common findings are an increased ovarian size and an abnormal position in relation to
the uterus. The addition of Doppler ultrasound may demonstrate decreased blood flow to the ovary but these findings are inconsistent.
Additionally, Doppler ultrasound may be completely normal in intermittent torsion. Ultimately, patients with suspected ovarian torsion
may require laparoscopy to confirm or rule out torsion.
Abdominal X-ray (A) does not aid in diagnosis of ovarian pathology. CT scan of the abdomen and pelvis (B) has a sensitivity that is
similar to ultrasound but exposes the patient to the risks of radiation and IV contrast. A small percentage of patients with torsion will
have an elevated white blood cell count (D) over 15,000 but this is not a reliable finding.
2. A 17-year-old G1P0 woman at 25-weeks gestation presents with intermittent blurred vision. On presentation, she is currently
asymptomatic. Vital signs are HR 84, BP 165/97, oxygen saturation 97%. Physical examination reveals 2+ pitting edema on both
lower extremities and urinalysis has 3+ protein on dip. Which of the following is the next best step in management?
Administration of phenytoin
Admit for further obstetrics evaluation
Arrange follow up with the patient's obstetrician
Emergency cesarean section:
Correct Answer ( B )
Explanation:
This patient presents with severe preeclampsia and should be admitted for further obstetric evaluation. Preeclampsia is defined as
gestational hypertension (>140/90 mm Hg) with proteinuria (>300 mg/24 hr) that occurs after 20-weeks gestation. Progression from
preeclampsia to eclampsia (hypertension, proteinuria and seizures) is unpredictable and can occur rapidly. In preeclampsia, patients
may be asymptomatic. In severe disease, typically defined as a blood pressure >160/110 mm Hg, patients may have associated
epigastric or liver tenderness, visual disturbances or severe headaches. These patients should be admitted for further management.
Treatment for these patients is the same as in eclampsia. The goal of treatment is prevention of seizures or permanent maternal organ
damage. Magnesium should be given for seizure prophylaxis.
Phenytoin (A) is not indicated for seizure prophylaxis in preeclampsia. Instead, magnesium is the drug of choice for seizure
prophylaxis when necessary. Patients with mild preeclampsia without symptoms or isolated maternal hypertension can be managed as
outpatients (C) but not those with severe preeclampsia. Ultimately, delivery is the potentially curative therapy for preeclampsia but at
this stage in pregnancy, an emergent cesarean section (D) would not be indicated.
Beyond The Boards

Recent ACOG guidelines state that proteinuria is not required to make a diagnosis of preeclampsia if there is evidence of end-organ
damage as noted above. Massive proteinuria is also not necessary for a diagnosis of severe preeclampsia.]
3. 18-year-old G1P0 woman at 16 weeks gestation presents with vaginal bleeding. She has had no prenatal care. Vital signs are
unremarkable and physical examination only reveals a small amount of blood in the vaginal vault. A transvaginal ultrasound is
performed as seen above. What is the next best step in management of this patient?
Administer methotrexate
CT scan of the abdomen and pelvis
Intravenous antibiotics
Obstetrics consultation:
Correct Answer ( D )
Explanation:
This patient presents with vaginal bleeding and an ultrasound consistent with a hydatidiform mole or molar pregnancy requiring
obstetrics consultation. Molar pregnancy is a spectrum of diseases characterized by abnormal chorionic villi proliferation. A complete
hydatidiform mole refers to the situation in which there is no fetal tissue. In an incomplete mole, there is some fetal tissue along with
trophoblastic hyperplasia. Patients with molar pregnancy may present with nausea, vomiting, abdominal pain, and vaginal bleeding.
Without ultrasound, it is difficult to differentiate these patients from a threatened miscarriage or ectopic pregnancy. Often, the uterine
size is larger than the expected for dates in molar pregnancy and the beta-hCG is higher than expected for dates. Diagnosis is based
on characteristic findings on ultrasound. Hydropic vessels within the uterus cause a "snowstorm" appearance. Because of the potential
for complications and the non-viability of the pregnancy, dilation and curettage is recommended. Once a hydatidiform mole is
diagnosed, a chest X-ray should be obtained as trophoblastic tumors metastasize to lung, liver, and brain.
4. An 18-year-old woman at 37 weeks gestation presents with a spontaneous leakage of fluid from the vagina. She has no other
signs of active labor. Vital signs are unremarkable and the patient has no complaints except for the leakage of fluid. What
management is indicated?
Administer corticosteroids
Admit to obstetrics for delivery
Amoxicillin IV
Tocolysis:
Explanation:
This patient presents with likely premature rupture of membranes (PROM) at 37 weeks of gestation and should be delivered to reduce
the risk of developing an infectious complication. PROM or amniorrhexis is the rupture of the amniotic and chorionic membranes prior
to the onset of labor. It is important to note that premature here does not refer to fetal prematurity. Once the membranes rupture,
management will proceed based on fetal maturity, gestational age, presence or absence of infection and fetal well-being or distress. If
the fetus is immature (24 - 34 weeks of gestation), corticosteroids should be considered to accelerate pulmonary maturity. Over 34
weeks of gestation, delivery is preferred. All patients should be assessed for signs of intra-amniotic infection, which typically manifests
with fever and lower abdominal pain. In PROM with fetal immaturity, ampicillin or amoxicillin is given prophylactically. PROM is
confirmed with a sterile speculum exam showing one of the following: (1) A pool of fluid in the posterior fornix, (2) A pH > 6.5
(nitrazine paper turns blue), (3) ferning of fluid as it dries on a slide.
Corticosteroids (A) have not been shown to be effective in patients with PROM (as opposed to those with preterm PROM). Amoxicillin
(C) should be considered in PROM if there are signs of infection. Tocolysis (D) is controversial and delivery is preferred.
5. A 18-year-old woman at full term presents in labor. On examination, the baby's head is out but you are unable to deliver either
shoulder. What should the first step in management be?
Foley catheter placement and instillation of 500-750 ml of normal saline

Leg flexion of mother and apply suprapubic pressure
Place in left lateral decubitus position
Push fetal head back into the vagina and transfer for cesarean section:
Explanation:
This delivery is complicated by shoulder dystocia or failure to deliver either shoulder and should first be managed by the McRoberts'
maneuver of leg flexion to a knee-chest position and application of pressure to the suprapubic region. Shoulder dystocia is the second
most common malpresentation after breech presentation and has devastating complications. Traumatic brachial plexus injuries,
clavicular fractures and hypoxic brain injury are seen in the fetus. Maternal complications include perineal, sphincter and vaginal tears.
Shoulder dystocia is diagnosed when the head has presented but the shoulders cannot be delivered. The fetal head may retract
toward the perineum ("turtle sign"). Traction on the head may worsen shoulder dystocia by abducting the shoulders and increasing the
bisacromial diameter. A number of maneuvers can help in delivering the shoulder and thus relieving the dystocia. The McRoberts'
maneuver involves positioning the maternal legs in flexion with knee-chest position. This may result in disengaging of the anterior
shoulder allowing for rapid vaginal delivery. Application of pressure suprapubically can help the process. Additionally, an episiotomy
can be performed, which may allow access to the posterior shoulder and improve fetal maneuvering.
A Foley catheter (A) should be placed to drain the bladder not instill fluid as draining the bladder may create more room for
maneuvering. Placement in the left lateral decubitus position (C) is used to relieve pressure from the IVC and increase blood return to
the right heart in patients with hypovolemic shock. Pushing the fetal head back into the vagina (D) and proceeding to cesarean
delivery is not a recommended option.
6. An 18-year-old woman in her third trimester presents with acute onset of significant pelvic pain and blood per vagina. Thus far,
her pregnancy has been normal. Her past medical history is significant for hypertension, asthma and recreational cocaine use.
Examination reveals a tender, extremely tense uterus. Which of the following is the most likely diagnosis?
Abruptio placentae
Preeclampsia
Uterine atony
Vasa previa:
Correct Answer ( A )
Explanation:
Abruptio placentae, also called placental abruption, is defined as a premature separation of a normally implanted placenta from the
uterus. Similar to placenta previa, it too causes third trimester bleeding, however unlike placenta previa, it is associated with significant
pain, fetal stress and maternal complications. The amount of bleeding is variable and depends on the extent of placental separation.
Significant painful contractions accompany this condition. Risk factors include maternal hypertension, cocaine use, trauma (namely
motor vehicle collisions) and sudden uterine cavity decompression, as in rupture of membranes in a patient with excessive amniotic
fluid (hydramnios). Abruption is diagnosed clinically, based on the presence of bleeding, frequent painful uterine contractions and fetal
distress. Ultrasound plays a limited role in diagnosis, except for excluding placenta previa in the differential. Definitive treatment
includes early fetal monitoring, hemodynamic stabilization and delivery. If the fetus is immature, close monitoring of maternal and
fetal status may be considered.
Preeclampsia (B) refers to a condition of maternal hypertension and proteinuria which typically occurs in the second half of
pregnancy. Uterine atony (C) is a common cause of postpartum, not prepartum, bleeding, in which uterine contractions are insufficient,
resulting in a flaccid, not tense, uterus. Vasa previa (D) is a condition in which the umbilical cord attaches into the placental
membranes instead of the central placental tissue. This abnormal attachment generates an errant vessel which lies between the
cervical os and the fetus, leading to the possibility of rupture and fetal demise.
7. A 19-year-old G1P0 woman at 26 weeks presents with abdominal pain after being involved in a motor vehicle collision. External
pelvic examination reveals vaginal bleeding. Which of the following is true regarding this presentation?
A normal ultrasound rules out placental abruption

Disseminated intravascular coagulation is uncommon in placental abruption
Early pelvic digital examination should be performed
Emergent fetal monitoring and obstetric consultation are required:
Explanation:
This patient presents with painful vaginal bleeding in late pregnancy after a trauma concerning for placental abruption and should
have emergent fetal monitoring and obstetric consultation. Late pregnancy vaginal bleeding is never normal and raises suspicion for
placental abruption, placenta previa and vasa previa; all potentially life threatening disorders to both the mother and fetus. Abruption
occurs when there is separation of the placenta from the uterine wall leading to hemorrhage. It is more common in women with
hypertension, preeclampsia, smoking, thrombophilia, cocaine use, trauma and prior abruption. Although most patients with abruption
will present with dark vaginal bleeding, there are patients who will have hidden hemorrhage in which bleeding is contained between
the placenta and the uterus. In patients with late term vaginal bleeding, emergent obstetric consultation should be obtained to further
investigate and differentiate the causes. Fetal monitoring should be performed as distress may prompt emergent delivery depending
on gestational age.
Disseminated intravascular coagulation (DIC) (B) is relatively common and should always be considered. A digital examination (C)
should be deferred until placenta previa is ruled out as digital examination may lead to worsening hemorrhage in this disorder.
Ultrasound (A) should be obtained early in management to help to identify placenta previa and placental abruption but it is insensitive
as the echogenicity of fresh blood is difficult to distinguish from the placenta. Therefore, a normal ultrasound does not rule out
abruption.
8. A 19-year-old woman presents with lower abdominal pain for 5 days. You consider pelvic inflammatory disease as a diagnosis.
Which of the following is a likely contributor for this condition?
Age over 25 years

Barrier contraception
Multiple sexual partners
Pregnancy:
Explanation:
Although there are no definitive risk factors for pelvic inflammatory disease (PID), there are several contributors. Multiple sexual
partners increases the chances for developing PID. Other risk factors include earlier age at first intercourse; instrumentation, including
induced abortion and intrauterine device insertion; and the period immediately following menses.
Most cases of PID occur in women <25 years of age (A). Females 15-24 have increased numbers of sexual partners, have a cervical
barrier more easily breached by pathogens, often have less frequent use of barrier contraception (B) and tend to seek health care
later. Pregnancy (D) confers protection from PID after the 1st trimester when the uterine cavity is obliterated by the pregnancy.
However, PID can occur in the 1st trimester.
9. A 21-year-old woman at 36 weeks gestation presents to the ED with a sudden onset of severe constant abdominal pain and
vaginal bleeding. She states that the pain started shortly following smoking crack cocaine. Her BP is 156/68 mmHg, RR is 20, HR
is 122, oxygen saturation is 99% on room air, and T is 38.6°C. Which of the following is the most likely diagnosis?
Placenta accreta
Placenta previa
Uterine rupture
Vasa previa:
Explanation:
Uterine rupture presents as sudden severe uterine pain and vaginal bleeding. It is most prevalent in women who have had a previous
cesarean section or recent cocaine or prostaglandin use. Prior C-section may result in poor uterine healing or scar formation. Cocaine
use leads to a sympathomimetic state and may cause chronic vasoconstriction leading to compromised uterine blood flow with
development of thin, friable, necrotic uterine tissue that is prone to rupture. In the setting of 3rd-trimester bleeding, it is important to
note that any instrumentation or digital exam can provoke severe exsanguination and must be undertaken with extreme caution. If
possible, any pelvic examination should occur following abdominal ultrasound in the delivery suite with an obstetrician in attendance.
There are several other important causes of vaginal bleeding in the 3rd trimester. Placenta accreta (A) is usually painless and may be
associated with brisk, bright-red vaginal bleeding. It is caused by an indistinct placental cleavage plane and most commonly seen
during placental delivery. Placenta previa (B) also causes painless bright red vaginal bleeding that occurs as cervical effacement
exposes and disrupts a low lying placenta. This is typically mild but can be severe and lead to exsanguination. In vasa previa (D), the
fetal umbilical vessels are part of the amniotic membrane and can tear as labor progresses. It should be suspected when rupture of
membranes is followed by a painless intrapartum hemorrhage. Because the volume of fetal blood is small, even a small amount of
bleeding can result in fetal exsanguination and emergency C-section should be initiated.
10. A 21-year-old woman presents with acute pain in the right pelvis. Which of the following makes the diagnosis of ovarian torsion
more likely?
Elevated WBC count

