1.

A 25-year-old woman, gravida 2, para 1, at 36 and 4/7 weeks of gestation

with a history of prior cesarean section, presents with abdominal pain and
vaginal bleeding. She admits to using cocaine. Her vital signs are
significant for T = 99.9, HR = 120, BP = 170/100. Fetal heart rate baseline is
in the 160s with minimal variability and repetitive late decelerations. Her
blood work is significant for a hemoglobin of 7.5, platelets of 110,000, and
a fibrinogen level of 250 mg/dL. The most likely diagnosis is:
A. Trauma
B. Cervical polyp
C. Placenta previa
D. Placental abruption
E. Uterine rupture

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1. The answer is D [III C 19]. The most likely explanation is placental

abruption in the setting of cocaine use and hypertension. Although the patient
does have a history of cesarean section and is at risk for uterine rupture, this
clinical scenario is most consistent with placental abruption.
2. A 39-year-old woman, gravida 5, para 4004, presents at 38 weeks with
complaints of severe headache, abdominal pain, and vaginal bleeding. Her
past obstetric history is significant for an emergent cesarean section in
the setting of placental abruption with her last pregnancy. Her past
medical history is significant for chronic hypertension and tobacco use.
Her vital signs are as follows: P = 105, BP = 180/105. Her examination is
significant for right upper quadrant tenderness and a tender uterus. Her
urinalysis shows 3+ protein. The following are all risk factors for placental
abruption except:
A. Hypertension
B. History of previous placental abruption
C. Increased maternal age
D. History of previous cesarean section
E. Multiparity

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2. The answer is D [III C 19]. There are several risk factors associated with
placental abruption, including tobacco use, prior history, mulitparity, and
hypertension. A prior cesarean section has not been shown to increase the risk
for placental abruption.
4. A 34-year-old woman, gravida 2, para 1, at 34 and 2/7 weeks of
gestation, presents to labor and delivery reporting painless vaginal
bleeding. You immediately perform a transvaginal ultrasound and note the
placenta completely overlying the internal os, a fetus in cephalic
presentation, and an amniotic fluid index of 14. The cervical length
appears closed on speculum examination. Her blood pressure is 110/78
and her pulse is 106. She has slow, continuous bleeding from her vagina.
Fetal monitoring reveals one uterine contraction every 30 minutes, and
the fetal heart rate is reactive. What is the next best step in management?
A. Magnesium sulfate
B. Hospitalization
C. Vaginal delivery
D. Cesarean section
E. Dexamethasone

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4. The answer is B [II F 12]. Expectant management is justifiable if the fetus

is preterm (less than 37 weeks) and can benefit from further intrauterine
development. Hospitalization is appropriate until the bleeding subsides. The
patient may be discharged after the bleeding lessens and the physician judges
that the fetus is healthy. Tocolysis (magnesium sulfate) is not necessary
because the patient is not having significant, regular uterine contractions and
the cervix is closed. Vaginal delivery or cesarean section is not necessary at
this point because the pregnancy is preterm, the mother's vital signs are stable,
and the fetus is stable (reactive on fetal monitoring strip). Steroids
(dexamethasone or betamethasone) for advancement of fetal lung maturity are
useful only between 24 to 34 weeks of gestation in a pregnancy with intact
membranes.
5. A 28-year-old woman, gravida 3, para 1, at 37 weeks of gestation,
presents to labor and delivery for a scheduled repeat cesarean section
with possible cesarean hysterectomy. She has a history of two previous
low transverse cesarean sections. The first was because of fetal distress
during labor, and the second was an elective repeat cesarean section. Her
current pregnancy has been complicated with complete placenta previa
with occasional spotting and recent hospitalization. Delivery by low
transverse cesarean section is complicated by hemorrhage and
hypotension. The patient receives 20 units of packed red blood cells
(PRBCs). Which of the following organs is most likely to malfunction?
A. Adrenal cortex
B. Hypothalamus
C. Kidney
D. Liver
E. Heart

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5. The answer is C [II G 1]. After severe hemorrhage (e.g., 20 U PRBCs and
severe hypotension during surgery), renal damage in the form of acute tubular
necrosis is most likely to occur. This patient is also at risk for Sheehan
syndrome, which is pituitary necrosis (not hypothalamus). Injury to the liver,
heart, and adrenal glands can occur but is less likely.
131. A healthy 42-year-old G2P1001 presents to labor and delivery at 30
weeks gestation complaining of a small amount of bright red blood per
vagina earlier in the day. The bleeding occurred shortly after intercourse.
It started off as spotting and then progressed to a light bleeding. By the
time the patient arrived at L and D, the bleeding had completely resolved.
The patient denies any regular uterine contractions, but admits to
occasional abdominal cramping. She reports the presence of good fetal
movements. She denies any complications during the pregnancy. She
reported a normal ultrasound done at 14 weeks of gestation. Her
obstetrical history is significant for a previous low transverse cesarean
section at term for a fetus that was footling breech. She wants to have an
elective repeat cesarean section with a tubal ligation for delivery of this
baby when she gets to term. Which of the following can be ruled out as a
cause for her vaginal bleeding?
A. Cervicitis
B. Preterm labor
C. Placental abruption
D. Placenta previa
E. Subserous pedunculated uterine fibroid
F. Uterine rupture

