Bleeding During Pregnancy

1.

A 22 year old female presents to the ED with complaints of severe stabbing pain in her right inguinal region and right shoulder pain for the past 2 hours. Physical exam is positive for abdominal tenderness to palpation and minimal vaginal bleeding. Abdominal US shows intraabdominal fluid, bHCG of 1600 with an unknown LMP. VS= BP 90/42 P=105 T=98.3. What is the next best step in management.

A.

Pelvic MRI
B.

Bedside paracentesis
C.

IV fluids and monitor
D.

Exploratory laparotomy
E.

Administer methotrexate

Correct Answer
D. Exploratory laparotomy

Explanation
The patient's presentation is concerning for a ruptured ectopic pregnancy, which is a life-threatening emergency. The severe stabbing pain in the right inguinal region and right shoulder pain, along with abdominal tenderness and minimal vaginal bleeding, are consistent with this diagnosis. The positive abdominal US findings of intraabdominal fluid and the elevated bHCG level further support the suspicion of an ectopic pregnancy. With the patient's vital signs showing hypotension (BP 90/42) and tachycardia (P=105), immediate surgical intervention is necessary to control the bleeding and remove the ectopic pregnancy. Therefore, the next best step in management is exploratory laparotomy.

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2.

31 year old Asian female, G4P0030, presents to OB triage complaining of lightheadedness and moderate vaginal bleeding. She notes it has been 6 weeks since her 2^nd round of IVF. Emergency US reveals a viable intrauterine pregnancy with consistent gestational age, additionally free fluid is noted in the peritoneum. bHCG was positive with a pending quantification. Transvaginal US reveals left adnexal mass with low resistance flow. What is a risk factor for this patients diagnosis?

A.

Age
B.

Race
C.

IVF
D.

Placenta previa
E.

PID

Correct Answer
C. IVF

Explanation
The patient's history of undergoing in vitro fertilization (IVF) is a risk factor for her diagnosis. IVF involves the manipulation of eggs and sperm outside of the body, and it can increase the risk of certain complications, such as ovarian hyperstimulation syndrome (OHSS) and ovarian torsion. The presence of a left adnexal mass with low resistance flow on transvaginal ultrasound suggests the possibility of ovarian torsion, which is a potential complication of IVF. Therefore, IVF is the most likely risk factor for this patient's diagnosis.

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3.

32 year old homeless lady, G2P0100 who claims to be 32 weeks pregnant based on her last LMP presents to the ED with complaint of heavy vaginal bleeding. She has not received any prenatal care. She reports minimal cramping pain in her lower abdomen. Her uterus is soft and non-tender. Vital signs are stable. What is the next step in management?

A.

Begin PCN G
B.

Sterile speculum exam
C.

IV fluids with observation
D.

Digital pelvic exam
E.

Transabdominal ultrasound.

Correct Answer
E. Transabdominal ultrasound.

Explanation
The next step in management would be to perform a transabdominal ultrasound. This is necessary to determine the cause of the heavy vaginal bleeding in a pregnant woman. The ultrasound can help identify any potential complications such as placenta previa or placental abruption. It can also assess the well-being of the fetus and determine the gestational age. This information is crucial for making decisions regarding further management and appropriate care for the patient.

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4.

Which of the following is not a risk factor associated with the diagnosis is patient 3?

A.

Alcohol consumption
B.

Twins
C.

Age of 15
D.

Age of 25
E.

Age of 35

Correct Answer
D. Age of 25

Explanation
Age of 25 is not a risk factor associated with the diagnosis of patient 3. This suggests that being 25 years old does not increase the likelihood of developing the condition or disease being discussed. The other options, such as alcohol consumption and twins, may be considered risk factors as they have been associated with an increased risk of the diagnosis in question. However, the information provided does not give any indication of the specific condition or disease being discussed, so a definitive explanation cannot be provided.

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5.