Previous caesarean section
Teratoma of the right ovary
Vaginal bleeding:
Explanation:
Ovarian torsion must be on the differential diagnosis of women presenting with acute pelvic pain and is the cause of 3% of
gynecologic emergencies. Most commonly torsion occurs in women of reproductive age because of the development of corpus luteal
cysts. It is rare for a normal ovary to torse, but not impossible. More than 50% of cases of ovarian torsion are associated with an
ovarian tumor or cyst. Benign tumors, particularly teratomas or dermoid cysts, carry a particularly high risk of torsion. Other risk
factors include large ovarian cysts, ovarian hyperstimulation syndrome as a result of fertility treatment, and polycystic ovarian
syndrome. When the ovary twists on its pedicle, the venous and lymphatic systems initially obstruct causing edema of the ovary.
Eventually arterial flow is compromised causing ischemia and eventual necrosis of the ovary. The clinical presentation varies and may
be subtle, especially in the case of intermittent torsion. Pelvic ultrasonography with Doppler imaging of the ovary is the initial
diagnostic test of choice. Ultrasound findings are variable. Edema of the ovary is the most common finding. Cysts are commonly
visualized as well as pelvic fluid which may confuse the diagnosis with a ruptured ovarian cyst. Using Doppler, flow to the ovary may
be compromised compared to the contralateral ovary but this is a late finding and also not sensitive enough to exclude the diagnosis.
If clinical suspicion persists, patients need diagnostic laparoscopy to directly visualize the ovary in question.
An elevated WBC count (A) is non-specific for ovarian torsion. The WBC count is elevated in many conditions including infections,
inflammatory conditions and ischemia. Previous caesarean section (B) is not a risk factor for ovarian torsion. However, women who
have had a tubal ligation are at increased risk because of scarring that occurs around the fallopian tube and the chance of this scar
tissue creating a base on which the pedicle of the ovary can twist. Vaginal bleeding (D) is not a common symptom of ovarian torsion.
Vaginal bleeding with pregnancy is associated with ectopic pregnancy or threatened abortion. Additionally, hemorrhagic cysts may
lead to vaginal bleeding.
11. 21-year-old woman presents with foul-smelling vaginal discharge for 5 days. Her urine pregnancy test is negative. On exam, she
has no cervical or adnexal tenderness to palpation. A moderate amount of whitish-gray discharge is noted in the vault that you
perform microscopy on, as seen above. What is the appropriate antibiotic choice for this patient?
Azithromycin
Ceftriaxone
Doxycycline
Metronidazole:
Explanation:
The patient's presentation is consistent with bacterial vaginosis (BV), which is the most common cause of vaginitis. BV is not a sexually
transmitted disease; rather, it is caused by a change in the vaginal flora with the replacement of Lactobacillus species with high
concentrations of a polymicrobial group including anaerobic bacteria, Gardnerella vaginalis, and Mycoplasma hominis. It is also
associated with an increase in vaginal pH from 4.5 to as high as 7. The pathognomonic finding for BV is clue cells, which are bacteria
that line the borders of the vaginal epithelial cells. Diagnosis can also be made using the Amsel criteria (see table). The recommended
treatment regimen includes 1 week of metronidazole or clindamycin, either orally or intravaginally.
Azithromycin (A) and doxycycline (C) are indicated to treat chlamydia cervicitis. Ceftriaxone (B) or other 3rd-generation
cephalosporins can be used to treat gonorrheal cervicitis.
12. 21-year-old woman with no prenatal care presents for evaluation of lower abdominal pain and fever. She estimates that she is
approximately 7.5 months pregnant. On questioning, she acknowledges intermittent pain for two days and a gush of fluid
shortly after the pain began. Her temperature is 101.8°F. Physical examination is notable for purulent material in the vaginal
vault. Which of the following is the most likely diagnosis?
Chorioamnionitis
Endometritis
Pelvic inflammatory disease
Urinary tract infection:
Explanation:
Beginning at 16 weeks, the membranes of the chorioamniotic sac adhere to the cervical os and are at risk for infection.
Chorioamnionitis is an intra-amniotic infection of the chorion and amniotic layers of the amniotic sac. The placenta and fetal
membranes may also be involved. It is caused by an ascending infection of normal vaginal flora. Risk factors include: premature
rupture of membranes, preterm labor, prolonged rupture of membranes, multiple vaginal examinations and genital tract infections.
Clinical findings include fever, uterine tenderness and maternal and fetal tachycardia. Women may also have purulent vaginal
discharge on examination. This is a clinical diagnosis and patients require intravenous antibiotics, most commonly ampicillin and
gentamicin.
Endometritis (B) in an infection of the uterine endometrium that affects between 2 and 8% of pregnancies. The infection develops on
the second or third post-partum day and is characterized by fever, abdominal pain and foul-smelling lochia. Pelvic inflammatory
disease (C) does not occur during this stage of pregnancy due to the mucous plug that seals the cervix. It may occur during the first
trimester although it is quite rare. A urinary tract infection (D) does not cause systemic signs of infection as described in the patient
unless it has moved to the upper urinary tract causing pyelonephritis.
13. A 22-year-old woman presents complaining of vaginal bleeding and cramping for the last 4 hours. She is known to be 14-weeks
pregnant. Her cervical os is dilated to 4 cm and she is actively bleeding. Pelvic ultrasound shows the gestational sac in the
lower uterine segment near the cervix. Which of the following is the most likely diagnosis?
Complete abortion
Inevitable abortion
Missed abortion
Septic abortion:
Explanation:
The patient is experiencing an inevitable abortion, which is characterized by an open cervical os and a gestational sac at the opening
of the uterus on ultrasound. The case should be discussed with the patient's obstetrician as the patient may ultimately require dilatation
and curettage if all the products of conception (POC) do not pass spontaneously or the bleeding is not controlled.
A complete abortion (A) occurs when the patient has passed all POC have passed. On examination, the cervix is closed and the
uterus is firm and nontender. A missed abortion (C) occurs when a pregnant patient fails to pass the products of conception greater
than two months after fetal demise. The pregnancy test will be negative, however ultrasound will show retained POC. A septic
abortion (D) occurs when the patient develops foul-smelling discharge, vaginal bleeding, uterine tenderness and peritoneal signs
following a spontaneous or induced abortion.
14. A 22-year-old woman presents with lower abdominal pain and abnormal vaginal discharge for 4 days. She is sexually active with
multiple partners and does not consistently use barrier contraception. She has bilateral adnexal tenderness and yellow
discharge on pelvic exam. Her urine pregnancy test is negative. In addition to a 1-time dose of ceftriaxone, what is the most
appropriate outpatient course of antibiotics for the patient?
Azithromycin 1 gram PO x 1
Ciprofloxacin 500 mg PO BID x 14 days
Doxycycline 100 mg PO BID x 14 days
Metronidazole 500 mg PO BID x 14 days: Correct Answer ( C )
Explanation:
The patient's presentation is consistent with pelvic inflammatory disease (PID), which represents a spectrum of disorders usually
secondary to 1 or more sexually transmitted diseases involving the upper genital tract of women. PID can include any of the following:
mucopurulent cervicitis, endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis. Patients typically present with complaints of
lower abdominal pain, with or without dyspareunia; abnormal bleeding; or abnormal vaginal discharge. On exam, patients usually
have lower abdominal tenderness, cervical motion tenderness, and bilateral adnexal tenderness. Outpatient management is
appropriate for mild cases of PID and includes ceftriaxone 250 mg IM in a single dose plus doxycycline 100 mg PO BID for 14 days.
A single 1-gram dose of azithromycin (A) is part of the regimen to treat cervicitis and urethritis in men. It can also be used for PID but
should be administered once weekly for 2 weeks. The CDC no longer recommends fluoroquinolones (B) for the treatment of
gonococcal infections and associated conditions such as PID due to high resistance. Metronidazole (D) is not required as part of the
PID treatment regimen, but it is added sometimes to also treat trichomoniasis or vaginitis or if there is a concern for anaerobic
infection.
15. A 22-year-old woman presents with lower abdominal pain and vaginal discharge. She is sexually active with men with
inconsistent barrier protection. Her temperature is 101°F. On examination, there is yellow cervical discharge, no cervical motion
tenderness, but uterine and left adnexal tenderness. An ultrasound does not show any evidence of tubo-ovarian abscess. Which
of the following is the most appropriate treatment for this patient's condition?
Cefoxitin 2 gm and metronidazole 500 mg PO BID for 14 days

Cefoxitin 2 gm IM and clindamycin 600 mg IV
Ceftriaxone 250 mg IM and azithromycin 1 gm PO
Ceftriaxone 250 mg IM and doxycycline 100 mg BID for 14 days:
Explanation:
This patient has a clinical presentation consistent with pelvic inflammatory disease (PID). PID is an ascending infection that begins in
the vagina or cervix. In the sexually active female, the most common responsible organisms are Chlamydia trachomatis and Neisseria
gonorrhoeae. Frequently, the infection is polymicrobial. The most common presenting symptom is lower abdominal pain. Patients may
also develop fever, vaginal discharge, dyspareunia, or abnormal bleeding. On physical examination, the patient typically has a fever
and is tender on pelvic examination either in the lower abdomen over the uterus, on cervical motion, or in the adnexa. The absence of
cervical motion tenderness does not rule out PID and the CDC recommends empiric treatment for sexually active women presenting
with lower abdominal pain and one of the following if no other cause is identified: cervical motion tenderness, adnexal tenderness, or
uterine tenderness. For outpatient management, patients are treated with ceftriaxone 250 mg IM followed by a 2-week course of
doxycycline. Metronidazole is sometimes added to the regimen at the judgment of the clinician.
Ceftriaxone 250 mg IM and azithromycin 1 gm PO (C) is the recommended treatment choice for cervicitis without suspicion for PID.
The CDC changed the guidelines to recommend 250 mg of ceftriaxone for the treatment of all gonococcal infections because of
increasing resistance. Cefoxitin 2 gm IM and clindamycin 600 mg IV (B) and cefoxitin 2 gm IM and metronidazole 500 mg PO BID for
14 days (A) are not standard regimens for pelvic inflammatory disease. Cefoxitin and doxycycline are used together intravenously for
the inpatient treatment of PID. If the patient cannot tolerate those medications an alternative regimen is clindamycin and gentamicin
intravenously.
16. A 22-year-old woman presents with pain and swelling to the vulva. On examination, you notice an area of swelling with
induration and central fluctuance at the 8 o'clock position. Which of the following statements is true regarding this?
All patients require antibiotics

Gonorrhea and chlamydia are the most common causes
Incision should be performed in the operating room
Word catheter is placed for four to six weeks: Correct Answer ( D )
Explanation:
A Bartholin's abscess occurs with infection of an obstructed Bartholin gland, a pea-sized mucous secreting gland located on each side
of the labia minora in the 4 and 8 o'clock positions. When the duct that drains fluid from the gland becomes blocked, a mucous-filled
cyst forms and eventually, if not drained, bacterial overgrowth occurs leading to an abscess. It is also possible to have a primary
infection of the Bartholin gland itself. Most commonly, the causative organism is normal vaginal flora of which E. coli is most prevalent
in cultures. Treatment of the abscess is with incision and drainage. After the loculations are broken up and all contents of the abscess
have been expressed, either gauze packing or a Word catheter is placed. Gauze packing is removed after 24 to 48 hours and patients
may require marsupialization at a later date. The Word catheter is a plastic catheter with a balloon on the end that is filled with 2 to
4mL of water and expanded within the abscess cavity. It is important that the incision is made only slightly larger than the opening
required for catheter placement. The catheter remains in place for four to six weeks and patients are instructed to abstain from vaginal
intercourse. This duration is required for epithelialization of the tract and the formation of a small fistula tract that will allow
appropriate drainage without obstruction.
17. A 23-year-old, sexually active woman presents with abdominal pain. Vital signs are normal. Pelvic examination reveals cervical
motion tenderness and bilateral adnexal tenderness. Which of the following treatments is most likely indicated?
Ceftriaxone 250 mg IM once + azithromycin 1000 mg PO once