131. The answer is e.(Cunningham, pp 239, 614615, 811819, 962963.

Beckmann, pp 285292.) During pregnancy, if placental implantation occurs
over or in contact with a myoma, then there is an increased risk of placental
abruption, preterm labor, and postpartum hemorrhage. A subserous
pedunculated fibroid is attached to the uterus by a stalk and grows outward into
the abdominal cavity; therefore, there is no vaginal bleeding associated with
such a fibroid. Cervical inflammation (cervicitis) can render the cervix friable and
able to bleed easily, especially after intercourse. Placental abruption occurs
when there is a premature separation of the placenta from the uterine wall.
While vaginal bleeding can be observed, the hemorrhage can be completely
concealed, with the blood being trapped between the detached placenta and
the uterine wall. Labor can be associated with vaginal bleeding due to cervical
dilation. Placenta previa occurs when the placenta is located over or in close
proximity to the internal os of the cervix. When the lower uterine segment is
formed or cervical dilation occurs in the presence of placenta previa, a certain
degree of spontaneous placental separation and hemorrhage from disrupted
blood vessels will occur. Uterine rupture most commonly occurs as a result of a
separation of a previous cesarean scar. Most of the bleeding is into the
abdominal cavity, but vaginal bleeding can be observed as well.
132. A 34-year-old G2P1 at 31 weeks gestation presents to labor and
delivery with complaints of vaginal bleeding earlier in the day that
resolved on its own. She denies any leakage of fluid or uterine
contractions. She reports good fetal movement. In her last pregnancy, she
had a low transverse cesarean delivery for breech presentation at term.
She denies any medical problems. Her vital signs are normal and
electronic external monitoring reveals a reactive fetal heart rate tracing
and no uterine contractions. Which of the following is the most
appropriate next step in the management of this patient?

A. Send her home, since the bleeding has completely resolved and she is
experiencing good fetal movements
B. Perform a sterile digital exam
C. Perform an amniocentesis to rule out infection
D. Perform a sterile speculum exam
E. Perform an ultrasound exam

132. The answer is e.(Cunningham, pp 820822.) Any patient who gives a

history of vaginal bleeding in the third trimester should undergo an ultra-sound
exam as the first step in evaluation to rule out the presence of a placenta
previa. A digital or speculum exam performed in the presence of a placenta
previa can precipitate a hemorrhage. There is no indication to work the patient
up for infection in the case described here; therefore, an amniocentesis is not
indicated. She should not be sent home even though the bleeding has resolved.
She first needs to undergo an ultrasound and should be monitored for uterine
contractions and further bleeding prior to being discharged.
133. A 34-year-old G2P1 at 31 weeks gestation with a known placenta
previa presents to the hospital with vaginal bleeding. On assessment, she
has normal vital signs and the fetal heart rate tracing is 140 beats per
minute with accelerations and no decelerations. No uterine contractions
are demonstrated on external tocometer. Heavy vaginal bleeding is noted.

Which of the following is the best next step in the management of this
patient?

A. Administer intramuscular terbutaline

B. Administer methylergonovine
C. Admit and stabilize the patient
D. Perform cesarean delivery

133. The answer is c.(Cunningham, pp 819823.) In this patient who is starting

to hemorrhage from a placenta previa, steps should be taken to stabilize the
patient and prepare for possible emergent cesarean section. The patient is not
contracting, and therefore there is no role for tocolysis. In addition, terbutaline
should never be used in a patient who is actively bleeding because it is
associated with maternal tachycardia and vasodilation. The actively bleeding
patient should be resuscitated with intravenous fluids while blood is being cross-
matched for possible transfusion. A Foley catheter should be placed because
urinary output is a reflection of the patients volume status. Finally, anesthesia
should be notified because the patient may require imminent delivery.
134. A 34-year-old G2P1 at 31 weeks gestation with a known placenta
previa is admitted to the hospital for vaginal bleeding. The patient
continues to bleed heavily and you observe persistent late decelerations
on the fetal heart monitor with loss of variability in the baseline. Her blood
pressure and pulse are normal. You explain to the patient that she needs
to be delivered. The patient is delivered by cesarean section under
general anesthesia. The baby and placenta are easily delivered, but the
uterus is noted to be boggy and atonic despite intravenous infusion of
Pitocin. Which of the following is contraindicated in this patient for the
treatment of uterine atony?

A. Methylergonovine (Methergine) administered intramuscularly

B. Prostaglandin F2 (Hemabate) suppositories
C. Misoprostil (Cytotec) suppositories
D. Terbutaline administered intravenously
E. Prostaglandin E2 Suppositories

134. The answer is d. (Decherney, pp 538539. Cunningham, p 827.

Beckmann, pp 174175.) Methylergonovine, prostaglandin F2 , prostaglandin
E1 (Misoprostil), and prostaglandin E2 are all uretotonic agents than can be
used in situations where there is a postpartum hemorrhage due to uterine atony.
Terbutaline would be contraindicated in this situation because it is a tocolytic
that is used to promote uterine relaxation.
135. A 20-year-old G1P0 at 30 weeks gestation with a known placenta
previa is delivered by cesarean section under general anesthesia for
vaginal bleeding and nonreassuring fetal heart rate tracing. The baby is
easily delivered, but the placenta is adherent to the uterus and cannot be
completely removed, and heavy uterine bleeding is noted. Which of the
following is the best next step in the management of this patient?

A. Administer methylergonovine (Methergine) intramuscularly

B. Administer misoprostil (Cytotec) suppositories per rectum
C. Administer prostaglandin F2 (Hemabate) intramuscularly
D. Perform hysterectomy
E. Close the uterine incision and perform curettage

135. The answer is d. (Cunningham, pp 821. Beckmann, pp 286289.) Women

who have a placenta previa have about a 10% risk of also having a placenta
accreta. The risk of placenta accreta is even greater in women who have a
history of a previous cesarean section (estimated to be between 14 and 24%).
The incidence of placenta accreta continues to increase as the numbers of prior
cesarean sections increase. If a placenta accreta indeed exists, a hysterectomy
is indicated.