34 year old G3P2 at 37 weeks presents to OB triage with painful bright red vaginal bleeding. She reports tripping and landing on her buttocks nearly 1 hour ago. Physical exam reveals a tender and firm uterus. Emergency US reveals FHT in the 100’s with a posterior placenta. VS= BP 100/60 HR= 112 R=18= T=98.2. What is the most likely diagnosis?

A.

Vasa previa
B.

Placental abruption
C.

Normal labor
D.

Uterine rupture
E.

Placenta accrete

Correct Answer
B. Placental abruption

Explanation
Based on the given information, the most likely diagnosis is placental abruption. Placental abruption is characterized by painful vaginal bleeding, which is consistent with the patient's symptoms. The physical exam findings of a tender and firm uterus also support this diagnosis. Additionally, the presence of a posterior placenta on emergency ultrasound does not rule out placental abruption, as the location of the placenta does not necessarily correlate with the diagnosis.

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6.

What is the next best step in management.

A.

Kleihauer Betke test
B.

IV fluid and observe
C.

Type and Screen
D.

Administer pitocin
E.

Pelvic MRI

Correct Answer
C. Type and Screen

Explanation
The next best step in management would be to perform a Type and Screen. This test is used to determine the blood type and screen for any antibodies in the patient's blood. It is important to know the patient's blood type in case a blood transfusion is needed. Additionally, screening for antibodies is crucial to ensure compatibility between the patient and potential blood donors. This step would help guide further management decisions and ensure the patient's safety.

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7.

On a mission trip to Mexico a 35 year old G6P4105 has been in active labor for 12 hours. To facilitate her delivery she is given Pitocin. Three hours later the FHT drop to 90 from a previous baseline of 120, tocometry reveals no contractions. Moderate vaginal bleeding is also noted, and a vertical abdominal scar. What has likely occurred?

A.

Uterine rupture
B.

Intraamniotic infection
C.

Placental abruption
D.

Placenta previa

Correct Answer
A. Uterine rupture

Explanation
Based on the given information, it is likely that uterine rupture has occurred. Uterine rupture is a serious complication that can happen during labor, especially in women who have had previous cesarean deliveries. The presence of a vertical abdominal scar suggests a previous cesarean section, which increases the risk of uterine rupture. The symptoms of FHT drop, absence of contractions, and vaginal bleeding are consistent with uterine rupture. This is a medical emergency that requires immediate intervention.

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8.

What is a risk factor for this condition?

A.

AMA
B.

Previous C-section
C.

Gestational diabetes
D.

Smoking
E.

Nulliparity

Correct Answer
B. Previous C-section

Explanation
Having a previous C-section is a risk factor for this condition. This means that if a person has previously undergone a cesarean delivery, they are more likely to be at risk for the condition in question. The reason for this could be that the scar tissue from the previous surgery may increase the chances of complications or difficulties during subsequent pregnancies or deliveries.

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9.

22 year old female G1 at 17 weeks presents to Triage reporting spotting after sex with her husband. She is worried she may be having a miscarage. Doppler confirms FHT, and speculum exam reveals a closed cervix with bright red margins noted on the transformation zone. What is the likely cause of bleeding?

A.

Complete AB
B.

Placental abruption
C.

Ectropion
D.

Inevitable AB

Correct Answer
C. Ectropion

Explanation
The likely cause of bleeding in this case is ectropion. Ectropion refers to the presence of columnar epithelium on the ectocervix, which can be more susceptible to bleeding. The bright red margins noted on the transformation zone during the speculum exam support this diagnosis. Placental abruption, complete AB, and inevitable AB are less likely causes in this scenario.

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10.

Whats the next best step in management?

A.

IV Fluid
B.

Reassure
C.

Administer methotrexate
D.

D&C

Correct Answer
B. Reassure

Explanation
The next best step in management would be to reassure the patient. This implies that the patient may be experiencing a situation that is causing distress or anxiety, and providing reassurance can help alleviate their concerns. This step is likely appropriate before considering any medical interventions such as administering IV fluid, methotrexate, or performing a D&C. Reassurance can help create a sense of calm and trust between the patient and healthcare provider, allowing for further discussion and decision-making regarding the patient's condition.

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