Ceftriaxone 250 mg IM once + doxycycline 100 mg PO BID for 14 days
Clindamycin 300 mg PO BID for 7 days
Metronidazole 500 mg PO BID for 7 days:
Explanation:
This patient presents with signs and symptoms consistent with pelvic inflammatory disease (PID) and should be treated with
ceftriaxone 250 mg IM and 2 weeks of doxycycline. PID is an ascending infection beginning in the cervix and vagina and ascending to
the upper genital tract. Neisseria gonorrhoeae and Chlamydia trachomatis are most commonly implicated. It can present with a myriad
of symptoms although lower abdominal pain is the most common. Other symptoms include fever, cervical or vaginal discharge and
dyspareunia. Pelvic examination reveals cervical motion tenderness (CMT), adnexal tenderness and vaginal or cervical discharge.
Inadequately treated PID can lead to tubo-ovarian abscess, chronic dyspareunia and infertility. Due to the variable presentation and
serious sequelae, the CDC recommends empiric treatment of all sexually active women who present with pelvic or abdominal pain
and have any one of the following: 1) CMT, 2) adnexal tenderness or 3) uterine tenderness. Treatment should cover the most common
organisms and typically consists of a third generation cephalosporin (ceftriaxone) and a prolonged course of doxycycline. Patients
with systemic manifestations or difficulty tolerating PO should be admitted for management.
Ceftriaxone and azithromycin (A) are used in the treatment of cervicitis or urethritis. Clindamycin (C) and metronidazole (D) are used in
the treatment of bacterial vaginosis.
18. A 23-year-old woman presents with concerns of tender breast enlargement. Two weeks ago, she gave birth to a healthy
newborn, whom she currently breast feeds. Examination reveals subjective fevers, myalgias, and general erythema, warmth and
edema of the right breast. There are no superficial abnormalities, no palpable mass and no purulent nipple discharge is present.
The left breast appears normal. Which of the following is the most likely diagnosis?
Breast abscess
Breast engorgement
Inflammatory breast cancer
Lactation mastitis:
Explanation:
Mastitis generally refers to breast inflammation, which can be infectious, noninfectious or associated with inflammatory breast cancer.
Of the infectious subclass, lactation mastitis is the most common and occurs within a few weeks post-delivery in postpartum women.
Typical symptoms include, general body ache fever, malaise and tender breast engorgement (almost always unilateral) with erythema
and induration. More serious disease may present with purulent nipple discharge.
This condition may progress into or present initially as an abscess (A), a more defined and localized pocket of infection which is
usually discretely palpable. Postpartum women who do not breast feed may experience symmetric breast engorgement (B) typically
within 3 days post-delivery, but usually do not have the associated inflammatory symptoms as above. Although breast cancer (C) can
present at many different ages, the patient's young age makes inflammatory cancer less likely. Furthermore, inflammatory breast
cancer is associated with skin thickening and dimpling, as well as axillary lymphadenopathy. A blocked breast duct, inspissation, can
mimic mastitis, but usually does not have an associated fever.
19. A 24-year-old woman at full term presents with rupture of membranes and contractions. Sterile exam reveals a crowning infant
with a visible cord protruding. After elevating the fetal head, what management is indicated?
Clamp and cut cord and proceed with delivery

Continue with standard delivery
Emergent cesarean section
Intravenous tocolytics:
Explanation:
This patient presents with a prolapsed cord requiring emergent cesarean section as prolapse leads to decreased fetal oxygen supply.
Cord prolapse occurs when the umbilical cord precedes delivery of the fetus. Pressure from the presenting part of the fetus (usually
the head) compresses the cord leading to disrupted oxygen delivery to the fetus. Umbilical cord prolapse is associated with
malpresentations (shoulder, compound or breech). Typically, cord prolapse is apparent on pelvic examination. There are a number of
maneuvers and management strategies directed at both decreasing pressure on the umbilical cord and restoring blood flow to the
fetus and to reduce the prolapsed cord. Ultimately, cesarean section is the best management approach to patients with umbilical cord
prolapse. While preparing for cesarean section, the patient should be instructed not to push as this may worsen compression of the
cord. The mother should be placed in a knee-chest position with the bed in Trendelenburg and the presenting part should be elevated
off of the umbilical cord. Placement of a Foley catheter with instillation of 500-750 ml of saline will help to lift the fetus off the cord as
well. If surgical delivery cannot be performed, funic reduction (manual replacement of the cord into the uterus, should be attempted
followed by rapid vaginal delivery).
The cord should not be clamped and cut (A) at this time as it is the only supply of oxygenated blood to the fetus. Standard delivery
(B) should not be pursued with a prolapsed cord as pushing will result in further compression of the cord and hypoxia. Tocolysis (D)
with medications is not recommended as a primary treatment; however tocolysis can be useful to help prevent cord compression
while mobilizing the patient to the operating room for an emergent c-section.
20. A 24-year-old woman presents to the ED complaining of vaginal discharge and discomfort for 3 weeks. She has tried 2 different
intravaginal medications with only temporary improvement. The pelvic exam reveals vulvar erythema and excoriations with a
white discharge. The os is closed and there is no adnexal tenderness or masses. Urine dipstick is positive for moderate
leukocytes. You perform a wet mount as shown above. Which of the following is the most appropriate treatment for this patient?
Fluconazole
Intravaginal clindamycin cream
Intravaginal metronidazole gel
Oral metronidazole:
Explanation:
This patient has vulvovaginal candidiasis, usually caused by Candida albicans. Vulvovaginal candidiasis is quite common and causes
mild to moderate vulvar itching and vaginal discharge. Pelvic exam typically reveals a white "cottage-cheese" discharge. Satellite
lesions on the perineum are also sometimes observed. Wet mount with potassium hydroxide reveals pseudohyphae and spores.
Multiple over-the-counter and prescription topical (intravaginal) treatment options are available for uncomplicated candidiasis.
Overall, these have an 80% treatment success rate when used properly. Topical treatment failure, as in this patient, should be treated
with oral fluconazole. If patients have more than 4 episodes within a year, the presence of complicating factors such as
immunosuppression and poorly controlled diabetes mellitus should be investigated.
21. 24-year-old woman presents to the ED with complaints of vaginal discharge and pelvic discomfort for 3 days. The pelvic exam
reveals a thin, white discharge; a friable cervix diffusely tender; and mild adnexal tenderness. Which of the following additional
findings should prompt you to admit the patient to the hospital?
Allergy to doxycycline
Positive urine beta-hCG
Recent intrauterine device removal
Temperature of 38.3°C:
Explanation:
Pelvic inflammatory disease (PID) is an ascending infection of the upper portions of the genital tract, most commonly caused by
Chlamydia trachomatis and Neisseria gonorrhoeae. Woman with PID can have markedly divergent clinical symptoms ranging from
mild discomfort to frank peritonitis. Because of this variability, the CDC recommends empiric treatment for PID in all sexually active
women who have uterine or adnexal tenderness and cervical motion tenderness. The CDC has also developed several criteria for
admission of patients with PID. The patient in the clinical scenario has clinical PID and a positive urine pregnancy test. According to
the CDC recommendations (pregnancy), she should be admitted to the hospital for further management.
22. A 24-year old woman presents with URI symptoms. She is 34 weeks pregnant. As part of her work-up, you order a urinalysis,
which shows 2+ bacteria with no WBCs or squamous epithelial cells. Two days later, the lab calls you and informs you that the
urine culture is positive. You call the patient back and she denies symptoms of urinary tract infection. With regards to the urine
culture results, what treatment is indicated?
Cephalexin 500 mg QID for 7 days

Ciprofloxacin 500 mg QID for 7 days
No treatment is necessary
Trimethoprim-sulfamethoxazole 1 DS tablet BID for 3 days:
Explanation:
The patient has asymptomatic bacteriuria of pregnancy confirmed by a positive urine culture and should be treated with an oral
antibiotic that is known to be safe in pregnancy, such as cephalexin 500 mg QID for 7 days. Asymptomatic bacteriuria is common in
the general population and in most scenarios does not require therapy. However due to the high risk of complication seen during
pregnancy, it should be treated with antibiotics. It is seen in 2-10% of pregnant women and is commonly due to E. coli. Pregnant
women have an increased risk of developing urinary tract infections due to the pressure that the enlarged uterus exerts on the ureters
and bladder, incomplete emptying during voiding and impaired ureteral peristalsis from progesterone-induced relaxation of the
ureteral smooth muscle. Complications of untreated asymptomatic bacteriuria include development of a lower urinary tract infection,
pyelonephritis, renal abscess, renal failure, bacteremia, sepsis, intrauterine growth retardation, premature labor and neonatal death.
Treatment options generally include cephalosporins, such as cephalexin, amoxicillin (or amoxicillin-clavulanate) and nitrofurantoin. All
of which are recognized as Category B by the Food and Drug Administration; meaning that animal studies have failed to show a risk
to the fetus. Treatment duration should be for 7-10 days.
23. A 26-year-old sexually active woman presents to the clinic with several days of vulvovaginal discomfort and pruritus. A pelvic
exam shows copious frothy green vaginal discharge, inflamed vaginal walls, and a cervix with punctate hemorrhages. This
physical exam is most consistent with which of the following causes of vaginitis?
Atrophic vaginitis
Bacterial vaginosis
Trichomonas vaginalis
Vulvovaginal Candidiasis:
Explanation:
Trichomonas vaginalis is a common infectious cause of vulvovaginal discomfort in women that will likely present with the above
symptoms. Though Trichomonas vaginalis is often harbored asymptomatically for periods of 5 days to 4 weeks, patients who are
diagnosed while symptomatic typically present with vulvovaginal pruritus, dyspareunia, dysuria, or pelvic discomfort. A physical exam
will show a classic copious, yellow or green, frothy vaginal discharge. Examining the cervix may show punctate hemorrhages, referred
to as a "strawberry cervix." The diagnostic test of choice is a wet mount of the vaginal discharge, which shows mobile trichomonads.
The first line treatment for Trichomonas vaginalis is oral metronidazole. All infected sexual partners should also be treated, even if
asymptomatic, to prevent the development of symptomatic disease and reduce spread to future partners.
Atrophic vaginitis (A) is generally a condition of menopausal women in low-estrogen states that causes thinning of the vaginal mucosa
and decreased vaginal lubrication leading to vaginal discomfort and dyspareunia. A pelvic exam shows pale mucosa and a decrease
in size of the introitus and cervix. Bacterial vaginosis (B) is a non-sexually-transmitted disease caused by an overgrowth of Gardnerella
and other anaerobes. The hallmarks of this disease are a heavy, malodorous grey discharge without presence of vaginitis, increased
vaginal pH, and "clue cells" (epithelial cells with borders obscured by the presence of excessive bacteria) visualized on a wet mount.
There may also be a notable amine, or "fishy", odor with the addition of potassium hydroxide to a drop of the vaginal discharge.
Vulvovaginal Candidiasis (D) is an overgrowth of the yeast Candida which cause vaginal burning and pruritus. The physical exam
should show vaginitis, erythema, and a white, curd-like vaginal discharge with no apparent odor. A wet mount with potassium
hydroxide added will show spores and hyphae.
24. 26-year-old woman is brought to the ED after a first-time seizure. She is postictal and unable to give you any information. Vital
signs are T 37.5°C (rectal), BP 220/110 mm Hg, HR 114 bpm, RR 26 per minute. Her exam is normal except for a gravid abdomen
and bilateral pitting ankle edema. Her blood glucose is 105 g/dL. What is the most important test to perform next?
Bedside ultrasound
CT scan of the head
Electrocardiogram
Lactate level:
Explanation:
This patient has eclampsia, a condition that includes pregnancy-induced hypertension and seizures in a woman who is at least 20
weeks pregnant. A bedside transabdominal ultrasound can quickly confirm a second or third trimester pregnancy. Eclampsia is initially
treated with magnesium sulfate (4 to 6 grams IV followed by a drip) rather than anti-epileptic drugs. The definitive treatment of
eclampsia is delivery. Eclampsia can occur up to four weeks postpartum.
A CT of the head (B) will not lead to the correct diagnosis, although it should be obtained at some point in the workup of a first-time
adult seizure. Pregnancy is a prothrombotic state. Seizures may be associated with an underlying stroke. To evaluate for potential
toxigenic causes, an electrocardiogram (C) should be considered in any patient who presents with new onset seizure. However, in this
particular patient, an electrocardiogram will have limited diagnostic yield. Due to anaerobic metabolism during a seizure, the lactate
level (D) will invariably be elevated in the immediate postictal period and provide minimal diagnostic information. The lactate should
clear after 30-60 minutes.
25. 26-year-old woman presents with abdominal cramping after a positive home pregnancy test. Her vitals are T 98.7°F, HR 94, BP
110/66, RR 18, oxygen saturation 97%. Her exam is unremarkable. Labs reveal a serum beta HCG of 1000 mIU and she is Rh
positive. She states that the pregnancy is wanted. An ultrasound is performed as seen above. Which of the following is
appropriate management for this patient?
Administer Rhogam and discharge home with repeat beta hCG in 48 hours
Administer Rhogam and methotrexate
Discharge home with repeat beta hCG in 48 hours:
Explanation:
This patient presents with abdominal pain and a positive pregnancy test raising the concern for an ectopic pregnancy. Ectopic
pregnancy complicates about 1.5 - 2.0% of pregnancies and is potentially life threatening. There are a number of risk factors for
ectopic pregnancy including pelvic inflammatory disease, prior tubal surgery, and previous ectopic pregnancy. This patient has an
early pregnancy based on the low beta hCG. The transvaginal ultrasound shows an early gestational sac without a yolk sac or fetal
pole within the uterus. This ultrasound does not rule out the diagnosis of an ectopic pregnancy as an ectopic pregnancy can cause a
decidual reaction in the uterus, which appears similar to an early gestational sac. The definitive ultrasound finding for an intrauterine
pregnancy would be the presence of a yolk sac or fetal pole. It is expected that above the discriminatory hCG zone of 1500-2500
mIU, a definitive IUP should be identified. Patients with a beta hCG below the discriminatory zone without a definitive IUP can be
managed conservatively with a repeat hCG level in 48 hours (the level should double every 48 hours) and repeat ultrasound.
Rhogam (B & C) is recommended for patients who are Rh negative and have vaginal bleeding. If the mother is exposed to fetal blood,
she may develop antibodies that threaten future pregnancies. This patient does not have vaginal bleeding and is Rh positive obviating
the need for Rhogam. Methotrexate (A) is a chemotherapeutic agent that can be used for the treatment of early ectopic pregnancy. This
approach is not indicated in a wanted pregnancy with a beta hCG below the discriminatory zone as repeat testing may show a viable
intrauterine pregnancy.
26. A 26-year-old woman presents with abdominal cramping after a positive home pregnancy test. Her vitals are T 98.7°F, HR 94, BP
110/66, RR 18, oxygen saturation 97%. Her exam is unremarkable. Labs reveal a serum beta HCG of 1000 mIU and she is Rh
positive. She states that the pregnancy is wanted. An ultrasound is performed as seen above. Which of the following is
appropriate management for this patient?
Administer Rhogam and discharge home with repeat beta hCG in 48 hours
Administer Rhogam and methotrexate
Discharge home with repeat beta hCG in 48 hours:
Explanation:
This patient presents with abdominal pain and a positive pregnancy test raising the concern for an ectopic pregnancy. Ectopic
pregnancy complicates about 1.5 - 2.0% of pregnancies and is potentially life threatening. There are a number of risk factors for
ectopic pregnancy including pelvic inflammatory disease, prior tubal surgery, and previous ectopic pregnancy. This patient has an
early pregnancy based on the low beta hCG. The transvaginal ultrasound shows an early gestational sac without a yolk sac or fetal
pole within the uterus. This ultrasound does not rule out the diagnosis of an ectopic pregnancy as an ectopic pregnancy can cause a
decidual reaction in the uterus, which appears similar to an early gestational sac. The definitive ultrasound finding for an intrauterine
pregnancy would be the presence of a yolk sac or fetal pole. It is expected that above the discriminatory hCG zone of 1500-2500
mIU, a definitive IUP should be identified. Patients with a beta hCG below the discriminatory zone without a definitive IUP can be
managed conservatively with a repeat hCG level in 48 hours (the level should double every 48 hours) and repeat ultrasound
Rhogam (B & C) is recommended for patients who are Rh negative and have vaginal bleeding. If the mother is exposed to fetal blood,
she may develop antibodies that threaten future pregnancies. This patient does not have vaginal bleeding and is Rh positive obviating
the need for Rhogam. Methotrexate (A) is a chemotherapeutic agent that can be used for the treatment of early ectopic pregnancy. This
approach is not indicated in a wanted pregnancy with a beta hCG below the discriminatory zone as repeat testing may show a viable
intrauterine pregnancy
27. A 27-year-old woman 32 weeks pregnant presents with bright-red vaginal bleeding for 1 day. The patient denies any pain and is
not tender on abdominal exam. Her vital signs are BP 115/70, HR 90, and RR 16. What is the most appropriate next step in
management?
Obtain intravenous access

Order an ultrasound
Perform a digital vaginal exam
Perform a speculum exam:
Explanation:
Placenta previa is characterized by painless, fresh vaginal bleeding in late pregnancy. Placenta previa occurs in 1% of pregnancies and
is defined as a placenta that extends near, partially over, or completely over the cervical os. These patients are at an increased risk for
life-threatening hemorrhage. As a result, the first step in management of placental previa is to obtain intravenous access in anticipation
of fluid resuscitation and possible transfusion. Obstetrical consultation is also advised.
Digital vaginal exam (C) and speculum exam (D) should be avoided in 3rd-trimester bleeding; these procedures can precipitate
significant hemorrhage. Ultrasound (B) can be performed to determine fetal and placental positioning. However, this exam should not
precede the initiation of IV access and preparation for fluid resuscitation.
28. A 27-year-old woman currently breast-feeding presents to the ED with an inflamed and painful right breast. Her vital signs are
BP 125/70 mm Hg, HR 105, RR 16, and T 38.3°C. On exam, you note extensive cellulitis of the right breast that begins at the
nipple. You begin antibiotic therapy. The patient wants to know whether to continue breast-feeding. What should you advise her
to do?
Consult her obstetrician

Continue to breast-feed but only from the noninfected breast
Continue to breast-feed from both breasts
Wean from breast-feeding and begin formula feeding:
Explanation:
The patient has acute puerperal mastitis. In all cases of mastitis, the woman should be advised to nurse as frequently as possible from
the affected breast. Nursing dilates the mammary blood vessels, thus improving blood flow to the infected tissue. The flow of milk
also helps to clear milk ducts of infective organisms. Studies have demonstrated that contamination of the infant's skin, mouth, or nose
with the pathogen preceded infection of mother's milk. Therefore, the patient should be started on an oral antibiotic such as
dicloxacillin and instructed to continue breast-feeding from both breasts.
The patient can be referred to her obstetrician (A) as an outpatient. There is no increased risk of transmitting the pathogen from mom to
infant by breast-feeding from the affected breast. Continued feeding from the infected breast (B) is recommended to enhance blood
flow, clear milk ducts, and maintain infant's feeding. Weaning (D) from the onset of mastitis means that the already contaminated infant
is deprived of antibodies to the infecting organism that mother develops in the course of her mastitis
29. A 27-year-old woman presents with vaginal bleeding. Her last menstrual period was eight weeks ago. On physical examination,
there is a small amount of blood in the vaginal vault with an open internal cervical os. Bedside ultrasound reveals an intrauterine
pregnancy with a fetal pole but no heartbeat. Which of the following is the most likely diagnosis?
Incomplete miscarriage
Inevitable miscarriage
Missed abortion
Threatened miscarriage:
Explanation:
Spontaneous miscarriage before 20 weeks of gestation is the most common serious complication of pregnancy. Most miscarriages
(80%) occur in the first trimester of pregnancy and almost all occur before 20 weeks gestation. Up to 25% of pregnant women
experience bleeding during pregnancy so the evaluation of threatened miscarriage or abortion is common. The ultimate risk of fetal
demise in threatened abortion decreases substantially once a fetal heart beat is visible on ultrasound. The results of the physical
examination and ultrasound classify the type of miscarriage. In the case presented, the presence of an open internal os defines the
miscarriage as inevitable. Additionally, patients will typically have vaginal bleeding and products of conception can often be felt or
visualized through the internal cervical os.
An incomplete miscarriage (A) is one in which the products of conception are visible either in the os or vaginal canal. Once all
products are expelled and the uterus contracts with a closed cervical os, the miscarriage is complete. A missed abortion (C) is a term
that encompasses several clinical scenarios when the pregnancy does not progress but the uterus has not expelled the products of
conceptions and the cervical os remains closed. These scenarios include: failure of the uterus to grow over time; an anembryonic
gestation where no fetus develop; and fetal death when the age/size of the fetus would have a heart beat but none is detected on
ultrasound. A threatened miscarriage (D) is the presence of vaginal bleeding in pregnancy with a closed cervical os. Between 35% and
50% of women will ultimately lose the pregnancy when they have experienced a threatened miscarriage.
30. A 28-year-old woman 37 weeks pregnant presents with bilateral lower extremity edema, hypertension, and proteinuria. She is
placed on a magnesium sulfate drip. Which of the following is a sign of magnesium toxicity?
Clonus
Hypercalcemia
Hyporeflexia
Tachypnea:
Explanation:
Symptoms of hypermagnesemia are not often seen unless significantly elevated (> 4 meq/L). Neurological symptoms are the most
commonly seen symptoms of hypermagnesemia. The initial clinical manifestation of this problem is diminished deep tendon reflexes
usually first noted when the plasma magnesium concentration reaches 4-6 meq/L. More severe hypermagnesemia can result in
somnolence, loss of deep tendon reflexes, and muscle paralysis, potentially leading to flaccid quadriplegia and, because smooth
muscle function is also impaired, decreased respiration and eventual apnea. Parasympathetic blockade—inducing fixed and dilated
pupils, thereby mimicking a central brain-stem herniation syndrome—can also be seen in this setting. Treatment is based on renal
function and ranges from withdrawal of the magnesium drip to treating with IV fluids, intravenous calcium, and/or dialysis.
Clonus (A) is less likely because hyperexcitability or upper motor neuron lesions typically cause clonus. Tachypnea (D) is also less
likely, given magnesium also impairs smooth muscle, which can lead to respiratory depression and eventually apnea. Hypocalcemia,
not hypercalcemia (B), is typically seen with hypermagnesemia because magnesium can inhibit the secretion of parathyroid hormone.
31. 28-year-old woman at 37 weeks gestation presents with abdominal pain and vaginal bleeding. Her vital signs are normal and she
has uterine tenderness on palpation of her abdomen. What is the most important diagnosis to rule out given this presentation?
Abruptio placenta
Placenta previa
Subchorionic hemorrhage
Vasa previa:
Explanation:
Abruptio placenta is premature separation of the placenta from the uterine wall occurring in 1% of pregnancies. Abruption occurs both
spontaneously (associated with hypertension, cocaine use, previous abruption, multiparity, increased maternal age, smoking) or as a
result of trauma. Patients experience abrupt onset of bleeding often with abdominal pain. The uterus is tender with contractions. The
clinician should defer the pelvic examination in the third trimester until placenta previa has been ruled out by ultrasound. Abruption
may be diagnosed on ultrasound but the sensitivity is poor due to similar echogenicity of blood to the placenta, therefore it is usually
a clinical diagnosis. Depending on the size of abruption, patients may lose a significant amount of blood. Laboratory analysis may
show markers of disseminated intravascular coagulation. Immediate consultation with an Obstetrician should be obtained.
Placenta previa (B) is the implantation of the placenta over the cervical os. Patients present with painless vaginal bleeding. Risk factors
include multiparity, previous cesarean section, advanced maternal age and smoking. Ultrasound is 95% sensitive and must be
performed prior to vaginal examination as bleeding may increase with digital or speculum exam. Subchorionic hemorrhage (C) occurs
during the first trimester and is the accumulation of blood between the chorionic membranes and uterine wall. Patients may have
vaginal bleeding. The presence of a subchorionic hemorrhage increases the chance of spontaneous abortion. Vasa previa (D) occurs
when fetal vessels within the membrane but unsupported by the umbilical cord pass across the internal os ahead of the presenting
fetal part. Patients may experience painless vaginal bleeding. These patients require emergent C-section.
32. A 28-year-old woman G1P0 at 38 weeks gestation presents with severe abdominal pain and vaginal bleeding. On examination,
the uterus is tetanically contracted and tender to palpation. Fetal monitoring shows decreased heart rate variability and late
decelerations. Which of the following is the most likely diagnosis?
Abruptio placentae
Amniotic fluid embolism
Placenta previa
Uterine rupture:
Explanation:
The patient has abruptio placentae. Abruptio placenta refers to premature separation of the placenta from the uterine wall, and occurs
in approximately 1% of pregnancies. The cause of placental abruption is unknown, but identified risk factors include hypertension,
trauma, smoking, cocaine use, and previous abruptions. The classic triad of abruptio placenta is vaginal bleeding, painful uterine
contractions, and fetal distress. As the placenta separates from the uterine wall vaginal bleeding ensues, though bleeding may be
concealed if the blood pools behind the placenta. Uterine irritability is present and the uterus may be tetanically contracted. In severe
abruptions, maternal hypotension and tachycardia develop due to blood loss, and activation of the maternal coagulation cascade can
result in disseminated intravascular coagulation (DIC). Fetal distress is caused by loss of placental blood flow, and fetal death occurs
in approximately 15% of cases. In this case, decreased heart rate variability and late decelerations on fetal tracing signify fetal distress,
and are a clue to the diagnosis of placental abruption. Ultrasound may confirm the presence of a retroplacental clot, but is insensitive
due to similar echogenicities of fresh blood and placental tissue. Patients with placental abruption should be managed aggressively
with crystalloid fluid resuscitation, blood transfusion if hemodynamically unstable, correction of associated coagulopathy, and
obstetric consultation for emergent cesarean section.
Amniotic fluid embolism (B) is a rare, life-threatening condition caused by amniotic fluid entering the maternal circulation. It presents
with hypotension, respiratory distress, altered mental status, and can progress to cardiovascular collapse. Placenta previa (C) presents
with painless vaginal bleeding. Mild uterine irritability may be present, but a tetanically contracted, tender uterus suggests placental
abruption. Uterine rupture (D) is another third trimester emergency condition which can present with abdominal pain and vaginal
bleeding. However, it usually presents nonspecifically with gradually worsening abdominal pain and progresses to fetal distress. There
is loss of station of the fetus on cervical exam, and fetal parts, such as foot or hand, may be palpated directly through the abdominal
wall.
33. A 29-year-old woman who is one week postpartum following a pregnancy complicated by preeclampsia with delivery of a full-
term infant is brought in by emergency medical services with an ongoing generalized tonic-clonic seizure. Which of the
following medications should be administered first?
Labetalol
Lorazepam
Magnesium sulfate
Phenobarbital: Correct Answer ( C )
Explanation:
A pregnant or recently postpartum patient with new-onset seizure should be considered to have eclampsia. Eclampsia refers to
seizures that develop as a complication of severe preeclampsia. The clinical manifestations of preeclampsia are hypertension after 20
weeks of pregnancy plus proteinuria. Severe preeclampsia is evidenced by marked hypertension (blood pressure ≥ 160 mm Hg
systolic or ≥110 mm Hg diastolic) with evidence of end-organ dysfunction, such as visual disturbances, mental status changes,
pulmonary edema, epigastric or right upper quadrant pain, elevated liver function tests, thrombocytopenia, proteinuria, oliguria, or
impaired fetal growth. Most cases of eclampsia occur in the 3rd trimester, with approximately 80% occurring during delivery or within
the first 48 hours after delivery, though seizures may occur as late as several weeks postpartum. Seizures are most commonly tonic-
clonic and last 60 to 90 seconds. Magnesium sulfate is the drug of choice for eclamptic seizures. A loading dose of 4-6 g of
magnesium sulfate should be administered over 15-20 minutes followed by a maintenance infusion of 1-2 g per hour. Most eclamptic
seizures terminate with magnesium.
Labetalol (A) may be used to control severe hypertension in a patient with preeclampsia or eclampsia, but does not treat seizures.
Lorazepam (B) and phenobarbital (D) are second- and third-line choices, respectively, if eclamptic seizures are refractory to
magnesium.
34. A 30-year-old woman presents with fever and abdominal pain. She is three days postpartum after cesarean section. Physical
examination reveals lower abdominal tenderness to palpation and foul smelling vaginal discharge. What management is
indicated?
Ceftriaxone IM and azithromycin PO

Clindamycin IV plus gentamicin IV
Fluconazole
Metronidazole:
Explanation:
This patient presents with endometritis and should be treated with broad-spectrum antibiotics and admitted to the hospital.
Endometritis affects 1 in 20 vaginal deliveries and 1 in 10 cesarean sections. There are a number of associated risk factors including
operative delivery, prolonged rupture of membranes, lack of prenatal care and frequent vaginal examinations. Endometritis is a
polymicrobial infection with gram-positive cocci and gram-negative coliforms involved. Patients typically present with abdominal pain,
fever and foul-smelling lochia or discharge. It commonly develops the second or third day post partum. Diagnosis is made clinically
but ultrasound is recommended to identify any possible retained products of conception. Patients should be treated empirically with
broad spectrum antibiotics. Clindamycin IV and gentamicin IV are typically recommended. Although most patients with endometritis
are admitted for IV antibiotics (especially those who are ill appearing, have had cesarean section or have underlying illnesses),
patients with mild illness may be treated as an outpatient with oral antibiotics and close OB follow up.
35. A 31-year-old woman at 35-weeks gestation presents with brief painless, bright red vaginal bleeding. In addition to fetal
monitoring, which of the following is the most important initial management?
Administration of betamethasone to hasten fetal lung maturity

Sterile digital cervical exam
Sterile speculum examination
Transvaginal ultrasound:
Explanation:
The differential diagnosis for third-trimester vaginal bleeding includes placental abruption, placenta previa, cervical or rectal lesions,
or bloody show (expulsion of a blood-tinged mucus plug). The clinical scenario of painless, bright red vaginal bleeding is most
suggestive of placenta previa. In placenta previa, the placenta abnormally overlies the cervical os. Most cases of placenta previa
diagnosed on 20-week ultrasound resolve in the months prior to delivery as the lower uterine segment elongates and the placenta no
longer overlies the cervical os. However, in up to 20% of cases the placenta remains positioned over the cervix, which can cause
significant and life-threatening hemorrhage at the time of delivery. A patient presenting to the ED with vaginal bleeding should
undergo ultrasound to evaluate for placenta previa. Transvaginal ultrasound is safe and more accurate than transabdominal ultrasound
for diagnosis of placenta previa, although transabdominal ultrasound can be utilized as an initial screening study. Patients with
suspected placenta previa should not undergo speculum exams or digital cervical exams due to the risk of precipitating significant
hemorrhage. The vagina may be visually inspected to confirm and quantify vaginal bleeding but more invasive exams should not
performed unless an obstetrician is present. Patients with confirmed placenta previa are managed by elective cesarean section.
Administration of betamethasone to hasten fetal lung maturity (A) is indicated for women with preterm labor (contractions resulting in
cervical dilatation) prior to 37 weeks gestation. Sterile speculum examination (C) and sterile digital cervical exam (B) are
contraindicated until placenta previa is ruled out as this can lead to significant hemorrhage.
36. A 32-year-old gravida 2 para 1 at 33 weeks gestation presents to the emergency room for sharp abdominal pain. She has not had
any prenatal care during this pregnancy. Her symptoms include vaginal bleeding, uterine pain between contractions, and fetal
distress. Her first pregnancy was uncomplicated, with a vaginal delivery at term. Which one of the following is the most likely
diagnosis?
Placenta previa
Placental abruption
Uterine rupture
Vasa previa:
Explanation:
Placental abruption is the separation of the placenta from the uterine wall before delivery and is considered an obstetric emergency.
Placental abruption typically manifests as painful vaginal bleeding and evidence of fetal distress in the third trimester. The fundus
often is tender to palpation, and pain occurs between contractions. Bleeding may be completely or partially concealed or may be
bright, dark, or intermixed with amniotic fluid. Common risk factors include abdominal trauma, maternal hypertension, smoking,
cocaine use, multiple gestation and previous abruption. The method and timing of delivery depends on the gestational age and the
maternal and fetal status. If the mom or the fetus is unstable then immediate cesarean section is the optimal delivery method,
regardless of the gestational age. If the mother and the fetus are stable then vaginal delivery is warranted, however the timing
depends on the gestational age.
37. 32-year-old woman 8 weeks pregnant by dates presents to the ED with a 2-cm laceration to her index finger sustained while she
was cutting a tomato. On review of systems, she also notes 2 days of vaginal spotting and lower abdominal cramping. Vital
signs are within normal limits. Physical exam is consistent with a simple 2-cm laceration. The pelvic exam reveals a closed os and
no adnexal tenderness or masses. Which of the following statements best describes the next step in management?
Delay treating her laceration until her pregnancy status is further clarified
Treat her laceration as indicated, and perform a beta-hCG quantitative level
Treat her laceration as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound
Treat her laceration as indicated, then discharge with outpatient obstetrical follow-up: Correct Answer ( C )
Explanation:
This patient presents with an isolated finger laceration, but the review of systems revealed signs concerning for a threatened abortion
or ectopic pregnancy. In addition to caring for her laceration, the patient requires further workup of her pregnancy. A beta-hCG level
should be obtained to correlate with her stated dates and to help identify an intrauterine pregnancy, miscarriage, ectopic pregnancy,
or molar pregnancy. A pelvic ultrasound should also be performed to evaluate for ectopic pregnancy, given the severity, prevalence,
and difficulty of diagnosis without the ultrasound. A type and screen should also be obtained to determine her Rh status and the
potential need for RhoGam administration.
Delay of treatment is not necessary (A) in this patient. If her vital signs were unstable, then priority would be given to treating a life-
threatening condition. The patient should not be discharged (D) without further investigation into her pregnancy-related complaints.
Determining the beta-hCG level (B) alone is insufficient to investigate the state of her pregnancy and the cause of her vaginal
bleeding.
38. A 32-year-old woman presents with an increase in vaginal secretions. You decide to perform a potassium hydroxide wet
preparation of a sample. This test evaluates which of the following secretion qualities?
Color
Odor
pH
Viscosity:
Explanation:
The main finding in vaginitis is increased vaginal discharge, a symptom which is 80-90% associated with a biologic organism and 10-
20% associated with fluctuating chemicals or hormones. A common office test is the KOH "whiff" wet preparation test, in which a
secretion sample is mixed with saline and 10-20% potassium hydroxide. The presence of a "fishy" amine odor represents a positive test,
while the absence of this abnormal amine-like odor represents a negative result. Normal vaginal secretions, which are mainly
comprised of cervical mucus, have a pH of 3.8 - 4.2, are clear or white and have a negative KOH test. Secretions become more basic
(pH >4.5), thin, adherent, and gray in bacterial vaginosis and frothy-green in trichomoniasis. White, thick, "cottage-cheese like"
secretions are associated with candida vaginitis. The KOH test is mostly positive in bacterial vaginosis and trichomoniasis, but negative
in candidiasis.
39. A 32-year-old woman presents with fever and lower abdominal pain. She has a history of pelvic inflammatory disease. Her vitals
are T 38.4°C, HR 133, and BP 101/60. On examination, the patient is toxic appearing and has marked lower abdominal tenderness
to palpation with rebound and guarding. Pelvic examination reveals cervical motion tenderness, scant discharge, and left
adnexal tenderness. The patient's urine beta-hCG is negative. A transvaginal ultrasound is performed and reveals a complex
cystic, thick-walled, well-defined mass in the left adnexa. Which of the following is the most appropriate next step in
management?
Administer ceftriaxone and discharge home with a 14-day course of doxycycline

Begin intravenous antibiotics and admit for possible drainage
Obtain a CT scan to rule out appendicitis
Send a serum beta-hCG to rule out ectopic pregnancy:
Explanation:
A tubo-ovarian abscess (TOA) typically results as a complication of pelvic inflammatory disease (PID) and is most commonly seen in
sexually active women. Since it is a complication of PID, patients typically present with lower abdominal and pelvic pain, fever,
vaginal discharge, and cervical motion or adnexal tenderness. Pelvic exam may reveal a palpable mass in the adnexa. Ultrasound is
the test of choice for suspected TOA, and transvaginal is best for visualizing the adnexa. Ultrasound findings typically include
identification of a complex cystic, thick-walled, well-defined mass in the adnexa or retrouterine area. The mass is usually
multiloculated with air-fluid levels. If ultrasound is equivocal, a CT scan can aid in the diagnosis. Treatment involves administration of
intravenous antibiotics. Some abscesses require surgical drainage. Tubo-ovarian abscesses can result in irreversible tubal and ovarian
damage and pose a serious threat to fertility.
40. A 32-year-old woman presents with pain and swelling in the vaginal area. Examination reveals the above finding. What
management is indicated?
Acyclovir
Cephalexin and surgery follow up
Incision and drainage of the external surface of the vestibule
Incision and drainage of the mucosal surface of the vestibule:
Explanation:
This patient presents with a Bartholin's abscess and should have incision and drainage (I+D) performed with the incision on the mucosal
surface. Bartholin's abscesses are infections located in the Bartholin's glands which lie inferiorly to the vaginal opening. Patients
develop cysts of the gland that become secondarily infected. These abscesses typically are caused by normally occurring aerobic
and anaerobic bacteria in the vagina but may also be caused by sexually transmitted infections. Patients present with swelling and pain
near the labium. Examination revels a tender, fluctuant mass along the posterolateral margin of the vaginal vestibule. Treatment
focuses on incision and drainage with insertion of a Word catheter. The Word catheter has a small balloon at the end that is inflated
after insertion and remains in place for 6 to 8 weeks. Because of this duration, the incision should be made on the mucosal surface so
that the Word catheter can be tucked into the vaginal opening for patient comfort. Incision and drainage is usually adequate but
patients with overlying cellulitis may require antibiotics. After discharge, patients should perform sitz baths to aid with drainage.
Recurrence is common.
41. A 32-year-old woman presents with vaginal bleeding for two weeks. She states she has had to change her pad every 2-3 hours
with the bleeding. Vital signs are stable and physical exam only reveals blood coming from the cervical os. The patient's
hemoglobin is 12 g/dL and her pregnancy test is negative. What treatment is indicated for this patient?
Admission for dilation and curettage

Combination oral contraceptives
Hysterectomy
Intravenous estrogen therapy: Correct Answer ( B )
Explanation:
This patient presents with non-life threatening abnormal uterine bleeding (previously called dysfunctional uterine bleeding), which can
initially be managed with combination oral contraceptives. Bleeding is typically split into anovulatory (90%) and ovulatory (10%). In
patients with vaginal bleeding of childbearing age, the most important first step in diagnosis is to rule out pregnancy. After this, it is
important to explore other causes including medications, genital tract pathology and systemic disease. Once these are excluded, a
diagnosis of abnormal uterine bleeding can be reached. Some treatments include NSAIDs that inhibit PGE1 production and can both
relieve cramping and pain and also decrease bleeding. In anovulatory bleeding, combination oral contraceptive pills can aid in
regulating the menstrual cycle and counteract the effects of unopposed estrogen. Typically, patients are instructed to take combination
oral contraceptive pills twice a day for 5-7 days or until the bleeding stops followed by once daily dosing.
Dilation and curettage (A) is typically offered to patients with heavy vaginal bleeding evidenced by hemodynamic instability. A
hysterectomy (C) is rarely needed in the treatment of AUB but is indicated for patients with heavy bleeding and hemodynamic
instability in which conservative management fails. Intravenous estrogen therapy (D) is effective in stopping heavy bleeding but is not
considered first-line therapy.
42. A 34-year-old woman presents complaining of dysuria and vaginal itching. Your speculum exam reveals the findings seen in the
image. Which of the following statements is correct regarding this diagnosis?
A fishy odor is present when vaginal discharge is mixed with potassium hydroxide
Metronidazole is the recommended treatment
Multiple petechiae are often seen on the vaginal wall
The pH of the discharge is less than 4.5
Vaginal discharge is often foul smelling:
Explanation:
Candidal vaginitis is characterized by a thick, curdy white (cottage cheese-like) discharge. Patients typically complain of vaginal
itching, dysuria, and dyspareunia. Risk factors include diabetes, HIV, recent antibiotic use, and pregnancy. A microscopic slide
prepared with 10% potassium hydroxide (KOH) will reveal characteristic branch chain hyphae (pseudohyphae) and spores. The pH of
the discharge is less than 4.5, whereas the pH of the other causes of vaginitis is greater than 4.5.
Bacterial vaginosis (A) is characterized by a malodorous discharge with a pH >4.5 and a transient fishy odor when mixed with a drop
of potassium hydroxide. Vaginal candidiasis is treated with topical antifungals (clotrimazole) or oral fluconazole. Metronidazole (B) is
used for Trichomonal vaginitis and bacterial vaginosis. Trichomonal vaginitis is occasionally associated with petechiae (C) on the
vaginal wall or cervix. This is often referred to as a strawberry cervix. Unlike Trichomonal vaginitis and bacterial vaginosis, the
discharge of candidal vaginitis generally has no associated odor (E).
43. A 36-year-old G1P0 woman presents at 32 weeks gestation with right upper quadrant abdominal pain. She has no past medical
history and her pregnancy has thus far been uncomplicated. Her vital signs on arrival are T 37.3°C, HR 110, BP 125/75, RR 24. Her
physical exam is significant for moderate right upper quadrant tenderness to palpation. Her laboratory studies are remarkable
for WBC 14 x 109/L, hemoglobin 9 g/dL, hematocrit 27%, platelets 70 X 109/microL, AST 120 U/L, ALT 100 U/L, total bilirubin 1.5
mg/dL and LDH 1000 U/L. Which of the following is the most likely diagnosis?
Cholecystitis
Choledocholithiasis
Fitz-Hugh Curtis syndrome
HELLP syndrome:
Explanation:
HELLP syndrome is a severe form of preeclampsia associated with hemolysis, transaminitis, and thrombocytopenia. While most cases
of HELLP are associated with the hallmark hypertension and proteinuria of preeclampsia, hypertension and proteinuria are not
necessary for the diagnosis of HELLP syndrome. In fact, hypertension and proteinuria are absent in 15% of cases of HELLP syndrome.
Labetalol, hydralazine, and nifedipine are the drugs of choice for acute, severe hypertension associated with HELLP syndrome. Like in
preeclampsia and eclampsia, delivery is the only definitive management of HELLP.
Cholecystitis (A) is inflammation of the gallbladder most commonly due to gallbladder disease. Fever, leukocytosis and right upper
quadrant pain are typically seen. Choledocholithiasis (B) refers to obstruction of the common bile duct with a stone. Presenting
symptoms include right upper quadrant pain, nausea, and vomiting. While elevation of liver function tests can be seen with
cholecystitis and choledocholthiasis, neither is associated with thrombocytopenia or anemia as shown above. Fitz-Hugh Curtis
syndrome (C), also known as perihepatitis, is inflammation of the liver capsule and the associated peritoneal surface due to pelvic
inflammatory disease from infection with N. gonorrhoeae or C. trachomatis. It is associated with severe right upper quadrant
tenderness but would not cause the anemia and thrombocytopenia seen in the laboratory results above.
44. A 38-year old woman presents with right upper quadrant pain that is worse with deep breathing. She reports having multiple
sexual partners. She was recently treated for "an STD," however didn't complete the entire course of antibiotics because "she
felt fine." What is the most likely organism causing this condition?
Chlamydia trachomatis
Escherichia coli
Treponema pallidum
Trichamonas vaginalis:
Explanation:
The patient is likely suffering from Fitz-Hugh-Curtis syndrome or perihepatitis that resulted from a partially treated Chlamydia
trachomatis infection. Fitz-Hugh- Curtis syndrome causes right upper quadrant pain, which is commonly pleuritic in nature. In most
cases, the patient will have either a preceding episode of pelvic inflammatory disease (PID) or have concomitant PID symptoms.
Fitz-Hugh-Curtis syndrome can also be seen with a concomitant or preceding gonorrhea infection, although Chlamydia trachomatis is
now thought to be more common. Fitz-Hugh-Curtis is not commonly associated with Escherichia coli (B), Trichamonas vaginalis (D) or
Treponema pallidum (C) infection.
45. A 40-year-old woman with a history of asthma presents to the ED with symptoms of wheezing and shortness of breath similar to
previous exacerbations. Her vital signs are BP 115/70, HR 80, RR, 14, and pulse oximetry is 99% on room air. The patient is
offered and agrees to a point-of-care beta-hCG test that returns positive. Upon further questioning, patient denies any vaginal
or urinary complaints. On exam, you note mild bilateral wheezing with good air movement. Which of the following is the most
appropriate next step in management?
Delay treating her asthma until her pregnancy status is further clarified
Treat her asthma as indicated, and perform a beta-hCG quantitative level
Treat her asthma as indicated, if improved, discharge with outpatient obstetrical follow-up
Treat her asthma as indicated, perform a beta-hCG quantitative level, and obtain a pelvic ultrasound:
Explanation:
As a good public health practice, many EDs offer routine screening for pregnancy using point-of-care testing. In this patient—with
isolated respiratory complaints and lack of findings on physical or pelvic exam that indicate anything other than a normal pregnancy—
an incidental positive beta-hCG does not warrant any further attention other than a referral for follow-up with an obstetrician. The
patient's asthma is the treatment priority. Standard therapy should be administered even in the setting of pregnancy.
46. One Step Further
Question: Approximately what percentage of pregnant females with untreated asymptomatic bacteriuria will go on to develop
pyelonephritis?: Answer: 30%.
Question: At what age should patients be referred to a gynecologist to rule out Bartholin gland cancer?: Answer: 40.
Question: At what crown-rump length is a heartbeat expected on ultrasound?: Answer: 5 mm.
Question: Does bacterial vaginosis increase a woman's susceptibility to other sexually transmitted infections, such as herpes
simplex virus and HIV?: Answer: Yes.
Question: Does magnesium potentiate or block extracellular and intracellular calcium?: Answer: Magnesium is an effective calcium
channel blocker both extracellularly and intracellularly; in addition, intracellular magnesium profoundly blocks several cardiac
potassium channels.
Question: Does the insertion of an IUD increase the risk of developing pelvic inflammatory disease?: Answer: No.
Question: Does the presence of an intrauterine pregnancy rule out PID?: Answer: Although rare, it can take place concurrently
with fertilization or throughout the 1st trimester.
Question: How do normal vital signs change during pregnancy?: Answer: Heart rate increases by 10-15 beats per minute. Blood
pressure typically drops during the 2nd trimester.
Question: How long after successful methotrexate therapy will the beta-hCG reach 0?: Answer: In about 2-3 months.
Question: How many days after implantation is beta-hCG detectable?: Answer: Beta-hCG is secreted from the time of implantation
and is detectable about 7-8 days after fertilization.
Question: How often do patients with placental abruption present without pain or vaginal bleeding?: Answer: Up to 1/5th of
patients with placental abruption will have neither bleeding nor pain.
Question: In reproductive age women, what is the most common cause of abnormal vaginal bleeding?: Answer: Pregnancy-related
complications.
Question: Mixing alcohol and metronidazole leads to what reaction?: Answer: Disulfram-like reaction: flushing, tachycardia,
hypotension.
Question: Should breast-feeding continue even in the presence of a breast abscess?: Answer: Yes.
Question: True or False: Liver transaminases are usually elevated in cases of Fitz-Hugh-Curtis syndrome?: Answer: False.
Question: What are 3 consequences of PID?: Answer: Tubo-ovarian abscess, infertility, ectopic pregnancy.
Question: What are some common risk factors for MRSA colonization?: Answer: Recent or prolonged hospitalization, incarceration,
HIV infection, diabetes, military service and needle sharing.
Question: What are the most common causes of pelvic pain in the nonpregnant patient?: Answer: Salpingitis, ruptured corpus
luteal cyst, adnexal torsion, tubo-ovarian abscess, and appendicitis. However, in up to 20% of patients with pelvic pain, no etiologic
agent is determined
Question: What are the most common complications of a molar pregnancy?: Answer: Preeclampsia/eclampsia, pulmonary
embolism of trophoblastic cells and hyperemesis gravidarum.
Question: What are the most common complications of shoulder dystocia?: Answer: Asphyxia, brachial plexus injuries and
clavicular or humeral fracture.
Question: What are the most common risk factors for bacterial vaginosis?: Answer: Vaginal pH > 4.5, frequent douching, pregnancy
and intrauterine device presence.
Question: What are two side effects of hypermagnesemia?: Answer: Hyporeflexia and hypoventilation.
Question: What bacteria cause bacterial vaginosis?: Answer: It is due to polymicrobial overgrowth of several bacteria that replace
the normal vagnial flora. These abnormal bacteria include Prevotella, Mobiluncus, Bacterioides, Gardnerella vaginalis, and
Mycoplasma hominis.
Question: What Category is ranitidine?: Answer: Category B.
Question: What do late decelerations signify on fetal tracing?: Answer: Uteroplacental insufficiency.
Question: What impact does PID have on future pregnancies?: Answer: It increases the risk of ectopic pregnancy and infertility.
Question: What is a corpus luteum cyst?: Answer: The corpus luteum of the ovary supports the pregnancy by secreting beta-
hCG/progesterone during the first 6-7 weeks. It often becomes cystic.
Question: What is an alternative regimen to treat endometritis?: Answer: Intravenous ceftriaxone and Intravenous metronidazole.
Question: What is another initial test done in any patient with increased vaginal discharge?: Answer: Microscopic examination of
the secretions.
Question: What is a septic abortion?: Answer: Any type of abortion accompanied by a uterine infection.
Question: What is Fitz-Hugh-Curtis syndrome?: Answer: Perihepatitis associated with PID. It manifests as right upper quadrant pain
and is seen in 10% of patients with PID.
Question: What is the average difference in resting heart rate in a pregnant woman vs. a nonpregnant woman?: Answer:
Approximate increase of 10 to 15 beats/minute in pregnancy.
Question: What is the classic clinical presentation of placental abruption?: Answer: Painful third-trimester vaginal bleeding.
Question: What is the clinical condition when the placenta attaches to the myometrium?: Answer: Placenta accreta.
Question: What is the definition of preterm or premature labor?: Answer: Before 37 weeks.
Question: What is the first clinical manifestation of magnesium toxicity?: Answer: Loss of deep tendon reflexes.
Question: What is the HELLP syndrome?: Answer: HELLP syndrome is a severe form of preeclampsia characterized by hemolysis,
elevated liver enzymes and low platelets.
Beyond The Boards

Recent ACOG guidelines state that proteinuria is not required to make a diagnosis of preeclampsia if there is evidence of end-organ
damage as noted above. Massive proteinuria is also not necessary for a diagnosis of severe preeclampsia.]
Question: What is the most common cause of bleeding in the primigravid woman?: Answer: Threatened abortion.
Question: What is the most common cause of ovarian torsion?: Answer: Ovarian mass, either tumor (benign) or heavy cysts seen in
ovarian hyperstimulation.
Question: What is the most common cause of postpartum hemorrhage?: Answer: Uterine atony.
Question: What is the most common malpresentation in fetal delivery?: Answer: Breech presentation occurs in approximately 4% of
all deliveries.
Question: What is the most frequently occurring pelvic tumor in women?: Answer: Leiomyoma (uterine fibroid).
Question: What is the perinatal mortality for umbilical cord compression?: Answer: Overall, the perinatal mortality rate is about 15%.
However, if a cesarean section can be performed within 10 minutes, the rate decreases to 5%.
Question: What is the preferred diagnostic test for placenta previa?: Answer: Ultrasound.
Question: What is the preferred method of delivery in a woman with placental abruption?: Answer: Oxytocin-induced vaginal
delivery. Cesarean delivery is reserved for significant maternal and fetal instability.
Question: What is the recommended treatment for pregnant patients with bacterial vaginosis?: Answer: Oral clindamycin 300 mg
by mouth every 12 hours x 7 days, or metronidazole 500 mg orally twice a day for 7 days, or metronidazole 250 mg orally three times
a day for 7 days.
Question: What is the success rate of methotrexate in the management of early ectopic pregnancy?: Answer: 85-93%.
Question: What is the treatment for postpartum hemorrhage that cannot be controlled with medications?: Answer: Hysterectomy.
Question: What is the treatment of tender breast engorgement in a non-breast feeding postpartum woman?: Answer: Supportive
bra, cold cabbage leaves, and ice packs.
Question: What is the treatment of uterine rupture?: Answer: Emergency C-section.
Question: What is the underlying pathophysiology behind anovulatory bleeding?: Answer: Anovulatory bleeding is caused by the
failure of the corpus luteal cyst to form leading to absence of progesterone and unopposed estrogen stimulation on the endometrium.
Question: What is Wood's corkscrew maneuver?: Answer: It is an alternate approach to shoulder dystocia management. The fetus is
rotated 180 degrees in order to release the impacted shoulder
Question: What other blood product is commonly transfused in a woman with abruptio placentae?: Answer: Packed red blood
cells, to treat the volume-depleting and oxygen-carrying insult which stems from abruption.
Question: What percentage of pregnant patients develop 1st-trimester vaginal bleeding?: Answer: Up to 20% of all pregnant
patients develop vaginal bleeding within the first 20 weeks of gestation. Of these, 50% will miscarry; the other 50% will go on to have
a term pregnancy.
Question: What treatment is required for recurrent Bartholin's abscesses?: Answer: Marsupialization or excision in the operating
room.
Question: When is HELLP syndrome most commonly diagnosed?: Answer: 28-36 weeks gestation.
Question: When prescribing metronidazole, patients should be counseled to avoid consumption of what substance?: Answer:
Alcohol should be avoided due to the disulfiram-like reaction that occurs when taken with metronidazole.
Question: When treating bacterial vaginosis, is it necessary to treat sexual partners?: Answer: No, treatment of sexual partners
does not affect response to therapy or recurrence rates and is not recommended.
Question: Which embryologic period is associated with increased teratogenicity during organogenesis?: Answer: Days 21-56 of
gestation (3-8 weeks).
Question: Which organisms are commonly found in tubo-ovarian abscesses?: Answer: Infection is often polymicrobial and can
include E. Coli, aerobic streptococci, and Bacteroides.
Question: Which population is at greatest risk for a heterotopic pregnancy?: Answer: Women with fertility-assisted pregnancies.
Question: Why is amoxicillin/clavulanic acid avoided in the treatment of Preterm PROM?: Answer: Amoxicillin/clavulinic acid has
been associated with an increased risk of necrotizing enterocolitis.
Question: Why is complete arterial obstruction rare in ovarian torsion?: Answer: The ovary receives dual blood supply from the
uterine and ovarian arteries.
Question: Why is ovarian torsion more common on the right side?: Answer: It is believed that the sigmoid colon stabilizes the left
ovary so that it is less likely to torse.
110. Where is the uterine fundus palpable at 36 weeks gestation?
At the umbilicus
At the xiphoid process
Between the pubic symphysis and umbilicus
Between the umbilicus and xiphoid process:
Explanation:
At six to eight weeks, the gravid uterus is approximately the size of an orange. At 12 weeks, the top of the fundus should be at the level
of the symphysis pubis; at 20 weeks, at the level of the umbilicus; and at 36 weeks, at the level of the xiphoid process. Subsequently,
the fetus descends into the pelvis, and the fundal height may decrease.
111. Which of the following best describes an inevitable abortion?
Parts of the product of conception have been passed and may be visible in the cervical os or the vaginal canal
Retention of a nonviable intrauterine pregnancy within the uterus, no cardiac activity, and a closed cervical os
Vaginal bleeding before 20 weeks of gestation with a closed internal cervical os
Vaginal bleeding before 20 weeks of gestation with an open internal os:
Explanation:
Approximately 80% of miscarriages occur during the first trimester; the rest occur before 20 weeks of gestation or when the fetus is
<500 g, considered premature birth. Approximately 25% of pregnant patients experience bleeding. Approximately 50% of all women
who have bleeding during early pregnancy miscarry. Those with a history of bleeding who do not miscarry have otherwise fairly
normal pregnancies, although they have an increased risk of premature birth and low-birth-weight infants. The 2 major causes of
miscarriage are uterine malformations and chromosomal abnormalities. There are several stages of miscarriages. An inevitable
abortion is defined by vaginal bleeding before 20 weeks of gestation with an open internal os and no passage of placental or fetal
parts.
First trimester bleeding and a closed internal cervical os (C) is defined as a threatened abortion. The risk of miscarriage in this
population is up to 50%. If products of conception (POC) are present at the cervical os or in the vaginal canal, the abortion is termed
an incomplete abortion (A). A missed abortion (B) is a term rarely used anymore. It refers to the retention of a nonviable intrauterine
pregnancy within the uterus. Products of conception are demonstrable, but fetal development has ceased, there is no cardiac activity
visible, and the cervical os is closed. It is better referred to as 1st- or 2nd trimester fetal death.
112. Which of the following confirms an intrauterine pregnancy?
Beta-hCG of 200,000
Fetal heart activity
Intrauterine fetal pole and yolk sac
Single layer intrauterine gestational sac:
Explanation:
The fetal pole is a mass of fetal cells separate from the yolk sac that first becomes apparent on transvaginal ultrasound just after the
6th week of gestation. It is the fetus in its somite stage. Usually, you can identify rhythmic fetal cardiac movement within the fetal pole,
although it may need to grow several millimeters before this is apparent. Identification of an intrauterine fetal pole and yolk sac on
ultrasound confirms an intrauterine pregnancy. Other ways that increase the likelihood, but does not confirm an intrauterine pregnancy
include identifying the double ring, also known as the double decidual sign, which usually appears by 5.5-6 weeks' gestation. The
double ring helps to distinguish a true gestational sac from an intrauterine fluid collection or pseudosac. Identifying intrauterine fetal
heart activity within the uterus confirms an intrauterine pregnancy; however presence of fetal heart activity alone does not guarantee
an intrauterine pregnancy.
Beta-hCG levels (A) increase at a predictable rate in the early stages of pregnancy. Levels of beta-hCG double every 2-3 days during
the first 7-8 weeks of normal pregnancies. However, there are conditions other than an intrauterine pregnancy that can lead to
significant elevations of beta-hCG, such as gestational trophoblastic disease and molar pregnancy. This disorder is characterized by
proliferation of chorionic villi. The associated high level of beta-hCG often leads to hyperemesis. Identifying fetal heart activity (B)
does not confirm an intrauterine pregnancy because an ectopic pregnancy can progress to have fetal activity. Only when fetal heart
activity is detected within the gestational sac can the pregnancy be confirmed as intrauterine. A true gestational sac is identified on
ultrasound by the double ring, also known as the double decidual sign, and strongly suggests an intrauterine pregnancy. A single layer
gestational sac (D), or pseudosac, is possible, which looks very similar to a true gestational sac. In this setting, there can still be an
ectopic fetus. Therefore, most clinicians confirm an intrauterine pregnancy when a gestational sac with a fetal pole or yolk sac is
present.
113. Which of the following drugs must be prescribed in a patient with cervicitis in whom bacterial vaginosis is also suspected?
Azithromycin
Ceftriaxone
Doxycycline
Metronidazole:
Explanation:
Bacterial vaginosis (BV) is a syndrome caused by polymicrobial overgrowth and requires treatment with either metronidazole or
clindamycin. The typical species involved include anaerobic species (Mobiluncus, Bacteroides, Prevotella), Gardnerella vaginalis and
Mycoplasma hominis. BV is the most common cause of vaginal discharge but may be asymptomatic in up to half of women. It
typically manifests with malodorous vaginal discharge. This discharge is thin and white in consistency. Diagnosis of BV is based on the
Amsel criteria: 1) thin, white, homogenous discharge, 2) presence of clue cells (epithelial cells stippled with bacteria), 3) vaginal pH >
4.5 and 4) fishy odor of discharge with addition of 10% KOH (whiff test). Treatment for BV is with metronidazole 500 mg PO BID or
clindamycin 300 mg PO BID for 7 days. Alternatively, metronidazole and clindamycin can be prescribed as a vaginal suppository.
Unlike with other sexually transmitted infections, treatment of the partner does not reduce the response rate or rate of recurrence.
114. Which of the following is a contraindication to methotrexate therapy for ectopic pregnancy?
Beta-hCG <5,000 mIU/mL

Ectopic gestational sac <3.5 cm
No fetal cardiac activity
Renal insufficiency:
Explanation:
Single-dose methotrexate (MTX) is effective in 85% of patients. Methotrexate is a folic acid antagonist that inhibits DNA synthesis and
cell reproduction, targets rapidly growing cells, and has replaced surgery for many patients with ectopic pregnancy at low risk for
rupture. Methotrexate is rapidly cleared from the body by the kidneys, with 90% of an intravenous dose excreted unchanged within 24
hours of administration. Methotrexate is renally cleared, and in women with renal insufficiency, a single dose of methotrexate can lead
to death or severe complications, including bone-marrow suppression, acute respiratory distress syndrome, and bowel ischemia.
Treatment with methotrexate is associated with significant abdominal pain several days after treatment. Patients with lower Beta-hCG
tend to have lower treatment failures with MTX. Patients should be counseled on risks and benefits, understand the need for follow-up
visits and lab work, and that MTX may fail. Some side effects include stomatitis, conjunctivitis, enteritis, pleuritis. Beta-hCG may
increase for 4 days after MTX, repeat Beta-hCG testing is usually between 4-7 days. By day 7, if Beta-hCG has not decreased by 25%,
a second dose of MTX is given.
115. Which of the following is a risk factor for ectopic pregnancy?
Alcohol use
Cocaine use
Heroin use
Tobacco use: Correct Answer ( D )
Explanation:
Ectopic pregnancy is the 3rd-leading cause of maternal death and now accounts for up to 2% of all pregnancies. Multiple risk factors
for ectopic pregnancy include prior ectopic pregnancy or tubal surgery, pelvic inflammatory disease (PID), tobacco use, advanced
maternal age, prior spontaneous or medically induced abortion, a history of infertility treatment, and a current intrauterine device
(IUD). The classic presentation is the sudden onset of severe unilateral pelvic pain and vaginal bleeding in a patient with a known or
suspected pregnancy. Unfortunately, these findings are nonspecific. Up to 25% of patients with an ectopic pregnancy will lack some or
all of them. Physical exam findings are also quite variable, and a normal exam does not eliminate the possibility of the diagnosis.
Alcohol (A) is considered a teratogen, and abuse during pregnancy has been associated with a characteristic syndrome of
neurological and structural abnormalities known as fetal alcohol syndrome. Cocaine (B) is a potent vasoactive substance associated
with spontaneous abortion and placental abruption, as well as preterm and low-birth-weight babies. The abuse of heroin (C) and other
opiates leads to fetal physical dependence and can result in neonatal withdrawal.
116. Which of the following is considered appropriate treatment for bacterial vaginosis?
Azithromycin 1 g PO x 1
Ceftriaxone 250 mg IM x 1
Clindamycin 300 mg PO BID x 7 days
Metronidazole 2 g PO x 1:
Explanation:
Bacterial vaginosis (BV) is a polymicrobial vaginal infection that occurs when the normal Lactobacillus species are replaced with high
concentrations of anaerobic bacteria. BV is characterized by a thin, white discharge that has a fishy odor, a vaginal pH of >4.5 and
clue cells on microscopy. It can be associated with sexual intercourse or anything that disrupts the normal vaginal flora (ie, douching).
It is not necessarily a sexually transmitted infection. The CDC recommended treatment regimens include metronidazole 500 mg PO
BID for 7 days, metronidazole gel 0.75% 5 g intravaginally daily for 5 days, or clindamycin cream 2% 5 g intravaginally at bedtime for
7 days. For patients who cannot tolerate metronidazole, clindamycin 300 mg PO BID for 7 days is an alternative.
Alternative treatment options according to the CDC include tinidazole 2 g PO daily for 2 days, tinidazole 1 g PO daily for 5 days, or
clindamycin ovules 100 mg intravaginally daily for 3 days. Azithromycin 1 g PO (A) is for treatment of uncomplicated Chlamydia
cervicitis/urethritis. Ceftriaxone 250 mg IM (B) is treatment for Gonorrhea cervicitis/urethritis. Metronidazole 2 g PO (D) is therapy for
trichomonas vaginitis. Although metronidazole is an appropriate medication for treatment of BV, the one time dosing is not sufficient.
117. Which of the following is most associated with amenorrhea?
Adenomyosis
Neoplasia
Perimenopause
Uterine fibroid: Correct Answer ( C )
Explanation:
Perimenopause is the period between the onset of irregular menstrual cycles and the last menstrual period. This period is marked by
fluctuations in reproductive hormones and is characterized by the following menstrual irregularities: prolonged and heavy
menstruation intermixed with episodes of amenorrhea, decreased fertility, vasomotor symptoms, and insomnia. Some of these
symptoms may emerge 4 years before menses ceases, with a perimenopausal mean age of onset of 47.5 years. During the
menopausal transition, estrogen levels decline, and levels of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) increase.
Adenomyosis (A) is the condition in which endometrial glands grow deeply into the underlying myometrium. Dysmenorrhea occurs
just before or at the time of menstruation. Neoplasia (B) typically leads to bleeding. Endometrial hyperplasia or endometrial cancer
must be considered in women >35 years old or in younger women with other risk factors who present with abnormal vaginal bleeding.
Uterine fibroids (D) are associated with pain and bleeding.
118. Which of the following is the greatest risk factor for an ectopic pregnancy?
Multiple sexual partners

Previous abdominal surgery
Previous ectopic pregnancy
Previous pelvic inflammatory disease:
Explanation:
An ectopic pregnancy is when implantation of the gestational sac occurs outside of the uterus. The most common location for an
ectopic pregnancy is the fallopian tubes. It can also occur in the interstitial or cornual portion of the uterus (2%), intraabdominally
(1.5%), on the ovary (0.1%) and or within the cervix (0.1%). A history of a previous ectopic pregnancy is regarded as the greatest risk
factor for an ectopic pregnancy with an odds ratio of 8.3. Other high-risk features include previous tubal surgery and in utero
diethylstilbestrol (DES) exposure.
Multiple sexual partners (A) and previous abdominal surgery (B) increase the risk of ectopic pregnancy modestly with an odds ratio of
0.9-3.8. Previous pelvic inflammatory disease (D) is a strong risk factor for an ectopic pregnancy with an odds ratio of 2.1 and is
associated with up to 50% of ectopic pregnancies.
119. Which of the following is the most common ultrasound finding for patients with ovarian torsion?
Enlargement of the ovary

Free pelvic fluid
Lack of blood supply to the ovary
Ovarian cyst:
Explanation:
An ultrasound exam is usually the initial diagnostic study in the workup for ovarian torsion. The most common ultrasound finding in
ovarian torsion is enlargement of the ovary. Enlargement develops due to impaired venous and lymphatic drainage, in addition to
edema and hemorrhage that may occur. Less common findings include identification of a twisted pedicle (whirlpool sign), free pelvic
fluid, and identification of an ovarian mass.
Free pelvic and intraperitoneal fluid (B) may surround the twisted ovary. This is usually the result of interstitial fluid that weeps off an
affected ovary rather than true rupture of the capsule. Many cases of surgically proven ovarian torsion will have documented blood
flow (C) on Doppler exam because the ovary has a dual blood supply from both the ovarian and uterine arteries. In addition, torsion
is often intermittent, so findings may vary, depending on the time of the exam. Identification of an ovarian mass or cyst (>4 cm) (D)
may suggest the diagnosis of ovarian torsion, but it is not the most common finding on ultrasound.
120. Which of the following is true regarding uterine fibroids?
Increase in size during menopause

More common in White women than African American women
Surgical removal is associated with a 25% to 30% rate of recurrence
Typically occur as a single fibroid:
Explanation:
Leiomyomas (uterine fibroids) are benign tumors of muscle cell origin that cause pain and abnormal bleeding. Uterine fibroids are
associated with severe pain when part of the fibroid undergoes torsion or degeneration (due to rapid growth and loss of blood supply
most common in early pregnancy). Diagnosis is made by ultrasound. The treatment depends on size and symptoms. Initial
management usually includes NSAIDs, medroxyprogesterone, and gonadotropin-releasing hormone agonists. Surgical removal is
associated with a 25% to 30% rate of recurrence and significant bleeding complications.
Uterine fibroids decrease in size during menopause (A) and enlarge early in pregnancy. Uterine fibroids are 2x more common in
African American women (B) than in White women. Uterine fibroids are usually multiple in nature (D) rather than single.
121. Which of the following medications commonly used to treat hyperemesis gravidarum is considered Category B?
Metoclopramide
Prochlorperazine
Promethazine
Trimethobenzamide: Correct Answer ( A )
Explanation:
The FDA has developed a classification system to categorize mediations based on potential teratogenic effects. Medications are
assigned to one of the following categories based on human and animal data. Metoclopramide is a Category B antiemetic. It is a
centrally acting dopaminergic anatagonist that is used in the treatment of nausea and vomiting.
Prochlorperazine (B), promethazine (C), and trimethobenzamide (D) are all Category C agents. Prochlorperazine and promethazine
are also dopamine antagonists. The mechanism of action for trimethobenzamide is not well understood. Ondansetron, another
commonly prescribed antiemetic, is also Category B.
122. A woman has just delivered a term fetus via normal spontaneous vaginal delivery. She continues to have bleeding after delivery
of the placenta. She is tachycardic and hypotensive. What is the most common cause of postpartum hemorrhage?
Maternal birth trauma

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

Hypofibrinogenemia
Proteinuria
Thrombocytosis:
Explanation:
Abruptio placentae is a condition of premature separation of the placenta from the uterus. This patient exemplifies the presentation of
placental abruption. Abnormal placenta-uterus separation may lead to significant fetal and maternal stress. One of the most common
maternal complications is a consumptive coagulopathy. Placental separation results in intravascular and retroplacental coagulation.
This excessive coagulation depletes platelets, fibrinogen and other clotting factors, leading to thrombocytopenia and
hypofibrinogenemia, as well as an increase in the INR and the activated partial thromboplastin time. If placental abruption is a
suspected cause of third trimester bleeding, laboratory evaluation of the above values should be obtained early in the management
plan. If abnormalities are found, component therapy should be initiated via transfusions of platelets and fresh frozen plasma.
124. A woman presents with fever and foul-smelling vaginal discharge 3 days after delivery of a full-term fetus. She is febrile, with
uterine tenderness on pelvic exam. Which of the following is the strongest risk factor for postpartum endometritis?
Cesarean section
Internal fetal monitoring
Multiple gestation
Premature rupture of membranes:
Explanation:
Postpartum endometritis is the most common puerperal infection, usually developing on the 2nd or 3rd day postpartum. Typically, the
lochia has a foul odor, and the patient develops a leukocytosis. The infection begins in the endometrium and can extend to the
myometrium or parametrium. It is a serious infection that can lead to complications such as peritonitis, septic thrombophlebitis, and
necrotizing fasciitis. The pathogens involved are typically the flora of the bowel, perineum, vagina, and cervix. The strongest risk factor
for endometritis is a cesarean section.
Manternal fetal monitoring (B), multiple gestation (C), and premature rupture of membranes (D) also increase the risk for endometritis
but are less common than cesarean delivery. Other risk factors include young maternal age, maternal HIV infection, and lower
socioeconomic class.
125. A woman presents with right breast pain, fever, and malaise for 3 days. She has been breastfeeding her newborn child for the
last 3 weeks. On exam, there is an area of focal erythema and tenderness. No mass or fluctuance is noted. What is the most
likely pathogen responsible for causing her condition?
Escherichia coli
Staphylococcus aureus
Streptococcus agalactiae
Streptococcus pyogenes:
Explanation:
Mastitis is a localized and painful inflammation of the mammary gland that can be associated with fever and malaise. Lactational
mastitis primarily occurs within the 1st few months of breastfeeding when the skin of the breast is prone to damage due to frequent
feedings. It may also occur much later when the infant develops teeth and can cause local trauma to the area during feeding. The
most common pathogen is Staphylococcus aureus, which accounts for 40% of the cases. It is important to distinguish mastitis
(cellulitis) from an abscess (requires surgical drainage) and inflammatory breast cancer (rare, but deadly). In addition to antibiotics such
as dicloxacillin or cephalexin that cover for Staphylococcus aureus, the patient should be encouraged to apply cool compresses and
continue breastfeeding. If the patient does not respond to antibiotics within 72 hours, the patient should be evaluated again for the
possibility of breast abscess.
Escherichia coli (A) and Streptococcus species, such as Streptococcus agalactiae (C) and Streptococcus pyogenes (D) have been
noted as causes of mastitis as well, but less frequently than Staphylococcus aureus.
126. You are the emergency physician in a rural hospital with no obstetrical backup when a woman is brought into the ED in active
labor. You perform a pelvic exam and note a prolapsed umbilical cord. Which of the following is the most appropriate next step
in management?
Clamp the cord in 2 places and cut it

Instruct the patient to stop pushing and arrange to transfer to a hospital with obstetrical services
Manually replace the cord into the uterus and prepare for rapid vaginal delivery
Perform a crash bedside cesarean section:
Explanation:
Umbilical cord prolapse occurs when the umbilical cord precedes the fetal presenting part or the presenting part does not fill the birth
canal completely. Cord prolapse is associated with 50% of malpresentations (compound, shoulder, and breech). Whenever a
prolapsed cord occurs with a viable infant, cesarean section is the delivery method of choice. However, if surgical delivery cannot be
achieved in a timely manner, as in this case, the clinician should perform maneuvers to preserve umbilical circulation. The patient
should be placed in the knee-chest position with the bed in Trendelenburg as the presenting part is digitally elevated off the umbilical
cord and the umbilical cord is manually replaced into the uterus.
The cord should not be clamped (A) until delivery is completed or there is evidence of a nuchal cord. The risk of fetal hypoxia
depends on the time of cord prolapse. Transfer (B) will likely delay delivery and increase the likelihood of fetal hypoxia. Performing a
cesarean section (D) is not in the scope of practice for the emergency physician. In the rare circumstance, a perimortem cesarean
section may be necessary. In the case of a prolapsed cord, temporizing measures can be performed.
127. You are treating a 23-year-old woman for a suspected ectopic pregnancy. Which of the following is an indication for an
emergent laparotomy?
A positive ßhCG with an empty uterus on ultrasound

Heavy vaginal bleeding with use of 1 pad every 2 hours
Hemoglobin level of 10 mg/dL with no history of anemia
Persistent tachycardia despite adequate resuscitation: Correct Answer ( D )
Explanation:
When evaluating a patient with suspected ectopic pregnancy, stable versus unstable hemodynamic status is the first critical decision.
Hemodynamically stable patients should be evaluated with a quantitative ßhCG, ultrasound, and other indicated testing. Unstable
patients should be resuscitated by aggressive volume repletion with normal saline and blood products, as indicated. Persistent
tachycardia, despite adequate volume resuscitation in a patient known or suspected to have an ectopic pregnancy, should undergo an
emergent laparotomy.
A positive ßhCG with an empty uterus (A) on ultrasound should increase suspicion for an ectopic pregnancy. Most ectopic pregnancies
develop within the fallopian tubes and can be visualized on ultrasound as a mass in the adnexa. A missed abortion or early pregnancy
is also in the differential. If the vital signs are stable, the patient can be discharged with obstetric follow-up and repeat ßhCG in 48
hours. Ongoing vaginal bleeding may indicate continued hemodynamic instability, but pads (B) are a notoriously inaccurate measure
of the extent of bleeding. A ruptured ectopic pregnancy can cause significant hemorrhage; however, hemoglobin levels (C) may not
accurately measure the extent of bleeding. The value can lag behind the clinical course and does not correlate with hemodynamic
instability.
128. You diagnose lactation mastitis in a postpartum 17-year-old woman. She is currently breast feeding her healthy newborn. She
has no allergies. In addition to local cool compresses and ibuprofen, which of the following is the most appropriate treatment?
Aztreonam
Dicloxacillin
Metronidazole
Penicillin V:
Explanation:
In lactating women, mastitis typically presents within a few weeks postpartum, and occurs in 2-10% of breastfeeding women. The
infection is almost always unilateral. The most common causative agent is Staphylococcus aureus, which actually originates mainly
from the newborn's pharynx. The antibiotic of choice for non-severe disease is a penicillinase resistant agent, such as dicloxacillin or
cephalexin. If the patient has beta lactam sensitivity, clindamycin is recommended. If there is concern for maternal methicillin-resistant
staphylococcus aureus (MRSA) colonization, trimethoprim-sulfamethoxazole or clindamycin is recommended. If the patient is
unstable, inpatient intravenous vancomycin should be initiated after local and blood cultures are obtained.
Aztreonam (A) and penicillin (D) are antibiotics that do not properly cover staphylococcal infections. Although metronidazole (C) is a
common treatment of many gynecologic conditions, it is ineffective against Staphylococcus aureus. However, it should be
administered if mastitis is associated with subareolar abscess and nipple retraction.
129. A young woman presents with a complaint of stained underwear. She reports that for the last three days she has noticed a
malodorous, greenish discharge emanating from her groin. You take a thorough history and perform a pelvic examination. Which
of the following is the next best step in evaluating this complaint?
Bacterial culture
Microscopic examination of discharge
Pelvic ultrasonography
Serum complete blood count and chemistries:
Explanation:
Infective vaginitis is very likely given the above clinical description. In the initial evaluation of these symptoms, it is important to
determine the causative agent. A KOH whiff test can be performed to detect the amine-like fishy odor of bacterial vaginosis or
trichomonas vaginitis. However, direct microscopic examination of the discharge suspended in saline (termed wet preparation, or wet
prep) will reliably establish the diagnosis, and subsequently direct proper therapy.

Rosh Review Obs-gyn (2019)

Uploaded by

Document Informationclick to expand document information

Copyright:

Available Formats

Rosh Review Obs-gyn (2019)

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Rosh Review Obs-gyn (2019)

Uploaded by

Copyright:

Available Formats

Obstetrics/Gynecology ER

Study online at quizlet.com/_677kec

Beyond The Boards

Foley catheter placement and instillation of 500-750 ml of normal saline

A normal ultrasound rules out placental abruption

Age over 25 years

Elevated WBC count

Cefoxitin 2 gm and metronidazole 500 mg PO BID for 14 days

All patients require antibiotics

Ceftriaxone 250 mg IM once + azithromycin 1000 mg PO once

Clamp and cut cord and proceed with delivery

Cephalexin 500 mg QID for 7 days

Obtain intravenous access

Consult her obstetrician

Ceftriaxone IM and azithromycin PO

Administration of betamethasone to hasten fetal lung maturity

Administer ceftriaxone and discharge home with a 14-day course of doxycycline

Admission for dilation and curettage

Beyond The Boards

Beta-hCG <5,000 mIU/mL

Multiple sexual partners

Enlargement of the ovary

Increase in size during menopause

Maternal birth trauma

Decreased prothrombin time

Clamp the cord in 2 places and cut it

A positive ßhCG with an empty uterus on ultrasound

You might also like